Primary Insomnia

Primary insomnia is sleeplessness, insufficient sleep, or the perception of poor quality sleep not caused by medical or psychiatric diseases.

• Primary insomnia is sleeplessness or the perception of poor quality sleep that is not caused by medical or psychiatric diseases, conditions, genetics, or illnesses; or environmental causes (such as drug abuse, medication, or shift work).
• There are two classifications of insomnia: primary and secondary.
• Primary insomnia is caused by one of the following:
• Psychophysiological causes
• Idiopathic (no known cause)
• Sleep state misperception
• Secondary insomnia is caused by another disease, condition, or illness, for example:
  • Medications
  • Alcohol
  • Illegal drugs
  • Lifestyle habits
  • Depression
  • Anxiety
  • stress
  • Arthritis
  • Asthma
  • Chronic pain
  • Low back pain
  • Parkinson's disease
  • Acid reflux
  • Allergies.
• Signs and symptoms of primary insomnia may include the following:
  • Problems falling asleep and/or staying awake
  • Sleep varies, for example, one night of good sleep comes after several nights of difficult sleep.
  • Daytime sleepiness
  • Problems performing normal daily functions, for example, difficulties with memory or concentration, or problems at school or work.
  • Eye redness
  • Irritability or moodiness
  • Concerns about sleep
• Primary insomnia is diagnosed using the International Classification of Sleep Disorders, 2nd Edition (ICSD-2) classification criteria.
• Primary insomnia is treated with medication and lifestyle changes including sleep hygiene and eliminating alcohol and caffeine before bedtime.

Insomnia refers to insufficient or poor-quality sleep. It is not defined by a specific length of time spent in sleep but upon the lack of sleep relative to an individual's needs.

• Primary insomnia is insomnia that occurs without a known medical, psychiatric, or environmental reason.

Psychophysiological insomnia symptoms:

• Sleep disturbance varies from mild to severe.
• Sleeplessness may manifest as difficulty falling asleep or as frequent awakenings in the night.
• Persons with insomnia often find that they can sleep well anywhere else but in their own bedroom.
• Persons with this type of insomnia tend to be more tense and dissatisfied compared to good sleepers. Emotionally, they are typically repressors (suppress their feelings), denying problems.

Idiopathic insomnia symptoms:

• Insomnia is long-standing, typically beginning in early childhood.
• Persons with idiopathic insomnia often complain of difficulties with attention or concentration or hyperactivity.
• Emotionally, persons with childhood-onset insomnia are often repressors, denying and minimizing emotional problems.
• Individuals often show atypical reactions, such as hypersensitivity or insensitivity, to medications.
• Insomnia tends to persist over the entire life span and can be aggravated by stress or tension.

Sleep state misperception: Persons complain of insomnia subjectively, while sleep duration and quality are completely normal. They typically do not display daytime sleepiness or other signs of poor-quality sleep. These people may be described as having "sleep hypochondriasis." They may subsequently develop anxiety and depression.

Sleeplessness without any medical, psychological, or environmental cause can be divided into the following three subgroups:

Psychophysiological insomnia

In a person with previously adequate sleep, sleeplessness begins because of a prolonged period of stress. Tension and anxiety resulting from the stress cause awakening. Thereafter, sleep in such persons becomes associated with frustration and arousal, resulting in poor sleep hygiene. In most people, as the initial stress decreases, normal sleep habits are gradually restored because the bad sleep habits are not reinforced. However, in some people, the bad habits are reinforced, the person "learns" to worry about his or her sleep, and sleeplessness continues for years after the stress has subsided. Therefore, it is also called learned insomnia or behavioral insomnia.

Idiopathic insomnia

Lifelong sleeplessness is attributed to an abnormality in the neurologic control of the sleep-wake cycle involving areas of the brain responsible for wakefulness and sleep. It may begin in childhood. Those affected may have a dysfunction in the sleep state that predisposes the person towards arousal.

Sleep state misperception

The person complains of insomnia without objective evidence or symptoms of any sleep disturbance.

Primary care providers, including family practitioners and internists, often diagnose and treat insomnia.

• Depending upon the individual situation, other specialists, such as sleep medicine specialists, neurologists, and psychiatrists, may be consulted.
• Other mental health care practitioners may also be involved in managing insomnia.

Exams and tests may be done to rule out medical (for example, pain caused by arthritis or cancer) and psychiatric conditions that may cause insomnia.

The health care professional takes a thorough clinical interview with the person and his or her sleep partner regarding the person's sleep habits.

