Insomnia
Highlights
What Is Insomnia?
Insomnia can be a short-term or chronic condition, but it always involves problems with falling or staying asleep. Short-term (transient) insomnia can be caused by stress, travel, or environmental factors. Long-term (chronic) insomnia may be due to underlying psychological or physical conditions.
Who Is At Risk?
Anyone can get insomnia, but it is generally more common in women than in men. The elderly are also particularly at risk for insomnia.
Diagnosing Insomnia
A doctor will make a diagnosis of insomnia based on information about your sleep patterns. Your doctor may ask:
- How long does it take you to fall asleep at night?
- How many times during the night do you wake up?
- Do you experience daytime fatigue?
- Do you have a medical condition that may interfere with sleep?
- What medications do you take (including prescription drugs, over-the counter drugs, and herbs or supplements?)
- Do you drink alcohol or smoke?
Your doctor may also ask you to keep a sleep diary to record specific sleep-related information.
Treating Insomnia
- Sleep hygiene is an important first step for controlling insomnia. These simple self-help measures include establishing a regular bedtime routine, regulating mealtimes and fluid consumption, and limiting caffeine consumption.
- Behavioral therapy methods include various approaches for training new sleep behaviors and helping patients relax and sleep well. Behavioral therapy can help cure insomnia in people of all ages.
- If self-help or behavioral therapy do not solve the problem, a doctor may prescribe medications for use on a short-term basis. Non-benzodiazepine sedative hypnotics are usually the preferred type of drugs. They include zolpidem (Ambien, generic), zaleplon (Sonata), eszopiclone (Lunesta), and ramelteon (Rozerem). These drugs can cause side effects, and it is important that your doctor explains the risks of these drugs and the precautions you need to take.
Introduction
Insomnia comes from the Latin words for “no sleep.” Insomnia is characterized by:
- Difficulty falling asleep
- Difficulty staying asleep
- Waking up too early in the morning
Some experts believe that poor quality (“non-restorative”) sleep is also related to insomnia. Insomnia can cause daytime fatigue, irritability, and impaired performance. About 60 million Americans each year suffer from insomnia.
Insomnia may be primary or secondary:
- Primary insomnia means that the inability to sleep is not caused by other health problems.
- Secondary insomnia is due to other health conditions that interfere with sleep. Some experts prefer the term “co-morbid insomnia.”
Insomnia, usually temporary, is often categorized by how long it lasts:
- Transient insomnia lasts for a few days.
- Short-term insomnia lasts for no more than 3 weeks.
- Chronic insomnia occurs at least 3 nights per week for 1 month or longer.
Insomnia may also be defined in terms of inability to sleep at conventional times. The following examples are referred to as circadian rhythm disorders:
- Delayed Sleep-Phase Syndrome. Delayed sleep-phase syndrome is the term for a circadian clock that runs late but reliably. People who have this condition (usually adolescents) fall asleep very late at night or in early morning hours, but then sleep normally.
- Advanced Sleep-Phase Syndrome. This syndrome tends to develop in older people. It produces excessive sleepiness in the morning and undesired awakening early (3 - 5 a.m.) in the morning.
In sleep studies, subjects spend about one-third of their time asleep, suggesting that most people need about 8 hours of sleep each day. Individual adults differ in the amount of sleep they need to feel well rested, however. (Infants may sleep as many as 16 hours a day.)
The daily cycle of life, which includes sleeping and waking, is called a circadian (meaning "about a day") rhythm, commonly referred to as the biologic clock. Hundreds of bodily functions follow biologic clocks, but sleeping and waking comprise the most prominent circadian rhythm. The sleeping and waking cycle is about 24 hours. (If confined to windowless apartments, with no clocks or other time cues, sleeping and waking as their bodies dictate, humans typically live on slightly longer than 24-hour cycles.) It usually takes the following daily patterns:
- Humans are designed for daytime activity and nighttime rest.
- Additionally, there is a natural peak in sleepiness at mid-day, the traditional siesta time.
In addition, daily rhythms intermesh with other factors that may interfere or change individual patterns:
- The fraction-of-a-second-firing of nerve cells in the brain may be faster or slower in different individuals.
- The monthly menstrual cycle in women can shift the pattern.
- Light signals coming through the eyes reset the circadian cycles each day, so changes in season or various exposures to light and dark can unsettle the pattern. The importance of sunlight as a cue for circadian rhythms is dramatized by the problems experienced by people who are totally blind. They commonly suffer trouble sleeping and other rhythm disruptions.
The response to light signals in the brain is an important key factor in sleep:
- Light signals travel to a tiny cluster of nerves in the hypothalamus in the center of the brain, the body's master clock, which is called the supra chiasmatic nucleus (SCN).
- This nerve cluster takes its name from its location, which is just above (supra) the optic chiasm, a major junction for nerves transmitting information about light from the eyes.
- The approach of dusk each day prompts the SCN to signal the nearby pineal gland (named so because it resembles a pine-cone) to produce the hormone melatonin.
- Melatonin is thought to act as the body's time-setting hormone. The longer a person is in darkness the longer the duration of melatonin secretion. Secretion can be diminished by staying in bright light. Melatonin also appears to trigger the need to sleep.
Sleep consists of two distinct states that alternate in cycles and reflect differing levels of brain nerve cell activity:
Non-Rapid Eye Movement Sleep (NonREM). NonREM sleep is also termed quiet sleep. NonREM is further subdivided into three stages of progression:
- Stage 1 (light sleep)
- Stage 2 (so-called true sleep)
- Stage 3 to 4 (deep "slow-wave" or delta sleep)
With each descending stage, awakening becomes more difficult. It is not known what governs NonREM sleep in the brain. A balance between certain hormones, particularly growth and stress hormones, may be important for deep sleep.
