insomnia

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Insomnia

 

Definition

Insomnia is the inability to obtain an adequate amount or quality of sleep. The difficulty can be in falling asleep, remaining asleep, or both. People with insomnia do not feel refreshed when they wake up. Insomnia is a common symptom affecting millions of people that may be caused by many conditions, diseases, or circumstances.

Description

Sleep is essential for mental and physical restoration. It is a cycle with two separate states: rapid eye movement (REM), the stage in which most dreaming occurs; and non-REM (NREM). Four stages of sleep take place during NREM: stage I, when the person passes from relaxed wakefulness; stage II, an early stage of light sleep; stages III and IV, which are increasing degrees of deep sleep. Most stage IV sleep (also called delta sleep), occurs in the first several hours of sleep. A period of REM sleep normally follows a period of NREM sleep.
Insomnia is more common in women and older adults. People who are divorced, widowed, or separated are more likely to have the problem than those who are married, and it is more frequently reported by those with lower socioeconomic status. Short-term, or transient, insomnia is a common occurrence and usually lasts only a few days. Long-term, or chronic insomnia lasts more than three weeks and increases the risk for injuries in the home, at the workplace, and while driving because of daytime sleepiness and decreased concentration. Chronic insomnia can also lead to mood disorders like depression.

Causes and symptoms

Transient insomnia is often caused by a temporary situation in a person's life, such as an argument with a loved one, a brief medical illness, or jet lag. When the situation is resolved or the precipitating factor disappears, the condition goes away, usually without medical treatment.
Chronic insomnia usually has different causes, and there may be more than one. These include:
  • A medical condition or its treatment, including sleep apnea
  • Use of substances such as caffeine, alcohol, and nicotine
  • Psychiatric conditions such as mood or anxiety disorders
  • Stress, such as sadness caused by the loss of a loved one or a job
  • Disturbed sleep cycles caused by a change in work shift
  • Sleep-disordered breathing, such as snoring
  • Periodic jerky leg movements (nocturnal myoclonus), which happen just as the individual is falling asleep
  • Repeated nightmares or panic attacks during sleep.
Another cause is excessive worrying about whether or not a person will be able to go to sleep, which creates so much anxiety that the individual's bedtime rituals and behavior actually trigger insomnia. The more one worries about falling asleep, the harder it becomes. This is called psychophysiological insomnia.

Symptoms of insomnia

People who have insomnia do not start the day refreshed from a good night's sleep. They are tired. They may have difficulty falling asleep, and commonly lie in bed tossing and turning for hours. Or the individual may go to sleep without a problem but wakes in the early hours of the morning and is either unable to go back to sleep, or drifts into a restless unsatisfying sleep. This is a common symptom in the elderly and in those suffering from depression. Sometimes sleep patterns are reversed and the individual has difficulty staying awake during the day and takes frequent naps. The sleep at night is fitful and frequently interrupted.

Diagnosis

The diagnosis of insomnia is made by a physician based on the patient's reported signs and symptoms. It can be useful for the patient to keep a daily record for two weeks of sleep patterns, food intake, use of alcohol, medications, exercise, and any other information recommended by the physician. If the patient has a bed partner, information can be obtained about whether the patient snores or is restless during sleep. This, together with a medical history and physical examination, can help confirm the doctor's assessment.
A wide variety of healthcare professionals can recognize and treat insomnia, but when a patient with chronic insomnia does not respond to treatment, or the condition is not adequately explained by the patient's physical, emotional, or mental circumstances, then more extensive testing by a specialist in sleep disorders may be warranted.

Treatment

Treatment of insomnia includes alleviating any physical and emotional problems that are contributing to the condition and exploring changes in lifestyle that will improve the situation.

Changes in behavior

Patients can make changes in their daily routine that are simple and effective in treating their insomnia. They should go to bed only when sleepy and use the bedroom only for sleep. Other activities like reading, watching television, or snacking should take place somewhere else. If they are unable to go to sleep, they should go into another room and do something that is relaxing, like reading. Watching television should be avoided because it has an arousing effect. The person should return to bed only when they feel sleepy. Patients should set the alarm and get up every morning at the same time, no matter how much they have slept, to establish a regular sleep-wake pattern. Naps during the day should be avoided, but if absolutely necessary, than a 30 minute nap early in the afternoon may not interfere with sleep at night.
Another successful technique is called sleep-restriction therapy, which restricts the amount of time spent in bed to the actual time spent sleeping. This approach allows a slight sleep debt to build up, which increases the individual's ability to fall asleep and stay asleep. If a patient is sleeping five hours a night, the time in bed is limited to 5-5 1/2 hours. The time in bed is gradually increased in small segments, with the individual rising at the same time each morning; at least 85% of the time in bed must be spent sleeping.

