Insomnia - Wikipedia

Insomnia, also known as sleeplessness, is a sleep disorder in which people have trouble sleeping. ... They may have difficulty falling asleep, or staying asleep ... Insomnia FromWikipedia,thefreeencyclopedia Jumptonavigation Jumptosearch Inabilitytofallorstayasleep Thisarticleisaboutthesleepingdisorder.Forotheruses,seeInsomnia(disambiguation). "Troublesleeping"redirectshere.Forotheruses,seeTroublesleeping(disambiguation). MedicalconditionInsomniaOthernamesSleeplessness,troublesleepingAdrawingofsomeonewithinsomniafromthe14thcenturyPronunciation/ɪnˈsɒmniə/[1]SpecialtyPsychiatry,sleepmedicineSymptomsTroublesleeping,daytimesleepiness,lowenergy,irritability,depressedmood[1]ComplicationsMotorvehiclecollisions[1]CausesUnknown,psychologicalstress,chronicpain,heartfailure,hyperthyroidism,heartburn,restlesslegsyndrome,others[2]DiagnosticmethodBasedonsymptoms,sleepstudy[3]DifferentialdiagnosisDelayedsleepphasedisorder,restlesslegsyndrome,sleepapnea,psychiatricdisorder[4]TreatmentSleephygiene,cognitivebehavioraltherapy,sleepingpills[5][6][7]Frequency~20%[8][9][10] Insomnia,alsoknownassleeplessness,isasleepdisorderinwhichpeoplehavetroublesleeping.[1]Theymayhavedifficultyfallingasleep,orstayingasleepaslongasdesired.[9][11]Insomniaistypicallyfollowedbydaytimesleepiness,lowenergy,irritability,andadepressedmood.[1]Itmayresultinanincreasedriskofmotorvehiclecollisions,aswellasproblemsfocusingandlearning.[1]Insomniacanbeshortterm,lastingfordaysorweeks,orlongterm,lastingmorethanamonth.[1] Insomniacanoccurindependentlyorasaresultofanotherproblem.[2]Conditionsthatcanresultininsomniaincludepsychologicalstress,chronicpain,heartfailure,hyperthyroidism,heartburn,restlesslegsyndrome,menopause,certainmedications,anddrugssuchascaffeine,nicotine,andalcohol.[2][8]Otherriskfactorsincludeworkingnightshiftsandsleepapnea.[9]Diagnosisisbasedonsleephabitsandanexaminationtolookforunderlyingcauses.[3]Asleepstudymaybedonetolookforunderlyingsleepdisorders.[3]Screeningmaybedonewithtwoquestions:"doyouexperiencedifficultysleeping?"and"doyouhavedifficultyfallingorstayingasleep?"[9] Althoughtheirefficacyasfirstlinetreatmentsisnotunequivocallyestablished,[12]sleephygieneandlifestylechangesaretypicallythefirsttreatmentforinsomnia.[5][7]Sleephygieneincludesaconsistentbedtime,aquietanddarkroom,exposuretosunlightduringthedayandregularexercise.[7]Cognitivebehavioraltherapymaybeaddedtothis.[6][13]Whilesleepingpillsmayhelp,theyaresometimesassociatedwithinjuries,dementia,andaddiction.[5][6]Thesemedicationsarenotrecommendedformorethanfourorfiveweeks.[6]Theeffectivenessandsafetyofalternativemedicineisunclear.[5][6] Between10%and30%ofadultshaveinsomniaatanygivenpointintimeanduptohalfofpeoplehaveinsomniainagivenyear.[8][9][10]About6%ofpeoplehaveinsomniathatisnotduetoanotherproblemandlastsformorethanamonth.[9]Peopleovertheageof65areaffectedmoreoftenthanyoungerpeople.[7]Femalesaremoreoftenaffectedthanmales.[8]DescriptionsofinsomniaoccuratleastasfarbackasancientGreece.[14] Contents 1Signsandsymptoms 1.1Poorsleepquality 1.2Subjectivity 2Causes 2.1Genetics 2.2Substance-induced 2.2.1Alcohol-induced 2.2.2Benzodiazepine-induced 2.2.3Opioid-induced 2.3Riskfactors 3Mechanism 4Diagnosis 4.1DSM-5criteria 4.2Types 5Prevention 6Management 6.1Non-medicationbased 6.1.1Sleephygiene 6.1.2Cognitivebehavioraltherapy 6.1.3Internetinterventions 6.2Medications 6.2.1Antihistamines 6.2.2Antidepressants 6.2.3Melatoninagonists 6.2.4Benzodiazepines 6.2.5Z-Drugs 6.2.6Orexinantagonists 6.2.7Antipsychotics 6.2.8Othersedatives 6.3Alternativemedicine 7Prognosis 8Epidemiology 9Societyandculture 10References 11Externallinks Signsandsymptoms[edit] Potentialcomplicationsofinsomnia.[15] Symptomsofinsomnia:[16] Difficultyfallingasleep,includingdifficultyfindingacomfortablesleepingposition Wakingduringthenight,beingunabletoreturntosleepandwakingupearly Notabletofocusondailytasks,difficultyinremembering Daytimesleepiness,irritability,depressionoranxiety Feelingtiredorhavinglowenergyduringtheday[17] Troubleconcentrating Beingirritable,actingaggressiveorimpulsive Sleeponsetinsomniaisdifficultyfallingasleepatthebeginningofthenight,oftenasymptomofanxietydisorders.Delayedsleepphasedisordercanbemisdiagnosedasinsomnia,assleeponsetisdelayedtomuchlaterthannormalwhileawakeningspillsoverintodaylighthours.[18] Itiscommonforpatientswhohavedifficultyfallingasleeptoalsohavenocturnalawakeningswithdifficultyreturningtosleep.Two-thirdsofthesepatientswakeupinthemiddleofthenight,withmorethanhalfhavingtroublefallingbacktosleepafteramiddle-of-the-nightawakening.[19] Earlymorningawakeningisanawakeningoccurringearlier(morethan30minutes)thandesiredwithaninabilitytogobacktosleep,andbeforetotalsleeptimereaches6.5hours.Earlymorningawakeningisoftenacharacteristicofdepression.[20]Anxietysymptomsmaywellleadtoinsomnia.Someofthesesymptomsincludetension,compulsiveworryingaboutthefuture,feelingoverstimulated,andoveranalyzingpastevents.[21] Poorsleepquality[edit] Poorsleepqualitycanoccurasaresultof,forexample,restlesslegs,sleepapneaormajordepression.Poorsleepqualityisdefinedastheindividualnotreachingstage3ordeltasleepwhichhasrestorativeproperties.[22] Majordepressionleadstoalterationsinthefunctionofthehypothalamic–pituitary–adrenalaxis,causingexcessivereleaseofcortisolwhichcanleadtopoorsleepquality. Nocturnalpolyuria,excessivenighttimeurination,canalsoresultinapoorqualityofsleep.[23] Subjectivity[edit] Mainarticle:Sleepstatemisperception Somecasesofinsomniaarenotreallyinsomniainthetraditionalsense,becausepeopleexperiencingsleepstatemisperceptionoftensleepforanormalamountoftime.[24]Theproblemisthat,despitesleepingformultiplehourseachnightandtypicallynotexperiencingsignificantdaytimesleepinessorothersymptomsofsleeploss,theydonotfeelliketheyhavesleptverymuch,ifatall.