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BACKGROUND

Insomnia is difficulty in falling asleep, staying asleep, and waking up too early in the morning.  It is a common health problem that can cause excessive daytime sleepiness and a lack of energy. Long-term insomnia can cause an individual to feel tired, depressed or irritable, have trouble paying attention, learning, and remembering, and not be able to perform fully on the job or at school. Severe insomnia can result in neuro-chemical (brain chemical) changes that may cause problems such as depression and anxiety, further complicating insomnia.

Insomnia increases sleep latency or the length of time that it takes to go from full wakefulness to falling asleep. During the daytime, a sleep latency of 15-25 minutes is considered normal. Insomnia is classified as transient (occasional), mild, and severe, depending on how often it occurs and for how long. Chronic insomnia is defined as having symptoms at least three nights per week for more than a month. Insomnia that lasts for less than a month is known as short-term or acute insomnia.

Most adults have experienced insomnia or sleeplessness at one time or another in their lives. An estimated 30-50% of the general population of the United States has been affected at one time or another by acute insomnia and 10% have chronic (long-term) insomnia. Insomnia affects all age groups, but its prevalence tends to increase with age. Insomnia affects approximately 40% of women and 30% of men at any given time. The average American gets seven hours of sleep nightly, instead of the eight to ten hours recommended by doctors.

TYPES OF INSOMNIA

Transient insomnia: Transient insomnia lasts from one night to a few weeks. Most people suffer occasionally from transient insomnia due to different factors in their lives, such as jetlag or short-term anxiety. If transient insomnia continues to occur more frequently, but still not nightly, the insomnia is classified as intermittent.

Acute insomnia: Acute insomnia is the inability to consistently sleep without interruption for a period of three weeks to six months. Stress or psychological problems such as anxiety are the most common trigger for short-term or acute insomnia.

Chronic insomnia: Chronic insomnia is long-term, and persists almost nightly for more than one month.

RISK FACTORS

Risk factors associated with developing insomnia include stress, depression, pregnancy, menopause, having frequent, major shifts in work hours, and traveling long distances with time changes (jet lag). Stimulant drinks containing caffeine may increase the risk of developing insomnia, as do certain prescription and non-prescription medications, including nasal decongestants (including pseudoephedrine or Sudafed®), weight loss drugs (including phentermine and sibutramine), amphetamines, and some antidepressants (including bupropion or Wellbutrin®), asthma (including albuterol or Ventolin®), and blood pressure medications (including beta blockers).

CAUSES

Psychological: The most common psychological problems include anxiety, stress, and depression. In fact, insomnia may be an indicator of depression. Many people will have insomnia during the more severe phases of mental illness (such as in mania of bipolar disorder). Mania causes the excessive release of neurochemicals such as dopamine. Feelings of grief, depression or major depression, worry, anxiety or stress, exhilaration or excitement all may cause insomnia, either acute or chronic, depending upon the individual.

Physiological: Medical conditions can cause insomnia, such as chronic (long-term) pain (including arthritis, fibromyalgia, cancer), enlarged prostate, cystitis (common in women), over-active thyroid glands, congestive heart failure (CHF), gastroesophageal reflux disease (GERD, heartburn), chronic obstructive pulmonary disease (COPD), gastrointestinal disorders such as diarrhea, ulcers, or irritable bowel syndrome (IBS), and nervous system diseases, such as Alzheimer’s disease or Parkinson’s disease. These conditions cause imbalances and changes in circadian rhythm (24 hour light and dark balance) and sleep/wake balance.

Medications: Certain prescription and non-prescription medications may also cause acute or chronic (long-term) insomnia. If the insomnia is related to a medication side effect, a normal sleep/wake pattern should be achieved shortly after discontinuing the medication. Medicines that stimulate brain neurochemistry may cause insomnia. These include nasal decongestants, weight loss drugs, amphetamines (including methamphetamine or crystal meth), some antidepressants, cocaine, and some asthma and heart medications. Caffeine, alcohol, and nicotine may also contribute to insomnia by altering brain chemistry, thereby disrupting the normal sleep/wake cycle. The abrupt discontinuation of alcohol (in alcoholics) can also contribute to insomnia. The abrupt stopping of medications (such as sleeping pills, hypnotics, anti-anxiety drugs, and antidepressants) can cause acute insomnia.

Sleep apnea: Sleep apnea may also cause insomnia. Sleep apnea means cessation of breath and is characterized by repetitive episodes of upper airway obstruction (mouth, nose, and throat) that occur during sleep, usually associated with a reduction in blood oxygen saturation. Airway muscles relax and collapse when asleep, causing them to become obstructed (blocked) at several possible sites, resulting in snoring. The upper airway can be obstructed by excess tissue in the airway, such as large adenoids (tonsils) or a large tongue. Another site of obstruction can be the nasal passages.

