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Revision as of 13:59, 5 October 2015

For patient information click here

Insomnia
ICD-10 F51.0, G47.0
ICD-9 307.42, 307.41, 780.51, 780.52
DiseasesDB 26877
MedlinePlus 000805
MeSH D007319

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Experimental / Informatics

List of terms related to Insomnia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Synonyms and keywords: Insomnia disorder

Overview

Insomnia is a sleep disorder characterized by an inability to sleep and/or inability to remain asleep for a reasonable period. Insomniacs typically complain of being unable to close their eyes or "rest their mind" for more than a few minutes at a time. Both organic and nonorganic insomnia constitute a sleep disorder.[1][2]

Classification

Types of insomnia

Three types of insomnia exist: transient, acute, and chronic

  1. Transient insomnia lasts from one night to a few weeks. Most people occasionally suffer from transient insomnia due to such causes as jet lag or short-term anxiety. If this form of insomnia continues to occur from time to time, the insomnia is classified as intermittent.
  2. Acute insomnia is the inability to consistently sleep well for a period of between three weeks to six months.
  3. Chronic insomnia is regarded as the most serious; persists almost nightly for at least a month.

Patterns of Insomnia

The pattern of insomnia often is related to the etiology.[3]

  1. Initial insomnia - difficulty falling asleep at the beginning of the night, often associated with anxiety disorders.
  2. Middle insomnia - waking during the middle of the night, difficulty maintaining sleep. Often associated with pain syndromes or medical illness.
  3. Terminal (or late) insomnia - early morning waking. Characteristic of Clinical depression.