[24]Becausetheirperceptionoftheirsleepisincomplete,theyincorrectlybelieveittakesthemanabnormallylongtimetofallasleep,andtheyunderestimatehowlongtheyremainasleep.[24] Causes[edit] Symptomsofinsomniacanbecausedbyorbeassociatedwith: Sleepbreathingdisorders,suchassleepapneaorupperairwayresistancesyndrome[25] Useofpsychoactivedrugs(suchasstimulants),includingcertainmedications,herbs,caffeine,nicotine,cocaine,amphetamines,methylphenidate,aripiprazole,MDMA,modafinil,orexcessivealcoholintake[26] Useoforwithdrawalfromalcoholandothersedatives,suchasanti-anxietyandsleepdrugslikebenzodiazepines[26] Useoforwithdrawalfrompain-relieverssuchasopioids[26] Heartdisease[27] Restlesslegssyndrome,whichcancausesleeponsetinsomniaduetothediscomfortingsensationsfeltandtheneedtomovethelegsorotherbodypartstorelievethesesensations[28] Periodiclimbmovementdisorder(PLMD),whichoccursduringsleepandcancausearousalsofwhichthesleeperisunaware[29] Pain:[30]aninjuryorconditionthatcausespaincanprecludeanindividualfromfindingacomfortablepositioninwhichtofallasleep,andcanalsocauseawakening. Hormoneshiftssuchasthosethatprecedemenstruationandthoseduringmenopause[31] Lifeeventssuchasfear,stress,anxiety,emotionalormentaltension,workproblems,financialstress,birthofachild,andbereavement[28] Gastrointestinalissuessuchasheartburnorconstipation[32] Mental,neurobehavioral,orneurodevelopmentaldisorderssuchasbipolardisorder,clinicaldepression,generalizedanxietydisorder,posttraumaticstressdisorder,schizophrenia,obsessivecompulsivedisorder,autism,dementia,[33]: 326 ADHD,[34]Aspergersyndrome,andFASD Disturbancesofthecircadianrhythm,suchasshiftworkandjetlag,cancauseaninabilitytosleepatsometimesofthedayandexcessivesleepinessatothertimesoftheday.Chroniccircadianrhythmdisordersarecharacterizedbysimilarsymptoms.[26] Certainneurologicaldisorderssuchasbrainlesions,orahistoryoftraumaticbraininjury[35] Medicalconditionssuchashyperthyroidism[2] Abuseofover-the-counterorprescriptionsleepaids(sedativeordepressantdrugs)canproducereboundinsomnia[26] Poorsleephygiene,e.g.,noiseorover-consumptionofcaffeine[26] Araregeneticconditioncancauseaprion-based,permanentandeventuallyfatalformofinsomniacalledfatalfamilialinsomnia[36] Physicalexercise:exercise-inducedinsomniaiscommoninathletesintheformofprolongedsleeponsetlatency[37] Increasedexposuretothebluelightfromartificialsources,suchasphonesorcomputers[38] Chronicpain[39] Lowerbackpain[39] Asthma[39] Sleepstudiesusingpolysomnographyhavesuggestedthatpeoplewhohavesleepdisruptionhaveelevatednighttimelevelsofcirculatingcortisolandadrenocorticotropichormone.Theyalsohaveanelevatedmetabolicrate,whichdoesnotoccurinpeoplewhodonothaveinsomniabutwhosesleepisintentionallydisruptedduringasleepstudy.Studiesofbrainmetabolismusingpositronemissiontomography(PET)scansindicatethatpeoplewithinsomniahavehighermetabolicratesbynightandbyday.Thequestionremainswhetherthesechangesarethecausesorconsequencesoflong-terminsomnia.[40] Genetics[edit] Heritabilityestimatesofinsomniavarybetween38%inmalesto59%infemales.[41]Agenome-wideassociationstudy(GWAS)identified3genomiclociand7genesthatinfluencetheriskofinsomnia,andshowedthatinsomniaishighlypolygenic.[42]Inparticular,astrongpositiveassociationwasobservedfortheMEIS1geneinbothmalesandfemales.Thisstudyshowedthatthegeneticarchitectureofinsomniastronglyoverlapswithpsychiatricdisordersandmetabolictraits. Ithasbeenhypothesisedthattheepigeneticsmightalsoinfluenceinsomniathroughacontrollingprocessofbothsleepregulationandbrain-stressresponsehavinganimpactaswellonthebrainplasticity.[43] Substance-induced[edit] Alcohol-induced[edit] Mainarticle:Alcoholuseandsleep Alcoholisoftenusedasaformofself-treatmentofinsomniatoinducesleep.However,alcoholusetoinducesleepcanbeacauseofinsomnia.Long-termuseofalcoholisassociatedwithadecreaseinNREMstage3and4sleepaswellassuppressionofREMsleepandREMsleepfragmentation.Frequentmovingbetweensleepstagesoccurs,withawakeningsduetoheadaches,theneedtourinate,dehydration,andexcessivesweating.Glutaminereboundalsoplaysaroleaswhensomeoneisdrinking;alcoholinhibitsglutamine,oneofthebody'snaturalstimulants.Whenthepersonstopsdrinking,thebodytriestomakeupforlosttimebyproducingmoreglutaminethanitneeds. Theincreaseinglutaminelevelsstimulatesthebrainwhilethedrinkeristryingtosleep,keepinghim/herfromreachingthedeepestlevelsofsleep.[44]Stoppingchronicalcoholusecanalsoleadtosevereinsomniawithvividdreams.DuringwithdrawalREMsleepistypicallyexaggeratedaspartofareboundeffect.[45] Benzodiazepine-induced[edit] Likealcohol,benzodiazepines,suchasalprazolam,clonazepam,lorazepam,anddiazepam,arecommonlyusedtotreatinsomniaintheshort-term(bothprescribedandself-medicated),butworsensleepinthelong-term.Whilebenzodiazepinescanputpeopletosleep(i.e.,inhibitNREMstage1and2sleep),whileasleep,thedrugsdisruptsleeparchitecture:decreasingsleeptime,delayingtimetoREMsleep,anddecreasingdeepslow-wavesleep(themostrestorativepartofsleepforbothenergyandmood).[46][47][48] Opioid-induced[edit] Opioidmedicationssuchashydrocodone,oxycodone,andmorphineareusedforinsomniathatisassociatedwithpainduetotheiranalgesicpropertiesandhypnoticeffects.OpioidscanfragmentsleepanddecreaseREMandstage2sleep.Byproducinganalgesiaandsedation,opioidsmaybeappropriateincarefullyselectedpatientswithpain-associatedinsomnia.[30]However,dependenceonopioidscanleadtolong-termsleepdisturbances.