Rapid Eye-Movement Sleep (REM). REM sleep is termed active sleep. Most vivid dreams occur in REM sleep. REM-sleep brain activity is comparable to that in waking, but the muscles are virtually paralyzed, possibly preventing people from acting out their dreams. In fact, except for vital organs like lungs and heart, the only muscles not paralyzed during REM are the eye muscles. REM sleep may be critical for learning and for day-to-day mood regulation. When people are sleep-deprived, their brains must work harder than when they are well rested.
The REM/NREM Cycle. The cycle between quiet (nonREM) and active (REM) sleep generally follows this pattern:
- After about 90 minutes of nonREM sleep, eyes move rapidly behind closed lids, giving rise to REM sleep.
- As sleep progresses the nonREM/REM cycle repeats.
- With each cycle, nonREM sleep becomes progressively lighter, and REM sleep becomes progressively longer, lasting from a few minutes early in sleep to perhaps an hour at the end of the sleep episode.
Causes of Short-Term or Transient Insomnia
A reaction to change or stress is one of the most common causes of short-term and transient insomnia. This condition is sometimes referred to as adjustment sleep disorder.
The trigger could be a major or traumatic event such as:
- An acute illness
- Injury or surgery
- The loss of a loved one
- Job loss
Temporary insomnia could also develop after a relatively minor event, including:
- Extremes in weather
- An exam
- Traveling
- Trouble at work
In most cases, normal sleep almost always returns when the condition resolves, the individual recovers from the event, or the person becomes used to the new situation. Treatment is needed if sleepiness interferes with functioning or if it continues for more than a few weeks. Individual responses to stress vary and some people may not experience insomnia at all, even during very stressful situations while others may suffer from insomnia in response to very mild stressors.
Fluctuations in female hormones play a major role in insomnia in women over their lifetimes. This insomnia is usually temporary.
- During Menstruation. Progesterone promotes sleep, and levels of this hormone plunge during menstruation, causing insomnia. (When they rise during ovulation, women may become sleepier than usual.)
- During Pregnancy. The effects of changes in progesterone levels in the first and last trimester can disrupt normal sleep patterns.
- Menopause. Insomnia can be a major problem in the first phases of menopause, when hormones are fluctuating intensely. Insomnia during this period may be due to different factors that occur. In some women, hot flashes, sweating, and a sense of anxiety can awaken women suddenly and frequently at night. Insomnia may also be caused by psychologic distress provoked by this life passage. In many cases, insomnia is temporary. Treating hot flashes may help resolve chronic insomnia.
Air travel across time zones often causes insomnia. After long plane trips, 1 day of adjustment is usually needed for each time zone crossed. Traveling west to earlier times seems to be less traumatic than going east to a later time because it is easier to lengthen a circadian phase than to shorten it.
Light, noise, and uncomfortable temperatures can cause sleeplessness. Depending on the time of day, too much or too little light can disrupt sleep.
- Excessive Light at Night. A person's biologic circadian clock is triggered by sunlight, and very bright artificial light maintains wakefulness. One study indicated that even dim artificial light might disrupt sleep.
- Insufficient Light during the Day. Insufficient exposure to light during the day, as occurs in some disabled elderly patients who rarely venture outside, may also be linked with sleep disturbances. One study suggested that when a person is exposed to bright daylight, melatonin levels increase in response to darkness at night, which aids sleep.
Caffeine. Caffeine is a stimulant, which can interfere with falling asleep.
Nicotine. Nicotine is also a stimulant, but quitting smoking itself can lead to transient insomnia. In fact, it has been suggested that if sleeping could be improved during withdrawal from smoking, perhaps it would be easier to quit smoking.
Partner's Sleep Habits. In one survey, 17% of women and 5% of men reported that their partner's sleep habits impaired their own sleep. Snoring can certainly be a factor in a partner's insomnia.
Medications. Insomnia is a side effect of many common medications, including over-the-counter preparations that contain caffeine. People who suspect their medications are causing them to lose sleep should check with their doctors or pharmacists.
Causes of Chronic Insomnia
Sleep problems seem to run in families. About 35% of people with insomnia have a family history of insomnia, with the mother being the most commonly affected family member. Still, because so many factors are involved in insomnia, a genetic component is difficult to define.
Many cases of chronic insomnia cases have a psychologic or psychiatric basis. The disorders that most often cause insomnia are:
- Anxiety
- Depression
- Bipolar disorder
- Attention-deficit hyperactivity disorder
- Post-traumatic stress disorder
- Brain injuries
Insomnia may also cause emotional problems. It is often unclear which condition has triggered the other, or if the two conditions, in fact, have a common source. [For more information, see In-Depth Reports #28: Anxiety; #08: Depression; #66: Bipolar disorder; #30: Attention-deficit hyperactivity disorder.]
In many cases, it is unclear if chronic insomnia is a symptom of some physical or psychological condition or if it is a primary disorder of its own. In most instances, a mix of psychological and physical conditions causes the insomnia.
Psychophysiologic insomnia occurs when:
- Transient insomnia disrupts the person's circadian rhythm.
- The patient begins to associate the bed not with rest and relaxation but with a struggle to sleep. A pattern of sleep failure emerges.
- Over time, this event repeats, and bedtime becomes a source of anxiety. Once in bed, the patient broods over the inability to sleep, the consequences of sleep loss, and the lack of mental control. All attempts to sleep fail.
- Eventually excessive worry about sleep loss becomes persistent and provides an automatic nightly trigger for anxiety and arousal. Unsuccessful attempts to control thoughts, images, and emotions only worsen the situation. After such a cycle is established, insomnia becomes a self-fulfilling prophecy that can persist indefinitely.
