FitSugar

Valerian Root: Nature's Valium

FitSugar — Tue, 10 Apr 2007 08:45:00 -0700

Valerian Root may smell like disgustingly stinky feet, but it's great for relaxing the body and the muscles. It has been used for centuries in Europe and Asia as a sedative, and is believed to help you fall asleep faster, and improve the quality of your sleep. The Greeks also used valerian root to treat digestive problems.

It's a hardy perennial flowering plant with heads of sweetly scented pink or white flowers. It is dried and used in herbal supplements such as tablets, capsules, tinctures, teas, and liquid extracts. Many Herbalists, Naturopaths, and Chiropractors recommend taking valerian root to relieve tension headaches, insomnia, anxiety, or for muscular pain because of its ability to act as a muscle relaxer.

What else is great about this amazing herb? Although valerian root has been referred to as "nature's Valium," it is not at all addictive. It's not recommended to take more than 15g a day. Though side effects are rare, some people who use valerian root for long periods of time may develop headaches, insomnia, or feel irritable, which are similar side-effects experienced with prescription sleep-aids.

Fit's Tips: If you are taking valerian root for muscle pain, it won't knock you out and make you feel totally spacey like most prescription muscle relaxers, but it is recommended that you take it at bedtime because it'll calm you down and help you fall asleep, that is why I love Extra Sleepytime Tea - it is fortified with valerian root.

Insomnia

FitSugar — Wed, 08 Oct 2008 17:35:00 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Sedative Hypnotic Drug Warnings

In March 2007, the FDA ordered stronger warning labels on sedative hypnotic drugs. These medications include benzodiazepine and non-benzodiazepine drugs, such as zolpidem (Ambien), eszopiclone (Lunesta), ramelteon (Rozerem), and triazolam (Halcion). The FDA warned that these drugs may be associated with:

Severe allergic reactions (anaphylaxis) and severe facial swelling (angioedema), which can occur even the first time a drug is taken
Complex sleep-related behaviors, such as sleep driving, making phone calls, and preparing and eating food while asleep

Patients who take sleeping pills should be sure to follow the directions. These include not combining sleeping pills with alcohol or other drugs and not taking more than the prescribed dose. All patients prescribed sedative hypnotic drugs should receive a patient medication guide that describes the potential risks, and precautions to reduce these risks.

Behavioral and Psychological Therapies

Behavioral and psychological treatments, such as cognitive behavioral therapy and relaxation techniques, are effective approaches for insomnia and can produce long-lasting benefits, according to a 2006 study in Sleep.
Behavioral interventions help over 80% of children who try them, indicates another 2006 Sleep study.

Complementary and Alternative Medicine

More than 1.6 million adults use complementary and alternative medicine to treat their insomnia, according to results of a national survey published in the Archives of Internal Medicine. About half of patients who tried herbal medicine or relaxation techniques found that these approaches helped improve their sleep.
In 2006, the American Academy of Sleep Medicine issued a position statement advising that there is only limited scientific evidence that herbal remedies are effective sleep aids.

Insomnia and Mood Disorders

Chronic insomnia can increase the risk of developing depression and anxiety, according to a 2007 study in Sleep. Research also indicates that insomnia and daytime sleepiness can cause and worsen depression and anxiety in children as well as adults.

Introduction

Insomnia comes from the Latin words for “no sleep.” Insomnia is characterized by:

Difficulty falling asleep
Difficulty staying asleep
Waking up too early in the morning

Some experts believe that poor quality (“non-restorative”) sleep is also related to insomnia. Insomnia can cause daytime fatigue, irritability, and impaired performance. About 60 million Americans each year suffer from insomnia.

Insomnia may be primary or secondary:

Primary insomnia means that the inability to sleep is not caused by other health problems.
Secondary insomnia is due to other health conditions that interfere with sleep. Some experts prefer the term “co-morbid insomnia.”

Insomnia, usually temporary, is often categorized by how long it lasts:

Transient insomnia lasts for a few days.
Short-term insomnia lasts for no more than 3 weeks.
Chronic insomnia occurs at least 3 nights per week for 1 month or longer.

Insomnia may also be defined in terms of inability to sleep at conventional times. The following examples are referred to as circadian rhythm disorders:

Delayed Sleep-Phase Syndrome. Delayed sleep-phase syndrome is the term for a circadian clock that runs late but reliably. People who have this condition (usually adolescents) fall asleep very late at night or in early morning hours, but then sleep normally.
Advanced Sleep-Phase Syndrome. This syndrome tends to develop in older people. It produces excessive sleepiness in the morning and undesired awakening early (3 - 5 a.m.) in the morning.

In sleep studies, subjects spend about one-third of their time asleep, suggesting that most people need about 8 hours of sleep each day. Individual adults differ in the amount of sleep they need to feel well rested, however. (Infants may sleep as many as 16 hours a day.)

The daily cycle of life, which includes sleeping and waking, is called a circadian (meaning "about a day") rhythm, commonly referred to as the biologic clock. Hundreds of bodily functions follow biologic clocks, but sleeping and waking comprise the most prominent circadian rhythm. The sleeping and waking cycle is approximately 24 hours. (If confined to windowless apartments, with no clocks or other time cues, sleeping and waking as their bodies dictate, humans typically live on slightly longer than 24-hour cycles.) It usually takes the following daily patterns:

Humans are designed for daytime activity and nighttime rest.
Additionally, there is a natural peak in sleepiness at mid-day, the traditional siesta time.

In addition, daily rhythms intermesh with other factors that may interfere or change individual patterns:

The fraction-of-a-second-firing of nerve cells in the brain may be faster or slower in different individuals.
The monthly menstrual cycle in women can shift the pattern.
Light signals coming through the eyes reset the circadian cycles each day, so changes in season or various exposures to light and dark can unsettle the pattern. The importance of sunlight as a cue for circadian rhythms is dramatized by the problems experienced by people who are totally blind. They commonly suffer trouble sleeping and other rhythm disruptions.

The response to light signals in the brain is an important key factor in sleep:

Light signals travel to a tiny cluster of nerves in the hypothalamus in the center of the brain, the body's master clock, which is called the supra chiasmatic nucleus (SCN).
This nerve cluster takes its name from its location, which is just above (supra) the optic chiasm, which is a major junction for nerves transmitting information about light from the eyes.
The approach of dusk each day prompts the SCN to signal the nearby pineal gland (named so because it resembles a pine-cone) to produce the hormone melatonin.
Melatonin is thought to act as the body's time-setting hormone. The longer a person is in darkness the longer the duration of melatonin secretion. Secretion can be diminished by staying in bright light. Melatonin also appears to trigger the need to sleep.

Sleep consists of two distinct states that alternate in cycles and reflect differing levels of brain nerve cell activity:

Non-Rapid Eye Movement Sleep (NonREM). NonREM sleep is also termed quiet sleep. NonREM is further subdivided into three stages of progression:

Stage 1 (light sleep)
Stage 2 (so-called true sleep)
Stage 3 to 4 (deep "slow-wave" or delta sleep)

With each descending stage, awakening becomes more difficult. It is not known what governs NonREM sleep in the brain. A balance between certain hormones, particularly growth and stress hormones, may be important for deep sleep.

Rapid Eye-Movement Sleep (REM). REM sleep is termed active sleep. Most vivid dreams occur in REM sleep. REM-sleep brain activity is comparable to that in waking, but the muscles are virtually paralyzed, possibly preventing people from acting out their dreams. In fact, except for vital organs like lungs and heart, the only muscles not paralyzed during REM are the eye muscles. REM sleep may be critical for learning and for day-to-day mood regulation. When people are sleep-deprived, their brains must work harder than when they are well rested.

The REM/NREM Cycle. The cycle between quiet (nonREM) and active (REM) sleep generally follows this pattern:

After about 90 minutes of nonREM sleep, eyes move rapidly behind closed lids, giving rise to REM sleep.
As sleep progresses the nonREM/REM cycle repeats.
With each cycle, nonREM sleep becomes progressively lighter, and REM sleep becomes progressively longer, lasting from a few minutes early in sleep to perhaps an hour at the end of the sleep episode.

Causes of Short-Term or Transient Insomnia

A reaction to change or stress is one of the most common causes of short-term and transient insomnia. This condition is sometimes referred to as adjustment sleep disorder.

The trigger could be a major or traumatic event such as:

An acute illness
Injury or surgery
The loss of a loved one
Job loss

Temporary insomnia could also develop after a relatively minor event, including:

Extremes in weather
An exam
Traveling
Trouble at work

In most cases, normal sleep almost always returns when the condition resolves, the individual recovers from the event, or the person becomes used to the new situation. Treatment is needed if sleepiness interferes with functioning or if it continues for more than a few weeks. Individual responses to stress vary and some people may not experience insomnia at all, even during very stressful situations while others may suffer from insomnia in response to very mild stressors.

Fluctuations in female hormones play a major role in insomnia in women over their lifetimes. This insomnia is usually temporary.

During Menstruation. Progesterone promotes sleep, and levels of this hormone plunge during menstruation, causing insomnia. (When they rise during ovulation, women may become sleepier than usual.)
During Pregnancy. The effects of changes in progesterone levels in the first and last trimester can disrupt normal sleep patterns.
Menopause. Insomnia can be a major problem in the first phases of menopause, when hormones are fluctuating intensely. Insomnia during this period may be due to different factors that occur. In some women, hot flashes, sweating, and a sense of anxiety can awaken women suddenly and frequently at night. Insomnia may also be caused by psychologic distress provoked by this life passage. In many cases, insomnia is temporary. However, a 2006 study found that hot flashes in perimenopausal and postmenopausal women are strongly associated with chronic insomnia (sleep problems lasting more than 1 month). Treating hot flashes may help resolve chronic insomnia.

Air travel across time zones often causes insomnia. After long plane trips, 1 day of adjustment is usually needed for each time zone crossed. Traveling west to earlier times seems to be less traumatic than going east to a later time because it is easier to lengthen a circadian phase than to shorten it.

In one study, 20% of adults reported that light, noise, and uncomfortable temperatures caused their sleeplessness. Depending on the time of day, too much or too little light can disrupt sleep.

Excessive Light at Night. A person's biologic circadian clock is triggered by sunlight, and very bright artificial light maintains wakefulness. One study indicated that even dim artificial light might disrupt sleep.
Insufficient Light During the Day. Insufficient exposure to light during the day, as occurs in some disabled elderly patients who rarely venture outside, may also be linked with sleep disturbances. One study suggested that when a person is exposed to bright daylight, melatonin levels increase in response to darkness at night, which aids sleep.

Caffeine. Caffeine is a stimulant, which can interfere with falling asleep.

Nicotine. Nicotine is also a stimulant, but quitting smoking itself can lead to transient insomnia. In fact, it has been suggested that if sleeping could be improved during withdrawal from smoking, perhaps it would be easier to quit smoking.

Partner's Sleep Habits. In one survey, 17% of women and 5% of men reported that their partner's sleep habits impaired their own sleep. Snoring can certainly be a factor in a partner's insomnia.

Medications. Insomnia is a side effect of many common medications, including over-the-counter preparations that contain caffeine. People who suspect their medications are causing them to lose sleep should check with their doctors or pharmacists.

Causes of Chronic Insomnia

Sleep problems seem to run in families. About 35% of people with insomnia have a family history of insomnia, with the mother being the most commonly affected family member. Still, because so many factors are involved in insomnia, a genetic component is difficult to define.

Abnormal levels of certain brain chemicals have been observed in some people with chronic insomnia.

Melatonin. Low levels of melatonin, the hormone secreted by the pineal gland, have sometimes been observed in chronic insomnia.
Stress Hormones. Some studies have reported persistently high levels of stress hormones, particularly cortisol, in people with chronic insomnia, particularly insomnia related to aging and psychiatric disorders. High levels of cortisol reduce REM sleep. However, a 2003 study of people with chronic insomnia reported that cortisol levels were high only when their sleep was of poor quality. When they slept well, levels were lower. This study and other research suggests that high levels of stress hormones are caused by poor sleep, rather than being the cause.
Growth Hormone. Normal aging is associated with a blunting of regular, cyclical surges of growth hormone, which may affect sleep as one gets older. This hormone, which is normally secreted in the late night, is associated not only with growth but with deep, slow-wave sleep. (Older people generally have less slow-wave sleep.)

Chronic insomnia occurs in people who have persistently high levels of stress hormones and a shift in the levels of certain immune factors. Studies indicate that people with chronic insomnia have higher levels of interleukin-6 and tumor necrosis factor during the day, but lower levels at night. These immune factors, called cytokines, cause symptoms of fatigue. Levels are usually higher at night in people with healthy sleep. The implications of these immune changes in people with insomnia are not known.

Many cases of chronic insomnia cases have a psychologic or psychiatric basis. The disorders that most often cause insomnia are:

Anxiety.
Depression. Sleep abnormalities are an integral part of depressive disorders, with more than 90% of depressed patients experiencing insomnia.
Bipolar disorder.

Insomnia may also cause emotional problems. It is often unclear which condition has triggered the other, or if the two conditions, in fact, have a common source.

In many cases, it is unclear if chronic insomnia is a symptom of some physical or psychological condition or if it is a primary disorder of its own. In most instances, a mix of psychological and physical conditions causes the insomnia.

Psychophysiologic insomnia occurs when:

An episode of transient insomnia disrupts the person's circadian rhythm.
The patient begins to associate the bed not with rest and relaxation but with a struggle to sleep. A pattern of sleep failure emerges.
Over time, this event repeats, and bedtime becomes a source of anxiety. Once in bed, the patient broods over the inability to sleep, the consequences of sleep loss, and the lack of mental control. All attempts to sleep fail.
Eventually excessive worry about sleep loss becomes persistent and provides an automatic nightly trigger for anxiety and arousal. Unsuccessful attempts to control thoughts, images, and emotions only worsen the situation. After such a cycle is established, insomnia becomes a self-fulfilling prophecy that can persist indefinitely.

Sometimes anxiety and the inability to sleep dates back to childhood when parents used various threats to force their children into sleep for which they may not have been ready.

In one survey, 22% of adults reported that health conditions, pain, or discomfort impaired their sleep. These conditions can include:

Nightly Leg Problems. Leg disorders that occur at night, such as restless legs syndrome or leg cramps, are of special note. They are very common and an important cause of insomnia, particularly in older people.

Medical Problems. Among the many medical problems that can cause chronic insomnia are allergies, arthritis, cancer, fibromyalgia, heart disease, gastroesophageal reflux disease (GERD), hypertension, asthma, emphysema, rheumatologic conditions, Alzheimer's disease, Parkinson's disease, hyperthyroidism, and attention deficit hyperactivity disorder.

Medications. Among the many medications that can cause insomnia are antidepressants (fluoxetine, bupropion), theophylline, lamotrigine, felbamate, beta-blockers, and beta-agonists.

An estimated 10 -15% of chronic insomnia cases result from substance abuse, especially alcohol, cocaine, and sedatives. One or two alcoholic drinks at dinner, for most people, pose little danger of alcoholism and may help reduce stress and initiate sleep. Excess alcohol or alcohol used to promote sleep, however, tends to fragment sleep and cause wakefulness a few hours later. It also increases the risk for other sleep disorders, including sleep apnea and restless legs. Alcoholics often suffer insomnia during withdrawal and, in some cases, for several years during recovery.

Shift work throws off the body's circadian rhythm and may lead to chronic insomnia.

Risk Factors

Studies estimate that between 25 - 33% of adults experience some insomnia each year. In spite of this widespread problem, however, studies suggest that only about 30% of American adults who visit their doctor ever discuss sleep problems. And, doctors seem rarely to ask patients about their sleep habits or problems.

A 2003 study suggested that there were seven significant factors that predicted high risk for insomnia:

Being older
Having conflicts with relatives
Being overworked on the job
Being overworked at home
Having a sick relative
Having low social status
Having a psychiatric or psychologic problem

Stressful events do not cause insomnia in everyone. However, negative thoughts and attitudes toward events can be significant factors in insomnia. In one study, for example, the number of stressful events did not differ between good and poor sleepers. Those with insomnia, however, tended to experience these stressful events more intensively than the healthy sleepers.

In another study, patients with insomnia and good sleepers were asked to record their pre-sleep images using a handheld counter. People with insomnia not only reported fewer images, but their images also tended to be more unpleasant than those of good sleepers. More of the images in people with insomnia were related to intimate relationships and to sleep itself. The images of sleepers were more likely to be random and disconnected.

Studies report that the strongest risk factors for insomnia are psychiatric problems (particularly depression) and physical complaints (such as headaches and chronic pain) that have no identifiable cause (called somatic symptoms). About 90% of people with depression have insomnia. A study presented at the 2005 Associated Professional Sleep Societies meeting indicated that insomnia may contribute to, and prolong, depression. Researchers analyzed data from over 1,800 adults age 65 years and older. Compared with depressed patients who did not have sleep problems, depressed patients with insomnia were 11 times more likely to remain depressed after 6 months and 17 times more likely to still be depressed after a year. The researchers suggested that treating insomnia may help patients recover from depression more quickly.

Overall, insomnia is more common in women than men, although men are not immune from insomnia. Sleep efficiency deteriorates equally in men and women as they get older.

Men. One major study suggested that as men age from 16 - 50, they lose about 80% of their deep sleep. During that period, light sleep increases and REM sleep remains unchanged. (The study did not use women as subjects, and there is some evidence to suggest they are not as affected.) After age 44, REM and total sleep diminish and awakenings increase.

Women. It is not clear why women suffer more from insomnia than men. Some theories include:

In women, a number of hormonal events can disturb sleep, including premenstrual syndrome, menstruation, pregnancy, and menopause. All these conditions are short-term, however, and in most cases the wakefulness associated with them is temporary and can be eliminated with sleep hygiene and time.
After childbirth, most women develop a high sensitivity to the sounds of their children, which causes them to wake easily. Women who have had children sleep less efficiently than women who have not had children. It is possible that many women never unlearn this sensitivity and continue to wake easily long after the children have grown.
Women are at higher risk than men are for depression and anxiety, which are known risk factors for insomnia. In fact, some researchers believe that this is a main reason for the gender differences in insomnia.

After menopause, women are susceptible to the same environmental and biologic causes of insomnia as men. In fact, older women who are not bothered by sleeplessness tend to have longer and better sleep than noninsomniac men their own age.

As people grow older, sleep patterns change. In a major 2003 survey, a third of older adults reported that they woke up frequently during the night. About a quarter of participants reported waking up too early and being unable to go back to sleep. In the same study, 33% of adults age 55 - 64 reported waking up feeling unrefreshed.

Although age itself does not appear to be a risk factor for insomnia, a number of factors may interfere with sleep as one gets older:

Elderly people are more likely to be sedentary than younger adults.
Medical conditions that cause pain or nighttime distress are common in the elderly and pose a high risk for insomnia. They include arthritis, gastrointestinal distress, frequent urination, lung disease, and heart conditions.
Neurologic diseases in the elderly, such as restless legs syndrome, Parkinson's, Alzheimer's, and other forms of dementia can cause nighttime disorientation, confused wandering, and delirium.
Older people often take a number of prescription drugs whose side effects include insomnia.
The elderly are prone to grief, depression, and anxiety, emotional factors that can cause sleeplessness. One study of healthy older adults found that psychologic factors, such as anxiety and depression, were more likely to cause insomnia than illness, medications, or living conditions.
Melatonin levels are generally lower in older people. Some research suggests, however, that elderly people have lower levels simply because they stay mostly indoors and do not receive adequate sunlight.

Lack of sleep at night can lead to excessive sleepiness during the day. A 2006 study reported the following risk factors for excessive daytime sleepiness among the elderly:

Male gender
Sleep apnea or other sleep breathing disorders
Nighttime chest wheezing
Poor sleep quality
Longer time spent in REM sleep
More than 3 episodes of nighttime pain within a week
Medications that cause sleepiness

Sleep loss among the elderly is not inevitable. While older people are more susceptible to many conditions that can cause insomnia, treatments and a healthy lifestyle, particularly regular exercises, are as useful in providing relief to the elderly as to the young. And, a number of studies have found no significant increase in insomnia in older healthy adults.

Shift workers are at considerable risk for insomnia. In a major survey, 65% of shift workers reported one or more symptoms of insomnia at least a few nights a week. Workers over age 50 and those whose shifts are always changing are particularly susceptible to insomnia, although night-shift workers also have a high rate of sleeplessness. One study found that 53% of night-shift workers fall asleep on the job at least once a week, implying that their internal clocks do not adjust to unusual work times. (They are also at much higher risk than other workers for automobile accidents due to their drowsiness and may also have a higher risk for health problems in general.) A Japanese study reporting on different aspects of insomnia found that excessive computer work was associated with all forms of insomnia. People who were over-involved with their work tended to have trouble falling asleep, and they tended to awaken earlier than average.

Among the many conditions that pose a high risk for insomnia are:

Frequent travel, particularly crossing time lines
Post-traumatic stress syndrome
Brain injuries
Many chronic medical conditions ranging from seemingly minor ones, such as tinnitus (ringing in the ears) to major conditions, such as respiratory problems, heart disease, or being on dialysis

Prognosis

A 2002 study of sleeping habits in over 1 million people reported that people who slept 7 hours a night lived the longest. People who slept more than 8 hours or less than 6 hours, or who took sleeping pills, had lower survival rates.

Insomnia is not life-threatening, except in very rare cases, such as in those who have the genetic disorder called fatal familial insomnia. This rare degenerative brain disease develops in late adulthood.

Sleepiness causes as many as 200,000 automobile accidents in the U.S. and 1,500 deaths from such accidents. Studies indicate that drowsy driving is as risky as drunk driving. In a major 2003 survey, 60% of young adults reported driving while drowsy, and 20% dosed off while driving. In the study, 1% of adults who dozed off reported having an accident because of it. (One study strongly suggested that it is habitual sleepiness, however, and not just being sleepy at the time of an accident that places people at higher risk.)

Surveys show that people with severe insomnia have a quality of life that is almost as poor as those who have chronic conditions, such as heart failure. In addition to more daytime sleepiness, people with insomnia complain of more attention and memory problems compared to good sleepers.

Insomnia can also lead to irritability, mistakes at work, and poorer relationships.

Effect on Thinking and Performance. Studies suggest that insomnia makes it harder to concentrate and perform tasks.

Reduced concentration. Deep sleep deprivation impairs the brain's ability to process information.
Impaired task performance. One study reported that missing only 2 - 3 hours of sleep every night for a week significantly impaired performance and mood. An Australian study reported that 17 hours of sleep deprivation causes impaired performance levels comparable to those found in people who have blood alcohol levels indicating intoxication.
Memory problems. Whether insomnia significantly impairs learning is unclear. Some studies have reported problems in memorization, although others have found no differences in test scores between people with temporary sleep loss and those with full sleep.

Insomnia and Depression. Although stress and depression are major causes of insomnia, insomnia may also increase the activity of the hormones and pathways in the brain that can produce emotional problems. Research indicates that chronic insomnia can increase the risk of developing depression and anxiety. Some investigators are exploring the possibility of preventing psychiatric disorders by early recognition and treatment of insomnia.

Even modest alterations in waking and sleeping patterns can have significant effects on a person's mood. In both children and adults, the combination of insomnia and daytime sleepiness can produce more severe depression than either condition alone.

