Adult Insomnia: A Review For The Primary Care Physician

Dennis Sorresso, M.D., Assistant Professor of Medicine, Division of Pulmonary/CCM Shands Jacksonville/ University of Florida, Director, Sleep Medicine Center

 

Introduction

Insomnia can be defined as an individual's perception of disturbed or unrestorative sleep with or without daytime consequences. Disruption of sleep may come in several forms: difficulty initiating sleep, frequent arousals after sleep onset with difficulty falling back to sleep, or early morning awakening. Daytime consequences of disturbed sleep may include: decline in an individual's performance at home or at work due to memory deficits, changes in mood, an inability to concentrate, excessive daytime somnolence, irritability, fatigue, or feelings of restlessness.

Estimates reveal that at any given time 30-50% of the general population suffer from insomnia, and the impact of insomnia on our society is staggering. The direct cost of insomnia to society falls in the range of 11-35 billion dollars per year, and its indirect costs are even higher, ranging from 92.5-107.5 billion dollars per year. 1 Furthermore, insomniacs have a greater than six-fold chance of having an automobile accident as compared to normal. 2 In addition, women, the elderly, lower socioeconomic groups, and individuals who are divorced, separated, or widowed are more likely to develop insomnia in their lifetimes. 3


Etiology

Insomnia is neither a disease nor a syndrome but a subjective complaint. Categories of insomnia include 1) transient (days), 2) short-term (weeks) or 3) chronic (months to years). Insomnia is typically secondary to some underlying cause, which can be vast and varied. Although there are exceptions such as primary or idiopathic insomnia, diagnosis of the underlying disease process is essential in the management and treatment of secondary causes of chronic insomnia. In 1997 Ohayon 4 studied a sample size of the French population consisting of 5622 individuals and revealed that the prevalence of chronic insomnia was approximately 10 %. By far, psychiatric disorders were the most common cause. There are close associations between insomnia and mental disorders as well as hyperaroused states 5,8 or stress-related disorders. Insomnia may also be an early marker for other psychiatric disorders such as anxiety and alcohol/drug dependence. 6

Transient insomnia is most likely caused by an acute, minor, stressful event and / or change of environment. This disruption in sleep is usually self-limited, rarely brought to the clinician's attention, and usually does not require treatment. Individuals with short-term or chronic insomnia are more likely to seek professional help.

Broad categories, including a more detailed differential diagnosis of chronic and short-term insomnia, can be found in Table 1.

Evaluation

A complete history and physical examination may disclose obvious medical causes for disturbed sleep such as chronic pain or cardiopulmonary disease. The history should include a complete psychiatric interview including discussion of past psychiatric disorders as well as a mental status examination. Questionnaires such as the Minnesota Multiphasic Personality Inventory (MMPI) or various depression questionnaires may also be helpful in the evaluation. Investigation into tobacco, alcohol and caffeine consumption (including coffee, tea, chocolate, and soft drinks) as well as the use of prescribed, OTC, illicit / recreational drugs is essential. Lastly, probing into the individual's sleeping habits with input from the patient's bed partner is vital.

 

Although not validated in the diagnosis and treatment of chronic insomnia, objective measures may be useful to rule out physiologic causes or primary sleep disorders. Objective testing may include an all-night polysomnogram (PSG), Multiple Sleep Latency Test (MSLT), actigraphy, and sleep logs.

Treatment

Several modalities are available for the treatment of insomnia. These include: 1) pharmacotherapy 2) behavioral modification 3) cognitive therapy 4) sleep hygiene education 5) medical treatment 6) psychiatric therapy 7) light box / bright light therapy and 8) environmental change.

Obviously, if the cause of insomnia is readily identified, then therapy should be geared toward treatment of the underlying cause. However, many times chronic insomnia may prove to be especially challenging to treat because of the poor sleep hygiene, decline in mental health, or maladaptive coping mechanisms (e.g., drug addiction or alcoholism) fostered during attempts at self-treatment. Due to the chronicity or progression of disease, the cause of insomnia may be multi-factorial or may have changed over time. Therefore, many clinicians advocate a combined approach to the treatment of chronic insomnia.

Pharmacotherapy for Insomnia

Long-term treatment with a hypnotic or other sedating prescription or OTC medication is discouraged for the treatment of chronic insomnia. For transient or short term insomnia (e.g. due to traumatic life event) or anxiety disorder, short- term pharmacotherapy may be justified. This may also be warranted in the initial treatment of chronic insomnia until other therapies may be instituted.

The sedating effects of benzodiazepines is well established 20,21,22 and treatment for 1-4 weeks with the lowest effective dose of a short-acting benzodiazepine hypnotic is recommended. Selected short-acting benzodiazepine and benzodiazepine-like medications such as temazepam, triazolam, zolpidem and zaleplon are preferred. These substances have short half-lives without active metabolites and are less likely to cause daytime sedation. 2,3 Treatment beyond this may have untoward effects causing addiction or further disruption of sleep architecture.

The plan to treat for a short period with a hypnotic should be discussed with the patient and reasonable expectations should be outlined. The patient should be cautioned about rebound insomnia with tapering (or withdrawal symptoms with abrupt cessation). A few nights of rebound insomnia upon discontinuing the drug should be expected and discussed with the patient. The use of benzodiazepines are contraindicated in patients with alcoholism or other drug dependence and should be used with caution or not at all if sleep disordered breathing is suspected.

