Chronic Insomnia, Causes, Diagnosis, Treatment

Chronic Insomnia
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Chronic Insomnia is the type lasts for months, and sometimes years. According to the National Institutes of Health, the majority of chronic insomnia cases are secondary, meaning they are side effects or symptoms resulting from another primary problem.

Insomnia is the most common sleep disorder affecting millions of people as either a primary or comorbid condition. Insomnia has been defined as both a symptom and a disorder, and this distinction may affect its conceptualization from both research and clinical perspectives. However, whether insomnia is viewed as a symptom or a disorder, it nevertheless has a profound effect on the individual and society. The burden of medical, psychiatric, interpersonal, and societal consequences that can be attributed to insomnia underscores the importance of understanding, diagnosing, and treating the disorder[Rx]

Types of Chronic Insomnia

Insomnia includes a wide range of sleeping disorders, from lack of sleep quality to lack of sleep quantity.

The International Classification of Sleep Disorders 2[] codes insomnia under the broad heading of dyssomnias, either intrinsic or extrinsic sleep disorders. Based on the severity, it classifies insomnia into three types as follows.

  • Mild insomnia – This term describes an almost nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by little or no evidence of impairment of social or occupational functioning. Mild insomnia is often associated with feelings of restlessness, irritability, mild anxiety, daytime fatigue, and tiredness.
  • Moderate insomnia – This term describes a nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by mild or moderate impairment of social or occupational functioning. Moderate insomnia is always associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness.
  • Severe insomnia –  This term describes a nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by severe impairment of social or occupational functioning. Severe insomnia is associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness.

According to Severity

  • Transient insomnia – occurs when symptoms last from a few days to a few weeks.
  • Acute insomnia – also called short-term insomnia. Symptoms persist for several weeks.
  • Chronic insomnia – this type lasts for months, and sometimes years. According to the National Institutes of Health, the majority of chronic insomnia cases are secondary, meaning they are side effects or symptoms resulting from another primary problem.

Although insomnia can affect people of any age, it is more common in adult females than adult males. The sleeping disorder can undermine school and work performance, as well as contributing to obesity, anxiety, depression, irritability, concentration problems, memory problems, poor immune system function, and reduced reaction time.

Insomnia has also been associated with a higher risk of developing chronic diseases.

According to the National Sleep Foundation, 30-40 percent of American adults report that they have had symptoms of insomnia within the last 12 months, and 10-15 percent of adults claim to have chronic insomnia.

Normal Sleep 

Before thinking about disturbed sleep, it’s important to understand what normal sleep really is. Normal slumber involves falling asleep relatively easily once you’re in bed, Silberman said. “People have a range of how quickly they go to sleep,” she said, but typically they can drift off to sleep anywhere from a few minutes to 15 minutes.

Normal sleepers will also go through four stages of sleep several times a night, she said. According to The Insomnia Workbook, the stages are:

  • Stage N1 –  the lightest stage, which usually makes up 10 percent of your total sleep time.
  • Stage N2 –  unlike stage N1, you lose awareness of external stimuli, and people spend most of their sleep time in this stage.
  • Stage N3 – known as slow-wave sleep, and believed to be the most restorative.
  • Stage R – known as REM sleep, or rapid eye movement. It’s the most active of the stages for your brain and body functions, such as breathing and heart rate. Your muscles relax, however, so you don’t act out your dreams.It’s also normal for it to take about 20 to 30 minutes to feel truly awake in the morning.

Causes of Chronic Insomnia

Symptoms of insomnia can be caused by or be associated with:

  • Use of psychoactive drugs (such as stimulants), including certain medications, herbs, caffeine, nicotine, cocaine, amphetamines, methylphenidate, aripiprazole, MDMA, modafinil, or excessive alcohol intake.
  • Use of or withdrawal from alcohol and other sedatives, such as anti-anxiety and sleep drugs like benzodiazepines.
  • Use of or withdrawal from pain-relievers such as opioids.
  • Previous thoracic surgery.
  • Heart disease.
  • Deviated nasal septum and nocturnal breathing disorders.
  • Restless legs syndrome, which can cause sleep onset insomnia due to the discomforting sensations felt and the need to move the legs or other body parts to relieve these sensations.
  • Periodic limb movement disorder (PLMD), which occurs during sleep and can cause arousals of which the sleeper is unaware.
  • Pain, an injury or condition that causes pain can preclude an individual from finding a comfortable position in which to fall asleep and can in addition cause awakening.
  • Hormone shifts such as those that precede menstruation and those during menopause.
  • Life events such as fear, stress, anxiety, emotional or mental tension, work problems, financial stress, the birth of a child, and bereavement.
  • Gastrointestinal issues such as heartburn or constipation.
  • Mental disorders such as bipolar disorder, clinical depression, generalized anxiety disorder, post traumatic stress disorder, schizophrenia, obsessive compulsive disorder, dementia, and ADHD.
  • Disturbances of the circadian rhythm, such as shift work and jet lag, can cause an inability to sleep at some times of the day and excessive sleepiness at other times of the day. Chronic circadian rhythm disorders are characterized by similar symptoms.
  • Certain neurological disorders, brain lesions, or a history of traumatic brain injury.
  • Medical conditions such as hyperthyroidism and rheumatoid arthritis.
  • Abuse of over-the-counter or prescription sleep aids (sedative or depressant drugs) can produce rebound insomnia.
  • Poor sleep hygiene, e.g., noise or over-consumption of caffeine.
  • A rare genetic condition can cause a prison-based, permanent and eventually fatal form of insomnia called fatal familial insomnia.
  • Physical exercise. Exercise-induced insomnia is common in athletes in the form of prolonged sleep onset latency.