Effects on the Heart. Although there has been some concern that insomnia may increase the risk for heart problems, little evidence has supported any significant dangers. One study reported signs of heart and nervous system activity in people with chronic insomnia that might place such individuals at risk for coronary heart disease. If it exists, however, this increased danger is very modest compared with other risk factors for heart disease. Yet another report suggested that sleep complaints in elderly people without coronary artery disease predicted a first heart attack. Sleep disorders in such cases may have been a marker for depression, however, which is a risk factor for heart attacks in elderly people.

Effects on Weight. Lack of sleep can cause weight gain and obesity. In a 16-year study of over 68,000 women, those who slept no more than 5 hours a night were 32% more likely to gain at least 33 pounds, and those who slept 6 hours had a 12% increased risk of weight gain compared to women who slept at least 7 hours a night.

Effects on the Immune System. A 2003 study reported significant differences in immune factors among sleepers, with higher levels of certain infection-fighters observed in good sleepers than in people with chronic insomnia. The significance of these findings is still unknown, however.

Diagnosis

Diagnosing sleep disturbance and its cause is the most important step in restoring healthy sleep. However, there is little agreement, even among experts, on the best methods for effectively assessing a patient's insomnia.

A major difficulty in diagnosing this problem is its subjective nature. One study showed that there was no difference in sleep behaviors between people who said they were insomniacs and people who said they weren't. People who believe they have insomnia may have actually had frequent brief awakenings during sleep that they perceive as being continuously awake.

A number of questionnaires are available for determining whether a patient has insomnia or other sleep disorders. For example, the doctor may ask:

How would you describe your sleep problem?
How long have you had the sleep problem?
How long does it take to fall asleep?
How many times a week does it occur?
How restful is sleep?
Do you have trouble falling asleep or do you wake up too early?
What is the sleep environment like (Noisy? Not dark enough?)?
How does insomnia affect daytime functioning?
What medications do you take? (Include herbs, alcohol, and over-the-counter or prescription drugs.)
Are you taking or withdrawing from stimulants, such as coffee or tobacco?
How much alcohol is consumed per day?
What stresses or emotional factors may be present?
Have you experienced any significant life changes?
Do you snore or gasp during sleep (an indication of sleep apnea)?
Do you have leg problems (cramps, twitching, crawling feelings)?
If there is a bed partner? Is this person's behavior distressing or disturbing?
Are you a shift worker?

Sleep Diary. If the patient cannot answer these questions, keeping a sleep diary is a helpful diagnostic tool. Every day for 2 weeks, the patient should record all sleep-related information, including responses to questions listed above described on a daily basis. A bed partner can help by adding their observations of the patient's sleep behavior.

The Epworth Sleepiness Scale. The Epworth Sleepiness Scale (ESS) uses a simple questionnaire to measure excessive sleepiness during eight situations.


Situation	Chance of Dozing 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading.	(Indicate a score of 0 to 3)
Watching TV.	(Indicate a score of 0 to 3)
Sitting inactive in a public place (e.g., a theater or a meeting).	(Indicate a score of 0 to 3)
As a passenger in a car for an hour without a break.	(Indicate a score of 0 to 3)
Lying down to rest in the afternoon when circumstances permit.	(Indicate a score of 0 to 3)
Sitting and talking to someone.	(Indicate a score of 0 to 3)
Sitting quietly after a lunch without alcohol.	(Indicate a score of 0 to 3)
In a car, while stopped for a few minutes in traffic.	(Indicate a score of 0 to 3)
Score Results	1-6: Getting enough sleep 4-8: Tends to be sleepy but is average. 9-15: Very sleepy and should seek medical advice. Over 16: Dangerously sleepy

Multiple Sleep Latency Test. The multiple sleep latency test (MSLT) uses a machine to measure the time it takes to fall asleep while lying in a quiet room during the day:

The patient takes four or five scheduled naps 2 hours apart.
People with healthy sleep habits fall asleep in about 10 - 20 minutes.
The test can detect changes in sleepiness associated with sleep deprivation in patients with insomnia.

It has limitations, however, and does not take into consideration any situations that may affect the patients' mental state and the actual home situation. The test is used mainly after other sleep disorders have been ruled out and the doctor is uncertain whether or not insomnia is a correct diagnosis.

If unexplained insomnia persists after treatment or there is evidence of a primary sleep disorder, such as sleep apnea or narcolepsy, the doctor may recommend a sleep specialist or a sleep disorders center. Centers are accredited by the American Academy of Sleep Medicine. Patients should investigate centers carefully, to be sure that they offer full sleep studies.

Among the signs that may indicate a need for a sleep disorders center are:

Insomnia due to psychologic disorders
Sleeping problems due to substance abuse
Snoring and sudden awakening with gasping for breath (possible sleep apnea)
Severe restless legs syndrome
Persistent daytime sleepiness
Sudden episodes of falling asleep during the day (possible narcolepsy)

At most sleep disorders centers, patients undergo an in-depth analysis, usually supervised by a multidisciplinary team of consultants who can provide both physical and psychiatric evaluations.

Treatment

The American Academy of Sleep Medicine (AASM) recommends cognitive behavioral therapy (CBT) and prescription medications as the main treatments for insomnia. According to the AASM, these treatment options can improve both quality and quantity of sleep for people with insomnia.

Experts agree that behavioral therapies should be the first-line treatment for insomnia. For children in particular, medications should rarely be used as initial treatment. A 2006 study reported that behavioral interventions can provide sustained improvement in over 80% of children with insomnia.

Prevention of sleeplessness depends upon the patient's ability to learn how to relax and sleep well. A number of behavioral methods are aimed at achieving these goals. Behavioral techniques can actually cure chronic insomnia in many cases and studies report that they help nearly all patients with primary chronic insomnia. The benefits of psychological and behavioral therapy in managing insomnia are long-lasting.

Although medications are equally effective for helping people with insomnia to sleep, they cannot cure the condition. In addition, behavioral methods act faster. Behavioral methods work in all age groups, including children and elderly patients.

Behavioral methods include:

Stimulus control
Cognitive behavioral therapy
Progressive muscle relaxation
Paradoxical intention
Biofeedback
Sleep restriction
Imagery tasks

Studies have reported that between 70 - 80% of patients who are treated with non-drug methods experience improved sleep with an average treatment duration of only 5 hours over a 4-week period. Furthermore, studies report that 75% of those who have been taking drugs are able to stop or reduce their use.

Proper sleep hygiene is the first step and should accompany any behavioral method. A number of behavioral approaches are available, but all have the same basic goals:

To reduce the time it takes to go to sleep to below 30 minutes
Reduce wake-up periods during the night

Stimulus Control. Stimulus control is now considered the standard treatment for primary chronic insomnia and may be helpful for some patients with secondary insomnia as well. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following:

Go to bed only when ready to sleep or for sex.
If unable to sleep within 15 - 20 minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, like reading a book.)
Maintain a regular wake-up time no matter how few hours you actually sleep.
Avoid naps.

Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep such as, "I'll never fall asleep." It uses actions intended to change behavior. A 2004 study of young and middle-aged adults suggested that CBT is more effective than medication in treating chronic insomnia, and should be considered as a first-line intervention. Adding medication to CBT did not provide additional benefit. In a 2006 study of older adults, CBT worked better than zopiclone (Imovane) in managing chronic insomnia. [Zopiclone is a European sleep medication that is similar to the American drug eszopiclone (Lunesta).] Compared to zopiclone or placebo, CBT helped patients spend less time awake at night. The benefits of 6 weeks of weekly CBT sessions lasted for 6 months.

Progressive Muscle Relaxation. Progressive muscle relaxation is another technique for inducing sleep that works well for many people. It takes about 10 minutes to perform:

Focus on one specific muscle group at a time. Most people start with the muscles in one foot. Inhale and tense the foot muscles for about 8 seconds. (Do this gently. It is not intended to cause severe pain or muscle contractions.)
Relax the foot, and let it become loose and limp. Stay relaxed for 15 seconds, then repeat with the other foot.
Move up to the next muscle group and repeat the sequence, doing one side of the body at a time. Move progressively from each foot and leg up through the abdomen and chest, to each hand and arm, then to the neck, shoulders, and face.

Paradoxical Intention. Paradoxical intention is a psychological approach that is based on doing the opposite of what one wants or fears and takes it to the extreme. The first step is to make a plan to take such a paradoxical approach to insomnia.

Instead of going through activities leading to sleep, the patient prepares for staying awake and doing something energetic.
In some cases, people may take specific psychological barriers to sleep to an extreme limit. For example, if worry is a factor in insomnia, the patient intensifies the worries.

Biofeedback. Biofeedback is also effective, but requires being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily.

Sleep Restriction Therapy. Sleep restriction therapy may be effective, although evidence is inconclusive. In a 2001 study, patients practiced sleep hygiene and sleep restriction. Sleep hygiene was very helpful during the first 2 months while sleep restriction led to sustained benefits and deeper sleep. The approach is a systematic method for achieving sleep and restricting the time spent in bed.

The first step is to calculate a person's sleep efficiency number:

Keep a sleep diary for 14 days. Calculate the average hours of actual sleep and hours in bed. Then divide the average hours slept by the hours spent in bed. The result, given as a percentage, is the sleep efficiency number. (For example, if a patient sleeps an average of 5 hours out of 7 hours spent in bed then the result is .714, and the sleep efficiency percentage is 71%.)
The patient's goal is to achieve sleep efficiencies of between 85 - 90%, which means only 10 - 15% of the time is spent staying awake in bed. (Sleep efficiency in older people normally falls between 75 - 85%.)

To achieve this goal, the patient takes the following actions:

Begin by going to bed 15 minutes later than usual the first week.
If 85% sleep efficiency isn't reached by the end of the week, add another 15 minutes before going to bed. Refrain from going to bed even if tired, although bedtime should not be reduced below 5 hours.
Once efficiency reaches 90% or more, begin to go to bed 15 minutes earlier each week.

Other parts of the program include stopping any sleep medications and following good sleep hygiene. People using this treatment have reported lasting improvements after just 8 weeks, and studies suggest that it is significantly more successful than relaxation techniques.

Imagery Tasks. A 2002 study enrolled people whose chronic insomnia was associated with unwanted thoughts and worries. They were given specific positive mental tasks that gave them a sense of positive control (as opposed to their real life concerns, which felt out of their control). These images distracted them and allowed them to fall asleep faster. In support of this approach, another study evaluated patients with insomnia who were given a problem before sleep. One group was asked to think of the problem in images and the other in words. The group who used imagery fell asleep more quickly and woke up with less anxiety.

Sleep Hygiene. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep.

Establish a regular time for going to bed and getting up in the morning. Stick to this schedule even on weekends and during vacations.
Use the bed for sleep and sexual relations only, not for reading, watching television, or working. Excessive time in bed disrupts sleep.
Avoid naps, especially in the evening.
Exercise before dinner. A low point in energy occurs a few hours after exercise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness.
Take a hot bath about 1.5 - 2 hours before bedtime. This alters the body's core temperature rhythm and helps people fall asleep more easily and more continuously. (Taking a bath shortly before bed increases alertness.)
Do something relaxing in the 30 minutes before bedtime. Reading, meditation, and a leisurely walk are all appropriate activities.
Keep the bedroom relatively cool and well ventilated.
Do not look at the clock. Obsessing over time will just make it more difficult to sleep.
Eat light meals, and schedule dinner 4 - 5 hours before bedtime. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.
Spend a half hour in the sun each day. The best time is early in the day. (Take precautions against overexposure to sunlight by wearing protective clothing and sunscreen.)
Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.
Avoid caffeine in the hours before sleep.
If one is still awake after 15 - 20 minutes, go into another room, read or do a quiet activity using dim lighting until feeling very sleepy. (Don't watch television or use bright lights.)
If distracted by a sleeping bed partner, moving to the couch or a spare bed for a couple of nights might be helpful.
If a specific worry is keeping one awake, thinking of the problem in terms of images rather than in words may allow a person to fall asleep more quickly and to wake up with less anxiety.

Exercise may be one of the best ways to promote healthy sleep. One study found that exercise is as good for inducing sleep as the use of benzodiazepines, a prescription sleep aid. Some research has found that yoga practice may have specific benefits on sleep health. Yoga uses meditation, deep breathing techniques, and movements that emphasize stretching and balance.

The circadian rhythm is more a function of darkness and light rather than actual time of day. Bright light can discourage drowsiness, and darkness can cause sleepiness, day or night. The use of a special box that gives off very bright fluorescent light (over 4,000 lux) for about 30 minutes each day may be helpful.

The following people might benefit from light therapy:

Shift workers. Light therapy should be maximized during hours they are at work and minimized when they need to sleep.
Frequent travelers. Light therapy may be useful for adjusting to new time zones and reducing jet lag.
Nursing home patients.
People with delayed sleep-phase syndrome. These people have a natural tendency to fall asleep very late at night or in early morning hours, but then sleep normally.

Patients should check with their doctors before using light therapy. The following people should avoid light therapy or use it only under a doctor's direction:

Anyone with eyes or skin that are highly sensitive to light
Anyone taking medications that increase the risk for photosensitivity
People with bipolar disorder

Timing of the therapy depends on the type of insomnia or sleep schedule of the individual. For example, in people who cannot get to sleep at night, light therapy in the morning and restricting bright light at night may be helpful. People who wake up early in the morning may benefit from light therapy performed in the evening, although a 2002 study reported that it had no effect in this group. Some light boxes have dawn/dusk simulators that help determine the correct brightness.

Medications

According to a major 2003 survey, about 20% of American older adults use some form of sleep aid, including prescription or over-the-counter drugs or alcohol. Furthermore, 15% use such aids every night.

However, while behavioral or psychologic techniques can actually cure insomnia, prolonged use of sleeping pills can only result in dependency.

In general, the following precautions are important:

Start with non-prescription medication.
Drugs used specifically for improving sleeping are called sedative hypnotics. These drugs include benzodiazepines and non-benzodiazepines. Until recently benzodiazepines were most commonly prescribed, but newer non-benzodiazepines may be better tolerated and have less risk of dependency. These medicines, however, may be associated with potentially severe allergic reactions, such as anaphylaxis and facial swelling (angioedema). These medicines may also cause hazardous behaviors, such as driving, making phone calls, or eating while asleep. If you need to take one of these prescription drugs, start with as low a dose as possible.
For adults over age 60 years, studies suggest that the risks of sedative hypnotics may far outweigh their benefits.
As a general rule, do not take either prescription nor non-prescription sleeping pills on consecutive days or for more than 2 - 4 days a week.
If insomnia is still a problem after stopping the drug and continuing with good sleep hygiene, this pattern can be repeated again, but for only up to 4 weeks.
Medication should be withdrawn gradually, and the patient should be aware of the possibility of rebound insomnia after stopping medication.
Alcohol intensifies the side effects of all sleeping medication and should be avoided.
If chronic insomnia is a companion to depression or anxiety, treating these problems first may be the best approach.

Brands with Antihistamines. Many over-the-counter sleeping medications use antihistamines, which cause drowsiness. Diphenhydramine is the most common antihistamine used non-prescription sleep aids. Some drugs contain diphenhydramine alone (Nytol, Sleep-Eez, Sominex), while others contain combinations of diphenhydramine with pain relievers (Anacin P.M., Excedrin P.M., Tylenol P.M.). Doxylamine (Unison) is another antihistamine used in sleep medications. Certain antihistamines indicated only for allergies, such as chlorpheniramine (Chlor-Trimeton), diphenhydramine (Benadryl), or hydroxyzine (Atarax or Vistaril) may also be used as mild sleep-inducers.

Unfortunately, most of these drugs leave patients feeling drowsy the next day and may not be very effective in providing restful sleep. Side effects include:

Daytime sleepiness
Dizziness
Drunken movements
Blurred vision
Dry mouth and throat

In general, these drugs should be avoided by people with angina, heart arrhythmias, glaucoma, or problems urinating. They should not be used at the same time as medications that prevent nausea or motion sickness. Some non-prescription sleeping aids, such as those containing doxylamine, should also be avoided by patients with chronic lung disease.

Common Pain Relievers. When sleeplessness is caused by minor pain, simply taking acetaminophen (Tylenol) or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (Advil, Motrin), can be very helpful without causing any daytime sleepiness. The extra "P.M." antihistamine found in combination products is simply an extra, needless chemical in these situations.

Benzodiazepines, also referred to as benzodiazepine receptor agonists (BzRAs), were once the most commonly prescribed sedative hypnotics. Originally developed in the 1960s to treat anxiety, these drugs nonselectively target receptor sites in the brain that modulate the effects of the neurotransmitter gamma-aminobutyric acid (GABA).

Brands. Commonly prescribed benzodiazepines:

Long-acting benzodiazepines include flurazepam (Dalmane) and clonazepam (Klonopin), quazepam (Doral).
Medium- to short-acting benzodiazepines include triazolam (Halcion), lorazepam (Ativan), alprazolam (Xanax), temazepam (Restoril), oxazepam (Serax), prazepam (Centrax), estazolam (ProSom), and flunitrazepam (Rohypnol). Short-acting benzodiazepines may be useful for air travelers who want to reduce the effects of jet lag.

Side Effects. Elderly people are more susceptible to side effects and should usually start at half the dose prescribed for younger people. They should not take long-acting forms.

Side effects may differ depending on whether the benzodiazepine is long- or shorting acting. They include:

Severe allergic reactions, including facial swelling, can occur even with the first use of a benzodiazepine drug.
Respiratory problems may occur with overuse or in people with pre-existing respiratory illness
The drugs may increase depression, a common co-condition in many people with insomnia.
Respiratory depression may occur with overuse or with people with pre-existing respiratory illness.
Long-acting drugs have a very high rate of residual daytime drowsiness compared to other types of sleeping pills. They have been associated with a significantly increased risk for automobile accidents and falls in the elderly, particularly in the first week after taking them. Shorter-acting benzodiazepines do not appear to pose as high a risk.
Memory loss (so-called traveler's amnesia), sleepwalking, sleep driving, eating while asleep and other odd mood states may occur. These effects are enhanced by alcohol.
Incontinence. In one study, 33% of patients experienced incontinence at least twice a week. The risk is highest in the elderly and with older, long-acting drugs.
Because these drugs cross the placenta and enter breast milk, pregnant women or nursing mothers should not use them. Benzodiazepine use in the first trimester of pregnancy may be associated with the development of cleft lip in newborns.
In rare cases, overdoses have been fatal.

Interactions. Benzodiazepines are potentially dangerous when combined with alcohol. Some medications, like the ulcer medication cimetidine, can slow the metabolism of the benzodiazepine.

Withdrawal Symptoms. Withdrawal symptoms usually occur after prolonged use and indicate dependence. They can last 1 - 3 weeks after stopping the drug and may include:

Gastrointestinal distress
Sweating
Disturbed heart rhythm
In severe cases, patients might hallucinate or experience seizures, even a week or more after the drug has been stopped.

Rebound Insomnia. Rebound insomnia, which often occurs after withdrawal, typically includes 1 - 2 nights of sleep disturbance, daytime sleepiness, and anxiety. In some cases, patients may experience the return of the original severe insomnia. The chances for rebound are higher with the short-acting benzodiazepines than with the longer-acting ones.

Newer short-acting non-benzodiazepines can induce sleep with fewer side effects than the benzodiazepines. Both benzodiazepine and non-benzodiazepine sedative hypnotics act on GABA-A receptor sites in the brain, but non-benzodiazepines are more specific in the subunits they target. Developed in the late 1980s, these drugs are increasingly prescribed and are becoming the hypnotics of choice for many doctors.

Brands and Benefits. Non-benzodiazepine hypnotics currently approved in the United States are zolpidem (Ambien, Ambien CR), zaleplon (Sonata), eszopiclone (Lunesta), and ramelteon (Rozerem).

Zolpidem (Ambien, generic) is one of the most commonly prescribed drugs for insomnia. It lasts longer than zaleplon. Patients should not take it unless they plan on getting at least 7 - 8 hours of sleep. The recommended dose is 10 mg/day for adults, although elderly patients may be prescribed half that dose. A 2002 study suggested that the drug might be used on an as-needed basis, with up to 5 tablets taken a week. After 3 weeks, two-thirds of the patients taking zolpidem this way were able to reduce their tablet intake by more than 25% without losing improvements in sleep. Ambien CR, an extended-release form, received approval from the Food and Drug Administration (FDA) in late 2005. It is the first extended-release prescription medicine for insomnia. The medicine is delivered in two steps. The first layer dissolves quickly, allowing the patient to fall asleep. The second layer helps the patient stay asleep.
Zaleplon (Sonata) is the shortest-acting hypnotic available. Because it is rapidly eliminated from the body it may be best for people who have difficulty falling asleep, not those who wake up often throughout the night. The drug takes effect within 30 minutes and may be taken at bedtime or later as long as the patient can sleep for at least 4 hours. The recommended dose is 5 - 10 mg/day. The drug is usually taken for 7 - 10 days.
Eszopiclone (Lunesta) is a newer, non-benzodiazepine hypnotic approved by the FDA in 2004. It may help improve both sleep maintenance and daytime alertness. Eszopiclone is related to zopiclone (Imovane), which has been used for many years in Europe. Unlike other sleep medications, eszopiclone can be taken on a long-term basis. In clinical trials, patients used eszopiclone for up to 6 months. Recommended doses are 2 - 3 mg/day for adults and 2 mg/day for elderly patients. Patients whose main problem is falling asleep may need only 1 mg/day.
Ramelteon (Rozerem) was approved by the FDA in 2005. Ramelteon is a novel non-benzodiazepine hypnotic. Unlike most sleep drugs, which target the gamma-aminobutyric acid (GABA) receptors, ramelteon targets the MT1 and MT2 receptors. Ramelteon does not cause dependence and is the first sleep drug not designated as a controlled substance.

These drugs can be particularly helpful for preventing jet lag (but zolpidem should not be used on flights less than 7 - 8 hours). They also may be helpful for people who also have accompanying mood disorders, such as depression or post-traumatic stress disorder. Because they are short-acting, zaleplon and zolpidem may pose fewer risks for falls and memory loss in elderly patients. In general, these drugs are recommended for short-term use (7 - 10 days) and treatment should not exceed 4 weeks. No studies have yet confirmed safety for longer-term use.

Side Effects. All of these drugs have fewer morning side effects than the benzodiazepines, including morning sedation and memory loss (although they can occur to some degree). Zolpidem’s (Ambien) record of adverse effects is similar to that of triazolam (Halcion), the short-acting benzodiazepine. Zaleplon (Sonata) and Ramelteon (Rozerem) appear to have less severe morning side effects. When patients first start taking any of these drugs, they should use caution during morning activities until they are sure how the drug affects them.

General side effects are mild but may include:

Drowsiness
Dizziness
Fatigue
Headache
Unpleasant taste
Diarrhea

Rarer side effects may include sleepwalking and hallucinations. In 2006, reports emerged of zolpidem (Ambien) causing sleepwalking and, even more bizarrely, sleep-driving. Most of these cases likely were due to patients using zolpidem along with alcohol or other drugs or taking more than the recommended dose. However, in March 2007, the FDA ordered stronger warning labels for zolpidem and all other non-benzodiazepine drugs. The new labels warn that that these drugs can cause sleep-related behavior, including sleep-driving, making phone calls, and preparing and eating food while asleep. In addition, severe allergic reactions (anaphylaxis) and facial swelling (angioedema) can occur even the first time one of these drugs is taken.