Other common causes: A disruptive bed partner with loud snoring or periodic leg movements (restless leg syndrome or RLS) may also cause insomnia. Nocturnal polyuria, or excessive nighttime urination, can be very disturbing to sleep. Excessive thirst or the use of diuretics can also cause these symptoms. Not getting enough light during the day can cause the natural circadian rhythm and the sleep/wake cycle to be disturbed, causing insomnia. Jet lag, shift work, wake-sleep pattern disturbances, bed or bedroom not conducive to sleep, aging, excessive sleep during the day, and excessive physical or intellectual stimulation at bedtime can all contribute to acute or chronic insomnia.

MEDICAL TREATMENT

Benzodiazepines: Benzodiazepines are a class of sedative/hypnotic drugs that were once the standard therapy for insomnia. The benzodiazepines used for insomnia include temazepam (Restoril®), flurazepam (Dalmane®), estazolam (ProSom®), and triazolam (Halcion®). Benzodiazepines have the potential of causing psychological and physical dependence. Benzodiazepines may cause depletion of the natural hormone melatonin from the body. Melatonin helps the body regulate sleep/wake cycles and circadian rhythm.

Over The Counter (OTC) sleep aids: Antihistamines may be used short-term for insomnia. Diphenhydramine (Benadryl®) is the most commonly used OTC antihistamine sleep aid, and can be purchased alone (Benadryl®, Nytol®, Sominex®) or in combination with other OTC items such as acetaminophen (Tylenol PM®). Acetaminophen has been reported to cause severe liver damage in overdose. It is recommended by healthcare professionals to not take more than

Atypical antipsychotic drugs: Other medications used off-label for insomnia are low doses of the atypical antipsychotics, including quetiapine (Seroquel®), mirtazapine (Remeron®), and olanzapine (Zyprexa®). Antipsychotics appear to work by blocking the action of the neurotransmitters serotonin and dopamine, thus producing a tranquilizing, sedating, an antipsychotic effect.

Others: Requip® (ropinirole) may be used if restless leg syndrome (RLS) is present. Restless legs syndrome (RLS) causes a powerful urge to move the legs.

SLEEP SOLUTIONS

Exercise: Exercise regularly, at least 30 minutes daily, five days a week. Aerobic exercise and general fitness are important in maintaining good health and preventing insomnia. Exercising within two hours of bedtime may cause trouble falling asleep.

Diet: Eating for Health approach: Fresh, seasonal, local, plant-based whole food diet, with organic, chemical-free meats and dairy products. Avoid large meals and excessive fluids before bedtime, as they can cause trouble falling asleep. Healthcare professionals recommend avoiding caffeine, nicotine, beer, wine and liquor six to eight hours before bedtime. Caffeine and nicotine are stimulants to the nervous system and may cause insomnia. Alcohol interferes with normal sleep patterns by disrupting neurotransmitters (nerve chemicals) in the brain that control or regulate sleep. When these neurotransmitters (including dopamine and serotonin) are disrupted, disturbances, such as insomnia, can result. However, the use of alcohol as an effective sedative can be extremely misleading because the side effects that can result are usually even more harmful and detrimental to the natural sleep cycle. Alcohol can also be associated with sleep apnea.

Environment: Controlling the environment, such as light, noise, and temperature, may help prevent insomnia. Night shift workers especially must address these factors. Going to bed at the same time daily helps develop the natural circadian rhythm cycle and the sleep/wake cycle.

Sleep Hygiene: In order to prevent insomnia, healthcare professionals recommend to establish a regular bedtime, use the bedroom for bedroom activities only, avoid staying in bed for long periods of time while awake, or going to bed because of boredom, take the TV or computer out of the bedroom (too much stimulation), relax by reading, taking a bath, or listening to soothing music before getting to bed, and avoid emotional upset or stressful situations prior to bedtime.

INTEGRATIVE THERAPIES

Vital Scoop: All in One Nutritional Powder: Take one scoop 30 minutes before bed in a glass of warm milk, (cow, goat or nut milk). Contains protein, fiber, fruits, vegetables and seeds to support blood sugar, blood pressure, brain neurotransmitters. It calms and nourishes the body, allowing it to drop into a deep sleep.

Magnesium: The safest and surest way to get to sleep and stay asleep. Take 1-2, 200 mg. capsules, 1-3 times per day, especially before bed to relax and unwind. Magnesium works well to quiet a restless leg and mind.  Best with a 50 mg. B vitamin complex capsule.

