Introduction
What should I know about Sleep Disorders and Insomnia?
Good health and happiness are impossible when we are robbed of sleep for very long. For many people, this is all too often a way of life. One of mankind’s oldest complaints, insomnia is the chronic inability to fall asleep or to stay asleep. While everyone occasionally experiences a sleepless night now and then without harm, long-term insomnia can be debilitating. After yet another night of inadequate sleep, insomnia sufferers typically report impaired mental and physical abilities, diminished memory, reduced alertness, and slow reaction times. (1) Chronic lack of sleep threatens the well-being, productivity, and safety of millions of Americans.
Insomnia is not a disease unto itself but a condition associated with a number of different physical and emotional disorders. The incidence of insomnia is higher among people with chronic illnesses such as hyperthyroidism, kidney trouble, multiple sclerosis, and Alzheimer’s disease. Pregnancy, alcohol intake, stress, and depression are also leading causes of insomnia.
Sleep is one of the most mysterious of all human activities. Exactly what happens during sleep is still not completely understood. By studying brain wave patterns, sleep researchers have identified four separate stages in a normal period of sleep. Stage 1 begins when we first fall asleep. Stage 1 is light sleep. Muscles relax and the heart slows down in stage 1. During stage 2,the heart rate increases. Stage 2 sleep is called REM sleep because of the rapid eye movements that occur during this stage. The autonomic nervous system is active in REM sleep, causing rapid breathing and increased stomach acid secretion. Stage 2 is the period when we dream. During deep sleep (stages 3 and 4), no dreaming occurs. In a normal sleep period, a person cycles from stage 1 to stage 4 in about 90 minutes. (2) Waking after one full sleep cycle is complete is common among the elderly and small children.
Statistic
National Sleep Foundation, 2000.
Nearly two-thirds of adults in the U.S. (62%) experienced a sleep problem a few nights per week or more during the past year.
Specifically, more than one-half of the adults surveyed (58%) report having experienced one or more symptoms of insomnia a few nights per week or more within the past year.
One-third (33%) of adults say they get fewer than 6.5 hours of sleep per night during the workweek.
Signs and Symptoms
The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.
Difficulty falling asleep, called “sleep-onset insomnia,” is the most common sleep disorder. Typically, sleep occurs within about 20 minutes. Individuals with sleep-onset insomnia may take hours to fall asleep. Oddly, sleep often seems to come around 3:00 AM for many suffering from this type of insomnia. (3) The inability to fall asleep may be related to abnormal fluctuations in body temperature. Body temperature goes through phases during the night, dropping when we fall asleep and rising as we wake up. It has been shown that insomniacs have temperature rhythms that are about 2.5 hours later than normal sleepers. (4)
Still other insomnia sufferers fall asleep normally, but wake up too early. This early morning waking is called “terminal insomnia.” The actual hour of awakening depends on the initial bedtime and the “circadian rhythm,” the pattern of sleeping and waking, of the individual. Once awake, the terminal insomniac simply can not go back to sleep. Early morning waking is a classic sign of depression. (5) It is thought that this type of insomnia is also related to an early rise in body temperature. A recent study among the elderly with sleep disorders demonstrated that elevated core body temperature is associated with night waking. (6)
Sleep-onset insomnia
- Difficulty falling asleep for hours
- Body temperature rhythms that are about 2.5 hours later than normal sleepers
- Decreased concentration, fatigue and muscle aches during the day
Terminal insomnia
- Normal sleep onset with early awakening
- Once awake, can not go back to sleep
- Depression may be present
- Decreased concentration, fatigue and muscle aches during the day
Treatment Options
Conventional
Conventional treatment of insomnia includes the use of antihistamines, a class of sleep medications called “benzodiazepines,” antidepressants, or a combination of the above. In 1999, the FDA approved a new prescription drug, zolpidem, for the short-term relief of insomnia in adults.