Sometimes anxiety and the inability to sleep dates back to childhood when parents used various threats to force their children into sleep for which they may not have been ready.
Leg disorders that occur at night, such as restless legs syndrome or leg cramps, are of special note. They are very common and an important cause of insomnia, particularly in older people. [See In-Depth Report #95: Restless legs syndrome.]
Among the many medical problems that can cause chronic insomnia are allergies, arthritis, cancer, fibromyalgia, heart disease, gastroesophageal reflux disease (GERD), hypertension, asthma, emphysema, rheumatologic conditions, Alzheimer's disease, Parkinson's disease, hyperthyroidism, epilepsy, and fibromyalgia. Many patients with chronic pain also sleep poorly.
Medications. Among the many medications that can cause insomnia are antidepressants (fluoxetine, bupropion), theophylline, lamotrigine, felbamate, beta-blockers, and beta-agonists.
An estimated 10 - 15% of chronic insomnia cases result from substance abuse, especially alcohol, cocaine, and sedatives. One or two alcoholic drinks at dinner, for most people, pose little danger of alcoholism and may help reduce stress and initiate sleep. Excess alcohol or alcohol used to promote sleep, however, tends to fragment sleep and cause wakefulness a few hours later. It also increases the risk for other sleep disorders, including sleep apnea and restless legs. Alcoholics often suffer insomnia during withdrawal and, in some cases, for several years during recovery.
Shift work throws off the body's circadian rhythm and may lead to chronic insomnia.
Risk Factors
Studies estimate that 25 - 33% of adults experience some insomnia each year. In spite of this widespread problem, however, studies suggest that only about 30% of American adults who visit their doctor ever discuss sleep problems. And, doctors seem rarely to ask patients about their sleep habits or problems.
Stressful events do not cause insomnia in everyone. However, negative thoughts and attitudes toward events can be significant factors in insomnia. Those with insomnia, however, tend to experience stressful events more intensively than the healthy sleepers.
Overall, insomnia is more common in women than men, although men are not immune from insomnia. Sleep efficiency deteriorates equally in men and women as they get older.
Men. One major study suggested that as men age from 16 - 50, they lose about 80% of their deep sleep. During that period, light sleep increases and REM sleep remains unchanged. (The study did not use women as subjects, and there is some evidence to suggest they are not as affected.) After age 44, REM and total sleep diminish and awakenings increase.
Women. It is not clear why women suffer more from insomnia than men. Some theories include:
- In women, a number of hormonal events can disturb sleep, including premenstrual syndrome, menstruation, pregnancy, and menopause. All these conditions are short-term, however, and in most cases the wakefulness associated with them is temporary and can be eliminated with sleep hygiene and time.
- After childbirth, most women develop a high sensitivity to the sounds of their children, which causes them to wake easily. Women who have had children sleep less efficiently than women who have not had children. It is possible that many women never unlearn this sensitivity and continue to wake easily long after the children have grown.
- Women are at higher risk than men are for depression and anxiety, which are known risk factors for insomnia. In fact, some researchers believe that this is a main reason for the gender differences in insomnia.
After menopause, women are susceptible to the same environmental and biologic causes of insomnia as men. In fact, older women who are not bothered by sleeplessness tend to have longer and better sleep than noninsomniac men their own age.
As people grow older, sleep patterns change. Elderly adults tend to wake up frequently during the night, wake up earlier, and report waking up feeling unrefreshed. There is no gold standard for the normal number of hours of sleep an elderly person needs.
Although age itself does not appear to be a risk factor for insomnia, a number of factors may interfere with sleep as one gets older:
- Elderly people are more likely to be sedentary than younger adults.
- Medical conditions that cause pain or nighttime distress are common in the elderly and pose a high risk for insomnia. They include arthritis, gastrointestinal distress, frequent urination, lung disease, and heart conditions.
- Neurologic diseases in the elderly, such as restless legs syndrome, Parkinson's, Alzheimer's, and other forms of dementia can cause nighttime disorientation, confused wandering, and delirium.
- Older people often take a number of prescription drugs whose side effects include insomnia.
- The elderly are prone to grief, depression, and anxiety, emotional factors that can cause sleeplessness. One study of healthy older adults found that psychologic factors, such as anxiety and depression, were more likely to cause insomnia than illness, medications, or living conditions.
Lack of sleep at night can lead to excessive sleepiness during the day. Consequences of poor sleep include daytime sleepiness, excessive fatigue, anxiety, impaired mental function, increased risk of falls, and decreased quality of life.
Sleep loss among the elderly is not inevitable. While older people are more susceptible to many conditions that can cause insomnia, treatments and a healthy lifestyle, particularly regular exercises, are as useful in providing relief to the elderly as to the young. And, a number of studies have found no significant increase in insomnia in older healthy adults.
Shift workers are at considerable risk for insomnia. Over half of shift workers report one or more symptoms of insomnia at least a few nights a week. Workers over age 50 and those whose shifts are always changing are particularly susceptible to insomnia, although night-shift workers also have a high rate of sleeplessness. Night shift workers are at risk for falling asleep on the job at least once a week, implying that their internal clocks do not adjust to unusual work times. (They are also at much higher risk than other workers for automobile accidents due to their drowsiness and may also have a higher risk for health problems in general.)
Prognosis
Insomnia is not life threatening, except in very rare cases, such as in those who have the genetic disorder called fatal familial insomnia. This rare degenerative brain disease develops in late adulthood.
Sleepiness increases the risk for motor vehicle accidents. Studies indicate that drowsy driving is as risky as drunk driving.
