Insomnia

Contrary to what a lot of people believe, the term “insomnia” doesn’t only refer to when people can’t sleep at all. It also refers to the common kind of sleep problem; struggles to fall asleep at night, or waking up in the middle of the night and struggling to get back to sleep. Or both. With the various effects that this may then have on your ability to function properly during the day.

Insomnia defined

Physiologically insomnia is associated with hyperarousal of the central nervous system. The typical symptoms of insomnia are: repeated difficulty falling asleep, prolonged awakenings, inadequate sleep quality, short sleep duration occurring despite adequate opportunity for sleep. However, some people with insomnia do not have complaints regarding the quantity of sleep, but rather describe their sleep as nonrestorative or too light. This may be because insomniacs tend to spend more time in NREM stage 1 sleep, and less time in stages 3-4, and have more frequent shifts between sleep stages through the night [Ref. 1].

To be considered a medical disorder, insomnia must result in some degree of daytime impairment, and accordingly the World Health Organisation defines insomnia as a problem initiating and/or maintaining sleep, or the complaint of nonrestorative sleep, that occurs on at least three nights a week, and is associated with daytime distress or impairment. It may therefore be useful to think of insomnia in terms of a syndrome, consisting of the symptoms as mentioned above, combined with effects on a person’s mood (e.g. irritability, low level depression, low stress tolerance), on their cognitive functioning (e.g. concentration, performing complex abstract/creative tasks, completing tasks), or on their general energy level (e.g. fatigue) [2].

Depending on the stringency in the criteria for insomnia, different studies report insomnia to occur in anywhere between 10% and 50% of adults at any given time. Insomnia that lasts less than one month is considered as ‘acute’, and can usually be explained by changes in sleep environment, emotional or physical discomfort, stress and similar factors. When insomnia persists beyond one month, it is considered as ‘chronic’, and has often taken on a life of its own [3].

Effects of insomnia

While sleep loss (deprivation) is a common complaint from people who suffer from insomnia, the actual sleep loss is usually less than what is reflected by the patient’s subjective complaints. Similarly, studies show that effects on cognitive performance (memory, judgement, creativity, mental flexibility, attention, concentration) are less than subjectively experienced [1]. Unquestionably though, insomnia does have a detrimental impact on psychological well-being and quality of life, including the ability to enjoy interpersonal relationships [4]. It is a risk factor for development of depression, anxiety, substance abuse, and is associated with increased motor vehicle and other accidents [2].

Primary and Secondary insomnia

Traditionally insomnia has been separated into primary (not caused by other conditions) and secondary (caused by e.g. physical or mental disorders, or by medications). The distinction between primary and secondary insomnia may, however, become obsolete, since more and more research appears to indicate that insomnia is always caused by something, and is perhaps also causing something in turn [5]. It may therefore be more useful to think in terms of insomnia ‘associated with’ another disorder, than to try and distinguish which is the cause and which the effect. As long as extrinsic factors (see below) that contribute to insomnia are not overlooked and are adequately addressed, psychotherapy treatment of all insomnia is warranted [6].

Factors associated with insomnia

Extrinsic factors that may contribute to insomnia are:

• Current medication or other drugs; e.g. alcohol, caffeine, nicotine, amphetamines, reserpine, clonidine,  SSRI antidepressants, steroids, etc.
• Withdrawal from drugs or medication; e.g. benzodiazepines, barbiturates, alcohol etc.
• Poor sleep environment; e.g. noise, ambient temperature, light, sleeping surface, bed partner, family pets etc.
• Poor sleep habits; extended time in bed, naps, irregular schedule etc.
• Situational factors; life stress, bereavement, unfamiliar sleep environment, jet lag, shift work etc.

Other factors that are often associated with insomnia are:

• Medical conditions; e.g. chronic and acute pain conditions (arthritis, fibromyalgia, back pain, headaches), asthma, diabetes, cardiac conditions, hyperthyroidism, gastroesophageal reflux disease, Alzheimer’s disease, kidney disease etc.
• Psychiatric illness; e.g. major depression, generalised anxiety disorder, post traumatic stress disorder (PTSD), panic disorder, bipolar disorder, dementia, schizophrenia etc. [3].

Insomnia treatments

Sleeping tablets and other sedatives are prescribed to over 95% of people who seek medical help for insomnia [7]. The most commonly used class of sleeping medication prescribed for insomnia are the benzodiazepines, which come in various formulations (e.g. Zaleplon, Zolpidem, Eszopiclone, Triazolam, Temazepam, Estazolam, Quazepam, Flurazepam). It should be noted that benzodiazepines promote light sleep and decrease deep sleep, and are therefore only recommended for short-term use. Benzodiazepines also have side effects, such as daytime fatigue, cognitive impairments, impaired motor speed and coordination, and increased risk for motor vehicle accidents [2]. They can furthermore cause physical dependence, manifesting as withdrawal symptoms (rebound insomnia) if the drug is not carefully tapered down.

Notwithstanding their side effects, drugs do produce quicker and slightly better results in the acute phase (first week of treatment) than non-pharmaceutical treatment, such as sleep hygiene, stimulus control, behavioural interventions, and relaxation therapy. In the short-term (4-8 weeks) non-pharmaceutical treatment is equally effective, however. With regard to long term effectiveness, sleep improvements are well sustained after behavioural interventions, whereas with drug therapy sleep improvements are quickly lost after medication is discontinued [1].

Both as a first line and long term solution for overcoming insomnia, therefore, the recommendation is to use a drug-free treatment that integrates psychotherapy, sleep hygiene, behavioural interventions and mental relaxation into a highly effective strategy; Relax-the-Mind Sleep Therapy!

References:

1. Morin, C. M., & Espie, C. A. (2003). Insomnia: A clinical guide to assessment and treatment. New York: Kluwer.
2. Buysse, D. J., Germain, A., Moul, D., & Nofzinger, E. A. (2005). Insomnia. In D. J. Buysse (Ed.), Sleep Disorders and Psychiatry (Vol. 24, pp. 29-75). Washington, DC: American Psychiatric Publishing.
3. Smith, M. T., Smith, L. J., Nowakowski, S., & Perlis, M. L. (2003). Primary insomnia: Diagnostic issues, treatment, and future directions. In M. J. Perlis & K. L. Lichstein (Eds.), Treating sleep disorders: Principles and practice of behavioral sleep medicine (pp. 214-261). Hoboken, N. J.: Wiley.
4. Krahn, L. E. (2007). Insomnia: Differential Pearls. In T. J. Barkoukis & A. Y. Avidan (Eds.), Review of sleep medicine (2 ed., pp. 95-104). Philadelphia, PA: Elsevier.
5. Lack, L. C., & Bootzin, R. R. (2003). Circadian rhythm factors in insomnia and their treatments. In M. J. Perlis & K. L. Lichstein (Eds.), Treating sleep disorders: Principles and practice of behavioral sleep medicine (pp. 305-343). Hoboken, N. J.: Wiley.
6. Lichstein, K. L., McCrae, C. S., & Wilson, N. M. (2003). Secondary insomnia: Diagnostic issues, cognitive-behavioral treatment, and future directions. In M. J. Perlis & K. L. Lichstein (Eds.), Treating sleep disorders: Principles and practice of behavioral sleep medicine (pp. 286-304). Hoboken, N. J.: Wiley.
7. Harrison, C., & Britt, H. (2009). “Insomnia”. Australian Family Physician, 32, p. 283.