[49] Riskfactors[edit] Insomniaaffectspeopleofallagegroupsbutpeopleinthefollowinggroupshaveahigherchanceofacquiringinsomnia:[50] Individualsolderthan60 Historyofmentalhealthdisorderincludingdepression,etc. Emotionalstress Workinglatenightshifts Travelingthroughdifferenttimezones[11] Havingchronicdiseasessuchasdiabetes,kidneydisease,lungdisease,Alzheimer's,orheartdisease[51] Alcoholordrugusedisorders Gastrointestinalrefluxdisease Heavysmoking Workstress[52] Mechanism[edit] Twomainmodelsexistsastothemechanismofinsomnia,cognitiveandphysiological.Thecognitivemodelsuggestsruminationandhyperarousalcontributetopreventingapersonfromfallingasleepandmightleadtoanepisodeofinsomnia. Thephysiologicalmodelisbaseduponthreemajorfindingsinpeoplewithinsomnia;firstly,increasedurinarycortisolandcatecholamineshavebeenfoundsuggestingincreasedactivityoftheHPAaxisandarousal;second,increasedglobalcerebralglucoseutilizationduringwakefulnessandNREMsleepinpeoplewithinsomnia;andlastly,increasedfullbodymetabolismandheartrateinthosewithinsomnia.Allthesefindingstakentogethersuggestadysregulationofthearousalsystem,cognitivesystem,andHPAaxisallcontributingtoinsomnia.[9][53]However,itisunknownifthehyperarousalisaresultof,orcauseofinsomnia.AlteredlevelsoftheinhibitoryneurotransmitterGABAhavebeenfound,buttheresultshavebeeninconsistent,andtheimplicationsofalteredlevelsofsuchaubiquitousneurotransmitterareunknown.Studiesonwhetherinsomniaisdrivenbycircadiancontroloversleeporawakedependentprocesshaveshowninconsistentresults,butsomeliteraturesuggestsadysregulationofthecircadianrhythmbasedoncoretemperature.[54]Increasedbetaactivityanddecreaseddeltawaveactivityhasbeenobservedonelectroencephalograms;however,theimplicationofthisisunknown.[55] Aroundhalfofpost-menopausalwomenexperiencesleepdisturbances,andgenerallysleepdisturbanceisabouttwiceascommoninwomenasmen;thisappearstobedueinpart,butnotcompletely,tochangesinhormonelevels,especiallyinandpost-menopause.[31][56] Changesinsexhormonesinbothmenandwomenastheyagemayaccountinpartforincreasedprevalenceofsleepdisordersinolderpeople.[57] Diagnosis[edit] Inmedicine,insomniaiswidelymeasuredusingtheAthensinsomniascale.[58]Itismeasuredusingeightdifferentparametersrelatedtosleep,finallyrepresentedasanoverallscalewhichassessesanindividual'ssleeppattern. Aqualifiedsleepspecialistshouldbeconsultedforthediagnosisofanysleepdisordersotheappropriatemeasurescanbetaken.Pastmedicalhistoryandaphysicalexaminationneedtobedonetoeliminateotherconditionsthatcouldbethecauseofinsomnia.Afterallotherconditionsareruledoutacomprehensivesleephistoryshouldbetaken.Thesleephistoryshouldincludesleephabits,medications(prescriptionandnon-prescription),alcoholconsumption,nicotineandcaffeineintake,co-morbidillnesses,andsleepenvironment.[59]Asleepdiarycanbeusedtokeeptrackoftheindividual'ssleeppatterns.Thediaryshouldincludetimetobed,totalsleeptime,timetosleeponset,numberofawakenings,useofmedications,timeofawakening,andsubjectivefeelingsinthemorning.[59]Thesleepdiarycanbereplacedorvalidatedbytheuseofout-patientactigraphyforaweekormore,usinganon-invasivedevicethatmeasuresmovement.[60] Workerswhocomplainofinsomniashouldnotroutinelyhavepolysomnographytoscreenforsleepdisorders.[61]Thistestmaybeindicatedforpatientswithsymptomsinadditiontoinsomnia,includingsleepapnea,obesity,athickneckdiameter,orhigh-riskfullnessofthefleshintheoropharynx.[61]Usually,thetestisnotneededtomakeadiagnosis,andinsomniaespeciallyforworkingpeoplecanoftenbetreatedbychangingajobscheduletomaketimeforsufficientsleepandbyimprovingsleephygiene.[61] Somepatientsmayneedtodoanovernightsleepstudytodetermineifinsomniaispresent.Suchastudywillcommonlyinvolveassessmenttoolsincludingapolysomnogramandthemultiplesleeplatencytest.Specialistsinsleepmedicinearequalifiedtodiagnosedisorderswithinthe,accordingtotheICSD,81majorsleepdisorderdiagnosticcategories.[62]Patientswithsomedisorders,includingdelayedsleepphasedisorder,areoftenmis-diagnosedwithprimaryinsomnia;whenapersonhastroublegettingtosleepandawakeningatdesiredtimes,buthasanormalsleeppatternonceasleep,acircadianrhythmdisorderisalikelycause. Inmanycases,insomniaisco-morbidwithanotherdisease,side-effectsfrommedications,orapsychologicalproblem.Approximatelyhalfofalldiagnosedinsomniaisrelatedtopsychiatricdisorders.[63]Forthosewhohavedepression,"insomniashouldberegardedasaco-morbidcondition,ratherthanasasecondaryone;"insomniatypicallypredatespsychiatricsymptoms.[63]"Infact,itispossiblethatinsomniarepresentsasignificantriskforthedevelopmentofasubsequentpsychiatricdisorder."[9]Insomniaoccursinbetween60%and80%ofpeoplewithdepression.[64]Thismaypartlybeduetotreatmentusedfordepression.[64] Determinationofcausationisnotnecessaryforadiagnosis.[63] DSM-5criteria[edit] TheDSM-5criteriaforinsomniaincludethefollowing:[65] Predominantcomplaintofdissatisfactionwithsleepquantityorquality,associatedwithone(ormore)ofthefollowingsymptoms: Difficultyinitiatingsleep.(Inchildren,thismaymanifestasdifficultyinitiatingsleepwithoutcaregiverintervention.) Difficultymaintainingsleep,characterizedbyfrequentawakeningsorproblemsreturningtosleepafterawakenings.(Inchildren,thismaymanifestasdifficultyreturningtosleepwithoutcaregiverintervention.) Early-morningawakeningwithinabilitytoreturntosleep. Inaddition: Thesleepdisturbancecausesclinicallysignificantdistressorimpairmentinsocial,occupational,educational,academic,behavioral,orotherimportantareasoffunctioning. Thesleepdifficultyoccursatleast3nightsperweek. Thesleepdifficultyispresentforatleast3months. Thesleepdifficultyoccursdespiteadequateopportunityforsleep. Theinsomniaisnotbetterexplainedbyanddoesnotoccurexclusivelyduringthecourseofanothersleep-wakedisorder(e.g.,narcolepsy,abreathing-relatedsleepdisorder,acircadianrhythmsleep-wakedisorder,aparasomnia). Theinsomniaisnotattributabletothephysiologicaleffectsofasubstance(e.g.,adrugofabuse,amedication). Coexistingmentaldisordersandmedicalconditionsdonotadequatelyexplainthepredominantcomplaintofinsomnia. Types[edit] Insomniacanbeclassifiedastransient,acute,orchronic. Transientinsomnialastsforlessthanaweek.Itcanbecausedbyanotherdisorder,bychangesinthesleepenvironment,bythetimingofsleep,severedepression,orbystress.Itsconsequences –sleepinessandimpairedpsychomotorperformance –aresimilartothoseofsleepdeprivation.