Melatonin: The natural hormone known as melatonin helps to regulate sleep/wake cycles (circadian rhythm). Certain diseases such as cancer, prescription medications such as benzodiazepines, and age may decrease melatonin levels. Several human trials suggest that melatonin taken by mouth, started on the day of travel (close to the target bedtime at the destination) and continued for several days helps with symptoms of jet lag such as reducing the number of days required to establish a normal sleep pattern, diminishing the time it takes to fall asleep (“sleep latency”), improving alertness, and reducing daytime fatigue.  Melatonin has been studied for delayed sleep phase syndrome (DSPS), insomnia in the elderly, sleep disturbances in children with neuro-psychiatric disorders, and sleep enhancement in healthy individuals. Although study results are promising, additional research with larger studies is needed before a conclusion can be made.

Music therapy: Music is used to influence physical, emotional, cognitive and social wellbeing, and improve quality of life for healthy people, as well as those who are disabled or ill. It may involve either listening to or performing music, with or without the presence of a music therapist. In older adults music may result in significantly better sleep quality as well as longer sleep duration, greater sleep efficiency, shorter time needed to fall asleep, less sleep disturbance and less daytime dysfunction. Music therapy is generally known to be safe.

5-HTP (5-hydroxytryptophan): 5-HTP is the precursor of the neurotransmitter serotonin. It is obtained commercially from the seeds of the plant Griffonia simplicifolia. Although many naturopathic regimens for sleep include 5-HTP, there is insufficient evidence in its use for sleep disorders or insomnia. Additional studies are needed before a conclusion can be drawn. 5-HTP may cause drug interactions with medications such as antidepressants and sleep medicines. 5-HTP is not recommended during pregnancy or breastfeeding unless otherwise advised by a doctor.

Chamomile: Chamomile (Matricaria recutita) has been used medicinally for thousands of years, and is widely used in Europe. Traditionally, chamomile preparations, such as tea and essential oil aromatherapy, have been used as a sleep aid and for sedation. Better research is needed. Chamomile is not recommended for individuals allergic to flowers in the daisy family, or during pregnancy or breastfeeding unless otherwise advised by a doctor.

Hops: Hops may have sedative and sleep-enhancing (hypnotic) effects. However, little human research has evaluated the effects of hops on sleep quality and insomnia. Further study is needed in this area. Hops may cause drowsiness, so caution is used when operating automobile or heavy machinery. Hops supplements are not recommended during pregnancy or breastfeeding unless otherwise advised by a doctor.

Kava: Kava may cause sedation or lethargy. However, early research suggests that kava may not be effective for insomnia. Additional study is needed in this area. Consult with a qualified healthcare professional before taking kava due to the risk of harmful side effects. Avoid if allergic to kava or kavapyrones. Avoid with liver disease, Parkinson’s disease, a history of medication-induced extrapyramidal effects, and chronic lung disease. Avoid if taking medications for liver disease or CNS depressants such as alcohol or tranquilizers. Avoid while driving or operating heavy machinery (may cause drowsiness). Use cautiously with depression or if taking antidepressants. Avoid if pregnant or breastfeeding.

Lavender: Lavender aromatherapy is often promoted as a sleep aid and hypnotic. Although early evidence suggests possible benefits, more research is needed before a firm conclusion can be drawn. Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.

Lemon balm: Lemon balm (Melissa officinalis) is a commonly used herb with a lemon like smell. High-quality clinical evidence supporting the use of lemon balm as a sedative/hypnotic is lacking, although it has been used with positive results with valerian for improving sleep quality. Rigorous clinical studies are required to better support the use of lemon balm as a sedative/hypnotic. Based on available research, lemon balm taken by mouth has been reported to be relatively well tolerated when taken for up to eight weeks. Evidence for topical administration of cream suggested minimal side effects for up to 10 days of application. Avoid with Grave’s disease or thyroid hormone replacement therapy

Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually nondirected relaxation. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), adoption of a passive attitude towards intruding thoughts, and return to the focus. Several human trials suggest that relaxation techniques may be beneficial in people with insomnia, although effects appear to be short-lived. Research suggests that relaxation techniques may produce improvements in some aspects of sleep such as sleep latency and time awake after sleep onset. Better research is necessary before a firm conclusion can be drawn.

REFERENCES:

1. American Academy of Family Physicians. http://familydoctor.org. Accessed April 11, 2009.

2. American Academy of Otolaryngology. www.entnet.org. Accessed April 11, 2009.

3. American Academy of Sleep Medicine. www.aasmnet.org. Accessed April 11, 2009.

4. Atkinson G, Davenne D. Relationships between sleep, physical activity and human health. Physiol Behav. 2007;90(2-3):229-35.

5. National Institutes of Health. www.nlm.nih.gov. Accessed April 11, 2009.

6. National Sleep Foundation. www.sleepfoundation.org. Accessed April 11, 2009.

7. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.

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