Anyone who receives a prescription for these medicines will also get a patient medication guide explaining the risks of the drugs and the precautions to take. Talk to your doctor if you have any questions concerning these drugs or their potential side effects.

Patients should carefully read the information labels for all drugs and follow the directions. Some sleeping pills take 30 - 60 minutes to take effect, while others (such as zolpidem) are fast-acting. For zolpidem, patients should:

Take zolpidem immediately before going to sleep
Take zolpidem only when able to get a full night’s sleep (7 – 8 hours)
Not drink alcohol the same evening
Not take more than the prescribed dose
Use caution in the morning when getting out of bed, driving, or operating heavy machinery

Interactions. As with any hypnotics, alcohol increases the sedative effects of these drugs. These hypnotics also interact with other drugs, including rifampin, ketoconazole, erythromycin, and cimetidine. They may also interfere or be interfered by other drugs. Patients should report all medications to their doctors.

Dependency, Withdrawal Symptoms, and Rebound Insomnia. The risk for rebound insomnia, dependence, and tolerance is lower with non-benzodiazepine hypnotics than with benzodiazepine drugs. These drugs are still subject to abuse. In any case, no hypnotic should be taken for more than 7 - 10 days or at higher than the recommended dose without a doctor's approval.

Antidepressants are sometimes used to treat insomnia that may be caused by depression (secondary insomnia). In addition, some antidepressants with sedating properties are prescribed for the treatment of primary insomnia. For example, trazodone has been frequently prescribed in low doses as a hypnotic to help induce sleep. However, there are few studies that address its safety and efficacy as a drug for treating insomnia in non-depressed patients. Several studies have warned against trazodone's use in elderly patients, due to its risk for side effects (daytime sleepiness, dizziness, priapism) and drug interactions. In fact, all hypnotics can have serious side effects in the elderly, and all must be used with caution.

Chloral Hydrate. Chloral hydrate has been in use since 1832. It has significant adverse effects, however, and most experts believe it no longer has a role in the treatment of insomnia. In any case, it does not appear to be effective in the elderly. Chloral hydrate poses a risk for addiction, and it can be fatal in overdose. It also has cancer-causing properties. Side effects include irritation of the skin, mucous membranes, and stomach. People with stomach, heart, kidney, or liver disorders should not take this drug at all. If a child is given it (usually for minor surgery), that child should never be given chloral hydrate again in their lifetime.

Barbiturates. Barbiturates (Seconal, Nembutal) were the standard sleeping medications before the introduction of benzodiazepines. Overdose is dangerous and frequent; addiction and abuse are common. These drugs should rarely or never be prescribed for insomnia.

Indiplon. The FDA is reviewing indiplon, a new non-benzodiazepine hypnotic.

According to results from a national survey published in 2006 in the Archives of Internal Medicine, more than 1.6 million Americans use complementary and alternative therapies to treat insomnia. Many people choose herbal and dietary supplement remedies. Some, such as chamomile tea or lemon balm, are generally harmless for most people. Others have more serious side effects and interactions. [See Box.] According to a 2007 study, valerian and melatonin are among the most popular alternative remedies for insomnia.

Although about half of people who use herbal medicine report that these products help their sleep, experts are not sure whether these remedies really work or whether a placebo effect is the main reason for the improvement. The American Academy of Sleep Medicine (AASM) states that there is only limited scientific evidence to show that herbal and dietary supplements are effective sleep aids. The AASM recommends that these products should be taken only if approved by a doctor. Be sure to talk to your doctor if you are considering taking any herbal or dietary supplement. Some of these products can interact with prescription medications.

Melatonin is the most studied natural remedy for insomnia. A 2005 analysis of 17 melatonin studies found that melatonin significantly reduced the time to fall asleep (sleep onset) and the time spent asleep (sleep duration). However, there are no consistent standards on melatonin doses. Some research suggests that 0.3 mg may be the most effective dosage in many people with insomnia. However, higher doses may keep some people awake.

Although melatonin may not have many benefits for most people with chronic insomnia, studies suggest that it may help the following individuals:

Elderly people. It may help certain older people with insomnia, such as those with evidence of low melatonin levels and those dependent on prescription sleeping medications. It is not clear, however, how significant the benefits are.
People without sight. A 2000 study reported that melatonin can help people without sight retrain their circadian cycle so that they can sleep at regular hours. The best dosages and timing, however, need to be clarified.
Travelers suffering jet lag. Some studies have reported that melatonin may help prevent jet lag in some travelers.
Those in withdrawal from prescription sleep medication. Melatonin may help people who are dependent on sleeping medications withdraw from these drugs and maintain good quality sleep.
People with delayed sleep syndrome. It might be somewhat helpful for people who fall asleep very late at night or in early morning hours but then sleep normally.
Children. Melatonin may help some children with chronic insomnia. In one small study, or example, melatonin was specifically helpful for children with Asperger syndrome, who are at risk for sleep disturbances. More research is warranted, however. At this time, no one should give their child melatonin without a doctor's recommendation.

Melatonin is a powerful hormone that can have major effects on all parts of the body. Doses of melatonin over 0.3 mg can disrupt the circadian system in the brain. Long-term consequences are unknown. High doses have been associated with the following adverse events:

Mental impairment
Severe headaches
Nightmares

Interactions with other drugs are not completely known. Melatonin is classified as a dietary supplement and not as a drug, so its quality is not regulated in the U.S.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Patients should always check with their doctors before using any herbal remedies or dietary supplements.

The following are special concerns for people taking natural remedies for insomnia:

Chamomile. Many people drink chamomile tea for its sedative properties. Although it is generally safe, it may cause allergic reactions in people who have plant or pollen allergies.

Valerian root. Valerian is an herb that has sedative qualities and has been helpful in people with insomnia. One study reported that it was also useful for helping patients withdraw from benzodiazepines -- the standard prescription sleeping pills. In another study, 83% of patients rated the effects of valerian on sleep as being very good. In the same study, valerian was as effective as oxazepam, a standard prescription sleeping medication. Valerian's side effects may include vivid dreams. High doses of valerian can cause blurred vision, excitability, and changes in heart rhythm. Valerian's effects can be dangerously increased if it is used with standard sedatives.

Chinese Herbal Remedies. Studies suggest that up to 30% of herbal patent remedies imported from China are laced with potent pharmaceuticals such as phenacetin and steroids. They may also contain toxic metals. The herbal remedy Sleeping Buddha was recalled in 1998 because it contained a benzodiazepine, the major ingredient in many prescription sleeping pills, and also appeared to increase the risk for birth defects in pregnant women. Reports of a few cases of acute hepatitis have occurred from Jin Bu Huan, a Chinese herbal remedy sold as treatment for pain and insomnia.

Kava. Kava has been used to relieve anxiety and improve sleep. It is not considered safe. There have been reports of liver failure and death from this herb, with highest risk in those with liver disease. Other side effects include itchy, scaly skin, muscle weakness, and problems with coordination. It also interacts dangerously with certain medications, including alprazolam, an anti-anxiety drug. Kava also increases the strength of certain other drugs, including other sleep medications, alcohol, and antidepressants.

Tryptophan and 5-L-5-hydroxytryptophan (HTP). Tryptophan is an amino acid used in the formation of the neurotransmitter serotonin, which is known to promote well-being and has been associated with healthy sleep. L-tryptophan was marked for insomnia and other disorders but was withdrawn from the market after contaminated batches caused a rare and even fatal disorder called eosinophilia myalgia syndrome. 5-HTP, a byproduct of tryptophan, is still available as a supplement. There have been reports that some brands contain a substance called Peak X, which may be harmful. There is little evidence that 5-HTP relieves insomnia.

Resources

www.aasmnet.org -- American Academy of Sleep Medicine
www.nhlbi.nih.gov/about/ncsdr -- National Center for Sleep Disorders Research
www.sleepfoundation.org -- National Sleep Foundation
www.sleepeducation.com -- Sleep Education from the American Academy of Sleep Medicine
www.wfsrs.org -- World Federation of Sleep Research Societies
www.clinicaltrials.gov -- Find clinical trials

References

Bliwise DL, Ansari FP. Insomnia associated with valerian and melatonin usage in the 2002 National Health Interview Survey. Sleep. 2007 July 1;30(7):881-884.

Liu X, Buysse DJ, Gentzler AL, Kiss E, Mayer L, Kapornai K, et al. Insomnia and hypersomnia associated with depressive phenomenology and comorbidity in childhood depression. Sleep. 2007 Jan 1;30(1):83-90.

Mindell JA, Emslie G, Blumer J, Genel M, Glaze D, Ivanenko A, et al. Pharmacologic management of insomnia in children and adolescents: consensus statement. Pediatrics. 2006 Jun;117(6):e1223-32.

Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh A; American Academy of Sleep Medicine. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006 Oct 1;29(10):1263-76.

Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006 Nov 1;29(11):1398-414.

Neckelmann D, Mykletun A, Dahl AA. Chronic insomnia as a risk factor for developing anxiety and depression. Sleep. 2007 July 1;30(7):873-880.

Pearson NJ, Johnson LL, Nahin RL. Insomnia, trouble sleeping, and complementary and alternative medicine: Analysis of the 2002 National Health Interview Survey data. Arch Intern Med. 2006 Sep 18;166(16):1775-82.

Review Date:
7/18/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Anxiety

FitSugar — Wed, 08 Oct 2008 17:34:56 -0700

Overview

Signs and Symptoms
What Causes It?
What to Expect at Your Provider's Office
Treatment Options
Following Up
Special Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Anxiety is a general feeling of being worried, and everyone occasionally experiences anxiety. People with generalized anxiety disorder (GAD), however, feel anxious frequently or excessively, not necessarily due to a particular situation.

Signs and Symptoms

Muscle tension, trembling
Fast heartbeat (tachycardia)
Fast or troubled breathing (dyspnea)
Dizziness or impaired concentration
Palpitations
Headache
Sweating
Fatigue
Irritability
Sleep disturbances

What Causes It?

Anxiety can result from many specific causes, such as an underlying medical condition or drugs you are taking. However, there may be no specific cause. Factors such as genetics and early life experiences may play a role.

What to Expect at Your Provider's Office

Your health care provider will talk to you about when you feel anxious and what it feels like. He or she will take your medical history, give you a physical examination, and may take blood or urine samples for laboratory tests. Sometimes, you will have an electrocardiogram (EKG) to rule out heart problems.

Treatment Options

Treatment Plan

If a physical cause is identified as the reason for your anxiety, your health care provider can make a treatment plan for you. There are also several ways to treat anxiety that has no physical cause. Short-term counseling can boost your self-esteem and help you learn coping strategies and problem-solving techniques. Your health care provider may also suggest trying a method of relaxation, such as deep breathing techniques. Occasionally, your health care provider may prescribe drugs to help until you have mastered these techniques.

Drug Therapies

Prescription

Antianxiety Medications

Benzodiazepines -- a group of drugs that help reduce anxiety and have sedating effects. They may cause drowsiness, constipation, or nausea. Do not take these drugs if you have narrow-angle glaucoma, a psychosis, or are pregnant.
Buspirone (BuSpar) -- an anti-anxiety drug that does not appear to cause drowsiness. However, you must take it for 2 weeks before feeling any effect. Side effects include insomnia, nervousness, light-headedness, upset stomach, nausea, diarrhea, and headaches.

Antidepressant Medications

Tricyclic antidepressants -- a group of drugs that relieve depression (which can accompany anxiety). These medications tend to have numerous side effects.

Over the Counter

N/A

Complementary and Alternative Therapies

Mind-body techniques, nutrition, exercise, and herbs may treat anxiety. Progressive muscle relaxation, diaphragmatic breathing, biofeedback, meditation, and self-hypnosis can help you relax and reduce your anxiety. A regular program of exercise can help treat generalized anxiety disorder and panic attacks. Talk with your health care provider about these techniques.

Nutrition

Avoid caffeine, alcohol, nicotine, sugar, and refined foods,. Cut down on foods that are known to cause allergies. Common food allergens are dairy, soy, citrus, peanuts, tree nuts, wheat, fish, wheat, fish, eggs, corn, food colorings, and additives. Eat more fresh vegetables, whole grains, and protein to nourish your nervous system,.
Calcium (1,000 mg per day), magnesium (400 to 600 mg per day), and B complex (50 to 100 mg per day) help support the nervous system and minimize the effects of stress.

Herbs

Herbs can be a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). People with a history of alcoholism should not use tinctures. Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. You may use tinctures singly or in combination as noted.

A tea (3 to 4 cups per day) or tincture (10 to 20 drops 4 to 6 times per day) from the following herbs will help reduce anxiety and strengthen the nervous system.

Kava kava (Piper methysticum) for mild to moderate anxiety. The FDA has issued a warning concerning kava's effect on the liver. In rare cases, severe liver damage has been reported. If you take kava, do not use it for more than a few days, and tell your doctor before taking it.
Valerian (Valeriana officinalis) and lemon balm (Melissa officinalis), or valerian combined with St. John's wort (Hypericum perforatum) for mild to moderate anxiety. Valerian may interact with other drugs that have a sedative effect, such as benzodiazepines; barbiturates, narcotics; antidepressants; and antihistamines. Do not take valerian if you are pregnant or nursing. Valerian can also affect the liver, so do not take it if you have liver problems. St. John's wort can affect other drugs you may be taking, including antidepressants, birth control, or other medications. You should avoid St. John's wort while pregnant or nursing. Talk to your doctor before using St. John's wort with any other medications.
Other herbs sometimes suggested for anxiety include passionflower (Passiflora incarnata), ginger (zingiber officinalis), chamomile (Matricaria chamomilla), lemon balm, and licorice (glycyrrhiza glabra). Avoid licorice if you have heart failure, heart disease, kidney or liver disease, or high blood pressure. Do not take licorice if you take a diuretic, blood thinner, or anti-depressant such as Prozac.

You may take kava kava (100 to 200 mg 2 to 4 times a day) and valerian (150 mg 2 to 3 times per day) as a dried extract to maximize its effect on moderate anxiety.

Essential oils of lemon balm, bergamot, and jasmine are calming, and you can use them as aromatherapy. Place several drops in a warm bath or atomizer, or on a cotton ball.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of anxiety based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

Aconitum -- for anxiety accompanied by irregular or forceful heartbeat, shortness of breath, or fear of death.
Arsenicum album -- for excessive anxiety that has no clear cause and is accompanied by restlessness, especially after midnight. It also may be used for perfectionists, including children, who worry about everything.
Phosphorus -- for an impending sense of doom and anxiety when alone. It also may be used for impressionable adults and children who are easily influenced by the anxiety of others.
Lycopodium -- for performance and other types of anxiety in those who are insecure, yet hide their low self-esteem with arrogance and bravado. It also may treat children with anxiety accompanied by bedwetting.
Gelsemium -- for performance anxiety resulting in diarrhea, headache, dizziness, weakness, shakiness and trembling, or trouble speaking.
Argentum nitricum -- for performance anxiety (such as before tests in school-age children) with rapid heart rate, feeling of faintness, diarrhea, or flatulence.

Acupuncture

Some evidence shows that acupuncture can help reduce the symptoms of anxiety, particularly when combined with behavioral desensitization (including psychotherapy). One study showed that benefits continued as long as one year after treatment. Acupuncturists treat people with anxiety based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. With anxiety, a qi deficiency is often detected in the kidney or spleen meridians. In addition to performing needling techniques, acupuncturists may also employ lifestyle and breathing techniques as well as herbal and dietary therapy.

Massage

Therapeutic massage can help reduce anxiety and alleviate stress.

Following Up

Follow your health care provider's instructions, and practice relaxation techniques as needed.

Special Considerations

Be sure to tell your health care provider if you are pregnant. Call your provider if you experience any significant side effects from prescribed medications.

While the herbal tea suggested above is safe during pregnancy, you should avoid the dried extracts of kava kava, valerian and St. John's wort if you are pregnant or nursing.

Supporting Research

Akhondzadeh S, Naghavi HR, Vazirian M, et al. Passionflower in the treatment of generalised anxiety: a pilot double-blind randomized controlled trial with oxazepam. J Clin Pharm Ther 2001;26:362-367.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine. 3rd ed. Philadelphia, Pa: WB Saunders; 1993.

Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine. 4th ed. Baltimore, Md: Williams & Wilkins; 1995:139-154.

Bilia AR, Gallon S, Vincieri FF. Kava-kava and anxiety: growing knowledge about the efficacy and safety. Life Sci. 2002;70:2581-2597.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:422,463-464.

Cummings S, Ullman D. Everybody's Guide to Homeopathic Medicines. 3^rd ed. New York, NY: Penguin Putnam; 1997:334-338.

Davidson JR, Connor KM. St. John's Wort in generalized anxiety disorder: three case reports. J Clin Psychopharmacol 2001;21:635-636.

Goldberg RJ. Anxiety reduction by self-regulation: theory, practice, and evaluation. Ann Intern Med. 1982;96:483.

Guizhen L, Yunjun Z, Linxiang G, Aizhen L. Comparative study on acupuncture combined with behavioral desensitization for treatment of anxiety neuroses. Am J Acupunct. 1998;26:117-120.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996:250.

Kennedy DO, Little W, Haskell CF, Scholey AB. Anxiolytic effects of a combination of Melissa officinalis and Valeriana officinalis during laboratory-induced stress. Phytother Res. 2006;20(2):96-102.

Kohnen R, Oswalkd D. The effects of valerian, propranolol, and their combination on activation, performance and mood of healthy volunteers under social stress conditions. Pharmacopsychiatry. 1988;21:447-448.

Mantani R, Cimino A. A primer of comlentary and alternative medicine and its relevance in the treatment of mental health problems. Psychiatr Q 2002;73:367-381.

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:4,40,293.

Olukoga A, Donaldson D. Liquorice and its health implications. J R Soc Health. 2000;120:83-89.

Panijel M. Treatment of moderately severe anxiety states. Therapiewoche. 1985;35:4659-4668.

Petruzzello SJ, Landers DM, Hatfield BD, et al. A meta-analysis on the anxiety-reducing effects of acute and chronic exercise: outcomes and mechanisms. Sports Med. 1991;11:143-182.

Pittler MH, Ernst E. Kava extract for treating anxiety [Cochrane Review]. The Cochrane Library, Issue 1, 2003.

Stein JH, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year Book; 1994.

Ullman D. Homeopathic Medicine for Children and Infants. New York, NY: Penguin Putnam; 1992:44-45.

Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995:309.

Volz HP, Kieser M. Kava kava extract WS 1490 versus placebo in anxiety disorders-a randomized placebo controlled 25 week outpatient trial. Pharmacopsychiatry. 1997;30:1-5.

Wang SM, Kain ZN. Auricular acupuncture: a potential treatment for anxiety. Anesth Analg. 2001;92:548-553.

Review Date:
6/15/2006
Reviewed By:
Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

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Post-traumatic stress disorder

FitSugar — Wed, 08 Oct 2008 17:35:45 -0700

Overview

Signs and Symptoms
What Causes It?
Who's Most At Risk?
What to Expect at Your Provider's Office
Treatment Options
Prognosis/Possible Complications
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Post-traumatic stress disorder (PTSD) is an anxiety disorder that is brought on by memories of an extremely stressful event or series of events that cause intense fear, particularly if feelings of helplessness accompanied the fear. That event may be war, physical or sexual assault or abuse, an accident (such as an airplane crash or a serious motor vehicle accident), or a mass disaster. You can develop PTSD if the event happened to you or even if you witnessed it. It's normal to feel stress when you experience a traumatic event. PTSD persists long after the event and is characterized by the intensity of the feelings, how long they last, how you react to these feelings, and the presence of particular symptoms. More than 5 million adults in the United States are affected by PTSD each year.

Signs and Symptoms

Symptoms of PTSD may develop months or even years after the original traumatic event and may include the following:

Intrusive thoughts recalling the traumatic event
Nightmares
Flashbacks
Efforts to avoid feelings and thoughts that either remind you of the traumatic event or that trigger similar feelings
Feeling detached or unable to connect with loved ones
Depression, hopelessness
Feelings of guilt (from the false belief that you were responsible for the traumatic incident)
Irritability
Hypervigilance (Being overly aware of possible danger)
Hypersensitivity, including at least two of the following reactions: trouble sleeping, being angry, having difficulty concentrating, startling easily, having a physical reaction (rapid heart rate or breathing, increase in blood pressure)

What Causes It?

Experts aren't entirely sure what causes some people to develop PTSD, but many think it happens when you are confronted with a traumatic event and your mind isn't able to process all the thoughts and feelings as it usually does. Scientists studying the brain think there may be some differences in the brain structure or chemistry of those with PTSD. For example, certain areas of the brain involved with feeling fear may be hyperactive in people with PTSD. Other researchers have focused on the hippocampus, the area of the brain responsible for memory and for how we deal with stress, and are investigating whether changes in that area also appear in people with PTSD.

Who's Most At Risk?

How severe the traumatic event was and how long it lasted affect whether you are likely to develop PTSD. These factors also increase the risk:

A history of sexual or physical abuse
Working in a high-risk occupation, such as firefighting or law enforcement
A history of depression or other psychological disorder
Abusing drugs or alcohol
Not having adequate social support
Women are twice as likely as men to show signs of PTSD.

What to Expect at Your Provider's Office

There are no laboratory tests to detect PTSD. Your doctor will ask about your symptoms and ask you to describe the traumatic event. Your doctor will likely also use psychological assessment tools to confirm the diagnosis. You may be asked to see a specialist (such as a psychologist or psychiatrist) for evaluation and treatment.

Treatment Options

Prevention

Early intervention immediately after a traumatic event -- through support groups, psychotherapy, and certain medications -- may help prevent PTSD. Rituals such as prayer or healing ceremonies may be helpful in relieving stress and other effects of the trauma.

Treatment Plan

The treatment for PTSD includes:

Cognitive-behavior therapy -- With the help of a psychotherapist, you learn techniques to manage your thoughts and feelings when you are in situations that remind you of the traumatic event. You may gradually expose yourself to situations and thoughts that cause anxiety, as you build up a tolerance for them and your fear is lessened. Ultimately, the goal of cognitive therapy is to allow you to control your fear and anxiety.
Stress management therapy -- With a therapist, you work to learn relaxation techniques that help you overcome fear and anxiety, and to break the cycle of negative thoughts.
Medication may be used as well.

Drug Therapies

Antidepressants such as selective serotonin re-uptake inhibitors (SSRIs), including sertraline (Zoloft), fluoxetine (Prozac), fluvoxamine (Luvox), or paroxetine (Paxil).
Benzodiazepines, a group of medications sometimes used for anxiety, including lorazepam (Ativan) and alprazolam (Xanax). These drugs have sedating properties and may cause drowsiness, constipation, or nausea. Do not take them if you have narrow-angle glaucoma, a psychosis, or are pregnant. They also interact with other drugs, including some antidepressants (such as Luvox).