Causes

Common Causes

Causes by Organ System

Cardiovascular Angina, buerger's disease, congestive cardiac failure, hypertension, ischemic heart disease, ischemic heart disease, nocturnal angina, sleep apnea
Chemical/Poisoning Acrodynia, Aldehyde syndrome, antimony, asbestosis, benzoate , cathinone poisoning, celery, chemical-related eczema, cumin, erythrosine, ethylbenzene, gasoline, gasoline, irritant contact eczema, lead, mercury poisoning, monocrotophos, Msg, parsley, quinoline yellow, rdx, silo unloader syndrome, sulfite, sunset yellow, tartrazine, tetryl, toluene
Dental Dental problems
Dermatologic Chemical-related eczema, eczema, environmental allergen related eczema, erythrodermic eczema,chemical-related eczema, eyelid eczema,irritant contact eczema, lyme disease, mycosis fungoides,familial, pruritus, sle related fibromyalgias, stress-related eczema, temperature-related eczema
Drug Side Effect 4-Aminopyridine,abecarnil, alcohol withdrawal syndrome, alemtuzumab, amantadine, ambien withdrawal, amifampridine, aminophylline, amobarbital sodium, amoxicillin, antidepressants, armodafinil, aspirin, ativan withdrawal, benzphetamine, beta antagonists, bronchodilators, bupropion, Caffeine, central nervous system depressants, central nervous system stimulants, chronic amphetamine use, clonazepam, clonidine, cocaine withdrawal, crack withdrawal, dalfampridine, dapsone, demerol withdrawal, desmopressin, desmopressin,morphine withdrawal, dexamfetamine, dexedrine withdrawal, diazepam, dilaudid withdrawal, dimebon, dxedrine withdrawal, ecstasy withdrawal, efavirenz, eribulin, escitalopram, felbamate, flibanserin, glucocorticoids, hydrocodone withdrawal, isoproterenol (aerosol), lacosamidemepenzolate, lamotrigine, lisdexamfetamine, lorazepam, lysergic acid diethylamide, Marie-seé syndrome, melatonin,lacosamidemepenzolate, meropenem, meropenem, methcathinone, methcathinone, methylenedioxymethamphetamine, methylphenidate, middle ear infection, milnacipran hydrochloride, modafinil, opioid withdrawal, oxazepam, oxycontin withdrawal, peramivir, percocet withdrawal, pergolide, phentermine,posaconazole, pramipexole, pregabalin, propranolol, pyrimethamine, ramelteon, ritalin withdrawal, rotigotine, selegiline, sesame, sibutramine, smoking especially at bedtime, steroid withdrawal syndrome,, suvorexant, tartrazine, tasimelteon, temazepam, terbutaline, tetryl, tolcapone, toluene, tribavirin, varenicline, vicodin withdrawal, vilazodone, withdrawal of sleeping pills, xanax withdrawal, zonisamide
Ear Nose Throat Acute sinusitis, earache, middle ear infection,
Endocrine Andropause, cushing's diseases, hyperthyroidism, melatonin, menopause, menstruation, pituitary tumors, alcohol-induced pseudo-cushing syndrome, calcium deficiency, cushing's diseases, diabetes, graves disease, autoimmune thyroid diseases, hyperthyroidism, calcium deficiency, melatonin, menopause, menstruation, pineal teratoma, pinealoma, pituitary tumors, premenstrual dysphoric disorders, premenstrual syndrome, resistance to thyroid stimulating hormone,
Environmental disrupted sleep schedules, dyssomnia, environmental allergen related eczema, high altitude,injury,chronic stress, inadequate sleep hygiene, jet lag, light, noise
Gastroenterologic Acute intermittent porphyria, cirrhosis of liver, colic,congenital hepatic porphyria, Glucocorticoids,Indigestion,Inflammatory bowel disease, congenital hepatic porphyria, duodenal ulcers, Food allergies, gastroesophageal reflux disease, glenard syndrome, gluten allergy, heartburn, indigestion, inflammatory bowel disease, peptic ulcer disease, reflux esophagitis, seafood allergy
Genetic Acute intermittent porphyria, congenital hepatic porphyria,Down's syndrome associated alzheimer's disease, down's syndrome associated alzheimer's disease, huntington's disease, inborn amino acid metabolism disorder, Neuromuscular disorders including painful peripheral neuropathies, nocturnal frontal lobe epilepsy type 1, perry syndrome, phenol sulfotransferase deficiency, pick's disease, prion fatal familial insomnia, variegate porphyria, wiskott-aldrich syndrome, x-linked angelman-like syndrome
Hematologic Aplastic anemia, iron-deficiency anemia, mycosis fungoides,familial, wiskott-aldrich syndrome
Iatrogenic no underlying causes
Infectious Disease Acquired immunodeficiency syndromes, ascariasis , creutzfeldt-jakob disease, Duodenal ulcers, east african trypanosomiasis, Epstein barr virus related fibromyalgias, Lyme disease, peptic ulcer disease, trigeminal neuralgia, west african trypanosomiasis, worms, urinary tract infection
Musculoskeletal/Orthopedic Arthritis,Restless legs syndrome, fibromyalgia, Epstein barr virus related fibromyalgias,leg cramps, tension myositis related fibromyalgias
Neurologic Acute mountain sickness, allergic tension-fatigue syndrome, alzheimer disease, brain injury, brain tumor, chronic pain, central sleep apnea, cerebral hemispheric and brainstem strokes, cluster headache,brain concussion, creutzfeldt-jakob disease, diaphragmatic paralysis, epstein barr virus related fibromyalgias, fatal familial insomnia, glut-1 deficiency syndrome, headache syndromes, huntington's disease, inborn amino acid metabolism disorder, irregular sleep-wake rhythm disorder, jet lag, mild traumatic brain injury, movement disorders, neuromuscular disorders including painful peripheral neuropathies, nocturnal frontal lobe epilepsy type 1,glucose transport defect, nocturnal myoclonus, olivopontocerebellar atrophy, pain, parkinson's disease, perry syndrome, pick's disease,respiratory muscle paralysis, pickwickian syndrome, prion fatal familial insomnia, restless leg syndrome,seizures, right parietal lobe syndrome, rolandic epilepsy, sleep apnea, sleep paralysis, sopite syndrome, traumatic brain injury causing post-traumatic insomnia, trigeminal neuralgia, ulcer pain, wernicke-korsakoff syndrome, x-linked angelman-like syndrome,
Nutritional/Metabolic aldehyde syndrome, alzheimer disease, amaranth, aniseed, Annatto, antioxidants, bell pepper, bha, bht, calcium deficiency, carageenan gum, carmine, chestnut, cinnamon, dementia, fennel, folic acid toxicity, glut-1 deficiency syndrome, guar gum, gum acacia, hops, iron deficiency anemia, lecithin, lentil, lettuce, milk, msg, mussel,niacin, parkinson's disease, phenol sulfotransferase deficiency, pyridoxine deficiency, quorn, thiamine deficiency, thyme, vitamin B12 deficiency, wernicke-korsakoff syndrome, wheat, xanthan gum, zucchini
Obstetric/Gynecologic No underlying causes
Oncologic Brain tumor, cancer, mycosis fungoides, familial, pineal teratoma, pinealoma, pituitary tumors
Ophthalmologic No underlying causes
Overdose/Toxicity Acrodynia, alcoholism, amphetamine intoxication, chronic amphetamine use, chronic vitamin a toxicity, excessive caffeine, folic acid toxicity, ginseng overuse, guarana overuse, vitamin b1 toxicity
Psychiatric Advanced sleep-wake phase disorder, alzheimer disease, amphetamine abuse, chronic amphetamine use, pain killer addiction, anger, anxiety disorder, fear of not sleeping, barbiturate abuse, benzodiazepine abuse, bipolar affective disorder, disturbing thoughts, teeth grinding, burnout syndrome, butorphanol, allergic tension-fatigue syndrome, chronic pain, chronic stress, irregular sleep-wake rhythm disorder, cluster headache, cocaine abuse, combat stress reaction, crack addiction, crystal meth addiction, delayed sleep-wake phase disorder, dementia, primary affective disorder, dyssomnia, double depression, alcohol-induced pseudo-cushing syndrome, exhilaration or excitement, prion fatal familial insomnia, generalized anxiety disorder, grief, heroin dependence, increased arousal, illness, jet lag, lsd addiction, lysergic acid diethylamide, mania, ecstasy abuse, mood disorder, narcolepsy, daytime napping, narcotic addiction, night eating syndrome]],nightmares, nocturia, nocturnal myoclonus, opioid addiction, overeating, oxycontin addiction, nocturnal panic disorder, parasomnias, parkinson's disease, pick's disease, post-traumatic stress, postpartum depression, premenstrual dysphoric disorders, primary insomnia, psychiatric disorders, abuse dwarfism syndrome, rape trauma syndromes, rem-behavior disorder, rett's syndromes, schizophrenia, holiday depression, sedative dependence, sleeping pill addiction, tranquilizer addiction, tranquilizer withdrawal, not enough exercise, endogenous insomnia, shift work, chronic sleep restriction, sleep disorder, situational/acute insomnia, chronic insomnia disorder, somnambulism, stress, substance abuse, tension myositis related fibromyalgias, discontinuation syndrome, perry syndrome
Pulmonary Acute mountain sickness,breathing-related sleep disorder, nocturnal asthma, diaphragmatic paralysis,