 

Combined Behavioral Modification

Combined behavioral therapy (CBT) 18,19 consists of both cognitive and behavioral modification; it has been used to treat psychiatric disorders such as depression and general anxiety disorder and has been adopted for the treatment of insomnia. Data suggests that CBT may be the treatment of choice for insomnia without identifiable medical or psychiatric cause 13,16,17. Brief descriptions and goals of therapy are detailed below. A summary can be found in Table 2.

Behavioral Therapy:

Sleep Restriction, Stimulus Control Therapy and Sleep

Hygiene Education:

As previously mentioned, many patients come to the clinician after developing months of maladapted behaviors and counterproductive self-help measures. These may include: extended bedtimes, daytime naps, alcohol consumption, use of OTC sedative agents, reading, eating, and watching TV in bed. In short, the patient utilizes the bed and bedroom for everything except sleeping. In time, the patient becomes conditioned to associate the bed and bedroom with the inability to initiate sleep. Therefore, sleep restriction, stimulus control techniques, and sleep hygiene education to limit the time in bed and condition the patient to associate the bed and bedroom with sleep are used.

Cognitive Therapy:

  1. Relaxation Therapy: The primary goal of relaxation therapy is to assist the patient in achieving a physiologically and mentally relaxed state prior to bedtime which is conducive to sleep. Cognitive relaxation techniques include guided imagery training and meditation whereas somatic relaxation techniques include progressive muscular relaxation and autogenic training.
  2. Cognitive Restructuring Therapy: Dysfunctional beliefs/attitudes as well as negative self-statements or thought patterns may underlie and perpetuate maladaptive behaviors. The goal of cognitive restructuring therapy is to first help the patient identify and recognize the erroneous belief and then challenge that belief. Subsequently, the patient is encouraged to generate alternate, more accurate, and positive self-statements.

A handful of studies have shown that only behavioral therapy will improve insomnia long-term. 13,14,24 Although sufficient data comparing pharmacotherapy with CBT is lacking, most clinicians believe that a combined approach utilizing cognitive-behavioral therapy as the mainstay of treatment with the intermittent "as needed" use of a sedating medication as rescue therapy is most efficacious. For instance, individuals who may be more prone to anxiety or stress-induced sleep disturbance may benefit from the knowledge that, if all else fails, they have available and may use a sedative to help initiate sleep. This combined approach is especially useful when treating psychophysiologic insomnia or extremely anxious individuals in order to maintain good sleep hygiene and prevent conditioned hyperarousal.

Light Box / Bright Light Therapy

Chronic insomnia associated with circadian rhythm disorders are best treated by adjusting the individual lifestyle and/or occupation with his/her sleep-wake cycle. Many times, due to demands of work or family, this is not possible and light box therapy to readjust the patient's circadian rhythm is helpful. Exposure to sunlight or bright light (approximately 2500 Lux for 30 minutes to 2 hours) 25 depending on the circadian disorder or sleep-wake cycle will help to readjust the body's circadian clock.

Summary

In conclusion, insomnia is a complaint or symptom and is best managed by identifying and treating the underlying cause. Evaluation must include a complete history and physical, including psychiatric interview, and deep probing into sleep habits as well as food and drug consumption. More objective measures of sleep such as all-night polysomnography and MSLT may be useful to disclose primary sleep disorders.

Many times, the etiology may be multi-factorial and devoid of medical or psychiatric cause. The insomnia may persist for months to years causing the patient to develop unreliable and counterproductive habits fostered by attempts at self-treatment. This in turn may create a vicious cycle whereby these maladaptive behaviors now continue to generate the sleep disturbance. In these cases, a combination of short-term or intermittent use of a benzodiazepine hypnotic together with cognitive-behavioral modification is the best approach to management. The use of long-term hypnotic therapy or melatonin is not recommended.

References

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  2. Hauri, PJ. Insomnia. Clin Chest Med 1998; 19: 157-168
  3. Kupfer, DJ, Reynolds, CF. Management of insomnia. NEJM 1997; 336:341-346
  4. Ohayon MM. Prevalence of DSM-IV diagnostic criteria of insomnia: distinguishing insomnia related to mental disorders from sleep disorders. J Psychiatr Res. 1997; 31: 333-46.
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  14. Milby J et al. Effectiveness of combined triazolam-behavioral therapy for primary insomnia. Am J Psych. 1993;150:1259-60
  15. Johnson MD et al. Fatal familial insomnia: clinical and pathologic heterogeneity in genetic half brothers. Neuro. 1998; 51: 1715-17.
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  17. Murtagh DR, et al. Identifying effective psychological treatments for insomnia: A meta-analysis. J Consult Clin Psychol. 1995; 63: 79-89.
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  19. Edinger JD, et al. A cognitive-behavioral therapy for sleep maintenance insomnia in older adults. Psychology and Aging 1992; 7: 282-289.
  20. Roth T, et al. Intermediate use of triazolam: A sleep laboratory study. J Int Med Res 1976; 4: 59-63.
  21. Roth T, et al. Zolpidem in the treatment of transient insomnia: A double blind randomized comparison with placebo. Sleep 1995; 18: 246-251.
  22. Greenblatt D. Benzodiazepine Hypnotics: Sorting the pharmacological facts. J Clin Psychiat 1991; 53 Suppl 9:4-10.
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  24. Hauri P et al. Can we mix behavioral therapy with hypnotics when treating insomniacs? Sleep. 1997; 20:1111-18
  25. Rosenthal NE, et al. Phase-shifting effects of bright morning lights treatment for delayed sleep phase syndrome. Sleep 1990; 13:354-361.
Jacksonville Medicine / March, 2001

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