Complementary and Alternative Therapies

Conventional psychotherapy, such as cognitive behavior therapy, is the main treatment for PTSD. However, several mind-body techniques may be used as supportive treatments:

Eye Movement Desensitization and Reprocessing (EMDR), in which you move your eyes rapidly from side to side while recalling the traumatic event, seems to help reduce distress for many with PTSD. Doctors aren't sure how it works, and whether it is any better than standard treatment. It's also not clear how long PTSD symptoms are reduced using EMDR.
Biofeedback involves using a machine, at first, to see bodily functions that are normally unconscious and occur involuntarily (for example, heart rate and temperature). As you see how your body reacts to stress, you learn to control the reactions, and eventually you can perform the techniques to control the reactions without using a machine. Some studies suggest that biofeedback, among other forms of relaxation training, may be an effective treatment for some people with PTSD.
Hypnosis has long been used to treat war-related post-traumatic conditions. More recently it has been used in cases of sexual assault (including rape), anesthesia failure, Holocaust survival, and car accidents. Hypnosis induces a deep state of relaxation, which may help people with PTSD feel more safe and less anxious, decrease intrusive thoughts, and become involved in daily activities again. Hypnosis is usually used in conjunction with psychotherapy and requires a trained, licensed hypnotherapist.

Nutrition and Supplements

Although no studies have examined how nutrition can be used to treat PTSD, these general nutritional guidelines may be helpful:

Avoid stimulants, such as caffeine and nicotine.
Avoid alcohol.
Maintain balanced blood sugar to help stabilize mood. For example, eat small, frequent meals that include a small amount of protein. Avoid processed and refined foods.
Eat whole grains, fresh fruits and vegetables, protein from plants (legumes and nuts, for example) and fish to nourish the nervous system.
Inositol (18 g per day), a B vitamin that is found in citrus fruits, vegetables, cereal grains and meats, helps the nervous system function properly and may play a role in reducing depression and anxiety associated with PTSD.

Herbs

Herbs are a generally safe way to strengthen and tone the body's systems. As with any therapy, it is important to work with your doctor to get a clear diagnosis before you start any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerin extracts), or tinctures (alcohol extracts). People with a history of alcoholism should not take tinctures. Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures singly or in combination as noted.

Although studies using herbs specifically to treat PTSD are lacking, some herbs have been studied for symptoms such as depression and anxiety.

Kava kava (Piper methysticum, 100 - 200 mg two to four times per day) may help reduce mild to moderate anxiety, although it has not been studied specifically for PTSD. The FDA has issued a warning concerning kava kava's effect on the liver. In rare cases, severe liver damage has been reported. If you take kava, do not use it for more than a few days, and tell your doctor before taking it.
Valerian (Valeriana officinalis, 150 mg two to three times per day), sometimes combined with lemon balm (Melissa officinalis), has also proven effective for mild to moderate anxiety, although it has not been studied for PTSD either. Valerian may interact with other drugs that have a sedative effect, such as benzodiazepines, barbiturates, narcotics, antidepressants, and antihistamines. Do not take valerian if you are pregnant or nursing. Valerian also can affect the liver, so do not take it if you have liver problems.
St. John's wort (Hypericum perforatum, 300 mg three times per day) has been sued to treat mild to moderate depression and may help symptoms of PTSD, though studies are lacking. St. John's wort interacts with numerous other drugs and herbs, and should be avoided when pregnant or nursing. Speak to your doctor before using St. John's wort with any other medications.

The following herbs may help relieve restlessness, nervousness, and anxiety that can be associated with PTSD:

Passionflower herb (Passiflora incarnata)
Ginger (Zingiber officinalis)
Chamomile (Matricaria chamomilla)
Catnip ( Nepeta cataria)
Lemon balm (Melissa officinalis)

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for PTSD based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. When being treated with homeopathic remedies, it is possible to experience a brief intensification of symptoms before your condition improves. In the case of PTSD, it is important to have a qualified support team in place to help you handle any worsening of symptoms. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

Aconitum -- for recurring panic following a traumatic experience. This remedy is most appropriate for individuals who have heart palpitations and shortness of breath which produce a tremendous fear of death. Aconitum is often the first remedy given for trauma, even if the trauma occurred years ago.
Arnica -- for chronic conditions (such as depression) that occur after a traumatic experience. This remedy is most appropriate for individuals who generally deny that anything is wrong.
Staphysagria -- for individuals who feel fearful, powerless, or unable to speak up or defend themselves.
Stramonium -- for anxiety disorders that occur after a shock or traumatic experience involving violence. The individual for whom this remedy is most appropriate tends to be generally fearful and have night terrors.

Acupuncture

Acupuncture may help with symptoms of PTSD, including insomnia, anxiety, and depression. In one case involving a Vietnam War veteran, acupuncture and relaxation with guided imagery reportedly reduced insomnia, nightmares, and panic attacks over a treatment period of 12 weeks. One study for anxiety (not PTSD-related) found that benefits lasted as long as 1 year after treatment. Acupuncturists treat people based on an individualized assessment of the excesses and deficiencies of qi located in various meridians in the body.

Prognosis/Possible Complications

If PTSD symptoms continue for longer than 3 months, the condition is considered to be chronic (ongoing). Chronic PTSD may become less severe even if it is not treated, or it may become severely disabling, interfering with many areas of life and causing physical complaints.

Supporting Research

Allen SN. Psychological assessment of post-traumatic stress disorder. Psychometrics, current trends, and future directions. Psychiatr Clin North Am. 1994;17(2):327-349.

Beers MH, Porter RS, et al. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2006:1678.

Benjamin J, Levine J, Fuz M, Aviv A, Levy D, Belmaker RH. Double-blind, placebo-controlled, crossover trial of inositol treatment for panic disorder. Am J Psychiatry 1995;152(7):1084-1086.

Blank AS Jr. Clinical detection, diagnosis, and differential diagnosis of post-traumatic stress disorder. Psychiatr Clin North Am. 1994;17(2):351-383.

Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded Commission E Monographs. Newton, Mass: Integrative Medicine Communications; 2000.

Brady K, Pearlstein T, Asnis GM, et al. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. JAMA. 2000;283(14):1837-1844.

Bryant RA, Moulds ML, Nixon RD, Mastrodomenico J, Felmingham K, Hopwood S. Hypnotherapy and cognitive behaviour therapy of acute stress disorder: a 3-year follow-up. Behav Res Ther. 2006 Sep;44(9):1331-5.

Cahill SP, Carrigan MH, Frueh BC. Does EMDR work? And if so, why?: A critical review of controlled outcome and dismantling research. J Anxiety Disord. 1999;13(1-2):5-33.

Cardena E. Hypnosis in the treatment of trauma: a promising, but not fully supported, efficacious intervention. Int J Clin Exp Hypn. 2000;48(2):225-238.

Chambers RA, Bremner JD, Moghaddam B, Southwick SM, Charney DS, Krystal JH. Glutamate and post-traumatic stress disorder: toward a psychobiology of dissociation. Semin Clin Neuropsychiatry. 1999;4(4):274-281.

Davidson J. Drug therapy of post-traumatic stress disorder. Br J Psychiatry. 1992;160:309-314.

Davies WH, Flannery DJ. Post-traumatic stress disorder in children and adolescents exposed to violence. Pediatr Clin North Am. 1998;45(2):341-353.

Friedman MJ. Progress in the psychobiology of post-traumatic stress disorder: an overview. Semin Clin Neuropsychiatry. 1999;4(4):230-233.

Jacobs WJ, Dalenberg C. Subtle presentations of post-traumatic stress disorder. Diagnostic issues. Psychiatr Clin North Am. 1998;21(4):835-845.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctor's Guide. New York, NY: Warner Books; 1996:249.

Levin P, Lazrove S, Van Der Kolk B. What psychological testing and neuroimaging tell us about the treatment of posttraumatic stress disorder by Eye Movement Desensitization and Reprocessing. J Anxiety Disord. 1999;13(1-2):159-172.

Mason S, Rowlands A. Post-traumatic stress disorder. J Accid Emerg Med. 1997;14(6):387-391.

Medley I. Post-traumatic stress disorder. Br J Hosp Med. 1996;55(9):567-70.

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:3-4, 36-37, 364.

Novey DW, ed. Clinician's Complete Reference to Complementary and Alternative Medicine. St. Louis, Mo: Mosby; 2000:180-181.

Peniston EG. EMG biofeedback-assisted desensitization treatment for Vietnam combat veterans post-traumatic stress disorder. Clin Biofeedback Health. 1986;9(1):35-41.

Pitman RK, Orr SP, Shalev AY, Metzger LJ, Mellman TA. Psychophysiological alterations in post-traumatic stress disorder. Semin Clin Neuropsychiatry. 1999;4(4):234-241.

Raboni MR, Tufik S, Suchecki D. Treatment of PTSD by eye movement desensitization reprocessing (EMDR) improves sleep quality, quality of life, and perception of stress. Ann N Y Acad Sci. 2006 Jul;1071:508-13.

Scherer J. Kava-kava extract in anxiety disorders: an outpatient observational study. Adv Ther. 1998;15(4):261-269.

Schnurr PP, Jankowski MK. Physical health and post-traumatic stress disorder: review and synthesis. Semin Clin Neuropsychiatry.1999;4(4):295-304.

Seidler GH, Wagner FE. Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychol Med. 2006 Nov;36(11):1515-22.

Shapiro F. Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. J Trauma Stress. 1989;2:199-223.

Sherman JJ. Effects of psychotherapeutic treatments for PTSD: a meta-analysis of controlled clinical trials. J Trauma Stress. 1998;11(3):413-435.

Stapleton JA, Taylor S, Asmundson GJ. Effects of three PTSD treatments on anger and guilt: exposure therapy, eye movement desensitization and reprocessing, and relaxation training. J Trauma Stress. 2006 Feb;19(1):19-28.

Sutherland SM, Davidson JR. Pharmacotherapy for post-traumatic stress disorder. Psychiatr Clin North Am. 1994;17(2):409-423.

Tarrier N, Humphreys L. Subjective improvement in PTSD patients with treatment by imaginal exposure or cognitive therapy: session by session changes. Br J Clin Psychol. 2000;39(pt 1):27-34.

Tarrier N, Sommerfield C, Pilgrim H, Humphreys L. Cognitive therapy or imaginal exposure in the treatment of post-traumatic stress disorder. Twelve-month follow-up. Br J Psychiatry. 1999;175:571-575.

The expert consensus guideline series. Treatment of posttraumatic stress disorder. J Clin Psychiatry. 1999;60(suppl 16):3-76.

Turnbull GJ. A review of post-traumatic stress disorder. Part II: Treatment. Injury. 1998;29(3):169-175.

Ulett GA. Conditioned healing with electroacupuncture. Altern Ther Health Med. 1996;2(5):56-60.

Ullman D. Homeopathic Medicine for Children and Infants. New York, NY: Penguin Putnam; 1992: 148-150.

Volz HP, Kieser M. Kava-kava extract WS 1490 versus placebo in anxiety disorders-a randomized placebo-controlled 25-week outpatient trial. Pharmacopsychiatry. 1997;30(1):1-5.

Watson CG, Tuorila JR, Vickers KS, Gearhart LP, Mendez CM. The efficacies of three relaxation regimens in the treatment of PTSD in Vietnam War veterans. J Clin Psychol. 1997;53(:917-923.

Wessely S, Rose S, Bisson J. Brief psychological interventions ("debriefing") for trauma-related symptoms and the prevention of post traumatic stress disorder. Cochrane Database Syst Rev 2000;No. 2:CD000560

Witt PH,Greenfield DP, Steinberg J. Evaluation and treatment of post-traumatic stress disorder. N J Med. 1993;90(6):464-467.

Review Date:
12/18/2006
Reviewed By:
Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Seizure disorders

FitSugar — Wed, 08 Oct 2008 17:35:11 -0700

Overview

Signs and Symptoms
What Causes It?
What to Expect at Your Provider's Office
Treatment Options
Following Up
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Seizures occur when your brain cells, which communicate through electrical signals, send out abnormal signals. Recurrent seizures from one of many chronic processes are considered epilepsy. Epilepsy can occur at all ages, but it is most common in the elderly. Seizures are not considered to be epilepsy if they occur only once or are correctable.

Signs and Symptoms

There are several types of seizures, each with its own symptoms. Seizures are usually classified as partial (involving a part of the brain) or generalized (involving most or all of the brain). Depending on the type of seizure, symptoms may include:

Aura (before generalized seizures), including lethargy, depression, irritability, involuntary jerks of limbs, abdominal pains, pale complexion, headache, constipation, or diarrhea
Loss of consciousness
Falling down
Staring during momentary episodes of unconsciousness
Total body muscle spasms
Temporary cessation of breathing
Bluish color of skin and mucous membranes
Dilated pupils that do not react to light
Bowel or bladder incontinence
Increased pulse and blood pressure
Increased salivation and sweating
Deep coma, post-seizure confusion, and deep sleep

What Causes It?

Seizures are caused by hyperexcitable nerve cells in the brain (cerebral cortex) that fire abnormally. No one knows why this happens. The following conditions are associated with seizure activity:

Central nervous system infection (bacterial meningitis, encephalitis)
Drug toxicity or withdrawal (for example, alcohol or illicit drug use)
Genetic mutations
Head trauma
Electrolyte or metabolic abnormalities
Drugs that lower the seizure threshold
High fevers
Brain abnormalities (for example, tumors, stroke)
Low sugar and low calcium levels in the blood

What to Expect at Your Provider's Office

Precipitating events (for example, head trauma) and risk factors (for example, family or personal history of seizures) are important factors to discuss with your health care provider. It is also important to note how you felt before and after the seizure. Your health care provider will do blood tests and an electroencephalogram (EEG) to help in your diagnosis. You may also have a computerized tomography (CT) scan, a magnetic resonance imaging (MRI) scan, and a positron emission tomography (PET) scan.

Treatment Options

The goal of therapy is to stop the seizures, minimize drug side effects, prevent recurrences, and help you readjust to your home life and work environment after a seizure.

Drug Therapies

Your health care provider will most likely prescribe medication to help control your seizures (30 - 70% of people who have one seizure will have a second seizure within 1 year). You may need to try several medications or combinations before you find one that works for you. Medications can include anticonvulsants (anti-seizure drugs) and sedatives.

If medications do not work, ask your doctor about a procedure called vagus nerve stimulation.

Complementary and Alternative Therapies

You should always see a doctor if you or your child has a seizure. Taking some supplements and adjusting one's diet may help some people lessen the frequency of seizures, but the same supplements may have the opposite effect in some people. You should never take any supplements without your doctor's knowledge. You should never take any medication your doctor has prescribed without your doctor's knowledge, either. Make sure to inform all of your health care providers of any medications, herbs, supplements, and regimens you are using.

Nutrition and Supplements

A ketogenic diet -- high in fat and low in protein and carbohydrates -- may help control the frequency of seizures. It has been used most frequently in children, and seems to be more effective for children than adults. A doctor needs to closely monitor this diet, both for side effects and for compliance with its rigid structure.
Some studies have shown a connection with food allergies and seizures in children. Avoid alcohol, caffeine, and aspartame, along with any supplements that have stimulating effects. A holistically oriented health care provider can help you pinpoint possible food allergies.
Taurine (500 mg three times per day) is an amino acid that may help inhibit seizures. It acts in a similar fashion to GABA (gamma aminobutyric acid, 500 mg two times per day), another amino acid that is often low in people with seizures. Take one of these only under your doctor's supervision.
Folic acid may be depleted during seizures and in some people with seizures. However, taking extra folic acid can reduce the effectiveness of anticonvulsant drugs and lead to more seizures. Take folic acid only under your doctor's supervision.
Vitamin B12 (100 - 200 mcg per day): B12 levels may be reduced by some anticonvulsant drugs.
Vitamin B6 (20 - 50 mg per kilogram of body weight) may help control seizures in children, but B6 may also interfere with anticonvulsant medications, leading to more seizures. Take only under your doctor's supervision.
Vitamin E (400 IU per day) may help reduce the frequency of seizures when used with prescription drugs, but studies have shown mixed results.
Manganese (5 mg per day) levels are often low in people with epilepsy.
Anticonvulsant drugs may cause low levels of calcium, vitamin D, and vitamin K, so people who take anticonvulsant drugs should ask their doctor about taking a supplement. You should know that calcium can interfere with anticonvulsant drugs and should be taken only under a doctor's supervision.
Melatonin (3 g at bedtime) may not only decrease the frequency of seizures in children but also increase seizures in some people. Take melatonin only under a doctor's supervision.
5-HTP can help increase serotonin levels in the brain, which some researchers think can lessen seizures by having a calming effect on the nervous system. Others feel that raising serotonin levels past a certain threshold may actually increase the frequency of seizures. While no conclusive studies exist, some doctors are using 5-HTP to treat seizures. This therapy should be used only under strict medical supervision. 5-HTP can have dangerous interactions with other medications, such as antidepressants and certain neurological drugs. Make sure your doctor has a complete list of your medications before starting you on 5-HTP therapy.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to diagnose your problem before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

Many of the herbs used to treat seizures have sedative effects, and they interact with other herbs, supplements, and prescription medications. Take these herbs only under a doctor's supervision, so that they can monitor side effects and interactions. Most of these herbs have been used traditionally for seizures, but scientific evidence showing they work is lacking.

Brahmi (Bacopamonnieri), an herb used in Ayurvedic medicine to treat epilepsy.
Chamomile (Matricaria recutita), a sedative herb. Take 400 - 1,600 mg per day or 3 cups tea per day. Steep 2 - 4 g flowerheads in one cup boiling water, strain, and cool. Or use commercially prepared tea bags. Your doctor should determine the dose.
Kava (Piper methysticum) has been used as a sedative herb for seizures. However, there is some concern that kava can be very damaging to the liver even if taken for a short time. Take kava only under your doctor's supervision, so they can monitor liver function. Do not take kava if you have Parkinson's disease.
Valerian (Valeriana officinalis, 120 mg three times per day) is a sedative and anticonvulsive. It interacts with several medications, herbs, and alcohol, so take it only under your doctor's supervision. Valerian is sometimes combined with lemon balm (Melissa officinalis ), another herb that has sedative effects.
Passionflower (Passiflora incarnata) may treat and prevent seizures. Dose is 3 cups tea per day. Steep 2 g in one cup boiling water, strain, and cool. Or take 45 - 60 drops of liquid extract.

Avoid the following herbs:

Ginkgo (Ginkgo biloba) and ginseng (Panax ginseng and Panax quinquefolius) have caused seizures in some people.
There is some evidence that GLA, a type of fatty acid found in evening primrose oil (Oenothera biennis) and borage oil (borago officinalis), may worsen epilepsy, although it has not been confirmed.
St. John's wort (Hypericum perforatum) interacts with a number of medications and herbs used to treat epilepsy.
White willow (Salix alba) may interact with medications for epilepsy.

Avoid these essential oils:

Eucalyptus (Eucalyptus globulus)
Fennel (Foeniculum vulgare)
Hyssop (Hyssopus officinalis)
Pennyroyal (Mentha pulegium)
Rosemary (Rosmarinus officinalis)
Sage (Salvia officinalis)
Tansy (Tanacetum vulgare)
Thuja (Thuya occidentalis)
Wormwood (Artemesia absinthium)

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. Professional homeopaths, however, may recommend one or more of the following treatments for seizure disorders based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

Belladonna -- for seizures that occur in individuals with a high fever
Causticum -- for individuals whose seizures may be triggered by receiving bad news or by feelings of sadness such as from grief; this remedy is most appropriate for individuals who tend to feel hopeless and fearful
Cicuta -- for individuals who develop seizures after a head injury
Cuprum metallicum -- for individuals whose seizures are accompanied by mental dullness; may be triggered by menstruation or vomiting

Physical Medicine

Chiropractic, osteopathic, or naturopathic manipulation may be helpful, especially in children or for seizures after head trauma.

Acupuncture

Acupuncture may be helpful with specific acupressure points that have been used to stop seizures. However, a recent study for people with severe epilepsy showed no benefit. Chinese medical literature contains examples of treating seizure disorders through traditional acupuncture, as well as scalp and auricular (ear) acupuncture or a combination of all these techniques. If you choose to have acupuncture, work with a qualified acupuncturist and keep all of your other health care providers well-informed about your treatments.

Following Up

Determining the best dosage or drug combinations is an inexact science. Your health care provider will monitor you until your seizures are under control.

Supporting Research

Coman DJ, Sinclair KG, Burke CJ, Appleton DB, Pelekanos JT, O'Neil CM, Wallace GB, Bowling FG, Wang D, DeVivo DC, McGill JJ. Siezures, ataxia, developmental delay and the general pediatrician: Glucose transporter 1 deficiency syndrome. J Paediatr Child Health. 2006;42(5):263-7.

Duncan JS, Sander JW, Sisodiya SM, Walker MC. Adult epilepsy. Lancet. 2006;367(9516):1087-100.

Guerrini R, Parmeggiani L. Practitioner review: Use of antiepileptic drugs in children. J Child Psychol Psychiatry. 2006;47(2):115-26.

Jackson N, Ridge CA, Delanty N. Imaging in patients with a first seizure. Ir Med J. 2006;99(6):173-5.

Muller M, Byres M, Jaspars M. et al. 2D NMR spectroscopic analyses of archangelicin from the seeds of Angelica archangelica. Acta Pharm. 2004;54:277-85.

Perucca E, Aldenkamp A, Tallis R, Kramer G. Role of valproate across the ages. Treatment of epilepsy in the elderly. Acta Neurol Scand Suppl. 2006;184:28-37.

Towne AR. Epidemiology and outcomes of status epilepticus in the elderly. Int Rev Neurobiol. 2007;81:111-27.

Yuan CS, Mehendale S, Xiao Y, et al. The gamma-aminobutyric acidergic effects of valerian and valerenic acid on rat brainstem neuronal activity. Anesth Analg. 2004;98:353-8.

Review Date:
2/27/2008
Reviewed By:
Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Dysphagia

FitSugar — Wed, 08 Oct 2008 17:35:32 -0700

Overview

Signs and Symptoms
What Causes It?
What to Expect at Your Provider's Office
Treatment Options
Following Up
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Dysphagia is the medical term for difficulty swallowing, or the feeling that food is "sticking" in your throat or chest. The feeling is actually in your esophagus, the tube that carries food from your mouth to your stomach. You may experience dysphagia when swallowing solid foods, liquids, or both.

Oropharyngeal dysphagia is when you have trouble moving food from your mouth into your upper esophagus. Esophageal dysphagia is when you have trouble moving food through your esophagus to your stomach. It is the most common kind of dysphagia.

Dysphagia can affect you at any age, although your risk increases as you age.

Signs and Symptoms

The following are symptoms of oropharyngeal dysphagia:

Difficulty trying to swallow
Choking or breathing saliva into your lungs while swallowing
Coughing while swallowing
Regurgitating liquid through your nose
Breathing in food while swallowing
Weak voice
Weight loss

The following are symptoms of esophageal dysphagia:

Pressure sensation in your mid-chest area
Sensation of food stuck in your throat or chest
Chest pain
Pain with swallowing
Chronic heartburn
Belching
Sore throat

What Causes It?

Several conditions can cause dysphagia. In children, it is often due to physical malformations, conditions such as cerebral palsy or muscular dystrophy, or gastroesophageal reflux disease (GERD). Dysphagia in adults may be due to tumors (benign or cancerous), conditions that cause the esophagus to narrow, neuromuscular conditions, stroke, or GERD. It can also be caused when the muscle in your esophagus doesn't relax enough to let food pass into your stomach. Other risk factors include smoking, excessive alcohol use, certain medications, and teeth or dentures in poor condition.

