Natural Insomnia Cure and Treatment

Natural Insomnia Program

Natural Insomnia Program is credited to Christian Goodman, who is a health expert, and he is willing to help those people suffering from insomnia for long. Many people end up suffering from the sleepless night, which ends up affecting their following day schedule. For instance, the author sleepless night has destructed his marriage and also career, but with the help of the program, he has been to overcomes this problem. Through the various studies, it shows that most of the people sleep after 45 minutes, but with the help of the program, this would be reduced to 10 to 15 minutes. The most common solution to relaxing the body is through linguistic audio, which would help the brain to relax and thus sleep effectively. Many people have used the program, and they have ended solving the problem entirely. The program is available either in the video series and e-Book and works within the shortest time possible. Continue reading...

Natural Insomnia Program Summary


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Alcohol Induced Sleep Disorder

Alcohol consumed at bedtime may decrease the time required to fall asleep but typically disrupts the second half of the sleep cycle, resulting in subsequent daytime fatigue and sleepiness. Even a moderate dose of alcohol consumed within 6 hours prior to bedtime can increase wakefulness during the second half of sleep (Vitiello, 1997). Alcohol use prior to bedtime will also aggravate obstructive sleep apnea, and heavy drinkers or those with alcoholism are at increased risk for sleep apnea. Patients with severe obstructive sleep apnea are at a fivefold increased risk for fatigue-related traffic crashes if they consume two or more drinks per day compared to obstructive sleep apnea patients who consume little or no alcohol (Bassetti & Aldrich, 1996). In alcoholics, heavy drinking eventually leads to increased time required to fall asleep, frequent awakenings, and a decrease in subjective quality of sleep. Slow-wave sleep is interrupted, and during periods of withdrawal there is pronounced...

Fatal Familial Insomnia

FFI, dominantly inherited or sporadic, is characterized by intractable insomnia, autonomic dysfunction (changes in blood pressure, heart rate, temperature, and respiratory rate), myoclonus, cerebellar ataxia, and pyramidal and extrapyramidal signs. Atrophy, neuronal losses, and severe gliosis of the thalamus are distinctive features. Spongiform changes and prion amyloid plaques are not conspicuous.

Hypothesis of Melatonin

One possible interaction hypothesis under investigation is that exposure to EM fields suppresses the production of melatonin, which is a hormone produced by the pineal gland, a small pinecone-shaped gland located deep near the center of the brain. Melatonin is produced mainly at night and released into the blood stream to be dispersed throughout the body. It surges into almost every cell in the human body, destroying free radicals and helping cell division to take place with undamaged DNA. Melatonin also assists in regulating the female menstrual cycle and circa-dian rhythms. Melatonin secretion decreases over a lifetime, peaking in childhood and gradually lessening after puberty. Usually, people over 60 secrete far less than they do when young. Also, melatonin regulates sleep, mood, behavior, and gene expression. It reduces secretion of tumor-promoting hormones. It has the ability to increase cytotoxicity of the immune system's killer lymphocytes therefore, its production is...

Increase Melatonin Levels

Melatonin stimulates progesterone production and lowers estrogen levels by binding estrogen receptors (26). Melatonin levels are highest during the second half of the menstrual cycle, and it may be beneficial to increase this hormone to improve the function of the corpus luteum (27). Melatonin is derived from its precursor, serotonin. Banana, tomato, cucumber, beetroot, rice, and corn are high in serotonin (28). Simple lifestyle changes, such as sleeping in a dark room, also increase melatonin levels (29).

Cachexia and Melatonin

Among the possible mediators involved in the pathophysiology of cancer anorexia-cachexia, the increased production of tumour necrosis factor (TNF)-a has long been implicated 45 as one of the major cytokines inducing wasting syndrome and enhancing REE. Melatonin was demonstrated to be able, both in vitro and in animals, to inhibit the lipopolysaccharide-induced TNF production in an endotoxic shock model 46 . In a preliminary study 47 , we found evidence of feedback systems between the pineal release of melatonin and TNF secretion other studies on the clinical use of mela-tonin in the palliation of symptoms suggested a role for melatonin activity in the improvement of the clinical conditions of patients with advanced-stage cancer 48 .

Overview of Supportive Cancer Care with Melatonin

The therapeutic potential of melatonin is wideranging 54 . Evidence derived from clinical and biological studies has supported our view that melatonin administration should be considered as hormone-replacement therapy aimed at the restoration of the physiological circadian rhythm in cancer patients. The cancer-associated disruption of circadian endocrine, immune, and neurologic systems is still far from being understood 55 , although their prognostic impact on survival In cancer patients, the addition of melatonin to standard treatments improved patient outcome in chemotherapy-treated patients 57, 58 and in those receiving hormone therapy 59, 60 or IL-2 immunotherapy 61,62 . In chemotherapy-treated patients with advanced-stage cancer 63-65 the addition of melatonin decreased the rate of chemo-associated toxicity. In our above-reported study, 250 advanced cancer patients with poor clinical status (lung cancer 104 breast cancer 77 gastrointestinal tract -supportive care+melatonin - -...

Table 82 Summary of Dsmivtr diagnostic criteria for primary insomnia

The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia. potentially lethal situation. Similarly, optimization of sleep hygiene should always be attempted before hypnotic agents are prescribed for other than occasional use. Table 8-3 lists the features regarded by The International Classification of Sleep Disorders (American Sleep Disorders Association 1997) as diagnostic of inadequate sleep hygiene. Interventions as simple as systematically restricting time spent in bed and providing education about normal variability in sleep patterns and age-related changes have been effective in increasing sleep efficiency and reducing daytime sleepiness in older patients with insomnia (Riedel et al. 1995). Modifying thoughts about good and poor sleep (e.g., 8 hours of sleep per night is not necessary for everyone) is an example of a cognitive-behavioral intervention that may also be...

Physiology Of Healthy Sleep

Normal sleep is made up of rapid eye movement (REM) sleep and non-REM sleep. In non-REM sleep, the sleeper passes from wakefulness into stage I, a light sleep that is easily disrupted by environmental stimuli. Stage II is deeper and most stimuli will pass unnoticed by the sleeper. Stages III and IV are deeper still and the sleeper's electroencephalogram (EEG) shows higher-voltage slow waves, leading to these stages of sleep being described as deep, slow-wave, or delta-wave sleep. Here environmental stimuli go unnoticed unless extreme and prolonged. The normal sleep cycle consists of passage from wakefulness to stage I, then through the stages to the deeper levels of sleep. The sleeper then returns to stage II, which occupies the greater part of the night, and from that level into a period of REM sleep. During REM sleep, the sleeper is dreaming and exhibits high levels of cortical activation but with muscle atonia that prevents the movements usually associated with such activation....

Diagnosis of insomnia

The diagnostic criteria for insomnia can indeed become very precise. Insomnia in the ICSD 3 was defined as the complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode , which might denote that sleep quantity and quality should be considered as equivalent. However, there were actually two quantitative requirements in ICSD for the diagnosis of insomnia at least 20 min sleep latency and at the most 6.5 hours total sleep time, otherwise the condition was considered as sleep state misperception also called pseudoinsomnia 3 . According to ICD-10 4 , the sleep disturbance must have occurred at least three times per week for at least 1 month. The 1-month timeframe is essential also for primary insomnia in the American Psychiatric Association's DSM-IV classification 5 . Also the patient must complain either of difficulty falling asleep or maintaining sleep, or of poor quality of sleep. However, the presence of the complaint of unsatisfactory sleep is...

Treatment of insomnia

The effective management of insomnia begins with recognition and adequate assessment. Family doctors and other health care providers should routinely enquire about sleep habits as a component of overall health assessment. Identification and treatment of primary psychiatric disorders, medical conditions, circadian disorders, or specific physiological sleep disorders, such as sleep apnea and periodic limb movement disorder, are essential steps in the management of insomnia 8 . Insomnia may be distinguished in two different states. The first is a state of transient insomnia due to an acute event, while the second is the state of chronic insomnia. What is required in the first case is a treatment lasting for a few days only, i.e., for the period of the underlying event that caused insomnia. Such a case requires a medicine able to induce sleep immediately, while its effect quickly diminishes, so that the individual does not experience after effects when awakened. In the case of chronic...

Administration of Melatonin in Cancer Associated Cachexia

To investigate the in vivo relationships between cancer cachexia, TNF, and melatonin, our Institution carried out a randomised clinical trial in 1994 in advanced-stage cancer patients with progressive disease after standard treatment 53 . Table 1. Clinical characteristics of metastatic untreatable patients receiving supportive care or supportive care and melatonin (MLT) 20 mg day in the evening Table 1. Clinical characteristics of metastatic untreatable patients receiving supportive care or supportive care and melatonin (MLT) 20 mg day in the evening Supportive care + melatonin informed consent and were stratified according to tumour type and disease site. They were then randomised to receive standard supportive care (control arm) or standard supportive care plus melatonin (treated arm). Patients were considered evaluable when observed for at least 2 months. Standard supportive care included nonsteroidal anti inflammatory drugs and opioid drugs for pain palliation. Steroids...

