For years, doctors have been discouraged by Americans disregard for and mismanagement of their sleep.

But bragging about how little you sleep, a hallmark of the 80s power broker is starting in certain circles to come off as masochistic buffoonery. The sleep doctors we once ignored appear on morning shows to offer tips. Health professionals and marketers are hopeful that a new seriousness about sleep will continue moving out of a luxury-minded vanguard and into the mainstream. Sleep may finally be claiming its place beside diet and exercise as both a critical health issue and a niche for profitable consumer products. -- From "The Sleep-Industrial Complex," by Jon Mooallem, Nov. 18, 2007 Harvey Simon author the new york times 1997-2008 Sleeping difficulty, called insomnia, can involve difficulty falling asleep when you first go to bed at night, waking up too early in the morning, and waking up often during the night. Alternative Names Insomnia; Inability to sleep; Dyssomnia; Sleeplessness; Wakefulness In-Depth From A.D.A.M. Background Insomnia comes from the Latin words for no sleep. Insomnia is characterized by: Difficulty falling asleep Difficulty staying asleep Waking up too early in the morning Some experts believe that poor quality (nonrestorative) sleep is also related to insomnia. Insomnia can cause daytime fatigue, irritability, and impaired performance. Approximately 60 million Americans each year suffer from insomnia. Insomnia may be primary or secondary: Primary insomnia means that the inability to sleep is not caused by other health problems. Secondary insomnia is due to other health conditions that interfere with sleep. Some experts prefer the term comorbid insomnia. Wikipedia Sleep is a natural state of bodily rest observed throughout the animal kingdom. It is common to all mammals and birds, and is also seen in many reptiles, amphibians and fish. In humans, other mammals, and a substantial majority of other animals which have been studied such as fish, birds, ants, and fruit-flies regular sleep is essential for survival However, its purposes are only partly clear and are the subject of intense research. 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. According to the U.S. Department of Health and Human Services in year 2007, approximately 64 million Americans suffer from insomnia each year.[4] Insomnia occurs 1.4 times more commonly in women than in men.
Insomnia: The perception or complaint of inadequate or poor-quality sleep because of one or more of the following: difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Insomnia is not defined by the number of hours of sleep a person gets or how long it takes to fall asleep. Individuals vary normally in their need for, and their satisfaction with, sleep. Insomnia may cause problems during the day, such as tiredness, a lack of energy, difficulty concentrating, and irritability.

4.) Children need a greater amount of sleep per day than adults to develop and function properly: up to 18 hours for newborn babies, with a declining rate as a child ages.[8][6] A newborn baby spends almost half of its sleep time in REM-sleep. By the age of five or so, only a bit over two hours are spent in REM.[16] Average amount of Age sleep per day Newborn 1-12 months 1-3 years 3-5 years 5-12 years Adolescents Adults, elderly including up to 18 hours 1418 hours 12-15 hours 11-13 hours 9-11 hours 9-10 hours 7-8 (+) hours

Pregnant women 8 (+) hours Duration of Insomnia Insomnia, usually temporary, is often categorized by how long it lasts: Transient insomnia lasts for a few days Short-term insomnia lasts for no more than 3 weeks Chronic insomnia occurs at least 3 nights per week for 1 month or longer Forms of Insomnia Insomnia may also be defined in terms of inability to sleep at conventional times. The following examples are referred to as circadian rhythm disorders: Delayed Sleep-Phase Syndrome. Delayed sleep-phase syndrome is the term for a circadian clock that runs late but reliably. People who have this condition (usually adolescents) fall asleep very late at night or in early morning hours, but then sleep normally. Advanced Sleep-Phase Syndrome. This syndrome tends to develop in older people. It produces excessive sleepiness in the morning and undesired awakening early (3:00 - 5: Considerations Everyone has an occasional sleepless night, and this is not a problem for most people. However, as many as 25% of Americans report occasional sleeping problems, and