Sleep studies using polysomnography have suggested that people who have sleep disruption have elevated nighttime levels of circulating cortisol and adrenocorticotropic hormone. They also have an elevated metabolic rate, which does not occur in people who do not have insomnia but whose sleep is intentionally disrupted during a sleep study. Studies of brain me

  • Disruptions in circadian rhythm – jet lag, job shift changes, high altitudes, environmental noise, heat, or cold.
  • Psychological issues – people with mood disorders such as bipolar disorder, depression, anxiety disorders, or psychotic disorders are more likely to have insomnia.
  • Medical conditions – brain lesions and tumors, stroke, chronic pain, chronic fatigue syndrome, congestive heart failure, angina, acid-reflux disease (GERD), chronic obstructive pulmonary disease, asthma, sleep apnea, Parkinson’s and Alzheimer’s diseases, hyperthyroidism, arthritis.
  • Hormones – estrogen, hormone shifts during menstruation.
  • Other factors – sleeping next to a snoring partner, parasites, genetic conditions, overactive mind, pregnancy.
  • Media technology in the bedroom – researchers from the University of Helsinki, Finland, reported in the journal BMC Public Health that media technology in the bedroom disrupts sleep patterns in children. They found that children with TVs, computers, video games, DVD players, and mobile phones in their bedrooms slept considerably less than kids without these devices in their bedrooms. In addition, a study conducted by Rensselaer Polytechnic Institute found that back-lit tablet computers can affect sleep patterns.

Medications – according to the American Association of Retired Persons (AARP), the following medications can cause insomnia in some patients

  • Corticosteroids – used for treating patients with allergic reactions, gout, Sjögren’s syndrome, lupus, rheumatoid arthritis, and inflammation of the muscles and blood vessels. Examples include prednisone, triamcinolone, methylprednisolone, and cortisone.
  • Statins – medications used for treating high cholesterol levels. Examples include simvastatin, rosuvastatin, lovastatin, and atorvastatin.
  • Alpha blockers – used for treating hypertension (high blood pressure), Raynaud’s disease and BPH (benign prostatic hyperplasia). Examples include terazosin, silodosin, alfuzosin, prazosin, doxazosin, and tamsulosin.
  • Beta blockers – used for treating hypertension and irregular heartbeat (arrhythmias). Examples include carvedilol, propranolol, atenolol, metoprolol, and sotalol.
  • SSRI antidepressants – used for treating depression. Examples include fluoxetine, citalopram, paroxetine, escitalopram, and sertraline.
  • ACE inhibitors – used for the treatment of hypertension and other heart conditions. Examples include ramipril, fosinopril, benazepril, enalapril, lisinopril, and captopril.
  • ARBs (Angiotensin II-receptor blockers) – used for treatment of hypertension (generally when patient cannot tolerate ACE inhibitors). Examples include candesartan, valsartan, and losartan.
  • Cholinesterase inhibitors – used for treating memory loss and other symptoms in patients with dementia, including Alzheimer’s disease. Examples include rivastigmine, donepezil, and galantamine.
  • Second generation (non-sedating) H1 agonists – used for treating allergic reactions. Examples include loratadine, levocetirizine, desloratadine, and cetirizine.
  • Glucosamine/chondroitin – dietary supplements used for relieving the symptoms of joint pain and to reduce inflammation.

Who gets insomnia?

Insomnia

 

Shift workers commonly suffer from insomnia because of inconsistent sleep routines.

Some people are more likely to suffer from insomnia than others; these include:

  • Travelers
  • Shift workers with frequent changes in shifts (day vs. night)
  • The elderly
  • Drug users
  • Adolescent or young adult students
  • Pregnant women
  • Menopausal women
  • Those with mental health disorders

Symptoms of Chronic Insomnia

Insomnia itself may be a symptom of an underlying medical condition. However, there are several signs and symptoms that are associated with insomnia:

  • Difficulty falling asleep at night
  • Waking during the night
  • Waking earlier than desired
  • Still feeling tired after a night’s sleep
  • Daytime fatigue or sleepiness
  • Irritability, depression, or anxiety
  • Poor concentration and focus
  • Being uncoordinated, an increase in errors or accidents
  • Tension headaches (feels like a tight band around head)
  • Difficulty socializing
  • Gastrointestinal symptoms
  • Worrying about sleeping

Sleep deprivation can cause other symptoms. The afflicted person may wake up not feeling fully awake and refreshed and may have a sensation of tiredness and sleepiness throughout the day. Having problems concentrating and focusing on tasks is common for people with insomnia.

According to the National Heart, Lung, and Blood Institute, 20 percent of non-alcohol related car crash injuries are caused by driver sleepiness.

General Criteria for Insomnia

  • A complaint of difficulty initiating sleep, difficulty maintaining sleep, or waking up too early or sleep that is chronically nonrestorative or poor in quality. In children, the sleep difficulty is often reported by the caretaker and may consist of observed bedtime resistance or inability to sleep independently.
  • The above sleep difficulty often occurs despite adequate opportunity and circumstances for sleep.

At least one of the following forms of daytime impairment related to the nighttime sleep difficulty is reported by the patient:

  • Fatigue or malaise
  • Attention, concentration, or memory impairment
  • Social or vocational dysfunction or poor school performance
  • Mood disturbance or irritability
  • Daytime sleepiness
  • Motivation, energy, or initiative reduction
  • Proneness for errors or accidents at work or while driving
  • Tension, headaches, or gastrointestinal symptoms in response to sleep loss
  • Concerns or worries about sleep
Adapted from the International Classification of Sleep Disorders, Second Edition ().

