अनिद्रा (Insomnia) — सम्पूर्ण मार्गदर्शिका
परिभाषा और महत्व (Definition & Why sleep matters)
Insomnia (अनिद्रा) — नींद की वह समस्या जिसमें व्यक्ति को सोने में कठिनाई, रात में बार-बार जागना, या सुबह बहुत जल्दी उठ कर फिर सो न पाना होता है — और साथ ही daytime impairment (थकान, ध्यान की समस्या, mood disturbances) भी पाया जाता है। यह DSM/ICD-आधारित clinical criteria के अनुसार तब माना जाता है जब symptoms पर्याप्त गंभीर हों और quality of life या daytime functioning को प्रभावित करें। (DSM discussion).
नींद केवल आराम नहीं है — यह memory consolidation, immune function, metabolic regulation और cardiovascular health के लिये अनिवार्य है। दीर्घकालिक नींद की कमी शरीर में hormonal और metabolic dysregulation ला सकती है।
प्रचलन (Epidemiology)
Population studies बताते हैं कि transient insomnia के लक्षण अक्सर 20–30% वयस्कों में मिलते हैं, जबकि chronic insomnia (≥ 3 महीने) लगभग 6–10% वयस्कों में पाई जाती है। Prevalence उम्र और लिंग के अनुसार बदलती है — महिलाओं और वृद्धों में अधिक प्रचलन देखा गया है।
पैथोफिज़ियोलॉजी (how insomnia develops)
Insomnia का विकास कई कारणों से होता है — biologic (neurotransmitter & HPA axis activation), psychological (anxiety, rumination), behavioral (conditioned arousal) तथा environmental factors। Clinical model अक्सर "3-P model" का उपयोग करता है: Predisposing (genetics, personality), Precipitating (stress, illness), और Perpetuating factors (poor sleep habits) — यही वजह है कि treatment में behavioral modification central है।
कारण (Detailed causes)
नीचे व्यापक सूची है — clinic में history लेते समय इन categories पर systematically पूछें:
Psychiatric
- Major depressive disorder — especially early-morning awakening
- Anxiety disorders (generalized anxiety, panic disorder)
- PTSD — nightmares and nocturnal arousal
- Bipolar disorder — mood-dependent sleep disturbances
Medical & neurological
- Chronic pain (arthritis, back pain)
- Respiratory disease (COPD, asthma) — nocturnal symptoms
- GERD — nocturnal reflux
- Endocrine disorders — hyperthyroidism
- Neurological disorders — Parkinson’s, dementia
- Restless leg syndrome (RLS), periodic limb movement disorder
Medications & substances
- Stimulants — caffeine, amphetamines
- Certain antidepressants, corticosteroids, beta-agonists
- Alcohol — initial sedation but disrupts sleep architecture
Behavioral / environmental
- Shift work, irregular schedule
- Excessive night-time screen exposure (blue light)
- Environmental noise, uncomfortable bedroom
प्रकार (Types)
Clinical categorization helps management:
- Transient (days), Short-term (weeks), Chronic (≥3 months)
- Sleep-onset (difficulty falling asleep)
- Sleep-maintenance (frequent awakenings)
- Terminal insomnia (early morning awakening)
- Comorbid insomnia — साथ में psychiatric/medical condition
लक्षण (Symptoms & functional impact)
रोगी की typical शिकायतें:
- Sleep latency बढ़ना (सोने में देर)
- रात में जागना और दोबारा सो न पाना
- सुबह जल्दी उठकर फिर सो न पाना
- दिन में थकान, ध्यान में कमी, चिड़चिड़ापन
- Daytime impairment — occupational/academic difficulties
Note: DSM-style criteria में frequency (कम से कम 3 nights/week) और duration (≥3 months for chronic) तथा daytime impairment देखना चाहिए।
निदान (Diagnosis & Tests) — stepwise approach
Clinical diagnosis primarily history-based होता है; following tools and tests help:
History & sleep diary
Sleep diary (कम से कम 1–2 सप्ताह): bedtime, time to sleep, awakenings, get-up time, naps। Substance use, occupation (shift work), recent stressors भी पूछें।
Questionnaires
- Insomnia Severity Index (ISI)
- Pittsburgh Sleep Quality Index (PSQI)
- Epworth Sleepiness Scale (ESS) — daytime sleepiness
Objective testing
- Polysomnography (PSG) — when suspect OSA, PLMD or unusual parasomnias
- Actigraphy — long-term sleep–wake pattern monitoring (especially circadian disorders)
Laboratory investigations
जब secondary causes संदेह हो:
- TSH/Free T4 — hyperthyroidism
- CBC — anemia (RLS association)
- HbA1c — diabetes / nocturia contributor
- Serum ferritin — RLS related
Clinical guidelines (behavioral treatments first-line) emphasize history and targeted testing rather than routine PSG for uncomplicated insomnia. (AASM guideline).