Drug therapy

Medications given for insomnia include sedatives, tranquilizers, and antianxiety drugs. All require a doctor's prescription and may become habit-forming. They can lose effectiveness over time and can reduce alertness during the day. The medications should be taken two to four times daily for approximately three to four weeks, though this will vary with the physician and patient. If the insomnia is related to depression, then an antidepressant medication may be helpful. Over-the-counter drugs such as antihistamines are not very effective in bringing about sleep and can affect the quality of sleep.

Other measures

Relaxing before going to bed will help a person fall asleep faster. Learning to substitute pleasant thoughts for unpleasant ones (imagery training) is a technique that can be very helpful in reducing worry. Another effective measure is the use of audiotapes which combine the sounds of nature with soft relaxing music. These, alone or in combination with other relaxation techniques, can safely promote sleepiness.
Changes in diet and exercise routines can also have a have a beneficial effect. Dietary items to be avoided include drinks that contain caffeine such as coffee, tea and colas, chocolate (which contains a stimulant), and alcohol, which initially makes a person sleepy but a few hours later can have the opposite effect. Maintaining a comfortable bedroom temperature, reducing noise and eliminating light are also helpful. Regularly scheduled morning or afternoon exercise can relax the body. This should be done 3-4 times a week and be sufficient to produce a light sweat.

Alternative treatments

Many alternative treatments are effective in treating both the symptom of insomnia and its underlying causes. Incorporating relaxation techniques into bedtime rituals will help a person go to sleep faster, as well as improve the quality of sleep. These methods include meditation, massage, breathing exercises, and a warm bath, scented with rose, lavender (Lavendula officinalis), marjoram, or chamomile (Matricaria recutita). Eating a healthy diet rich in calcium, magnesium, and the B vitamins is also beneficial. A high protein snack like yogurt before going to bed is recommended, or a cup of herb tea made with chamomile, hops (Humulus lupulus), passionflower (Passiflora incarnata), or St John's Wort (Hypericum perforatum) to encourage relaxation. Acupuncture and biofeedback have also proven useful.

Prevention

Prevention of insomnia centers around promotion of a healthy lifestyle. A balance of rest, recreation and exercise in combination with stress management, regular physical examinations, and a healthy diet can do much to reduce the risk.

Resources

Organizations

American Sleep Disorders Association. 1610 14th St. NW, Ste. 300, Rochester, MN 55901. (507) 287-6006. http://www.asda.org.

Other

"What to Do When You Can't Sleep." The Virtual Hospital Page. University of Iowa. http://www.vh.org.

Key terms

Biofeedback — A training technique that enables an individual to gain some element of control over involuntary body functions.
Mood disorder — A group of mental disorders involving a disturbance of mood, along with either a full or partial excesseively happy (manic) or extremely sad (depressive) syndrome not caused by any other physical or mental disorder. Mood refers to a prolonged emotion.
Sleep apnea — A condition in which a person stops breathing while asleep. These periods can last up to a minute or more, and can occur many times each hour. In order to start breathing again, the person must become semi-awake. The episodes are not remembered, but the following day the client feels tired and sleepy. If severe, sleep apnea can cause other medical problems.
Sleep disorder — Any condition that interferes with sleep. At least 84 have been identified, according to the American Sleep Disorders Association.

insomnia

 [in-som´ne-ah]
abnormal wakefulness; a sleep disorder consisting of an inability to fall asleep easily or to remain asleep throughout the night. The frequency of persistent insomnia is high; epidemiologic data indicate that it is the most common sleep disorder in the industrialized world. The causes may be physical, psychological, psychiatric, or presence of a specific sleep disorder. adj., adj insom´niac. 

The American Academy of Sleep Medicine recommends that health care practitioners should screen all patients for symptoms of insomnia during health examinations. Fatigue, irritability, reduction in memory, and loss of ability to concentrate are among the daytime manifestations of insomnia.