Diagnosis of Chronic Insomnia

Insomnia Differential Diagnosis and Common Comorbidities

(References: Buysse(); Sateia et al. ())
Medical Conditions:
  Cardiovascular congestive heart failure, arrythmia, coronary artery disease
  Pulmonary COPD, asthma
  Neurologic stroke, Parkinson’s disease, neuropathy traumatic brain injury
  Gastrointestinal gastroesophageal reflux
  Renal chronic renal failure
  Endocrine diabetes, hyperthyroidism
  Rheumatologic rheumatoid arthritis, osteoarthritis, fibromyalgia, headaches
Sleep Disorders:
  Restless legs syndrome
  Periodic limb movement disorder
  Sleep apnea
  Circadian rhythm disorder
  Parasomnias
  Nocturnal panic attacks
  Nightmares
  REM behavior disorder
Psychiatric Conditions:
  Depression
  Anxiety
  Panic disorder
  Post-traumatic stress disorder
Medications:
  Decongestants
  Antidepressants
  Corticosteroids
  Beta-agonists
  Beta-antagonists
  Stimulants
  Statins
Substances:
  Caffeine
  Alcohol
  Nicotine
  Cocaine

Diagnosis of primary insomnia

DSM IV TR criteria of primary insomnia
These include any of the following:
  • The predominant complaint is difficulty initiating or maintaining sleep, or non-restorative sleep, for at least 1 month.
  • The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
  • The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, a circadian rhythm sleep disorder or a parasomnia.
  • The disturbance does not occur exclusively during the course of another mental disorder (e.g., major depressive disorder, generalized anxiety disorder, a delirium).
  • The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

A sleep specialist will usually begin a diagnostic session by asking a battery of questions about the individual’s medical history and sleep patterns. A physical exam may be conducted to look for conditions that could be causing insomnia. Similarly, doctors might screen for psychiatric disorders and drug and alcohol use.

The Stanford Center for Sleep Sciences and Medicine explains that the term “insomnia” is often used colloquially in reference to “disturbed sleep.”

  • For somebody to be diagnosed with an insomnia disorder, their disturbed sleep should have persisted for more than 1 month. It should also negatively impact the patient’s wellbeing, either through the distress that results or the disturbance in mood or performance.
  • A sleep specialist is trained to determine whether the symptoms are being caused by an underlying condition. The patient may be asked to keep a sleep diary to help understand their sleeping patterns.
  • More sophisticated tests may be employed, such as a polysomnograph, which is an overnight sleeping test that records sleep patterns. In addition, actigraphy may be conducted, which uses a small, wrist-worn device called an actigraph to measure movement and sleep-wake patterns.

DSM-5 criteria

The DSM-5 criteria for insomnia include the following

Predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:

  • Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
  • Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
  • Early-morning awakening with inability to return to sleep.

In addition,

  • The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
  • The sleep difficulty occurs at least 3 nights per week.
  • The sleep difficulty is present for at least 3 months.
  • The sleep difficulty occurs despite adequate opportunity for sleep.
  • The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
  • The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
  • Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

Use of prescription drugs

  • Various prescription drugs may be responsible for chronic insomnia. Such a use should be asked for specifically and ruled out. The drugs may include anticonvulsants such as phenytoin and lamotrigine, beta-blockers like acebutolol, atenolol, metoprolol, oxprenolol, propranolol, and sotalol, antipsychotics like sulpiride, antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRIs) or Monoamine oxidase inhibitors (MAOIs) and non-steroidal anti-inflammatory drugs (NSAIDs) such as indomethacin, diclofenac, naproxen, and sulindac.

Sleep diary or sleep log

  • A sleep diary helps in specifically estimating the severity of the problem, the night to night variability, and presence of maladaptive habits such as taking naps or spending excessive time in bed (more than 8 hours). Sleep diary also keeps track of compliance with behavioral interventions and response to treatment.

Sleep and psychological rating scale

  • Epworth Sleepiness Scale (ESS) rates the chance of dozing in the following situations[] which may be during sitting and reading, watching television, sitting inactively in a public place, being a passenger in a car for an hour without a break, during lying down to rest in the afternoon, sitting and talking to someone, sitting quietly after lunch without alcohol or while waiting at a traffic signal in a car.

The ESS is rated on a 4-point scale for each of the above factors based on the following scores:

  • 0 – no chances of dozing;
  • 1 – slight chances of dozing;
  • 2 – moderate chances of dozing; and
  • 3 – high chances of dozing.

A score of more than 16 indicates daytime somnolence, while a cutoff of 11 is often employed to indicate a possible disorder associated with excessive sleepiness.

Focused physical examination

  • A general physical examination may help assess certain organic pathologies such as chronic obstructive pulmonary diseases (COPD), asthma, or restless leg syndrome which may disturb sleep.

Blood tests

  • Blood tests may help to rule out subtle manifestations of thyroid diseases, iron deficiency anemia, and vitamin B12 deficiency (restless leg syndrome).

Polysomnography

  • It is considered the gold standard for measuring sleep. electroencephalogram (EEG), electrooculography (EOG), electromyography (EMG), electrocardiography (ECG), pulse oximetry, and air flow are used to reveal a variety of findings like periodic limb movement disorder, sleep apnea, and narcolepsy.[]

Actigraphy

  • Actigraphy measures physical activity with a portable device (usually including an accelerometer) worn on the wrist. Data recorded can be stored for weeks and then downloaded into a computer. Sleep and wake time can be analyzed by analyzing the movement data. This approach to estimating sleep and wake time has been shown to correlate with polysomnographic measures in normal sleepers, with reduced values noted in patients with insomnia.[,]

Summary of investigations

  • Investigations do not always correlate well with the patient’s experience of insomnia and cannot replace a thorough clinical evaluation. Hence, it is important to recognize that insomnia is a subjective clinical diagnosis, and therefore, a patient’s subjective report of sleep difficulties should play the most important role in directing management in most cases.
  • It is also important to ask questions about the range of symptoms experienced and changes over time. Because insomnia is a patient-reported symptom, rather than a polysomnographically defined disorder, referral to a sleep laboratory for polysomnographic diagnosis should be reserved for cases in which another primary sleep disorder, such as obstructive sleep apnea or periodic movement disorder, is suspected, because these may require greater expertise in sleep medicine.[] Other measures that can be used are evaluation of mental status, subjective sleep quality, psychological assessment scales, daytime function, quality of life, and dysfunctional beliefs and attitudes.