insomnia is a chronic problem for about 10% of people. The lack of restful sleep can affect your ability to carry out daily responsibilities because you are too tired or have trouble concentrating. All types of insomnia can lead to daytime drowsiness, poor concentration, and the inability to feel refreshed and rested in the morning. Most adults do best with about 8 hours of sleep each night until age 60, after which 6 hours may be enough. Even though the elderly need less sleep, almost one half of people over 60 experience some degree of insomnia. The best measure of the amount of sleep needed is how you feel. If you awaken feeling refreshed, you are getting enough sleep. For some people, this may take only 4 hours. Others can need up to 10 hours to feel rested. Using long-acting or high-dose sedatives as a "cure" for insomnia can make the problem worse, not better, over time. Antihistamines (the main ingredient in over-the-counter sleeping pills) can lead to similar difficulties. Using antihistamines over time may also affect your memory. Strong, prescription sedatives do not produce a natural, restful sleep. In addition, you can become dependent on or tolerant of these drugs. In this case, the same dose of the drug no longer produces sleep, which may lead you to try a higher dose. Higher doses worsen the chance of dependence, tolerance, and side effects. Stopping these medications can cause a rebound insomnia and withdrawal. A life-threatening disease is rarely the cause of problems with sleep. For many people, poor sleep habits are the cause. However, because insomnia is a key symptom of depression, you should be checked for depression if you are having trouble sleeping. Insomnia may cause: Dark circles under the eyes Disorientation Fatigue Irritability Posture changes Reduced energy level It may help to see a psychiatrist, doctor, or another mental health provider to evaluate psychiatric disorders that can lead to insomnia. If you are depressed, antidepressants can help both the sleeping problem and the depression. These medications do not carry the same concerns about tolerance and dependence as sedatives. Counseling may help with nightmares and dreams that interfere with sleep. Causes Sleeplessness in adults may be due to: Aging Alcoholism or abruptly stopping alcohol after long-term use Anxiety

Bed or bedroom that does not promote sleep Depression or major depression Diseases, such as an enlarged prostate, cystitis, COPD, arthritis, heartburn, and heart or lung problems Exhilaration or excitement Grief Illicit street drugs, such as amphetamines and cocaine Jet lag Lack of exposure to bright light or sunlight Medications, such as too much thyroid medicine, ephedrine, phenylpropanolamine, theophylline derivatives, and others Overactive thyroid Restless leg syndrome Shift work Sleeping too much during the day Stimulants taken in the evening, including nicotine, alcohol, caffeine, or food Stress and worrying Suddenly stopping a medication (such as sleeping pills or sedatives) Too much stimulation at bedtime Wake-sleep pattern disturbances IN INFANTS Most newborn babies wake several times during the night, but by the age of 6 months they usually sleep through the night. At age 1, babies will sleep an average of 16 out of every 24 hours. Two to three hours of this sleep will be during the day. Sleeplessness in infants may be due to: Desire for attention from parents Fever or other illness Hunger Indigestion Infantile colic or other digestive problems Teething Home Care Try changing your nighttime sleeping habits and other behavior before taking drugs for insomnia. For example: Avoid emotional upset or stressful situations before bedtime. Avoid using alcohol in the evening. Avoid caffeine for at least 8 hours before bedtime. Give up smoking, because nicotine is a stimulant. Eat a light snack before bedtime. Foods such as warm milk or turkey contain a natural sleep inducer called Ltryptophan. Establish a regular bedtime, but don't go to bed if you feel wide awake. Exercise regularly, but not in the last 2 hours before going to bed. Exercise, especially aerobic exercise, has been shown to make people fall asleep faster and get deeper and more restful sleep. Sex can be a natural sleep inducer for some people. Relax by reading, taking a bath, or listening to soothing music before going to bed.

Take your TV or computer out of your bedroom. Otherwise, your brain becomes used to the stimulation and starts to expect it when you are there. This makes it harder for you to fall asleep. Use the bedroom for bedroom activities only. Once in bed, use creative imagery and relaxation techniques to keep your mind off unrestful thoughts. Avoid staying in bed for long periods of time while awake, or going to bed because of boredom. IN INFANTS AND CHILDREN Avoid going in to your child's room throughout the night. Otherwise, the child may depend on the attention and become sleepless if you don't offer it. Avoid sending your child to bed as punishment, which can make the child afraid and lead to poor sleep. For children who have trouble falling asleep, try to make sure that the child is not disturbed by noise. Leaving a radio playing soft music may help cover up disturbing noises. Never give a child sleeping medicine without asking the doctor first. It's usually not a good idea to treat the problem with drugs. MEDICATION Avoid all sedatives, including benzodiazepines, during pregnancy. Over-the-counter sleep medicines can have side effects, including a "hangover" effect the next morning. If these fail, you may want to ask your health care provider to recommend other options. Use medication as a last resort. MEDICATIONS Most people don't need medication. Your health care provider can talk to you about using prescribed medications if everything else has failed. Some antidepressants such as Elavil (amitriptyline) can be used at bedtime because they make you drowsy. They require a prescription. If insomnia is caused by depression, treating the depression with the right medications or therapy should solve the problem. Benzodiazepines such as Valium (diazepam) or Ativan (lorazepam) are anti-anxiety medications that can also help people sleep. They must be used with caution because they can be addictive. They also require a prescription. Newer sleep medicines help reduce the time it takes you to fall asleep. They are less likely to be addictive than benzodiazepines. Two examples are the prescription medicines Ambien (zolpidem) and Sonata (zaleplon). WARNING: The FDA has asked manufacturers of sedative-hypnotic sleep medicines to put stronger warning labels on their products so that consumers are more aware of the potential risks. Possible risks while taking such medicines include severe

