Psychiatr News September 16, 2005
Volume 40, Number 18, page 30
© 2005 American Psychiatric Association
Insomnia: Both Symptom and Syndrome
Insomnia is the most common sleep complaint in all stages of adulthood.
About 30 percent of American adults report sleeping poorly a few nights a
week, and 10 percent say the problem is chronic.
About 40 percent of people with psychiatric disorders report chronic
insomnia, as do 50 percent of patients in primary care practices.
These individuals typically describe persistent difficulty falling asleep,
staying asleep, or falling back to sleep, waking too early, or unsatisfying
sleep, even when they have adequate opportunities for sleep. While intensity
of symptoms may vary over time, many people report struggling with sleep for
years, even a lifetime.
Insomnia disrupts waking life as well. Poor sleepers commonly complain of
daytime fatigue, disturbed mood, faulty memory, and trouble thinking. Few
report daytime sleepiness, however. Rather, they often report feeling anxious
and irritable, a suggestion that persistent hyperarousal plays a key role in
the disorder.
A sleep study, or polysomnography, usually the gold standard for
quantifying sleep disturbances, is not routinely used to evaluate chronic
insomnia, Daniel Buysse, M.D., a professor of psychiatry at the University of
Pittsburgh School of Medicine, told a National Institutes of Health review
panel. Polysomnographic studies typically confirm a patient's subjective
report without revealing the cause for the sleep disturbance. Sleep
specialists often use sleep diaries, questionnaires, and activity monitors to
document sleep problems and their consequences.
While primary insomnia can occur, most chronic insomnia coexists with other
conditions. These include psychiatric disorders that involve depression,
anxiety, substance abuse, dementia in the elderly,
attention-deficit/hyperactivity disorder in the young, and medical disorders
that cause pain, breathing difficulty, and impaired mobility. Such
comorbidities no longer are termed "secondary insomnia." That
concept may promote undertreatment, Buysse suggested.
"People used to think of insomnia as a symptom," he said. That
drove practice. Physicians treated the alleged underlying disorder. But
evidence now indicates that insomnia can exist independently. It may respond
to treatments different from those used for the comorbid disorder. Treating
pain in a person with arthritis, for example, he said, still might not relieve
the person's insomnia.
When depression and troubled sleep coexist, treatment that resolves the
depression sometimes does not improve the sleep disturbance. Treating the
sleep problem, however, often benefits the depression. Untreated sleep
disturbance may contribute to the recurrence of the depression.
Antidepressants sometimes induce periodic limb movements or the restless legs
syndrome, further disturbing sleep, and necessitating specific treatment.
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