Treatment of Chronic Insomnia

Studies have suggested that electronic devices with self-luminous “backlit” displays can affect evening melatonin, which might result in delayed sleep.

Some types of insomnia resolve when the underlying cause is treated or wears off. In general, insomnia treatment focuses on determining the cause.

Once identified, this underlying cause can be properly treated or corrected. In addition to treating the underlying cause of insomnia, both medical and non-pharmacological (behavioral) treatments may be used as therapies.

Non-pharmacological approaches and home remedies for insomnia include:

  • Improving “sleep hygiene” – not sleeping too much or too little, exercising daily, not forcing sleep, maintaining a regular sleep schedule, avoiding caffeine at night, avoiding smoking, avoiding going to bed hungry, and ensuring a comfortable sleeping environment
  • Using relaxation techniques – such as meditation and muscle relaxation
  • Cognitive therapy – one-on-one counseling or group therapy
  • Stimulus control therapy – only go to bed when sleepy, avoid watching TV/ reading/ eating/ worrying in bed, set an alarm for the same time every morning (even weekends), avoid long daytime naps
  • Sleep restriction – decrease the time spent in bed and partially deprive the body of sleep, this increases tiredness ready for the next night.
  • Relaxation training – aims to reduce tension or minimise intrusive thoughts that may be interfering with sleep
  • Paradoxical intention – you try to stay awake and avoid any intention of falling asleep; it’s used if you have trouble getting to sleep, but not maintaining sleep
  • Biofeedback – sensors connected to a machine are placed on your body to measure your body’s functions, such as muscle tension and heart rate; the machine produces pictures or sounds to help you recognise when you’re not relaxed

Sleeping tablets

Sleeping tablets (hypnotics) are medications that encourage sleep. In the past, they were frequently used to help with insomnia, but they’re used much less often nowadays.

They will generally only be considered:

  • if your insomnia is severe
  • as a temporary measure to help ease short-term insomnia
  • if the good sleep habits and cognitive and behavioural treatments mentioned above don’t help

Doctors are usually reluctant to recommend sleeping tablets in the long-term because they just mask the symptoms without treating the underlying cause.They can also cause potentially dangerous side effects, such as drowsiness the following morning, and some people become dependent on them.

If they are recommended, you should have the smallest effective dose possible for the shortest time (usually no more than two to four weeks).

Over-the-counter sleeping pills

  • A number of sleeping tablets are available to buy over the counter (OTC) from pharmacies. These are usually a type of antihistamine medicine that causes you to feel drowsy.
  • Taking OTC sleeping tablets regularly isn’t usually recommended if you have insomnia, because it’s not clear how effective they are, they don’t tackle the underlying cause of your sleeping difficulties and they can cause side effects.
  • In particular, they can cause you to feel drowsy the next morning, which can make activities such as driving and operating machinery dangerous.
  • Speak to your GP for advice if you find yourself needing to take OTC sleeping tablets regularly.

Benzodiazepines

  • Benzodiazepines are prescription medicines that can reduce anxiety and promote calmness, relaxation and sleep. Your GP may prescribe them for a short time if you have severe insomnia or it’s causing extreme distress.

Examples of benzodiazepines include temazepam, loprazolam, lormetazepam, diazepam and nitrazepam.

Long-term treatment with benzodiazepines isn’t usually recommended because they can become less effective over time and some people become dependent upon them.

They can also cause a number of side effects, including:

  • drowsiness and dizziness, which can persist into the next day
  • finding it difficult to concentrate or make decisions
  • depression
  • feeling emotionally numb
  • irritability

You should avoid driving if you feel drowsy, dizzy, or unable to concentrate or make decisions, as you may not be able to do so safely.

  • Z-drugs

Z–drugs are a newer type of medicine that work in a similar way to benzodiazepines and are similarly effective. They include zaleplon, zolpidem and zopiclone.

As with benzodiazepines, long-term treatment with Z–drugs isn’t normally recommended because they can become less effective over time and some people become dependent on them.

They’re usually only prescribed for a maximum of two to four weeks.

Side effects of Z-drugs can include:

  • drowsiness and dizziness, which can persist into the next day
  • feeling and being sick
  • diarrhoea
  • increased snoring and breathing problems during sleep
  • dry mouth
  • confusion

Z–drugs can also sometimes cause psychiatric reactions, such as delusions, nightmares and hallucinations. Contact your GP if you experience any of these effects.

