Insomnia

Insomnia is also known as the Disorder of Initiation and/or Maintenance of Sleep ( DIMS).

Insomnia means one or more of the following:

1. Difficulty in initiating sleep (going-off to sleep).

2. Difficulty in maintaining sleep (remaining asleep).

This can include both:

a. Frequent awakenings during the night, and

b. Early morning awakening.

3. Non-restorative sleep where despite an adequate duration of sleep, there is a feeling of not having rested fully (poor quality sleep).

Insomnia is very common, with nearly 15-30% of general population complaining of a period of insomnia per year requiring treatment.

It is required for diagnosis that sleep disturbance occurs at least three times a week for at least 1 month, and that it causes either marked distress or interferes with social and occupational functioning.

The ICD-10 classification defines non-organic insomnia as a condition of unsatisfactory quantity also quality of sleep, which persists for a considerable period of time, including difficulty falling asleep, difficulty staying asleep, or early final wakening. [2]

The patient may complain of:

• Not being able to get to sleep
• Repeated awakenings throughout the night
• Early morning awakening
• Inadequate total quantity of sleep
• Daytime sleepiness
• Irritability
• Fatigue
• Poor attention and concentration
• Substandard performance at daily activities

The patient is usually distressed and preoccupied by sleep problems, and in severe cases social or occupational functioning is negatively affected.

Rarely, the consequences will have been severe; for example, loss of a job due to poor performance secondary to fatigue.

There are often comorbid symptoms of anxiety related to the attempts to obtain adequate sleep.

1. Medical illnesses:

• Any painful or uncomfortable condition
• Heart diseases
• Respiratory diseases
• Rheumatic and musculoskeletal disease
• Old age
• Either Brain stem or hypothalamic lesions
• Delirium
• PMS ( in other words, Periodic movements in sleep)

2. Alcohol and drug use:

• Drug or alcohol withdrawal syndrome
• Delirium tremens
• Amphetamine or other stimulants, e.g. caffeine
• Chronic alcoholism

3. Current medication:

Such as: fluoxetine, steroids, theophylline, propranolol

4. Psychiatric disorders:

• Mania (may not complain of decrease in sleep, as there is often a decreased need for sleep)
• Major depression (diffi culty in maintenance of sleep is more prominent, although diffi culty in initiating sleep is also present)
• Dysthymia (difficulty in initiating sleep is characteristic)
• Anxiety disorder (difficulty in initiating sleep is common)
• Stressful life situation (may cause temporary insomnia)

5. Idiopathic insomnia [2]

Others:

Primary (idiopathic) insomnia i.e.:

No cause found (very rare)

Paradoxical insomnia i.e.:

Complaint of poor sleep despite normal patterns

Psychophysiological insomnia i.e.:

Learned sleep prevention behaviours

Sleep apnoea syndromes, e.g. obstructive sleep apnoea i.e.:

Central alveolar hypoventilation syndrome (Ondine’s curse)

Restless leg syndrome i.e.:

Painful sensations in legs which prevent sleep (in other words, Ekbom’s syndrome)

Periodic limb movement syndrome i.e.:

Episodes of repeated, stereotyped leg movements which prevent sleep, common over 60 years

Environmental i.e.:

Poor sleep hygiene, also stress

Hormonal i.e.:

Menstruation or menopause related

Circadian rhythm disturbance i.e.:

Jet lag, shift work

Rebound insomnia from overuse of hypnotics [1]

According to DSM-IV criteria, the following criteria must be met irrespective of the type of insomnia:

• The predominant complaint is difficulty initiating or maintaining sleep.
• It has been present for at least 1 month.
• It is accompanied by daytime fatigue or impaired daytime functioning.
• Sleep disturbance causes clinically significant distress in social or occupational functioning.
• The disturbance is not better accounted for by another sleep disorder.

