Definition of Insomia | Symptoms and Treatment

Insomnia: The perception or complaint of inadequate or poor-quality sleep because of one or more of the following: difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Insomnia is not defined by the number of hours of sleep a person gets or how long it takes to fall asleep. Individuals vary normally in their need for, and their satisfaction with, sleep. Insomnia may cause problems during the day, such as tiredness, a lack of energy, difficulty concentrating, and irritability.

Types of Insomnia: Insomnia can be classified as transient (short term), intermittent (on and off), and chronic (constant). Insomnia lasting from a single night to a few weeks is referred to as transient. If episodes of transient insomnia occur from time to time, the insomnia is said to be intermittent. Insomnia is considered to be chronic if it occurs on most nights and lasts a month or more.

Causes of Insomnia: Certain conditions seem to make individuals more likely to experience insomnia. Examples of these conditions include: advanced age (insomnia occurs more frequently in those over age 60); female gender; and a history of depression. If other conditions (such as stress, anxiety, a medical problem, or the use of certain medications) occur along with the above conditions, insomnia is more likely.

There are many causes of insomnia. Transient and intermittent insomnia generally occur in people who are temporarily experiencing one or more of the following: stress, environmental noise, extreme temperatures, a change in the surrounding environment, sleep/wake schedule problems such as those due to jet lag, or medication side effects.

Chronic insomnia is more complex and often results from a combination of factors, including underlying physical or mental disorders. One of the most common causes of chronic insomnia is depression. Other underlying causes include arthritis, kidney disease, heart failure, asthma, sleep apnea, narcolepsy, restless leg syndrome, Parkinson disease, and hyperthyroidism. However, chronic insomnia may also be due to behavioral factors, including the misuse of caffeine, alcohol, or other substances; disrupted sleep/wake cycles as may occur with shift work or other nighttime activity schedules; and chronic stress.

Certain Behaviors: Behaviors that perpetuate insomnia in some people include: expecting to have difficulty sleeping and worrying about it, ingesting excessive amounts of caffeine, drinking alcohol or smoking cigarettes before bedtime, excessive napping in the afternoon or evening, and irregular or continually disrupted sleep/wake schedules. These behaviors may prolong existing insomnia, and they can also be responsible for causing the sleeping problem in the first place. Stopping these behaviors may eliminate the insomnia altogether.

Who Has Insomnia? Insomnia is found in males and females of all age groups, although it seems to be more common in females (especially after menopause) and in the elderly. The ability to sleep, rather than the need for sleep, appears to decrease with advancing age.

Treatment with Medication
Alcohol. Commonly self-prescribed as a sleep aid, alcohol is of limited benefit. A very small amount of alcohol can be relaxing and produce sleepiness early in the evening, but later in the evening there may be a rebound effect of difficulty sleeping. In addition, chronic alcohol use can produce tolerance and dependence and cause many other medical problems.

Antihistamines. Usually sold as remedies for colds, over-the-counter antihistamines (e.g., diphenhydramine) can produce sedation and are often used as sleeping pills. These agents can be effective for short-term use, but they have not been shown to be consistently effective. Since they are long acting medications, grogginess can persist into the daytime.

Benzodiazepines. These drugs, relatives of diazepam (Valium), improve sleep by decreasing the amount of time needed to fall asleep and the number of awakenings during sleep. Their use has declined considerably with the introduction of non-benzodiazepine drugs (see below). The side effects of using these drugs are poor coordination, reduced reaction time, and impaired memory. These "hangover effects" occur when the blood level is at its peak and will vary depending on how long the drug remains in the body. These drugs may also worsen sleep apnea.

Non-benzodiazepines - These drugs have been introduced over the past 10-12 years and have become the primary treatment for short-term insomnia. They work in the same area of the brain as the BZDs, but tend to be more specific for inducing sleep. They also do not cause significant hangover effects and do not seem to worsen sleep apnea. Examples of this class of drugs are Ambien, Sonata, and Lunesta.

Ramelteon (Rozerem) - A newly approved medication that acts at the melatonin receptor to help induce sleep (see below).

Melatonin - This herbal agent seems to be effective in helping transient and short-term insomnia. However, as an herbal supplement which is not regulated by the Food and Drug Administartion, there is a great discrepancy in the quality of the products and no firm recommendations and can be given for its use.

Antidepressants - These agents are often prescribed as sleep aids in those with co-existing psychiatric problems. The most commonly used sedating antidepressant is trazodone.

Herbal medications such as valerian, chamomile, and kava-kava, are often used to help sleep, but long-term effectiveness and safety data are not available.