Benzodiazepine Receptor Agonist (BzRA) Drugs

Class/Drug TMax (hours) Elimination Half
Life (hours)
Usual Hypnotic
Dose (mg)
Approved
for
Insomnia
Comments
Benzodiazepine
Triazolam 1 – 2 2 – 6 0.125 – 0.25 Yes Early reports of adverse effects
were likely dose-related
Temazepam 1 – 2 8 – 22 15 – 30 Yes Metabolized mainly by
conjugation (no CYP-related
drug interactions)
Estazolam 1.5 – 2 10 – 24 1 – 2 Yes Triazolo ring structure similar to
triazolam
Quazepam 2 – 3 48 – 120 7.5 – 15 Yes Active metabolite (Ndesalkylflurazepam)
accumulates
with repeated dosing
Flurazepam 1.5 – 4.5 48 – 120 15 – 30 Yes Active metabolite (Ndesalkylflurazepam)
accumulates
with repeated dosing
Alprazolam 0.6 – 1.4 6 – 20 No Often noted for significant
withdrawal
Lorazepam 0.7 – 1 10 – 20 1 – 4 No Metabolized by conjugation (no
CYP-related drug interactions)
Clonazepam 1 – 2.5 20 – 40 0.5 – 3 No Often used for other sleep
disorders including RLS,
parasomnias
Non-Benzodiazepine
Zaleplon 1 (0.5 – 2) 1 (0.8 – 1.3) 5 – 20 Yes Shortest-acting BzRA
Eszopiclone 1.5 (0.5 – 2) 6 (5 – 8) 1 – 3 Yes ~30% may have unpleasant taste
or side-effects
Zolpidem – Oral
tablet
1.6 (0.5 – 1.5) 2.5 (1.4 – 4.5) 5 – 10 Yes Most widely-prescribed hypnotic
Zolpidem: Extended
Release (Ambien
CR
1.5 (1.5 – 2.0) 2.8 (1.6 – 4.5) 6.25 – 12.5 Yes Higher concentrations 3-8 hours
post dose than traditional
zolpidem
Zolpidem: Sublingual
(Intermezzo)
0.6 (0.6 – 1.3) 2.5 (1.4 – 3.6) 1.75 – 3.5 Yes Buffer permits increased buccal
absorption, lower dose
Zolpidem: Sublingual
(Edluar)
1.4 (0.5 – 3.0) 2.7 ( 1.5 – 6.7) 10 Yes Mainly absorbed via GI tract
Zolpidem: Oral Spray
(Zolpimist)
0.9 2.8 (1.7 – 8.4) 10 Yes Bioequivalent to tablets in terms
of Cmax, Tmax, t1/2

Antihistamines

  • As an alternative to taking prescription drugs, some evidence shows that an average person seeking short-term help may find relief by taking over-the-counter antihistamines such as diphenhydramine or doxylamine.
  • Diphenhydramine and doxylamine are widely used in nonprescription sleep aids. They are the most effective over-the-counter sedatives currently available, at least in much of Europe, Canada, Australia, and the United States, and are more sedating than some prescription hypnotics.
  • Antihistamine effectiveness for sleep may decrease over time, and anticholinergic side-effects (such as dry mouth) may also be a drawback with these particular drugs. While addiction does not seem to be an issue with this class of drugs, they can induce dependence and rebound effects upon abrupt cessation of use. However, people whose insomnia is caused by restless legs syndrome may have worsened symptoms with antihistamines.

Melatonin

  • The evidence for melatonin in treating insomnia is generally poor. There is low quality evidence that it may speed the onset of sleep by 6 minutes. Ramelteon, a melatonin receptor agonist, does not appear to speed the onset of sleep or the amount of sleep a person gets.
  • Most melatonin drugs have not been tested for longitudinal side effects. Prolonged-release melatonin may improve quality of sleep in older people with minimal side effects.
  • Studies have also shown that children who are on the Autism spectrum or have learning disabilities, Attention-Deficit Hyperactivity Disorder (ADHD) or related neurological diseases can benefit from the use of melatonin. This is because they often have trouble sleeping due to their disorders.
  • For example, children with ADHD tend to have trouble falling asleep because of their hyperactivity and, as a result, tend to be tired during most of the day. Another cause of insomnia in children with ADHD is the use of stimulants used to treat their disorder.
  • Children who have ADHD then, as well as the other disorders mentioned, may be given melatonin before bedtime in order to help them sleep.

Antidepressants

  • While insomnia –  is a common symptom of depression, antidepressants are effective in treating sleep problems whether or not they are associated with depression. While all antidepressants help regulate sleep, some antidepressants such as amitriptyline, doxepin, mirtazapine, and trazodone can have an immediate sedative effect and are prescribed to treat insomnia.
  • Amitriptyline –  and doxepin both have anti histaminergic, anticholinergic, and antiadrenergic properties, which contribute to both their therapeutic effects and side effect profiles, while mirtazapine’s side effects are primarily anti histaminergic, and trazodone’s side-effects are primarily antiadrenergic.
  • Mirtazapine – is known to decrease sleep latency (i.e., the time it takes to fall asleep), promoting sleep efficiency and increasing the total amount of sleeping time in people with both depression and insomnia.

Cognitive-Behavioral Interventions for Insomnia

Intervention General description Specific techniques
Sleep hygiene
education
Recommendations
promoting behaviors that
help sleep, discouraging
behaviors that interfere with
sleep
  • Don’t try to sleep
  • Avoid stimulants (caffeine, nicotine)
  • Limit alcohol intake
  • Maintain a regular sleep schedule 7 nights a week
  • Avoid naps
  • Get regular exercise, at least 6 hours before sleep
  • Keep the bedroom dark and quiet
Stimulus control Based on operant and
classical conditioning
principles: Non-sleep
activities and the bedroom
environment can serve as
stimuli that interfere with
sleep. Treatment prescribes
behaviors that strengthen
associations between the
environment and sleep.
  • Go to bed only when sleepy.
  • Use the bed and bedroom for sleep only. Do not read, watch television, talk on the phone, worry, or plan activities in the bedroom.
  • If unable to fall asleep within 10-20 minutes, leave the bed and the bedroom. Return only when felling sleepy again.
  • Set the alarm and wake up at a regular time every day.
  • Do not snooze. Do not nap during the day.
Sleep restriction
therapy
Based on experimental
evidence that sleep is
regulated by circadian and
homeostatic processes.
Treatment increases
homeostatic sleep drive by
reducing time in bed, and
maintaining a consistent
wake time in the morning to
reinforce circadian rhythms.
  • Restrict time awake in bed using by setting strict bedtime and rising schedules limited to the average number of hours of actual sleep reported in one night.
  • Increase time in bed by advancing bedtime by 15-30 minutes when the time spent asleep is >85% of time in bed.
  • Keep a fixed wake-up time, regardless of actual sleep duration.
  • If after 10 days, sleep efficiency is lower that 85%, further restrict bedtime by 15-30 minutes.
Relaxation training Muscular tension and
cognitive arousal are
incompatible with sleep.
Relaxation decreases waking
arousal, and facilitates sleep
at night.
Specific techniques may include:

  • Progressive muscle relaxation
  • Guided imagery
  • Paced breathing
Cognitive therapy Identify, challenge, and
replace dysfunctional beliefs
and attitudes regarding sleep
and sleep loss. These beliefs
increase arousal and tension,
which impede sleep and
further reinforce the
dysfunctional beliefs.
  • Challenge unhelpful beliefs and fears about sleep, e.g.:

    • ○ Overestimation of numbers of hours of sleep necessary to be rested.
    • ○ Apprehensive expectation that sleep cannot be controlled.
    • ○ Fear of missing opportunities for sleep.
  • Thought journaling to reduce rumination
  • Design behavioral ―experiments‖ to test beliefs about sleep
Cognitive
Behavioral
Treatment of
Insomnia (CBT-I)
Multi-modal treatment
combining elements of above
techniques
  • Sleep education
  • Stimulus control techniques
  • Sleep restriction techniques
  • Cognitive therapy techniques
  • May include relaxation training
Brief Behavioral
Treatment of
Insomnia
Core techniques from
Stimulus Control, Sleep
Restriction therapies
  • Limit time in bed to actual sleep time + 30 minutes
  • Establish regular wake time every day, regardless of prior night’s sleep duration
  • Do not go to bed until sleepy
  • Do not stay in bed if awake

Good Sleep Habits for Beating Chronic Insomnia

Good sleep habits, also called sleep hygiene, can help you get a good night’s sleep and beat insomnia. Here are some tips:

  • Try to go to sleep at the same time each night and get up at the same time each morning. Try not to take naps during the day, because naps may make you less sleepy at night.
  • Avoid prolonged use of phones or reading devices (“e-books”) that give off light before bed. This can make it harder to fall asleep.
  • Avoid caffeine, nicotine, and alcohol late in the day. Caffeine and nicotine are stimulants and can keep you from falling asleep. Alcohol can cause waking in the night and interferes with sleep quality.
  • Get regular exercise. Try not to exercise close to bedtime, because it may stimulate you and make it hard to fall asleep. Experts suggest not exercising for at least three to four hours before the time you go to sleep.
  • Don’t eat a heavy meal late in the day. A light snack before bedtime, however, may help you sleep.
  • Make your bedroom comfortable. Be sure that it is dark, quiet, and not too warm or too cold. If light is a problem, try a sleeping mask. If noise is a problem, try earplugs, a fan, or a “white noise” machine to cover up the sounds.
  • Follow a routine to help you relax before sleep. Read a book, listen to music, or take a bath.
  • Avoid using your bed for anything other than sleep or sex.
  • If you can’t fall asleep and don’t feel drowsy, get up and read or do something that is not overly stimulating until you feel sleepy.
  • If you find yourself lying awake worrying about things, try making a to-do list before you go to bed. This may help you to not focus on those worries overnight.

Home Remedies to Overcome Chronic Insomnia

Severe Insomnia

Milk

A glass of lukewarm milk before bedtime gives soporific effect on your body that helps you doze off easily. Additionally, it contains amino acid- tryptophan, which stimulates serotonin production that ultimately provides you with a better sleep.

  • You can mix honey in the milk.
  • Alternatively, along with honey, mix a dash of cinnamon powder in it.
  • Massaging your toes with milk can induce sleep.

Bottle Gourd  

  • Bottle gourd is one of the excellent remedies to induce sleep. Take out the bottle gourd juice and add sesame oil in same proportion. Massage with this on your scalp, before going to bed. Alternatively, include bottle gourd in your diet.

Poppy Seeds

  • Poppy seeds are a good source of minerals, calcium, carbohydrates and B-complex vitamins. Taking 1 teaspoon of poppy seed/oil before going to bed can actually solve the problem of insomnia.
  • Alternatively, get 1 teaspoon each of white poppy seeds and coconut powder and adds a small amount of water, in order to make a thick paste. Now, take a frying pan and melt some clarified butter in it. Then, add a pinch of cumin and turmeric and remove immediately from heat. After a minute, mix that paste in it and add salt to taste. Chomp this mixture one hour before you sack out.
  • Or else, consume 30 grams of poppy seeds’ milk flavored with a little sugar.

Nutmeg

  • Nutmeg effectually heals insomnia. It is loaded with myristicin which works as a tranquilizer and helps you get natural sleep. You can mix a pinch of nutmeg powder with one teaspoon of fresh Indian gooseberry juice. Consume it 3 times a day. Apart from insomnia, it also resolves the problem of indigestion and depression.
  • Alternatively, blend ½ teaspoon of powdered nutmeg with a pinch of cinnamon powder, 1 teaspoon each of raw honey and water to form a paste. Now, boil a cup of milk and pour all the mixture in it. Stir well and sip it before you hit the hay.
  • Take a one-eighth teaspoon of nutmeg powder and mix it with one cup of lukewarm milk.
  • Take a quarter teaspoon of nutmeg powder. Add it in a cup of warm water or any of your favorite juice.

Note:

  • Don’t consume it more than a pinch, at one time.
  • Over doses of nutmeg may cause hallucination and some other psychiatric turmoil.

Green Tea

  • Green tea is full of theanine and amino acid that helps combat anxiety and de-stress a person. Drink a cup of green tea 1-2 hours before bedtime.