- Benzodiazepines (estazolam, lorazepam, quazepam) have been prescribed since the 1960’s for the management of anxiety. These drugs act on the emotional centers in the brain. Benzodiazepines stimulate a neurotransmitter called “GABA” that calms the nervous system. Physicians like benzodiazepines because of their low toxicity; lethal overdoses are rare. They do have side effects, however. Users may be groggy during the daytime and experience impaired muscular coordination. For these reasons, elderly persons may be more prone to falling down when taking benzodiazepines. Dizziness and headaches are also common side effects. Some benzodiazepine sleeping pills can be habit forming.
Antihistamines (diphenhydramine, hydroxyzine) give short-term relief for temporary insomnia. Typically used to treat allergic reactions, antihistamines also cause drowsiness. They are relatively mild with few adverse effects. Some side effects may include dry mouth and shakiness. Many antihistamines are readily available over the counter.
Antidepressants can be effective in treating insomnia. Commonly used antidepressant medications include “tricyclics” such as amitriptyline and “selective serotonin re-uptake inhibitors” (SSRIs) such as fluoxetine, sertraline, paroxetine, fluvoxamine and citalopram. Side effects of antidepressants may include dry mouth, constipation, urinary retention, bone-marrow depression, and decreased libido.
Zolpidem is the newest prescription medication available for the treatment of insomnia. Zolpidem is a sleep-inducing drug that works somewhat like the benzodiazepines, without the side effects. Although zolpidem produces some psychomotor and memory impairment initially, it appears to have no leftover effects the following day. This is because it stays in the system only for a short time. Zolpidem also works quickly, so it can be taken as needed right before bedtime. Zolpidem appears to be effective for both sleep-onset insomnia and early-morning waking. The most common adverse effects are nausea, dizziness, and drowsiness. During a clinical trial of the drug, there were no indications of “rebound effect” where the insomnia gets worse as a result of going off the drug, or withdrawal after it was discontinued.
Nutritional Supplementation
Melatonin
Melatonin is a brain hormone that regulates the body’s sleep/wake cycles, also known as the “circadian rhythm.” Available over-the-counter, melatonin has been become popular in recent years as a dietary supplement for promoting sleep. It has been suggested that changes in melatonin secretion may cause sleep disorders in people with certain nervous conditions. One group of psychiatric researchers has found that in many people mistakenly diagnosed with depression disruption of the circadian rhythm is the real problem. (7)
Melatonin reportedly is effective in improving sleeping patterns in night shift workers, and people who have trouble sleeping due to what is called delayed sleep phase syndrome (DSPS). (8) , (9) Melatonin has been suggested as an aid in reducing the effects of jet-lag, but evidence is inconclusive as to whether it really works for this. (10) , (11)
5-Hydroxytryptophan (5-HTP)
5-HTP (5-Hydroxytryptophan) is a cousin of the amino acid tryptophan. The body uses 5-HTP to manufacture serotonin, which in turn is converted into melatonin in the brain. Thus, 5-HTP is a product that can be used to improve sleep patterns. (12) Animal studies report that 5-HTP is significantly more effective than tryptophan for improving sleep. (13)
Herbal Supplementation
Kava
Now widely popular in the U.S. as a calming, relaxing herb, Kava has been a favorite among South Pacific island peoples for centuries. The root is used to prepare a recreational beverage known by a variety of local names (kava, yaqona, awa). Kava occupies a prominent position in Pacific island culture, similar to tea and coffee in the West. An important part of social gatherings and ceremonies, kava is enjoyed for its ability to produce a relaxed, yet alert, frame of mind.