allergic reactions and dangerous sleeprelated behaviors, including sleep-driving. Female Hormonal Fluctuations Fluctuations in female hormones play a major role in insomnia in women over their lifetimes. This insomnia is usually temporary. During Menstruation. Progesterone promotes sleep, and levels of this hormone plunge during menstruation, causing insomnia. (When they rise during ovulation, women may become sleepier than usual.) During Pregnancy. The effects of changes in progesterone levels in the first and last trimester can disrupt normal sleep patterns. Menopause. Insomnia can be a major problem in the first phases of menopause, when hormones are fluctuating intensely. Insomnia during this period may be due to different factors that occur. In some women, hot flashes, sweating, and a sense of anxiety can awaken women suddenly and frequently at night. Insomnia may also be caused by psychologic distress provoked by this life passage. In many cases, insomnia is temporary. Excessive Light at Night. A person's biologic circadian clock is triggered by sunlight and very bright artificial light maintains wakefulness. One study indicated that even dim artificial light might disrupt sleep. Insufficient Light During the Day. Insufficient exposure to light during the day, as occurs in some disabled elderly patients who rarely venture outside, may also be linked with sleep disturbances. One study suggested that when a person is exposed to bright daylight, melatonin levels increase in response to darkness at night, which aids sleep. Other Causes of Short-Term or Transient Insomnia Caffeine. Caffeine is a stimulant, which can interfere with falling asleep. Nicotine. Nicotine is also a stimulant, but quitting smoking itself can lead to transient insomnia. In fact, it has been suggested that if sleeping could be improved during withdrawal from smoking, then perhaps it would be easier to quit smoking. Partner's Sleep Habits. In one survey, 17% of women and 5% of men reported that their partner's sleep habits impaired their own sleep. Snoring can certainly be a factor in a partner's insomnia. Medications. Insomnia is a side effect of many common medications, including over-the-counter preparations that contain caffeine. People who suspect their medications are causing them to lose sleep should check with their doctors or pharmacists. Sleep problems seem to run in families. About 35% of people with insomnia have a family history of insomnia, with the

mother being the most commonly affected family member. Still, because so many factors are involved in insomnia, a genetic component is difficult to define. Brain Chemicals and Hormones Affecting Chronic Insomnia Abnormal levels of certain brain chemicals have been observed in some people with chronic insomnia. Melatonin. Low levels of melatonin, the hormone secreted by the pineal gland, have sometimes been observed in chronic insomnia. Stress Hormones. Some studies have reported persistently high levels of stress hormones, particularly cortisol, in people with chronic insomnia, particularly insomnia related to aging and psychiatric disorders. High levels of cortisol reduce REM sleep. However, a 2003 study of people with chronic insomnia reported that cortisol levels were high only when their sleep was of poor quality. When they slept well, levels were lower. This study and other research suggests that high levels of stress hormones are caused by poor sleep, rather than being the cause. Growth Hormone. Normal aging is associated with a blunting of regular, cyclical surges of growth hormone, which may affect sleep as one gets older. This hormone, which is normally secreted in the late night, is associated not only with growth but with deep, slowwave sleep. (Older people generally have less slow-wave sleep.) Chronic Insomnia and the Immune System Chronic insomnia occurs in people who have persistently high levels of stress hormones and a shift in the levels of certain immune factors. Studies indicate that people with chronic insomnia have higher levels of interleukin-6 and tumor necrosis factor during the day, but lower levels at night. These immune factors, called cytokines, cause symptoms of fatigue. Levels are usually higher at night in people with healthy sleep. The implications of these immune changes in people with insomnia are not known. Emotional Disorders Many cases of chronic insomnia cases have a psychologic or psychiatric basis. The disorders that most often cause insomnia are: Anxiety Depression; sleep abnormalities are an integral part of depressive disorders, with more than 90% of depressed patients experiencing insomnia Bipolar disorder Insomnia may also cause emotional problems. It is often unclear which condition has triggered the other, or if the two conditions, in fact, have a common source. Psychophysiologic Insomnia

