Preoperative sedation/anxiolysis

Related Terms

Actigraphy, acute, adenoids, alcohol, amphetamines, angioedema, antidepressants, anxiety, anxiousness, asthma, atypical antipsychotic, benzodiazepine, bipolar disorder, caffeine, CHF, chronic obstructive pulmonary disease, chronic, circadian rhythm disorders, cognitive behavior therapy, congestive heart failure, COPD, decongestants, delayed sleep phase syndrome, diabetes, dopamine, DSPS, Epworth Sleepiness Scale, fatigue, fibromyalgia, high blood pressure, hypertension, mania, melatonin agonist, melatonin, neurochemistry, nicotine, nocturnal poyuria, nocturnal, polysomnogram, pseudoephedrine, psychological, restless leg syndrome, RLS, serotonin, sleep apnea, sleep latency, stimulant, tonsils, transient.

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 neurochemical (brain chemical) changes that may cause problems such as depression and anxiety, further complicating the 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.

Signs and symptoms

The main signs and symptoms of insomnia are trouble getting, staying asleep, or waking early, followed by a distinct feeling of fatigue (tiredness) the following day. Most often, daytime symptoms will bring people to seek medical attention. Daytime problems caused by insomnia include anxiousness, irritability, fatigue (tiredness), poor concentration and focus, difficulty with memory, impaired motor coordination, irritability and impaired social interaction, and motor vehicle accidents because of fatigued, sleep-deprived drivers.

Diagnosis

Medical history: A doctor will ask the individual experiencing insomnia questions to evaluate the medical history. Questions investigate mental health problems, medications (supplements, prescription and non-prescription), history of pain, leisure habits, work and home situation, and others.
Sleep history: The doctor will also inquire about the individual's sleep history. Questions inquire about length and severity of the sleeping problem, routines before sleeping, snoring, and noise levels.
Physical exam: The doctor will also give the individual a full physical exam, including blood tests for conditions that may interfere with sleep including thyroid problems.
Sleep study (Polysomnogram): A polysomnogram is a recording of the breathing, movements, heart function, and brain activity during sleep. For this study, the individual sleeps overnight at a sleep center or hospital. A sleep study will be recommended if there are signs of sleep apnea or restless legs syndrome (RLS).
Other: The Epworth Sleepiness Scale is an example of a validated questionnaire that can be used to assess daytime sleepiness. It asks questions about the chances of dozing off during various daily functions such as watching TV, sitting and reading, or driving a car. Actigraphy is another technique to assess sleep-wake patterns over time. Actigraphs are small, wrist-worn devices (about the size of a wristwatch) that measure movement. They contain a microprocessor and on-board memory and can provide objective data on daytime activity. Actigraphs measure day-to-day activity of an individual, recording movement being made during waking and sleeping hours along with light, sound, and temperature. Actigraphy is useful for assessing daytime sleepiness in situations where a laboratory sleep latency test is not appropriate. Actigraphy is used to clinically evaluate insomnia, circadian rhythm sleep disorders, excessive sleepiness, and restless leg syndrome. It is also used in the assessing of the effectiveness of treatments for these disorders.

Complications

Whatever the reason for sleep loss, insomnia can affect people both mentally and physically. The impact can build up over time.
People with chronic insomnia are more likely than others to develop psychiatric problems, such as depression or an anxiety disorder. Additionally, lack of sleep slows problem-solving skills. Long-term sleep deprivation may be due to conditions such as sleep apnea, which increase the severity of chronic diseases (including high blood pressure and diabetes).
Insufficient sleep can also lead to serious or even fatal accidents. According to the National Highway Traffic Safety Administration, more than 100,000 crashes each year are due to drivers falling asleep at the wheel.
In a recent study, scientists discovered that youngsters who snore nightly scored significantly lower on vocabulary tests than those who snore less often.