The treatment of insomnia must be individualized, based on the underlying cause. Physical and mental health problems must be addressed, although they cannot always be successfully treated. Specific medications for sleep, such as sedatives, hypnotics, and other agents are frequently used but are often asociated with development of tolerance, or with rebound insomnia when they are discontinued. Nonpharmacologic treatments that have strong research support include the following: stimulus control to retrain the person who is unable to sleep so that he or she re-associates the bed and bedroom with sleep; progressive muscle relaxation; paradoxical intention therapy where the patient stays awake to eliminate performance anxiety related to sleep; biofeedback; and multi-component (cognitive) therapy.

Numerous papers and guidelines to support evidence-based practice in the management of insomnia are available by writing to the American Academy of Sleep Medicine, 6301 Bendel Road NW, Suite 101, Rochester, MN 55901 or looking at their web site at http://www.aasmnet.org/practiceparameters.htm.
fatal familial insomnia an inherited prion disease, transmitted as an autosomal dominant trait. The cause is unknown, but it seems to affect primarily the thalamus with disruptions in the sleep-wake cycle. Onset is typically in midlife, characterized by progressive insomnia, hallucinations, and motor abnormalities followed by stupor and coma ending in death within 6 months to 3 years of onset. There may also be excessive sweating, elevated body temperature and blood pressure, and tachycardia.
primary insomnia a dyssomnia characterized by persistent difficulty initiating or maintaining sleep or by persistently nonrefreshing sleep, but not due to any other psychological or physical condition.

cyclosporine ophthalmic emulsion

Restasis, Sandimmun (UK)CNS: tremor, headache, confusion, paresthesia, insomnia, anxiety, depression, lethargy, weakness

Pharmacologic class: Polypeptide antibiotic

Therapeutic class: Immunosuppressant

Pregnancy risk category C

Respiratory: cough, dyspnea, Pneumocystis jiroveci pneumonia, bronchospasm

FDA Box Warning

• Drug should be prescribed only by physicians experienced in managing systemic immunosuppressive therapy for indicated disease. At doses used for solid-organ transplantation, it should be prescribed only by physicians experienced in immunosuppressive therapy and management of organ transplant recipients. Patient should be managed in facility with adequate laboratory and medical resources. Physician responsible for maintenance therapy should have complete information needed for patient follow-up.

• Neoral may increase susceptibility to infection and neoplasia. In kidney, liver, and heart transplant patients, drug may be given with other immunosuppressants.

• Sandimmune should be given with adrenal corticosteroids but not other immunosuppressants. In transplant patients, increased susceptibility to infection and development of lymphoma and other neoplasms may result from increased immunosuppression.

• Sandimmune and Neoral aren't bioequivalent. Don't use interchangeably without physician supervision.

• In patients receiving Sandimmune soft-gelatin capsules and oral solution, monitor at repeated intervals (due to erratic absorption).

Action

Unclear. Thought to act by specific, reversible inhibition of immunocompetent lymphocytes in G0-G1 phase of cell cycle. Preferentially inhibits T lymphocytes; also inhibits lymphokine production. Ophthalmic action is unknown.

Availability

Capsules: 25 mg, 100 mg

Injection: 50 mg/ml

Oral solution: 100 mg/ml

Solution (ophthalmic): 0.05% (0.4 ml in 0.9 ml single-use vial)

Indications and dosages

Psoriasis

Adults:Neoral only-1.25 mg/kg P.O. b.i.d. for 4 weeks. Based on patient response, may increase by 0.5 mg/kg/day once q 2 weeks, to a maximum dosage of 4 mg/kg/day.

Severe active rheumatoid arthritis

Adults:Neoral only-1.25 mg/kg P.O. b.i.d. May adjust dosage by 0.5 to 0.75 mg/kg/day after 8 weeks and again after 12 weeks, to a maximum dosage of 4 mg/kg/day. If no response occurs after 16 weeks, discontinue therapy. Gengraf only-2.5 mg/kg P.O. daily given in two divided doses; after 8 weeks, may increase to a maximum dosage of 4 mg/kg/day.

To prevent organ rejection in kidney, liver, or heart transplantation

Adults and children:Sandimmune only-Initially, 15 mg/kg P.O. 4 to 12 hours before transplantation, then daily for 1 to 2 weeks postoperatively. Reduce dosage by 5% weekly to a maintenance level of 5 to 10 mg/kg/day. Or 5 to 6 mg/kg I.V. as a continuous infusion 4 to 12 hours before transplantation.

To increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca

Adults: 1 drop in each eye b.i.d. given 12 hours apart

Off-label uses

• Aplastic anemia
• Atopic dermatitis

Contraindications

• Hypersensitivity to drug and any ophthalmic components
• Rheumatoid arthritis, psoriasis in patients with abnormal renal function, uncontrolled hypertension, cancer (Gengraf, Neoral)
• Active ocular infections (ophthalmic use)

Precautions

Use cautiously in:
• hepatic impairment, renal dysfunction, active infection, hypertension
• herpes keratitis (ophthalmic use)
• pregnant or breastfeeding patients
• children younger than age 16 (safety and efficacy not established for ophthalmic use).

Administration

• For I.V. infusion, dilute as ordered with dextrose 5% in water or 0.9% normal saline solution. Administer over 2 to 6 hours.
• Mix Neoral solution with orange juice or apple juice to improve its taste.
• Dilute Sandimmune oral solution with milk, chocolate milk, or orange juice. Be aware that grapefruit and grapefruit juice affect drug metabolism.
• In postoperative patients, switch to P.O. dosage as tolerance allows.
• Be aware that Sandimmune and Neoral aren't bioequivalent. Don't use interchangeably.
• Before administering eyedrops, invert unit-dose vial a few times to obtain a uniform, white, opaque emulsion.
• Know that eyedrops can be used concomitantly with artificial tears, allowing a 15-minute interval between products.

Adverse reactions

CNS: tremor, headache, confusion, paresthesia, insomnia, anxiety, depression, lethargy, weakness

CV: hypertension, chest pain, myocardial infarction

EENT: visual disturbances, hearing loss, tinnitus, rhinitis; (with ophthalmic use) ocular burning, conjunctival hyperemia, discharge, epiphora, eye pain, foreign body sensation, itching, stinging, blurring

GI: nausea, vomiting, diarrhea, constipation, abdominal discomfort, gastritis, peptic ulcer, mouth sores, difficulty swallowing, anorexia, upper GI bleeding, pancreatitis

GU: gynecomastia, hematuria, nephrotoxicity, renal dysfunction, glomerular capillary thrombosis Hematologic: anemia, leukopenia, thrombocytopenia

Metabolic: hyperglycemia, hypomagnesemia, hyperuricemia, hyperkalemia, metabolic acidosis

Musculoskeletal: muscle and joint pain

Respiratory: cough, dyspnea, Pneumocystis jiroveci pneumonia, bronchospasm

Skin: acne, hirsutism, brittle fingernails, hair breakage, night sweats

Other: gum hyperplasia, flulike symptoms, edema, fever, weight loss, hiccups, anaphylaxis

Interactions

The following interactions pertain to oral and I.V. routes only.

Drug-drug.Acyclovir, aminoglycosides, amphotericin B, cimetidine, diclofenac, gentamicin, ketoconazole, melphalan, naproxen, ranitidine, sulindac, sulfamethoxazole, tacrolimus, tobramycin, trimethoprim, vancomycin: increased risk of nephrotoxicity

Allopurinol, amiodarone, bromocriptine, clarithromycin, colchicine, danazol, diltiazem, erythromycin, fluconazole, imipenem and cilastatin, itraconazole, ketoconazole, methylprednisolone, nicardipine, prednisolone, quinupristin/dalfopristin, verapamil: increased cyclosporine blood level

Azathioprine, corticosteroids, cyclophosphamide: increased immunosuppression Carbamazepine, isoniazid, nafcillin, octreotide, orlistat, phenobarbital, phenytoin, rifabutin, rifampin, ticlopidine: decreased cyclosporine blood level

Digoxin: decreased digoxin clearance

Live-virus vaccines: decreased antibody response to vaccine

Lovastatin: decreased lovastatin clearance, increased risk of myopathy and rhabdomyolysis

Potassium-sparing diuretics: increased risk of hyperkalemia

Drug-diagnostic tests.Alanine aminotransferase, aspartate aminotransferase, bilirubin, blood urea nitrogen, creatinine, glucose, low-density lipoproteins: increased levels

Hemoglobin, platelets, white blood cells: decreased values

Drug-food.Grapefruit, grapefruit juice: decreased cyclosporine metabolism, increased cyclosporine blood level

High-fat diet: decreased drug absorption (Neoral)

Drug-herbs.Alfalfa sprouts, astragalus, echinacea, licorice: interference with immunosuppressant action St. John's wort: reduced cyclosporine blood level, possibly leading to organ rejection

Patient monitoring

• Observe patient for first 30 to 60 minutes of infusion. Monitor frequently thereafter.
• Monitor cyclosporine blood level, electrolyte levels, and liver and kidney function test results.
• Assess for signs and symptoms of hyperkalemia in patients receiving concurrent potassium-sparing diuretic.