[66] Acuteinsomniaistheinabilitytoconsistentlysleepwellforaperiodoflessthanamonth.Insomniaispresentwhenthereisdifficultyinitiatingormaintainingsleeporwhenthesleepthatisobtainedisnon-refreshingorofpoorquality.Theseproblemsoccurdespiteadequateopportunityandcircumstancesforsleepandtheymustresultinproblemswithdaytimefunction.[67]Acuteinsomniaisalsoknownasshortterminsomniaorstressrelatedinsomnia.[68] Chronicinsomnialastsforlongerthanamonth.Itcanbecausedbyanotherdisorder,oritcanbeaprimarydisorder.Commoncausesofchronicinsomniaincludepersistentstress,trauma,workschedules,poorsleephabits,medications,andothermentalhealthdisorders.[69]Peoplewithhighlevelsofstresshormonesorshiftsinthelevelsofcytokinesaremorelikelythanotherstohavechronicinsomnia.[70]Itseffectscanvaryaccordingtoitscauses.Theymightincludemuscularweariness,hallucinations,and/ormentalfatigue.[66] Prevention[edit] Preventionandtreatmentofinsomniamayrequireacombinationofcognitivebehavioraltherapy,[13]medications,[71]andlifestylechanges.[72] Amonglifestylepractices,goingtosleepandwakingupatthesametimeeachdaycancreateasteadypatternwhichmayhelptopreventinsomnia.[11]Avoidanceofvigorousexerciseandcaffeinateddrinksafewhoursbeforegoingtosleepisrecommended,whileexerciseearlierinthedaymaybebeneficial.[72]Otherpracticestoimprovesleephygienemayinclude:[72][73] Avoidingorlimitingnaps Treatingpainatbedtime Avoidinglargemeals,beverages,alcohol,andnicotinebeforebedtime Findingsoothingwaystorelaxintosleep,includinguseofwhitenoise Makingthebedroomsuitableforsleepbykeepingitdark,cool,andfreeofdevices,suchasclocks,cellphones,ortelevisions Maintainregularexercise Tryrelaxingactivitiesbeforesleeping Management[edit] Itisrecommendedtoruleoutmedicalandpsychologicalcausesbeforedecidingonthetreatmentforinsomnia.[74]Cognitivebehavioraltherapyisgenerallythefirstlinetreatmentoncethishasbeendone.[75]Ithasbeenfoundtobeeffectiveforchronicinsomnia.[13]Thebeneficialeffects,incontrasttothoseproducedbymedications,maylastwellbeyondthestoppingoftherapy.[76] Medicationshavebeenusedmainlytoreducesymptomsininsomniaofshortduration;theirroleinthemanagementofchronicinsomniaremainsunclear.[8]Severaldifferenttypesofmedicationsmaybeused.[77][78][71]Manydoctorsdonotrecommendrelyingonprescriptionsleepingpillsforlong-termuse.[72]Itisalsoimportanttoidentifyandtreatothermedicalconditionsthatmaybecontributingtoinsomnia,suchasdepression,breathingproblems,andchronicpain.[72][79]Asof2022,manypeoplewithinsomniawerereportedasnotreceivingoverallsufficientsleeportreatmentforinsomnia.[80][81] Non-medicationbased[edit] Non-medicationbasedstrategieshavecomparableefficacytohypnoticmedicationforinsomniaandtheymayhavelongerlastingeffects.Hypnoticmedicationisonlyrecommendedforshort-termusebecausedependencewithreboundwithdrawaleffectsupondiscontinuationortolerancecandevelop.[82] Nonmedicationbasedstrategiesprovidelonglastingimprovementstoinsomniaandarerecommendedasafirstlineandlong-termstrategyofmanagement.Behavioralsleepmedicine(BSM)triestoaddressinsomniawithnon-pharmacologicaltreatments.TheBSMstrategiesusedtoaddresschronicinsomniaincludeattentiontosleephygiene,stimuluscontrol,behavioralinterventions,sleep-restrictiontherapy,paradoxicalintention,patienteducation,andrelaxationtherapy.[83]Someexamplesarekeepingajournal,restrictingthetimespentawakeinbed,practicingrelaxationtechniques,andmaintainingaregularsleepscheduleandawake-uptime.[79]Behavioraltherapycanassistapatientindevelopingnewsleepbehaviorstoimprovesleepqualityandconsolidation.Behavioraltherapymayinclude,learninghealthysleephabitstopromotesleeprelaxation,undergoinglighttherapytohelpwithworry-reductionstrategiesandregulatingthecircadianclock.[79] Musicmayimproveinsomniainadults(seemusicandsleep).[84]EEGbiofeedbackhasdemonstratedeffectivenessinthetreatmentofinsomniawithimprovementsindurationaswellasqualityofsleep.[85]Self-helptherapy(definedasapsychologicaltherapythatcanbeworkedthroughonone'sown)mayimprovesleepqualityforadultswithinsomniatoasmallormoderatedegree.[86] Stimuluscontroltherapyisatreatmentforpatientswhohaveconditionedthemselvestoassociatethebed,orsleepingeneral,withanegativeresponse.Asstimuluscontroltherapyinvolvestakingstepstocontrolthesleepenvironment,itissometimesreferredinterchangeablywiththeconceptofsleephygiene.Examplesofsuchenvironmentalmodificationsincludeusingthebedforsleepandsexonly,notforactivitiessuchasreadingorwatchingtelevision;wakingupatthesametimeeverymorning,includingonweekends;goingtobedonlywhensleepyandwhenthereisahighlikelihoodthatsleepwilloccur;leavingthebedandbeginninganactivityinanotherlocationifsleepdoesnotoccurinareasonablybriefperiodoftimeaftergettingintobed(commonly~20min);reducingthesubjectiveeffortandenergyexpendedtryingtofallasleep;avoidingexposuretobrightlightduringnighttimehours,andeliminatingdaytimenaps.[87] Acomponentofstimuluscontroltherapyissleeprestriction,atechniquethataimstomatchthetimespentinbedwithactualtimespentasleep.Thistechniqueinvolvesmaintainingastrictsleep-wakeschedule,sleepingonlyatcertaintimesofthedayandforspecificamountsoftimetoinducemildsleepdeprivation.Completetreatmentusuallylastsupto3weeksandinvolvesmakingoneselfsleepforonlyaminimumamountoftimethattheyareactuallycapableofonaverage,andthen,ifcapable(i.e.whensleepefficiencyimproves),slowlyincreasingthisamount(~15min)bygoingtobedearlierasthebodyattemptstoresetitsinternalsleepclock.Brightlighttherapymaybeeffectiveforinsomnia.[88] Paradoxicalintentionisacognitivereframingtechniquewheretheinsomniac,insteadofattemptingtofallasleepatnight,makeseveryefforttostayawake(i.e.essentiallystopstryingtofallasleep).Onetheorythatmayexplaintheeffectivenessofthismethodisthatbynotvoluntarilymakingoneselfgotosleep,itrelievestheperformanceanxietythatarisesfromtheneedorrequirementtofallasleep,whichismeanttobeapassiveact.Thistechniquehasbeenshowntoreducesleepeffortandperformanceanxietyandalsolowersubjectiveassessmentofsleep-onsetlatencyandoverestimationofthesleepdeficit(aqualityfoundinmanyinsomniacs).