Surveys show that people with severe insomnia have a quality of life that is almost as poor as those who have chronic conditions, such as heart failure. In addition to more daytime sleepiness, people with insomnia complain of more attention and memory problems compared to good sleepers.
Insomnia can also lead to irritability, mistakes at work, and poorer relationships.
Effect on Thinking and Performance. Studies suggest that insomnia makes it harder to concentrate and perform tasks.
- Reduced concentration. Deep sleep deprivation impairs the brain's ability to process information.
- Impaired task performance. One study reported that missing only 2 - 3 hours of sleep every night for a week significantly impaired performance and mood. An Australian study reported that 17 hours of sleep deprivation causes impaired performance levels comparable to those found in people who have blood alcohol levels indicating intoxication.
- Memory problems. Whether insomnia significantly impairs learning is unclear. Some studies have reported problems in memorization, although others have found no differences in test scores between people with temporary sleep loss and those with full sleep.
Insomnia and Depression. Although stress and depression are major causes of insomnia, insomnia may also increase the activity of the hormones and pathways in the brain that can produce emotional problems. Research indicates that chronic insomnia can increase the risk of developing depression and anxiety. Some investigators are exploring the possibility of preventing psychiatric disorders by early recognition and treatment of insomnia.
Even modest alterations in waking and sleeping patterns can have significant effects on a person's mood. In both children and adults, the combination of insomnia and daytime sleepiness can produce more severe depression than either condition alone.
Effects on the Heart. Despite some concern that insomnia may increase the risk for heart problems, little evidence has supported any significant dangers. If any increased risk exists, however, this increased danger is very modest compared with other risk factors for heart disease.
Effects on Weight. Lack of sleep can cause weight gain and obesity.
Diagnosis
Having a doctor diagnose sleep disturbance and its cause is the most important step in restoring healthy sleep. However, there is little agreement, even among experts, on the best methods for effectively assessing a patient's insomnia.
A major difficulty in diagnosing this problem is its subjective nature. Actual sleep behaviors between people who believe they have insomnia are often similar to those who do not feel they have insomnia. People who believe they have insomnia may have actually had frequent brief awakenings during sleep that they perceive as being continuously awake.
A number of questionnaires are available for determining whether a patient has insomnia or other sleep disorders. For example, the doctor may ask:
- How would you describe your sleep problem?
- How long have you had the sleep problem?
- How long does it take to fall asleep?
- How many times a week does it occur?
- How restful is sleep?
- Do you have trouble falling asleep or do you wake up too early?
- What is the sleep environment like? (Noisy? Not dark enough?)
- How does insomnia affect daytime functioning?
- What medications do you take? (Include herbs, alcohol, and over-the-counter or prescription drugs.)
- Are you taking or withdrawing from stimulants, such as coffee or tobacco?
- How much alcohol is consumed per day?
- What stresses or emotional factors may be present?
- Have you experienced any significant life changes?
- Do you snore or gasp during sleep (an indication of sleep apnea)?
- Do you have leg problems (cramps, twitching, crawling feelings)?
- If there is a bed partner? Is this person's behavior distressing or disturbing?
- Are you a shift worker?
Sleep Diary. If the patient cannot answer these questions, keeping a sleep diary is a helpful diagnostic tool. Every day for 2 weeks, the patient should record all sleep-related information(including responses to questions listed above). Other information should include time the patient went to bed, time spent falling asleep, number of nocturnal awakenings, and rising time. A bed partner's observations of the patient's sleep behavior can also help.
Actigraphy. Actigraphy uses a portable device with a sensor to monitor a patient's movement. Actigraphy may be used in some situations to help give a doctor a better picture of the patient's sleep pattern. It cannot, however, determine the severity of sleep problems. Most patients with insomnia are diagnosed and treated without this test. However, actigraphy may help identify insomnia in some patients.
If unexplained insomnia persists after treatment or there is evidence of a primary sleep disorder, such as sleep apnea or narcolepsy, the doctor may recommend a sleep specialist or a sleep disorders center. Centers are accredited by the American Academy of Sleep Medicine. Patients should investigate centers carefully, to be sure that they offer full sleep studies. [For more information, see In-Depth Report #65: Sleep apnea and #98: Narcolepsy.]
Among the signs that may indicate a need for a sleep disorders center are:
- Insomnia due to psychologic disorders
- Sleeping problems due to substance abuse
- Snoring and sudden awakening with gasping for breath (possible sleep apnea)
- Severe restless legs syndrome
- Persistent daytime sleepiness
- Sudden episodes of falling asleep during the day (possible narcolepsy)
At most sleep disorders centers, patients undergo an in-depth analysis, usually supervised by a multidisciplinary team of consultants who can provide both physical and psychiatric evaluations.
Treatment
The American Academy of Sleep Medicine (AASM) recommends a number of behavioral methods and prescription medications as the main treatments for insomnia. According to the AASM, these treatment options can improve both quality and quantity of sleep for people with insomnia.
Experts agree that behavioral therapies should be the first-line treatment for insomnia. For children in particular, medications should rarely be used as initial treatment. A 2006 study reported that behavioral interventions can provide sustained improvement in over 80% of children with insomnia.
Proper sleep hygiene should accompany any behavioral method. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep. These include:
- Establish a regular time for going to bed and getting up in the morning. Stick to this schedule even on weekends and during vacations.
- Use the bed for sleep and sexual relations only, not for reading, watching television, or working. Excessive time in bed disrupts sleep.
- Avoid naps, especially in the evening.
- Exercise before dinner. A low point in energy occurs a few hours after exercise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness.
- Take a hot bath about 1.5 - 2 hours before bedtime. This alters the body's core temperature rhythm and helps people fall asleep more easily and more continuously. (Taking a bath shortly before bed increases alertness.)