asbestosis, bronchial asthma including nocturnal asthma, chronic obstructive pulmonary disease, shortness of breath, nocturnal asthma, pickwickian syndrome, respiratory muscle paralysis, silo unloader syndrome, sleep-disordered breathing, sleep apnea

Renal/Electrolyte Calcium deficiency, chronic renal disease, kidney disease, renal failure, SLE related fibromyalgias, uremia
Rheumatology/Immunology/Allergy Autoimmune thyroid diseases, Epstein barr virus related fibromyalgias,Inflammatory bowel disease, Bronchial asthma including nocturnal asthma, chronic insomnia disorder, fibromyalgias, buerger's disease, allergic tension-fatigue syndrome, environmental allergen related eczema, eyelid eczema, seafood allergy, graves disease, autoimmune thyroid diseases, inflammatory bowel disease, rheumatoid arthritis related fibromyalgias, SLE related fibromyalgias, resistance to thyroid stimulating hormone, gluten allergy, wiskott-aldrich syndrome
Sexual No underlying causes
Trauma Brain concussion, mild traumatic brain injury, post-traumatic stress, postconcussive syndrome, traumatic brain injury causing post-traumatic insomnia, whiplashs
Urologic enlarged prostate, Bladder distention, enlarged bladder, Enlarged prostate, uremia, cystitis , prostatitis, urinary tract infection
Miscellaneous Ageing, Chronic pain, Chronic stress, dyssomnia, hunger, illness, injury, pregnancy