What to Expect at Your Provider's Office

Your health care provider may ask about your symptoms and eating habits. For infants and children, the health care provider may want to observe them eating. Your provider may also listen to your heart, take your pulse, and ask about your medical history.

A variety of tests can be used for dysphagia:

In endoscopy or esophagoscopy, a tube is inserted into your esophagus to help your health care provider evaluate the condition of your esophagus, and to try to open any parts that might be closed off.
In esophageal manometry, a tube is inserted into your stomach to measure pressure differences in various regions.
X-rays of your neck, chest, or abdomen may be taken.
In a barium x-ray, moving picture or video x-rays are taken of your esophagus as you swallow barium, which is visible on an x-ray.

Treatment Options

Dysphagia generally is treated with drugs, exercises, and procedures that open the esophagus, or with surgery. Your treatment will depend on the cause, the seriousness, and any complications you may be experiencing. You usually do not need to go to the hospital, as long as you are able to eat enough and have a low risk of complications. If your esophagus is severely blocked, however, you may be hospitalized. Infants and children with dysphagia are often hospitalized.

To treat oropharyngeal dysphagia, you may learn special exercises that help stimulate the nerves involved in swallowing. You may also learn to position your head in ways that help you swallow.

For esophageal dysphagia involving an esophageal muscle that doesn't relax, your doctor may dilate your esophagus with a balloon attached to an endoscope. If the problem is GERD, you will be given antacids or proton pump inhibitors. You may also be prescribed medications that relax your esophagus and prevent spasms. If dysphagia is due to a tumor or other obstruction, you may need surgery.

Complementary and Alternative Therapies

Herbs can effectively decrease spasms and can heal an inflamed esophagus. Homeopathic remedies may be used at the same time.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink two to four cups a day. You may use the following tinctures, alone or in combination:

Licorice (Glycyrrhiza glabra) standardized deglycyrrhizinated licorice (DGL) extract, 250 mg three times daily, taken either 1 hour before or 2 hours after meals, for reducing spasms and swelling and as a pain reliever specifically for the gastrointestinal tract. DGL has a chemical removed from the licorice that has been known to cause high blood pressure. Chewable lozenges may be the best form of licorice for treating GERD.
Slippery elm (Ulmus fulva), as a tea, for demulcent (protects irritated tissues and promotes their healing). One teaspoon of slippery elm powder may be mixed with water. Drink three to four times a day.
Marshmallow (Althaea officinalis), as a tea, for demulcent and emollient effects. The dose is one cup of tea three times per day. To make tea, steep 2 - 5 g of dried leaf or 5 g dried root in one cup of boiling water. Strain and cool. Avoid marshmallow if you have diabetes.

In addition, you may use a combination of four of the following herbs as a tea or tincture. Use equal parts of the herbs, 1 tsp. of each per cup of water and steep 10 minutes three times a day; or equal parts of tincture, 30 - 60 drops three times a day.

Valerian (Valeriana officinalis) may improve digestion and help you relax, especially if you feel anxious or depressed.
Skullcap (Scutellaria lateriflora) for antispasmodic and sedative effects.
Linden flowers (Tilia cordata) for antispasmodic and as a mild diuretic.

Homeopathy

Few clinical studies have examined the effectiveness of specific homeopathic remedies. However, a professional homeopath may recommend one or more of the following treatments for menstrual pain based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

The following are some of the most common remedies used for dysphagia:

Baptesia tinctoria if you can swallow only liquids, especially if have a red, inflamed throat that is relatively pain free
Baryta carbonica if you have large tonsils
Carbo vegatabilis for bloating and indigestion that is worse when lying down, especially with flatulence and fatigue
Ignatia for "lump in the throat," back spasms, cough, especially when symptoms appear after you have experienced grief
Lachesis if you cannot stand to be touched around the throat (including clothing that is tight at the neck)

Acupuncture

Several clinical studies have reported that acupuncture can stimulate the swallowing reflex in people who have dysphagia due to stroke.

Following Up

Dysphagia should not limit your activities, but your health care provider may restrict your diet.

Supporting Research

Burton C, Pennington L, Roddam H, et al. Assessing adherence to the evidence base in the management of poststroke dysphagia. Clin Rehabil. 2006;20(1):46-51.

Carnaby-Mann G, Crary M. Pill swallowing by adults with dysphagia. Arch Otolaryngol Head Neck Surg. 2005;131(11):970-5.

Griffith R, Tengnah C. A guideline for managing medication related dysphagia. Br J Community Nurs. 2007;12(9):426-9.

Matta Z, Chambers E 4th, Mertz Garcia J, et al. Sensory characteristics of beverages prepared with commercial thickeners used for dysphagia diets. J Am Diet Assoc. 2006;106(7):1049-54.

Roy N, Stemple J, Merrill RM, Thomas L. Dysphagia in the elderly: preliminary evidence of prevalence, risk factors, and socioemotional effects. Ann Otol Rhinol Laryngol. 2007;116(11):858-65.

Seki T, Iwasaki K, Arai H, Sasaki H, et al. Acupuncture for dysphagia in poststroke patients: a videofluoroscopic study. J Am Geriatr Soc. 2005;53(6):1083-84.

Su Y, Li P, Zhao G. Electroacupuncture treatment for 45 cases of postapoplectic dysphagia. J Tradit Chin Med. 2004;24(2):129-30.

Wang LP, Xie Y. [Systematic evaluation on acupuncture and moxibustion for treatment of dysphagia after stroke]. Zhongguo Zhen Jiu. 2006;26(2):141-6.

Wang LP, Xie Y. Jing B, Bao-dong L, Zhi-yong W, et al. [The role of different needling manipulation in adjusting swallow-period obstacle of dysphagia after stroke]. Zhongguo Zhen Jiu. 2007;27(1):35-7.

Review Date:
2/12/2008
Reviewed By:
Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network. Also reviewed by Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources.

A.D.A.M. Copyright

adam.com

Bursitis

FitSugar — Wed, 08 Oct 2008 17:35:34 -0700

Overview

Signs and Symptoms
What Causes It?
What to Expect at Your Provider's Office
Treatment Options
Following Up
Special Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Bursitis is inflammation of a small fluid-filled sack (bursa) inside every joint. The sack helps to lubricate and cushion the joint. Usually bursitis occurs in larger joints, such as the shoulder, hip, knee, or elbow. Repetitive motion is often the cause, and it can happen once or several times. Without seeing your health care provider, you usually can't easily tell the difference between bursitis and pain caused by a strain or arthritis.

Signs and Symptoms

Pain in the joint that gets worse when you move the joint (the pain may come all at once or develop gradually over time)
Swelling
Redness
Fever and warm joint area (if an infection is present)

What Causes It?

Typically the bursa becomes irritated or injured after overuse from repetitive motion or strenuous activity. It may also be caused by a bacterial infection. Other health problems, such as gout or rheumatoid arthritis, can also cause bursitis.

What to Expect at Your Provider's Office

Your health care provider will ask you to identify exactly where the joint hurts and feel the joint for swelling or tenderness. Your health care provider may remove some fluid from the bursa with a small needle to check for infection. You may also need a blood test to check for other health problems.

Treatment Options

Sometimes simply resting and elevating the joint can help the area heal. A splint, sling, or other device can support the joint and keep it from moving. Applications of heat or cold may help relieve pain and swelling.

Drug Therapies

Corticosteroids -- injections into the bursa or oral steroids may reduce inflammation. Side effects include blurred vision, frequent urination, and increased thirst. Steroids may be given with a local anesthetic to reduce pain.
Antibiotics -- for bursitis that is infected.
Acetaminophen, aspirin, and ibuprofen -- to reduce pain.

Surgical and Other Procedures

In rare cases, the bursa is surgically removed.

Complementary and Alternative Therapies

Alternative therapies may help reduce the pain and inflammation of bursitis while supporting healthy connective tissue.

Nutrition and Supplements

Include in your diet anti-inflammatory oils such as those found in cold-water fish, nuts, and seeds. The following supplements may help.

Glucosamine sulfate (500 mg two or three times a day), for connective tissue support.
Omega-3 oils (1,000 mg two or three times a day), such as fish oil or flaxseed oil. While not a direct anti-inflammatory, omega-3 oils, particularly those in fish, can lessen the amount of inflammatory chemicals your body produces over time.
Vitamin C with flavonoids (250 - 500 mg two times a day), for connective tissue repair.
Proteolytic enzymes such as bromelain (250 mg twice a day), to reduce inflammation.
Flavonoids and oral digestive enzymes for inflammation. When used to treat inflammation, digestive enzymes are best taken on an empty stomach.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

Herbs that reduce swelling include meadowsweet (Filipendula ulmaria) and Jamaica dogwood (Piscidia piscipula). You may take a tincture of one, or a combination of these herbs, at 15 drops every 15 minutes up to four doses for relief of severe pain, or 30 drops four times per day for relief of general pain.
Herbs used for their anti-inflammatory effects include:
- Boswellia (Boswellia serrata), 150 mg taken 3 times per day
- Turmeric (Curcuma longa), 375 mg 3 times per day for 12 weeks
- White willow (Salix alba), which acts similar to aspirin and can be made into a tea by boiling 1/2 tsp. (2 grams) of bark in 8 ounces of water.
- Drink up to 5 cups per day. Do not take white willow if you are also taking aspirin, and check with your doctor if you are allergic to aspirin or salicylates before taking white willow. Turmeric and white willow also can be used to reduce swelling. Turmeric increases the effects of bromelain.
Evening primrose oil may also help fight inflammation. The dose is 1,200 mg per day.
For bursitis with muscle spasm, add valerian (Valeriana officinalis).
For frequent bursitis, add hawthorn (Crataegus monogyna).

Homeopathy

Some of the most common remedies are listed below. Usually, the dose is 3 to 5 pellets of a 12X to 30C remedy every 1 -4 hours.

Arnica gel applied topically (to the skin) as directed gives excellent short-term pain relief.
Arnica for bursitis occurring after an injury to the joint.
Ruta graveolons for rheumatic pains in the joint.
Bellis perennis for injury with a great deal of bruising.
Rhus toxicodendron for pain that gets better with movement.
"Traumeel" injections by a trained health care provider as an alternative to corticosteroids.

Acupuncture

Acupuncture can be helpful in reducing swelling and inflammation, and especially in relieving pain.

Chiropractic

Although no well-designed trials have evaluated the effectiveness of chiropractic treatment for bursitis, chiropractors commonly treat people with this condition and report that some experience improvements in symptoms, including reduced pain and increased range of motion. Chiropractors are also likely to use other treatments in addition to spine and joint manipulation (such as ice massage and ultrasound therapy) for the treatment of bursitis.

Movement Therapy

Gentle yoga may help bursitis by increasing flexibility and reducing muscle tension in the area of the bursa. Other movement therapies, such as Pilates and Tai Chi, may also help improve muscle and ligament conditioning and reduce the tension caused by repetitive motions.

Massage

You should not use massage if your bursitis is caused by an infection. Otherwise, you can use massage (especially myofascial release therapy) for general relaxation and to reduce discomfort from inflammation and from compensating for a sore joint.

Following Up

Tell your health care provider if your treatment does not relieve your symptoms. Be sure to follow your provider's instructions for resting the joint to allow the swelling to subside before returning to your usual routines. You can help prevent bursitis from recurring by avoiding repetitive motions, resting between periods of intense activity, and doing stretching exercises before starting an activity.

Special Considerations

Do not take aspirin, acetaminophen, or ibuprofen for more than a few days unless so directed by your provider. Be sure to tell your health care provider if you are pregnant.

Supporting Research

Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1993.

Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine. 4th ed. Baltimore, Md: Williams & Wilkins; 1995:885-894.

Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans. Am J Clin Nutr. 1999;69(6):1086-1107.

Foster S. 101 Medicinal Herbs. Loveland, CO: Interweave Press, 1998:200-1.

Gerber JM, Herrin SO. Conservative treatment of calcific trochanteric bursitis. J Manipulative Physiol Ther. 1994;17(4):250-252.

JAMA Patient Page. How much vitamin C do you need? JAMA. 1999;281(15):1460.

Joe LA, Hart LL. Evening primrose oil in rheumatoid arthritis. Ann Pharmacother. 1993;27:1475-7.

Johnston CS. Recommendations for vitamin C intake. JAMA. 1999;282(22):2118-2119.

Levine M, Rumsey SC, Daruwala R, Park JB, Wang Y. Criteria and recommendations for vitamin C intake. JAMA. 1999;281(15):1415-1453.

Murray MT. The Healing Power of Herbs: The Enlightened Person's Guide to the Wonders of Medicinal Plants. 2nd ed. Rocklin, Calif: Prima Publishing; 1998.

Singh GB, Atal CK. Pharmacology of an extract of salai guggal ex-Boswellia serrata, a new non-steroidal anti-inflammatory agent. Agents Actions. 1986;18:407-12.

Stein JH, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year Book; 1994:2400-2404.

Review Date:
6/15/2006
Reviewed By:
Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Anxiety disorders

FitSugar — Wed, 08 Oct 2008 17:34:56 -0700

In This Report

Highlights
Introduction
Causes
Risk Factors
Complications
Diagnosis
Treatment
Medications
Other Treatments
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Drug Approval

In 2007, duloxetine (Cymbalta) was approved for treatment of generalized anxiety disorder. Duloxetine is a dual inhibitor antidepressant.

Anxiety Disorders Under-Recognized and Under-Treated

About 41% of patients with an anxiety disorder do not receive any treatment, indicates a 2007 study in the Annals of Internal Medicine. Anxiety disorders can interfere with daily functioning, and problems worsen when people have more than one type of anxiety disorder. The study’s researchers recommend that screening for anxiety become a regular part of office visits in the same way that primary care doctors screen patients for depression.

Antidepressants and Children

The benefits of antidepressants for treating pediatric anxiety disorders appear to outweigh the risks for suicide, according to a 2007 review in the Journal of the American Medical Association. Researchers also found that antidepressants did not work as well for treating obsessive compulsive disorder compared to other types of anxiety disorders. This review was the largest to date of antidepressant use in children and adolescents. Most doctors recommend cognitive behavioral therapy as the first treatment approach for childhood anxiety disorders.

Psychological Therapies for Post-Traumatic Stress Disorder

Specially designed psychotherapies -- such as trauma-focused cognitive behavioral therapy, eye movement desensitization and reprocessing, and stress management -- are the most effective therapies for patients with post-traumatic stress disorder, according to a 2007 review in the Cochrane Database.

Introduction

Fear and stress reactions are essential for human survival. They enable people to pursue important goals and to respond appropriately to danger. In a healthy individual, the stress response (fight, fright, or flight) is provoked by a genuine threat or challenge and is used as a spur for appropriate action.

An anxiety disorder, however, involves an excessive or inappropriate state of arousal characterized by feelings of apprehension, uncertainty, or fear. The word is derived from the Latin, angere, which means to choke or strangle. The anxiety response is often not attributable to a real threat. Nevertheless it can still paralyze the individual into inaction or withdrawal. An anxiety disorder persists, while a healthy response to a threat resolves, once the threat is removed.

Anxiety disorders have been classified according to the severity and duration of their symptoms and specific behavioral characteristics. Categories include:

Generalized anxiety disorder (GAD), which is long lasting and low-grade
Panic disorder, which has more dramatic symptoms
Phobias
Obsessive-compulsive disorder (OCD)
Post-traumatic stress disorder (PTSD)
Separation anxiety disorder (which is almost always seen in children)

GAD and panic disorder are the most common. Anxiety disorders are usually caused by a combination of psychological, physical, and genetic factors, and treatment is, in general, very effective.

Generalized anxiety disorder (GAD) is the most common anxiety disorder. It affects about 5% of Americans over the course of their lifetimes. It is characterized by the following:

A more-or-less constant state of worry and anxiety, which is out of proportion to the level of actual stress or threat in their lives.
This state occurs on most days for more than 6 months despite the lack of an obvious or specific stressor. (It worsens with stress, however.)
It is very difficult to control worry. For a clear diagnosis of GAD, the specific worries should be differentiated from those that would define other anxiety disorders, such as fear of panic attacks or appearing in public. Moreover, they are not obsessive like people with obsessive-compulsive disorder. (It should be noted, however, that over half of those with GAD also have another anxiety disorder or depression.)
Patients with anxiety may experience physical symptoms (such as gastrointestinal complaints) in addition to, or even in place of, mental worries. (This latter case may be more common in people from non-Western cultures such as those with Asian backgrounds.)
People with GAD tend to be unsure of themselves, overly perfectionist, and conforming.

Given these conditions, a diagnosis of GAD is confirmed if three or more of the following symptoms are present (only one for children) on most days for 6 months:

Being on edge or very restless
Feeling tired
Having difficulty with concentration
Being irritable
Having muscle tension
Experiencing disturbed sleep

Symptoms should cause significant distress and impair normal functioning and not be due to a medical condition, another mood disorder, or psychosis. It should be noted that pure GAD is uncommon. It typically occurs with other mood disorders (anxiety or depression) or substance use.

Panic disorder is characterized by periodic attacks of anxiety or terror (panic attacks). They usually last 15 - 30 minutes, although residual effects can persist much longer. The frequency and severity of acute states of anxiety determine the diagnosis. (It should be noted that panic attacks can occur in nearly every anxiety disorder, not just panic disorder. In other anxiety disorders, however, there is always a cue or specific trigger for the attack.) A diagnosis of panic disorder is made under the following conditions:

A person experiences at least two recurrent, unexpected panic attacks.
For at least a month following the attacks, the person fears that another will occur.

Symptoms of a Panic Attack. During a panic attack a person feels intense fear or discomfort with at least four or more of the following symptoms:

Rapid heart beat
Sweating
Shakiness
Shortness of breath
A choking feeling or a feeling of being smothered
Dizziness
Nausea
Feelings of unreality
Numbness
Either hot flashes or chills
Chest pain
A fear of dying
A fear of going insane

Women may be more likely than men to experience shortness of breath, nausea, and feelings of being smothered. More men than women have sweating and abdominal pain. Panic attacks that include only one or two symptoms, such as dizziness and heart pounding, are known as limited-symptom attacks. These may be either residual symptoms after a major panic attack or precursors to full-blown attacks. (It should be noted that panic attacks can also accompany other anxiety disorders, such as phobias and post-traumatic stress disorder. In such cases, however, additional characteristics differentiate these disorders from panic disorder.)

Frequency of Panic Attacks. Frequency of attacks can vary widely. Some people have frequent attacks (for example, every week) that occur for months; others may have clusters of daily attacks followed by weeks or months of remission.

Triggers of Panic Attacks. Panic attacks may occur spontaneously or in response to a particular situation. Recalling or re-experiencing even harmless circumstances surrounding an original attack may trigger subsequent panic attacks.

Phobias, manifested by overwhelming and irrational fears, are common. In most cases, people can avoid or at least endure phobic situations, but in some cases, as with agoraphobia, the anxiety associated with the feared object or situation can be incapacitating.

Agoraphobia. Agoraphobia has been somewhat misleadingly described as fear of open spaces, the term having been derived from the Greek word agora, meaning outdoor marketplace. In its severest form, agoraphobia is characterized by a paralyzing terror of being in places or situations from which the patient feels there is neither escape nor accessible help in case of an attack. (One patient described the terror of going outside as opening a door onto a landscape filled with snakes.) Consequently, people with agoraphobia confine themselves to places in which they feel safe, usually at home. The patient with agoraphobia often makes complicated plans in order to avoid confronting feared situations and places.

Social Phobia. Social phobia, also known as social anxiety disorder, is the fear of being publicly scrutinized and humiliated and is manifested by extreme shyness and discomfort in social settings. This phobia often leads people to avoid social situations and is not due to a physical or mental problem (such as stuttering, acne, or personality disorders). The incidence of social phobia is about 13% and has been termed "the neglected anxiety disorder" because it is often not properly diagnosed.

The associated symptoms vary in intensity, ranging from mild and tolerable anxiety to a full-blown panic attack. (Unlike a panic attack, however, social phobia is always directly related to a social situation.) Symptoms include sweating, shortness of breath, pounding heart, dry mouth, and tremor.

The disorder may be further categorized as generalized or specific social phobia:

Generalized social phobia is the fear of being humiliated in front of other people during nearly all social situations. People with this subtype are the most socially impaired and also the most likely to seek treatment.
Specific social phobia usually involves a phobic response to a specific event. Performance anxiety ("stage fright") is the most common specific social phobia and occurs when a person must perform in public. These patients usually feel comfortable in informal social situations.

Children with social anxiety develop symptoms in settings that include their peers, not just adults, and they may include tantrums, blushing, or not being able to speak to unfamiliar people. These children should be able to have normal social relationships with familiar people, however.

Specific Phobias. Specific phobias (formerly simple phobias) are an irrational fear of specific objects or situations. Specific phobias are among the most common medical disorders. Most cases are mild and not significant enough to require treatment.

The most common phobias are fear of animals (usually spiders, snakes, or mice), flying (pterygophobia), heights (acrophobia), water, injections, public transportation, confined spaces (claustrophobia), dentists (odontiatophobia), storms, tunnels, and bridges.

When confronting the object or situation, the phobic person experiences panicky feelings, sweating, avoidance behavior, difficulty breathing, and a rapid heartbeat. Most phobic adults are aware of the irrationality of their fear, and many endure intense anxiety rather than disclose their disorder.

Obsessive-compulsive disorder (OCD) has been described as hiccups of the mind. OCD is time-consuming, distressing, and can disrupt normal functioning. Much research suggests that a critical feature in this disorder is an overinflated sense of responsibility, in which the patient's thoughts center around possible dangers and an urgent need to do something about it.

Obsessions are recurrent or persistent mental images, thoughts, or ideas. The obsessive thoughts or images can range from mundane worries about whether one has locked a door to bizarre and frightening fantasies of behaving violently toward a loved one.
Compulsive behaviors are repetitive, rigid, and self-directed routines that are intended to prevent the manifestation of an associated obsession. Such compulsive acts might include repetitive checking for locked doors or unlit stove burners or calls to loved ones at frequent intervals to be sure they are safe. Some people are compelled to wash their hands every few minutes or to spend inordinate amounts of time cleaning their surroundings in order to subdue the fear of contagion.

Over half of OCD-sufferers have obsessive thoughts without the ritualistic compulsive behavior. Although individuals recognize that the obsessive thoughts and ritualized behavior patterns are senseless and excessive, they cannot stop them in spite of strenuous efforts to ignore or suppress the thoughts or actions. OCD often accompanies depression or other anxiety disorders. There is some evidence that the symptoms improve over time and that nearly half will eventually recover completely or have only minor symptoms.

Symptoms in children may be mistaken for behavioral problems (taking too long to do homework because of perfectionism, refusing to perform a chore because of fear of germs). Children do not usually recognize that their obsessions or compulsions are excessive.

Associated Obsessive Disorders. Certain other disorders that may be part of, or strongly associated with, the OCD spectrum include the following:

Body dysmorphic disorder (BDD). In BDD, people are obsessed with the belief that they are ugly, or part of their body is abnormally shaped.
Hypochondriasis. People who have hypochondiasis have an excessive fear of having a serious disease.
Anorexia nervosa. OCD frequently accompanies this eating disorder, where the compulsive behavior focuses on food restriction and thinness.
Trichotillomania. People with trichotillomania continually pull their hair, leaving bald patches.
Tourette syndrome. Symptoms of Tourette syndrome include jerky movements, tics, and uncontrollably uttering obscene words.