- Do something relaxing in the 30 minutes before bedtime. Reading, meditation, and a leisurely walk are all appropriate activities.
- Keep the bedroom relatively cool and well ventilated.
- Do not look at the clock. Obsessing over time will just make it more difficult to sleep.
- Eat light meals, and schedule dinner 4 - 5 hours before bedtime. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.
- Spend a half hour in the sun each day. The best time is early in the day. (Take precautions against overexposure to sunlight by wearing protective clothing and sunscreen.)
- Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.
- Avoid caffeine in the hours before sleep.
- If one is still awake after 15 - 20 minutes, go into another room, read or do a quiet activity using dim lighting until feeling very sleepy. (Don't watch television or use bright lights.)
- If distracted by a sleeping bed partner, moving to the couch or a spare bed for a couple of nights might be helpful.
- If a specific worry is keeping one awake, thinking of the problem in terms of images rather than in words may allow a person to fall asleep more quickly and to wake up with less anxiety.
Prevention of sleeplessness depends upon the patient's ability to learn how to relax and sleep well. A number of behavioral methods can help achieve these goals. Behavioral techniques can actually cure chronic insomnia in many cases, and studies report that they help nearly all patients with primary chronic insomnia. The benefits of psychological and behavioral therapy in managing insomnia last long.
Although medications are equally effective for helping people with insomnia to sleep, they cannot cure the condition. In addition, behavioral methods act faster. Behavioral methods work in all age groups, including children and elderly patients.
Behavioral methods include:
- Stimulus control
- Cognitive behavioral therapy
- Progressive muscle relaxation
- Paradoxical intention
- Biofeedback
- Sleep restriction
- Imagery tasks
All behavioral approaches have the same basic goals:
- To reduce the time it takes to go to sleep to below 30 minutes
- Reduce wake-up periods during the night
Studies have reported that 70 - 80% of patients who are treated with non-drug methods have improved sleep, with an average treatment duration of only 5 hours during a 4-week period. Furthermore, studies report that 75% of those who have been taking drugs are able to stop or reduce their use.
Stimulus Control. Stimulus control is now considered the standard treatment for primary chronic insomnia and may be helpful for some patients with secondary insomnia as well. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following:
- Go to bed only when ready to sleep or for sex.
- If unable to sleep within 15 - 20 minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, like reading a book.)
- Maintain a regular wake-up time no matter how few hours you actually sleep.
- Avoid naps.
Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep such as, "I'll never fall asleep." It uses actions intended to change behavior. The goal is to change or correct misconceptions about the ability to fall and stay asleep. Emphasis is on reinforcing the need for 7 - 8 hours of sleep each night and addressing the anxiety that patients with insomnia often develop around sleep. Several studies have shown it to work as well or better than medications, including some of the newer drugs available. Adding medication to CBT did not provide additional benefit in several studies.
Progressive Muscle Relaxation. Progressive muscle relaxation is another technique for inducing sleep that works well for many people. It takes about 10 minutes to perform:
- Focus on one specific muscle group at a time. Most people start with the muscles in one foot. Inhale and tense the foot muscles for about 8 seconds. (Do this gently. It is not intended to cause severe pain or muscle contractions.)
- Relax the foot, and let it become loose and limp. Stay relaxed for 15 seconds, then repeat with the other foot.
- Move up to the next muscle group and repeat the sequence, doing one side of the body at a time. Move progressively from each foot and leg up through the abdomen and chest, to each hand and arm, then to the neck, shoulders, and face.
Paradoxical Intention. Paradoxical intention is a psychological approach that is based on doing the opposite of what one wants or fears and then take it to the extreme. The goal is to remove the performance anxiety associated with insomnia in some patients The first step is to make a plan to take such a paradoxical approach to insomnia:
- Instead of going through activities leading to sleep, the patient prepares for staying awake and doing something energetic.
- In some cases, people may take specific psychological barriers to sleep to an extreme limit. For example, if worry is a factor in insomnia, the patient intensifies the worries.
Biofeedback. Biofeedback requires being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily. The effectiveness of biofeedback compared to other techniques has not been well evaluated.
Sleep Restriction Therapy. Sleep restriction therapy may be effective, although the evidence is inconclusive. It is suggested as a possible therapy only when there are no psychologic or medical problems underlying the insomnia and when sleep hygiene has failed. The approach is a systematic method for achieving sleep and restricting the time spent in bed, particularly time spent in bed when not asleep.
The first step is to calculate a person's sleep efficiency number:
- Keep a sleep diary for 14 days. Calculate the average hours of actual sleep and hours in bed. Then divide the average hours slept by the hours spent in bed. The result, given as a percentage, is the sleep efficiency number. (For example, if a patient sleeps an average of 5 hours out of 7 hours spent in bed then the result is .714, and the sleep efficiency percentage is 71%.)
- The patient's goal is to achieve sleep efficiencies of 85 - 90%, which means only 10 - 15% of the time is spent staying awake in bed. (Sleep efficiency in older people normally falls to 75 - 85%.)
To achieve this goal, the patient takes the following actions:
- Begin by going to bed 15 minutes later than usual the first week.
- If 85% sleep efficiency isn't reached by the end of the week, add another 15 minutes before going to bed. Refrain from going to bed even if tired, although bedtime should not be reduced below 5 hours.
- Once efficiency reaches 90% or more, begin to go to bed 15 minutes earlier each week.
Other parts of the program include stopping any sleep medications and following good sleep hygiene. People using this treatment have reported lasting improvements after just 8 weeks, and studies suggest that it is significantly more successful than relaxation techniques.