Treatment

Insomnia is often caused by another disease or psychological problem. In any such case, it is important that the underlying condition be treated to eradicate the insomnia. A psychologist or psychiatrist may be able to determine if psychological issues are causing the insomnia. A physical examination may help determine if the insomnia is caused by other health issues. Recent research has reported that cognitive behavior therapy can be more effective than medication in controlling insomnia. In this therapy, patients are taught improved sleep habits and are counseled on counter-productive thoughts about sleep. For success with this type of therapy, the individual may need to see a therapist weekly over two to three months.
The U.S. Food and Drug Administration (FDA) has issued warnings for all sedative-hypnotic drugs used for sleep regarding the potential for adverse events. Anaphylaxis and severe facial angioedema (swelling) can occur the first time a sleep product is taken. Complex sleep-related behaviors may include sleep-driving (driving while not fully awake, and with no memory of driving), making phone calls, and preparing and eating food while asleep.
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. Physical withdrawal symptoms may occur if the drug is not carefully tapered following long-term use. Most common side effects of benzodiazepines include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heart beat. Benzodiazepines may cause depletion of the natural hormone melatonin from the body. Melatonin helps the body regulate sleep/wake cycles and circadian rhythm.
Non-benzodiazepines: In recent years, a newer class of sedative hypnotic medications has been developed, often termed the non-benzodiazepine, benzodiazepine receptor agonists. These newer medications appear to have better safety profiles and less adverse effects than the benzodiazepines. They are also associated with a lower risk of abuse and dependence than the benzodiazepines, although abuse and dependence do occur. Examples of medications in this class include zolpidem (Ambien?), zaleplon (Sonata?), and eszopiclone (Lunesta?).
Zolpidem (Ambien?, Ambien CR?) may help the individual have a more restful sleep and stay asleep longer. It is typically prescribed for administration at bedtime and may be used when the individual has trouble falling asleep and/or staying asleep. Zaleplon (Sonata?) is generally used in individuals who have trouble falling asleep. It is often taken at bedtime or later, such as when awakening during the night, as long as there are at least four or more hours left to sleep. Eszopiclone (Lunesta?) helps people get to sleep faster and also appears to help the individual stay asleep through the night. The FDA has approved Eszopiclone for patients who have difficulty falling asleep, as well as those who are unable to sleep through the night. Eszopiclone must be taken immediately before bedtime and the individual should make sure that he or she has a full eight hours devoted to sleeping before taking it. As with the other medications, side effects can occur, including daytime drowsiness, dry mouth, and dizziness. Unlike the other medications in this class which are recommended only for use on a temporary basis, Eszopiclone is approved for longer term use (longer than seven days).
Melatonin agonists: Ramelteon (Rozerem?) belongs to a new class of drugs called melatonin agonists. Melatonin is a hormone produced by the pineal gland (located in the brain) during the dark hours of the day-night cycle, also known as the circadian rhythm. Melatonin levels in the body are low during daylight hours. The pineal gland responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize normal circadian rhythm and sleep/wake cycles. Ramelteon is approved by the U.S. Food and Drug Administration (FDA) for insomnia characterized by difficulty falling asleep. These drugs have a relatively mild side effect profile, a lower likelihood of causing morning sedation, and may lack the potential for abuse and dependence. The body regulates back to normal daytime levels of melatonin when it is daylight. Side-effects may include daytime sleepiness, dizziness, and fatigue.
Antidepressants: The sedating antidepressant medications most commonly used to help with sleep include trazodone (Desyrel?), amitriptyline (Elavil?), and doxepin (Sinequan?). When used for sleep, these medicines are used in lower doses than when used in the treatment of depression. Benefits of these antidepressants include a lack of addictive properties or tolerance and the added benefit of providing some analgesic (pain relieving) benefit. Side effects include dry mouth, blurred vision, a "hangover" in the morning, constipation, urinary retention, and nausea.
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?). Combining diphenhydramine with acetaminophen has the added benefits of not only helping the individual sleep better, but providing pain relief also. OTC sleep aids are not intended for long term use, because dependency can develop. Diphenhydramine can cause sedation, dry mouth, and constipation. In the elderly, diphenhydramine can cause confusion and oversedation. Also, many OTC products contain the same ingredients, such as acetaminophen which can be purchased in many combinations. Tylenol? and Tylenol PM? both contain acetaminophen and should not be taken together. Acetaminphen has been reported to cause severe liver damage in overdose. It is recommended by healthcare professionals to not take more than four grams of acetaminophen daily.
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, and antipsychotic effect. Atypical antipsychotics may increase the incidence of extrapyramidal side effects (abnormal movements, muscle stiffness/shaking, or an uncomfortable restless feeling) and weight gain in higher doses. More serious side effects may include diabetes and high cholesterol and triglycerides.
Others: Requip? (ropinirol) may be used if restless leg syndrome (RLS) is present. Restless legs syndrome (RLS) causes a powerful urge to move the legs. The legs become uncomfortable when lying down or sitting. Some people describe it as a creeping, crawling, tingling or burning sensation. Moving makes the legs feel better, but not for long. RLS occurring at night can disrupt sleeping patterns and cause insomnia. Common side effects associated with Requip? include nausea, drowsiness, vomiting, and dizziness.

