Sleep Disorders

Spring 1999
Volume 10, Number 1

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Introduction. On a list of quintessential maladies for our age, fatigue and insomnia would undoubtedly occupy prominent positions. Of the two, insomnia might be considered the most insidious and unfair, coming upon us as it does during one of our most vulnerable, private, and needed times. Insomnia is blamed by our patients for their forgetfulness and imprecise thinking, for their irritability and exhaustion, for their nervousness, and for troubles at home, school and work. It is sometimes not a simple thing to diagnose and treat; nevertheless, a better understanding of disorders of sleeplessness can help practitioners assist a majority of their insomniac patients. This article will address some of the current thinking in the sleep community about insomnia in adults, and offer an approach for the clinician with regard to first-line non-pharmacologic therapy.

Epidemiology. While estimates of incidence and prevalence must be extrapolated, insomnia undoubtedly constitutes a major on-going health problem in the United States. Various surveys estimate the incidence for complaints of insomnia at around 35% of the adult population each year, and another 3% to 10% or so appear to suffer from chronic insomnia. Between one-fifth and one-third of medical outpatients struggle significantly with sleepiness during the course of their illness.1 As age increases, so do complaints of sleep disruption. More than one-quarter of individuals over the age of 65 are affected. Aging changes the nature of the problem as well, while younger insomniacs complain more often of sleep induction difficulties, sleep-maintenance problems predominate in older adults. Finally, women complain more than twice as often as men of disturbed sleep.

One study estimated the total direct cost of treating American insomniacs in 1995 alone to be around $14 000 000.2 An IMS National Prescription Audit in that year suggested that the annual costs of sedative-hypnotics in America ran above $1 billion. The total US consumption of sedative-hypnotics was found sufficient to supply a dose every night of the year to two million Americans.3 Indeed, the survey noted that nearly 1% of the population may take hypnotics virtually every night. Moreover, it is well-known that protracted withdrawal of benzodiazepines may be expected in 10% to 25% of chronic users, and may persist for many months.

Diagnosis. The International Classification of Sleep Disorders considers 3 types of problems under the rubric of “primary insomnias:” Psychophysiological Insomnia, which is a “disorder of somatized tension and learned sleep-preventing associations...”, Idiopathic Insomnia, “a lifelong inability to obtain adequate sleep” presumed due to an abnormality of neurological control, and Sleep State Misperception, a disorder in which complaint of insomnia occurs in the absence of objective evidence of sleep disturbance. The focus in this article will be on the first of these conditions.

Within these larger categories, sleep-onset insomnia implies that sleep-onset latency after lights-out is regularly longer than 30 minutes. Sleep-maintenance insomnia is diagnosed when time awake after sleep is achieved totals more than 30 minutes during the night, or when a person experiences unwanted early morning awakening after fewer than 6.5 hours of sleep. Both conditions can obviously co-exist in the same patient at the same time.

Duration of insomnia also has significant etiological and therapeutic implications. Transient insomnia, for example, has been defined as that lasting several days. Short-term insomnia has a duration of 1-to-3 weeks, while chronic insomnia may be considered acute (less than 1 month), subacute (1-to-6 months), or chronic (greater than 6 months). The sleep disorders specialist is likely to approach each of these with somewhat different therapeutic parameters in mind.

Perhaps most important to remember at all times when analyzing patient complaints of disturbed sleep is that insomnia is nearly always a symptom, not a disease.4 Concomitant psychiatric disorders are often seen in patients with complaints of insomnia, and indeed, the diagnosis of a primary sleep disorder is not made when persons can be diagnosed with a generalized anxiety syndrome, major depressive disorders, and various other DSM-IV psychopathologic conditions. Therefore, it becomes important for clinicians to do more than inquire about depression, the presence or absence of panic attacks, or about “stress” in superficial ways. Knowing your patients, their life circumstances, sleep habits and history, psychological vulnerabilities and the like is necessary before precise diagnosis and focused, effective treatment can be made. Table 1 highlights a set of important review issues around which to organize an initial insomnia examination.

