Insomnia

Insomnia is defined as difficulty in initiating or maintaining sleep, in other words, difficulty getting to sleep or staying asleep. We all sleep badly if we are worried or have ‘things on our minds’. This is called acute or reactive insomnia . It is a part of human nature, and when our worries subside, we generally start to sleep well again. Sometimes sleep does not get better, and sufferers continue to sleep badly. When this lasts for more than one month, it is called chronic insomnia

Acute or reactive insomnia can be caused by anxiety – money, family, work, relationships, are the most common. Pain in bed is also a common cause, for instance from arthritis, or degeneration of the spine. Such issues need to be addressed before seeking specialist help for poor sleep – if the anxiety or pain continues, bad sleep is bound to continue too. General practitioners may be able to help with a short course of sleeping tablets, but these should be used according to the specific guidelines published by NICE .

Chronic insomnia constitutes difficulty in initiating sleep, staying asleep, or both. When the condition has been present for more the one month and on at least 3 days per week. Often poor sleep has been present for many years when patients seek specialist help, and some will have been on [sleeping tablets] for long periods of time. Chronic insomnia may be due to external causes co-morbid or secondary insomnia or for no obvious reason non co-morbid or primary insomnia].

Secondary or co-morbid insomnia has many causes that either restrict the time available to sleep, or spoil the quality of sleep. Both of these are likely to cause non restorative sleep and lead to excessive daytime sleepiness Sleep may be disturbed by external factors or other medical conditions, when is called secondary or co-morbid insomnia, or for no obvious reason, when it is called [primary or non co-morbid insomnia]. The symptoms and treatments are very different, so it is important to know which one you suffer from.

Primary or non co-morbid insomnia is common, but poorly understood and treated in the UK. When patients are seen in specialist clinics they have often suffered poor sleep for up to 20 years. There is a female predominance, and patients are often middle aged. Changes in sleep occur with age, and some people are just short sleepers, so symptoms have to be put into context. Some suffer from sleep state misperception. [Symptoms] reduce quality of life and are distressing for patients, whilst impacting upon family life. Certain types of personality are predisposed to developing insomnia Predisposing factor. There may have been a trigger which caused bad sleep to start originally Precipitating factor, but which has now resolved. If sleep does not improve, it is in danger of becoming a focal problem in itself, and this leads to a perpetuation of poor sleep Perpetuating factor, and hence to chronic insomnia. Bad sleep becomes a learned behaviour and a nightly expectation at bedtime. These three factors each beginning with ‘P’ are known as the 3P Model of insomnia

Learned behaviour acts like a psychological barrier or fence between the sufferer and good sleep. “Sleep comes best when sleep comes naturally” (Espie C), but sufferers often focus on their bad sleep and think about it during the day. They may be resentful of others who sleep well, and become angry or frustrated with themselves. They begin to fear or dislike the bedroom, and dread going to bed. They try to develop strategies to force themselves to go to sleep. Often, they are relieved when morning comes, and ‘it is all over’. One patient recently said “I can always get to sleep just before the alarm goes, because the pressure is off”.

Treatment of chronic secondary or non co-morbid insomnia consists of getting the sufferer across the barrier. between themselves and good sleep. There are two basic approaches. To help the sufferer climb over the barrier to good sleep with drug treatments, or to remove the barrier with cognitive behavioural techniques or therapy specifically focussed upon sleep, and often known as sleep focused CBT.

Secondary or co-morbid insomnia is due to causes outside sleep that are restricting either total sleep or sleep efficiency, or causing poor sleep quality with non restorative sleep and increased daytime sleepiness and a desire to nap in the daytime. There are many causes, but the most common are snoring , obstructive sleep apnoea syndrome , central sleep apnoea, restless legs syndrome, periodic limb movements during sleep.
Others include extraneous sleep disturbance, narcolepsy, circadian rhythm disorders, delayed sleep phase syndrome, shift work related sleep disorder, age related sleep disorder, sleep state misperception, short sleepers, depression, drug related, substance abuse, other psychiatric disorders.