In many cases, it is unclear if chronic insomnia is a symptom of some physical or psychological condition or if it is a primary disorder of its own. In most instances, a mix of psychological and physical conditions causes the insomnia. Psychophysiologic insomnia occurs when: An episode of transient insomnia disrupts the person's circadian rhythm. The patient begins to associate the bed not with rest and relaxation but with a struggle to sleep. A pattern of sleep failure emerges. Over time, this event repeats, and bedtime becomes a source of anxiety. Once in bed, the patient broods over the inability to sleep, the consequences of sleep loss, and the lack of mental control. All attempts to sleep fail. Eventually excessive worry about sleep loss becomes persistent and provides an automatic nightly trigger for anxiety and arousal. Unsuccessful attempts to control thoughts, images, and emotions only worsen the situation. After such a cycle is established, insomnia becomes a selffulfilling prophecy that can persist indefinitely. Sometimes anxiety and the inability to sleep dates back to childhood when parents used various threats to force their children into sleep for which they may not have been ready. Medical Conditions and Treatments In one survey, 22% of adults reported that health conditions, pain, or discomfort impaired their sleep. These conditions can include: Nightly Leg Problems. Leg disorders that occur at night, such as restless legs syndrome or leg cramps, are of special note. They are very common and an important cause of insomnia, particularly in older people. Medical Problems. Among the many medical problems that can cause chronic insomnia are allergies, arthritis, cancer, fibromyalgia, heart disease, gastroesophageal reflux disease (GERD), hypertension, asthma, emphysema, rheumatologic conditions, Alzheimer's disease, Parkinson's disease, hyperthyroidism, and attention deficit hyperactivity disorder. Medications. Among the many medications that can cause insomnia are antidepressants (fluoxetine, bupropion), theophylline, lamotrigine, felbamate, beta-blockers, and beta-agonists. Alcohol Overuse An estimated 10 -15% of chronic insomnia cases result from substance abuse, especially alcohol, cocaine, and sedatives. One or two alcoholic drinks at dinner, for most people, pose little danger of alcoholism and may help reduce stress and initiate sleep. Excess alcohol or alcohol used to promote

sleep, however, tends to fragment sleep and cause wakefulness a few hours later. It also increases the risk for other sleep disorders, including sleep apnea and restless legs. Alcoholics often suffer insomnia during withdrawal and, in some cases, for several years during recovery. In-Depth From A.D.A.M. Treatment Behavioral Methods Prevention of sleeplessness depends upon the patient's ability to learn how to relax and sleep well. A number of behavioral methods are aimed at achieving these goals. Behavioral techniques can actually cure chronic insomnia and studies report their effectiveness in nearly all patients with primary chronic insomnia. Although medications are equally effective for helping people with insomnia to sleep, they can not cure the condition, and prolonged use frequently resulted in dependency. In addition, behavioral methods act faster. Behavioral methods are effective in all age groups, including elderly patients. Studies have reported that between 70 80% of patients who are treated with non-drug methods experience improved sleep with an average treatment duration of only 5 hours over a 4-week period. Furthermore, studies report that 75% of those who have been taking drugs are able to stop or reduce their use. Proper sleep hygiene is the first step and should accompany any behavioral method. A number of behavioral approaches are available, but all have the same basic goals: To reduce the time it takes to go to sleep to below 30 minutes Reduce wake-up periods during the night Behavioral methods include: Stimulus Control. Stimulus control is now considered the standard treatment for primary chronic insomnia and may be helpful for some patients with secondary insomnia as well. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following: Go to bed only when ready to sleep or for sex. If unable to sleep within 15 - 20 minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, like reading a book.) Maintain a regular wake-up time no matter how few hours you actually sleep. Avoid naps. Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep such as, "I'll never fall asleep." It uses actions intended to change behavior. A 2004 study of young and middle-aged adults suggested that CBT is more