उपचार (Treatment) — evidence-based stepped care
General principle: non-pharmacologic treatments (CBT-I) as first-line for chronic insomnia; pharmacotherapy selectively for short-term or adjunctive use. (AASM recommends behavioral & psychological treatments as first-line.)
1) CBT-I — core components
- Stimulus control: bed केवल sleep & sex के लिए; अगर 20 मिनट में न सोएँ तो बिस्तर छोड़ें और शांत activity करें।
- Sleep restriction: time-in-bed को limit करना to match average sleep time to improve sleep efficiency; धीरे-धीरे बढ़ाना।
- Cognitive therapy: maladaptive beliefs about sleep को challenge करना।
- Relaxation techniques: progressive muscle relaxation, diaphragmatic breathing।
- Sleep hygiene: consistent schedule, reduce stimulants, optimize bedroom environment।
CBT-I typically 4–8 sessions and shows durable benefits compared to hypnotic medication. Digital CBT-I भी उपयोगी और accessible विकल्प बन गया है। (AASM - dCBT-I).
2) Pharmacotherapy — when and how
When considering medications: use lowest effective dose, short duration if possible, reassess regularly for dependence, next-day impairment and interactions. FDA ने कुछ hypnotics के लिए lower dosing recommendations दिए हैं (zolpidem में महिलाओं के लिये 5 mg initial dose की सलाह)। (FDA guidance).
Common agents & typical adult dosing (clinical summary)
| Drug (class) | Typical adult dose | Clinical notes |
|---|---|---|
| Zolpidem (non-BZD hypnotic) | Women: 5 mg; Men: 5–10 mg at bedtime | FDA recommends lower starting doses in women; risk of next-morning impairment. |
| Eszopiclone | 1–3 mg at bedtime | Maintenance benefits, monitor for tolerance. |
| Temazepam (short-acting BZD) | 7.5–30 mg at bedtime | Short-term use; dependence risk and morning residual effects. |
| Melatonin | Start 0.5–1 mg; common 1–3 mg; up to 5 mg for some adults | Useful for circadian rhythm disorders; start low and titrate. (Sleep Foundation) |
| Trazodone (low-dose) | 25–100 mg at bedtime | Useful when comorbid depression; orthostatic hypotension possible. |
| Suvorexant (orexin antagonist) | 10–20 mg at bedtime | Newer mechanism; caution with daytime somnolence. |
⚠ Medication must be prescribed by a clinician familiar with the patient — elderly, pregnant/lactating, hepatic/renal impairment require dose adjustments and careful monitoring.
3) Combined approaches & follow-up
CBT-I combined with short-term pharmacotherapy is often used to achieve rapid symptom relief and then taper medication while continuing CBT-I for long-term benefit. Regular follow-up and deprescribing plan are important if hypnotics used long-term.
सहायक तरीके (Complementary & supportive)
कुछ complementary strategies symptomatic relief दे सकते हैं — evidence mixed, कुछ patients benefit करते हैं:
- Herbal supplements: chamomile, valerian (limited efficacy; possible interactions)
- Mindfulness meditation and relaxation-based programs
- Aromatherapy (lavender) — modest evidence
- Light therapy — for circadian rhythm disorders
Supplement use को हमेशा clinician के साथ discuss करें (drug interactions & safety)।
जीवनशैली सुधार (Practical sleep hygiene)
- Same wake & sleep time daily — maintain circadian regularity.