Causes in Alphabetical Order

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3


Causes of Insomnia Based On Severity

Acute

  • Environment changes
  • Extremes of temperature
  • Illness
  • Injury
  • Light
  • Noise
  • Poor bed
  • Situational stress

Chronic

Other

Differential Diagnosis

  • Breathing-related sleep disorders
  • Delayed sleep phase and shift work types of circadian rhythm sleep-wake disorder
  • Narcolepsy
  • Normal sleep variations
  • Parasomnias
  • Restless legs syndrome
  • Situational/acute insomnia
  • Substance/medication-induced sleep disorder, insomnia type[3]

Epidemiology and Demographics

Prevalence

The prevalence of insomnia disorder is 10,000-20,000 per 100,000 (10%-20%) in the primary care setting.[3]

According to the U.S. Department of Health and Human Services in year 2007, approximately 64 million Americans suffer from insomnia each year.[4] Insomnia tends to increase with age and affects about 40 percent of women and 30 percent of men.[5] The average American gets 7 hours of sleep, instead of the 8 to 10 hours recommended by doctors. Children however are recommended more than 8 hours.

Risk Factors

  • Advancing age
  • Anxiety or worry-prone personality
  • Chronic daily stress
  • Cognitive styles
  • Familial disposition
  • Fear of not sleeping
  • Female gender
  • High altitude
  • Increased arousal
  • Irregular sleep scheduling
  • Excessive caffeine use
  • Irregular sleep schedules
  • Light
  • Major life events (e.g., illness, separation)
  • Noise
  • Poor sleep habits
  • Poor sleep hygiene practices
  • Tendency to repress emotions
  • Uncomfortably high or low temperature[3]

Diagnosis

Patients with delayed sleep phase syndrome are often mis-diagnosed with insomnia. If the patient has trouble getting to sleep, but has normal sleep architecture once asleep, a circadian rhythm disorder is a more likely cause.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Insomnia Disorder[3]

  • A.A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
  • 1.Difficulty initiating sleep.(In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
  • 2.Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.):
  • 3. Early-morning awakening with inability to return to sleep.

AND

  • B.The sleep disturbance causes clinically significant distress or impairment in social, occupational,educational, academic, behavioral, or other important areas of functioning.

AND

  • C.The sleep difficulty occurs at least 3 nights per week.

AND

  • D.The sleep difficulty is present for at least 3 months.

AND

  • E.The sleep difficulty occurs despite adequate opportunity for sleep.

AND

  • F.The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).

AND

  • G.The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

AND

  • H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

Specify if:

  • With non-sleep disorder mental comorbidity, including substance use disorders
  • With other medical comorbidity
  • With other sleep disorder

Specify if:

  • Episodic:Symptoms last at least 1 month but less than 3 months.
  • Persistent: Symptoms last 3 months or longer.
  • Recurrent: Two (or more) episodes within the space of 1 year.

Note:Acute and short-term insomnia (i.e., symptoms lasting less than 3 months but otherwise meeting all criteria with regard to frequency, intensity, distress, and/or impairment)should be coded as an other specified insomnia disorder.

Insomnia versus poor sleep quality

Poor sleep quality can occur as a result of sleep apnea or major depression. Poor sleep quality is caused by the individual not reaching stage 4 or delta sleep which has restorative properties. There are, however, people who are unable to achieve stage 4 sleep due to brain damage who still lead perfectly normal lives.

  • Sleep apnea is a condition that occurs when a sleeping person's breathing is interrupted, thus interrupting the normal sleep cycle. With the obstructive form of the condition, some part of the sleeper's respiratory tract loses muscle tone and partially collapses. People with obstructive sleep apnea often do not remember awakening or having difficulty breathing, but they complain of excessive sleepiness during the day. Central sleep apnea interrupts the normal breathing stimulus of the central nervous system, and the individual must actually wake up to resume breathing. This form of apnea is often related to a cerebral vascular condition, congestive heart failure, and premature aging.

