Insomnia is the inability to sleep during a period in which sleep should
normally occur. Sufficient and restful sleep is a human necessity. The average
adult needs slightly more than eight hours of sleep per day and only 35% of
American adults consistently get this amount of rest. People with insomnia tend
to experience one or more of the following sleep disturbances: (1) difficulty
falling asleep at night, (2) waking too early in the morning, or (3) waking
frequently throughout the night. Insomnia may stem from a disruption of the
body's circadian rhythm, an internal clock that governs the timing of hormone
production, sleep, body temperature, and other functions. While occasional
restless nights are often normal, prolonged insomnia can interfere with daytime
function, and may impair concentration, diminish memory, and increase the risk
of substance abuse, motor vehicle accidents, headaches, and depression. Recent
surveys indicate that at least one out of three people in the United States have
insomnia, but only 20% bring it to the attention of their physicians.
|Signs and Symptoms|
Common symptoms of insomnia include:
- Not feeling refreshed after sleep
- Inability to sleep despite being tired
- Daytime drowsiness, fatigue, irritability, difficulty concentrating,
and impaired ability to perform normal activities
- Anxiety as bedtime approaches
Insomnia is occasionally a symptom of an underlying medical or psychological
condition, but it may also be caused by stress (from work, school, or family) or
lifestyle choices, such as excessive coffee and alcohol consumption. About 50%
of insomnia cases have no identifiable cause.
Some conditions or situations that commonly lead to insomnia
- Substance abuse—consuming excessive amounts
of caffeine, alcohol, recreational drugs, or certain prescription medications;
smoking can cause restlessness and smoking cessation may also result in
- Disruption of circadian rhythms—shift work,
travel across time zones, or vision loss; circadian rhythms are regulated, in
part, by release of melatonin from the brain
- Menopause—between 30% and 40% of menopausal
women experience insomnia; this may be due to hot flashes, night sweats,
anxiety, and/or fluctuations in hormones
- Hormonal changes during menstrual
cycle—insomnia may occur during menstruation; sleep
improves mid-cycle with ovulation
- Advanced age—biological changes associated
with aging, underlying medical conditions, and side effects from medications all
contribute to insomnia
- Medical conditions—gastroesophageal reflux
(return of stomach contents into the esophagus; frequently causes heartburn),
fibromyalgia or other chronic pain syndromes, heart disease, arthritis,
attention deficit hyperactivity disorder, and obstructive sleep apnea
(difficulty breathing during sleep)
- Psychiatric and neurologic
conditions—anxiety, depression, manic-depressive
disorder, dementia, Parkinson's disease, restless leg syndrome (a sense of
indescribable uneasiness, twitching, or restlessness that occurs in the legs
after going to bed), post-traumatic stress disorder
- Certain medications—decongestants,
bronchodilators, and beta-blockers
- Excessive computer work
- Partners who snore
The following factors may increase an individual's risk for insomnia:
- Age—the elderly are more prone to
- Stressful or traumatic event
- Night shift or changing work schedule
- Travel across time zones
- Substance abuse
- Asthma—bronchodilators occasionally cause
- Excessive computer work
If you report symptoms of insomnia or sleep disorders to your physician, he
or she will first obtain a detailed sleep history by asking questions about your
sleep patterns and sleep quality. He or she will also ask questions to determine
whether you snore, have any underlying medical conditions, take medications, or
have recently undergone any significant life changes. Keeping a sleep diary
(recording all sleep-related information) may help the physician determine the
type of insomnia and how best to treat it. The primary care physician may
recommend a sleep specialist or a sleep disorders center where brain waves, body
movements, breathing, and heartbeats may be electronically monitored during
The following lifestyle changes can help prevent insomnia:
- Exercising regularly—best when done before
dinner; exercise can stimulate arousal so should not be done too close to
- Avoiding caffeine (especially after noon) and nicotine
- Getting regular exposure to late afternoon
sun—stimulates release of melatonin which helps
regulate circadian rhythm
- Practicing stress reduction techniques such as yoga, meditation, or
- Early treatment of insomnia may also help prevent psychiatric
disorders such as depression
Behavioral techniques are the
preferred treatments for people with chronic insomnia. Up to 80% of those with
insomnia improve with these approaches, and, unlike many medications for
insomnia, behavioral techniques do not carry significant risks and side effects.