Sleep Disorders

Sleep disorders are grouped into four sections on the basis of presumed etiology (primary, related to another mental disorder, due to a general medical condition, and substance induced). Two types of primary sleep disorders are included in DSM-IV-TR dyssomnias (problems in regulation of amount and quality of sleep) and parasomnias (events that occur during sleep). The dyssomnias include primary insomnia, primary hyper-somnia, circadian rhythm sleep disorder, narcolepsy, and breathing-related sleep disorder, whereas the para-somnias include nightmare disorder, sleep terror disorder, and sleepwalking disorder. Sleep disorders are described in detail in Chapter 39.

Primary insomnia

The high prevalence of insomnia is well documented. One national phone survey estimated that 9 of the population reported difficulties sleeping on a consistent basis, and 27 indicated occasional sleeping problems 7 . A large survey-based epidemiological study conducted in France 8 found that 19 of the population met criteria for insomnia as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 9 . Another recent study assessed the sleep of 772 individuals using 2 weeks of sleep diaries and found that 16 of individuals reported consistent sleeping problems for at least 6 months, including reported daytime impairment 1 . The prevalence studies noted above only consider the general population without regard for differences between specific groups. Research has identified many characteristics that may influence the frequency severity of insomnia complaints including age, gender, socioeconomic status, and ethnicity. It is well documented that insomnia complaints...


Although melatonin is not an herb, its widespread use warrants discussion. Melatonin is a chronobiotic, a term analogous to nutribiotic when used for vitamins and herbs. Melatonin is a derivative of serotonin metabolism. It is marketed as a dietary supplement because it is found in some plants. It is neither FDA-approved nor regulated. Melatonin is normally produced by the pineal gland, and it is secreted to the hypothalamus, where it likely promotes sleep. The circadian rhythm of melatonin production reveals secretion beginning in the evening, with peak melatonin levels about 2-3 a.m., and then a rapid fall at approximately 6 a.m. Melatonin can be helpful for jet lag and disorders of delayed sleep phase. Normal sleep phase can be restored in patients with delayed sleep phase syndrome after administration of melatonin for 2 to 6 weeks. There are reports of antiseizure effects of melatonin. Animal models suggest a link between seizures and melatonin. In animals, antimelatonin antibody...


A good night's sleep is whatever allows a person to feel rested, refreshed, and alert during the day. Some people need 9 to 10 hours, while others only 6 hours. Insomnia is a persistent difficulty in obtaining adequate sleep. Symptoms can include difficulty in falling asleep, frequent awakenings with difficulty falling back asleep, or poor quality, light sleep. Between 25 and 30 of adults suffer from insomnia. Insomnia can have many causes, including stress, depression, anxiety, or poor nutrition.

Diet Insomnia

For the evening meal, foods that contain a high tryptophan to total protein ratio should be eaten. Tryptophan is the precursor for brain synthesis of serotonin, a sleep-inducing neurotransmitter (see pp. 109).1 Eating a tryp-tophan-rich supper (or late-evening snack) together with ample carbohydrate can improve sleep quality. Carbohydrates stimulate production of insulin, and insulin enhances uptake of tryptophan into the brain. Although alcohol has a sedative effect that can hasten sleep onset, heavy alcohol intake often produces light, unsettled sleep and increases nighttime awakening. Because alcohol can interfere with deep sleep, alcoholic nightcaps should generally be avoided A better bedtime drink is a glass of warm milk. Milk is rich in tryptophan and calcium, both of which have a calming effect and may improve sleep quality. The more caffeine consumed during the day, the higher the risk of insomnia. Consumption of coffee, tea, or cola drinks should be avoided within 6 hours of...

Melatonin Hypothesis

Circadian rhythms of pineal activity and melatonin release. The melatonin hypothesis, first proposed many years ago, explained how EMF exposure is related to certain kinds of hormone-dependent cancers, particularly breast cancer. Kato et al. 87 , Wilson et al. 88 , and Huuskonen et al. 89 reported that exposure to magnetic fields between 1 and 130 T caused a decrease in melatonin levels in rats and hamsters. However, other studies found no evidence of any effect on melatonin in baboons, rats, and mice at fields between 1 and 100 T 90-97 . Karasek and Lerchl 98 reported the results of 60 independent assessments in animals of EMF exposure and nocturnal melatonin. Fifty-four percent reported no effect or inconsistent effects, 43 reported decreased melatonin, and 3 reported increased melatonin. Juutilainen and Kumlin 99 reported that daytime occupational exposure to magnetic fields enhances the effects of nighttime light exposure on melatonin production. Juutilainen and Kumlin reanalyzed...

Obstructive sleep apnea

Factors that predispose to OSA include obesity, gender, age, ethnic (including genetic) factors, and craniofacial structure, and OSA may be aggravated by use of certain drugs and smoking. It is pathophysiologically characterized by repetitive episodes during sleep of upper airway narrowing and or closure, accompanied by increased breathing efforts in attempts to overcome such narrowing closure, also by arousals and or outright wakenings from sleep, as well as attendant respiratory and cardiovascular perturbations such as hypoxia, systemic and pulmonary hypertension and tachy- and bradycardia. The adverse effects of OSAS are well documented, and include poor sleep quality and consequent neurobehavioral dysfunction, reduced daytime vigilance and excessive daytime sleepiness, and risk for motor vehicle and other accidents, and cardiovascular morbidity and mortality 3-8 . A full description of the epidemiology, the diagnosis and clinical correlates of OSA has been presented recently 1, 2,...

Introduction and history

The word 'narcolepsy' refers to a syndrome of unknown origin that is characterized by abnormal sleep tendencies, including excessive daytime sleepiness and often disturbed nocturnal sleep and pathological manifestations of REM sleep. The REM sleep abnormalities include sleep onset REM periods and the dissociated REM sleep inhibitory processes, cataplexy and sleep paralysis. Excessive daytime sleepiness, cataplexy, and less often sleep paralysis and hypnagogic hallucinations are the major symptoms of the disease 12 .

Pharmacological studies

Systematic pharmacological studies have also been conducted in canine narcolepsy. Pharmacological studies performed in these animals suggest that both the choliner-gic and monoaminergic systems are critically involved. The administration of choli-nomimetic drugs known to increase REM sleep exacerbates cataplexy in narcoleptic dogs, while the administration of anticholinergic substances decreases cataplexy 78 . These results are similar to the facilitation of REM sleep obtained in animals after pharmacological increase of the central cholinergic transmission 79 . On the other hand, drugs that block the reuptake of noradrenaline have a powerful anti-cataplectic effect 80, 81 , as opposed to dopamine-reuptake inhibitors, which seem to have little effect on canine cataplexy. Animal studies also looked at the pharmacology of a and 3 adrenergic receptors. a-1 adrenergic antagonists (prazosine, phenoxyben-zamine) facilitated, whereas a-1 adrenergic agonists (methoxamine, cirazoline)...

Other drug therapies

There may be some amelioration of sleep-disordered breathing in OSA patients treated with tricyclic antidepressants, such as protriptyline and imipramine, possibly through a REM stage-restricting effect 68, 69 . Improvement in the OSA symptom of daytime sleepiness, independent of any effect on sleep quality or architecture, has been reported in some studies with protriptyline 70 . However, a recent Cochrane Systematic Review comparing studies using protriptyline and placebo found no significant advantage for the active drug in terms of AHI or any other objective measure of respiratory disturbance in sleep 70 . Chronic systemic hypertension is certainly a common association of OSA. Acute blood pressure rises also occur during termination of apneas. Short-term trials of antihypertensives in OSA have had varying modest effects on indices of sleep-disordered breathing. Cilazapril, an ACE inhibitor, and the -blocker metoprolol both reduce AHI by about 30 in OSA patients 77 . Some calcium...

Clinical features

Narcoleptic individuals experience EDS, usually associated with REM sleep phenomena, such as sleep paralysis, cataplexy (emotion-induced weakness), and hypnagogic hallucinations (visual, tactile, kinetic, and auditory phenomena occurring during sleep onset) 37 . Disrupted nocturnal sleep occurs frequently. Sleepiness is usually the first symptom to appear, followed by cataplexy, sleep paralysis and hypnagogic hallucinations 6, 37-40 . Cataplexy onset occurs within five years after the occurrence of daytime somnolence in approximately two thirds of the cases 38, 40 . The mean age of onset of sleep paralysis and hypnagogic hallucinations is also 2-7 years later than that of sleepiness 39, 41 . In most cases, EDS and irresistible sleep episodes persist throughout the lifetime. Several tests have been designed to objectively evaluate sleepiness. Yoss et al. 52 described the electronic pupillogram as a method of measuring decreased levels of sleepiness. Schmidt and Fortin 53 reviewed the...

