Insomnia: symptoms and treatment of sleep disorder

Insomnia disorder consists of a condition of dissatisfaction with the quantity or quality of sleep

Insomnia is characterised by

  • difficulty in initiating sleep
  • difficulty in maintaining sleep

Insomnia is a subjective disorder in that it refers to the subjective sense of difficulty falling asleep, maintaining sleep, or poor sleep quality.

Insomnia, specific characteristics of the sleep disorder

Specifically, insomnia can be characterised by:

  • Difficulty falling asleep (initial/early insomnia);
  • Frequent and prolonged nocturnal awakenings (maintenance insomnia);
  • Early awakening in the morning (late insomnia);
  • A combination of these difficulties (mixed or generalised insomnia).

How can one tell if a person suffers from insomnia?

In order to be able to consider a person truly suffering from a significant degree of insomnia, the minimum criteria are:

  • amount of time for falling asleep and waking up at night equal to or greater than 30 minutes;
  • frequency equal to or greater than 3 nights per week;
  • duration equal to or greater than 6 months.

Although insomnia is defined as a sleep disorder, it has repercussions that extend beyond the sleep period, significantly affecting the waking period.

In fact, people who suffer from sleep disorders complain of daytime sleepiness and a deterioration in their ability to work (Morin, 1993).

Those who suffer from insomnia, compared to individuals without insomnia, also report high levels of anxiety and depression.

Insomnia may therefore represent a risk factor or a causal factor for the development of certain psychiatric disorders (Harvey, 2001; Lichstein, 2000).

Widespread occurrence of insomnia

Approximately 30 to 50 per cent of adults experience occasional difficulty sleeping through the night.

A sudden or stressful event may cause an episode of insomnia.

Generally, however, once that event is resolved, the sleep disturbances subside, thus denoting a transient feature of the problem.

However, for some predisposed persons, the difficulty may persist even after the trigger has disappeared.

6-13% of adults meet the criteria for a sleep disorder (DSM-5).

Insomnia disorder appears to have a higher frequency in women than in men.

Treatment of insomnia

The main forms of treatment for Insomnia Disorder are drug therapy and cognitive-behavioural psychotherapy.

Medication for sleep disorders

Drug therapy is often the first treatment for insomnia recommended by general practitioners.

The prescription of hypnoinducing drugs is especially common in the elderly, who seem to use sleeping pills twice as often (14%) as the general population (7.4%).

The use of hypnotic drugs or anxiolytics with a hypnotic function (benzodiazepines) is not recommended for longer than two weeks.

Prolonged use may cause side effects such as daytime drowsiness and dizziness, as well as habituation and tolerance.

Attempts at drastic withdrawal cause a withdrawal syndrome, characterised by a bloody return of insomnia (rebound effect), psychomotor agitation, anxiety and tremors (Gillin, Spinwerber and Johnson, 1989).

This prompts the insomniac to take the drug again, creating a vicious circle.

Chronic intake of hypnotics is an important factor in maintaining the sleep problem.

For the long-term treatment of Insomnia Disorder, drugs with antidepressant and sedative effects (Trazodone) and melatonin are also used.

The latter has become a frequent choice especially for self-medication, however its administration is only indicated for individuals with reduced levels of this hormone.

Psychotherapy for sleep disorder

The integrated cognitive-behavioural treatment of insomnia involves the use of various intervention techniques, the choice of which is made according to the findings of the initial assessment.

That is, based on the phenomenological characteristics of the disorder of a specific insomniac patient.

The intervention techniques, which form the core of the cognitive-behavioural treatment for Insomnia Disorder are:

Education and sleep hygiene: in this phase, the aetiological and maintenance factors of insomnia are explained according to the cognitive-behavioural model.

The patient is also given basic information about sleep physiology (sleep stages, internal and external clock, individual differences) and sleep hygiene rules to improve sleep quality (e.g. avoidance of both alcoholic and caffeinated drinks and smoking in the two hours before bedtime).

Sleep restriction: this is a technique that aims to match the time spent in bed by the patient with the time actually spent sleeping.

Stimulus control: aims to extinguish the association of the bed and bedroom with activities incompatible with sleep (e.g. watching TV or planning the next day’s work).

Cognitive restructuring: procedure to change dysfunctional beliefs and expectations about sleep.

Relaxation techniques and imaginative distraction.

Efficacy of psychological treatment

The results of two meta-analyses (Morin, Culbert and Scwartz, 1994; Murtagh and Greenwood, 1995), in which more than 50 studies with a total of more than 2000 patients were considered, demonstrated the effectiveness of cognitive-behavioural therapy for insomnia problems in adults.

Behavioural techniques of stimulus control and sleep restriction appear to be the ‘active ingredient’ of cognitive-behavioural therapy for insomnia.

Approximately 70% to 80% of patients benefit from cognitive-behavioural therapy that aims to eliminate the cognitive and behavioural factors involved in the maintenance and exacerbation of insomnia.

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