Imagery Tasks. Chronic insomnia may be associated with unwanted thoughts and worries. In imagery therapy, patients are given specific positive mental tasks that gave them a sense of positive control (as opposed to their real life concerns, which can feel out of their control). These images are used to distract patients and allow them to fall asleep faster. In general, there is not enough evidence to clearly support the use of this technique for the treatment of insomnia.
Exercise may be one of the best ways to promote healthy sleep. One study found that exercise is as good for inducing sleep as the use of benzodiazepines, a prescription sleep aid. Some research has found that yoga practice may have specific benefits on sleep health. Yoga uses meditation, deep breathing techniques, and movements that emphasize stretching and balance.
No hi-quality studies have evaluated the use of acupuncture to treat insomnia. Therefore, there is no good evidence to claim that acupuncture is helpful for treating insomnia.
Medications
About 20% or more of older American adults use some form of sleep aid, including prescription or over-the-counter drugs or alcohol. Many use such aids every night. Over-the-counter or nonprescription medications make use of the drowsiness caused by some common medications. Prescription drugs used specifically for improving sleeping are called sedative hypnotics. These drugs include benzodiazepines and non-benzodiazepines.
In general, the following considerations are important regarding the use of medications for the treatment of insomnia:
- Underlying mental health problems, such as anxiety or depression, should be addressed first.
- Behavioral or psychologic techniques can actually cure insomnia, while prolonged use of sleeping pills can only result in dependency.
- Start with non-prescription medication.
- Non-benzodiazepine sedative hypnotics may be better tolerated than benzodiazepines and have less risk of dependency. These medicines, however, may be associated with potentially severe allergic reactions, such as anaphylaxis and facial swelling (angioedema). These drugs may also cause hazardous or strange behaviors, such as driving, making phone calls, or eating while asleep. If you need to take one of these prescription drugs, start with as low a dose as possible.
- For adults over age 60 years, studies suggest that the risks of sedative hypnotics may far outweigh their benefits.
- As a general rule, do not take either prescription nor non-prescription sleeping pills on consecutive days or for more than 2 - 4 days a week.
- If insomnia is still a problem after stopping the drug and continuing with good sleep hygiene, this pattern can be repeated again, but for only up to 4 weeks.
- Medication should be withdrawn gradually, and the patient should be aware of the possibility of rebound insomnia after stopping medication.
- Alcohol intensifies the side effects of all sleeping medication and should be avoided.
- If chronic insomnia is a companion to depression or anxiety, treating these problems first may be the best approach.
Brands with Antihistamines. Many over-the-counter sleeping medications use antihistamines, which cause drowsiness. Diphenhydramine is the most common antihistamine used non-prescription sleep aids. Some drugs contain diphenhydramine alone (such as Nytol, Sleep-Eez, and Sominex), while others contain combinations of diphenhydramine with pain relievers (such as Anacin P.M., Excedrin P.M., and Tylenol P.M.). Doxylamine (Unison) is another antihistamine used in sleep medications. Certain antihistamines indicated only for allergies, such as chlorpheniramine (Chlor-Trimeton), diphenhydramine (Benadryl), or hydroxyzine (Atarax or Vistaril) may also be used as mild sleep-inducers.
Unfortunately, most of these drugs leave patients feeling drowsy the next day and may not be very effective in providing restful sleep. Side effects include:
- Daytime sleepiness
- Cognitive impairment
- Dizziness
- Drunken movements
- Blurred vision
- Dry mouth and throat
In general, people with angina, heart arrhythmias, glaucoma, or problems urinating should avoid these drugs. They should not be used at the same time as medications that prevent nausea or motion sickness. Patients with chronic lung disease should also avoid some non-prescription sleeping aids, such as those containing doxylamine.
Common Pain Relievers. When sleeplessness is caused by minor pain, simply taking acetaminophen (Tylenol) or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil, Motrin), can be very helpful without causing any daytime sleepiness. The extra "P.M." antihistamine found in combination products is simply an extra, needless chemical in these situations.
Newer short-acting non-benzodiazepines can induce sleep with fewer side effects than benzodiazepines. Both benzodiazepine and non-benzodiazepine sedative hypnotics act on GABA-A receptor sites in the brain, but non-benzodiazepines are more specific in the subunits they target. Developed in the late 1980s, these drugs are now the preferred sedative hypnotic drugs for the treatment of insomnia.
Brands and Benefits. Non-benzodiazepine hypnotics currently approved in the United States are zolpidem (Ambien, Ambien CR), zaleplon (Sonata), eszopiclone (Lunesta), and ramelteon (Rozerem). The FDA is currently considering whether to approve indiplon, a new non-benzodiazepine hypnotic.
- Zolpidem (Ambien, generic) is one of the most commonly prescribed drugs for insomnia. It lasts longer than zaleplon. Patients should not take it unless they plan on getting at least 7 - 8 hours of sleep. The recommended dose is 10 mg/day for adults, although elderly patients may be prescribed half that dose. Studies indicate that this drug also may be used on an as needed basis. Ambien CR, an extended-release form, received approval from the Food and Drug Administration (FDA) in late 2005. It is the first extended-release prescription medicine for insomnia. The medicine is delivered in two steps. The first layer dissolves quickly, allowing the patient to fall asleep. The second layer helps the patient stay asleep.
- Zaleplon (Sonata) is the shortest-acting hypnotic available. Because it is rapidly eliminated from the body it may be best for people who have difficulty falling asleep, not those who wake up often throughout the night. The drug takes effect within 30 minutes and may be taken at bedtime or later as long as the patient can sleep for at least 4 hours. The recommended dose is 5 - 10 mg/day. The drug is usually taken for 7 - 10 days.