In European herbal medicine, kava is widely used as a safe, effective treatment for mild anxiety, nervous tension, muscle tension, and mild insomnia. (14) , (15) The results of a study revealed that kava may be effective and safe when used for sleep disturbances associated with anxiety disorders. (16) Studies have reported that kava preparations compare favorably to benzodiazepines in controlling symptoms of anxiety and minor depression, while increasing alertness, sociability, memory, and reaction time. (17) , (18)
Kavalactones: Kava root contains a group of active ingredients called “kavalactones” that appear to act on the brain’s emotional center, called the “limbic system.” (19) It is thought that kava may promote relaxation, sleep, and rest by altering the way in which the limbic system processes emotions. Kava does not seem to be habit-forming. (20) , (21)
Passionflower
Passionflower, also called “maypop,” is a common roadside vine in many areas of the United States. Long used as a relaxing herb, passionflower has been reported to have sleep-promoting, muscle-relaxing, and pain-relieving properties. Herbalists have traditionally recommended passionflower for neuralgia (nerve pain), seizures, hysteria, rapid heartbeat due to nervousness, asthma, and insomnia. Passionflower extracts have been reported to reduce locomotor activity, prolong sleeping time, raise the pain threshold, and produce an anti-anxiety effect in laboratory animals. (22) In humans, passionflower has been reported effective when used in combination with other sedative and anti-anxiety herbs such as valerian. There is evidence that certain active ingredients in passionflower may bind to the same receptors on the surface of brain cells as benzodiazepines do. (23) , (24)
Valerian
Valerian has long been used as a calming, relaxing herb that soothes the nervous system under stress. Studies on humans report that valerian helps improve sleep quality. (25) , (26) , (27) Several active ingredients in the herb are believed to account for valerian’s influence, including valepotriates, valeric acid, and pungent oils. These components have a sedative effect on the central nervous system, as well as a relaxing effect on the smooth muscles of the GI tract. (28) , (29) , (30) As with passionflower, it is believed that valepotriates and valeric acid bind to receptor sites similar to the benzodiazepines. (31) Valerian does not seem to produce the morning drug hangover effect as seen with some benzodiazepines. (32) Valerian extract did not alter mood or impair psychomotor/cognitive performance and had fewer side effects in healthy volunteers. Valerian could be taken into consideration as an alternative to drugs in treating insomnia. (33) , (34)
Chamomile
Chamomile has been used as a medicinal herb for centuries, most frequently as a mild sedative for individuals with minor anxiety or nervousness. (35) Chamomile does not seem to induce drowsiness or impair motor activity. Chamomile also soothes digestive upset and is considered a “carminative” (anti-gas) agent. (36) Chamomile can also be applied to the skin for various conditions such as acne, infections, burns, and wounds. (37) Its active ingredient apigenin has been reported to link up with benzodiazepine receptors, exerting anti-anxiety and slight sedative effects. Chamomile does not have a muscle relaxing or anticonvulsant effect. (38)
Hops
Hops have been used since the Roman times in brewing and as a traditional nerve tonic and sedative herb. Hops are classified as an herb with hypnotic, antispasmodic, and topical antibiotic properties. (39) Traditional uses of hops include neuralgia, insomnia, excitability, topically for skin ulcerations, and primarily for restlessness associated with nervous tension. (40) The sedative effect of hops is not fully understood, and early research in laboratory animals produced conflicting results. (41) Human studies of the sedative action have generally combined hops with one or more additional herbs. In laboratory studies, hops have been reported to increase the sleeping time induced by pentobarbital. (42) One study showed improvement of sleep disturbances with combinations of hops and other sedative herbs such as valerian root and passionflower. (43)
Diet & Lifestyle
Avoid caffeine and alcohol in the afternoon and evening. Some people report that small amounts of caffeine can keep them awake, even 8-10 hours after consumption.
Maintain a consistent bedtime routine. Go to bed and wake up at the same time every day, even on weekends.
Exercise during the day can improve sleep at night.
Increase your body temperature slightly before bed in a warm bath or shower. The subsequent decline can help induce and maintain sleep.
Try to stop work or doing tasks that keep the mind active earlier in the evening.
Avoid television before bed. The lights and sounds can over-stimulate the nervous system.
If the insomnia is stress induced, try and learn stress reduction techniques. This is different for many, but exercise, yoga, tai chi, or any activity that will bring joy and calmness is a big step in the right direction.
Some people who wake up during the middle of the night do so because of hypoglycemia. Consuming a small snack just before bedtime helps to stabilize blood sugar levels throughout the night. Ideally, snacks should consist of complex carbohydrates, along with a little fat and protein. This allows for more of a timed-release breakdown and release of energy into the body.
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