Obsessive-Compulsive Personality. OCD should not be confused with obsessive-compulsive personality, which defines certain character traits (being a perfectionist, excessively conscientious, morally rigid, or preoccupied with rules and order). These traits do not necessarily occur in people with obsessive-compulsive disorder.

Post-traumatic stress disorder (PTSD) is a severe, persistent emotional reaction to a traumatic event that severely impairs one’s life. It is classified as an anxiety disorder because of its symptoms. Not every traumatic event leads to PTSD, however. There are two criteria that must be present to qualify for a diagnosis of PTSD:

The patient must have directly experienced, witnessed, or learned of a life-threatening or seriously injurious event.
The patients' response is intense fear, helplessness, or horror. Children may behave with agitation or with disorganized behavior.

Triggering Events. PTSD is triggered by violent or traumatic events that are usually outside the normal range of human experience. There is some evidence that events most likely to trigger PTSD are those that involve deliberate and destructive behavior (murder, rape) and those that are prolonged or physically challenging. Such events include, but are not limited to, experiencing or witnessing sexual assaults, accidents, military combat, natural disasters (such as earthquakes), or unexpected deaths of loved ones. PTSD may also occur in people who have serious illness and receive aggressive treatments or who have close family members or friends with such conditions.

Symptoms of PTSD. There are three basic sets of symptoms associated with PTSD. They may begin immediately after the event or can develop up to a year afterward:

Re-experiencing. In such cases, patients persistently re-experience the trauma in at least one of the following ways: in recurrent images, thoughts, flashbacks, dreams, or feelings of distress at situations that remind them of the traumatic event. Children may engage in play, in which traumatic events are enacted repeatedly.
Avoidance. Patients may avoid reminders of the event, such as thoughts, people, or any other factors that trigger recollection. They tend to have an emotional numbness, a sense of being in a daze or of losing contact with their own identity or even external reality. They may be unable to remember important aspects of the event.
Increased Arousal. This includes symptoms of anxiety or heightened awareness of danger (sleeplessness, irritability, being easily startled, or becoming overly vigilant to unknown dangers).

To further qualify for a diagnosis of PTSD, patients must have at least one symptom in the re-experiencing category, three avoidance symptoms, and two arousal symptoms. Symptoms are chronic (3 months or more). Symptoms should also not be associated with alcohol, medications, or drugs and should not be intensifications of a pre-existing psychological disorder.

Acute Stress Disorder. Experts have identified a syndrome called acute stress disorder, in which symptoms of PTSD occur within 2 days to 4 weeks after the traumatic event. Acute stress disorder can accurately identify up to 94% of victims at risk for PTSD. Between 50 - 80% of these patients actually develop the more chronic and serious disorder. In other words, it is very sensitive for identification of those at highest danger for PTSD but less successful in determining specifically who will or will not recover emotionally.

Long-Term Outlook. The long-term impact of a traumatic event is uncertain. In one study of people who survived a mass killing spree in Texas, less than half of those who suffered PTSD (28% of all survivors) had recovered after a year. In another study, PTSD became chronic in 46% of the subjects. In fact, PTSD may cause physical changes in the brain, and in some cases the disorder can last a lifetime.

Separation anxiety disorder almost always occurs in children. It is suspected in children who are excessively anxious about separation from important family members or from home. For a diagnosis of separation anxiety disorder, the child should also exhibit at least three of the following symptoms for at least 4 weeks:

Extreme distress from either anticipating or actually being away from home or being separated from a parent or other loved one
Extreme worry about losing or about possible harm befalling a loved one
Intense worry about getting lost, being kidnapped, or otherwise separated from loved ones
Frequent refusal to go to school or to sleep away from home
Physical symptoms such as headache, stomach ache, or even vomiting, when faced with separation from loved ones

Separation anxiety often disappears as the child grows older, but if not addressed, it may lead to panic disorder, agoraphobia, or combinations of anxiety disorders.

Studies suggest that an imbalance of certain substances called neurotransmitters (chemical messengers in the brain) may contribute to anxiety disorders. The neurotransmitters targeted in anxiety disorders are gamma-aminobutyric acid (GABA), serotonin, dopamine, and epinephrine. Serotonin appears to be specifically important in feelings of well-being, and deficiencies are highly related to anxiety and depression.

Examples of study findings on some neurotransmitters are:

Abnormalities in the neurotransmitters gamma-aminobutyric acid (GABA) and serotonin may have a particular role in susceptibility to generalized anxiety disorder. GABA helps prevent nerve cells from over-firing and serotonin is a brain chemical important in feelings of well-being.
Serotonin is a major player in OCD.
Changes in serotonin and dopamine have been observed in social phobia.
People with post-traumatic stress disorder have abnormalities in stress hormones (cortisol) and neurotransmitters associated with stress (epinephrine and norepinephrine). Such imbalances could account for the higher anxiety levels and a tendency to startle easily after a threat in people with PTSD.
Corticotropin-releasing factor (CRF), which is believed to be a stress hormone and a neurotransmitter, is thought to be involved in depression and anxiety by causing changes in serotonin levels.

The best way to envision the brain's response to a threat is to imagine a primal situation, such as being chased by a bear.

The Brain's Response to Acute Stress. In response to seeing the bear, a part of the brain called the hypothalamic-pituitary-adrenal (HPA) system is activated.

Release of Steroid Hormones and the Stress Hormone Cortisol. The HPA systems trigger the production and release of steroid hormones (glucocorticoids), including the primary stress hormone cortisol. Cortisol is very important in marshaling systems throughout the body (including the heart, lungs, circulation, metabolism, immune systems, and skin) to deal quickly with the bear.

Release of Catecholamines and Activation of the Amygdala. The HPA system also releases certain neurotransmitters (chemical messengers) called catecholamines, particularly those known as dopamine, norepinephrine, and epinephrine (also called adrenaline).

Catecholamines activate the amygdala, a small structure deep in the brain, which regulates control of major emotional activities, including anxiety, depression, aggression, and affection. In fact, the amygdala is sometimes known as the "fear" center.

Effects on Long- and Short-Term Memory. During the stressful event, catecholamines also suppress activity in areas at the front of the brain concerned with short-term memory, concentration, inhibition, and rational thought. This sequence of mental events allows a person to react quickly to the bear, either to fight or to flee from it. (It also hinders the ability to handle complex social or intellectual tasks and behaviors during that time.)

On the other hand, neurotransmitters at the same time signal the hippocampus (a nearby area in the brain) to store the emotionally loaded experience in long-term memory. In primitive times, this brain action would have been essential for survival, since long-lasting memories of dangerous stimuli (the large bear) would be critical for avoiding such threats in the future.

Response by the Heart, Lungs, and Circulation to Acute Stress. The stress response also affects the heart, lungs, and circulation:

As the bear comes closer, the heart rate and blood pressure increase instantaneously.
Breathing becomes rapid and the lungs take in more oxygen.
The spleen discharges red and white blood cells, allowing the blood to transport more oxygen throughout the body. Blood flow may actually increase 300 - 400%, priming the muscles, lungs, and brain for added demands.

The Immune System's Response to Acute Stress. The effect on the immune system from confrontation with the bear is similar to marshaling a defensive line of soldiers to potentially critical areas. The steroid hormones dampen parts of the immune system, so that specific infection fighters (including important white blood cells) or other immune molecules can be redistributed. These immune-boosting troops are sent to the body’s front lines where injury or infection is most likely, such as the skin, the bone marrow, and the lymph nodes.

The Acute Response in the Mouth and Throat. As the bear gets closer, fluids are diverted from nonessential locations, including the mouth. This causes dryness and difficulty in talking. In addition, stress can cause spasms of the throat muscles, making it difficult to swallow.

The Skin's Response to Acute Stress. The stress effect diverts blood flow away from the skin to support the heart and muscle tissues. (This also reduces blood loss in the event that the bear catches up.) The physical effect is a cool, clammy, sweaty skin. The scalp also tightens so that the hair seems to stand up.

Metabolic Response to Acute Stress. Stress shuts down digestive activity, a nonessential body function during short-term periods of physical exertion or crisis.

The Relaxation Response: the Resolution of Acute Stress. Once the threat has passed and the effect has not been harmful (the bear has not eaten or seriously wounded the human), the stress hormones return to normal. This is known as the relaxation response. In turn, the body's systems also normalize.

Causes

A person's genetics, biochemistry, environment, history, and psychological profile all seem to contribute to the development of anxiety disorders. Most people with these disorders seem to have a biological vulnerability to stress, making them more susceptible to environmental stimuli than the rest of the population.

Abnormalities in the Brain. Scientists are using imaging techniques, particularly magnetic resonance imaging (MRI), to identify different areas of the brain associated with anxiety responses.

An MRI (magnetic resonance imaging) of the brain creates a detailed image of the complex structures in the brain. An MRI can give a three-dimensional depiction of the brain, making location of problems such as tumors or aneurysms more precise.

Important research in anxiety disorders is focusing on changes in the amygdala, which is sometimes referred to as the "fear center." This part of the brain regulates fear, memory, and emotion and coordinates these resources with heart rate, blood pressure, and other physical responses to stressful events. Some evidence suggests that the amygdala in people with anxiety disorders is highly sensitive to novel or unfamiliar situations and reacts with a high stress response.

Obsessive-compulsive disorder (OCD) is the anxiety disorder most strongly associated with specific brain dysfunction. For example, abnormalities in a specific pathway of nerves have been linked to OCD, attention deficit disorder, and Tourette syndrome. The symptoms of the three disorders are similar and they often coexist.

A number of imaging studies have reported less volume in the hippocampus in people with post-traumatic stress disorder. This important region is related to emotion and memory storage.

The influence of the family on anxiety is complicated by both genetic and psychological factors.

Panic Disorder and Family Influence. Certain psychodynamic theories suggest, and a few studies support the idea, that some people may develop panic disorder if they cannot resolve the early childhood conflict of dependence vs. independence. In one study, for example, young adults who had experienced childhood anxiety were more likely to live with their parents until their early to mid-twenties. Many people with panic disorder perceive their parents as being extremely controlling and overly protective while showing little actual affection.

Phobias and Family Influence. Several studies show a strong correlation between a parent's fears and those of the offspring. Although an inherited trait may be present, some researchers believe that many children can "learn" fears and phobias, just by observing a parent or loved one's phobic or fearful reaction to an event. People who have social phobias and severe agoraphobia generally report less parental affection and more strictness, overprotection, and encouragement of dependence than those without these disorders.

Obsessive-Compulsive Disorder and Family Influence. One study found that parental influence played no part in obsessive-compulsive disorder if the OCD patient was also not suffering from depression. However, depression coexists in two-thirds of OCD patients, and in the study patients who had both OCD and depression reported lower levels of parental care and overprotectiveness.

Traumatic events generally trigger anxiety disorders in individuals who are susceptible to them because of psychological, genetic, or biochemical factors. The clearest example is post-traumatic stress disorder. Specific traumatic events in childhood, particularly those that threaten family integrity, such as spousal or child abuse, can also lead to other anxiety and emotional disorders. Some individuals may even have a biological propensity for specific phobias, for instance of spiders or snakes, that have been triggered and perpetuated after a single exposure.

The acronym PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus) is a term for an autoimmune condition associated with group A streptococcal infection in children (the cause of "strep throat" and rheumatic fever). Children with PANDAS develop tic-related disorders, including OCD and Tourette syndrome. In such cases, the OCD symptoms develop abruptly soon after the infection. It is unlikely to be an important cause of OCD.

Risk Factors

As many as 25% of all American adults experience intense anxiety sometime in their lives. The prevalence of true anxiety disorders is much lower, although they are still the most common psychiatric conditions in the United States and affect more than 20 million Americans.

Gender. With the exception of obsessive-compulsive disorder (OCD), women have twice the risk for most anxiety disorders as men. A number of factors may increase the reported risk in women, including cultural pressures to meet everyone else's needs except their own, and fewer self-restrictions on reporting anxiety to doctors.

Age. In general, phobias, OCD and separation anxiety show up early in childhood, while social phobia and panic disorder are often diagnosed during the teen years. Studies suggest that 3 - 5% of children and adolescents have some anxiety disorder. Children and adolescents who have an anxiety disorder are at risk of later developing other anxiety disorders, depression, and substance abuse.

Personality Factors. Children's personalities may indicate higher or lower risk for future anxiety disorders. For example, research suggests that extremely shy children and those likely to be the target of bullies are at higher risk for developing anxiety disorders later in life. Children who cannot tolerate uncertainty tend to be worriers, a major predictor of generalized anxiety. In fact, such traits may be biologically based and due to a hypersensitive amygdala -- the "fear center" in the brain.

Family History and Dynamics. Anxiety disorders tend to run in families. Genetic factors may play a role in some cases, but family dynamics and psychological influences are also often at work.

Social Factors. Several studies have reported a significant increase in anxiety levels in children and college students in the past two decades compared to children in the 1950s. In several studies, anxiety was associated with a lack of social connections and a sense of a more threatening environment. It also appears that more socially alienated populations have higher levels of anxiety. For example, a study of Mexican adults living in California reported that native-born Mexican Americans were three times more likely to have anxiety disorders (and even more likely to be depressed) as those who had recently immigrated to the U.S. The longer the immigrants lived in the U.S., the greater their risk for psychiatric problems. Traditional Mexican cultural and social ties seemed to protect recently arrived immigrants from mental illness.

Genetic Factors. Up to 50% of people with panic disorder and 40% of patients with generalized anxiety (GAD) have close relatives with the disorder. (About half of GAD patients also have family members with panic disorder, and about 30% have relatives with simple phobias.)

Obsessive-compulsive disorder (OCD) is also strongly related to a family history of the disorder. Close relatives of people with OCD are up to 9 times more likely to develop OCD themselves. Researchers are making progress in identifying specific genetic factors that might contribute to an inherited risk. Of particular interest are genes that regulate specific neurotransmitters (brain chemical messengers), including serotonin and glutamate. Recent research has suggested that the SLC1A1 gene, which is associated with glutamate regulation, may play an important role in early-onset OCD in boys. Research is also beginning to pinpoint regions on specific chromosomes (1, 3, 7, 6, 9, 15) that may contain genes linked to OCD.

However, there are no genetic tests to date that can identify patients at risk for anxiety disorders.

Medical Conditions. Although no causal relationships have been established, certain medical conditions have been associated with panic disorder. They include migraines, obstructive sleep apnea, mitral valve prolapse, irritable bowel syndrome, chronic fatigue syndrome, and premenstrual syndrome.

GAD affects about 1 - 5% of Americans in the course of their lives and is more common in women than in men. Some experts believe that it is underdiagnosed and more common than any other anxiety disorder. It is certainly the most common anxiety disorder among the elderly. GAD usually begins in childhood and often becomes a chronic ailment, particularly when left untreated. Depression in adolescence may be a strong predictor of GAD in adulthood. Depression commonly accompanies this anxiety disorder in any case.

Age and Panic Disorder. Studies indicate that the prevalence of panic disorder among adults is between 1.6 - 2% and is much higher in adolescence, 3.5 - 9%. Panic disorder usually first occurs either in late adolescence or in the mid-30s.

Gender and Panic Disorder. Women have about twice the risk for panic disorder as men. Panic attacks are very common after menopause. In one study, nearly 18% of older women reported panic attacks within a 6-month period, with over half of these attacks being full-blown. They tended to be associated with stressful life events and poor health. The effects of pregnancy on panic disorder appear to be mixed. It seems to improve the condition in some women and worsen it in others.

Obsessive-compulsive disorder occurs equally in men and women, and it affects about 2 - 3% of people over a lifespan. Most cases of OCD first develop in childhood or adolescence, although the disorder can occur throughout the life span.

Social anxiety disorder is currently estimated to be the third most common psychiatric disorder in the U.S. Studies have reported a prevalence of 7 - 12% in Western nations.

Age and Phobias. The onset of social anxiety disorder is usually during the early teenage years.

Gender and Phobias. Women are more likely to develop social anxiety disorder than men, although equal numbers of men and women seek treatment for it. Most people seeking treatment have had symptoms for at least 10 years.

Studies estimate a lifetime risk for PTSD in the U.S. of up to 8%. People exposed to traumatic events, of course, are at highest risk, but many people can go through such events and not experience PTSD. Studies estimate that 6 - 30% or more of trauma survivors develop PTSD, with children and young people being among those at the high end of the range. Women have the twice the risk of PTSD as men.

Furthermore, PTSD can occur in people not directly involved with a traumatic event. For example, 17% of the U.S. population outside New York City reported some symptoms of post-traumatic stress 2 months after the September 11 attack on the World Trade Towers. (In the city itself, where the attack occurred, an estimated 7.5% of New York's population reported PTSD within the month of the event, which declined to 0.6% at 6 months.)

Researchers are trying to determine factors that might increase vulnerability to catastrophic events and put people at risk for develop PTSD. Some studies report the following may be risk factors:

Pre-existing emotional disorder. People who have a history of an emotional disorder, particularly depression, before the traumatic event are at higher risk for PTSD.
Drug or alcohol abuse
A family history of anxiety
A history of abuse, particularly that which threatens family integrity, such as spousal or child abuse. Studies of individuals who had suffered physical or sexual abuse or neglect as children suggest that up to one-third develop PTSD.
An early separation from parents
Lack of social support and poverty
Sleep disorders. Insomnia and excessive daytime sleepiness even within a month after a traumatic event are important predictors for the development of PTSD. One specific sleep disorder -- sleep apnea -- may even intensify symptoms of PTSD, including sleeplessness and nightmares. Sleep apnea occurs when tissues in the upper throat (or airway) collapse at intervals during sleep, thereby blocking the passage of air. In one study, 91% of crime victims with PTSD had either sleep apnea or a lesser condition that partially blocked the airways during sleep. In fact, in one study treatment of sleep apnea eased PTSD. Sleep apnea has also been associated with a risk for panic disorder. [For more information, see In-Depth Report #65: Sleep apnea.]

Complications

Studies consistently report that all types of anxiety disorders can be very debilitating and seriously affect a person’s quality of life.

Depression. Depression is very common in people with an anxiety disorder, and it is sometimes difficult to distinguish one from the other because either or both can be accompanied by anxious feelings, agitation, insomnia, and problems with concentration.

Depression and nearly every anxiety disorder often go hand in hand, in both the young and old. In fact, the lifetime risk for depression in people with anxiety disorders may be higher than 70%. Furthermore, the combination of depression and anxiety is a major risk factor for both substance abuse and suicide. The following are examples of depression in specific anxiety disorders:

Between 50 - 65% of people with panic disorder also have major depression. Some studies have suggested that treating panic disorder early enough may help prevent major depression later on.
More than two-thirds of OCD patients suffer from depression.
Most patients with GAD will experience at least one episode of significant depression and many develop recurrent episodes. In patients with both disorders, GAD usually precedes the onset of depression.
Social anxiety during adolescence or young adulthood has been associated with a higher risk for depression, and the presence of both increases the chances for severe depression.
People with PTSD are four to seven times as likely to be depressed as are people without PTSD.

Bipolar Disorder. Symptoms of panic disorder are very common in people with bipolar disorder (manic-depression). In fact, people with bipolar have 26 times the rate of panic disorder as in the general population. Furthermore, anxiety worsens bipolar disorder. According to one study, anxiety disorders in teenagers were associated with bipolar disorder in adulthood, while manic behavior in adolescence was linked to later anxiety disorders.

Evidence now strongly supports an association between panic disorder and a risk for suicidal thoughts. Studies report that up to 18% of people with panic disorder attempt suicide and up to 38.5% regularly harbor suicidal thoughts, with the risks being higher in people with both panic disorder and depression. One study reported suicide attempts in about 12% of people with social phobias or OCD. If a person has an anxiety disorder and a mood disorders (such as depression), the risk for suicide is even higher.

Suicide is the third most common cause of death among adolescents, and is one of the most devastating events than can happen to a family. Suicide is most commonly associated with depression in young people, but it is also commonly associated with anxiety, psychosis, substance abuse, or impulsivity. More girls attempt suicide but more boys succeed, most often because they choose guns or violent methods while girls tend to overdose, which is more treatable. Nevertheless, unsuccessful attempts are major risk factors for a later suicide. Any expression of suicidal intent should be treated very seriously.

The following are danger signs in young people:

Withdrawal from friends
Sudden decrease in school performance
Loss of interest in activities that were previously pleasurable
Unusual irritability
Unusual changes in sleep or eating habits

Risk factors for suicide include a history of neglect or abuse, history of deliberate self-harm, a family member who committed suicide (nearly always one who shared a common mood disorder), access to firearms, and living in communities where there have been recent outbreaks of suicide in young people. A romantic break-up is often the trigger for a suicidal attempt in teenagers. Feeling connected with parents and family protected young people with depression in one study, regardless of gender or ethnicity.

In one study, adolescents failed to seek help for suicidal thoughts for the following reasons:

They believed nothing would help.
They were reluctant to tell anyone they had problems.
They thought it was a sign of weakness to seek help.
They did not know where to go.

Parents should not hesitate to seek professional help for their children if they suspect they are thinking about killing themselves. This is a medical emergency and requires immediate treatment.

[For more information on suicide, see In-Depth Report #8: Depression.]

Severely depressed or anxious people are at high risk for alcoholism, smoking, and other forms of addiction. Anxiety disorders are highly prevalent among people with alcoholism. Moreover, long-term alcohol use can itself cause biologic changes that may actually produce anxiety and depression.

Risk for Substance Abuse in Specific Anxiety Disorders. The following are some observations on specific anxiety disorders and substance abuse:

Some people with GAD and panic disorders may use alcohol or drugs to self-medicate.
Social phobia appears to pose a particular risk for alcohol abuse. People with this disorder are likely to drink in order to boost confidence. Alcohol itself has no direct beneficial effect on anxiety, but studies suggest that the belief in its effect appears to relieve anxious feelings. (Alcohol or substance abuse is not associated with specific phobias -- such as a fear of flying or spiders.)
Heavy smoking and substance abuse are common in people with PTSD. In adolescents, the disorder not only increases the risk for drug and alcohol use but also for eating disorders.

Studies consistently report that anxiety disorders have negative effects on work and relationships. Some examples:

In one study, more than 10% of patients with GAD missed at least 6 days of work within the previous month.
In a survey of OCD sufferers, 40% reported that they had to stop working because of the disorder. Only 40% worked full-time, while only half were married.
A 2006 study indicated that children with OCD are more likely to be bullied than other children.
Studies report that people with social phobias are less likely to get married, to leave home, and to finish school than those without this disorder. Their outlook worsens if they have other emotional disorders.

Anxiety disorders are associated with many different physical illnesses. Research suggests that people who have both an anxiety disorder and a physical illness have a worse quality of life and greater risk for disability than those who have only a physical illness. Anxiety disorders often tend to occur before the development of physical disorders.

Heart Disease. Anxiety has been associated with several heart problems, including unhealthy cholesterol levels, thicker blood vessels, and high blood pressure. Both anxiety and depression have been associated with a poorer response to treatment in heart patients, including a worse outcome after heart surgery.