[89] Sleephygiene[edit] Sleephygieneisacommontermforallofthebehaviorswhichrelatetothepromotionofgoodsleep.Theyincludehabitswhichprovideagoodfoundationforsleepandhelptopreventinsomnia.However,sleephygienealonemaynotbeadequatetoaddresschronicinsomnia.[60]Sleephygienerecommendationsaretypicallyincludedasonecomponentofcognitivebehavioraltherapyforinsomnia(CBT-I).[60][6]Recommendationsincludereducingcaffeine,nicotine,andalcoholconsumption,maximizingtheregularityandefficiencyofsleepepisodes,minimizingmedicationusageanddaytimenapping,thepromotionofregularexercise,andthefacilitationofapositivesleepenvironment.[90]Thecreationofapositivesleepenvironmentmayalsobehelpfulinreducingthesymptomsofinsomnia.[91] Cognitivebehavioraltherapy[edit] Mainarticle:Cognitivebehavioraltherapyforinsomnia Thereissomeevidencethatcognitivebehavioraltherapyforinsomnia(CBT-I)issuperiorinthelong-termtobenzodiazepinesandthenonbenzodiazepinesinthetreatmentandmanagementofinsomnia.[92]Inthistherapy,patientsaretaughtimprovedsleephabitsandrelievedofcounter-productiveassumptionsaboutsleep.Commonmisconceptionsandexpectationsthatcanbemodifiedinclude Unrealisticsleepexpectations Misconceptionsaboutinsomniacauses Amplifyingtheconsequencesofinsomnia Performanceanxietyaftertryingforsolongtohaveagoodnight'ssleepbycontrollingthesleepprocess Numerousstudieshavereportedpositiveoutcomesofcombiningcognitivebehavioraltherapyforinsomniatreatmentwithtreatmentssuchasstimuluscontrolandtherelaxationtherapies.Hypnoticmedicationsareequallyeffectiveintheshort-termtreatmentofinsomnia,buttheireffectswearoffovertimeduetotolerance.TheeffectsofCBT-Ihavesustainedandlastingeffectsontreatinginsomnialongaftertherapyhasbeendiscontinued.[93][94]TheadditionofhypnoticmedicationswithCBT-Iaddsnobenefitininsomnia.ThelonglastingbenefitsofacourseofCBT-Ishowssuperiorityoverpharmacologicalhypnoticdrugs.Evenintheshorttermwhencomparedtoshort-termhypnoticmedicationsuchaszolpidem,CBT-Istillshowssignificantsuperiority.ThusCBT-Iisrecommendedasafirstlinetreatmentforinsomnia.[95] CommonformsofCBT-Itreatmentsincludestimuluscontroltherapy,sleeprestriction,sleephygiene,improvedsleepingenvironments,relaxationtraining,paradoxicalintention,andbiofeedback.[96] CBTisthewell-acceptedformoftherapyforinsomniasinceithasnoknownadverseeffects,whereastakingmedicationstoalleviateinsomniasymptomshavebeenshowntohaveadversesideeffects.[97]Nevertheless,thedownsideofCBTisthatitmaytakealotoftimeandmotivation.[98] Metacognitionisarecenttrendinapproachtobehaviourtherapyofinsomnia.[99] Internetinterventions[edit] DespitethetherapeuticeffectivenessandprovensuccessofCBT,treatmentavailabilityissignificantlylimitedbyalackoftrainedclinicians,poorgeographicaldistributionofknowledgeableprofessionals,andexpense.[100]OnewaytopotentiallyovercomethesebarriersistousetheInternettodelivertreatment,makingthiseffectiveinterventionmoreaccessibleandlesscostly.TheInternethasalreadybecomeacriticalsourceofhealth-careandmedicalinformation.[101]Althoughthevastmajorityofhealthwebsitesprovidegeneralinformation,[101][102]thereisgrowingresearchliteratureonthedevelopmentandevaluationofInternetinterventions.[103][104] Theseonlineprogramsaretypicallybehaviorally-basedtreatmentsthathavebeenoperationalizedandtransformedfordeliveryviatheInternet.Theyareusuallyhighlystructured;automatedorhumansupported;basedoneffectiveface-to-facetreatment;personalizedtotheuser;interactive;enhancedbygraphics,animations,audio,andpossiblyvideo;andtailoredtoprovidefollow-upandfeedback.[104] ThereisgoodevidencefortheuseofcomputerbasedCBTforinsomnia.[105] Medications[edit] Manypeoplewithinsomniausesleepingtabletsandothersedatives.Insomeplacesmedicationsareprescribedinover95%ofcases.[106]They,however,areasecondlinetreatment.[107]In2019,theUSFoodandDrugAdministrationstateditisgoingtorequirewarningsforeszopiclone,zaleplon,andzolpidem,duetoconcernsaboutseriousinjuriesresultingfromabnormalsleepbehaviors,includingsleepwalkingordrivingavehiclewhileasleep.[108] Thepercentageofadultsusingaprescriptionsleepaidincreaseswithage.During2005–2010,about4%ofU.S.adultsaged20andoverreportedthattheytookprescriptionsleepaidsinthepast30days.Ratesofusewerelowestamongtheyoungestagegroup(thoseaged20–39)atabout2%,increasedto6%amongthoseaged50–59,andreached7%amongthoseaged80andover.Moreadultwomen(5%)reportedusingprescriptionsleepaidsthanadultmen(3%).Non-Hispanicwhiteadultsreportedhigheruseofsleepaids(5%)thannon-Hispanicblack(3%)andMexican-American(2%)adults.Nodifferencewasshownbetweennon-HispanicblackadultsandMexican-Americanadultsinuseofprescriptionsleepaids.[109] Antihistamines[edit] Asanalternativetotakingprescriptiondrugs,someevidenceshowsthatanaveragepersonseekingshort-termhelpmayfindreliefbytakingover-the-counterantihistaminessuchasdiphenhydramineordoxylamine.[110]Diphenhydramineanddoxylaminearewidelyusedinnonprescriptionsleepaids.Theyarethemosteffectiveover-the-countersedativescurrentlyavailable,atleastinmuchofEurope,Canada,Australia,andtheUnitedStates,andaremoresedatingthansomeprescriptionhypnotics.[111]Antihistamineeffectivenessforsleepmaydecreaseovertime,andanticholinergicside-effects(suchasdrymouth)mayalsobeadrawbackwiththeseparticulardrugs.Whileaddictiondoesnotseemtobeanissuewiththisclassofdrugs,theycaninducedependenceandreboundeffectsuponabruptcessationofuse.[112]However,peoplewhoseinsomniaiscausedbyrestlesslegssyndromemayhaveworsenedsymptomswithantihistamines.[113] Antidepressants[edit] Whileinsomniaisacommonsymptomofdepression,antidepressantsareeffectivefortreatingsleepproblemswhetherornottheyareassociatedwithdepression.Whileallantidepressantshelpregulatesleep,someantidepressantssuchasamitriptyline,doxepin,mirtazapine,andtrazodonecanhaveanimmediatesedativeeffect,andareprescribedtotreatinsomnia.