Studies also indicate that healthy sleep habits are necessary for treating
insomnia, regardless of its cause, particularly in combination with
mind/body therapies such as
stimulus control therapy, bright-light therapy, and cognitive-behavioral
acupuncture and acupressure have a long
tradition of treating insomnia successfully, particularly in the elderly; the
valerian, may be useful for certain
Homeopathic remedies may also improve
symptoms in some individuals. Generally,
medications by prescription or
over-the-counter (OTC) are helpful in promoting sleep, but they are not
recommended for insomnia that persists for more than 4 weeks. Long-term use of
some medications may cause addiction.
Studies reveal that healthy sleep habits are essential for treating insomnia.
The following healthy sleep habits (in addition to the steps mentioned in the
Preventive Care section) may help treat the condition:
- Maintaining a consistent bed and wake time
- Establishing the bedroom as a place for sleep and sexual activity
only, not for reading, watching television, or working
- Avoiding naps, especially in the evening
- Taking a hot bath about two hours before bedtime
- Keeping the bedroom cool, well-ventilated, quiet, and dark
- Avoiding looking at the clock; this promotes anxiety and obsession
- Avoiding fluids just before bedtime
- Avoiding television just before bedtime
- Eating a carbohydrate snack, such as cereal or crackers, just before
- If sleep does not occur within 15 to 20 minutes in bed, moving to
another room with dim lighting
Generally, medications may be helpful for short-term insomnia, but they are
not recommended for insomnia that persists for more than 4 weeks. These
- Over-the-counter sleeping pills (such as
diphenhydramine)—promote sleep if insomnia occurs only
- Antidepressants (such as trazodone)—may be
prescribed in low doses at night to promote sleep
- Benzodiazepines (such as triazolam and
lorazepam)—often very successful for resolving insomnia
in the short term; long-term use may have serious side effects including daytime
drowsiness, depression, sleep walking, and addiction; must not be used with
- Non-benzodiazepine short-acting hypnotics (such as zoldipam and
zaleplon)—fewer side effects and less likely to cause
addiction than benzodiazepines; particularly effective for elderly and depressed
people; side effects may include nightmares and headaches; should not be used
|Nutrition and Dietary Supplements|
A carbohydrate snack of cereal or crackers with milk before bed may help
because foods rich in carbohydrates and low in protein and fat may boost the
production of serotonin and melatonin, brain chemicals thought to promote sleep.
The following dietary supplements may also be helpful in promoting sleep:
L-tryptophan and 5-hydroxytryptophan (5-HTP)
Medical research indicates that supplementation with 1 g L-tryptophan before
bedtime can induce sleepiness and delay wake times. L-tryptophan is thought to
bring on sleep by raising levels of serotonin, a body chemical that promotes
relaxation. This supplement should be used with caution, however, as it may
adversely interact with certain anti-depressants (including selective serotonin
reuptake inhibitors [SSRIs] and monoamine oxidase inhibitors [MAOIs]) and cause
serious negative side effects. Reports of eosinophilia myalgia syndrome (EMS; an
autoimmune disorder characterized by fatigue, fever, muscle pain and tenderness,
cramps, weakness, hardened skin, and burning, tingling sensations in the
extremities), from contaminated L-tryptophan supplements surfaced in 1989, and
isolated incidents of EMS continue to be reported on occasion.
Studies also suggest that 5-hydroxytryptophan, made from tryptophan in the
body or available in supplement form, may be useful in treating insomnia
associated with depression. Like tryptophan, however, reports of EMS have been
associated with its use.
Melatonin supplements appear to be most useful for inducing sleep in certain
people, particularly those with disrupted circadian rhythms (such as from jet
lag or shift work) or those with low levels of melatonin (such as some people
with schizophrenia). In fact, a recent review of scientific studies found that
melatonin supplements help prevent jet lag, particularly in people who cross
five or more time zones. A few studies suggest that melatonin is significantly
more effective than placebo in decreasing the amount of time required to fall
asleep, increasing the number of sleeping hours, and boosting daytime alertness.
Although research suggests that melatonin may be modestly effective for treating
certain types of insomnia, few studies have investigated whether melatonin
supplements are safe and effective over the long term. More research is needed
in this area. Generally, when melatonin is used, 1 to 3 mg of the supplement is
recommended for sleep, but as little as 0.3 mg has been used
Valerian (Valeriana officinalis)
Studies have shown that valerian acts as a mild sedative and improves both
the ability to fall asleep and the quality of sleep. In one trial, 166 people
were randomly assigned to receive valerian extract, an herbal mixture containing
valerian, hops (Humulus lupulus), and lemon balm (Melissa
officinalis), or placebo. The participants who received either valerian
alone or the herbal mixture reported that sleep quality and the ability to fall
asleep improved. Other studies have reported similar results. Valerian should
not be combined with barbiturates, which currently are rarely prescribed for
insomnia. A typical dose of valerian ranges from 150 to 450 mg per day.