Major depression leads to alterations in the function of the hypothalamus and pituitary causing excessive release of cortisol which can lead to poor sleep quality.

Nocturnal polyuria or excessive nighttime urination can be very disturbing to sleep.[6] Nocturnal polyuria can be nephrogenic (related to kidney disease) or it may be due to prostate enlargement or hormonal influences. Deficiencies in vasopressin, which is either caused by a pituitary problem or by insensitivity of the kidney to the effects of vasopressin, can lead to nocturnal polyuria. Excessive thirst or the use of diuretics can also cause these symptoms.

Treatment

In many cases, insomnia is caused by another disease or psychological problem. In this case, medical or psychological help may be useful.

Medications

Many insomniacs rely on sleeping tablets and other sedatives to get rest. All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of sedatives such as benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down.

In comparing the options, a systematic review found that benzodiazepines and nonbenzodiazepines have similar efficacy which was insignificantly more than for antidepressants.[7] Benzodiazepines had an insignificant tendency for more adverse drug reactions.[7]

Benzodiazepines

The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. Benzodiazepines bind unselectively to the GABAA receptor.[7] This includes drugs such as temazepam, diazepam, lorazepam, flurazepam, nitrazepam and midazolam. These medications can be addictive, especially after taking them over long periods of time.

Non-benzodiazepines

Nonbenzodiazepine prescription drugs, including the nonbenzodiazepines zolpidem(Stilnoct) and zopiclone(Imovane), are more selective for the GABAA receptor[7] and may have a cleaner side effect profile than the older benzodiazepines; however, there are controversies over whether these non-benzodiazepine drugs are superior to benzodiazepines. These drugs appear to cause both psychological dependence and physical dependence, and can also cause the same memory and cognitive disturbances as the benzodiazepines along with morning sedation.

Antidepressants

Some antidepressants such as mirtazapine, trazodone and doxepin have a sedative effect, and are prescribed off label to treat insomnia. The major drawback of these drugs is that they have antihistaminergic, anticholinergic and antiadrenergic properties which can lead to many side effects. Some also alter sleep architecture.

Melatonin

Melatonin has proved effective for some insomniacs in regulating the sleep/waking cycle, but lacks definitive data regarding efficacy in the treatment of insomnia. Melatonin agonists, including Ramelteon (Rozerem), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation.

Antihistamines

The antihistamine diphenhydramine is widely used in nonprescription sleep aids, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs.

Atypical antipsychotics

Low doses of certain atypical antipsychotics such as quetiapine (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia.

Other substances

Some insomniacs use herbs such as valerian, chamomile, lavender, hops, and passion-flower. Valerian has undergone multiple studies and appears to be modestly effective.[8][9][10] Cannabis has also been suggested as a very effective treatment for insomnia. [11]

Alcohol may have sedative properties, but the REM sleep suppressing effects of the drug prevent restful, quality sleep. Middle-of-the-night awakenings due to polyuria or other effects from alcohol consumption are common, and hangovers can also lead to morning grogginess.

Insomnia may be a symptom of magnesium deficiency, or lower magnesium levels. A healthy diet containing magnesium, can help to improve sleep in individuals without an adequate intake of magnesium.[12]

Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal. [13]

Non-medicinal, complimentary and alternative medicine

Recent research has shown that cognitive behavior therapy can be more effective than medication in controlling insomnia [4]. In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep.[14]

Some traditional remedies for insomnia have included drinking warm milk before bedtime, taking a warm bath in the evening; exercising vigorously for half an hour in the afternoon, eating a large lunch and then having only a light evening meal at least three hours before bed, avoiding mentally stimulating activities in the evening hours, and making sure to get up early in the morning and to retire to bed at a reasonable hour.

Using aromatherapy, including jasmine oil, lavender oil, Mahabhringaraj and other relaxing essential oils, may also help induce a state of restfulness. Horlicks is marketed as a sleeping aid.