Cholesterol is a soft, waxy substance that is present in all parts of the body including the nervous system, skin, muscle, liver, intestines, and heart. It is made by the body and obtained from animal products in the diet. Cholesterol is manufactured in the liver and is needed for normal body functions including the production of hormones, bile acid, and vitamin D. Excessive cholesterol in the blood contributes to atherosclerosis and subsequent heart disease. The risk of developing heart disease or atherosclerosis increases as the level of blood cholesterol increases.

Some researchers speculate that intense anxiety might trigger abnormal and dangerous heart rhythms in people with existing heart problems. In other studies, panic disorders, post-traumatic stress disorder, and phobias have been associated with a higher rate of sudden death from cardiac events, including heart attack.

Gastrointestinal Disorders. Anxiety frequently accompanies gastrointestinal conditions. Of note, half the cases of irritable bowel syndrome are associated with anxiety.

Headache. Both tension and migraine headaches are associated with anxiety disorders. One study reported that 32% of people with chronic tension headaches met criteria for anxiety. Similarly, another study reported that young girls with anxiety disorders were three times more likely to have chronic headaches than those without the disorder. (Headaches in both studies were also strongly associated with depression.)

Respiratory Problems. Studies report an association between anxiety in patients with obstructive lung conditions (asthma, emphysema, and chronic bronchitis) and more frequent relapses.

Obesity. Anxiety disorders may lead to obesity, and the reverse may also be true. A 2006 study suggested that anxiety disorders and depression in childhood may lead to higher body mass index (BMI) in adult women (but not men). Another 2006 study indicated that obesity is associated with a 25% increased risk of developing anxiety and mood disorders.

Allergic Conditions. Anxiety disorders are associated with numerous allergic conditions including hay fever, eczema, hives, food allergies, and conjunctivitis.

Other Conditions. Other physical conditions associated with anxiety disorders include thyroid problems and arthritis.

People with obsessive-compulsive disorders can experience skin problems from excessive washing, injuries from repetitive physical acts, and hair loss from repeated hair pulling (behavior known as trichotillomania).

Effect of PTSD on the Brain. Studies are reporting that PTSD is associated with shrinkage in the hippocampus, the part of the brain important for memory and learning. Some animal studies indicate that such damage may result from long-term exposure to cortisol, the major stress hormone. In one study, people who had suffered severe trauma scored 40% lower in tests of verbal memory than did the general population. There was no difference in IQ or in scores of other types of memory. Some studies suggest that exposure to chronic stress, common in PTSD patients, may even compromise the function of the brain’s receptors for anti-anxiety medication. On the other hand, a small hippocampal volume may itself increase stress hormone levels, so people with genetically smaller hippocampi may be susceptible to PTSD.

Effects of PTSD on Health. Studies of military veterans who have endured major traumatic events have found a higher risk for health problems. One study of Vietnam veterans reported that PTSD was associated with greater physical limitations, poorer physical health, and a lower quality of life than was found in the general population, regardless of other accompanying emotional or medical disorders. In another study of these veterans, PTSD sufferers had twice the risk for abnormal heart rhythms and four times the risk of a heart attack compared to men without PTSD.

Evidence suggests an association between anxiety in children and recurrent stomach aches. Anxiety has been associated with a higher risk for sleep disorders in children, such as frequent nightmares, restless legs syndrome, and bruxism (grinding and gnashing of the teeth during sleep).

Diagnosis

A physical examination and medical and personal history is essential. Because anxiety accompanies so many medical conditions, some serious, it is extremely important for the doctor to uncover any medical problems or medications that might underlie or be masked by an anxiety attack.

The patient should describe any occurrence of anxiety disorders or depression in the family and mention any other contributing factors, such as excessive caffeine use, recent life changes, or stressful events.

It is very important to be honest with your doctor about all conditions, including excessive drinking, substance abuse, or other psychological or mood states that might contribute to, or result from, the anxiety disorder.

Diagnosing children with an anxiety disorder can be very difficult, since anxiety often results in disruptive behaviors that overlap with attention-deficit hyperactivity or oppositional disorder. Other conditions with symptoms similar to anxiety disorders include pervasive developmental disorders such Asperger syndrome, learning disabilities, bipolar disorder, and depression. Many children have anxiety disorder and a co-occurring condition, which should be treated along with anxiety.

People with anxiety disorders are more likely to see a family doctor before a mental health specialist, since their symptoms are often physical. Symptoms can include muscle tension, trembling, twitching, aching, soreness, cold and clammy hands, dry mouth, sweating, nausea or diarrhea, or urinary frequency. Anxiety attacks can mimic or accompany nearly every acute disorder of the heart or lungs, including heart attacks and angina (chest pain). In fact, nearly all individuals with panic disorders are convinced that their symptoms are physical and possibly life-threatening.

Heart Problems. Studies suggest that up to a third of patients entering the emergency room with chest pain and who are low-to-moderate risk for a heart attack are actually suffering from panic attacks. It is often difficult even for specialists to distinguish between heart conditions and a panic attack:

Women who are having an actual heart attack or acute heart problem are much more likely to be misdiagnosed as having an anxiety attack than are men with similar symptoms.
Mitral valve prolapse, a common and usually mild heart problem, may have symptoms that are nearly identical to those of panic disorder. The two conditions, in fact, frequently occur together.

Mitral valve prolapse is a disorder in which the mitral valve does not close properly when the heart contracts. When the valve does not close properly it allows blood to backflow into the left atrium. Some symptoms can include palpitations, chest pain, difficulty breathing after exertion, fatigue, cough, and shortness of breath while lying down.

People with a heart-rhythm disturbance called paroxysmal supraventricular tachycardia have many of the same symptoms as those with panic attacks.

Asthma. Asthma attacks and panic attacks have similar symptoms and can also coexist.

Hyperthyroidism. Hyperthyroidism can cause many of the same symptoms of generalized anxiety disorder and must be ruled out.

Click the icon to see an image of hyperthyroidism.

Epilepsy. The symptoms of partial seizures and panic attacks often overlap.

Other Medical Conditions. In addition, anxiety-like symptoms are seen in many other medical problems, including hypoglycemia, recurrent pulmonary emboli, and adrenal-gland tumors. Women can also experience intense anxiety attacks with hot flashes during menopause.

Medication Side Effects. Many drugs, including some for high blood pressure, diabetes, and thyroid disorders, can produce symptoms of anxiety. Withdrawal from certain drugs, often those used to treat sleep disorders or anxiety, can also precipitate anxiety reactions.

Substance Abuse. People with anxiety disorders often drink alcohol or abuse drugs in order to conceal or eliminate symptoms, but substance abuse and dependency can also cause anxiety. In addition, withdrawal from alcohol can produce physiologic symptoms similar to panic attacks. Clinicians often have difficulty determining whether alcoholism or anxiety is the primary disorder. Overuse of caffeine or abuse of amphetamines can cause symptoms resembling a panic attack.

Clinicians use various screening tests to determine the causes, type, severity, and frequency of anxiety. Such tests include the Hamilton Anxiety Rating Scale, the Beck Anxiety Inventory, the Penn State Worry Questionnaire, and the Yale-Brown Obsessive Compulsive Scale.

Treatment

Anxiety disorders require treatment. Simply trying to talk oneself out of anxiety is as futile as trying to talk oneself out of a heart or stomach problem. Most anxiety disorders, especially phobias, respond well to treatment. They may, however, require long-term treatment. Many patients have a recurrence and may require additional medications. Nevertheless, most patients do not receive appropriate care for anxiety disorders. Many patients do not receive any treatment at all.

The standard current approach to most anxiety disorders is a combination of cognitive-behavioral therapy (CBT) and an antidepressant medication. A selective serotonin reuptake inhibitor (SSRI) is typically the first choice, with the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor) an alternative. If patients do not respond to these drugs, tricyclic antidepressants or monoamine oxidase inhibitors (MAOIs) may be helpful. Benzodiazepines may be recommended for patients who are not helped by antidepressants. A healthy lifestyle that includes exercise, adequate rest, and good nutrition can also help to reduce the impact of anxiety.


Anxiety Disorder	Medications	Cognitive-Behavioral Therapy (CBT) and other Non-Drug Therapies
Generalized Anxiety Disorder	Antidepressants, benzodiazepines, and buspirone are helpful but have varying side effects. Investigational drugs include pregabalin and other anticonvulsants.	Cognitive-behavioral therapy or anxiety management therapy. Anxiety management therapy involves education, relaxation training, and exposure to anxiety-provoking stimuli but does not include cognitive restructuring.
Panic Attacks	SSRIs are treatment of choice. If patients do not respond to SSRIs, short-term treatment with a benzodiazepine may be used, or patients may switch to another type of antidepressant such as venlafaxine or tricyclics.	Cognitive-behavioral therapy, provided in 12 - 16 sessions over 3 - 4 months, focuses on recreating fear symptoms and helping patients change their response to them.
Social Anxiety Disorder	SSRIs or venlafaxine are first-line drug treatments. Benzodiazepines may help patients who do not respond to these antidepressants. In severe cases, an MAOI antidepressant may be prescribed. Anticonvulsants such as gabapentin (Neurontin) and pregabalin (Lyrica) are being investigated.	Cognitive-behavioral therapy can help improve symptoms after 6 - 12 weeks.
Obsessive-Compulsive Disorder	SSRIs are the first choice for adults. Clomipramine (a tricyclic antidepressant) is an alternative for adult patients who do not respond to SSRIs. For children, SSRIs do not seem to work as well for OCD as for other types of anxiety disorders.	Cognitive-behavioral therapy is the first treatment choice for children. For adults, either CBT or drug therapy may be offered as initial treatment. CBT techniques focus on exposure and response prevention (ERP).
Post-Traumatic Stress Disorder	Antidepressants, particularly SSRIs (sertraline and paroxetine approved for PTSD). The atypical antipsychotic olanzapine may be added to an antidepressant for patients who do not respond to a SSRI alone.	Trauma-focused psychological treatments include exposure therapy, trauma-focused cognitive therapy, and eye movement desensitization and reprocessing.
Note: For anxiety disorders in adults, the most effective treatments are usually combinations of drugs and CBT techniques. For children, CBT is usually the first treatment.

Medications

Selective serotonin-reuptake inhibitors (SSRIs), or the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor), are the primary first-line treatment for anxiety disorders. For patients who are not helped by these drugs, benzodiazepines, either alone or in combination with an antidepressant, may be prescribed. Other types of antidepressants, including tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs), may also be used to treat patients with severe or chronic forms of anxiety disorders.

Drug therapies for anxiety disorders work best in combination with cognitive behavioral therapy.

Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).

SSRIs can cause agitation, nausea, and diarrhea. Sexual function side effects include low sex drive, inability to have an orgasm, and impotence. Over time, many SSRI-treated patients gain weight, although the degree of weight gain varies depending on the drug. Elderly people taking these drugs should take the lowest effective dose possible, and those with heart problems should be monitored closely.

There have been many concerns about SSRIs and increased risk for suicidal behavior. Both adults and children who are treated with SSRIs should be carefully monitored for any worsening of depressive symptoms or changes in behavior. This is especially important during the first few months of antidepressant treatment.

Paroxetine has been linked to heart-related birth defects when women took this drug during the first trimester of pregnancy. Experts are also advising caution in prescribing other types of SSRIs to pregnant women. While certain SSRIs may carry increased risks for some specific type of rare birth defects, research suggests that the overall risks are minimal. Still, women who are pregnant or who are considering becoming pregnant should discuss the potential risks of these drugs with their doctors.

Serotonin-norepinephrine reuptake inhibitors (SNRIs). SNRIs are known as dual inhibitors because they work on two neurotransmitters -- norepinephrine and serotonin. Venlafaxine (Effexor) is an SNRI that is approved for treatment of generalized anxiety disorder, social anxiety disorder, and panic disorder in adults. (It is not approved for children.) As with many SSRIs, venlafaxine impairs sexual function. Venlafaxine can increase blood pressure and heart rate and should be used with caution in patients with high blood pressure or heart disease. Some patients report severe withdrawal symptoms, including dizziness and nausea. This drug has a serious risk for overdose. Venlafaxine should not be taken during the last trimester of pregnancy because the drug can cause complications in newborn infants.

Duloxetine (Cymbalta) also acts on both serotonin and norepinephrine. In 2007, it was approved for treatment of generalized anxiety disorder. Side effects are generally mild and include dry mouth, nausea, and sleepiness. Patients with narrow-angle glaucoma or patients with liver or kidney diseases should not take duloxetine. Because duloxetine can cause liver damage, patients who drink large quantities of alcoholic beverages should not take it.

Mitrazapine (Remeron) is another type of SNRI that is sometimes used for treatment of post-traumatic stress disorder and social anxiety disorder.

Tricyclic Antidepressants. Tricyclics are an older type of antidepressant. Tricyclics used for treatment of anxiety disorder include imipramine (Tofranil, for generalized anxiety disorder, panic disorder), nortriptyline (Pamelor, for panic disorder), desipramine (Norpramin, for panic disorder), and clomipramine (Anafranil, for obsessive compulsive disorder). Clomipramine is approved specifically for OCD, but because of its severe side effects it is usually used only if SSRIs have failed to help.

Side effects of TCAs include sleep disturbance, abrupt reduction in blood pressure upon standing, weight gain, sexual dysfunction, and mental disturbance. Elderly patients and those with a history of seizures, cardiac problems, closed-angle glaucoma, and urinary retention or obstruction should be closely supervised when taking tricyclics.

Monoamine Oxidase Inhibitors. Monoamine oxidase inhibitors (MAOIs) are the oldest type of antidepressant. The MAOI phenelzine (Nardil) is sometimes used to treat social anxiety disorder or post-traumatic stress disorder that has not responded to other treatments.

MAOIs commonly cause weight gain, drowsiness, dizziness, sexual dysfunction, and insomnia. Dietary restrictions are the main problem with these drugs. Severe high blood pressure (hypertension) can be brought on by eating certain foods that have a high tyramine content, including cheese, red wine, and processed meats. High blood pressure can also occur when MAOIs are taken with certain drugs, including some common over-the-counter cough medications and decongestants. MAOIs can cause birth defects and should not be taken by pregnant women.

Most serious, fatal reactions can occur when MAOIs and SSRIs or venlafaxine are taken at the same time. There should be at least a 2- to 5-week break if a patient is changing from one type of antidepressant to the other.

Benzodiazepines are safe and effective medications for most anxiety disorders and have been the standard of treatment for years. However, their on-going use has been associated with a high risk for dependency and abuse. Therefore, they have been supplanted in most cases by SSRIs and other newer antidepressants. For anxiety disorders, benzodiazepines are most often used to treat panic disorder, and are sometimes used for social anxiety disorder and generalized anxiety disorder. These drugs include alprazolam (Xanax), clonazepam (Klonopin), and lorazepam (Ativan).

Benzodiazepines have many side effects, generally associated with chronic use. The most common are daytime drowsiness and a hung-over feeling. In rare cases, they can cause agitation. They may worsen respiratory problems. Benzodiazepines are potentially dangerous when used in combination with alcohol. Overdoses can be serious, although they are very rarely fatal.

The elderly are more susceptible to side effects and should usually start at half the dose prescribed for younger people. These drugs increase the risk of falling, which can increase the risk for hip fracture in older people. Also of concern are studies showing a high risk of automobile accidents in people who take benzodiazepines. Benzodiazepines taken during pregnancy are associated with birth defects, and they should not be used by pregnant women or by nursing mothers.

Loss of Effectiveness and Dependence. Eventually these drugs can lose their effectiveness with continued use at the same dosage. As a result, patients may want to increase their dosage to prevent anxiety. This causes dependency, which can occur after taking these drugs for several weeks.

Withdrawal and its Treatments. Withdrawal symptoms can be very severe, even in people who rapidly discontinue benzodiazepines after taking them for only 4 weeks. Symptoms include sleep disturbance and anxiety, which can develop within hours or days after stopping the medication. Some patients experience stomach distress, sweating, and insomnia, which can last 1 - 3 weeks. The longer the drugs are taken and the higher their dose, the more severe these symptoms can become. Simply tapering off gradually helps about 60% of people stop taking these drugs. Certain medications (anti-seizure drugs, antidepressants, buspirone) may also help with withdrawal.

Azapirones, such as buspirone (BuSpar), act on serotonin receptors called 5-HT(1A). Buspirone appears to work as well as a benzodiazepine for treating generalized anxiety disorder. It usually takes several days to weeks for the drug to be fully effective. It is not useful against panic attacks.

Buspirone does not produce any immediate euphoria or change in sensation, so some people believe, erroneously, that the drug doesn't work. Such qualities result in a very low potential for abuse. In fact, unlike the benzodiazepines, buspirone is not addictive, even with long-term use, so it may be particularly useful for the patient whose anxiety disorder coexists with alcoholism or drug abuse.

Buspirone also seems to have less pronounced side effects than benzodiazepines and no withdrawal effects, even when the drug is discontinued quickly. Common side effects include dizziness, drowsiness, and nausea. Buspirone should not be used with monoamine oxidase inhibitors (MAOIs).

Beta-blockers, including propranolol (Inderal) and atenolol (Tenormin), block the nerves that stimulate the heart to beat faster. They affect only the physiologic symptoms of anxiety (particularly rapid heart rate) and are most helpful for phobias, particularly performance anxiety. They may be taken before entering a situation where anxiety symptoms tend to occur. Beta-blockers are less effective for other forms of anxiety.

Atypical antipsychotics are mostly used for treating schizophrenia, bipolar disorder, and major depressive disorder. Doctors sometimes use the atypical antipsychotic olanzapine (Zyprexa) for treating severe cases of post-traumatic stress disorder. However, olanzapine has severe side effects, including weight gain and increased high blood sugar levels, which can increase the risk for diabetes. [For more information, see In-Depth Report #47: Schizophrenia.]

Pregabalin (Lyrica) and gabapentin (Neurontin) are drugs used to treat seizures and other conditions. Researchers are investigating whether these drugs may be useful for certain anxiety disorders, such as social anxiety disorder and general anxiety disorder. Their exact role in the treatment of anxiety disorders is not clear, however.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Studies indicate that the dietary supplement inositol may have benefits for panic disorder and, possibly, obsessive compulsive disorder. Inositol is part of the vitamin B complex.

Some patients use aromatherapy as a relaxation aid. Aromatherapy is in general safe, but some plant extracts in these formulas have been linked to skin allergies.

There is no evidence supporting the efficacy of valerian, St. John’s wort, or passionflower for treatment of anxiety. The herbal remedy kava has been associated with liver problems and should not be avoided, especially by patients with liver disease or those who use alcohol. Kava can also interact dangerously with medications that are metabolized by the liver.

Other Treatments

The goal of cognitive-behavioral therapy (CBT) is to regain control of reactions to stress and stimuli, thus reducing the feeling of helplessness that often accompanies anxiety disorders. CBT works on the principle that the thoughts that produce and maintain anxiety can be recognized and altered using various techniques that change behavioral responses and eliminate the anxiety reaction. Many studies have shown that a combination of CBT and medication works best for treating anxiety disorders.

A number of CBT approaches work well for treating many types of anxiety disorders. Studies suggest that CBT is also helpful for patients who have additional conditions, such as depression, a second anxiety disorder, or alcohol dependency. (It may take longer to achieve a successful outcome in such cases, however.) CBT is often given along with drug treatment. A study in the Journal of the American Medical Association found that children and adolescents with OCD responded better to CBT alone than the antidepressant setraline (Zoloft) alone, but most patients did best when they were treated with a combination of CBT and sertraline.

Both individual and group treatments work well. (However, people with social phobia may do better in individual sessions.) Several recent studies also indicate that telephone-based behavioral therapy works well for people with OCD, generalized anxiety disorder, and panic disorders.

Anxiety disorders are chronic, however, and recurrence is common. Some studies indicate that 30 - 82% of people with panic disorder and phobias have a recurrence of attacks at an average of 9 months, even after successful short-term therapy. Medications, then, are also generally recommended for most patients.

Basic Cognitive Therapy Techniques. Treatment usually takes about 12 - 20 weeks. The essential goal of cognitive therapy is to understand the realities of an anxiety-provoking situation and to respond to reality with new actions based on reasonable expectations.

First, the patient must learn how to recognize anxious reactions and thoughts as they occur. One way of accomplishing this is by keeping a daily diary that reports the occurrences of anxiety attacks and any thoughts and events associated with them. A patient with OCD, for instance, may record repetitive thoughts.
These entrenched and automatic reactions and thoughts must be challenged and understood. Again, using the OCD example, one approach is to record and play back the words of the repetitive thoughts, over exposing the patient to the thoughts and reducing their effect. One effective approach for patients with generalized anxiety disorder targets their intolerance of uncertainty and helps them develop methods to cope with it.
Patients are usually given behavioral homework assignments to help them change their behavior. For example, a person with generalized social phobia may be asked to buy an item and then return it the next day. As the patient performs this action, they observe any unrealistic fears and thoughts triggered by such an event.
As the patient continues with self-observation, they begin to perceive the false assumptions that underlie the anxiety. For example, OCD patients may learn to recognize that their heightened sense of responsibility for preventing harm in non-threatening situations is not necessary or even useful.
At that point, the patient can begin substituting new ways of coping with the feared objects and situations.

Systematic Desensitization. Systematic desensitization is a specific technique that breaks the link between the anxiety-provoking stimulus and the anxiety response. This treatment requires the patient to gradually confront the object of fear. There are three main elements to the process:

Relaxation training
A list composed by the patient that prioritizes anxiety-inducing situations by degree of fear
The desensitization procedure itself, confronting each item on the list, starting with the least stressful

This treatment is especially effective for simple phobias, social phobias, agoraphobia, and post-traumatic stress syndrome.

Exposure and Response Treatment. Exposure treatment purposefully generates anxiety by exposing the patient repeatedly to the feared object or situation, either literally or using imagination and visualization. It uses the most fearful stimulus first. (This differs from the desensitization process because it does not involve relaxation or a gradual approach to the source of anxiety.)

Exposure treatments are usually known as either flooding or graduated exposure:

Flooding exposes the person to the anxiety-producing stimulus for as long as 1 - 2 hours.
Graduated exposure gives the patient a greater degree of control over the length and frequency of exposures.

In both cases, the patient experiences the anxiety over and over until the stimulating event eventually loses its effect. Combining exposure with standard cognitive therapy may be particularly beneficial. This approach has helped certain patients in most anxiety disorder categories, including post-traumatic stress disorder.

Modeling Treatment. Phobias can often be treated successfully with modeling treatment:

The therapy typically uses an actor who approaches an anxiety-producing object or engages in a fear-provoking activity that is similar to the patient's specific problem. Either a live or videotaped situation may be used, although the live model is considered to be more effective.
The patient observes this event and tries to learn how to behave in a comparable manner.

Other forms of psychotherapy, commonly called emotion-based psychotherapy (EBT), psychodynamic therapy, or "talk" therapy, deal more with childhood roots of anxiety and usually, although not always, require longer treatments. They include interpersonal therapy, supportive psychotherapy, attention intervention, and psychoanalysis. All work is done during the sessions. Some research indicates that such therapies might be more useful for generalized anxiety, which may require more sustained work to process and recover from early traumas and fears. Studies suggest that although emotion-based psychotherapies are not as effective as cognitive-behavioral therapy (CBT) in treating panic disorders, patients tend to stay longer in EBT than in CBT. Some doctors suggest adding elements of EBT to the usual CBT and medication treatments.