Kava kava (Piper methysticum)
Short-term clinical studies suggest that kava kava is effective for insomnia.
According to a recent study, kava kava and diazepam (one of the benzodiazepines)
induce similar changes in brain wave activity. Although quite rare, kava may
cause skin reactions and liver failure (when used at very high doses for a
prolonged period). This herb should not be used at the same time as
Other herbs that a professional herbalist may use to treat insomnia
- Passionflower (Passiflora incarnata)
- Hops (Humulus lupulus)
- Jamaica dogwood (Piscidia erythrina/Piscidia
- Lemon balm (Melissa officinalis)
- Lavender flower (Lavandula angustifolia)
- German chamomile (Matricaria recutita)
- Motherwort (Leonarus cardiaca)
- Gotu kola (Centella asiatica)
- Skullcap (Scultellaria
There have been few studies examining the effectiveness of specific
homeopathic remedies. A professional homeopath, however, may recommend one or
more of the following treatments for insomnia. based on his or her knowledge and
clinical experience. Before prescribing a remedy, homeopaths take into account a
person's constitutional type. In homeopathic terms, a person's constitution is
his or her physical, emotional, and intellectual makeup. An experienced
homeopath assesses all of these factors when determining the most appropriate
remedy for a particular individual.
- Aconitum — for insomnia that occurs as
a result of illness, fever, or vivid, frightening dreams; commonly used for
- Argentum nitricum — for impulsive
children who are restless and agitated before bedtime and cannot fall asleep if
the room is too warm
- Arsenicum album — for insomnia
that occurs after midnight due to anxiety or fear; this remedy is most
appropriate for demanding individuals who are often restless, thirsty, and
- Chamomilla — for insomnia caused by
irritability or physical pains; sleep may be disturbed by twitching and moaning;
this remedy is appropriate for infants who have difficulty sleeping because they
are teething or colicky; older children may demand things, then refuse them when
they are offered
- Coffea — for insomnia due to excitable
news or sudden emotions; this remedy is most appropriate for individuals who
generally have difficulty falling asleep and tend to be light sleepers; often
used to counteract the effects of caffeine, including in infants exposed to
caffeine by way of breastfeeding
- Ignatia — for insomnia caused by grief
or recent loss; this remedy is most appropriate for individuals who yawn
frequently or sigh while awake
- Kali phosphoricum — for night terrors
associated with insomnia; this remedy is most appropriate for individuals who
are easily startled and restless, often with fidgety feet; anxiety is often
caused by both nightmares and events in the individual's life
- Nux vomica — for insomnia caused by
anxiety, anger, irritability, or use of caffeine, alcohol, or drugs; this remedy
is most appropriate for individuals who wake up early in the morning, for
children who often have dreams of school or fights and may be awakened by slight
disturbances; nux vomica may also be used to treat insomnia that occurs
as a side effect of medications
- Passiflora — for the elderly and young
children, whose minds are often overactive
- Pulsatilla — for women and children
who are particularly emotional and do not like sleeping alone; sleeping in a
warm room tends to worsen insomnia and the individual may cry due to the
inability to fall asleep
- Rhus toxicodendron — for restlessness
and insomnia caused by pains that occur when the individual is lying
Some reports suggest that acupuncture may have a nearly 90% success rate for
the treatment of insomnia. Through a complex series of signals to the brain,
acupuncture increases the amount of certain substances in the brain, such as
serotonin, which promote relaxation and sleep. Studies of elderly people with
sleep disturbances suggest that acupressure enhances sleep quality and decreases
awakenings during the night. An acupressure practitioner works with the same
points used in acupuncture, but stimulates these healing sites with finger
pressure, rather than inserting fine needles.
No well-designed studies have evaluated the effect of chiropractic on
individuals with insomnia, but chiropractors report that spinal manipulation may
improve symptoms of the condition in some individuals. It is speculated that, in
these cases, spinal manipulation may have a relaxing effect on the nervous
|Massage and Physical Therapy|
Massage has long been known to enhance relaxation and improve sleep patterns.