The person may be asked to maintain a sleep diary. In this diary, the person describes the previous night's sleep. Data from the sleep diary may help minimize distortions in sleep information recalled in the health care professional's office.

Polysomnography (overnight sleep study test)

It is not recommended for the routine evaluation of sleeplessness but may be used in special circumstances (for example, to rule out causes of insomnia).

Psychophysiological insomnia and idiopathic insomnia manifest as increased sleep latency (taking a long time to fall asleep), reduced sleep efficiency, and increased number and duration of awakenings.

Sleep state misperception manifests as normal sleep latency (15-20 minutes), a normal number of arousal and awakenings, and normal sleep duration (6.5 hours).

Idiopathic insomnia, previously called childhood-onset insomnia, is defined as a lifelong difficulty in initiating and maintaining sleep and resulting in poor daytime functioning. Psychophysiological insomnia is chronic insomnia resulting from learned, sleep-preventing associations and increased tension or agitation. People with sleep state misperceptions report insomnia and sleeplessness but do not have objective evidence of a sleep disorder.

Multiple sleep latency test

In this test, the time taken by a person to fall asleep (sleep latency) during the day while lying in a quiet room is measured. In persons with sleep state misperception, this test shows normal daytime vigilance. Vigilance in this sense means a wakeful or alert state. The test shows that the person does not have increased or decreased sleep latency time (time required to fall asleep).

Sleep state misperception can only be diagnosed in the laboratory because of the need to document that sleep duration and quality are normal when a person describes having poor sleep.

The sleep hygiene recommendations that include environmental and lifestyle modifications include the following:

• Eliminate the use of caffeine, especially afternoon.
• Do not use tobacco or alcohol near bedtime.
• Avoid heavy meals close to bedtime.
• Exercise early in the day before dinner to alleviate stress, but do not exercise before bedtime.
• Avoid daytime naps and establish a regular schedule for going to bed and getting up.
• Keep the bedroom at a comfortable temperature, and minimize distractions from light and noise.

Treatment with medicine usually provides rapid symptomatic relief.

The mainstays of short-term treatment of primary insomnia include hypnotics (agents that promote sleep) and benzodiazepines (compounds with antianxiety, hypnotic, anticonvulsant, and muscle relaxant properties).

Hypnotics for primary insomnia

Basic principles for the treatment of insomnia include the following:

• Use the lowest effective dose of medication.
• Use intermittent dosing (2 to 3 nights per week).
• Use for a short term (2 to 3 weeks at a time).
• Discontinue after slow taper if the person has been taking it regularly.
• Use drugs with short and/or intermediate half-life to minimize daytime sedation.

*Zolpidem and Zaleplon are not structurally related to benzodiazepines.

Common side effects of hypnotics are as follows:

• Amnesia (total or partial inability to recall past experiences) and withdrawal effects may occur, especially with short-acting benzodiazepines (not with zolpidem and zaleplon).
• Residual daytime sedation with intermediate-acting and long-acting drugs may occur, depending on the dosage.
• Rebound insomnia may occur with short-acting and intermediate-acting benzodiazepine after discontinuation.
• Short-acting agents are recommended for persons with difficulty falling asleep, while intermediate-acting drugs are indicated for problems with sleep maintenance.
• Avoid long-acting agents, especially in older people, because they cause daytime sedation, impair cognition, and, thereby, increase the risk of falls.

Not everyone should take hypnotic medications. Contraindications of hypnotics are as follows:

• Pregnancy
• Untreated obstructive sleep apnea
• History of substance abuse

Caution and close monitoring are needed in older people and persons with hepatic, renal, or pulmonary disease.

Belsomra (suvorexant)

Belsomra (suvorexant) is an orexin antagonist, a newer classification of insomnia medication. Orexin antagonists work by decreasing activity in the wake center of the brain and helping individuals transition to sleep. The other hypnotic medications typically act on the sleep-promoting centers of the brain by attempting to increase activity in these areas. Dosage for Belsomra is 5-20 mg/2 hr. Belsomra is completely unrelated to both the benzodiazepine and non-benzodiazepine sedative-hypnotic drugs.

Side effects:

• The primary side effect of this drug class is increased sleepiness during the day.
• Overall it is considered relatively safe in early studies.
• As with other sleep medications, caution should always be considered when other CNS depressants are being used.
• At least 7 hours of sleep should be available after taking this medication, and any side effects such as abnormal behaviors during sleep, increased depressive symptoms, suicidal thoughts, daytime sleepiness, or breathing problems should be reported to your doctor.

