Insomnia can be defined as a condition when an individual suffers from sleeping difficulties. Insomnia may be primary or secondary insomnia. Primary insomnia is a sleep disorder that arises without the engrossment of medical, psychiatric and environmental concerns. In a broad sense insomnia may be transient, acute, or chronic. Transient insomnia has a very diminutive duration and may last for less than a week. A number of factors are blamable for transient insomnia for example some other disorders may also give rise to this condition. Changes in the sleeping environment, change in the sleeping time, depression and stress are other factors responsible for this type of insomnia. The consequences of this condition are sleepiness and impaired psychomotor performance of a person. Acute insomnia is a condition where the individual is incapable to sleep for a period of less than a month. Chronic insomnia as the name specifies is of longer duration and may be caused by another disorder. Its side effects comprise muscular fatigue, hallucinations or mental fatigue. The patients of this disorder may often experience double vision.
Sleep-onset insomnia is the problem of falling asleep at the commencement of night and may be catalogued under the category of delayed sleep phase disorder or anxiety disorder. Middle-of-the-night insomnia or terminal insomnia can be defined as the condition where if a person awakes from the sleep during midnight or early in the morning then he or she is unable to sleep again. The former condition arises due to pain disorders or illness while the latter condition is due to clinical depression. A person may have poor sleep quality due to restless legs or due to major depression. In this state a person is unable to reach the stage 3 or delta sleep phase of sleep that is characterized by restorative property. Major depression cause changes in the customary functioning of the hypothalamic-pituitary-adrenal axis resulting in disproportionate secretion of cortisol that is responsible for poor sleep quality. Nocturnal polyuria and excessive night time urination may be the secondary factors responsible for poor sleep quality. Individuals experiencing sleep state misperception generally sleep for about eight hours but think that they have taken a sleep of only four hours.
A number of factors are responsible for insomnia for example intake of psychoactive drugs like certain medications, herbs, caffeine, nicotine, cocaine, amphetamines and MDMA. Use of fluoroquinolone antibiotic drugs is responsible for severe chronic insomnia. Restless legs syndrome that causes sleep-onset insomnia can also be responsible for lack of proper sleep. Periodic Limb Movement Disorder (PLMD) that generally occurs during sleep results in frequent arousals in the individual that the sleeper is unaware of. Pain due to any injury can also cause discomfort in sleeping. Hormones that partake in menstruation and menopause can also cause sleeping difficulties. Fear, stress, anxiety, work problems, emotional or mental tension, financial stress of birth of a child are other factors that also lead to insomnia. Mental disorders like bipolar disorder, schizophrenia, clinical depression, post-traumatic stress disorder, generalized-anxiety disorder, and dementia or alcohol intake can also result in sleeping problems. Circadian rhythm disturbances like shift work and jet lag can also cause sleep disturbances. Brain lesions or traumatic brain injury also cause insomnia. Hypothyroidism and rheumatoid arthritis, poor sleep hygiene and a prion based fatal type of insomnia identified as fatal-familial insomnia can also be responsible for sleeping disorders.
Sleep studies carried out by using polysomnography has advocated that individuals that experience sleep disruptions have tremendously high levels of circulating cortisol and adrenocorticotrophic hormone during the night time. The metabolic rate of such individuals is also found to be high in contrast to the individuals that do not suffer from insomnia. Studies carried out on brain metabolism by using positron emission tomography (PET) scans have revealed that the persons suffering from insomnia have higher metabolic rates by day and by night. This issue whether this higher metabolic rate is responsible for the consequences of long term sleep disorder is still arguable. It is also clear that as a person reaches ageing the amount of sleep declines. The ability to sleep for longer periods as well as the need of sleep also deteriorates with progressing age.
In order to recommend a precise medicine for a person suffering from sleeping problems a health expert needs to be very careful and attentive. Individuals suffering from delayed-sleep phase syndrome are often confused with primary insomnia. When a person is feeling difficulty in getting awake but is able to sleep normally generally suffers from circadian rhythm disorder. In many cases insomnia arises due to side effects of medication or some psychological factors are associated with it. About half of the cases of insomnia are coupled with psychiatric problems. In order to diagnose a proper treatment for insomnia all the medical and psychological factors must be worked out. Sleep hygiene forms the first line treatment before any pharmacological approach is applied. Pharmacological approaches are generally followed in reducing the symptoms that crop up in acute insomnia. The role of these approaches in treatment of chronic insomnia is undecided.
Non-pharmacological techniques of treatment are superior to the hypnotic medication for insomnia as tolerance develops against the hypnotic effects. Hypnotic medication is generally recommended for short term use only as dependence develops in a person for it. Non-pharmacological treatments are generally preferred over the hypnotic one as they can be used for long term treatment of insomnia. These strategies include sleep hygiene, stimulus control, behavioral interventions, paradoxical intention, patient education, sleep restriction therapy and relaxation therapy. If the temperature of the blood flowing to the brain is reduced then the metabolic rate of brain also slows down resulting in declination of incidence of insomnia. EEG-biofeedback is helpful in the treatment of insomnia and it also improves the sleep quality. Stimulus control therapy is generally applied for those individuals who generally take sleep as a negative response. It is generally concerned with the improvement of the sleep environment and is sometimes also tied with the concept of sleep hygiene. The sleep environment can be modified by using the bed for the purpose of sleep or sex only and not for reading, writing and other purposes.