Russell G Foster Mark W Hankins and Stuart N Peirson

Research over the past decade has focused increasingly on the photoreceptor mechanisms that regulate the circadian system in all forms of life. Some of the results to emerge are surprising. For example, the rods and cones within the mammalian eye are not required for the alignment (entrainment) of circadian rhythms to the dawn-dusk cycle. There exists a population of directly light-sensitive ganglion cells within the eye that act as brightness detectors these regulate both circadian rhythms and melatonin synthesis. An understanding of these circadian photoreceptor pathways, and the features of the light environment used for entrainment, have been and will continue to be heavily dependent on the appropriate use and measurement of light stimuli. Furthermore, if results from different laboratories, or species, are to be compared in any meaningful sense, standardized methods for light measurement and manipulation need to be adopted by circadian biologists. To this end, we describe light...

Mammalian Photoentrainment

Through a dedicated pathway (the retinohypothalamic tract), which originates in the retina (3,4). Eye loss in every mammal, including humans, confirms that photoentrainment originates within the eye (5). However, studies during the 1990s in mice with hereditary retinal disorders produced some very puzzling results. Despite that fact that most of the rods and cones had been lost in these mice, and no visual light perception was detected, photoentrainment to the light-dark cycle still occurred. It seemed extraordinary that the sensitivity of the circadian system to light did not parallel the loss of either rod or cone photoreceptors, or the loss of visual function (6). This work paved the way for the development of a transgenic mouse model (rd rd cl) that was engineered to lack all functional rods and cones. Despite the ablation of the classical photo-receptors, both circadian entrainment and the regulation of pineal melatonin remained intact in these animals (7,8). There had to be...

Mental Health Resources

Although sharing personal information can be difficult, it is important for health care professionals to know if patients are having symptoms such as depression, tearfulness, unexplained sadness, irritability, nervousness, sleep problems, decreased or increased appetite, or even general feelings of being more stressed or overwhelmed. These symptoms may be signs of other medical problems, side effects of medication, and or signs of treatable mental health problems. It may be valuable to refer patients to a licensed psychologist, social worker, or other mental health professional for behavioral strategies.

Signs and Symptoms of Deficiency

Unrecognized thiamin deficiency can produce ill-defined symptoms, such as irritability, depression, fatigue, and insomnia, particularly in people with increased thiamin requirements (e.g., pregnant and breastfeeding women, women taking oral contraception, adolescents, diabetics, heavy alcohol users, the chronically ill). Mental confusion, defects in learning and memory, frequent headache, insomnia

Indication Risks and Contraindications

Generally, no features of epilepsy or personality discourage the use of massage. Systematic evaluations matching massage and seizure types, potential seizure precipitants, or epilepsies (68,69) underline this. In contrast, a major advantage of massage is its nonverbal nature. The application of massage in infants, for example, has yielded positive results in various cultures. Several RCTs confirm this, although the only effects on frequent seizure precipitants, such as sleep deprivation and depression, have been investigated (70). Rare negative reactions to touch can be overcome by skilled psychological treatment, thus making successful treatment possible. Substantial differences occur with regard to the types of massage that are effective for various conditions. The choice of acupoints may depend on whether consciousness is lost during seizures, and there are points and sequences of points primarily suitable for preventing seizures or seizure-favoring factors, such as sleep...

New Research Areas

The multiple receptor systems involved in sleep-wake regulation11 could provide avenues for future research as the biology becomes more fully elucidated. Histamine receptor (H3) antagonists are an active area of research where NCEs have reached clinical evaluation but proof of concept is still required. The orexin pathway has a clear link to the pathophysiology of narcolepsy, and selective OX2 antagonists are being targeted for clinical proof of concept. Drugs that can target the circadian clock mechanisms and related regulatory systems may offer new therapeutic approaches. Drugs targeting receptors for transforming growth factor a (TGFa) and prokineticin are two potential avenues for circadian rhythm modulation.12 Recent studies suggest a role for urotensin II receptors in the regulation of REM sleep through direct activation of cholinergic neurons in the brainstem but it is too early to know whether agents could be identified that could directly target the CNS receptors avoiding the...

Diseases with Akinetic Rigidity Idiopathic Parkinsons Disease

Combinations of extrapyramidal disorders and auto-nomic dysfunctions, frequently accompanied by neuro-psychiatric symptoms, define the disease. The cardinal motor symptoms are cogwheel rigidity of muscle tone, bradykinesia akinesia, postural instability, and pill-rolling tremor at rest. A stooped posture, shuffling and festinating gait, lack of facial expression, micrographia, weak monotonous speech, and dysphagia are additional characteristic features. In some patients, akinetic-rigidity predominates in others, resting tremor. Characteristic autonomic dysfunctions include orthostatic hypotension, seborrhea, sialorrhea, hyperhydrosis, constipation, bladder disorder, sleep disorder, and, rarely, sexual dysfunction. Anxiety, depression, psychosis, hallucination, and cognitive decline may emerge at any time during the course of the disease, which ranges from 10 to 20 years. No specific diagnostic tests are available. PET and SPECT show diminished striatal dopamine uptake. iPD....

Pharmacology Of Alcohol

More important than the disruption of the cell membrane is the effect of alcohol on the gamma-aminobutyric acid (GABA) system and glutamate system of the brain. The brain has three types of GABA receptors A, B, and C. GABA A receptors are the targets for alcohol, benzodiazepines, barbituates, and neurosteroids. Stimulation of the GABA receptor by the binding of these compounds causes an ion channel to open temporarily and emit chloride ions into the cell. Alcohol enhances the influx of chloride ion, and the result is sedative and anxiolytic effects. Chronic use of alcohol down-regulates the GABA system, and the neuron eventually becomes dependent on alcohol to enable GABA to function. If alcohol is withdrawn, the opening of the chloride ion channel fails, because GABA is no longer capable of performing the task secondary to the cell, having adapted to the role of alcohol. Thus, the cell becomes hyperexcitable, leading to irritability, insomnia, hypertension, tachycardia, and possibly...

Early Childhood Developmental Social and Family History

A history of trauma is significant in evaluating for trauma sequelae including dissociative phenomena, hyperarousal, depression, eating disorders, substance use disorders, psychiatric disorders (especially posttrau-matic stress disorder), domestic violence, and commercial sex work. Specific questions about posttrau-matic stress disorder include those about dissociation, intrusive thoughts, flashbacks, nightmares, easy startle, hypervigilance, insomnia, and a sense of a foreshortened future.

General Appearance Manner and Attitude

And neatness of attire, responsiveness, cooperation, and ability to maintain eye contact. Observation for psychomotor retardation (slowing) or agitation can be helpful. The psychiatrist can listen carefully for rate, quality, tone, audibility, modulation, and form of speech, including evidence ofprosody, aphasias, or dysphasias. Additionally, observation of skin for icterus, pallor, cyanosis, edema, rashes, or other lesions can be helpful. The psychiatrist should also evaluate whether the patient appears healthy or ill, robust or cachectic, with signs of wasting and protein energy undernutri-tion. Obvious signs ofspecific medical illness or organ impairment include seizures, involuntary movements, tremors, paresis, paralysis, facial droop or asymmetry, exophthalmos, neck fullness, spider angiomata, asci-tes, anascarca, dyspnea, clubbing, and pedal edema. The psychiatrist can look for signs of delirium such as fluctuating levels of consciousness, mood, and behavior and falling asleep...

Single global question and psychometrics

Usually subscales are made up of items that are positively correlated. However, there maybe problems with the statistical methodology, factor analysis, that often underlie this approach, as described by Fayers and Hand 49 who have attempted to divide symptoms into causal and effect indicators. Thus, increased nausea might cause a decrease in overall QL (i.e. nausea is a causal indicator), whereas poor overall QL might result in depression (i.e. depression is an effect indicator). In addition, some factors, such as insomnia, may be considered as both causal and effect indicators (see Fig. 6.5).

Compensatory Mechanisms

The analysis of interactions among endogenous chemical factors also needs to consider compensatory mechanisms that are activated during pro-catabolic activities or overriding anabolic processes. For instance, circulating ghrelin - a positive modulator of energy balance via orexi-genic, adipogenic and growth hormone releaser activities 39, 40 - levels are elevated in patients with wasting and cachexia and this elevation can be associated with increases in TNF-a 41 . The potential anti-cachectic activity of melatonin 42 is described by Lissoni et al. in Chapter 9.10.