- Eszopiclone (Lunesta) may help improve both sleep maintenance and daytime alertness. Eszopiclone is related to zopiclone (Imovane), which has been used for many years in Europe. Unlike other sleep medications, eszopiclone can be taken on a long-term basis. In clinical trials, patients used eszopiclone for up to 6 months. Recommended doses are 2 - 3 mg/day for adults and 2 mg/day for elderly patients. Patients whose main problem is falling asleep may need only 1 mg/day.
- Ramelteon (Rozerem) was approved by the FDA in 2005. Ramelteon is a novel non-benzodiazepine hypnotic. Unlike most sleep drugs, which target the gamma-aminobutyric acid (GABA) receptors, ramelteon targets the MT1 and MT2 receptors. Ramelteon does not cause dependence and is the first sleep drug not designated as a controlled substance.
These drugs can be particularly helpful for preventing jet lag (but zolpidem should not be used on flights less than 7 - 8 hours). They also may be helpful for people who also have accompanying mood disorders, such as depression or post-traumatic stress disorder. Because they are short-acting, zaleplon and zolpidem may pose fewer risks for falls and memory loss in elderly patients. In general, these drugs are recommended for short-term use (7 - 10 days), and treatment should not exceed 4 weeks. No studies have yet confirmed safety for longer-term use.
Side Effects. All of these drugs have fewer morning side effects than the benzodiazepines, including morning sedation and memory loss (although they can occur to some degree). Zolpidem’s (Ambien) record of adverse effects is similar to that of triazolam (Halcion), the short-acting benzodiazepine. Zaleplon (Sonata) and Ramelteon (Rozerem) appear to have less severe morning side effects. When patients first start taking any of these drugs, they should use caution during morning activities until they are sure how the drug affects them.
General side effects are mild but may include:
- Drowsiness
- Dizziness
- Fatigue
- Headache
- Unpleasant taste
- Diarrhea
Rarer side effects may include sleepwalking, sleep driving, and hallucinations. Most cases of sleepwalking and sleep driving likely occur when patients use zolpidem along with alcohol or other drugs or take more than the recommended dose. However, in March 2007, the FDA ordered stronger warning labels for zolpidem and all other non-benzodiazepine drugs. The new labels warn that that these drugs can cause sleep-related behavior, including sleep-driving, making phone calls, and preparing and eating food while asleep. In addition, severe allergic reactions (anaphylaxis) and facial swelling (angioedema) can occur even the first time one of these drugs is taken.
Anyone who receives a prescription for these medicines will also get a patient medication guide explaining the risks of the drugs and the precautions to take. Talk to your doctor if you have any questions concerning these drugs or their potential side effects.
Patients should carefully read the information labels for all drugs and follow the directions. Some sleeping pills take 30 - 60 minutes to take effect, while others (such as zolpidem) are act quickly. For zolpidem, patients should:
- Take zolpidem immediately before going to sleep
- Take zolpidem only when able to get a full night’s sleep (7 – 8 hours)
- Not drink alcohol the same evening
- Not take more than the prescribed dose
- Use caution in the morning when getting out of bed, driving, or operating heavy machinery
Interactions. As with any hypnotics, alcohol increases the sedative effects of these drugs. These hypnotics also interact with other drugs, including rifampin, ketoconazole, erythromycin, and cimetidine. They may also interfere or be interfered by other drugs. Patients should report all medications to their doctors.
Dependency, Withdrawal Symptoms, and Rebound Insomnia. The risk for rebound insomnia, dependence, and tolerance is lower with non-benzodiazepine hypnotics than with benzodiazepine drugs. These drugs are still subject to abuse. In any case, no hypnotic should be taken for more than 7 - 10 days or at higher than the recommended dose without a doctor's approval.
Benzodiazepines, also referred to as benzodiazepine receptor agonists (BzRAs), were once the most commonly prescribed sedative hypnotics. Originally developed in the 1960s to treat anxiety, these drugs nonselectively target receptor sites in the brain that modulate the effects of the neurotransmitter gamma-aminobutyric acid (GABA).
The risk of tolerance and dependence is higher with this group of drugs. Likewise, the efficacy of these drugs to help manage insomnia declines over a 30-day period.
Brands. Commonly prescribed benzodiazepines:
- Long-acting benzodiazepines include flurazepam (Dalmane), clonazepam (Klonopin), and quazepam (Doral).
- Medium- to short-acting benzodiazepines include triazolam (Halcion), lorazepam (Ativan), alprazolam (Xanax), temazepam (Restoril), oxazepam (Serax), prazepam (Centrax), estazolam (ProSom), and flunitrazepam (Rohypnol). Short-acting benzodiazepines may be useful for air travelers who want to reduce the effects of jet lag.
Side Effects. Elderly people are more susceptible to side effects and should usually start at half the dose prescribed for younger people. They should not take long-acting forms.
Side effects may differ depending on whether the benzodiazepine is long or shorting acting. They include:
- Severe allergic reactions, including facial swelling, can occur even with the first use of a benzodiazepine drug.
- Respiratory problems may occur with overuse or in people with pre-existing respiratory illness
- The drugs may increase depression, a common co-condition in many people with insomnia.
- Respiratory depression may occur with overuse or with people with pre-existing respiratory illness.
- Long-acting drugs have a very high rate of residual daytime drowsiness compared to other types of sleeping pills. They have been associated with a significantly increased risk for automobile accidents and falls in the elderly, particularly in the first week after taking them. Shorter-acting benzodiazepines do not appear to pose as high a risk.
- Memory loss (so-called traveler's amnesia), sleepwalking, sleep driving, eating while asleep, and other odd mood states may occur. These effects are enhanced by alcohol.
- Urinary incontinence may occur, particularly in elderly patients and when taking long-acting formulations.