Bananas

  • Banana contains melatonin, tryptophan, magnesium and serotonin, which work as body relaxants. The high amount of carbohydrate in bananas will make you sleepy. Simply eat a banana before going to bed.
  • A blend of mashed banana and roasted cumin seeds can be consumed after dinner.
  • Alternatively, you can also have a banana smoothie one hour before your bedtime.
  • You can also try banana with some toast and peanut butter.

Aniseed

  • Take one teaspoon of aniseeds and add it to 375ml of boiling water. Simmer this concoction for 15 minutes.  Filter this solution and add honey and milk to it. Sip this tea every day before bedtime.

Oatmeal

  • Oats are rich in melatonin which makes it a sleep inducing meal. Simply eat oatmeal regularly to get rid of this problem. You can also sprinkle two tablespoons of flaxseeds in your oatmeal. Chomp it at night.

Curd

  • Curd enables the body to absorb essential minerals and nutrients and improves the digestive system as well. A person suffering from insomnia should consume 3 cups of curd daily, in order to get a sound sleep. Besides eating curd, its massage on head is also beneficial.

Cumin Tea

  • Heat 1 teaspoon of cumin seeds for about 5 seconds. Then, add 1 cup of water in it and simmer it to the boiling point. Remove it from heat and cover it with a lid. Strain the solution after 5 minutes. Drink this tea before you hit the sack.

Saffron

  • Saffron contains mild sedative properties that help treat the problem of insomnia. Take 3-4 strands of saffron and soak them in a cup of warm milk. Sip this warm drink every day before you sack out.

Apple Cider Vinegar and Honey

  • Apple cider vinegar is loaded with amino acids that relieve body from fatigue, thereby help you get natural sleep. On the other side, honey raises the insulin levels that release serotonin, thus, promotes sleep. Take a glass of warm water and mix two tsp each of honey and organic apple cider vinegar to it. Drink it before you hit the hay.
  • Otherwise, blend 2 tsp of apple cider vinegar in a cup of honey. Take one tbsp of this mixture with or without water.

Hot Bath

  • Have a hot shower about two hours before going to sleep. It will soothe the nerves and relax your body. You can also add a few drops of essential oils like chamomile, lemon balm, lavender or rosemary to the bathwater, as it soothes your body in an effective way.

Acupuncture

  • Acupuncture is somewhat similar to acupressure. It heals the problem by putting a thin needle in your skin, at some specific points. It works wonders for insomnia.

Note- Get this therapy done from an experienced practitioner.

Almonds

  • Almonds relax your muscles, as it contains magnesium as well as tryptophan. Simply eat a handful of almonds throughout the day, in order to treat the problem of insomnia.

Honey

  • Honey works tremendously great for treating insomnia. Due to its hypnotic and sedative effects, it induces sound sleep. It also promotes relaxation. Simply mix 2 tbsp of honey in a cup of water. Stir well and drink it before you sack out.
  • Alternatively, intake a spoon full of honey before you hit the hayThis is one of the best remedies, for children suffering from insomnia.

Sesame Oil

  • Sesame seeds are affluent in polyunsaturated fat that helps relieve the nervous and muscular tension and gives sound sleep. Regular consumption of sesame oil improves blood circulation, prevents digestive disorders and reduces anxiety. Massage your feet with this oil daily before you hit the sack.

Celery

  • Celery is rich in phthalides that decreases the secretion of stress-inducing hormones and, ultimately, relax the muscular and nervous systems. This feature of celery makes it an excellent home cure for insomnia. Crush celery leaves along with their stalk, in order to extract their juice. Mix a tablespoon of honey with it. One should consume it at night before catching some zzz’s.

Note- Honey and celery should be taken in equal proportion.

Herbal Remedies to Cure Chronic Insomnia

  • Indian Sorrel – Juice of Indian sorrel leaves is very useful in healing insomnia. Extract some juice of these leaves and mix it with castor oil, in equal amount. Now, boil down the water content. Store it in a bottle when it cools down. Massage the scalp with this oil before bedtime. It gives cool sensation near the eyes which induces sound sleep.
  • Lavender Oil – This oil works as a tranquilizer and helps you get a good sleep. Take a few drops of this herbal oil and apply it on the forehead and temple. The fragrance of this oil induces sleep. So, use it before catching some zzz’s.
  • Jasmine Essential Oil – Take a few drops of this oil and apply it on your wrist. Perform this before you hit the sack and you will certainly have a better sleep.
  • Rauwolfia – Rauwolfia is loaded with sedative properties, which cures insomnia. Take around 0.25 to 0.5 grams of its root powder and mix it with cardamom. A patient of chronic insomnia can take it two times a day- in the morning and at night.
  • Basil – A person suffering from sleep disorder should be given a leaf of basil for chomping. Alternatively, spread some basil leaves beneath the patient’s pillow and around the corners of the bed throw.  The aroma of the leaves will strike the person’s nostril which will make him/her feel sleepy.
  • Fenugreek Juice – Fenugreek juice acts as a tranquilizer that induces sleep and effectively prevents insomnia. Extract 2 tsp of fresh fenugreek juice from its leaves. Add one tsp of honey to it. Take it on a daily basis before catching some zzz’s.
  • Valerian – Valerian is a very popular herb that is commonly used to treat sleep disorders. It gives sedative effect and relaxes body muscles. Combine ½ teaspoon of grated valerian root and nutmeg. Add this mixture in 2 cups of hot water. After 15 minutes, strain the solution and drink it.
  • Alternatively, boil a cup of water and remove it from heat. Add one tsp of valerian herb to it. Stir well. After a few minutes, strain this decoction and then, drink.
  • Or else, use valerian tincture. Dilute half tsp of its tincture in a glass of water. Drink it two times a day.

Note- This herb should not be consumed by children and pregnant or breastfeeding women.

