Insomnia

Introduction

            Pathological psychology deals with studying, explaining and treating abnormal behaviour? But what makes behaviour normal or abnormal? Is it statistically or socially? One major factor is that whatever the case may be, once there is an accompaniment of distress and impairment in daily activities or cognitively, it could be said that that particular individual behaves abnormally. Thus, in this paper, we shall examine a sleep-wake called which is also known as Insomnia. We shall look at its definition, diagnosis, gender-related issue and a possible treatment of Insomnia.

What is Insomnia?

The essential feature of insomnia disorder is dissatisfaction with sleep quantity or quality with complaints of difficulty initiating or maintaining sleep. The sleep complaints are ac­companied by clinically significant distress or impairment in social, occupational, or other important areas of functioning. The sleep disturbance may occur during the course of an­other mental disorder or medical condition, or it may occur independently. Different manifestations of insomnia can occur at different times of the sleep period.[1] Sleep-onset insomnia (or initial insomnia) involves difficulty initiating sleep at bedtime.  Sleep mainte­nance insomnia (or middle insomnia) involves frequent or prolonged awakenings throughout the night.[2]

 Late insomnia involves early-morning awakening with an inability to return to sleep.  Difficulty maintaining sleep is the most common single symptom of insomnia, followed by  difficulty  falling  asleep, while a combination of these symptoms is the most common presen­tation overall.[3] The specific type of sleep complaint often varies over time. Individuals who complain of difficulty falling asleep at one time may later complain of difficulty maintaining sleep, and vice versa. Symptoms of difficulty falling asleep and difficulty maintaining sleep can be quantified by the individual's retrospective self-report, sleep diaries, or other methods, such as actigraphy or polysomnography, but the diagnosis of insomnia disorder is based on the individual's subjective perception of sleep or a caretaker's report.[4]

Nonrestorative sleep, a complaint of poor sleep quality that does not leave the individual  rested upon awakening despite adequate duration, is a common sleep complaint usually  occurring in association with difficulty initiating or maintaining sleep, or less frequently in  isolation.[5] This complaint can also be reported in association with other sleep disorders (e.g., breathing-related sleep disorder). When a complaint of nonrestorative sleep occurs in isolation (i.e., in the absence of difficulty initiating and/or maintaining sleep) but all di­agnostic criteria with regard to frequency, duration, and daytime distress and impairments are otherwise met, a diagnosis of other specified insomnia disorder or unspecified insom­nia disorder is made.[6]

Insomnia disorder involves daytime impairments as well as night time sleep difficulties.  These include fatigue or, less commonly, daytime sleepiness; the latter is more common among older individuals and when insomnia is co morbid with another medical condition (e.g., chronic pain) or sleep disorder (e.g., sleep apnea). Impairment in cognitive performance may include difficulties with attention, concentration and memory, and even with performing simple manual skills. Associated mood disturbances are typically described as irritability or mood lability and less commonly as depressive or anxiety symptoms. Not all individuals with night time sleep disturbances are distressed or have functional impairment. For example, sleep continuity is often interrupted in healthy older adults who nevertheless identify themselves as good sleepers. A diagnosis of insomnia disorder should be reserved for those individuals with significant daytime distress or impairment related to their night time sleep difficulties.[7]

Gender-Related Diagnostic issues

The onset of insomnia symptoms can occur at any time during life, but the first episode is more common in young adulthood. Less frequently, insomnia begins in childhood or ad­olescence.[8] In women, new-onset insomnia may occur during menopause and persist even after other symptoms (e.g., hot flashes) have resolved. Insomnia may have a late-life onset, which is often associated with the onset of other health-related conditions. Insomnia can be situational, persistent, or recurrent. Situational or acute insomnia usu­ally lasts a few days or a few weeks and is often associated with life events or rapid changes in sleep schedules or environment. It usually resolves once the initial precipitating event subsides. For some individuals, perhaps those more vulnerable to sleep disturbances, in­somnia may persist long after the initial triggering event, possibly because of conditioning factors and heightened arousal.[9]

The factors that precipitate insomnia may differ from those that perpetuate it. For example, an individual who is bedridden with a painful injury and has difficulty sleeping may then develop negative associations for sleep. Conditioned arousal may then persist and lead to persistent insomnia. A similar course may develop in the context of an acute psychological stress or a mental disorder. For instance, insomnia that occurs during an episode of major depressive disorder can become a focus of attention, with consequent negative conditioning, and persist even after resolution of the depressive episode. In some cases, insomnia may also have an insidious onset without any identifi­able precipitating factor.[10]