Patient teaching

• Advise patient to dilute Neoral oral solution with orange or apple juice (preferably at room temperature) to improve its flavor.
• Instruct patient to use glass container when taking oral solution. Tell him not to let solution stand before drinking, to stir solution well and then drink all at once, and to rinse glass with same liquid and then drink again to ensure that he takes entire dose.
• Tell patient taking Neoral to avoid high-fat meals, grapefruit, and grapefruit juice.
• Advise patient to dilute Sandimmune oral solution with milk, chocolate milk, or orange juice to improve its flavor.
• Instruct patient to invert vial a few times to obtain a uniform, white, opaque emulsion before using eyedrops and to discard vial immediately after use.
• Inform patient that eyedrops can be used with artificial tears but to allow 15-minute interval between products.
• Caution patient not to wear contact lenses because of decreased tear production; however, if contact lenses are used, advise patient to remove them before administering eyedrops and to reinsert 15 minutes after administration.
• Inform patient that he's at increased risk for infection. Caution him to avoid crowds and exposure to illness.
• Instruct patient not to take potassium supplements, herbal products, or dietary supplements without consulting prescriber.
• Tell patient he'll need to undergo repeated laboratory testing during therapy.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, and herbs mentioned above.

in·som·ni·a

(in-som'nē-ă),
Inability to sleep, in the absence of external impediments (for example, noise, a bright light) during the period when sleep should normally occur; may vary in degree from restlessness or disturbed slumber to a curtailment of the normal length of sleep or to absolute wakefulness.
Synonym(s): sleeplessness
[L. fr. in- priv. + somnus, sleep]

insomnia

/in·som·nia/ (-som´ne-ah) inability to sleep; abnormal wakefulness.insom´niacinsom´nic
fatal familial insomnia  an inherited prion disease affecting primarily the thalamus and characterized by progressive insomnia, hallucinations, stupor, and coma ending in death; autonomic and motor disturbances are also present.
primary insomnia  a dyssomnia characterized by persistent difficulty initiating or maintaining sleep or by persistently nonrestorative sleep; not due to any other condition.

insomnia

(ĭn-sŏm′nē-ə)
n.
Chronic inability to fall asleep or remain asleep for an adequate length of time.

insomnia

[insom′nē·ə]
Etymology: L, in, not, somnus, sleep
chronic inability to sleep or to remain asleep throughout the night; wakefulness; sleeplessness. Insomnia may be the symptom of a psychiatric disorder. Formerly called agrypnia.

insomnia

Sleep disorders The perceived or actual inability to sleep one's usual amount of time; a condition characterized by any combination of difficulty with falling asleep, staying asleep, intermittent wakefulness, and early-morning awakening; episodes may be transient, short-term–lasting 2 to 3 wks, or chronic Triggers Illness, depression, anxiety, stress, poor sleep environment, caffeine, abuse of alcohol, heavy smoking, physical discomfort, daytime napping, medical conditions, poor sleep habits–eg, early bedtime, excessive time awake in bed Examples Psychophysiologic–learned insomnia, delayed sleep phase syndrome, hypnotic dependent sleep disorder, stimulant dependent sleep disorder. See Circadian rhythm, Conditioned insomnia, Familial fatal insomnia, Jet lag, Pseudoinsomnia, Rebound insomnia, REM sleep, Sleep disorder, Sleep-onset insomnia.
Insomnia
Chronologic classification
• Transient–eg, 'jet lag'; does not require treatment
• Short term < 3 weeks in duration, due to travel to high altitudes, grieving loss of loved one, hospitalization, pain
• Long term > 3 weeks in duration, eg related to medical, neurologic or psychiatric disorders or addiction
Etiology
• Pharmacologic Due to coffee, nicotine, alcohol
• Rebound (withdrawal) Related to abrupt discontinuation of hypnotic drugs
• Delayed sleep phase Due to shift work, chronic pain, sleep apnea and restless leg syndrome

in·som·ni·a

(in-som'nē-ă)
Inability to sleep, in the absence of external impediments (e.g., noise, a bright light) during the period when sleep should normally occur; may vary in degree from restlessness or disturbed slumber to a curtailment of the normal length of sleep or to absolute wakefulness.
[L. fr. in- priv. + somnus, sleep]

insomnia

Difficulty in falling asleep or in remaining asleep for an acceptable period. Insomnia is very common and is often caused by worry, tension, depression, pain or old age. Sleep requirements vary widely from person to person and those who sleep for apparently short periods seldom, if ever, suffer any harmful effects.

insomnia,

n sleeplessness; may be short- or long-term; has a variety of causes, including some psychiatric disorders.

in·som·ni·a

(in-som'nē-ă)
Inability to sleep, without external impediments when sleep should normally occur.
[L. fr. in- priv. + somnus, sleep]

insomnia,

n the chronic inability to sleep or remain asleep throughout the night.