The Course Of Acute Stress Reactions

Across the literature, there are reports of high rates of emotional numbing (Feinstein, 1989 Noyes, Hoenk, Kuperman, & Slymen, 1977), reduced awareness of one's environment (Berah, Jones, & Valent, 1984 Hillman, 1981), derealization (Cardena & Spiegel, 1993 Noyes & Kletti, 1977 Sloan, 1988 Freinkel, Koopman, & Spiegel, 1994), depersonalization (Noyes et al., 1977 Cardena & Spiegel, 1993 Sloan, 1988 Freinkel et al., 1994), intrusive thoughts (Feinstein, 1989 Cardena & Spiegel, 1993 Sloan, 1988), avoidance behaviors (Cardena & Spiegel, 1993 North, Smith, McCool, & Lightcap, 1989 Bryant & Harvey, 1996), insomnia (Feinstein, 1989 Cardena & Spiegel, 1993 Sloan, 1988), concentration deficits (Cardena & Spiegel, 1993 North et al., 1989), irritability (Sloan, 1988), and autonomic arousal (Feinstein, 1989 Sloan, 1988) in the weeks after a traumatic experience. Despite the high prevalence of acute stress reactions, it appears that

A case study tryptophan

Tryptophan is a naturally occurring amino acid, used for over 15 years in dietary supplements and infant formulas, and as a treatment for a number of conditions including depression, obesity, and insomnia. In late 1989, it was connected with a sudden outbreak of a debilitating syndrome that resulted in dozens of deaths in the U.S. and caused a variety of adverse effects in as many as 5,000 people.

Sensory consciousness as a test case

Complementary findings come from studies of unconscious states. In deep sleep, auditory stimulation activates only primary auditory cortex (Portas et al., 2000). In vegetative states following brain injury, stimuli that are ordinarily loud or painful activate only the primary sensory cortices (Laureys et al., 2000, 2002). Waking consciousness

Possible Antiepileptic Mechanisms of Action

Herbs may have antiepileptic effects in several ways. The most obvious may be via tran-quilizing properties and improvement of sleep, because sleep-deprivation can precipitate seizures. Valerian, kava, and passion flower may work in this fashion. Valerian and kava may also increase brain levels and or the binding of the nerve transmitter gamma aminobutyric acid (GABA), which quiets nerve activity (3). Passion flower may act by stimulating sites in the brain that usually receive tranquilizing benzodiazepine drugs, such as diazepam (Valium ) (3). Finally, some herbs, such as TJ-960, may act as antiox-idants and prevent cell damage in the brain.

Context and the firstperson perspective

Laureys (1999a, b, 2000) and Baars et al. (2003) list the following features of four unconscious states, that are causally very different from each other deep sleep, coma vegetative states, epileptic 2Although the spike-wave EEG of epileptic seizures appears different from the delta waves of deep sleep and general anesthesia, it is also synchronized, slow, and high in amplitude. The source and distribution of spike-wave activity varies in different seizure types. However, the more widespread the spike-wave pattern, the more consciousness is likely to be impaired (Blumenfeldt and Taylor, 2003). This is again marked in frontoparietal regions.

Diagnostic Criteria

If one or more of the following suggestive features are present, a diagnosis of probable dementia with Lewy bodies can be made in the presence of only one core feature REM rapid eye movement sleep behavior disorder vivid and often frightening dreams during REM sleep, but without muscle atonia, McKeith et al. 2005, p. 1866 severe neuroleptic sensitivity and low dopamine transporter uptake in basal ganglia as demonstrated by single photon emission computed tomography SPECT or positron emission tomography PET imaging (McKeith et al. 2005, p. 1864).

Studies in MS and Other Conditions

Symptoms that may occur with MS have been investigated in people with other conditions. Anxiety, which occurs frequently in MS, may be reduced through hypnosis-induced relaxation. Also, hypnosis may be an effective therapy for pain, which may be a particularly bothersome symptom in MS. Hypnosis appears to relieve different types of pain, including headache and pain associated with surgery, cancer, and fibromyalgia, a rheumatologic condition. Hypnosis may be used during surgery to reduce the amount of anesthesia or to completely eliminate the need for anesthesia in some cases. Hypnosis also may be beneficial for insomnia. Among other neurologic disorders, some beneficial effects of hypnosis have been reported in people with strokes, head injury, and spinal cord injury.

Pharmacological Treatment of Associated Syndromes

This is a common problem for FMS patients (127,128). It may be associated with poor memory and concentration and lead to problems with employment. It appears to be related to the effects of chronic pain, depression, mental fatigue, and sleep disorder. Treatment of these various problems is needed. In some patients medication treatment of fatigue may be helpful with this problem, which appears to be the result of one or more other FMS-associated problem(s).

Central Sensitivity Syndromes

Yunus notes that the various CSS entities share clinical characteristics including gender (female preponderance), age distribution, and symptomatology (pain, fatigue, sleep disorder, paresthesia, and global hyperesthesias) (1,3). Furthermore, he notes that there is no discernable structural pathology that can be found by typical laboratory and radiological testing. The CSS cannot be classified as psychiatric syndromes, in spite of the fact that psychological factors may play a role in a minority subgroup of patients with CSS (3).

Dosing and Administration

Although a large number of pathophysiological studies on the role of melatonin in several models of disease have been published, our knowledge of the pharmacology of melatonin in clinical settings is still very poor. Earlier studies hypothesised or calculated that the replacement of endogenous hormone by synthetic melatonin would need dosing between 0.5 and 2 mg in human adults, although a clear-cut dosage has not yet been established 49 . ferent routes of administration. This knowledge gap may be due to the fact that melatonin receptors have only recently been clearly identified. An understanding of the function of these receptors is fundamental to gaining insight into melatonin action and the therapeutic administration of exogenous melatonin, e.g. identifying the optimal time-range of administration based on receptor exposure 50 . Detailed studies of MLT receptors will no doubt be critical for successful melatonin-based treatment, in order to reproduce a therapeutic physiological...

Differential Diagnosis

Almost half of the 29 million Americans age 65 and older complain of inadequate amount or quality of sleep (Monane 1992). The differential diagnosis of insomnia in the elderly includes the conditions listed below. In general, with advancing age, sleep becomes more fragmented, more time is required to fall asleep, more awakenings occur, relatively less deep (Stage IV) sleep is experienced, and people tend to spend more time in bed. The subjective impression produced by these changes is unsatisfying sleep, which may be reported as insomnia it is not uncommon for elderly hospitalized patients to report not sleeping at all, despite nursing observations of 6 8 hours of apparent sleep, complete with snoring.

Treatment of Opiate Withdrawal

Symptomatic treatment of the opiate withdrawal syndrome can often be achieved using a combination of drugs, such as benzodiazepines for anxiety and insomnia loperamide or diphenoxylate and atropine for diarrhea promet-hazine, which has antiemetic and sedative properties and paracetamol or non-steroidal antiinflammatories for generalized aches. Pupillary dilation, piloerection, Yawning or sweating Insomnia

Highdose Dexamethasone Monotherapy

Dexamethasone, 20 mg m2 day on days 1-4, 9-12, and 17-20, induces responses in previously untreated patients with MM 40-50 of the time,55, 56 suggesting that dexamethasone accounts for most of the benefit derived from VAD and TD (described below). Dexamethasone monotherapy may be preferred for frail patients, since the toxicity is generally less than that seen with VAD or TD. Still, primary pulse dexam-ethasone treatment is somewhat more toxic than MP,57 and patients should be monitored closely for specific side effects, including hyperglycemia, gastrointestinal bleeding, mood disorder, insomnia, weight gain, increased susceptibility to infections, and rarely pancreatitis.58

Overview Review of the Literature

Chronic pain has the potential to significantly negatively impact many areas of a child' s life. These effects can be both physical and psychological and can have marked short- and long-term consequences 15 . Chronic pain in children has been found to be associated with increased disability, poorer mental health, distress, reduced school attendance, and decreased quality of life ' 16-18 . There is also increasing evidence of the importance of examining the interaction between chronic pain and sleep when creating a treatment program. There is a high level of comorbidity between chronic pain and sleep disorders in children ' 19, 20 ' It has been suggested that treating either of these problems will likely decrease the severity of the symptoms of the other disorder 21 .

Other Sedatives and Hypnotics

Despite the continued widespread use of antihistamines to treat insomnia, the Food and Drug Administration (FDA), noting the prominent sedative side effects encountered in the administration of antihistamines (including doxylamine, diphenhydramine, and pyrilamine), concluded that the antihistamines are not consistently effective in the treatment of sleep disorders. Tolerance rapidly develops to the sedating effects of these medicines, and the antihistamines can produce paradoxical stimulation. In addition, the antihistamine doses currently approved for the treatment of allergies are inadequate to induce sleep. Antihistamines used to treat sleep disorders can produce daytime sedation because of their relatively long half-lives (Charney et al., 2001). The use of sedating antidepressants such as Desyrel (trazodone) and Elavil (amitriptyline) to treat insomnia at dose levels lower than are effective for the treatment of depression, such as the use of sedating antihistamines for this...