[114]Amitriptylineanddoxepinbothhaveantihistaminergic,anticholinergic,andantiadrenergicproperties,whichcontributetoboththeirtherapeuticeffectsandsideeffectprofiles,whilemirtazapine'ssideeffectsareprimarilyantihistaminergic,andtrazodone'sside-effectsareprimarilyantiadrenergic.Mirtazapineisknowntodecreasesleeplatency(i.e.,thetimeittakestofallasleep),promotingsleepefficiencyandincreasingthetotalamountofsleepingtimeinpeoplewithbothdepressionandinsomnia.[115][116] Agomelatine,amelatonergicantidepressantwithclaimedsleep-improvingqualitiesthatdoesnotcausedaytimedrowsiness,[117]isapprovedforthetreatmentofdepressionthoughnotsleepconditionsintheEuropeanUnion[118]andAustralia.[119]AftertrialsintheUnitedStates,itsdevelopmentforusetherewasdiscontinuedinOctober2011[120]byNovartis,whohadboughttherightstomarketittherefromtheEuropeanpharmaceuticalcompanyServier.[121] A2018Cochranereviewfoundthesafetyoftakingantidepressantsforinsomniatobeuncertainwithnoevidencesupportinglongtermuse.[122] Melatoninagonists[edit] Melatoninreceptoragonistssuchasmelatoninandramelteonareusedinthetreatmentofinsomnia.Theevidenceformelatoninintreatinginsomniaisgenerallypoor.[123]Thereislow-qualityevidencethatitmayspeedtheonsetofsleepby6 minutes.[123]Ramelteondoesnotappeartospeedtheonsetofsleeportheamountofsleepapersongets.[123] UsageofMelatoninasatreatmentforinsomniahasincreasedfrom.4%between1999and2000tonearly2.1%between2017and2018.[124] Mostmelatoninagonistshavenotbeentestedforlongitudinalsideeffects.[125]Prolonged-releasemelatoninmayimprovequalityofsleepinolderpeoplewithminimalsideeffects.[126][127] Studieshavealsoshownthatchildrenwhoareontheautismspectrumorhavelearningdisabilities,attention-deficithyperactivitydisorder(ADHD)orrelatedneurologicaldiseasescanbenefitfromtheuseofmelatonin.Thisisbecausetheyoftenhavetroublesleepingduetotheirdisorders.Forexample,childrenwithADHDtendtohavetroublefallingasleepbecauseoftheirhyperactivityand,asaresult,tendtobetiredduringmostoftheday.AnothercauseofinsomniainchildrenwithADHDistheuseofstimulantsusedtotreattheirdisorder.ChildrenwhohaveADHDthen,aswellastheotherdisordersmentioned,maybegivenmelatoninbeforebedtimeinordertohelpthemsleep.[128] Benzodiazepines[edit] Normison(temazepam)isabenzodiazepinecommonlyprescribedforinsomniaandothersleepdisorders.[129] Themostcommonlyusedclassofhypnoticsforinsomniaarethebenzodiazepines.[33]: 363 Benzodiazepinesarenotsignificantlybetterforinsomniathanantidepressants.[130]Chronicusersofhypnoticmedicationsforinsomniadonothavebettersleepthanchronicinsomniacsnottakingmedications.Infact,chronicusersofhypnoticmedicationshavemoreregularnighttimeawakeningsthaninsomniacsnottakinghypnoticmedications.[131]Manyhaveconcludedthatthesedrugscauseanunjustifiablerisktotheindividualandtopublichealthandlackevidenceoflong-termeffectiveness.Itispreferredthathypnoticsbeprescribedforonlyafewdaysatthelowesteffectivedoseandavoidedaltogetherwhereverpossible,especiallyintheelderly.[132]Between1993and2010,theprescribingofbenzodiazepinestoindividualswithsleepdisordershasdecreasedfrom24%to11%intheUS,coincidingwiththefirstreleaseofnonbenzodiazepines.[133] Thebenzodiazepineandnonbenzodiazepinehypnoticmedicationsalsohaveanumberofside-effectssuchasdaytimefatigue,motorvehiclecrashesandotheraccidents,cognitiveimpairments,andfallsandfractures.Elderlypeoplearemoresensitivetotheseside-effects.[134]Somebenzodiazepineshavedemonstratedeffectivenessinsleepmaintenanceintheshorttermbutinthelongertermbenzodiazepinescanleadtotolerance,physicaldependence,benzodiazepinewithdrawalsyndromeupondiscontinuation,andlong-termworseningofsleep,especiallyafterconsistentusageoverlongperiodsoftime.Benzodiazepines,whileinducingunconsciousness,actuallyworsensleepas–likealcohol–theypromotelightsleepwhiledecreasingtimespentindeepsleep.[135]Afurtherproblemis,withregularuseofshort-actingsleepaidsforinsomnia,daytimereboundanxietycanemerge.[136]Althoughthereislittleevidenceforbenefitofbenzodiazepinesininsomniacomparedtoothertreatmentsandevidenceofmajorharm,prescriptionshavecontinuedtoincrease.[137]Thisislikelyduetotheiraddictivenature,bothduetomisuseandbecause–throughtheirrapidaction,toleranceandwithdrawaltheycan"trick"insomniacsintothinkingtheyarehelpingwithsleep.Thereisageneralawarenessthatlong-termuseofbenzodiazepinesforinsomniainmostpeopleisinappropriateandthatagradualwithdrawalisusuallybeneficialduetotheadverseeffectsassociatedwiththelong-termuseofbenzodiazepinesandisrecommendedwheneverpossible.[138][139] BenzodiazepinesallbindunselectivelytotheGABAAreceptor.[130]Sometheorizethatcertainbenzodiazepines(hypnoticbenzodiazepines)havesignificantlyhigheractivityattheα1subunitoftheGABAAreceptorcomparedtootherbenzodiazepines(forexample,triazolamandtemazepamhavesignificantlyhigheractivityattheα1subunitcomparedtoalprazolamanddiazepam,makingthemsuperiorsedative-hypnotics –alprazolamanddiazepam,inturn,havehigheractivityattheα2subunitcomparedtotriazolamandtemazepam,makingthemsuperioranxiolyticagents).Modulationoftheα1subunitisassociatedwithsedation,motorimpairment,respiratorydepression,amnesia,ataxia,andreinforcingbehavior(drug-seekingbehavior).Modulationoftheα2subunitisassociatedwithanxiolyticactivityanddisinhibition.Forthisreason,certainbenzodiazepinesmaybebettersuitedtotreatinsomniathanothers.[91] Z-Drugs[edit] NonbenzodiazepineorZ-drugsedative–hypnoticdrugs,suchaszolpidem,zaleplon,zopiclone,andeszopiclone,areaclassofhypnoticmedicationsthataresimilartobenzodiazepinesintheirmechanismofaction,andindicatedformildtomoderateinsomnia.Theireffectivenessatimprovingtimetosleepingisslight,andtheyhavesimilar—thoughpotentiallylesssevere—sideeffectprofilescomparedtobenzodiazepines.[140]PrescribingofnonbenzodiazepineshasseenageneralincreasesincetheirinitialreleaseontheUSmarketin1992,from2.3%in1993amongindividualswithsleepdisordersto13.7%in2010.[133] Orexinantagonists[edit] Orexinreceptorantagonistsareamorerecentlyintroducedclassofsleepmedicationsandincludesuvorexant,lemborexant,anddaridorexant,allofwhichareFDA-approvedfortreatmentofinsomniacharacterizedbydifficultieswithsleeponsetand/orsleepmaintenance.