Integrative therapies

Strong scientific evidence:
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. Although these results are compelling, the majority of studies have had problems with their designs and reporting, and some trials have not found benefits. Overall, the scientific evidence does suggest benefits of melatonin in up to half of people who take it for jet-lag. More trials are needed to confirm these findings, to determine optimal dosing, and to evaluate use in combination with prescription sleep aids.
Caution is advised when taking melatonin supplements, as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor. Melatonin should not be used long-term (nightly for more than four weeks).
Good scientific evidence:
Melatonin: 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.
Caution is advised when taking melatonin supplements, as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor. Melatonin should not be used long-term (nightly for more than four weeks). Case reports raise concerns about risks of blood clotting abnormalities (particularly in patients taking warfarin), increased risk of seizure, and disorientation with overdose.
Music therapy: Music is used to influence physical, emotional, cognitive and social well-being, 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. There is also evidence of benefit in elementary age children who use music during naptime and bedtime. Music therapy is generally known to be safe.
Unclear or conflicting scientific evidence:
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.
Acupressure, Shiatsu: Shiatsu literally means finger (Shi) pressure (Atsu) in Japanese. Shiatsu technique involves finger pressure at acupoints and along body meridians (divisions). It may incorporate palm pressure, stretching, massaging and other manual techniques. Preliminary research suggests that acupressure may be beneficial for improving sleep quality and for providing early prevention and treatment for sleep apnea, a common cause of insomnia. Further research is necessary to confirm these findings.
With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported in the available literature. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.
Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Traditional Chinese medicine commonly uses acupuncture to treat insomnia. A review of available studies found reports of benefit, but major weaknesses in the design of the research makes the evidence insufficient at this time.
Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers because therapy may interfere with the device.
Aromatherapy: Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. The oils are applied to the skin, sprayed in the air, or inhaled. Early research suggests that chamomile or lavender aromatherapy may be beneficial for improving sleep quality. Preliminary research also suggests that aromatherapy may be effective in the treatment of pediatric sleep apnea. More data are needed before definitive conclusions can be made.
Avoid with history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
Ayurveda: Ayurveda, which originated in ancient India over 5,000 years ago, is probably the world's oldest system of natural medicine. There is evidence that a traditional Ayurvedic formula (Blissful Sleep?, Maharishi Ayurvedic Products International) containing valerian (Valeriana wallichi), rose petals (Rosa centifolia), muskroot (Nardostachys jatamansi), heart-leaved moonseed (Tinospora cordifolia), winter cherry (Withania somnifera), pepper (Piper nigrum), ginger (Zingibar officinalis), aloeweed (Convolvulus pluricalis), and licorice root (Glycyrrhiza glabra) may decrease sleep latency (time needed to get to sleep) in people with sleep-onset insomnia, with no side effects. Further research is needed to confirm these results.
Ayurvedic herbs can interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before taking. Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Use guggul cautiously with peptic ulcer disease and avoid taking with sour food, alcohol, and heavy exercise. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages, and medical conditions that require surgery.
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.
Chiropractic: Chiropractic healthcare is a discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. The broad term "spinal manipulative therapy" incorporates all types of manual techniques, including chiropractic. Although physical manipulation is used traditionally for jet lag, there is not enough reliable scientific evidence at this time.
Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, and migraines. Use cautiously with risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis, or arthritis. Avoid if taking drugs that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.
Creatine: Creatine is an amino acid that is produced in the muscles. Early studies of creatine in animals and humans have found mixed results in patients with a breathing disorder in infants called apnea of prematurity. Well-designed studies are needed to better understand this relationship.
Avoid if allergic to creatine or if taking diuretics. Use cautiously with asthma, diabetes, gout, kidney, liver, or muscle problems, stroke, or with a history of these conditions. Avoid dehydration while taking creatine. Avoid if pregnant or breastfeeding.
Focusing: Focusing (experiential therapy) is a method of psychotherapy that involves being aware of one's feelings surrounding a particular issue and understanding the meaning behind words or images conveyed by those feelings. Behavioral intervention may improve sleep, especially in those who chronically use medication to treat insomnia. More research is needed to determine whether focusing can effectively treat insomnia, and whether it can ease withdrawal symptoms when chronic users stop medication.
Side effect reporting is rare, but patients should consult with a qualified healthcare practitioner before making decisions about medical conditions and practices. Individuals with severe emotional difficulties should not abandon proven medical and psychological therapies but rather choose focusing as a possible adjunct therapy.
Guided imagery: Therapeutic guided imagery uses the power of the imagination as a healing tool. Guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Early research supports the value of combined pharmacotherapy and relaxation training in the treatment of insomnia. Further research is necessary.
