Pain is also a reason for insomnia, disorders such as arthritis, back injury, headache and many other forms of discomfort may also upset sleep. Physical problems such as trouble with breathing or over active leg muscles account for over half of all cases in chronic insomnia. This finding makes sleep specialists think insomnia is not always an illness but a symptom. Familial fatal insomnia affects both sexes equally in an autosomal dominant manner with high likelihood of being genetically carried on. Onset is between 36 years and 62 years of age and is uniformly fatal. The disease duration, defined from the onset of insomnia, varies from 8 months to 72 months and carries the symptoms of a chronic insomniac.
Adjustment sleep disorder, or transient insomnia, is the experience of a few nights of poor sleep. Shorter instances of transient insomnia are probably experienced by most everybody now and then. Often people who experience transient insomnia complain of difficulty in concentrating, weariness and irritability the following day. Sudden changes in work shift and travel across time zones can also cause difficulties with sleep. Longer transient insomnia is caused by sudden emotional stress, such as a job loss or a hospitalization. However, these difficulties usually resolve within a brief period of time, typically a week or two. Guidelines have been developed to help produce a more rapid resolution to transient insomnia. Examples of transient insomnia response measures include: maintaining a regular bedtime schedule, avoiding excessive time in bed, avoid taking naps, use the bed only for sleeping and sexual relations, do not watch the clock, do something relaxing before bedtime, make the bedroom as quiet as possible, avoid the consumption of alcohol and caffeine within 12 hours of bedtime, exercise moderately, regularly, and not within 4 hours of bedtime, avoid going to bed hungry, and learn strategies to make bedtime as relaxing and tension-free as possible. Typically, medical treatment isn’t necessary for such short-lasting insomnia. The disorders below are examples of some of the more common chronic insomnia conditions that warrant further medical attention.
Psychophysiologic, situational, or short-term insomnia usually involves sleep disturbances that last for two to three weeks which follows adjustment sleep disorder. Here, ongoing stress at school, work or home is often the reason: worrying about grades, learning of your parents impending divorce or having a serious illness or death in the family are all events that trigger short-term insomnia. The sufferer is usually preoccupied with insomnia. Short-term insomnia is often managed with a combination of behavioral measures and medications. The most commonly utilized behavioral measures are relaxation training with EMG biofeedback training, and stimulus control therapy (asking patients to use the bed only for sleep and to not stay in bed trying to sleep for more than ten minutes at a time, then to go into another room and to return to bed only after feeling sleepy). Relief from the situation that provoked disturbed sleep or accommodation to it usually returns a person to his or her usual sleeping pattern.
Chronic insomnia is the third and most serious type of the sleeping problems. This sleeping problem lasts for three weeks or longer with poor sleep every night, most nights, or some nights in a month. This is a complex disorder with many possible causes. In more than half of all cases of persistent insomnia the cause appears to be a physical illness, such as disorders of breathing or muscle activity. These figures were derived from a nationwide study of 8,000 patients and conducted by the Association of Sleep Disorders Center. This form of insomnia is a complex disorder with many possible causes and afflicts more than 35 million Americans. While most people blame this on stress, the use of stimulants may also be at fault. It is relatively easy to find reasons for transient and short-term insomnia, but this isn’t the case for chronic insomnia, which may last for years disrupting sleep most or every night. The effective management of these sleep difficulties rests upon the medical or psychiatric condition. However, behavioral methods and sleeping pills could be used if appropriate. Depression is the one syndrome of insomnia that psychologists analyze most commonly. A depressive “episode” is usually accompanied by a characteristic set of changes to sleep patterns. These medications are used to treat depression and also affect sleep in ways that help alleviate chronic insomnia.
Many effective treatments have been discovered, but there is no cure to insomnia. The most prevalent treatment methods used are pharmacological treatment and behavioral-cognitive treatment.
Cognitive behavioral therapy (CBT) is a treatment that combines changing an individual's beliefs and attitudes about sleep and then teaching that person how to implement new behavioral patterns or habits in order to improve sleep. This treatment leads to clinically significant sleep improvements within six weeks. CBT has appeared to be a promising, more universally effective treatment for insomnia, opposed to the current treatment of sedative hypnotics or antidepressants. These pharmacologic therapies are recommend, but not for the long-term treatment of chronic primary insomnia. CBT effectively treats both sleep-onset and sleep-maintenance problems, and produces a better long-term outcome than do medications or placebos.
There are three main types of drugs used for treatment: benzodiapine hypnotics, sedating antidepressants, and antihistamines. Benzodiapine hypnotics are the most prescribed drugs for treating insomnia. They are most useful when treating short-term problems and have relatively few side effects. They reduce the time for sleep onset and increase sleep efficiency. Another option is sedating antidepressants. These drugs can “promote sleep onset and maintain sleep,” but they have not been scientifically proven to treat insomnia. When these drugs are used every night, they cease to benefit sleep after a few weeks, due to the fact that the body becomes used to the pills and they have no effect. The third drug option is antihistamines, which besides allergies, decrease sleep onset and reduce time in REM sleep. However, they are not recommended for treating insomnia because they are not sedatives and very few studies have been done to show their effectiveness.
The following case study and diagnosis is typical of an insomniac being treated by a physician:
A 68-year-old woman was referred for treatment of chronic insomnia, which began intermittently in her late 20's after the birth of her first child. Her insomnia increased in the context of stressful fife events, including caring for her ailing parents, her own surgery for breast cancer, death of a friend, etc., and in more recent years, her sleep had become gradually more disrupted with no obvious precipitating events. At the time of her initial consultation, she routinely experienced difficulty initiating and/or maintaining sleep at least 2-3 nights per week, resulting in a total of only 3-5 hours of total sleep time, followed by fatigue the subsequent day. She does not smoke or drink caffeinated beverages. She rarely drinks alcohol. The patient felt she experienced a lot of anxiety and "fear" specifically about her ability to fall asleep or return to sleep after awakenings and about the potential consequences of her sleep disruption. She denied symptoms suggestive of primary physiological sleep disorders, such as obstructive sleep apnea syndrome, narcolepsy, or periodic limb movement disorder. She has a past medical history of Fibromyalgia and Hypoglycemia. A physical examination performed by the patients primary care physician was normal.
In this case study, the patient demonstrated a typical progression of chronic insomnia over time. Although her insomnia began in her 20's, possibly associated with the sleep disruption and stress related to having young children, it became much more severe during times of stress. The more frustrated she became about her insomnia, the harder she tried to sleep, the more difficult it became to fall asleep. Coping mechanisms she used exacerbated the problem, leading to psychophysiologic (conditioned) insomnia. This patient tired to make up for her sleep loss by resting in bed and taking a compensatory nap. These naps were of prolonged wakefulness in bed, and only led to frustration and anxiety about not sleeping and heightened her efforts to "try" to sleep, which compounded the problem.
Also, it is likely that the increased stress and losses in the patient's life, often associated with aging, precipitated an episode of depression, leading to increased sleep disruption. There is a very close relationship between depression and insomnia. About half of chronic insomnia cases are attributable to a primary psychiatric disorder, usually depression or anxiety.
The DSM-IV TR classification for insomnia defines it as a difficulty in initiating or maintaining sleep. A term that is employed ubiquitously to indicate any and all gradations and types of sleep loss. Insomnia may be associated with any of a number of mental disorders. The classification notes that the predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Also, the sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-Related Sleep Disorder, Circadian Rhythm Sleep Disorder, or as Parasomnia. Insomnia also does not occur exclusively during the course of another mental disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, and Delirium). The DSM-IV TR doesn’t attribute the disturbance to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