Many believe that listening to slow paced music will help insomniacs fall asleep. [15]

The more relaxed a person is, the greater the likelihood of getting a good night's sleep. Relaxation techniques such as meditation have been shown to help people sleep. Such techniques can lower stress levels from both the mind and body, which leads to a deeper, more restful sleep.

Traditional Chinese medicine has included treatment for insomnia. A typical approach may utilize acupuncture, dietary and lifestyle analysis, herbology and other techniques, with the goal of resolving the problem at a subtle level.

In the Buddhist tradition, people suffering from insomnia or nightmares may be advised to meditate on "loving-kindness", or metta. This practice of generating a feeling of love and goodwill is claimed to have a soothing and calming effect on the mind and body[16]. This is claimed to stem partly from the creation of relaxing positive thoughts and feelings, and partly from the pacification of negative ones. In the Mettā (Mettanisamsa) Sutta[17], Siddhartha Gautama, the Buddha, tells the gathered monks that easeful sleep is one benefit of this form of meditation.

See also

References

  1. http://www3.who.int/icd/currentversion/fr-icd.htm?gf50.htm+f510
  2. http://www3.who.int/icd/currentversion/fr-icd.htm?gg40.htm+g47
  3. 3.0 3.1 3.2 3.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  4. "Brain Basics: Understanding Sleep: National Institute of Neurological Disorders and Stroke (NINDS)". Retrieved 2007-12-16.
  5. "Insomnia". Retrieved 2007-12-16.
  6. Sleep issues in Parkinson’s disease. Neurology. 2005. pp. 64, S12–20. Unknown parameter |accessyear= ignored (|access-date= suggested) (help); Unknown parameter |coauthors= ignored (help); Unknown parameter |accessmonth= ignored (|access-date= suggested) (help)
  7. 7.0 7.1 7.2 7.3 Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman M, Ospina M, Klassen TP, Witmans M. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med. 2007 Sep;22(9):1335-50. Epub 2007 Jul 10. PMID 17619935
  8. Donath F, Quispe S, Diefenbach K, Maurer A, Fietze I, Roots I (2000). "Critical evaluation of the effect of valerian extract on sleep structure and sleep quality". Pharmacopsychiatry. 33 (2): 47–53. PMID 10761819.
  9. Morin CM, Koetter U, Bastien C, Ware JC, Wooten V (2005). "Valerian-hops combination and diphenhydramine for treating insomnia: a randomized placebo-controlled clinical trial". Sleep. 28 (11): 1465–71. PMID 16335333.
  10. Meolie AL, Rosen C, Kristo D; et al. (2005). "Oral nonprescription treatment for insomnia: an evaluation of products with limited evidence". Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 1 (2): 173–87. PMID 17561634.
  11. http://www.cannabis.net/medical-marijuana/pot-docs.html
  12. Hornyak M, Voderholzer U, Hohagen F, Berger M, Riemann D (1998). "Magnesium therapy for periodic leg movements-related insomnia and restless legs syndrome: an open pilot study". Sleep. 21 (5): 501–5. PMID 9703590.
  13. "Cider Vinegar and Insomnia".
  14. [PhD, Gregg] (September 27, 2004). "Cognitive Behavior Therapy and Pharmacotherapy for Insomnia: A Randomized Controlled Trial and Direct Comparison". Archives of Internal Medicine. 164 (17): 1888–1896. Unknown parameter |coauthors= ignored (help); Check |author-link1= value (help)
  15. Robinson SB, Weitzel T, Henderson L (2005). "The Sh-h-h-h Project: nonpharmacological interventions". Holistic nursing practice. 19 (6): 263–6. PMID 16269944.
  16. Lutz A, Greischar LL, Rawlings NB, Ricard M, Davidson RJ (2004). "Long-term meditators self-induce high-amplitude gamma synchrony during mental practice". Proc. Natl. Acad. Sci. U.S.A. 101 (46): 16369–73. doi:10.1073/pnas.0407401101. PMID 15534199.
  17. http://www.accesstoinsight.org/tipitaka/an/an11/an11.016.than.html


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