Longterm Dose And Abuse

Other common nonmedical patterns are to use benzodiazepines (often alprazolam or lorazepam) concomitantly with stimulants (often cocaine or methamphetamine) to reduce the unpleasant experiences of the stimulant use, and or to use benzodiazepines (often triazolam Halcion ) to treat the insomnia that accompanies stimulant abuse. Daily use of benzodiazepines, even when there is no dose escalation and no abuse of alcohol or other nonmedical drugs has led to controversy. Clinical experience has shown that even over long periods of daily use, benzodiazepines typically do not lose their efficacy and do not produce significant problems for most patients. An example of this experience was a study of 170 adult patients treated for a variety of sleep disorders continuously with a benzodiazepine for 6 months or longer over a 12-year period. The study found sustained efficacy, with low risk of dose escalation, adverse effects, or abuse (Schenck & Mahowald, 1996).

Newer Sedative and Hypnotic Agents

In recent years, a variety of alternatives to the benzodiazepines have become available to treat both anxiety and insomnia. Buspirone (Buspar) has been shown to reduce anxiety in generalized anxiety disorders, but it does not suppress panic attacks, and is not used as a primary treatment of obsessive-compulsive disorder. Buspirone is not abused by alcoholics and drug addicts, and it does not produce withdrawal symptoms on abrupt discontinuation. Like the antidepressants, buspirone requires several weeks of daily dosing to produce antianxiety effects, which are less dramatic from patients' point of view than are the effects produced by the benzodiazepines (Sussman & Stein, 2002). The antidepressants as a class have been shown to possess antipanic and antianxiety effects opening a new range of uses for these medicines in the treatment of anxiety disorders. The selective serotonin reuptake inhibitors (SSRIs) have emerged as the first-line treatment for many anxiety disorders (Davidson,...

Mary Alice ODowd and Maria Fernanda Gomez

Shakespeare's Macbeth recognized the vital role of sleep in the renewal and nourishment of mind and body, but until recently, medical science has tended to give sleep disorders scant attention. Insomnia, the most common sleep disorder, can be a symptom of many disorders and has been described as a major public health problem that impacts the lives of millions of individuals, their families, and communities (NIH, 2005). However, random studies of adults have found that the majority of those with sleep complaints are unlikely to broach the topic with a health care provider (Martin and Ancoli-Israel, 2003). When a patient does complain of insomnia, the complaint may be either given short shrift by the clinician or a sleep medication maybe prescribed for short-term use without much attention to the etiology of the complaint or to follow-up. Insomnia is not just an annoyance. It has been shown to affect cognitive functioning, quality of life, and even longevity (Martin and Ancoli-Israel,...

Childhood Cancer and Leukemia

Henshaw and Reiter 23 proposed that the melatonin hypothesis, in which power frequency magnetic fields suppress the nocturnal production of melatonin in the pineal gland, accounts for the observed increased risk of childhood leukemia. Such melatonin disruption has been shown in animals, especially with exposure to electric and rapid on off magnetic fields. Support for the hypothesis is found in the body of studies showing magnetic field disruption of melatonin in related animal and human studies. Additional support comes from the observation that melatonin is highly protective of oxidative damage to the human hemopoietic system. Researchers hypothesize that EMF may be linked to breast cancer through the hormone melatonin. Feychting et al. 29 conducted a case-control study based on people who had lived within 300 m of 220- or 400-kV power lines in Sweden between 1960 and 1985. For calculated magnetic field levels 0.2 T closest in time before diagnosis, they estimated the risk ratio...

Tumour Necrosis Factor Alpha Inhibition

Four studies in cancer patients are especially noteworthy. First, Bruera et al. evaluated a cohort of 72 cancer patients who received thalidomide 100 mg night over 10 days 22 . Thirty-five patients dropped out of the study as a result of cancer-related morbidity. However, among the remaining patients, the majority reported improvement in insomnia (69 ), nausea (44 ) and loss of appetite (63 ). As many as 53 reported an improvement in their overall sense of well-being. A comparison of symptom improvement between thalidomide-treated and historical mege-strol acetate-treated patients suggests a trend in favour of thalidomide mean difference standard deviation -1.09 2.67 versus 0.04 1.71 for nausea (p 0.05) -2.21 2.83 versus -1.03 2.49 for appetite (p 0.073) and -1.65 3.19 versus -0.61 1.42 for sense of well-being (p 0.033), respectively. This study was neither randomised nor double-blinded, but its specific focus on quality of life and symptom control strategies suggests that thalidomide...

Assessment and Case Formulation

Results of the pretreatment assessment indicated that Danielle met full diagnostic criteria for PTSD, characterized primarily by symptoms of avoidance and intrusive thoughts related to the sexual abuse. Danielle was also exhibiting moderate levels of anxiety, including fear of men, difficulty falling asleep, and difficulty separating from her mother and grandparents. Similarly, Ms. Williams's responses to standardized measures revealed that she was experiencing moderate symptoms of depression, such as excessive guilt and self-blame, PTSD-related symptoms such as intrusive thoughts and avoidance of topics related to the sexual abuse, and excessive anger about the sexual abuse.

Sedative Hypnotic or Anxiolytic Induced Disorders

Dependence Abuse Intoxication Withdrawal Intoxication delirium Withdrawal delirium Induced persistent amnesic disorder Induced psychotic disorders With delusions With hallucinations Induced mood disorder Induced anxiety disorder Induced sexual disorder Induced sleep disorder

Biological Rationale of Medical Treatment of Cancer Cachexia

Recently, many authors have investigated the different pathogenetic events responsible for the clinical behaviour of cancer cachexia, and suggested a role for both tumour cells and immuno-mediated responses to tumour growth, as important events in the pathogenesis of the syndrome 1, 7, 9-41 . Although the main pathogenetic events are not fully understood and the relationship between tumour factors and host inflammatory cytokines still remains undefined, a role of different tumour products and an immuno-mediated action of the monocyte-macrophage system seem to be involved in the pathogenesis of cancer cachexia (Fig. 1). Besides the speculative value of the biological knowledge about the role of host and tumour cytokines, the efforts of clinical researchers have been addressing the possibility of down-regulating the pro-cachectic action of cytokines, favouring a control of the clinical manifestations of the syndrome. To this end, progestagens and corticos-teroids (and also non-steroidal...

GABAa Receptor Agonists

The GABAa receptor is an important target for the development of new drugs for a wide array of CNS disorders such as epilepsy, sleep disorders, anxiety, stress, depression, and cognitive failure.85-87 The development of novel GABAa receptor ligands as innovative drugs is specifically directed toward the design of partial agonists with an improved selectivity of action, inverse agonists for the treatment of cognitive failure, and receptor subtype selective ligands.

Dsmivtr Diagnostic Criteria

The family of the individual with Alzheimer's disease is also a victim of the disease. Family members must watch the gradual deterioration of the individual and accept that a significant part of their own lives must be devoted to the care of the individual. Difficult decisions about institutionalization and termination of life support are distinct possibilities, and individuals with AD often turn their anger and paranoia toward the car-egiver. Education is a valuable treatment tool for families. Information about the disease and peer support are available through Alzheimer's associations, and many such agencies provide family members with a companion for the individual with AD to allow the family some time away. For these reasons, family members are at risk for depression, anxiety disorders, insomnia, and a variety of other psychological manifestations. Should these occur, they should be promptly treated.

Table 92 Symptoms of Depression

Weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Cognitive vegetative or somatic. These symptoms are important markers, particularly for more severe types depression. Typically, a person with severe depression has a decreased appetite, which leads in turn to weight loss. But appetite may be increased in atypical or milder depression. Likewise, insomnia is an indicator of severe depression, but people with milder or atypical depression may sleep too much. Insomnia is sometimes described as initial, middle, or terminal. Initial insomnia is trouble falling asleep, and it is usually considered significant if the person tosses and turns for more than about a half hour before dozing off. Middle insomnia is the tendency to wake up in the middle of the night and to remain awake for an hour or two, usually followed by a fitful sleep. People with terminal insomnia wake up one or two hours before their usual time and are unable to fall...

Ensuring Utilization of Services

In the Hoge et al. (2004) study of Iraq or Afghanistan War returnees, concern about stigma as a result of seeking help was greatest among those most in need of help. Although most of those screening positive for a mental health problem acknowledged having a problem (78 ), many indicated that they don't trust mental health professionals, that mental health care doesn't work, that they would be seen as weak if they sought help (65 ), that participation in mental health services would harm their career, or that seeking help would be too embarrassing (41 ). Difede et al. (in press) reported that, among emergency services workers who responded to the World Trade Center collapse, distress at trauma reminders was seen as a normal reaction to the events and not a reason to seek treatment. Rather, anger, irritability, and sleep problems were seen as reasons to seek help. Zatzick et al. (2001a) conducted an open-ended assessment of the concerns expressed by...

