Insomnia is defined as difficulty 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. To find out what type of insomnia you have, go to diagnose my sleeping problem.
Acute or reactive insomnia can be caused by anxiety – money, family, work, relationships, are the most common. Pain in bed at night 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 three days per week. Often poor sleep has been present for many years by the time 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 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 (OSA), 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.
Primary or non co-morbid insomnia is common, but poorly understood and usually untreated in the UK except with sleep tablets. When patients are seen in specialist clinics they have often suffered poor sleep for 20 years or longer. 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. Others may suffer from sleep state misperception, when they sleep more they realise. This is often because they rouse frequently from sleep, and think they have been awake continuously.
THE GOLDEN RULE IN INSOMNIA IS THAT PATIENTS FIND THE DAYTIME DISTRESSING, BUT ARE NEVER SLEEPY AND NEVER NAP DURING THE DAY. THEIR EPWORTH SLEEINESS SCORES ARE THEREFORE ALWAYS LOW. IF THE EPWORTH SCORE IS NORMAL OR RAISED, THERE IS ANOTHER CONDITION THAT NEEDS INVESTIGATING - USUALLY RESTLESS LEGS OR SLEEP DISORDERED BREATHING
However, symptoms reduce quality of life and are very distressing for patients, whilst also impacting upon other members of the family. Sufferers become close to obsessed with their inability to sleep, and it dominates their waking lives too. They can't concentrate, feel irritable and unable to socialise, but can never nap by day.
'Predisposing factors' include certain types of personality who are predisposed to developing insomnia. Sufferers are often worriers, focussed and take themselves seriously. There may have been a 'Precipitating factor' or trigger which caused bad sleep to begin with, but which has now resolved. If sleep does not improve, there is a danger that it will become a focal problem in itself, and this leads to a 'Perpetuating factor' of poor sleep, and hence to chronic insomnia. Bad sleep becomes a 'learned behaviour' with the expectation at bedtime of another night lying awake. These three factors each beginning with 'P' (Predisposition, Precipitation, Perpetuation) are known as the Spielman 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.
In our clinic, typical triggers include worries about illness, money, family or marital problems, divorce, past abuse, issues at work, unemployment. Female patients often start to sleep badly after starting a family and worrying about children in the night. In men, the trigger is often less easily defined, but can be work related.
Treatment of chronic primary or non co-morbid insomnia consists of getting the sufferer across the barrier between themselves and good sleep. There are two basic approaches. The traditional way was to tip the sufferer over the barrier to good sleep with drug treatments, but a much better approach is to remove the barrier altogether with cognitive behavioural therapy specifically focussed upon sleep, and often known as sleep focused CBT or CBTi.
We offer a full service for CBTi in our centre, both on a fee paying basis and through the NHS if the local CCG with fund it.