While massage alone is an effective method for relaxation, studies suggest that
massage with essential oils, particularly lavender (Lavandula
angustifolia), may result in improved sleep quality, more stable mood,
increased mental capacity, and reduced anxiety. In one recent study,
participants who received massage with lavender felt less anxious and more
positive than participants who received massage alone.
A variety of behavioral techniques have proved helpful in treating insomnia.
These methods, with the guidance of a sleep specialist or a sleep specialty
team, are singly used to treat insomnia, but they may also be combined with
other methods of treatment. These methods include:
Keeping a daily/nightly record of sleep habits (including the amount of
sleep, how long it takes to fall asleep, the quality of sleep, the number of
awakenings throughout the night, any disruption of daytime behaviors, attempted
treatments and how well they worked, mood, and stress level) can help a person
understand and, consequently overcome his or her insomnia.
Stimulus Control Techniques
This technique involves learning to use the bedroom only for sleeping and
sexuality. Individuals using this technique learn to go to bed only when tired
and leave the bedroom when not asleep. They must also wake up at the same time
every day, including weekends and vacations, regardless of the amount of sleep
This method involves improving sleep "efficiency" by attempting to spend at
least 85% of time in bed asleep. The time spent in bed is decreased each week by
15 to 20 minutes until the 85% goal is achieved. Once accomplished, amount of
time in bed is increased again on a weekly basis.
Relaxation Training Techniques
Progressive relaxation, meditation, yoga, guided imagery, hypnosis, or
biofeedback can break the vicious cycle of sleeplessness by decreasing feelings
of anxiety about not being asleep. Studies indicate that these therapies
significantly reduce the amount of time it takes to fall asleep, increase total
sleep time, and decrease the number of nightly awakenings.
This therapy is intended to re-establish healthy sleep patterns by helping an
individual cope with his or her sleep problem. One cognitive-behavioral
approach, called paradoxical intention, helps to retrain an individual's fears
of sleep by doing the opposite of what is causing the anxiety. For example, a
person with insomnia worries long before going to bed about not being able to
sleep and the difficulty he or she will have at bedtime. Rather than preparing
to go to sleep, therefore, the person prepares to stay awake. Another
cognitive-behavioral technique, called thought stopping, allows a person with
insomnia a certain period of time to repeatedly and continuously think about
going to bed. This technique helps "wear out" the anxiety associated with going
to bed, and decreases the likelihood that he or she will obsess about falling
asleep at other times.
|Traditional Chinese Medicine|
Many methods have been used historically in Traditional Chinese Medicine to
treat insomnia including herbal remedies, acupuncture, Chinese massage (tui na),
and qi gong.
Acupuncture is considered to be the
- Insomnia usually occurs in the later months of pregnancy when the
mother's size and need to urinate disrupt sleep.
- Benzodiazepines should be avoided during pregnancy and while
|Warnings and Precautions|
- Alcohol should be avoided in those who are taking prescription
medications or OTC sleeping pills
- Discontinuing prescription medications or OTC sleeping pills can lead
to rebound insomnia
|Prognosis and Complications|
Most people who have insomnia with no underlying medical conditions tend to
recover within a few weeks. For those who develop insomnia from a traumatic
event (such as those with posttraumatic stress disorder), sleep disruptions can
continue indefinitely. People who become dependent on sleeping pills and
prescription medication for sleep often have the most difficulty overcoming
Attele AS, Xie JT, Yuan CS. Treatment of insomnia: an alternative
approach. Altern Med Rev. 2000;5(3):249-259.
Balderer G, Borbely AA. Effect of valerian on human sleep.
Psychopharmacology (Berl). 1985;87(4):406-409.
Blumenthal M, ed. Herbal Medicine: Expanded Commission E Monographs.
Boston, Mass: Integrative Medicine Communications; 2000:226-229, 267-269.
Bootzin RR, Perlils ML. Nonpharmacologic treatments of insomnia. J Clin
Cauffield JS, Forbes HJ. Dietary supplements used in the treatment of
depression, anxiety, and sleep disorders. Lippincotts Prim Care Pract.
A, Schmid K. Tolerability and efficacy of valerian/lemon balm in healthy
volunteers (a double-blind placebo-controlled, multicentre study).
Fitoterapia. 1999; 70(1999):221-228.
Chase JE, Gidal BE. Melatonin: Therapeutic use in sleep disorders. Ann
Chen ML, Lin LC, Wu SC, Lin JG. The effectiveness of acupressure in improving
the quality of sleep of institutionalized residents. J Gerontol A Biol Sci
Med Sci. 1999; 54(8):M389-M394.
