by Dr. Siobhan Kuhar
Nearly everyone has had the experience of having difficulty with getting to or staying asleep, typically related to a stressful time or event in a person’s life. But when does this sleep disturbance become classified as insomnia? The actual diagnosis of insomnia typically fulfills a handful of diagnostic criteria. The person must first of all perceive this as a problem and complain of difficulty with initiating or maintaining sleep, or have a perception of nonrestorative or disrupted sleep. The sleep disturbance must cause distress to the person or impair them in some way either socially or in their work. Finally, the disturbance of sleep is generally present for more than a month and is present three or more nights a week. It is considered normal for a person to sometimes take up to 30 minutes to fall asleep and even awakenings during the night are normal depending on the reason for awakening.
People with insomnia will often complain about feeling fatigued but unable to sleep, have difficulty with attention and concentration, have problems with their memory, and feel moody. Most adults need between 7 to 9 hours of sleep every night but there are also those that fall on either end of that spectrum feeling fully restored after 5 hours of sleep or requiring 10 hours of sleep to feel rested. The two major biological drives for getting and staying asleep are the mental and physical fatigue that we build over the course of the day and our body’s circadian clock for sleep that is set by our light exposure and activity during the day. This is why napping during the day in a person with insomnia can dissipate the pressure for sleep at night and why it is important to have exposure to light in the early part of our day as this helps with the release of melatonin by our brains at the appropriate time at night for sleep onset.
Insomnia typically has a beginning, middle and hopefully a successful end or at least end of an episode. People with this problem will often experience recurrent episodes of difficulty with sleep throughout their lives. The beginning of insomnia is often a triggering event such as a major life change or stress. This is typically followed by a period of time in which the individual responds to their difficulty with sleep in a way in which the problem ultimately becomes perpetuated. This often results from the trigger of sleep difficulty shifting from the inciting event to the individual’s response to the sleep problem. The fact that the person is unable to sleep becomes the focus that perpetuates the insomnia. A frequent description of this is the concern or worry that each night the problem with sleep will be repeated and this in essence “drives” the insomnia forward.
Treatment of insomnia can be relatively straight forward or quite challenging as it often results from a pattern of behavior that has been reinforced and repeated over time. Insomnia can be “primary” or “secondary” to another cause. Identifying a potential underlying cause for insomnia is extremely helpful in working toward improving the problem. Poor sleep habits and a poor sleep environment are frequent common problems that once identified can be addressed. Pain and mood disorders such as anxiety and depression can be very disruptive to sleep and have a reciprocal relationship with insomnia. Patients with pain or mood disorder are at high risk for developing insomnia and the successful control of the pain or the mood disorder is highly influenced by the control of the insomnia. Other sleep disorders such as Restless Leg Syndrome or Obstructive Sleep Apnea frequently have a component of insomnia and treatment of these will usually lead to improvement in sleep quality overall.
Sleep hygiene is a term often used to describe good habits related to sleep including creating an ideal sleep environment. People need a designated sleep space and often our bedroom becomes a place where we not only sleep but also watch television, eat and work. The bedroom needs to be a cool, dark, quiet sleep environment where we feel comfortable and safe. Preparation for sleep begins the moment we wake up in the morning and many of the choices we make during the day influence our sleep at night. We need exposure to light and physical activity beginning in the morning hours and at night the opposite pattern of behavior with decreased light exposure and a period of “unwinding” from the days activities with relaxing bedtime routines. What we eat and drink will often influence sleep quality. For example, caffeine works by competing with receptors in our brains for a natural chemical, melatonin, that our brain secretes prior to sleep onset. Alcohol will often have the affect of making a person sleepy, however, once metabolized we withdraw from its affects and this can lead to very disrupted sleep and awakening during the night.
Insomnia that persists despite a person's attempt to improve their sleep hygiene should be discussed with their medical care provider and may even require referral to a sleep specialist. Sleep specialists are physicians who are board-certified in treating sleep disorders and can provide additional evaluation and treatment of sleep disorders including insomnia. Evaluation would include a detailed history of the sleep complaint, physical examination of the upper airway if concern for sleep apnea exists, and then possibly overnight monitoring of sleep with a sleep study. Treatment of insomnia can involve identifying and treating underlying causes for the problem, guiding patients with cognitive behavioral therapies, and in some instances implementing appropriate use of medication.