Patient discussion about insomnia

Q. Is this a kind of Insomnia...? It's hard to explain my situation. I've always had a horrible sleeping pattern ever since I was really little. In fact, I've never really had a bed time. I always go to bed really early in the mornings, like 7, 8, 9 am. If I want to put myself on a normal sleeping schedule, I stay up all day and I manage to conk out around 10 pm...sometimes even later. But then, the next couple of days, I'm doing the same exact thing again. I was wondering, is this a type of insomnia? And if it is, should I see a doctor about it?

A. Your biological clock is upside down. Congratulations. You are not sick or anything you live in a different time zone than others. You can go to a sleep lab and they may find a reason for this. Or you can stop fighting it. Cause if you’ll do you’ll start sleeping only 3-4 hours a night and than it’ll affect your body- the hormone balance will change, and you’ll gain weight and things like that.

Q. Any other treatment for sleeplessness problem than Melatonin??? 33 years male having acute sleeping problem awake until 08:00-09:00am. Taking Melatonin failed.

A. Belladonna. [Bell]
The sleepless conditions calling for Belladonna are due to congestion; sleep is extremely restless, as a rule it is interrupted by talking, startings, muscular jerkings and spasmodic motions; frightful images appear on closing the eyes and the patient therefore dreads sleep. Children awake from sleep frightened. The dreams found under Belladonna are frightful ones, and they constantly awaken the patient. It is probably our best remedy for insomnia due to cerebral hyperaemia; that is, it will be most often indicated, also after morphine which produces cerebral hyperaemia of a passive variety. Aconite comes in here, too, but with Aconite there is intense anxiety and restlessness, fear of disaster or death. Cuprum, Stramonium and Zincum have the symptom that the patient is aroused from sleep frightened. For the complete list: http://www.hpathy.com/diseases/insomnia-sleeplessness-treatment-cure.asp Hope this helps.

Q. On stopping the medicines his insomnia like condition starts hi all………………my dad is bipolar II and he was on lithium and clonazepam which had put his mania under control, but he sleeps a lot, as he finds his sleep refreshing him; which is due to medicine. On stopping the medicines his insomnia like condition starts and so now he takes his doses in excess to sleep…..we were told not to stop on these medicines……is it all right?

A. I agree with the others it is very dangerous to start and stop medications. One has to be weined off Lithium slowly. If your dad is finding that his current doses are not working properly he should be discussing it with his doctor whom will tweak his dosages or change his medications. It is so important to take medications as perscribed. Clonezepam can be addictive so it should be taken exactly as perscribed and monitored. There are other medications in the "pam" family that he can be changed to if the Clonezepam is no longer effective, rather than taking more.
The insomnia syptoms are signs of mania which will happen when he stops taking his medications. If you stop taking medications that are controlling bipolar symptoms the only logical outcome is the return of the bipolar symptoms. I would have him visit his doctor and discuss changing or increasing his doseages if he is finding they are not working effectivly anymore.

More discussions about insomnia
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The most common symptoms of PND are: Feeling sad or low |most of the time A loss of interest in |things you used to enjoy A persistent lack of |energ y Other symptoms include: Difficulty sleeping | Poor appetite or over |eating Difficulty concen-|trating Low self-confidence | Feeling guilty | Thoughts about |self-harm or suicide If you think you or someone you know may be suffering from PND, there is lots of help and support available.
The cricketer said that several players of their team have had difficulty sleeping in the five-star Langham Hotel in central London, with several other teammates even demanding to change rooms.
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Researchers from the School of Life Sciences have found that Montmorency cherry juice significantly increases the levels of melatonin in the body, the hormone which regulates sleep, and could benefit those who have difficulty sleeping due to insomnia, shift work or jet lag.
Many people with difficulty sleeping don't have a medical condition with a labeled diagnosis.