Cummings S, Ullman D. Everybody's Guide to Homeopathic Medicines.
3rd ed. New York, NY: Penguin Putnam; 1997: 310-312.
Czeisler CA, Richardson GS. Disorders of sleep and circadian rhythms. In:
Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of
Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:154-155.
Escher M, Desmeules J, Giostra E, Mentha G. Hepatitis associated with kava, a
herbal remedy for anxiety. BMJ. 2001;322:139.
FDA Talk Paper. Impurities confirmed in dietary supplement
5-hydroxy-L-tryptophan. 1998. Accessed at
on February 2, 2001.
Fugh-Berman A, Cott JM. Dietary supplements and natural products as
psychotherapeutic agents. Psychosom Med. 1999;61(5):712-728.
Garfinkel D, Laundon M, Nof D, Zisapel N. Improvement in sleep quality in
elderly people by controlled-release melatonin (see comments). Lancet.
Herxheimer A, Petrie KJ. Melatonin for preventing and treating jet lag.
Copcharane Database Syst Rev. 2001;(1):CD001520.
Juhl JH. Fibromyalgia and the serotonin pathway. Altern Med Rev.
Leathwood PD, Chauffard F, Heck E, Munoz-Box R. Aqueous extract of valerian
root (Valeriana officinalis L.). Pharmacol Biochem Behav.
Lin Y. Acupuncture treatment for insomnia and acupuncture analgesia.
Psychiatry Clin Neurosci. 1995;49(2):119-120.
Miller LG. Herbal medicinals: selected clinical considerations focusing on
known or potential drug-herb interactions. Arch Intern Med.
Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for
insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry. 1994;
Murtagh DR, Greenwood KM. Identifying effective psychological treatments for
insomnia: a meta-analysis. J Consult Clin Psychol. 1995; 63(1):79-89.
National Heart, Lung, and Blood Institute Working Group on Insomnia.
Insomnia: Assessment and Management in Primary Care. National
Center on Sleep Disorders Research and Office of Prevention, Education, and
Control, National Institutes of Health and American Sleep Disorders Association.
September 1998. Accessed at
on February 15, 2001.
Rajput V, Bromley SM. Chronic insomnia: a practical review. Am Fam
Rakel RE, ed. Conn's Current Therapy. 50th ed. Philadelphia, Pa: WB
Saunders Co; 1998.
Schulz H, Stolz C, Muller J. The effect of valerian extract on sleep
polygraphy in poor sleepers: a pilot study. Pharmacopsychiatry.
Shamir E, Laudon M, Barak Y, Anis Y, Rotenberg V, Elizur A, Zisapel N.
Melatonin improves sleep quality of patients with chronic schizophrenia. J
Clin Psychiatry. 2000;61(5):373-377.
Skene DJ, Lockley SW, Arendt J. Use of melatonin in the treatment of phase
shift and sleep disorders. Adv Exp Med Biol. 1999;467:79-84.
Stoschitzky K, Sakotnik A, Lercher P, Zweiker R, Maier R, Liebmann P, Lindner
W. Influence of beta-blockers on melatonin release. Eur J Clin Pharmacol.
Ullman D. Homeopathic Medicine for Children and Infants. New York, NY:
Penguin Putnam; 1992: 108-110.
Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin
Putnam; 1995: 270-271.
Wagner DR. Circadian rhythm sleep disorders. Current Treatment Options in
Wagner J, Wagner ML, Hening WA. Beyond benzodiazepines: alternative
pharmacologic agents for the treatment of insomnia. Ann Pharmacother.
Wong AH, Smith M, Boon HS. Herbal remedies in psychiatric practice.
Arch Gen Psychiatry. 1998; 55(11):1033-1044.
|Review Date: December 2001|
|Reviewed By: Participants in the review process include: Ruth Debusk, RD, PhD, Editor,
Nutrition in Complementary Care, Tallahassee, FL; Gary Guebert, DC, DACBR,
(Chiropractic section October 2001) Login Chiropractic College, Maryland
Heights, MO; Lonnie Lee, MD, Internal Medicine, Silver Springs,
MD; Andrew Littman, MD, Psychiatry Department, Massachusetts General
Hospital, Boston, MA; Joseph Trainor, DC, (Chiropractic section October 2001)
Integrative Therapeutics, Inc., Natick, MA; Tom Wolfe, P.AHG, Smile Herb Shop,
College Park, MD.|
Copyright © 2004 A.D.A.M., Inc
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