effective than medication in treating chronic insomnia, and should be considered as a first-line intervention. Adding medication to CBT did not provide additional benefit. In a 2006 study of older adults, CBT worked better than zopiclone (Imovane) in managing chronic insomnia. [Zopiclone is a European sleep medication that is similar to the American drug eszopiclone (Lunesta).] Compared to zopiclone or placebo, CBT helped patients spend less time awake at night. The benefits of 6 weeks of weekly CBT sessions lasted for 6 months. Progressive Muscle Relaxation. Progressive muscle relaxation is another technique for inducing sleep that works well for many people. It takes about 10 minutes to perform: Focus on one specific muscle group at a time. Most people start with the muscles in one foot. Inhale and tense the foot muscles for about 8 seconds. (Do this gently. It is not intended to cause severe pain or muscles contractions.) Relax the foot and let it become loose and limp. Stay relaxed for 15 seconds, and then repeat in the other foot. Move up to the next muscle group and repeat the sequence, doing one side of the body at a time. Move progressively from each foot and leg up through the abdomen, chest, then to each hand and arm and then to the neck, shoulders, and face. Paradoxical Intention. Paradoxical intention is a psychological approach that is based on doing the opposite of what one wants or fears and takes it to extreme. The first step is to make a plan to take such a paradoxical approach to insomnia. Instead of going through activities leading to sleep, the patient prepares for staying awake and doing something energetic. In some cases, people may take specific psychological barriers to sleep to an extreme limit. For example, if worry is a factor in insomnia, the patient intensifies the worries. Biofeedback. Biofeedback is also effective, but requires being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily. Sleep Restriction Therapy. Sleep restriction therapy may be effective, although evidence is inconclusive. In a 2001 study, patients practiced sleep hygiene and sleep restriction. Sleep hygiene was very helpful during the first 2 months while sleep restriction led to sustained benefits and deeper sleep. The approach is a systematic method for

achieving sleep and restricting the time spent in bed. To achieve this goal, the patient takes the following actions: Begin by going to bed 15 minutes later than usual the first week. If 85% sleep efficiency isn't reached by the end of the week, add another 15 minutes before going to bed. Refrain from going to bed even if tired, although bedtime should not be reduced below 5 hours. Once efficiency reaches 90% or more, begin to go to bed 15 minutes earlier each week. Imagery Tasks. A 2002 study enrolled people whose chronic insomnia was associated with unwanted thoughts and worries. They were given specific positive mental tasks that gave them a sense of positive control (as opposed to their real life concerns, which felt out of their control.) These images distracted them and allowed them to fall asleep faster. In support of this approach, another study evaluated patients with insomnia who were given a problem before sleep. One group was asked to think of the problem in images and the other in words. The group who used imagery fell asleep more quickly and woke up with less anxiety. Sleep Hygiene. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep. Sleep Hygiene Tips Establish a regular time for going to bed and getting up in the morning. Stick to this schedule even on weekends and during vacations. Use the bed for sleep and sexual relations only, not for reading, watching television, or working. Excessive time in bed disrupts sleep. Avoid naps, especially in the evening. Exercise before dinner. A low point in energy occurs a few hours after exercise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness. Take a hot bath about 1.5 - 2 hours before bedtime. This alters the body's core temperature rhythm and helps people fall asleep more easily and more continuously. (Taking a bath shortly before bed increases alertness.) Do something relaxing in the 30 minutes before bedtime. Reading, meditation, and a leisurely walk are all appropriate activities. Keep the bedroom relatively cool and well ventilated. Do not look at the clock. Obsessing over time will just make it more difficult to sleep. Eat light meals and schedule dinner 4 - 5 hours before bedtime. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.

Spend a half hour in the sun each day. The best time is early in the day. (Take precautions against overexposure to sunlight by wearing protective clothing and sunscreen.) Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate. Avoid caffeine in the hours before sleep. If one is still awake after 15 - 20 minutes, go into another room, read or do a quiet activity using dim lighting until feeling very sleepy. (Don't watch television or use bright lights.) If distracted by a sleeping bed partner, moving to the couch or a spare bed for a couple of nights might be helpful. If a specific worry is keeping one awake, thinking of the problem in terms of images rather than in words may allow a person to fall asleep more quickly and to wake up with less anxiety. Exercise Exercise may be one of the best ways to promote healthy sleep. One study found that exercise is as good for inducing sleep as the use of benzodiazepines, a prescription sleep aid. Some research has found that yoga practice may have specific benefits on sleep health. Yoga uses meditation, deep breathing techniques, and movements that emphasize stretching and balance. Light Therapy The circadian rhythm is more a function of darkness and light rather than actual time of day. Bright light can discourage drowsiness, and darkness can cause sleepiness, day or night. The use of a special box that gives off very bright fluorescent light (over 4,000 lux) for about 30 minutes each day may be helpful. Siegel, Jerome M. (1999). "Sleep". Encarta Encyclopedia. Microsoft. Retrieved on 200801-25. Amanda Schaffer (Mai 27, 2007). "Why do we Sleep?". Slate.com. Retrieved on 2008-0823. Little, Nan (2007-01-01). "What Causes Sleep Difficulty?". Insight Journal. Retrieved on 2008-01-25