Guided imagery is usually intended to supplement medical care, not to replace it, and should not be relied on as the sole therapy for a medical problem.
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 an automobile or heavy machinery. Hops supplements are not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
Hypnotherapy, hypnosis: Hypnotherapy or hypnosis uses the power of suggestion to help individuals overcome various health issues such as insomnia. Several early studies report that hypnosis may decrease the amount of time it takes to fall asleep, increase the duration of sleep, and improve sleep quality. However, this research is not well designed or reported, and cannot be considered definitive.
Use cautiously with mental illnesses (e.g. psychosis, schizophrenia, manic depression, multiple personality disorder, or dissociative disorders) or seizure disorders.
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 antidpressants. Avoid if pregnant or breastfeeding.
Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. Limited available study suggests improved sleep quality with the help of a regime of Kundalini yoga practices. However, there is insufficient evidence for or against this intervention for insomnia.
Avoid exercises that involve stoppage of breath with heart or lung problems, insomnia, poor memory, or poor concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Use cautiously with mental disorders. Kundalini yoga is considered safe and beneficial for use during pregnancy and lactation when practiced under the guidance of expert instruction. Teachers of yoga are generally not medically qualified and should not be regarded as sources of medical advice for management of clinical conditions.
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 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 if allergic or hypersensitive to lemon balm. Avoid with Grave's disease or thyroid hormone replacement therapy. Use cautiously in glaucoma because lemon balm may increase eye pressure. Use caution when operating heavy machinery. Lemon balm preparations may contain trace amounts of lead. Avoid if pregnant or breastfeeding.
Meditation: There is currently not enough clinical evidence indicating that meditation improves sleep disorders in patients with breast cancer, drug abuse problems, or in healthy subjects. Additional research is needed in this area.
Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professionals before starting a program of meditation and should explore how meditation may or may not fit in with their current treatment plans. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnose or treatment with more proven techniques or therapies. Meditation should not be used as the sole approach to illnesses.
Melatonin: There is limited consistent evidence on the effectiveness of melatonin for circadian rhythm entraining in blind persons, insomnia of unknown origin in the non-elderly, REM sleep behavior disorder, sleep disturbances due to pineal region brain damage, or work shift sleep disorder. Better research is needed before a conclusion can be made.
Caution is advised when taking melatonin supplements, as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor. Melatonin should not be used long-term (nightly for more than four weeks). Case reports raise concerns about risks of blood clotting abnormalities (particularly in patients taking warfarin), increased risk of seizure, and disorientation with overdose.
Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed 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.
Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, and then relaxing the muscles) should be used cautiously with illnesses such as heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions and should not delay the time to diagnosis or treatment with more proven techniques.
Tai chi: Tai chi techniques aim to address the body and mind as an interconnected system. Tai chi may lead to improved sleep quality in older adults with sleep disorders. More studies are needed before definitive recommendations can be made.
Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.
Valerian: Valerian root (Valerian officinalis) has been used as a sedative and anti-anxiety treatment for more than 2,000 years. Several studies in adults suggest that valerian may improve quality of sleep and reduce the time to fall asleep (sleep latency), for up to four to six weeks. Ongoing nightly use may be more effective than single-dose use for insomnia, with effects increasing and then leveling out over the first four weeks of use. Better effects have been found in poor sleepers. However, most studies have not used scientific methods of measuring sleep improvements, such as sleep pattern data in a sleep laboratory.
Caution is advised when taking valerian supplements, as numerous adverse effects including drowsiness and drug interactions are possible. Caution is also advised when operating heavy machinery or an automobile. Valerian is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Preliminary research reports that yoga may benefit sleep efficiency, total sleep time, number of awakenings, and quality of sleep in patients with insomnia.
Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Certain yoga breathing techniques should be avoided with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction. However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
Fair negative scientific evidence:
Vitamin B12: Taking vitamin B12 orally, in methylcobalamin form, with or without bright light therapy, does not seem to be effective for treating primary circadian rhythm sleep disorders. Additional research would help to confirm these results.
Avoid if allergic or hypersensitive to cobalamin, cobalt, or any other vitamin B12 product ingredients. Avoid with coronary stents (mesh tube that holds clogged arteries open) and Leber's disease. Use cautiously if undergoing angioplasty and with anemia. Vitamin B12 is generally considered safe when taken in amounts that are not higher than the Recommended Dietary Allowance (RDA). There is not enough scientific data available about the safety of larger amounts of vitamin B12 during pregnancy and/or breastfeeding.