- Because these drugs cross the placenta and enter breast milk, pregnant women or nursing mothers should not use them. Benzodiazepine use in the first trimester of pregnancy may be associated with the development of cleft lip in newborns.
- In rare cases, overdoses have been fatal.
Interactions. Benzodiazepines are potentially dangerous when combined with alcohol. Some medications, like the ulcer medication cimetidine, can slow the metabolism of the benzodiazepine.
Withdrawal Symptoms. Withdrawal symptoms usually occur after prolonged use and indicate dependence. They can last 1 - 3 weeks after stopping the drug and may include:
- Gastrointestinal distress
- Sweating
- Disturbed heart rhythm
- In severe cases, patients might hallucinate or experience seizures, even a week or more after the drug has been stopped.
Rebound Insomnia. Rebound insomnia, which often occurs after withdrawal, typically includes 1 - 2 nights of sleep disturbance, daytime sleepiness, and anxiety. In some cases, patients may experience the return of the original severe insomnia. The chances for rebound are higher with the short-acting benzodiazepines than with the longer-acting ones.
Antidepressants are sometimes used to treat insomnia that may be caused by depression (secondary insomnia). In addition, some antidepressants with sedating properties are prescribed for the treatment of primary insomnia. For example, trazodone has been frequently prescribed in low doses as a hypnotic to help induce sleep. Other antidepressants used for insomnia include doxepin, trimipramine, amitriptyline, and mirtazipine. Care should be taken in the use of trazodone and other sedating antidepressants in elderly patients, due to the risk for side effects (daytime sleepiness, dizziness, and priapism) and drug interactions. In fact, all hypnotics can have serious side effects in the elderly, and all must be used with caution.
More than 1.5 million Americans use complementary and alternative therapies to treat insomnia. Many people choose herbal and dietary supplement remedies. (Valerian and melatonin are among the most popular alternative remedies for insomnia.) Some, such as chamomile tea or lemon balm, are generally harmless for most people. Others have more serious side effects and interactions.
Although about half of people who use herbal medicine report that these products help their sleep, experts are not sure whether these remedies really work or whether a placebo effect is the main reason for the improvement. The American Academy of Sleep Medicine (AASM) states that there is only limited scientific evidence to show that herbal and dietary supplements are effective sleep aids. The AASM recommends that these products should be taken only if approved by a doctor. Be sure to talk to your doctor if you are considering taking any herbal or dietary supplement. Some of these products can interact with prescription medications.
Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Patients should always check with their doctors before using any herbal remedies or dietary supplements.
There are several popular herbs and supplements used for insomnia.
Melatonin. Melatonin is the most studied natural remedy for insomnia. It appears to reduce the time to fall asleep (sleep onset) and the time spent asleep (sleep duration). However, there are no consistent standards on melatonin doses. Some research suggests that 0.3 mg may be the most effective dosage in many people with insomnia. However, higher doses may keep some people awake.
Although melatonin may not have many benefits for most people with chronic insomnia, studies suggest that it may help the following individuals:
- Elderly people. It may help certain older people with insomnia, such as those with evidence of low melatonin levels and those dependent on prescription sleeping medications. It is not clear, however, how significant the benefits are.
- Travelers suffering jet lag. Some studies have reported that melatonin may help prevent jet lag in some travelers.
- People with delayed sleep syndrome. It might be somewhat helpful for people who fall asleep very late at night or in early morning hours but then sleep normally.
Melatonin is a powerful hormone that can have major effects on all parts of the body. Doses of melatonin over 0.3 mg can disrupt the circadian system in the brain. Long-term consequences are unknown. High doses have been associated with the following adverse events:
- Mental impairment
- Severe headaches
- Nightmares
Interactions with other drugs are not completely known. Melatonin is classified as a dietary supplement and not as a drug, so its quality is not regulated in the U.S.
Valerian root. Valerian is an herb that has sedative qualities and is commonly used by people with insomnia. Some studies have indicated that it may help improve the quality of sleep, but there have been few rigorous and well-conducted trials to prove it is effective.
Chamomile. Many people drink chamomile tea for its sedative properties. Although it is generally safe, it may cause allergic reactions in people who have plant or pollen allergies.
Kava. Kava has been used to relieve anxiety and improve sleep. It is not considered safe. There have been reports of liver failure and death from this herb, with highest risk in those with liver disease. Kava can interact dangerously with certain medications, including alprazolam, an anti-anxiety drug. Kava also increases the strength of certain other drugs, including other sleep medications, alcohol, and antidepressants.
Chinese Herbal Remedies. Studies suggest that up to 30% of herbal patent remedies imported from China are laced with potent pharmaceuticals such as phenacetin, steroids, and toxic metals. They may also contain toxic metals. Some Chinese herbal remedies have contained benzodiazepines, the major ingredient in many prescription sleeping pills.
Tryptophan and 5-L-5-hydroxytryptophan (HTP). Tryptophan is an amino acid used in the formation of the neurotransmitter serotonin, which is known to promote well-being and has been associated with healthy sleep. L-tryptophan used to be marketed for insomnia and other disorders but was withdrawn after contaminated batches caused a rare and even fatal disorder called eosinophilia myalgia syndrome. 5-HTP, a byproduct of tryptophan, is still available as a supplement. There have been reports that some brands contain a substance called Peak X, which may be harmful. There is little evidence that 5-HTP relieves insomnia.
Resources
- www.aasmnet.org -- American Academy of Sleep Medicine
- www.nhlbi.nih.gov/about/ncsdr -- National Center for Sleep Disorders Research
- www.sleepfoundation.org -- National Sleep Foundation
- www.sleepeducation.com -- Sleep Education from the American Academy of Sleep Medicine
- www.clinicaltrials.gov -- Find clinical trials
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Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
