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Insomnia

Insomnia is a mental health disorder in which a person has trouble falling asleep or staying asleep.  These sleep troubles are severe enough to interfere with the insomniac’s daily functioning and cause significant distress.

Primary insomnia is listed in the Diagnostic and Statistical Manual for Mental Health Disorders fourth Edition (DSM IV) as having these diagnostic criteria:

  • The patient has troubles going or staying asleep, or the sleep is not restorative
  • The sleep problems last for a minimum of one month
  • The sleep troubles cause significant problems in daily functioning, such as functioning at work
  • The sleep troubles are not the result of another mental health disorder
  • The sleep troubles are not the result of substances (such as drugs) or from a medical problem

Insomnia can also be secondary, meaning that it occurs as a result of a known cause, such as a health disorder or triggers like drugs.  Insomnia can also be comorbid, meaning that it is primary insomnia also occurring with another health disorder such as depression.

What Causes Primary Insomnia Disorder?

Insomnia

Secondary insomnia can be caused by psychological issues such as anxiety.

By definition, there is no known cause of primary insomnia disorder.  However, primary insomnia can result partly as a result of psychological conditioning in which a person begins to associate the normal place of sleep with wakefulness.  In these cases, the insomniac originally had trouble sleeping due to a known cause, such as stomach pains.  As the period of secondary insomnia continues, a person begins to associate the bed with the struggle to sleep.  Once the person’s underlying condition – like the stomach pain – is resolved, he/she still associates the bed with sleep difficulties and develops primary insomnia.

Secondary insomnia can be caused by a wide variety of factors including health conditions such as bodily pain, anxiety disorders, breathing problems, or drug use, amongst others.  About half of insomnia cases are linked to mental health disorders.  However, some experts dispute the prevalence of secondary insomnia and instead believe that many of these cases should be diagnosed as comorbid insomnia as the sleep troubles often began before the symptoms of the other condition.

It is very important for physicians to find out the cause of insomnia before they recommend a treatment.  By misdiagnosing the cause of insomnia, patients could receive potentially dangerous treatments – such as a prescription of sedating medications to a patient whose insomnia is due to breathing problems.

Complications from Insomnia

Chronic insomnia can cause significant complications – including socially, physically, and psychologically.  Lack of sleep can cause low cognitive performance, difficulties focusing, stress, emotional distress, and a wide array of physical ailments.  Lack of sleep is associated with a significantly higher accident and mortality rate.

Further, some medications for insomnia – both prescription and non prescription – can cause complications.  Sedative drugs like benzodiazepines carry a risk of dependency, withdrawal effects, and addiction.  Other medications can cause complications ranging from psychotic reactions to amnesia.

How Common is Insomnia?

Insomnia is a very common problem and affects about 10-17% of adults in the United States.  In 2002, a survey showed that 58% of US adults had insomnia symptoms at least a few days a week.  Insomnia is more common in middle-age adults than the elderly, youths, or children.

Sleep: Are You Getting Enough?

What Treatments are Available for Insomnia?

In cases of secondary insomnia, it is crucial that the underlying condition causing the insomnia is treated.  However, patients may be given medications such as sleeping pills or be instructed to use certain relaxation techniques in order to aid in sleeping until the primary condition can be treated.

In cases of primary insomnia, there are numerous routes of treatment available to patients.  There are many over-the-counter alternative remedies for insomnia which have shown effective, such as valerian tea, hypnosis, or breathing techniques. Melatonin is another popular and effective treatment for insomnia and is widely available as a supplement.

Many prescription drugs also exist for treating insomnia but these must be used in extreme caution because of their potential risks and side effects.  Benzodiazepine drugs which are popular for treating insomnia can lead to addiction and severe withdrawal symptoms  of which include insomnia.  Because of the risks of these drugs, they are only indicated for short-term use of a few days to weeks. Further, benzodiazepines and many other prescription drugs for insomnia cause rebound insomnia when treatment is ceased.  Low doses of antidepressants may also be used for treating insomnia though they too have possible side effects and may take a while before patients experience benefits.

Cognitive and/or behavioral treatments are the most widely-recommended first-line treatment for insomnia because of the lack of side effects and long-term efficacy.  With stimulus control therapy, the goal is to create a cognitive connection between the bed and sleeping.  The treatment is very simple and essentially involves the patient refraining from any activity but sleep in the bed.

Sleep restriction therapy is a form of behavioral therapy in which patients are prohibited from spending more time in bed than they normally would spend asleep.  For example, an insomniac may spend hours in bed trying to fall asleep and eventually succeed to get only two hours of sleep.  With sleep restriction therapy, that person would be limited to spending two hours in bed per night.  The patient would then become increasingly sleep deprived as the therapy progressed, resulting in faster, uninterrupted, and better quality of sleep over time. When the patient is sleeping for the majority of the two hours, then the amount of time allowed in bed would be increased.

Sleep hygiene therapy is a cognitive behavioral therapy which works by first educating patients about insomnia and factors which contribute to it – like diet, exercise, and lifestyle.  By making changes to these contributory factors, the patient will be able to sleep better.

References:

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (Revised 4th ed.). Washington, DC: Author.

Eddy, Mark, Ph.D., and Gordon S. Walbroehl, MD. “Practical Therapeutics: Insomnia.” American Family Physician, (1 April 1999).  Web.

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