In addition to these clinical queries, standard diagnostic sleep practice involves employing a nightly sleep diary, to be filled out by patients for a period of at least several weeks. Various diary schemes are employed to different purposes across settings, but in general, a sleep diary should employ a simple-to-use format, and allow the patient to record the following every night: bedtime, time of arising, latency to sleep onset, number and duration of nocturnal awakenings, time of last awakening, daytime naps, medication and substance use (with time taken), as well as some sort of subjective assessment of sleep quality. After the patient has completed such a diary for a few weeks, the practitioner has an opportunity to analyze the sleep disturbance qualitatively, as well as to compute the patient’s sleep efficiency (SE). The latter is done by dividing actual time asleep by total time in bed. Current clinical convention suggests that SE less than 85% is useful for a formal diagnosis of insomnia. (It is extremely unusual for even significantly affected primary insomniacs to experience symptoms every single night. When the complaint is of unremitting insomnia, this is often a clue for consideration that psychological, psychiatric or medical etiologies may well be primary.)

Sleep Disturbance and Psychopathology. Complicating the diagnosis and treatment of insomnia is the significant, well-recognized comorbidity of psychological and psychiatric conditions. Research suggests about one-third of all patients who complain of sleep problems suffer from a concurrent diagnosable psychiatric disorder.5 Even in individuals who do not meet diagnostic psychiatric criteria, studies have found that as many as 77% of patients with a first diagnosis of primary insomnia also suffer from a psychological condition which experts rate as “significantly contributing” to the sleep problem.6 Finally, it is well-known that 50% to 80% of psychiatric patients complain of sleep disturbance during the acute phase of a mental disorder. When the deleterious effect of substance use or abuse (eg, caffeine and alcohol) on sleep is considered as well, the importance of solid screening and the need at times to refer patients for more detailed psychological evaluation becomes clear.

While a comprehensive review of psychopathology and sleep is beyond the scope of this article, the non-mental health practitioner should keep in mind a few basic issues when evaluating patients with complaints of insomnia. Screening for mood and anxiety disorders is actually most efficiently accomplished in a limited time by asking a few open-ended questions, as opposed to “Are you depressed these days?” (which frequently means different things to different people), or “Do you ever panic?” Similarly, rather than asking, “Are you under a lot of stress?” the practitioner is encouraged to “normalize” stress as a ubiquitous phenomenon and therefore elicit more accurate life portrayals from patients who may otherwise fear being pathologized: “What are the stresses you are struggling most with these days?” gets the job done more effectively. In fact, hassles may be more of a contributing factor in chronic psychophysiological conditions than major life stressors are.

When asking about substance use, clinical practice has suggested phrasing questions in a naively presumptive fashion rather than “Do you drink alcohol?” or “How much do you drink?” For example, more productive initial approach nearly always seems to be, “Do you drink more than 8 drinks per night on a regular basis?” Finally, when querying about onset of duration of the disorder, encourage patients to look for initial precipitating stressors that may have been incompletely managed or continue to exert their effects. Morin comments that psychological stress is the most common precipitant of insomnia, and that nearly three-fourths of patients will be able to recall a specific precipitating stressor that heralded the onset of their condition.7 This assessment can be invaluable in guiding care.

Treatment. Psychophysiological insomnia is the most common of the insomnias, and many sleep specialists view such patients as maintaining a state of chronically increased cognitive hyperarousal, which then feeds back into or results in psychophysioloigc hyperarousal. Common signs of such a state are indicated in Table 2. Sometimes all that is required is reassurance by the practitioner that loss of sleep is almost never dangerous or serious from a medical standpoint in and of itself, that in most cases sleep can be improved if not returned to normal by attending carefully to good sleep hygiene,7 that going without a good night’s sleep from time-to-time is normal, especially under conditions of chronic or acute stress, and that lost sleep does not need to be completely made up.