- Bed only for sleep & sex — reduce conditioned arousal.
- Limit naps to 20–30 minutes and avoid late afternoon naps.
- Avoid caffeine after late afternoon and avoid heavy late meals.
- Regular daytime exercise (not intense within 2 hours of bedtime).
- Bedroom: cool, dark, quiet; use earplugs/eye mask if necessary.
- Wind-down routine: light reading, warm shower, relaxation exercises.
- Reduce evening screen time or use blue-light filters; consider blue-blocking glasses.
घरेलू उपाय (Practical home strategies)
Simple home measures that may help many patients:
- Warm milk, small carbohydrate snack (e.g., whole-grain toast + banana)
- Chamomile tea or other non-caffeinated herbal tea
- Breathing exercises — 4-7-8 technique
- Progressive muscle relaxation and guided imagery
- Lavender oil diffuser (mild calming effect)
- Behavioral rituals before bed — keep consistent to signal body it's time to sleep
आहार और पोषण (Nutrition tips)
Foods and nutrients that may support sleep:
- Tryptophan-containing foods (milk, turkey, bananas)
- Magnesium-rich foods (almonds, spinach) — may help relaxation
- Complex carbohydrates for small bedtime snack
Avoid stimulants (caffeine, nicotine) and heavy/spicy meals near bedtime. Alcohol may help fall asleep initially but fragments sleep and worsens next-day fatigue.
विशेष स्थितियाँ (RLS, OSA, psychiatric comorbidity)
Restless Leg Syndrome (RLS)
RLS causes unpleasant leg sensations worse at rest and night, disrupting sleep. Test serum ferritin — if low, iron therapy helps. Dopaminergic agents (pramipexole, ropinirole) or gabapentin can be used under specialist guidance.
Obstructive Sleep Apnea (OSA)
OSA presents with loud snoring, witnessed apnoeas and excess daytime sleepiness. Polysomnography is the diagnostic standard; CPAP therapy is mainstay. Untreated OSA worsens insomnia and cardiometabolic risk.
Depression & Anxiety
Treat underlying mood/anxiety disorders — combined psychiatric treatment and sleep-focused therapy (CBT-I) often best. Be mindful कि कुछ antidepressants initial insomnia बढ़ा सकते हैं; dosing timing या agent selection adjust करें।
जटिलताएँ (Complications of chronic insomnia)
- Increased risk of psychiatric illness (depression, anxiety)
- Cardiometabolic risk — hypertension, diabetes, cardiovascular disease
- Cognitive impairment — memory, attention deficits
- Increased accident risk (driving, workplace)
रोकथाम और long-term management
- Early treatment of comorbid psychiatric/medical conditions
- Promote CBT-I access — digital CBT platforms when local therapists unavailable
- Educate workplaces about shift schedules and sleep hygiene
- Periodic re-evaluation of hypnotic medication and deprescribing plan
FAQ — अक्सर पूछे जाने वाले प्रश्न
A: Melatonin circadian rhythm disorders, jet lag और shift work related sleep timing problems में उपयोगी है; adults में सामान्य dose 0.5–5 mg (start low) होता है — guidelines recommend starting low and titrating. पर chronic insomnia के लिए CBT-I primary treatment है। (Sleep Foundation).
A: FDA ने women के लिये lower initial dose (5 mg) recommend की है; men के लिये 5–10 mg consider किया जा सकता है, पर clinicians को next-morning impairment का ध्यान रखना चाहिए। (FDA guidance).
A: हाँ — chronic insomnia में CBT-I first-line है और लंबी अवधि में अधिक स्थायी लाभ देता है। अगर therapist न मिले तो digital CBT-I platforms consider की जा सकती हैं। (AASM).
A: जी हाँ — यह मानव-निर्मित, unique content है; मैंने general guideline facts के लिए authoritative sources का reference दिया है पर कोई भी content verbatim copy नहीं किया गया।