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Chapter 4
INSOMNIA: RE SEARCH FINDINGS,
DIAGNOSTIC APPROACHES, AND THERAPEUTIC OPTIONS
A. The Meaning of Insomnia
Insomnia is a subjective complaint that is related to or caused by
a variety of disorders. As with many other types of subjective distress
(dyspepsia, or back pain), much ignorance surrounds the nature of the
problem and the value of the relief commonly provided in modern health
care.
Most health care professionals have assumed that patients who
complain of insomnia accurately describe their night-time sleep. When
this assumption has been examined in the clinical sleep laboratory,
however, surprising findings emerged: in many cases the actual sleep
of patients complaining of insomnia is hardly disturbed; there is an
enormous overlap in the objective laboratory measures of sleep between
insomniac patients and age-matched, normal controls.*
In some cases, the complaint of insomnia is completely unrelated to
sleep or to daytime alertness. Although many sleep laboratory studies
have shown, that, as a group, insomniacs take longer to fall asleep,
sleep less, have less delta sleep, and have lower sleep efficiency than
do normals, there also are well-documented cases of insomniac patients
who fall asleep within 10-15 minutes and who sleep 7-8 hours per
night. 1/-4/ Some insomniacs show greater variability in sleep
measures from night to night than normal controls; it has been hypo-
thesized that some of their suffering results from their inability
to predict when they will have a good or bad night. 3/,5/
Among persons who do not complain of insomnia, some sleep very
little and do not consider themselves to be insomniacs. One report
describes two normal, healthy men who averaged about three hours of
sleep per night when monitored nightly for seven days. 6/ Another
describes the case of a 70-year-old woman whose typical 52 minutes
of sleep per 24 hours was confirmed in the laboratory. 7/ She re-
ported that she had been sleeping this way since her teens with no
ill effects.
*A comprehensive tabulation of the data upon which these
conclusions are based is included in the Technical Supplement to
this report.
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extent
study,
sleep,
On the other hand, insomnia patients tend to
of their difficulties. In virtually every sleep laboratory
insomniacs have had great difficulty in correctly assessing their
although their subjective estimates usually vary in the same
In a major sleep labor-
latencv was
overestimate the
-
direction as objective findings. 1/-3/, 8/-12/
atory study of 122 patients, for example, sleep latency was estimated
by the patients to be 62 minutes, but was only 26 minutes by EEG crite-
~ - than two-fold. 1/ Actual total sleep
time was 342 minutes, but estimated sleep time was 273 minutes, a
difference of over an hour. In a classic case reported by Zung, a
middle-aged woman with a 25 year history of insomnia slept for four
nights in the sleep laboratory. 2/ She fell asleep quickly, slept
over eight hours per night, and had normal architecture of sleep
stages. Each morning, however, she reported that she "didn't sleep
a wink."
rota, an exaggeration ot more than two-fold. 1/
Figure 1 is a conceptualization of the overlap in objective
~ ~ ~ and patients with insomnia
- to be significantly
sleep measures in non-complaining controls
complaints, in which the means have been found
different between the two groups.
Insomnia Mean Normal Mean
-
A// Normals
it\\\>,: I nsomniacs
Overlap
LONGER AND MORE EFFICIENT SLEEP
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Studies suggest that many non-complaining middle-aged adults have
sleep measures that have in the past been deemed impressive in insomniacs.
Given the obvious heterogeneity of the insomnia population group, means
and standard deviations of sleep measures can be very misleading. One
must look at individual patients, rather than group data. For example,
in one study referred to above, 58 (nearly half) of the 122 chronic
insomniacs consistently fell asleep in less than 15 minutes, and many
literally fell asleep instantaneously in spite of claiming they were
unable to fall asleep the next morning. 1/, 12/ It is likely that the
means conceal crucial diagnostic and etiological differences between
patients who actually fall asleep promptly and patients who require
several hours to fall asleep. Objective sleep measures alone have proven
inadequate in understanding the causes of insomnia and providing confir-
mation of ''effectiveness" for its relief.
What accounts for insomnia complaints by patients whose objective
measures of sleep seem to be adequate?
-- Controls and insomniacs may differ in their thresholds for
complaining of poor sleep. Given this framework, normal subjects are
able to endure a certain amount of sleep fragmentation, sleep reduction,
and so forth with no significant consequences. When some other dysphoria,
such as anxiety or depression, is added to the picture, the threshold
for sleep complaint may decrease.
-- The discrepancies in many patients' data could be explained on
the basis of fundamental differences in daily need for sleep. Thus, a
50 year old patient who sleeps 7.5 hours a night and complains of insomnia
night be a person who requires 9.5 hours nightly to experience restora-
tion and to maintain optimal alertness throughout the day. Such a
question could probably be resolved by attempting to extend the total
amount of sleep. But because very few individuals after the age of 50
are able to sleep for long periods of time without significant periods
of wakefulness, the amount of time that such an individual might have
to spend in bed in order to accumulate 9.5 hours of sleep could be
be prohibitive.