CASE 1 Cushings Disease Difficulties In Diagnosis Case Description

A 38-yr-old woman was referred because of a 75-lb weight gain over the past 7 yr. She has noticed some increasing facial fullness and has had some problems with climbing stairs. She has had insomnia and nocturia for the past 3 yr and complains of some easy bruisability. She recently suffered a stress fracture in her right foot. She has maintained normal menstrual periods, but has had a decreased libido. She complains of emotional lability over the past 2 yr. She denied any history of diabetes, hypertension, or kidney stones.

Valerian Valeriana officinalis

Valerian is a flowering herb native to Europe and Asia that has been known as a sedative for thousands of years. It has remained an extremely popular herb in Western countries, particularly in Germany and Russia. Research has shown it to improve the quality of sleep (5), and it is the active component in many of the prescribed and nonprescription preparations used for nervousness and insomnia. Although it has been perhaps the most common herb prescribed for epilepsy throughout the ages, there remains no significant animal or human proof of its usefulness in this disorder. It might work against seizures by increasing the release of and inhibiting the breakdown of the brain transmitter GABA, thereby inhibiting nerve activity in a manner similar to that of the benzodi-azepine drugs, such as diazepam (5). Alternatively, valerian might have an indirect antiepileptic action because of its sedative effect and normalization of sleep. Notably, sudden discontinuation of valerian after chronic...

Smallfiber Neuropathy

Of interest is that even subclinical SFN may present with late-onset restless-legs syndrome (RLS) (81). While RLS is primarily classified as a sleep disorder, it may be associated with subclinical small fiber neuropathy, as well as, possibly, dysfunction of the postsynaptic dopamine receptors related to iron metabolism of the CNS as well as opiate receptors (82). Another study noted RLS frequently associated with acquired neuropathies, especially dysimmune neuropathies particularly small-fiber sensory neuropathies (83).

As Sources Of Distress

Insomnia One area that has been linked to distress and a reduction in quality of life in HIV is insomnia. Complaints of lack of sleep from persons with HIV disease are ubiquitous, but etiologies are varied and often include a combination of comorbid Axis I conditions, medical conditions affecting sleep quality, and potentially a direct role of HIV on the brain. In a review of insomnia in the setting of HIV, Reid and Dwyer (2005) noted that up to 60 ofHIV-positive individuals experienced sleep disturbances, and greater psychological distress appeared to be related to greater sleep difficulties and lower numbers of CD3 and CD8 cells. This review highlights the importance of effective interventions designed to improve sleep quality and in turn potentially reduce distress and improve life quality. Further details of HIV-associated sleep abnormalities are addressed in Chapter 15.

How Are Mood Disorders Treated

Other tricyclic antidepressants were subsequendy developed, as competing drug companies sought to capture a share of the growing antidepressant market with other new compounds. Soon clinicians had four or five to choose from. As more and more drugs were available, it became clear that most of the tricyclics were equally effective in reducing depressive symptoms, but they differed in side effects. Some were more sedating than others. For example, despramine (Norpramin) is the least sedating, while amitriptyline (Elavil) is among the most sedating. Clinicians have learned to exploit the side effects of these drugs by giving the more sedating ones to people who have severe insomnia and anxiety and using the less sedating ones for people who are more anxious or agitated. It also became clear that most of the tricyclic antidepressants took some time to achieve their therapeutic effects usually two to three weeks. Some of them had side effects that patients found uncomfortable, such as dry...

Substance Withdrawal Delirium

Alcohol and certain sedating drugs can produce a withdrawal delirium when their use is abruptly discontinued or significantly reduced. Withdrawal delirium requires a history of use of a potentially addicting agent for a sufficient amount of time to produce dependence. It is associated with such typical physical findings as abnormal vital signs, pupillary changes, tremor, diaphoresis, nausea and vomiting, and diarrhea. Individuals generally complain of abdominal and leg cramps, insomnia, nightmares, chills, hallucinations (especially visual), and a general feeling of wanting to jump out of my skin.

Third Line Agents Psychostimulants

Although controlled studies in elderly patients are lacking, a relatively large body of clinical literature supports the use of psychostimulants in elderly depressed patients, particularly those in whom medical illness precludes the use of cyclic antidepressants or MAOIs (Emptage and Semla 1996). Both amphetamines and methylphenidate have been administered, although meth-ylphenidate is generally preferred because of its relatively lower cardiovascular side-effect profile. Dosages range from 5 to 20 mg administered orally twice a day, generally immediately before breakfast and lunch so as not to interfere with appetite or sleep. Cardiovascular side effects are typically limited to very minor increases in blood pressure and heart rate. The most common side effect is mild jitteriness, which may be managed with small doses of benzodiaz-epine anxiolytics, but severe dysphoria and agitation, appetite disturbance, and insomnia requiring discontinuation of treatment may occur rarely. One...

Psychotherapy for Geriatric Depression

Assets or roles, and demands of caregiving, and these problems often form the content of psychotherapy. For persons with high levels of disability or recurrent mental and physical problems, appropriate clinical goals may be to manage, rather than eliminate, symptoms and to sustain as high a level of independence as possible. Higher-functioning older adults often do well with the usual forms of individual, group, or family therapies that are provided in outpatient settings. Depressed elders with cognitive impairment may benefit more from systematic adjustments in the social or physical environment to maximize functional skills, behavior modification (e.g., to increase participation in pleasurable activities), or specialized cognitive training techniques (see Chapter 6, Other Dementias and Delirium ). For individuals with chronic health problems or significant physical disabilities, techniques for addressing specific medical comorbidities (e.g., pain or insomnia) can be especially...

In Search and Discovery of Potential New Therapeutic Indications

The search for additional indications for modafinil naturally focused on diseases associated with wake deficits and somnolence. The effects of the drug in an animal model of sleep-disordered breathing suggested that modafinil might be effective in reducing sleepiness associated with sleep apnea,50 and this was subsequently demonstrated in the clinic.51-53 Other disorders where somnolence or sedation was concomitant with the disease, e.g., Parkinson's disease,54-56 myotonic dystrophy,57-60 fibromyalgia,61 amyotrophic lateral sclerosis,62 multiple sclerosis,63 cerebral lymphoma,64 or resulting from the side-effects of other medications such as antidepressants,65 antipsychotics,66 dopaminergic D2 agonists,67,68 opioids,69 or valproic acid,70 have also proven to be amenable to treatment with modafinil. Because wake and vigilance are essential requirements for attention, learning, and cognition, research on these topics has also been undertaken in animals. Modafinil was found to induce a...

Selective norepinephrine reuptake inhibitors

SNRIs are a class of antidepressants characterized by a mixed action on both major monoamines of depression NE and serotonin. In essence, SNRIs are improved TCAs with less off-target activity, e.g., muscarinic, histaminic and -adrenergic receptors, and MAOI. The combination of inhibition of 5HT and NE uptake confers a profile of effectiveness comparable to TCAs and is reported to be higher than SSRIs, especially in severe depression. SNRIs are purported to be better tolerated than TCAs and more similar to SSRIs without the associated sexual dysfunction seen with the latter. Venlafaxine (38) and milnacipran (4) have been approved so far, and several others are in development. They are active on depressive symptoms, as well as on certain comorbid symptoms (anxiety, sleep disorders) frequently associated with depression. SNRIs appear to have an improved rate of response and a significant rate of remission, decreasing the risk of relapse and recurrence in the medium and long term and...

Other CAM Therapies

Homeopathy is a low-risk approach of uncertain effectiveness for sleep problems. Several supplements are promoted for insomnia. As discussed elsewhere in this book, melatonin may be beneficial, but in people with MS it is associated with a theoretical risk because of its immune-stimulating activity. 5-HTP, another supplement, has unclear effectiveness for insomnia and may be harmful. Marijuana has produced positive results in some studies. However, it also may cause significant side effects and is illegal in most states. Kava kava sometimes is recommended for insomnia, but most studies of this herb have actually only evaluated its effectiveness for anxiety. In any case, kava kava should be avoided because of possible liver toxicity.

Yohimbe and Yohimbine

Limited studies have evaluated the effectiveness and safety of yohimbe for sexual disorders. Some studies indicate that yohimbe may be beneficial for erectile dysfunction in men and decreased libido in women. However, it has many serious side effects, including severely decreased blood pressure, abnormalities of heart rhythm (arrhythmias), heart failure, and death. Other side effects include insomnia, anxiety, tremor, high blood pressure, rapid heart rate, headache, nausea, and vomiting. The FDA has determined that yohimbe is not safe or effective and that it should not be available for over-the-counter use. Yohimbine, the active ingredient in yohimbe, is available by prescription in the United States.