Anxiety Management Therapy. Anxiety management therapy is sometimes used as an alternative to CBT for generalized anxiety disorder. It involves patient education, relaxation training, and exposure to anxiety-provoking stimuli but does not include exercises in cognitive retraining.

Relaxation Training. Relaxation techniques use muscle relaxation and mental visualization to help focus attention towards a calming feeling. Some people find meditation helpful.

Breathing Retraining. Breathing retraining techniques may help reduce the physical effects of anxiety. For example, hyperventilation is one of the primary physical manifestations of panic disorders. This involves rapid, tense breathing, resulting in chest pain, dizziness, tingling of the mouth and fingers, muscle cramps, and even fainting. By practicing measured, controlled breathing at the onset of a panic attack, patients may be able to prevent full attacks.

Biofeedback. Biofeedback uses special sensors that allow patients to recognize anxiety states by changes in specific physical functions, such as changes in pulse rate, skin temperatures, and muscle tone. Eventually they learn to modify these changes, which in turn helps relieve anxiety. While commonly used, there are not many rigorous studies showing that biofeedback helps patients reduce or eliminate their symptoms over the long term.

Several types of psychological treatments have been designed specifically for treating patients with PTSD. These approaches include a special type of CBT known as trauma-focused cognitive behavioral therapy (TFCBT), and a psychotherapy treatment called eye movement desensitization and reprocessing (EMDR).

With TFCBT, patients are taught stress management skills. The therapist helps the patient develop a narrative (verbal, written, or artistic) about the traumatic event. Patients may be exposed to reminders about the trauma and are taught how to cope with future reminders. Through the process, the patient learns how to reprocess their thoughts, feelings, and behaviors.

With EMDR, the patient focuses on remembering the traumatic experience while visually following the rhythmic movement of the therapist’s fingers. The patient recounts to the therapist what memories have been provoked during the exercise. EMDR may help patients recall details and sensations that they had blocked out. Through this breakthrough, patients learn how to regain emotional control.

Transcranial magnetic stimulation (TMS) uses high frequency magnetic pulses to target and stimulate specific areas of the brain. Research has particularly focused on possible benefits for obsessive-compulsive behavior. Some studies have found some improvement in mood, but more research is needed to determine its value for reducing anxiety and obsessions.

In 2006, the U.S. National Institutes of Health funded a large study to examine whether deep brain stimulation (DBS) can help patients with OCD. DBS involves implanting tiny stimulators into the brain to block abnormal nerve signals that cause obsessive symptoms. These “brain pacemakers” are approved to treat epilepsy and Parkinson’s disease. Researchers hope that DBS may eventually provide a new treatment option for patients with severe OCD.

A surgical technique called cingulotomy involves interrupting the cingulate gyrus, a bundle of nerve fibers in the front of the brain. It is sometimes used as a last resort for patients with severe OCD. A variation of this procedure using magnetic resonance imaging (MRI) to guide the surgeon has resulted in long-term improvement in about 25 - 33% of OCD patients in whom it is performed. The procedure is generally safe with few serious complications and does not affect intellect or memory.

Resources

www.nimh.nih.gov -- National Institute of Mental Health
www.adaa.org -- Anxiety Disorders Association of America
www.nami.org -- National Alliance on Mental Illness
www.psych.org -- The American Psychiatric Association
www.apa.org -- The American Psychological Association
www.istss.org -- International Society for Traumatic Stress Studies
www.ncvc.org -- National Center for Victims of Crime
www.ncptsd.va.gov -- National Center for Post-Traumatic Stress Disorders
www.rainn.org -- Rape, Abuse, and Incest National Network
www.aacap.org -- American Academy of Child and Adolescent Psychiatry
www.aabt.org -- Association for Behavioral and Cognitive Therapies
www.ocfoundation.org -- Obsessive Compulsive Foundation

References

Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003388.

Bisson JI. Post-traumatic stress disorder. BMJ. 2007 Apr 14;334(7597):789-93.

Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007 Apr 18;297(15):1683-96.

Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007 Feb;46(2):267-83.

Gale C, Davidson O. Generalised anxiety disorder. BMJ. 2007 Mar 17;334(7593):579-81.

Heyman I, Mataix-Cols D, Fineberg NA. Obsessive-compulsive disorder. BMJ. 2006 Aug 26;333(7565):424-9.

Hunot V, Churchill R, Silva de Lima M, Teixeira V. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001848.

Ipser JC, Carey P, Dhansay Y, Fakier N, Seedat S, Stein DJ. Pharmacotherapy augmentation strategies in treatment-resistant anxiety disorders. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005473.

Katon WJ. Clinical practice. Panic disorder. N Engl J Med. 2006 Jun 1;354(22):2360-7.

Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB; American Psychiatric Association. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry. 2007 Jul;164(7 Suppl):5-53.

Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007 Mar 6;146(5):317-25.

Saeed SA, Bloch RM, Antonacci DJ. Herbal and dietary supplements for treatment of anxiety disorders. Am Fam Physician. 2007 Aug 15;76(4):549-56.

Schneier FR. Clinical practice. Social anxiety disorder. N Engl J Med. 2006 Sep 7;355(10):1029-36.

Smoller JW, Pollack MH, Wassertheil-Smoller S, et al. Panic attacks and risk of incident cardiovascular events among postmenopausal women in the Women's Health Initiative Observational Study. Arch Gen Psychiatry. 2007 Oct;64(10):1153-60.

Review Date:
12/25/2007
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

adam.com

Insomnia

FitSugar — Wed, 08 Oct 2008 17:34:55 -0700

Overview

Signs and Symptoms
Causes
Risk Factors
Diagnosis
Preventive Care
Treatment
Other Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

Insomnia is the inability to sleep when sleep should normally occur. Sufficient and restful sleep is a human necessity. The average adult needs slightly more than 8 hours of sleep a day, but only 35% of American adults consistently get this amount of rest.

People with insomnia tend to experience one or more of the following sleep disturbances:

Difficulty falling asleep at night
Waking too early in the morning
Waking frequently throughout the night

Insomnia may stem from a disruption of the body's circadian rhythm, an internal clock that governs the timing of hormone production, sleep, body temperature, and other functions. While occasional restless nights are normal, prolonged insomnia can interfere with daytime function, concentration, and memory. Insomnia increases the risk of substance abuse, motor vehicle accidents, headaches, and depression. Recent surveys indicate that 50% of people suffer from sleep difficulties, and 20 - 36% of them struggle with such difficulties for at least 1 year. Other studies show that one person out of three in the United States has insomnia, but only 20% tell their health care providers about it.

Signs and Symptoms

Not feeling refreshed after sleep
Inability to sleep despite being tired
Daytime drowsiness, fatigue, irritability, difficulty concentrating, and impaired ability to perform normal activities
Anxiety as bedtime approaches

Causes

No known physical or mental condition causes primary insomnia. Everyday anxiety and stress, coffee, and alcohol are the most common culprits.

An underlying medical or psychological condition, such as depression,, often causes secondary insomnia.

About 50% of insomnia cases have no identifiable cause.

Some conditions or situations that commonly lead to insomnia include:

Substance abuse -- consuming excessive amounts of caffeine, alcohol, recreational drugs, or certain prescription medications such as stimulants. Smoking can cause restlessness and quitting smoking may also cause temporary insomnia.
Disruption of circadian rhythms -- shift work, travel across time zones, or vision loss. Circadian rhythms are regulated, in part, by release of a hormone called melatonin from the brain. As individuals age, less melatonin is available for use by the body.
Menopause -- between 30 - 40% of menopausal women experience insomnia. This may be due to hot flashes, night sweats, anxiety, or fluctuations in hormone levels.
Hormonal changes during menstrual cycle -- insomnia may occur during menstruation. Sleep improves mid-cycle with ovulation.
Advanced age -- biological changes associated with aging, underlying medical conditions, and side effects from medications all contribute to insomnia.
Medical conditions -- gastroesophageal reflux (return of stomach contents into the esophagus), fibromyalgia, other chronic pain syndromes, heart disease, arthritis, attention deficit hyperactivity disorder, and obstructive sleep apnea (difficulty breathing during sleep).
Psychiatric and neurologic conditions -- anxiety, depression, manic-depressive disorder, dementia, Parkinson's disease, restless legs syndrome, post-traumatic stress disorder.
Certain medications -- decongestants (such as pseudoephedrine or Sudafed), bronchodilators (such as albuterol or Proventil inhaler), and beta-blockers (such as metoprolol or Lopressor).
Excessive computer work.
Partners who snore.

Risk Factors

The following factors may increase an individual's risk for insomnia:

Age -- the elderly are more prone to insomnia
Stressful or traumatic event
Night shift or changing work schedule
Travel across time zones
Substance abuse
Asthma -- bronchodilators occasionally cause insomnia
Excessive computer work

Diagnosis

Clinical history (including all current medication and recreational drug use) and physical exam are usually sufficient to make the diagnosis. Polysomnography, an overnight sleep study, can be helpful to rule out other types of sleep disorders (such as breathing-related sleeping disorder).

Preventive Care

The following lifestyle changes can help prevent insomnia:

Exercising regularly -- best when done before dinner. Exercise should not be done too close to bedtime because it can cause restlessness.
Avoiding caffeine (especially after noon) and nicotine.
Getting regular exposure to late afternoon sun. This helps to stimulate release of melatonin to regulate circadian rhythm.
Practicing stress reduction techniques, such as yoga, meditation, or deep relaxation.
Early treatment of insomnia may also help prevent psychiatric disorders, such as depression.

Treatment

The preferred treatments for people with chronic insomnia are lifestyle changes and behavioral approaches that establish healthy sleeping habits. This is called improving sleep hygiene.

Mind-body therapies -- such as stimulus control therapy, bright-light therapy, and cognitive-behavioral therapy -- are particularly helpful.

Acupuncture and acupressure have a long tradition of treating insomnia successfully, particularly in the elderly. Vitamins, along with homeopathic and herbal remedies, may also improve symptoms in some individuals.

Lifestyle

Healthy sleep habits are essential for treating insomnia. The following strategies (in addition to the steps mentioned in the "Preventive Care" section) may help treat the condition:

Maintain a consistent sleeping and waking time.
Establish the bedroom as a place for sleep and sexual activity only, not for reading, watching television, or working.
Avoid naps, especially in the evening.
Take a hot bath about 2 hours before bedtime.
Keep the bedroom cool, well-ventilated, quiet, and dark.
Avoid looking at the clock -- this promotes anxiety and obsession about time.
Avoid fluids just before bedtime.
Avoid exercising before bedtime.
Avoid television just before bedtime.
Eat a carbohydrate snack, such as cereal or crackers, just before bedtime.
Move to another room with dim lighting if sleep does not occur within 15 - 20 minutes in bed.

Medications

If changes in sleep hygiene do not help, prescription medications (including benzodiazepines) may be appropriate. Benzodiazepines include temazepam (Restoril), flurazepam (Dalmane), estazolam (ProSom), and triazolam (Halcion). Benzodiazepines may cause psychological and physical dependence. Physical withdrawal symptoms may occur if the drug is not carefully tapered following long-term use. Most common side effects of benzodiazepines include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heart beat.

Another class of sedative hypnotic medications includes the non-benzodiazepine, benzodiazepine receptor agonists. These newer medications appear to have better safety profiles and fewer adverse effects than the benzodiazepines. They are also associated with a lower risk of abuse and dependence than the benzodiazepines, although abuse and dependence do occur. Examples of medications in this class include zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta).

Ramelteon (Rozerem) belongs to a new class of drugs called melatonin agonists. Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize normal circadian rhythm and sleep/wake cycles. Side-effects may include daytime sleepiness, dizziness, and fatigue.

Over-the-counter (OTC) antihistamines may be used short-term for insomnia. Diphenhydramine (Benadryl) is the most commonly used OTC antihistamine sleep aid, and can be purchased alone (Benadryl, Nytol, Sominex) or in combination with other OTC items, such as acetaminophen (Tylenol PM). Diphenhydramine can cause sedation, dry mouth, and constipation. In the elderly, diphenhydramine can cause confusion and oversedation.

Generally, OTC and prescription medications help promote sleep, but they are not recommended for insomnia that last for more than 4 weeks. Long-term use of some medications may cause addiction, particularly if the patient has a history of substance abuse.

Nutrition and Dietary Supplements

Following these nutritional tips may help reduce symptoms:

Eliminate all potential food allergens, including dairy, wheat (gluten), soy, corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
Eat more antioxidant rich foods (such as green leafy vegetables) and fruits (such as blueberries, pomegranates, and cherries).
Avoid refined foods, such as white breads, pastas, and sugar.
Eat fewer red meats and more lean meats, cold-water fish, or beans for protein.
Use healthy cooking oils, such as olive oil or vegetable oil.
Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
Avoid coffee and other stimulants, alcohol, and tobacco.
Drink 6 - 8 glasses of filtered water daily.
Exercise 30 minutes daily, 5 days a week. Exercising in the evening after dinner may lead to insomnia.
Foods rich in carbohydrates and low in protein and fat may boost the production of serotonin and melatonin, brain chemicals that are associated with sleep. A carbohydrate snack of granola, non-sweetened cereals, or crackers with milk before bed may help.

The following dietary supplements may also be helpful in promoting sleep:

A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tbsp. oil one to three times daily, to help decrease inflammation and help with mental balance.
Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
5-hydroxytryptophan (5-HTP), 50 mg two to three times daily, for mood stabilization and sleep improvement.
L-theanine, 200 mg one to three times daily, for nervous system support.
Melatonin, 1 - 6 mg one hour before bedtime, for sleep and immune protection. Ask your health care provider about potential prescription interactions.

L-tryptophan and 5-hydroxytryptophan (5-HTP)

Medical research indicates that taking 1 g L-tryptophan before bedtime can induce sleepiness and delay wake times. Researchers think L-tryptophan brings on sleep by raising levels of serotonin, a body chemical that promotes relaxation. However, consumers should take this supplement with caution as it may adversely interact with certain antidepressants [including selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs)] and cause serious negative side effects. Reports of eosinophilia myalgia syndrome (EMS: an autoimmune disorder characterized by fatigue, fever, muscle pain and tenderness, cramps, weakness, hardened skin, and burning, tingling sensations in the extremities) from contaminated L-tryptophan supplements surfaced in 1989, and isolated incidents of EMS continue to be reported.

Studies also suggest that 5-hydroxytryptophan (5-HTP), made from tryptophan in the body or available in supplement form, may be useful in treating insomnia associated with depression. Like tryptophan, reports of EMS have been associated with use of 5-hydroxytryptophan. Talk to a health care professional before taking 5-HTP supplements if you are on antidepressant medications. Drug interactions may occur.

Melatonin

Melatonin supplements help induce sleep, particularly in people who have disrupted circadian rhythms (such as from jet lag or shift work), or those with low levels of melatonin (such as some people with schizophrenia). In fact, a recent review of scientific studies found that melatonin supplements help prevent jet lag, particularly in people who cross five or more time zones. A few clinical studies suggest that melatonin is significantly more effective than placebo, or dummy pill, in decreasing the amount of time required to fall asleep, increasing the number of sleeping hours, and boosting daytime alertness. Although research suggests that melatonin may be modestly effective for treating certain types of insomnia, few studies have investigated whether melatonin supplements are safe and effective for long term use. More research is needed in this area.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink two to four cups per day. You may use tinctures alone or in combination as noted:

Kava kava (Piper methysticum) standardized extract, 100 - 250 mg one to three times daily, as needed for relaxation. Kava should not be used in those with liver problems or those drinking alcohol in excessive quantities.
Rhodiola (Rhodiola rosea ) standardized extract, 100 - 600 mg daily, for antioxidant and antistress activity.
Valerian (Valeriana sp.) standardized extract, 200 - 400 mg at bedtime, for sleep.
Chamomile (Anthemis nobilis), standardized extract, 400 - 1,600 mg daily, for relaxation. A tea may be prepared from chamomile flowers. Chamomile is not recommended for individuals allergic to flowers in the daisy family.

Homeopathy

A few studies have examined the effectiveness of specific homeopathic remedies. However, a professional homeopath may recommend one or more of the following treatments for insomnia, based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

Aconitum -- for insomnia that occurs as a result of illness, fever, or vivid, frightening dreams; commonly used for children.
Argentum nitricum -- for impulsive children who are restless and agitated before bedtime and cannot fall asleep if the room is too warm.
Arsenicum album -- for insomnia that occurs after midnight due to anxiety or fear. This remedy is most appropriate for demanding individuals who are often restless, thirsty, and chilly.
Chamomilla -- for insomnia caused by irritability or physical pains; sleep may be disturbed by twitching and moaning. This remedy is appropriate for infants who have difficulty sleeping because they are teething or colicky, and older children may demand things, then refuse them when they are offered.
Coffea -- for insomnia due to excitable news or sudden emotions. This remedy is most appropriate for individuals who generally have difficulty falling asleep and tend to be light sleepers. Often used to counteract the effects of caffeine, including in infants exposed to caffeine through breast-feeding.
Ignatia -- for insomnia caused by grief or recent loss. This remedy is most appropriate for individuals who yawn frequently or sigh while awake.
Kali phosphoricum -- for night terrors associated with insomnia. This remedy is most appropriate for individuals who are easily startled and restless, often with fidgety feet. Anxiety is often caused by both nightmares and events in the individual's life.
Nux vomica -- for insomnia caused by anxiety, anger, irritability, or use of caffeine, alcohol, or drugs. This remedy is most appropriate for individuals who wake up early in the morning, or for children who often have dreams of school or fights and may be awakened by slight disturbances. Nux vomica may also be used to treat insomnia that occurs as a side effect of medications.
Passiflora -- for the elderly and young children with often overactive minds.
Pulsatilla -- for women and children who are particularly emotional and do not like sleeping alone. Also used when sleeping in a warm room tends to worsen insomnia or when the individual may cry due to the inability to fall asleep.
Rhus toxicodendron -- for restlessness and insomnia caused by pains that occur when the individual is lying down.

Acupuncture

Some reports suggest that certain acupuncture procedures have a nearly 90% success rate for the treatment of insomnia. Through a complex series of signals to the brain, acupuncture increases the amount of certain substances in the brain, such as serotonin, which promote relaxation and sleep.

Several clinical studies have found that auricular acupuncture is effective in reducing symptoms of insomnia, such as difficultly in falling asleep and remaining asleep. Auricular acupuncture uses needles placed at various points in the ear. Further studies should be performed.

Clinical studies of elderly people with sleep disturbances suggest that acupressure enhances sleep quality and decreases awakenings during the night. An acupressure practitioner works with the same points used in acupuncture, but stimulates these healing sites with finger pressure, rather than inserting fine needles. Clinical studies support the use of auricular (ear) acupressure for improving sleep quality in elderly patients and possibly in healthy adults of all ages. A small clinical study also found that acupressure may help with sleep apnea.

Chiropractic

No well-designed studies have evaluated the effect of chiropractic care on individuals with insomnia, but chiropractors report that spinal manipulation may improve symptoms of the condition in some individuals. In these cases, spinal manipulation may have a relaxing effect on the nervous system.

Massage and Aromatherapy

Massage has long been known to enhance relaxation and improve sleep patterns. While massage alone is an effective method for relaxation, studies suggest that massage with essential oils (called aromatherapy), particularly lavender (Lavandula angustifolia), may result in improved sleep quality, more stable mood, increased mental capacity, and reduced anxiety. Clinical studies have found participants who received massage with lavender felt less anxious and more positive than participants who received massage alone.

Mind-Body Medicine

A variety of behavioral techniques have proved helpful in treating insomnia. These methods, with the guidance of a sleep specialist or a sleep specialty team, are singly used to treat insomnia, but they may also be combined with other treatment methods including:

Sleep Diary. Keeping a daily/nightly record of sleep habits (including the amount of sleep, how long it takes to fall asleep, the quality of sleep, the number of awakenings throughout the night, any disruption of daytime behaviors, attempted treatments and how well they worked, mood, and stress level) can help a person understand and, consequently overcome their insomnia.
Stimulus Control Techniques. This technique involves learning to use the bedroom only for sleep and sexual activity. Individuals using this technique learn to go to bed only when tired and leave the bedroom when they’re not sleeping. They wake up at the same time every day, including weekends and vacations, regardless of the amount of sleep they had.
Sleep Restriction. This method improves sleep "efficiency" by attempting to sleep at least 85% of time spent in bed asleep. The time spent in bed is decreased each week by 15 - 20 minutes until the 85% goal is achieved. Once accomplished, the amount of time in bed is increased again on a weekly basis.
Relaxation Training Techniques. Progressive relaxation, meditation, yoga, guided imagery, hypnosis, or biofeedback can break the vicious cycle of sleeplessness by decreasing feelings of anxiety about not being asleep. Studies indicate that these therapies significantly reduce the amount of time it takes to fall asleep, increase total sleep time, and decrease the number of nightly awakenings.
Cognitive-Behavioral Therapy. This therapy is intended to re-establish healthy sleep patterns by helping an individual cope with their sleep problem. One cognitive-behavioral approach, called paradoxical intention, helps to retrain an individual's fears of sleep by doing the opposite of the behavior that causes anxiety. For example, a person with insomnia worries long before going to bed about not being able to sleep and the difficulty they will have at bedtime. Rather than preparing to go to sleep, the person prepares to stay awake. Another cognitive-behavioral technique, called thought stopping, allows a person with insomnia a certain period of time to repeatedly and continuously think about going to bed. This technique helps "wear out" the anxiety associated with going to bed, and decreases the likelihood that he they will obsess about falling asleep at other times.

Traditional Chinese Medicine

Many methods have been used historically in Traditional Chinese Medicine to treat insomnia, including herbal remedies, acupuncture, acupressure, Chinese massage (tui na), and qi gong.

Other Considerations

Pregnancy

Insomnia usually occurs in the later months of pregnancy when the mother's size and need to urinate disrupt sleep.
Women who are pregnant and nursing mothers should avoid benzodiazepines.

Warnings and Precautions

People who are taking prescription medications or over-the-counter sleeping pills should avoid alcohol.
Discontinuing prescription medications or over-the-counter sleeping pills can lead to rebound insomnia.

Prognosis and Complications

Most people who have insomnia with no underlying medical conditions recover within a few weeks. For those who develop insomnia from a traumatic event (such as those with posttraumatic stress disorder), sleep disruptions can continue indefinitely. People who become dependent on sleeping pills and prescription medication for sleep often have the most difficulty overcoming insomnia.

Supporting Research

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Review Date:
12/7/2007
Reviewed By:
Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

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Extra! Extra! Sleepytime Tea

FitSugar — Tue, 07 Nov 2006 17:12:00 -0800

After dealing with my baby’s sleep issues (or should I say, her apparent aversion to a good night's sleep), I developed a few of my own. Mostly, I’ve become a light sleeper. My husband’s snoring often pulls me from my luscious slumber. Then I can’t fall back to sleep and my mind starts playing the “What if?” game. It's a vicious cycle.

Lately, my after dinner drink has been a giant mug of Celestial Seasonings SleepyTime Extra Wellness Tea – fortified with Valerian root. The herb Valerian has a similar affect on the brain as Valium - but you don't need a prescription for it and it is not addictive. A number of studies have proven its calming affect on the central nervous system.

It really seems to be helping me. It's not that I don't wake up, but lately I have a much easier time falling back to sleep.

So drink up (the tea, that is).