However, when sleep complaints persist despite initial treatment efforts, and/or if certain other conditions exist, referral to a sleep disorders specialist, program, or center may be indicated (see Table 3). Psychological and behavioral therapies produce reliable and durable improvements of sleep pattern in between 60% to 80% of patients with both chronic and primary insomnias.

Several specialized behavioral and psychological techniques, usually instituted in tandem with a short-term, focused form of cognitive-behavioral psychotherapy aimed at addressing sleep myths and misconceptions, may be employed by the sleep specialist. While psychophysiological arousal is common among insomniacs, it is frequently secondary to chronic cognitive hyperarousal or hyperactivation. The later is typically multifactorial, with variables like baseline autonomic reactivity, life pressures, general cognitive style, characterological tendencies (eg, toward obsessiveness, histrionic, or pessimistic bent), all playing a role in the process. For this reason, intervention with psychophysiological therapies like hypnosis, neuromuscular relaxation, and meditation, all of which engender a psychophysiological relaxation response and decrease sympathetic nervous system overactivity, is usually but one important aspect of the comprehensive treatment of such patients. However, techniques alone only rarely suffice to return patients to normal sleep patterns. While it is theoretically possible to learn to utilize these in the primary care setting, these techniques appear to be most beneficial when applied in a program that also evaluates and addresses potentially subtler, interwoven psychological and personality issues (eg, conditioned responses), as well as the interaction among these and broader life-style factors.

Most often, patients require in-depth analysis of sleep habits and hygiene, and suggestions for modifying the specific psychological, behavioral, and lifestyle factors that seem to be contributing in each particular case to the insomnia. In addition, reassurance and education about particular “sleep myths or misconceptions” that may be contributing to irrational worry and excessive cognitive activation often need to be addressed. Finally, where needed and useful, specialized behavioral sleep disorder interventions will be adapted and prescribed for the patient, depending upon presenting complaints and issues. These include, for example, sleep restriction therapy, which involves limiting (sometimes dramatically) the amount of time spent in bed, technically monitoring sleep efficiency closely over time, and then gradually increasing time in bed as sleep efficiency increases until desired optimum sleep duration is achieved.

Similarly, stimulus control techniques will be utilized if insomnia appears to be the result of problematic conditioning of associations between environmental (bed-and-bedroom) or nocturnal factors with behaviors incompatible with sleep. Important to note, recent research suggests that use of sedative-hypnotics be deferred while behavioral treatment for sleep problems is implemented, despite patients’ wishes for a “quick fix.” The use of such agents may actually interfere with ultimate sleep goals and patient progress.8

Conclusion. Patients with complaints of insomnia, of course, need an initial solid medical work-up as part of any approach to the sleep disturbance. Second, testing the waters about comorbid or contributing psychological issues or disorders is crucial, and referral for more in-depth psychodiagnostic work-up may be indicated in a fair proportion of cases, as the statistics cited above suggest. Such referral can be made on sleep grounds per se, and be directed to a sleep specialist or health psychologist, so as to minimize the patient’s worry that the referring doctor thinks the problem is “...all in my head...”, or that “I’m crazy.” Careful, subtle review of a wide variety of substance issues, including prescribed medication, keeping in mind that 10% to 15% of insomnia patients have substance abuse problems, should be undertaken.9 Review of the patient’s sleep habits and basic principles of sleep hygiene is almost always indicated. In some instances the problem can actually be solved right there. Should basic office care not suffice and amelioration of major symptoms not be noted in a month or so, referral to a sleep disorders program or specialist may be the most efficient and cost-effective way of providing your patients with optimal, maximum, and lasting symptomatic relief.

Address comments and questions to:

Jay Schneiders, PhD
701 East Hampden Avenue, Suite 420
Englewood, CO 80113

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