[141][142] Antipsychotics[edit] Certainatypicalantipsychotics,particularlyquetiapine,olanzapine,andrisperidone,areusedinthetreatmentofinsomnia.[143][144]However,whilecommon,useofantipsychoticsforthisindicationisnotrecommendedastheevidencedoesnotdemonstrateabenefitandtheriskofadverseeffectsaresignificant.[143][145][146][147][148]Someofthemoreseriousadverseeffectsmayalsooccuratthelowdosesused,suchasdyslipidemiaandneutropenia,[149][150]andarecentnetworkmeta-analysisof154double-blind,randomizedcontrolledtrialsofdrugtherapiesvs.placeboforinsomniainadultsfoundthatquetiapinedidnotdemonstratedanyshort-termbenefitsinsleepquality.[151]Concernsregardingsideeffectsaregreaterintheelderly.[125] Othersedatives[edit] Gabapentinoidslikegabapentinandpregabalinhavesleep-promotingeffectsbutarenotcommonlyusedfortreatmentofinsomnia.[152] Barbiturates,whileonceused,arenolongerrecommendedforinsomniaduetotheriskofaddictionandothersideeffects.[153] Alternativemedicine[edit] Herbssuchasvalerian,chamomile,lavender,orcannabis,maybeused,[154]butthereisnoclinicalevidencethattheyareeffective.Itisunclearifacupunctureisuseful.[155] Prognosis[edit] Disability-adjustedlifeyearforinsomniaper100,000 inhabitantsin2004.  nodata  lessthan25  25–30.25  30.25–36  36–41.5  41.5–47  47–52.5  52.5–58  58–63.5  63.5–69  69–74.5  74.5–80  morethan80 Asurveyof1.1millionresidentsintheUnitedStatesfoundthatthosethatreportedsleepingabout7hourspernighthadthelowestratesofmortality,whereasthosethatsleptforfewerthan6hoursormorethan8hourshadhighermortalityrates.Getting8.5ormorehoursofsleeppernightwasassociatedwitha15%highermortalityrate.Severeinsomnia –sleepinglessthan3.5hoursinwomenand4.5hoursinmen –isassociatedwitha15%increaseinmortality.[156] Withthistechnique,itisdifficulttodistinguishlackofsleepcausedbyadisorderwhichisalsoacauseofprematuredeath,versusadisorderwhichcausesalackofsleep,andthelackofsleepcausingprematuredeath.Mostoftheincreaseinmortalityfromsevereinsomniawasdiscountedaftercontrollingforassociateddisorders.Aftercontrollingforsleepdurationandinsomnia,useofsleepingpillswasalsofoundtobeassociatedwithanincreasedmortalityrate.[156] Thelowestmortalitywasseeninindividualswhosleptbetweensixandahalfandsevenandahalfhourspernight.Evensleepingonly4.5hourspernightisassociatedwithverylittleincreaseinmortality.Thus,mildtomoderateinsomniaformostpeopleisassociatedwithincreasedlongevityandsevereinsomniaisassociatedonlywithaverysmalleffectonmortality.[156]Itisunclearwhysleepinglongerthan7.5hoursisassociatedwithexcessmortality.[156] Epidemiology[edit] Between10%and30%ofadultshaveinsomniaatanygivenpointintimeanduptohalfofpeoplehaveinsomniainagivenyear,makingitthemostcommonsleepdisorder.[9][8][10][157]About6%ofpeoplehaveinsomniathatisnotduetoanotherproblemandlastsformorethanamonth.[9]Peopleovertheageof65areaffectedmoreoftenthanyoungerpeople.[7]Femalesaremoreoftenaffectedthanmales.[8]Insomniais40%morecommoninwomenthaninmen.[158] Therearehigherratesofinsomniareportedamonguniversitystudentscomparedtothegeneralpopulation.[159] Societyandculture[edit] ThewordinsomniaisfromLatin:in+somnus"withoutsleep"and-iaasanominalizingsuffix. Thepopularpresshavepublishedstoriesaboutpeoplewhosupposedlyneversleep,suchasthatofTháiNgọcandAlHerpin.[160]Hornewrites"everybodysleepsandneedstodoso,"andgenerallythisappearstrue.However,healsorelatesfromcontemporaryaccountsthecaseofPaulKern,whowasshotinwartimeandthen"neversleptagain"untilhisdeathin1943.[161]Kernappearstobeacompletelyisolated,uniquecase. 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Externallinks[edit] ClassificationDICD-11:7A00,7A01,7A0Z,8E02.2,SD84ICD-10:F51,G47.0ICD-9-CM:307.42,307.41,327.0,780.51,780.52MeSH:D007319DiseasesDB:26877SNOMEDCT:193462001ExternalresourcesMedlinePlus:000805eMedicine:med/2698PatientUK:Insomnia vteSleepandsleepdisordersStagesofsleepcycles Rapideyemovement(REM) Quiescentsleep Slow-wave Brainwaves Alphawave Betawave Deltawave Gammawave K-complex Murhythm PGOwaves Sensorimotorrhythm Sleepspindle Thetawave SleepdisordersAnatomical Bruxism Mouthbreathing Sleepapnea Catathrenia Centralhypoventilationsyndrome Obesityhypoventilationsyndrome Obstructivesleepapnea Periodicbreathing Snoring Dyssomnia Excessivedaytimesleepiness Hypersomnia Insomnia Kleine–Levinsyndrome Narcolepsy Nighteatingsyndrome Nocturia Sleepstatemisperception Circadianrhythmdisorders Advancedsleepphasedisorder Cyclicalternatingpattern Delayedsleepphasedisorder Irregularsleep–wakerhythm Jetlag Non-24-hoursleep–wakedisorder Shiftworksleepdisorder Parasomnia Nightmaredisorder Nightterror Periodiclimbmovementdisorder Rapideyemovementsleepbehaviordisorder Sleepwalking Sleepdriving Sleep-talking Benignphenomena Dreams Explodingheadsyndrome Hypnicjerk Hypnagogia/Sleeponset Hypnopompicstate Sleepparalysis Sleepinertia Somnolence Nocturnalclitoraltumescence Nocturnalpeniletumescence Nocturnalemission Treatment Sleepdiary Sleephygiene Sleepinduction Hypnosis Lullaby Somnology Polysomnography Other Sleepmedicine Behavioralsleepmedicine Sleepstudy Dailylife Bed Bunkbed Daybed Four-posterbed Futon Hammock Mattress Sleepingbag Bedbug Bedding Bedroom Bedtime Bedtimestory Biphasicandpolyphasicsleep Chronotype Comfortobject Dreamdiary Microsleep Nap Nightwear Powernap Secondwind Siesta Sleepandcreativity Sleepandlearning Sleepdeprivation/Sleepdebt Sleepingwhileonduty Sleepover vteHypnotics/sedatives(N05C)GABAAAlcohols 2M2B Chloralodol Ethanol(alcohol) Diethylpropanediol Ethchlorvynol Methylpentynol Trichloroethanol Barbiturates Allobarbital Amobarbital Aprobarbital Barbital Butabarbital Butobarbital Cyclobarbital Ethallobarbital Heptabarb Hexobarbital Mephobarbital Methohexital Narcobarbital Pentobarbital Phenallymal Phenobarbital Propylbarbital