Insomnia

Insomnia is a symptom of a sleeping disorder characterized by persistent difficulty falling asleep or staying asleep despite the opportunity. It is typically followed by functional impairment while awake. Insomniacs have been known to complain about being unable to close their eyes or "rest their mind" for more than a few minutes at a time. Both organic and non-organic insomnia constitute a sleep disorder.

Insomnia is the disturbance of a normal sleep pattern. For example, when you cannot get to sleep or wake up after only a few hours sleep.
Sleep is a state of consciousnesses, which gives your body time to rest and build up your strength. While you are asleep, your body goes through different stages at approximately 90 minute cycles. These include light sleep, deep sleep and dreaming, also known as rapid eye movement (REM) sleep.

Difficulties with sleep can appear in a variety of ways:
• Difficulty getting to sleep (sleep onset insomnia). This is most common in young people.
• Waking in the night (frequent nocturnal awakening). This is most common in older people.
• Waking early in the morning - the least common type of sleep disturbance.
• Not feeling refreshed after sleep. You may have trouble functioning normally during the day, feel irritable, tired, and find it difficult to concentrate.
• Waking when you have been disturbed from sleep by pain or noise.

Insomnia can last for days, months or even years and can be split into three categories:
• Transient insomnia lasts for 2-3 days.
• Short-term insomnia lasts for more than a few days, but less than three weeks.
• Chronic insomnia can be defined as insomnia most nights for three weeks or longer.

Chronic insomnia can lead to mental health problems such as depression, misuse of alcohol or other medicines in order to gain sleep.
Every individual is different so it is hard to define what normal sleep is for you. Other factors include your age, lifestyle, diet and environment.
Newborn babies can sleep for 16 hours a day, while children of school age need an average of 10 hours.

Adults usually need, on average, seven to nine hours sleep a night. As we get older, it's normal to need less sleep. Most people over 70 need less than six hours sleep per night; and they tend to be light sleepers.

Treatment for insomnia
In many cases, insomnia is caused by another disease, side effects from medications or a psychological problem. It is important to identify or rule out medical and psychological before deciding on the treatment for the insomnia. Attention to sleep hygiene is an important first line treatment strategy and should be tried before any pharmacological approach is considered.

Cognitive behavior therapy
A recent study found that cognitive behavior therapy is more effective than hypnotic medications in controlling insomnia. In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. Hypnotic medications are equally effective in the short term treatment of insomnia but their effects wear off over time due to tolerance. The effects of cognitive behavior therapy have sustained and lasting effects on treating insomnia long after therapy has been discontinued.

Medications
Many insomniacs rely on sleeping tablets and other sedatives to get rest. All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of sedatives such as benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down. The benzodiazepine and nonbenzodiazepine hypnotic medications also have a number of side effects such as day time fatigue, motor vehicle crashes, cognitive impairments and falls and fractures. Elderly people are more sensitive to these side effects.
In comparing the options, a systematic review found that benzodiazepines and nonbenzodiazepines have similar efficacy which was not significantly more than for antidepressants. Benzodiazepines did not have a significant tendency for more adverse drug reactions. Chronic users of hypnotic medications for insomnia do not have better sleep than chronic insomniacs who do not take medications. In fact, chronic users of hypnotic medications actually have more regular nighttime awakenings than insomniacs who do not take hypnotic medications. Thus short term or occasional use of hypnotics can be benefitial but long term use may be detrimental to sleep.

Benzodiazepines
The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. Benzodiazepines bind unselectively to the GABAA receptor. These include drugs such as temazepam, flunitrazepam, triazolam, flurazepam, nitrazepam and midazolam. These drugs can lead to tolerance, physical dependence and the benzodiazepine withdrawal syndrome upon discontinuation, especially after consistent usage over long periods of time. Benzodiazepines while inducing unconciousness, actually worsen sleep as they promote light sleep whilst decreasing time spent in deep sleep such as REM sleep. A further problem is with regular use of short acting sleep aids for insomnia, day time rebound anxiety can emerge.

Non-benzodiazepines
Nonbenzodiazepine sedative-hypnotic drugs, such as Ambien (zolpidem), Sonata (zaleplon), Imovane (zopiclone) and Lunesta (eszopiclone), are a newer classification of hypnotic medications. They work on the benzodiazepine site on the GABAA receptor complex similarly to the benzodiazepine class of drugs. Some but not all of the nonbenzodiazepines are selective for the α1 subunit on GABAA receptors which is responsible for inducing sleep and may therefore have a cleaner side effect profile than the older benzodiazepines. Zopiclone and eszopiclone like benzodiazepine drugs bind unselectively to α1, α2, α3 and α5 GABAA benzodiazepine receptors. Zolpidem is more selective and zaleplon is highly selective for the α1 subunit thus giving them an advantage over benzodiazepines in terms of sleep architecture and a reduction in side effects. However, there are controversies over whether these non-benzodiazepine drugs are superior to benzodiazepines. These drugs appear to cause both psychological dependence and physical dependence though less than traditional benzodiazepines and can also cause the same memory and cognitive disturbances along with morning sedation.

Antidepressants
Some older antidepressants such as amitriptyline, doxepin, mirtazapine, and trazodone may have a sedative effect, and are prescribed off label to treat insomnia. The major drawback of these drugs is that they have antihistaminergic, anticholinergic and antiadrenergic properties which can lead to many side effects. Some also alter sleep architecture. As with many benzodiazepines, the use of antidepressants in the treatment of insomnia can lead to physical dependence; withdrawal may induce rebound insomnia and actually further complicate matters in the long-term.

Melatonin
The hormone and supplement melatonin is effective in several types of insomnia. Melatonin has demonstrated effectiveness equivalent to the prescription sleeping tablet zopiclone in inducing sleep and regulating the sleep/waking cycle. One particular benefit of melatonin is that it can treat insomnia without altering the sleep architecture which is altered by many prescription sleeping tablets. Another benefit is it does not impair performance related skills.Melatonin agonists, including Ramelteon (Rozerem), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation. Natural substances such as 5-HTP and L-Tryptophan have been said to fortify the serotonin-melatonin pathway and aid people with various sleep disorders including insomnia.

Antihistamines
The antihistamine Benadryl (diphenhydramine) is widely used in nonprescription sleep aids such as Tylenol PM, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs.
Periactin (Cyproheptadine) is a useful alternative to benzodiazepine hypnotics in the treatment of insomnia. Cyproheptadine may be superior to benzodiazepines in the treatment of insomnia because cyproheptadine enhances sleep quality and quantity whereas benzodiazepines tend to decrease sleep quality.

Atypical Antipsychotics
Low doses of certain atypical antipsychotics such as quetiapine (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia. Over time, Seroquel may lose its ability to produce sedation.
Other Substances
Some insomniacs use herbs such as valerian, chamomile, lavender, hops, and passion-flower. Valerian has undergone multiple studies and appears to be modestly effective.Cannabis has also been proven as an effective treatment for insomnia.

Middle-of-the-night awakenings due to polyuria or other effects from alcohol consumption are common, and hangovers can also lead to morning grogginess.
Insomnia may be a symptom of magnesium deficiency, or low magnesium levels, but this has not yet been proven. A healthy diet containing magnesium, can help to improve sleep in individuals without an adequate intake of magnesium.
Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal.

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