Severe and chronic insomnia requires a minimum duration of 6 months with problems on at least three nights of the week. [1]

General measures:

• Identification also treatment of the cause of insomnia
• Psychoeducation

Improve sleep hygiene Psychological treatments (first line)

• Relaxation therapy
• Stimulus control therapy
• Sleep restriction
• Cognitive behavioural therapy

Pharmacological treatments (second line)

• Hypnotics: e.g. Benzodiazepines, Non-benzodiazepines
• Antihistamines
• Antidepressants

Sleep Hygiene:

• Ensure the bedroom is comfortable; additionally control light, temperature, and noise.
• Furthermore, Relax away from the day’s stresses for at least 1 hour before bed.
• Avoid caffeinated drinks (also other stimulants) after 4 pm.
• Avoid smoking for an hour before bed.
• Ensure regular exercise (although not late at night).
• Eat a stable, regular, also suitable diet.
• Besides this, Moderate alcohol consumption.
• Have a milky (or other tryptophan-containing) snack before bed.
• Do not take daytime naps.
• Avoid fluid intake also heavy meals just before bedtime.
• Avoid either reading or watching television while in bed.
• Regular times for going to sleep also waking-up [1]

Coffea cruda:

Drinking coffee causes a wakeful, somewhat excited state, and homeopathically prepared coffee is indicated for persons in just that same state.

This state is sometimes caused by joy, pleasurable excitement, or sudden happy surprises as well as by unexpected bad news.

Such a state may also be found in those who drink too much wine or in those over-fatigued from long journeys. When the person lies down to attempt to sleep, the mind is simply awake with a flow of ideas.

Nux vomica:

In the classic Nux vomica type of insomnia, the patient can often fall asleep early, but awakens at 3:00 or 4:00 a.m. with great mental activity or worries.

When the time to rise rolls around, the patient finally feels able to sleep but instead must get up in a tired, irritable state. This type of acute insomnia is commonly brought on by the overuse of drugs and/or stimulants including alcohol, coffee, and wine, or by overwork or excess studying.

The typical Nux vomica patient is irritable, easily angered, and impatient—in short, a grump. They are often chilly, nervous, and excitable.

Aconite:

The patient needing Aconite is restless and excited with an anguished kind of fear. Such a state often comes on in the early stages of a sudden acute illness, often after a chill.

But this state may also be caused by a shock or fright, such as a serious accident, natural disaster, or operation.

Chamomilla:

Those needing Chamomilla are usually in an irritable, uncivil state. They are often frantic with pain or irritability and say they “cannot stand it.”

They may have the peculiar symptom of being drowsy during the day, but unable to sleep in spite of sleepiness. This irritability is often found in teething infants who insist on being carried, or in adults who will walk the floor.

Arnica:

This is a well-known remedy for those with bruises and other sorts of trauma, and those needing this remedy for insomnia have often been in a recent accident or had recent exertion and strain.

Such a state is known to travelers as “jet lag.” Many of my patients routinely use Arnica for jet lag with great success.

The patient is overtire but cannot sleep and may feel bruised, or the bed may feel too hard. Remember Arnica for those who have nightmares of the accidents or the injuries that they have suffered.

Cocculus:

In generally, Those needing this remedy are sleepless from exhaustion. Additionally, this often comes on from loss of sleep associated with night watching or nursing ill persons.

Their sleep may interrupted by waking and starting. In detail, Patients needing this remedy are often emotionally sensitive, easily offended, also intolerant of contradiction, or they may be extremely sad.

All in all, Motion sickness is a symptom often see in those who will respond to this remedy.

Belladonna:

Patients who need this remedy may sleepy, yet unable to sleep. They often start or jerk suddenly during sleep or when falling asleep.

Teeth-grinding during sleep is a common symptom. They are often restless. This type of sleepless state is often see in those coming down with an acute illness or fever.

Gelsemium:

Those needing this remedy for insomnia are often dull and drowsy, may even trembling.

Yet they cannot get fully to sleep; their bodies are still and they may appear asleep from the outside, but they are on the edge of sleep internally.

Sometimes they start on falling asleep. When finally asleep they may have restless sleep or a stupid, heavy sleep.

Or, conversely, they may have a sort of nervous irritation, much like the Coffea patient, that comes on from anticipation of an upcoming event.

Capsicum:

Think of homeopathic Capsicum for those with sleeplessness from homesickness or similar emotional states, especially if they have red cheeks.

Staphysagria:

Consider this remedy for those who are sleepless after a fit of anger or after a dispute in which their honor wounded and they suppressed their anger.

Some of the other remedies mentioned, such as Nux vomica, Aconite, Chamomilla, and Coffea also may have sleeplessness after a fit of anger. Look at other characteristics to distinguish one from the other. [3]