The course of insomnia may also be episodic, with recurrent episodes of sleep difficul­ties associated with the occurrence of stressful events. Chronicity rates range from 45% to 75% for follow-ups of 1-7 years. Even when the course of the insomnia has become chronic, there is night-to-night variability in sleep patterns, with an occasional restful night's sleep interspersed with several nights of poor sleep. The characteristics of insomnia may also change over time. Many individuals with insomnia have a history of "light" or easily disturbed sleep prior to onset of more persistent sleep problems. Insomnia complaints are more prevalent among middle-age and older adults. The type  of insomnia symptom changes as a function of age, with difficulties initiating sleep being more common among young adults and problems maintaining sleep occurring more fre­quently among middle-age and older individuals.[11]

Difficulties initiating and maintaining sleep can also occur in children and adolescents, but there are more limited data on prevalence, risk factors, and comorbidity during these developmental phases of the lifespan. Sleep difficulties in childhood can result from con­ditioning factors (e.g., a child who does not learn to fall asleep or return to sleep without the presence of a parent) or from the absence of consistent sleep schedules and bedtime routines. Insomnia in adolescence is often triggered or exacerbated by irregular sleep sched­ules.[12] In both children and adolescents, psychological and medical fac­tors can contribute to insomnia. The increased prevalence of insomnia in older adults is partly explained by the higher incidence of physical health problems with aging. Changes in sleep patterns associated with the normal developmental process must be differentiated from those exceeding age-related changes. Although polysomnography is of limited value in the routine evaluation of in­somnia, it may be more useful in the differential diagnosis among older adults because the etiologies of insomnia are more often identifiable in older individuals.[13]

Treatment of Insomnia

            The most common cognitive-behavioural therapies for chronic insomnia are: stimulus controls, sleep restriction, sleep hygiene, relaxation training and cognitive therapy.[14] Typically, therapy includes three or more of the above components. Most clinical trials protocols adopt a multi-component approach to treatment; where the components are usually stimulus control and/ or sleep restriction therapy along with sleep hygiene instructions.[15]

Conclusion

From the above discussion, we have seen that the essential feature of insomnia disorder is dissatisfaction with sleep quantity or quality with complaints of difficulty initiating or maintaining sleep. We equally have seen that the onset of insomnia symptoms can occur at any time during life, but the first episode is more common in young adulthood. Less frequently, insomnia begins in childhood or ad­olescence. We also discussed several therapies which could help control this sleep disorder.

BIBLIOGRAPHY

Alexander Z. Golbin and Louis G. Keith. Sleep Psychiatry. UK: Taylor&Francis, 2004.

American Psychiatric Publishing. Diagnostic and Statistical Manual for Mental Disorder. 5th ed. American Pyschiatric Publishing, 2013.

Perlis L. Michael. Cognitive Behavioural Treatment of Insomnia: A session-by-session Guide. Springer Science&Business Media, 2006.

Swaiman F. Kenneth, ‎Ashwal StephenPediatric Neurology: Principles and Practice. USA: Mosby 1999.

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[1] See American Psychiatric Publishing. Diagnostic and Statistical Manual for Mental Disorder. 5th ed. (American Pyschiatric Publishing, 2013), p. 363

[2] American Psychiatric Publishing . Diagnostic and Statistical Manual for Mental Disorder, p. 363.

[3] American Psychiatric Publishing . Diagnostic and Statistical Manual for Mental Disorder, p. 363.

[4] American Psychiatric Publishing . Diagnostic and Statistical Manual for Mental Disorder, p. 363.

[5] See Alexander Z. Golbin and Louis G. Keith. Sleep Psychiatry (UK: Taylor&Francis, 2004), p. 98-12.

[6] Alexander Z. Golbin and Louis G. Keith. Sleep Psychiatry, p. 110.

[7] Alexander Z. Golbin and Louis G. Keith. Sleep Psychiatry

[8] Kenneth F. Swaiman, ‎Stephen Ashwal. Pediatric Neurology: Principles and Practice. (USA: Mosby 1999), p. 780.

[9] American Psychiatric Publishing . Diagnostic and Statistical Manual for Mental Disorder. 5th ed, p. 364.

[10] American Psychiatric Publishing . Diagnostic and Statistical Manual for Mental Disorder. 5th ed, p.364.

[11] American Psychiatric Publishing . Diagnostic and Statistical Manual for Mental Disorder. 5th ed, p.364

[12] American Psychiatric Publishing . Diagnostic and Statistical Manual for Mental Disorder. 5th ed, p.364

[13] American Psychiatric Publishing . Diagnostic and Statistical Manual for Mental Disorder. 5th ed, p.364

[14] Michael L. Perlis, Cognitive Behavioural Treatment of Insomnia: A session-by-session Guide. (Springer Science&Business Media, 2006), p.12.

[15] Michael L. Perlis, Cognitive Behavioural Treatment of Insomnia: A session-by-session Guide. P.12.