The important component of stimulus control therapy is sleep restriction that includes matching the time spent in bed with the time of falling asleep. This technique uses maintenance of a proper sleep-wake schedule and sleeping only for certain hours of day. The complete treatment includes a course of about three weeks and strictly follows the principle of taking less rest. Bright light therapy can be combined with the stimulus control therapy especially for the individuals that have a habit of getting up early in the morning and this technique helps them to maintain a new sleep-wake schedule. Paradoxical intention is a technique where the insomniac attempts to remain awake and is helpful in curing anxiety problems that crop up due to insomnia. Meditation is another tool that is used for treating insomnia.
In the present scenario Cognitive Behavioral Therapy for Insomnia (CBT-I) has given astonishing positive results in comparison to the hypnotic medication used for controlling insomnia. This therapy deals with the improvement of sleeping habits as well as adoption of positive aspects about sleep. The common misconceptions that require modification are unrealistic sleep expectations, misconceptions regarding the causes of insomnia, amplification of consequences of insomnia and anxiety problems associated with sleep. Positive results have been obtained when cognitive behavioral therapy was combined with stimulus control and sleep restriction therapies. Hypnotic medications are useful in the treatment of either acute or chronic insomnia but the danger of tolerance prevails. The combination of hypnotic medication with cognitive behavioral therapy does not give the desired results.
In about 95% cases the insomniacs rely on sleeping pills and other sedatives to overcome this condition. The common sedatives used in the treatment of insomnia are benzodiazepines and non-benzodiazepines that can result in physical dependence. The benzodiazepines and non-benzodiazepines cause a number of side effects like day time fatigue, motor vehicle crashes, cognitive impairments, falls and fractures. These drugs cause tolerance and dependence in long term usage. Benzodiazepines in general bind to the GABAA-receptors. Certain benzodiazepines have higher efficiency for the ?1 subunit of GABAA receptor in comparison to other benzodiazepines. Modulation of the ?1 subunit is coupled with motor impairment, amnesia, sedation, respiratory depression, ataxia and reinforcing behavior. Modulation of the ?2 is responsible for the anxiolytic activity and disinhibition. This is the major reason that why some benzodiazepines are suited perfectly for the treatment of insomnia in comparison to the others. The common hypnotic benzodiazepines are temazepam, triazolam, midazolam and quazepam. These drugs can cause tolerance, physical dependence and benzodiazepine withdrawal syndrome. These drugs are although helpful in initiating sleep and also increasing sleep timing but cause a reduction in deep sleep and increase light sleep.
Nonbenzodiazepine drugs include zolpidem, zopiclone and zaleplon and are used to treat mild to moderate insomnia. They also bear the efficiency for the same site of the GABAA receptors like the benzodiazepine drugs. Those nonbenzodiapzepines that have activity for the ?1 subunit of the GABAA receptors are helpful in sleep induction. Zopiclone unselectively binds to the ?1, ?2, ?3 and ?5 subunits of the GABAA benzodiazepine receptors. Zolpidem is more selective and zaleplon is more selective for the ?1 subunit and are superior over benzodiazepines and also reduce the side effects. These drugs cause both psychological as well as physical dependence and also cause memory and cognitive impairments along with morning sedation. Alcohol is also used as self-treatment for inducing sleep. However, use of alcohol for sleep induction can also cause insomnia. Long-term use of alcohol also causes decrease in the NREM stage 3 and 4 of sleep as well as suppression of REM sleep and REM fragmentation. Frequent awakenings with headaches, polyuria and dehydration are very common in insomniacs. Alcohol also inhibits glutamine activity which is the body's natural stimulants.
Opioid medications like hydrocodone, oxycodone and morphine are used to treat insomnia due to their analgesic and hypnotic effects. They cause sleep fragmentation and reduction in REM and stage 2 sleep. Antidepressants like doxepin and trazodone have a very strong sedative effect and are used to treat insomnia. They cause severe side effects. The hormone melatonin is often used in the treatment of insomnia. Melatonin is often helpful in inducing sleep and regulating the sleep/wake cycle. The positive effect of this hormone in treatment of insomnia is that it does not alter the sleep pattern of an individual. Another advantage is that it does not impair the performance related skills of the person. The common melatonin agonists are ramelteon and tasimelteon that are very effective in treating insomnia due to jet lag and chronic circadian rhythm disorders. Natural substances like L-Tryptophan and 5-HTP are also known to strengthen the serotonin-melatonin pathway.
Certain types of herbs like lavender, hops and passion flower is also used for treating insomnia. Some researchers believe that when magnesium falls below the normal level insomnia may occur but this issue needs more concern. The occurrence of insomnia is 40% more common in women in comparison to that of men. Insomnia becomes severe and problematic if left unattended so care must be taken.