  • Chamomile Tea – Chamomile tea is a good herbal remedy to get a sound sleep. It contains apigenin that gives sedative effect to the body. Brew 1 tsp of chamomile herb in one cup of water for a few minutes. Stir well and filter this solution. You can add a dash of cinnamon and a little bit of honey to it.
  • Lemon Balm – Mix 2-3 teaspoons of lemon balm to a cup of boiling water. Steep it for a few minutes. For effective results, drink this herbal tea before bedtime.
  • Lettuce – Lettuce contains a sleep stimulating substance called lectucarium, which has tranquilizing properties and give effects similar to the opium poppy. Take 2 lettuce leaves and boil them in two cups of water for 5 minutes. Add either honey or sugar to the solution. Wait until it cools down. Then, strain it. Drink a cup of lettuce tea at least half an hour before you sack out. It will definitely give you a sound sleep.
  • Alternatively, lettuce juice can also be consumed.
  • Moreover, take one tsp of lettuce seeds and boil them in half liter water until it reduces to 1/3. Strain this infusion and drink it throughout the day.

Homeopathic Treatment for Severe Insomnia

  • Acidum phos.(tds) – Sleeplessness after depressing events, sorrow or loss and death of a friend or a relative.
  • Ambra grisea (tds) – Sleeplessness due to worries or business troubles.
  • Ammonium val.3x(tds) Insomnia especially during pregnancy and menopause, with a neuralgic headache.
  • Arnica mont.(tds) Sleeplessness caused by over-exertion. Mental or physical. Bed appears too hard. Tosses about to find a soft portion of the bed.
  • Avena saliva Q 10 (bd) 10 drops in !A cup of water: Sleeplessness in alcoholics and those with morphine habits.
  • Cataria nep Q (od) 5 drops in ‘A cup of water. It relieves sleeplessness Of children who cannot sleep due to colic. It cures colic and produces sleep.
  • Chloralum 200 (od) It is a powerful sleep producing remedy in patients with mental diseases, with asthma, hallucinations and night terrors. Insomnia from over-fatigue.
  • Cimicifuga (tds)  Sleeplessness in children during the period of dentition.
  • Conium mac (tds) Sleeplessness due to neuralgic pains.
  • Helonias  Sleeplessness on account of tiring hard labor with aching of muscles.
  • Kalium phos A great remedy for. sleeplessness. The patient is weak and nervous. Sleeplessness due to business worries and due to mental disturbances.
  • Magnesium phos (tds) Sleeplessness on account of indigestion.
  • Nux vomica (tds) – Sleeplessness is due to over-excitement exhaustion and stress.
  • Pulsatilla nig.(tds) – falls asleep but cannot sleep. Bed feels hot. Moves about in vain in bed to find a cool spot. Even the ticking of a clock disturbs.
  • Antinionium crud.(Ids) Continuous drowsiness in old people.
  • Baptisia.(Ids) –  Falls asleep while being spoken to.
  • Causticum.(bd)   Very drowsy. Can hardly keep awake. Suited to old people.
  • Chloralosum.(tds) – A useful remedy for prolonged drowsiness, which may continue for number of days. It is also useful for drowsiness and sleep of drunkards, whose faculties are only partially depressed.
  • Cimex lect.(tds)  Irresistible sleepiness.
  • Gelsemium (tds) Patient is sluggish and always feels sleepy. He does not like to discuss matters but likes to be alone and undisturbed.
  • Hydrocyanicum acidum (tds) – Irresistible drowsiness.
  • Hypericum 3x (tds) The patient constantly feels drowsy.
  • Indolum (tds)  Wants to sleep all time. Aversion to work .
  • Lupulus (tds)  Drowsy during the day.
  • Lycopodium (tds) – Feels sleepy soon after taking dinner.
  • Natrium sulp.(tds)  Sleepy while reading.
  • Nux mosch (tds) – Great drowsiness.
  • Opium (tds)  Great drowsiness. Falls asleep at work.
  • Paullinia sorb (tds)  Feels sleepy after eating. Patient cannot control sleep. Head becomes heavy if he does not sleep.
  • Staphysagria (tds) – Feels sleepy after eating.

Simple Tips (Home Remedies) to Cure Chronic Insomnia

  • Maintaining regular sleep schedule and getting up the same time everyday morning. This helps synchronize the body’s biological clock
  • Do not mix activities like watching TV or mobile chatting from the Bed. Keep it reserved for sleeping activity only
  • If you do not fall asleep within 20 minutes of getting into bed, try and use a body massager, listen to slow music or try a warm oil head massage
  • Limit daytime sleep (cat naps)
  • Having a hot bath or a glass of warm milk before bed abets sleep better
  • Don’t drink caffeinated beverages & chocolate in the evening
  • Keeping hands & feet warm in a cold bedroom induces sleep quickly ( as per researchers at the Psychiatric university, clinic of chronobiology & sleep Laboratory, Switzerland)

Do’s

  • Perform deep breathing exercises, meditation, and yoga.
  • Sleep in a peaceful, dark, comfortable room.
  • Have dinner at least 2-3 hours before bedtime.
  • If you need to stay up late at night, then snack only on those stuffs that are low in protein and high in carbohydrates.
  • Listen to soft music around 45 minutes before catching some zzz’s.
  • Consume raw onion salad.
  • Take ample calcium, potassium and iron to cope up with sleep disorders.
  • Blue wavelengths of your phones reduce the secretion of melatonin which, in turn, affects your sleep. So, stay away from laptop, iPod, and smart phones at night.

Don’ts

  • Avoid watching TV before bedtime.
  • Reduce the consumption of alcohol and caffeine.
  • Avoid naps during the day time.
  • Don’t take excessive liquids half an hour before you hit the sack, in order to avoid urination.

References

Chronic Insomnia

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