Prevention

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: 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. Small amounts of alcohol can cause early sedation or sleepiness, and is often used as a sedative. 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.
Other: 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 try to avoid emotional upset or stressful situations prior to bedtime.
Infants and children: To help infants and children avoid insomnia, healthcare professionals recommend for the parent to avoid being readily available to a child during the night. Otherwise, the child may become dependent on attention and become sleepless if deprived of it. For children who have trouble falling asleep, try to make sure that the child is not disturbed by unnecessary noise. Leaving a radio playing soft music may help cover up disturbing noises. Avoid sending a child to bed as punishment, that can result in poor sleep caused by fear, and never give a child sleeping medicine without consulting a doctor first.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

American Academy of Family Physicians. .
American Academy of Otolaryngology. .
American Academy of Sleep Medicine. .
Atkinson G, Davenne D. Relationships between sleep, physical activity and human health. Physiol Behav. 2007;90(2-3):229-35.
National Institutes of Health. .
National Sleep Foundation. .
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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 a 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, 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. Sleep apnea can be a serious condition, and can result in excessive daytime sleepiness, loud snoring, morning headaches, hypertension (high blood pressure), weight gain, irritability and personality changes, depression, difficulty concentrating, excessive perspiring during sleep, heartburn, reduced libido (sexual drive), nocturia (frequent urination at night), restless sleep, and snorting, gasping, or choking.
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.
Causes in infants: Most newborn babies wake several times during the night, but by the age of six months they typically sleep through the night. At one year, babies will sleep an average of about 16 hours in every 24. Two to three hours of this sleep will be during the day. Causes of sleeplessness in infants may include a desire for parental attention, infantile colic or other digestive problems such as indigestion, hunger, teething, and fever or other illness such as a cold or influenza.

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).

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.
Fatal familial insomnia: Fatal familial insomnia, or FFI, is a very rare inherited disease of the brain. The dominant gene responsible for FFI has been found in just 28 families worldwide. If only one parent has the gene, the offspring have a 50% chance of inheriting it and developing the disease. The disease's progression into complete sleeplessness is untreatable, and ultimately fatal.