Proxibarbal Reposal Secobarbital Talbutal Thiamylal Thiopental Thiotetrabarbital Vinbarbital Vinylbital Benzodiazepines Brotizolam Cinolazepam Climazolam Clonazolam Doxefazepam Estazolam Flubromazolam Flunitrazalom Flunitrazepam Flurazepam Flutoprazepam Lorazepam Loprazolam Lormetazepam Midazolam Nimetazepam Nitemazepam Nitrazepam Nitrazolam Quazepam Temazepam Triazolam Carbamates Carisoprodol Emylcamate Ethinamate Hexapropymate Meprobamate Methocarbamol Phenprobamate Procymate Tybamate Imidazoles Etomidate Metomidate Propoxate Monoureides Acecarbromal Apronal(apronalide) Bromisoval Capuride Carbromal Ectylurea Neuroactivesteroids Acebrochol Allopregnanolone Alphadolone Alphaxolone Eltanolone Hydroxydione Minaxolone Progesterone Nonbenzodiazepines Eszopiclone Indiplon Lirequinil Necopidem Pazinaclone Saripidem Suproclone Suriclone Zaleplon Zolpidem Zopiclone Phenols Propofol Piperidinediones Glutethimide Methyprylon Pyrithyldione Piperidione Quinazolinones Afloqualone Cloroqualone Diproqualone Etaqualone Mebroqualone Mecloqualone Methaqualone Methylmethaqualone Nitromethaqualone SL-164 Others Acetophenone Acetylglycinamidechloralhydrate Bromidecompounds Lithiumbromide Potassiumbromide Sodiumbromide Centalun Chloralbetaine Chloralhydrate Chloralose Clomethiazole Dichloralphenazone Gaboxadol Kavalactones Loreclezole Paraldehyde Petrichloral Sulfonylalkanes Sulfonmethane(sulfonal) Tetronal Trional Triclofos Sesquiterpene Isovaleramide Isovalericacid Valerenicacid GABAB 1,4-Butanediol 4-Fluorophenibut Aceburicacid Baclofen GABOB GHB(sodiumoxybate) GBL GVL Phenibut Tolibut H1Antihistamines Captodiame Cyproheptadine Diphenhydramine Doxylamine Hydroxyzine Methapyrilene Perlapine Pheniramine Promethazine Propiomazine Antidepressants Serotoninantagonistsandreuptakeinhibitors Etoperidone Nefazodone Trazodone Tricyclicantidepressants Amitriptyline Doxepin Trimipramine,etc. Tetracyclicantidepressants Mianserin Mirtazapine,etc. Antipsychotics Typicalantipsychotics Chlorpromazine Thioridazine,etc. Atypicalantipsychotics Olanzapine Quetiapine Risperidone,etc. α2-Adrenergic Clonidine Detomidine Dexmedetomidine Lofexidine Medetomidine Romifidine Tizanidine Xylazine 5-HT2AAntidepressants Trazodone Tricyclicantidepressants Amitriptyline Doxepin Trimipramine,etc. Tetracyclicantidepressants Mianserin Mirtazapine,etc. Antipsychotics Typicalantipsychotics Chlorpromazine Thioridazine,etc. Atypicalantipsychotics Olanzapine Quetiapine Risperidone,etc. Others Niaprazine Melatonin Agomelatine Melatonin Ramelteon Tasimelteon Orexin Daridorexant Lemborexant Suvorexant α2δVDCC Gabapentin Gabapentinenacarbil Mirogabalin Phenibut Pregabalin Others Cannabidiol Cannabis Chlorophenylalkyldiols Fenpentadiol Metaglycodol Phenaglycodol Diethylpropanediol Evoxine Fenadiazole Guaifenesin-relatedmusclerelaxants Chlorphenesin Mephenesin Mephenoxalone Metaxalone Methocarbamol Midaflur Opioids(e.g.,morphine) Passionflower Scopolamine Trazodone UMB68 Valnoctamide vteInsomniamedicationsGABAAreceptorpositivemodulators Benzodiazepines:Brotizolam Cinolazepam Climazolam Clorazepate Doxefazepam Estazolam Etizolam Flunitrazepam Flurazepam Flutoprazepam Haloxazolam Loprazolam Lormetazepam Midazolam Nimetazepam Nitrazepam Quazepam Temazepam Triazolam Nonbenzodiazepines/Z-drugs:Eszopiclone Zaleplon Zolpidem Zopiclone Others:Alcohols(e.g.,ethchlorvynol,amylenehydrate,ethanol) Barbiturates(e.g.,amobarbital,pentobarbital,phenobarbital,secobarbital) Bromides(e.g.,potassiumbromide,sodiumbromide) Carbamates(e.g.,meprobamate) Chloralhydrate Clomethiazole Kava Paraldehyde Piperidinediones(e.g.,glutethimide) Quinazolinones(e.g.,methaqualone) Sulfonmethane Valerian Antihistamines(H1receptorinverseagonists) Alimemazine Captodiame Dimenhydrinate Diphenhydramine Doxylamine Etodroxizine Hydroxyzine Meclizine Methapyrilene Pheniramine Phenyltoloxamine Pimethixene Promethazine Propiomazine Pyrilamine Tricyclicantidepressants(e.g.,amitriptyline,doxepin,trimipramine) Tetracyclicantidepressants(e.g.,mirtazapine) Triprolidine Orexinreceptorantagonists Daridorexant Lemborexant Seltorexant† Suvorexant Melatoninreceptoragonists Melatonin Ramelteon Tasimelteon Miscellaneous Antipsychotics(e.g.,quetiapine,olanzapine,risperidone,chlorpromazine) Ashwagandha Benzoctamine Cannabinoids(e.g.,cannabis,dronabinol(THC),nabilone) Chamomile Fenadiazole Gabapentinoids(e.g.,gabapentin,pregabalin,phenibut) Hops Lavender Menthylisovalerate Niaprazine Opioids(e.g.,hydrocodone,oxycodone,morphine) Passionflower Scopolamine Serotoninprecursors(tryptophan,5-HTP) Sodiumoxybate(GHB) Sympatholytics(e.g.,clonidine,guanfacine,prazosin) Theanine Trazodone Tricyclicantidepressants(e.g.,amitriptyline,doxepin,trimipramine) Tetracyclicantidepressants(e.g.,mirtazapine) Valnoctamide #WHO-EM ‡Withdrawnfrommarket Clinicaltrials: †PhaseIII §NevertophaseIII vteDigitalmediauseandmentalhealthProposedorrecogniseddiagnosticcategories Gamingdisorder(Videogameaddiction) Problematicsocialmediause Internetaddictiondisorder Problematicsmartphoneuse Nomophobia Computeraddiction Televisionaddiction Internetsexaddiction Disciplinesinvolved Digitalsociology Digitalanthropology Psychiatry Evolutionary Psychology Evolutionary Neuroscience Associatedpsychiatricconditions Depression Anxiety Attentiondeficithyperactivitydisorder Autism Bipolardisorder Insomnia Relatedtopics Behavioralmodernity Computerrage CriticismofFacebook CriticismofNetflix Cyberbullying Digitaldetox Electronicmediaandsleep Evolutionarymismatch Humanmultitasking Mobilephonesanddrivingsafety Textingwhiledriving Mediamultitasking Onlineproblemgambling Screentime Smartphonezombie Socialaspectsoftelevision SocialimpactofYouTube Socialmediaandsuicide Technophobia Technostress AuthoritycontrolNationallibraries Spain France(data) 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