Antidepressants

Antidepressants are indicated for use in people with insomnia associated with psychiatric disorders or persons who have a previous history of substance abuse. Sedating (sleep-inducing) antidepressants, such as trazodone and nefazodone, are sometimes used at bedtime in small doses (50 mg). They are not associated with tolerance or withdrawal.

Melatonin stimulants

Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors. Melatonin is a hormone produced by the pineal gland (located in the brain) during the dark hours of the day-night cycle (circadian rhythm). Melatonin levels in the body are low during daylight hours. The pineal gland responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. Ramelteon promotes the onset of sleep and helps normalize circadian rhythm disorders. Ramelteon is approved by the FDA for insomnia characterized by difficulty falling asleep.

Over-the-counter drugs

The active agent in many of the over-the-counter medications is one of the sedating antihistamines (drugs used for the treatment of allergy). They are generally safe but have side effects such as dry mouth, blurred vision, urinary retention, and confusion in older persons. They are also only mildly effective in inducing sleep and may reduce sleep quality. Therefore, these drugs should not be used on a routine basis.

There is no scientific evidence that herbal or "natural" substances are effective at promoting sleep.

Melatonin is a hormone that is thought to induce sleep. Studies have shown that melatonin may be useful for short-term adaptation to jet lag or other circadian rhythm sleep disorders. This hormone is produced by the pineal gland (located in the brain) in response to darkness, and it may be an important part of an individual's "biologic clock." Melatonin may be particularly useful for individuals with conditions that do not produce sufficient melatonin in response to darkness, such as blindness. The effectiveness of melatonin for long-term sleeplessness is less clear. Melatonin is sold over the counter and, therefore, is not controlled by the FDA. The optimal dose and its long-term adverse effects are also not known.

Behavioral therapy: Behavioral therapy is now considered the most appropriate treatment for persons with sleeplessness without any medical, psychiatric, or environmental cause.

• It consists primarily of short-term cognitive-behavioral therapies. The focus is primarily on sleep hygiene or factors presumed to cause insomnia. As such, these therapies seek to modify maladaptive sleep habits and to educate persons about healthier sleep practices.

Stimulus control therapy: The purpose of this therapy is to re-establish the connection between the bed and sleep by prohibiting the person from engaging in nonsleep activities while in bed. The following instructions are given:

• Go to bed only when sleepy.
• Use the bed and bedroom only for sleep and intimacy.
• Avoid trying to force sleep (go into another room whenever unable to fall asleep within 20 to 30 minutes, and return to bed only when sleepy again).
• Get up at the same time each morning regardless of how much one has slept the previous night.
• Avoid daytime napping.

Sleep restriction therapy: This involves limiting the amount of time the person spends in bed to the actual amount of time the person usually spends sleeping. This results in sleep deprivation, which accumulates and causes more rapid sleep onset on subsequent nights. As sleep improves, the person is allowed to gradually increase time in bed by 15 to 30 minutes.

Relaxation therapies: The person is taught to identify and control tension. Relaxation-based interventions are advised based on the observation that persons with insomnia often display high levels of arousal both at night and during the daytime. The various techniques available to deactivate the arousal system are:

• The person is taught progressive muscle relaxation through a series of exercises that consist of first tensing and then relaxing each muscle group in a systematic way.
• The biofeedback technique is a training technique that enables an individual to gain some element of voluntary control over certain body parameters (for example, heart rate, rate of breathing). This technique provides immediate feedback regarding the levels of tension and teaches a person how to relax in a short time.
• Imagery training and thought stopping teach the person how to focus on neutral or pleasant things instead of focusing on racing thoughts.

Cognitive therapy: This consists of identifying person-specific activities associated with thinking that disrupts sleep, challenging their validity, and replacing them with substitutes such as reattribution training (a simple technique that has been used successfully to help persons to recognize that their minds play a part in causing their physical symptoms), reappraisal, and attention shifting.

Paradoxical intention: This method consists of persuading a person to engage in his or her most feared behavior (for example, staying awake). This serves to eliminate performance anxiety so that sleep may come more easily.

The outlook for primary insomnia is good if the person adopts good sleep habits. It is important to note that one's health is not at risk if one does not get 6-8 hours of sleep every day and that different people have different natural sleep requirements. However, the following have been associated with insomnia:

• Increased risk of death is associated with short sleep lengths.
• Insomnia is the best predictor of the future development of depression.
• Increased risk exists of developing anxiety, alcohol and drug use disorders, and nicotine dependence.
• Poor health and decreased activity occur.
• The onset of insomnia in older persons is related to decreased survival.