Preparation for Quitting

The physician should then provide the patient with some basic didactic information about quitting smoking. (1) Smoking represents an addiction to nicotine. Therefore smoking cessation must be undertaken as seriously as one would approach any other drug addiction. Willpower alone is insufficient. The patient must make quitting smoking his her top priority. (2) The goal should be total tobacco abstinence after the quit date. (3) The patient can expect to experience unpleasant nicotine withdrawal symptoms (e.g. mood disturbance, insomnia, irritability,

Sedatives Hypnotics and Benzodiazepines

The sedatives and the hypnotics, especially the benzodiazepines, are widely used in medical practice in the treatment of anxiety, insomnia, epilepsy, and for several other indications (Baldessarini, 2001). The combination of abuse by alcoholics and drug addicts, and the withdrawal symptoms on discontinuation leads to the view that these are addictive drugs (DuPont, 2000 Juergens & Cowley, 2003). The pharmacology and the epidemiology of sedatives and hypnotics are reviewed in this chapter, which focuses on the needs of the clinician. As the benzodiazepines became more controversial, and as various regulatory approaches were employed to limit their use in medical practice, there was a danger that clinicians would revert to the older and generally more toxic sedatives and hypnotics, which, in the era of the benzodiazepines, had become unfamiliar (Juergens & Cowley, 2003). Thus, there is more than historical interest in looking at these earlier sedatives, because for some younger medical...

Identification Of Problems Among Longterm Benzodiazepine Users

Physicians frequently encounter patients, or family members of patients, who are concerned about the possible adverse effects of long-term use of a benzo-diazepine in the treatment of anxiety or insomnia. In helping to structure the decision making for such a patient, we use the Benzodiazepine Checklist (DuPont, 1986 see Table 10.2). There are four questions to be answered

Sleep Disturbance In

Clinicians have long been aware of the frequency with which insomnia and fatigue figure in the complaints of individuals living with HIV. Fatigue and sleep disturbance can affect a wide range of activities and even health itself in this population, as the healing benefits of sleep are lost at the time when patients have the greatest need of rest and renewal. A study that compared HIV-positive and HIV-negative homosexual men found that the HIV-infected patients were significantly more likely to report a problem with fatigue, although they slept more and napped more than the HIV-negative subjects. This fatigue interfered with important activities such as employment and driving and was also correlated with measures of immunosuppression and inflammation (Darko et al., 1992). Why do HIV-positive individuals feel fatigued and sleep poorly Although these two complaints are obviously interrelated, they are not synonymous. Some patients with HIV infection may sleep relatively well, wake up...

Psychopharmacotherapy for Psychotic Depression

The proportion of depressed patients who present with delusions and or hallucinations appears to increase with age but does not seem to be related to age at onset of depression (Brodaty et al. 1997). Treatment entails the simultaneous administration of high-potency, low-dose antipsychotic medications such as haloperidol, risperidone, or olanzapine in combination with a TCA, SSRI, or other antidepressant. The Texas Medication Algorithm Project used this combination successfully to treat psychotic depression in nonelderly adults. Their algorithm specified that partial responders were switched from a TCA plus an antipsychotic to a non-TCA plus an antipsychotic or from a non-TCA plus an antipsychotic to a TCA plus an antipsychotic patients who still did not respond were switched to electroconvulsive therapy (ECT), and partial responders to ECT were treated with a previously untried antidepressant with lithium augmentation (Trivedi et al. 2004). The typical pattern of response is marked by...

Distinguishing Medical And Nonmedical Use Of Benzodiazepines

Is the substance used to treat a diagnosed medical problem, such as anxiety or insomnia, or is it used to get high (or to treat the complications of nonmedical use of other drugs) Typical medical use of a benzodiazepine or other controlled substance occurs without the use of multiple nonmedical drugs, whereas nonmedical use of the benzodiazepines is usually polydrug abuse. Although alcoholics and drug addicts sometimes use the language of medicine to describe their reasons for using controlled substances nonmedically, self-administration or self-medication of an intoxicating substance outside the ordinary practice boundaries of medical care is a hallmark of drug abuse (DuPont, 1998).

Pending and Interdisciplinary Research

The neurochemical and neurophysiologic markers of massage therapy are not well defined. Similarly, the biologic markers of relaxation and restorative sleep are incompletely defined. Understanding changes in the levels of inhibitory neurotransmitters such as GABA may help shed light on both seizure-provoking factors (e.g., sleep deprivation, stress) and seizure-relieving therapies (e.g., massage).

CASE 1 Tshsecreting Pituitary Adenoma Case Description

Two weeks later, the patient presented for an evaluation. Since starting on atenolol 50 mg twice daily, her palpitations had resolved. She denied nervousness, tremor, hyper-defecation, insomnia, weakness, shortness of breath, chest pain, or symptoms of ophthal-mopathy. she had not noticed anterior neck discomfort, dysphagia, hoarseness, or neck swelling. she also denied headaches, visual changes, or a personal or family history of thyroid disease.

Psychiatric Disorders 601411 Schizophrenia

Dyssomnias - primary insomnia, narcolepsy Sleep disorders Primary Related to another mental disorder Other sleep disorders Major depression (see 6.03 Affective Disorders Depression and Bipolar Disorders) is a chronic disorder that affects 10-25 of females and 5-12 of males. Suicide in 15 of chronic depressives makes it the ninth leading cause of death in the USA. Presenting complaints for depression include depressed or irritable mood, diminished interest or pleasure in daily activities, weight loss, insomnia or hypersomnia, fatigue, diminished concentration, and recurrent thoughts of death. The World Health Organization (WHO) has estimated that approximately 121 million individuals worldwide suffer from depression and that depression will become the primary disease burden worldwide by 2020. In the majority of individuals episodes of depression are acute and self-limiting. The genetics of major depression are not well understood and have focused on functional polymorphisms related to...

Initial Evaluation Of The Patient With Substance Use Disorders

Sleep disorders Sexual dysfunction Delirium Dementia Amnestic disorders ally begins crossing the blood-brain barrier within 15-20 seconds. Physical signs of acute opiate intoxication include euphoria and tranquility, sedation, slurred speech, problems with memory and attention, and miosis. Signs and symptoms of opioid withdrawal can be both objective (rhinorrhea and lacrimation, nausea and vomiting, diarrhea, piloerection, mydria-sis, yawning, and muscle spasms) and subjective (body aches, insomnia, craving, dysphoria, anxiety, hot and cold flashes, and anorexia). Heroin withdrawal usually begins within 4 to 8 hours after last use, whereas with methadone, with its longer elimination half-life, withdrawal may not begin until 24 to 48 hours after last use.

Oxidative And Nitrative Stress In Ad

Damage resulting from excessive production of reactive oxygen species (ROS), a condition known as oxidative stress (10), is evident in the AD brain in the form of oxidized proteins and lipids, and nuclear, and mitochondrial deoxyribonucleic acid (11-21). Such oxidative damage has a regional distribution that parallels the density of senile plaques, being greatest in the parietal lobe and hippocampus and low in the cerebellum (15). In view of the corresponding locations of senile plaques and oxidative damage in the AD brain, it is interesting that AP is not only neurotoxic (22-24), but the underlying mechanism involves increased ROS generation and oxidative stress (25). Furthermore, the neurotoxicity of AP in vitro is blocked by several antioxidants (26), including a-tocopherol (vitamin E ref. 27), curcumin (28), and melatonin (29). It has been sug gested that one way that Ap may mediate increased ROS production is by impairing the glutathione (GSH) antioxidant system (30). However, it...

Principles of Pediatric Pain Management

Sedation and respiratory depression in chronic opioid use can be addressed by rearrangement of dosing schedules or by the addition of psychostimulants such as dextroamphetamine. The nonamphetamine stimulant modafinil, 2- (diphenylmethyl) sulfanyl acetamide, has demonstrated efficacy in pediatric cases of daytime sleepiness and narcolepsy and may be beneficial to those patients displaying excessive opioid sedation in the face of good pain control (52,53). Adjuvants, such as TCAs, are added to improve sleep and enhance analgesia.

Background and Introduction

The female sex hormone estrogen plays an essential role in reproduction and is important for the overall maintenance of physiologic homeostasis in a woman's body.1'2 During menopause, which occurs in women at an average age of 51, the amount of estrogen produced by the ovaries decreases and this estrogen deficiency causes menstrual periods to become less frequent and then stop.3-5 The loss of estrogen is responsible for many of the uncomfortable symptoms associated with menopause, including hot flashes, mood swings or depression, sleep disorders, vaginal dryness, and urinary dysfunction.6 Osteoporosis or bone loss is another consequence of reduced estrogen levels after menopause.7-11 In women, bone density increases until ages 30-35,12 but slowly declines after menopause.13 Postmenopausal women are also at increased risk for coronary heart disease (CHD)14,15 and Alzheimer's disease,16-18 as a result of estrogen deficiency. The realization that the symptoms reported by postmenopausal...

