Insomnia
BACKGROUND
Insomnia is quite common. Up to 40% of the U.S. population has reported having had difficulties with insomnia at some point in the lives. Upwards of 5% may have chronic ongoing problems with sleep initiation and/or sleep maintenance on a continuous basis.There are different types of Insomnia, as well as different classification systems from various medical institutions or academic societies. For instance, the DSM, which is what is used by psychiatrists has a different format and criteria for Insmonia than the ICSD-2 which is what is used mainly by the American Academy of Sleep Medicine. The ICSD defines a few different types of Insomnia including:
Psychophysiologic (conditioned): This type of insomnia is the most common and unfortunately patients are put on sleep medications, to which they can become habituated or dependent. Sleep aids are not considered to be treatment of choice for this condition and should be treated ideally with cognitive behavioural strategies.
Adjustment insomnia (acute): This seen following significant stress or trauma and by definition is self limited and does not require ongoing intervention.
Paradoxical (sleep state misperception):Tthough considered rare, I have seen this type numerous times. It involves patients who believe they do not sleep when in fact they do. It is considered to be a sleep state misperception problem and currently thought to be more or psychiatric etiology though little is truly known.
Idiopathic (genetic?): Many patients fall under this category. There is typically a strong Family History of Insomnia or sleep difficulties. We are learning more about this set of sleep problems including genetic factors that may involve Melatonin production or regulation. Melatonin is a hormone that is produced by the pineal gland in response to circadian sleep/wake cycle processes.
Insomnia Due to Medical Disorders: As the name implies, some insomnia can be traced directly to a primary or underlying medical disorder. This type of insomnia may or may not require the use of sleep aids or other strategies depending on the circumstance.
Insomnia due to Psychiatric Disorders: Some patients may have primary psychiatric disorders which affect their ability to initiate or maintain sleep. Though treatment should be directed at the underlying disorder, some patients may require adjunctive therapy.
Insomnia due to Medications, Stimulants, or Sleep Hygiene: These are thought to be largely non-organic problems that should be treated a refinement or modification of the offending therapy or changing of the patients lifestyle that has led to the condition.
Insomnia due to dysfunction of Sleep/Wake Schedule: Up to 20% of the world population may be involved in Shift Work or fluctuating time schedules that are not in synch with their bodies’ own natural circadian rhythm. This can frequently result in insomnia. If a return to a normal sleep/wake schedule is not possible, various strategies such as Melatonin, Sleep Aids, scheduled naps, and UV light therapy may be indicated.
DIAGNOSIS
There is a number of issues that need to be identified when evaluating a patient with Insomnia. I will typically focus on Duration of symptoms, Inciting or initiating event, Sleep wake schedule, Sleep environment, Alcohol, caffeine, drugs, medication, Psychiatric history, and Medical problems. Rarely patients will require a formal Sleep Study but Sleep Logs can be very helpful for diagnosis as well as judging efficacy of interventions. The role of Actigraphy which measures ambient light and body movement as well as more non-prescripted devices are being evaluated as to the role they should play in the workup or treatment of insomnia.
TREATMENT
There are many modalities of Insomnia Therapy:
Stimulus control therapy: Avoiding classic Insomnia triggers
Sleep restriction therapy: Avoiding spending too much time in bed and slowly restricting bedtime until “sleep pressure” accumulated encouraging more regular and consolidated sleep.
Relaxation training: Developing Stress Reduction Strategies and routines that promote sleep.
Cognitive therapy: Retraining the thought processes which perpetuate and amplify insomnia, and interfere with treatment. This is a very typical obstacle in treating many patients with insomnia, and usually when they finally buy into these theories their condition dramatically improves.
Sleep hygiene education: Many patients with Insomnia have troubles due to their own environment and behaviors. Issues such as having a desk or television in the bedroom, “clock watching”, animals or children in the bed, or having a noisy, or uncomfortable environment, are some of the typical reasons that can lead to and perpetuate insomnia.
Medications: 40% of people with insomnia self-medicate with OTC products or alcohol. Sedating antidepressants are frequently prescribed off-label, but have not been well studied for chronic use. The commonly used Rx sedative-hypnotics are BzRAs (benzodiazepines and nonbenzodiazepine chemical compounds) and can be associated with numerous problems including Ataxia (balance effects), Daytime sedation, Cognitive effects, Anterograde amnesia, Respiratory depression, Tolerance and withdrawal, Rebound insomnia, and Potential for abuse and dependence (all BzRAs are Schedule IV controlled substances).
A newer agent, Rozerem is a Melatonin agonist which has shown no abuse or dependence in clinical trials, no CNS depression, no evidence of peak-level or next-day psychomotor, memory, or cognitive effects, and an excellent safety profile, Unfortunately it is not that successful for insomnia though has some clinical utility for the treatment of Circadian Rhythm disorders. Orexin receptor antagonist are under development and may provide a new and novel strategy for the treatment of insomnia.
