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Introduction

Insomnia is defined as difficulty initiating, or maintaining sleep at least 3 nights per week, in addition to complaints of sleep-related daytime impairment. It is the most common sleep disorder, affecting up to 10% of adults. Sufficient and restful sleep is a human necessity. The average adult needs slightly more than 8 hours of sleep a day. But 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:

  • Difficulty falling asleep at night

  • Waking too early in the morning

  • Waking frequently throughout the night

  • Sleep that is chronically non-restorative or poor

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 normal, prolonged insomnia can interfere with daytime function, concentration, and memory. Insomnia increases the risk of substance abuse, motor vehicle accidents, headaches, and depression. Recent surveys indicate that 50% of people suffer from sleep difficulties, and 20 to 36% of them struggle with such difficulties for at least 1 year. Other studies show that 1 person out of 3 in the United States has insomnia, but only 20% tell their health care providers about it.

 

Signs and Symptoms

Signs of insomnia may 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

  • Tension headaches

 

Causes

No known physical or mental condition causes primary insomnia, although doctors suspect it 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. Anxiety and stress, coffee, and alcohol are common culprits. Preliminary studies also suggest a genetic component.

An underlying medical or psychological condition, such as depression or sleep apnea, often causes secondary insomnia. Studies show that 40 to 60% of people who have insomnia show signs of depression.

About 50% of insomnia cases have no identifiable cause.

Some conditions or situations that commonly lead to insomnia include:

  • Substance abuse. Consuming excessive amounts of caffeine, alcohol, recreational drugs, or certain prescription medications, such as stimulants, can disrupt the body's natural sleep-wake cycles. Smoking can cause restlessness and quitting smoking may also cause temporary insomnia.

  • Disruption of circadian rhythms. Shift work, travel across time zones, or vision loss can impair the body's natural clock. Circadian rhythms are regulated, in part, by release of a hormone called melatonin from the brain. As individuals age, less melatonin is available for use by the body.

  • Menopause. Between 30 to 40% of menopausal women experience insomnia. This may be due to hot flashes, night sweats, anxiety, or fluctuations in hormone levels.

  • 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), fibromyalgia, other chronic pain syndromes, heart disease, arthritis, attention deficit hyperactivity disorder, and obstructive sleep apnea (difficulty breathing during sleep) may prevent you from settling into a restorative sleep.

  • Psychiatric and neurologic conditions. Anxiety, depression, manic depressive disorder, dementia, Parkinson's disease, restless legs syndrome, and post-traumatic stress disorder are associated with insomnia.

  • Certain medications. Decongestants (such as pseudoephedrine or Sudafed), bronchodilators (such as albuterol or Proventil inhaler), and beta-blockers (such as metoprolol or Lopressor) are associated with sleep disruptions.

  • Excessive computer work. Too much mental stimulation, particularly close to bedtime, can make it difficult to fall asleep.

  • Partners who snore. Unpredictable noises can prevent you from falling asleep or cause you to wake up in the middle of the night.

 

Risk Factors

The following factors may increase an individual's risk for insomnia:

  • Age. The elderly are more prone to insomnia.

  • Gender. Women are more likely to have insomnia than men.

  • Stressful or traumatic event

  • Night shift or changing work schedule

  • Travel across time zones

  • Substance abuse

  • Asthma. Bronchodilators occasionally cause insomnia.

  • Excessive computer work

  • Depression

  • Sedentary lifestyle

 

Diagnosis

Clinical history (including all current medication and recreational drug use) and physical exam are usually sufficient to make the diagnosis. Polysomnography, an overnight sleep study, can be helpful to rule out other types of sleep disorders, such as breathing-related sleeping disorder.

 

How acupuncture can help

Reviews are consistent in showing that most trials have found acupuncture (or acupressure or related procedures) to be significantly more effective than hypnotic drugs (usually benzodiazepines), no treatment, or sham acupuncture (Sun 2010, Cao 2009, Yeung 2009, Lee 2008, Cheuk 2007). Meta-analysis supports these conclusions. Nevertheless, reviewers have been cautious in their recommendations because of the poor methodological quality of most trials; rigorous, large scale studies are needed to address this. There are now substantial numbers of more recent (published subsequent to the reviews' data collection) randomised trials with positive results, though not for every sleep measure used in every trial (Luo 2010, Reza 2010, Yeung 2009, Lee 2009a, Huang 2009, and others). On the evidence that we have, given that acupuncture appears to be at least as effective as existing conventional drugs, without their level of side effects, it could be considered as one of the therapeutic options for insomnia. (See table overleaf for details).

 

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body's homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the 'analytical' brain, which is responsible for insomnia and anxiety (Hui 2010).

 

Research has shown that acupuncture treatment may specifically be of benefit in people with insomnia by:

  • increasing nocturnal endogenous melatonin secretion (Spence et al 2004).

  • stimulating opioid (especially b-endorphin) production and µ-opioid receptor activity (Cheng et al 2009).

  • increasing nitric oxide synthase activity and nitric oxide content, helping to promote normal function of brain tissues, which could help to regulate sleep (Gao et al 2007).

  • increasing cerebral blood flow (Yan 2010)

  • reducing sympathetic nervous system activity, hence increasing relaxation (Lee 2009a)

  • regulating levels of neurotransmitters (or their modulators) such as serotonin, noradrenaline, dopamine, GABA and neuropeptide Y; hence altering the brains's mood chemistry to help to increase relaxation and reduce tension (Lee 2009b; Samuels 2008; Zhou 2008).

Acupuncture can be safely combined with conventional medical treatments for insomnia, such as benzodiazepines, helping to reduce their side effects and enhance their beneficial effects (Cao et al 2009).

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