New Assignment Vice President of Basic Research

As Vice President I was to retain responsibility for the West Point Medicinal Chemistry Department. Since my wife and I had only recently moved into a new house in Blue Bell, PA, in December of 1972, and Lucy had started to build beautiful gardens, moving back to New Jersey in 1976 was not attractive. Dr Vagelos gave me the option of remaining in Blue Bell and commuting by limo to Rahway on a daily basis. He made it clear, however, that my responsibilities would be the same, even if I commuted. I accepted this proposal, generally spending one night a week in New Jersey. I remember using the 90 min ride on the Pennsylvania and New Jersey Turnpikes from home to Rahway to read the latest journals, and promptly falling asleep on the way home after a typical day in Rahway There was never a dull moment.

Anticytokine and Antiinflammatory Agents

Thalidomide and melatonin 131-134 are two agents for which there is some early evidence of clinical benefit. Melatonin has been studied in combination with chemotherapy and may modulate efficacy and toxicity 135 . Along with thalidomide it is a candidate for further study. Neither agent can currently be recommended for routine

Pineal Gland and Cancer

In cancer patients, the function of the pineal gland and the circadian secretion of pineal hormones are frequently disrupted 4-8 . Animal and in vitro models have shown that melatonin inhibits the growth of several tumours, such as breast cancer MCF7 9, 10 and prostatic cancer 11, 12 . Chemical pinealectomy increased the growth of experimental tumours in animals. Recent experimental evidence in animal models of cancer showed that exposure to light during the dark phase of an alternating light-dark cycle suppresses the synthesis of melatonin, increases fatty acid metabolism, and promotes the growth of trans-plantable murine liver tumours and human breast cancer xenografts 13-15 , In humans, different authors have reported several findings (1) the total 24-h amount of mela-tonin and its metabolites did not differ between healthy subjects and breast cancer patients 16 (2) pineal gland function and the circadian secretion of pineal hormones in patients with solid tumours was found to be...

Harold W Goforth Mary Ann Cohen and James Murrough

Mood disorders have complex synergistic and catalytic interactions with HIV infection. They are significant factors in nonadherence to risk reduction and to medical care. Mood disorders associated with HIV include illness- and treatment-related depression and mania, responses to diagnoses of HIV, and comorbid primary mood disorders such as major depressive disorder and bipolar disorder. While persons with HIV and AIDS may have potentially no or multiple psychiatric disorders, alterations in mood are frequent concomitants of HIV infection. They have a profound impact on quality of life, level of distress and suffering, as well as direct and indirect effects on morbidity, treatment adherence, and mortality. In this chapter we will describe the significance of each of the mood disorders and their impact on the lives ofpersons with HIV and AIDS and on their families and caregivers. More detailed discussions of the epidemiology and prevalence of mood disorders are found in Chapter 4....

General Health Questionnaire

The GHQ focuses on the client's ability to carry out normal functions and the appearance of any new disturbing phenomena. Designed for use by doctors, psychiatrists and researchers, the GHQ is ideal for use in community and non-psychiatric settings and has four different versions GHQ-60 the fully detailed 60-item questionnaire, GHQ-30 a short form without items relating to physical illness, GHQ-28 a 28 item scaled version - assesses somantic symptoms, anxiety and insomnia, social dysfunction and severe depression, and GHQ-12 a quick, reliable and sensitive short form - ideal for research studies

Table of Contents

Diagnosis 158 Treatment 158 Caffeine-Induced Sleep Disorder 159 Diagnosis 159 Treatment 159 Diagnosis 410 Dyssomnias 411 Primary Insomnia 411 Diagnosis 411 Treatment 413 Primary Hypersomnia 415 Diagnosis 415 Treatment 416 Narcolepsy 416 Diagnosis 416 Treatment 417 Breathing-Related Sleep Disorder 417 Diagnosis 417 Treatment 418 Circadian Rhythm Sleep Disorder (Sleep-Wake Schedule Disorders) 418 Delayed Sleep Phase Type 418 Diagnosis 418 Treatment 419 Shift-Work Type 419 Diagnosis 419 Treatment 419 Jet Lag Type 419 Diagnosis 419 Treatment 419 Periodic Limb Movements in Sleep 420 Diagnosis 420 Treatment 420 Parasomnias 420 Nightmare Disorder 420 Diagnosis 420 Treatment 421 Sleep Terror Disorder 421 Diagnosis 421 Treatment 421 Sleepwalking Disorder 421 Diagnosis 421 Treatment 421 REM Sleep Behavior Disorder 422 Diagnosis 422 Treatment 422 Nocturnal Panic Attacks 422 Sleep-Related Epilepsy 422 Sleep Disturbances Related to Other Mental Disorders 422 Diagnosis 422 Treatment 423 Sleep...

Stress and Epilepsy

Stress can be thought of as a diverse set of conditions, internal or external to an organism, that may disrupt physiologic balance. Categories of stressors include physiologic (sleep deprivation, hyperventilation, overexertion, dehydration, fever, illness, menstrual cycle) pharmacologic (medications, substances of abuse) environmental (extremes of temperature, noise, lighting, smells), and psychologic (situations resulting in fear, sadness, anger). These stressors, alone or in combination, can alter the normal balance of one's physical state, lower seizure threshold, and result in a seizure. The specific means by which stress precipitates a seizure is not known. How intense the stressor seems to the individual does not necessarily correlate with the likelihood of seizure occurrence. Similarly, the time that elapses between the stress and the seizure may vary however, in many circumstances, a specific stressor can be identified, and its intensity and relationship in time to the seizure...


Selective 5HT6 agonists and antagonists (e.g., WAY466 (68), Ro-63-0563 (69), SB-171046, and GW 742457) may show therapeutic promise while a selective 5HT7 receptor antagonist (SB-656104-A (70)) has recently been reported to modulate REM sleep, part of the sleep architecture that has long been associated with depression.

Sleep traits

Sleep is a deceptively complex phenomenon, which has physiological, behavioural, psychological and environmental components. It can be identified by sustained physical quiescence in a species-specific posture and site accompanied by reduced responsiveness to external stimuli and characteristic electroencephalogram (EEG) patterns, but where a wakeful condition may be quickly achieved (Zepelin, 1994). The timing and structure of daily sleep are species-specific and refer to the activity pattern of that species, such as diurnal, nocturnal or arrhythmic. The transition from a waking state into sleep in mammals is associated on a cortical level with a change from irregular, low-voltage, fast EEG waves to high-voltage, slow waves. This is called non-REM (NREM) or slow-wave sleep (SWS). Occasionally, the cortical waves change to a desynchronised, regular, low-voltage, fast pattern known as rapid eye movement sleep (REM), or paradoxical sleep (PS). In primates, non-REM sleep has been...

Chronic Pain

Individuals with chronic pain often have problems sleeping (101). Attention to sleep hygiene should be given, and medications should only be used when necessary. Amitriptyline, which may be effective in the treatment of neuropathic pain, has the useful side effect of sedation, which helps with sleep onset. Melatonin and trazodone may also be beneficial.

Disease State Classification of Primary Sleep Disorders Sleep disorders encompass a wide variety of clinical syndromes that prior to 1979 lacked a formal classification system. For instance, narcolepsy was considered a neurological disorder while insomnia was classified as a psychiatric disease. The International Classification of Sleep Disorders (ICSD) classified primary sleep disorders into two categories, the dyssomnias (insomnia or excessive sleepiness disorders) and parasomnias (abnormal behaviors or psychological events occurring during sleep) which are distinct from psychiatric sleep disorders.24 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (Table 1) divides sleep disorders into four major categories by etiology (1) primary sleep disorders (2) sleep disorders related to other mental disorders (3) sleep disorders due to general medical conditions and (4) substance-induced sleep disorders.25 Primary sleep disorders are divided...

Jnj5207852 Primary Insomnia Tricyclic antidepressants (TCAs) and other antidepressants including amitriptyline, 28, trimipramine, 29, doxepine, 30, mirtazapine, 31, trazodone, 32, and nefazodone, 33, are used to treat insomnia,23 but their therapeutic hypnotic benefit derives from their sedative side effect profiles.

Mixed Mood Disorder

Elderly patients with major mood disorder commonly present with a syndrome of mixed manic and depressive features. A typical picture might include severe psychomotor agitation accompanied by intrusive and demanding behavior, irritability, flight of ideas and circumstantiality, anorexia, and insomnia. The question of whether agitated depression or mixed manic-depressive syndrome is the correct diagnosis usually can be resolved by applying DSM-IV-TR criteria for mixed episode (Table 3-14).

Induced Currents

Kaune and Gillis 24 numerically analyzed currents induced in a rat by linearly and circularly polarized magnetic fields of 50 Hz. Special focus was placed on the pineal gland and retina of rats since these organs were often associated with the changes of melatonin synthesis. Induced currents in two MRI-based rat models with resolutions of up to 0.125 mm3 were calculated by using the impedance method. Calculated current densities were extremely small, i.e.,

Sleeping Sound

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