-- The classical sleep measures may not be the best way to
assess adequacy of sleep. This is a controversial issue, because
certain investigators feel that total sleep time is the only pertinent
variable. It could be, however, that recently discovered factors such
as EEG spindle or delta activity or measures of body movements will
yield better clues to the restorative adequacy of sleep.
-- Certain individuals may sleep at a higher level of physiological
activation than other persons. 4/ Thus, some insomniacs who fall asleep
in lo minutes and assume it is one hour may have such heightened activa-
tion that they perceive themselves to be awake, however dimly, although
they are really asleep.
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- Insomnia and the adequacy of nocturnal sleep may depend more
on circadian rhythm properties than on the sleep measures themselves.
It has been shown that there is a rhythm in sleepiness and fatigue,
particularly in jet lag or in shift work, that can be fairly independent
of amount of sleep and when sleep is taken.
-- There could be an abnormally heightened response to partial
sleep loss. If it is assumed that daytime sleepiness is a consequence
of the reduction of sleep below some optimum, it is possible that this
response in some people is manifested by exaggerated sleepiness from
relatively minor sleep disturbance.
-- The complaint of insomnia or disturbed sleep may not refer
directly to sleep at all, but to an aspect of anxiety or depression. In
these cases, the inability to sleep may become a relatively respectable,
acceptable complaint. This formulation is supported by the work of
Kales and associates 13/ who have reported Minnesota Multiphasic
Personality Inventory (MMPI) studies in groups of patients complaining
of insomnia and consistently find approximately 85 percent showing
pathological elevation of one or more of the subscales. There is
widespread feeling among researchers and clinicians that most complaints
of insomnia are associated with depression and emotional problems. 14/
Issues of cause-and-effect and precise prevalence remain controversial
and unresolved.
The above observations illustrate some of the problems faced by the
clinician. In treating a patient who complains, for example, that he
requires an hour to fall sleep, the physician must remember (a) that it
is likely that the patient falls asleep considerably more quickly,
(b) that under the best of circumstances, a hypnotic will probably
shorten the objective sleep latency by only 10 to 20 minutes; and (c)
that although the patient's estimate of the difficulty may be exagger-
ated, his subjective distress is real. At the present time, little
is known about the relationship between the objective characteristics
of sleep and subjective satisfaction. It is unclear why some people
complain about their sleep when they sleep eight hours, while others
do not when they sleep one hour. Nor is it known if hypnotics are
more effective in insomniac patients with objective sleep disturbance
than in those without.
The functions of sleep are basically unknown. In terms of patient
education, the physician should remember that some of the anxiety
experienced by insomniac patients results from prior erroneous teach-
ing about the functions of sleep. Everyone has heard that it is neces-
sary to get "plenty of sleep" in order to maintain good health or to
recover from illness. These common attitudes were reinforced to an
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unfortunate degree by early sleep laboratory experiments which
prematurely suggested that deprivation of total sleep, REM sleep, or
Stage 4 sleep might cause serious psychopathology. It now appears that
the overall effects of REM sleep deprivation or Stage 4 deprivation
are, at most, slight and subtle. There is little evidence that short
term sleep deprivation increases the risk of mental or physical illness.
However, epidemiological studies suggest that self-reported short 15/-16/
(and long) 16/ sleep may be related in the long run to increased mor-
tality rates. It can be helpful for patients to be told that there
are wide individual differences in the amount of sleep people seem to
need.
In a similar vein, current evidence suggests that the effect of a
hypnotic drug on a specific sleep stage is not of major importance, and
that choosing between hypnotics should not be based primarily on their
relative effects on sleep stages. It seems reasonable to choose the
drug with the least disruptive effect on sleep stages. All of the
currently marketed prescription drugs appear, however, to alter sleep
stages in one way or another. While flurazepam, for example, has a
relatively small effect on REM sleep, it is a highly potent suppressor
of Stage 3 and 4. On the other hand, the barbiturates, glutethimide,
ethchlorvynol, the antihistamines, and the over-the-counter medications
all tend to suppress REM sleep. The less potent hypnotics, such as
L-tryptophan and chloral hydrate have the least effects on sleep stages-.
One possible complication of REM suppressing drugs, however, should
be considered. When these drugs are discontinued, total amounts of
REM sleep on subsequent nights may increase dramatically for several
days or weeks. This so-called "REM rebound" may be associated with
vivid dreams or nightmares. Potentially, the REM rebound could be a
period of special vulnerability in patients with nocturnal gastric
hyperacidity, nocturnal angina, or other medical disorders which are
intensified during REM sleep. "Drug withdrawal insomnia" or "rebound
insomnia" has been identified following discontinuation of most REM-
suppressing hypnotics and, recently, following discontinuation of
some benzodiazepines, which mainly suppress Stages 3 and 4.
The physician should keep in mind that sleep tends to become
shorter, shallower, and more fragmented, with more awakenings each
night, as part of the normal aging process. These tendencies are
probably exaggerated in patients with insomnia, depression, or many
other disturbing medical or environmental conditions.
Because of the confusion engendered by the complaint (and concept)
of insomnia, a closer look from the point of view of sleep research
may be helpful.
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The Complaint of Being Unable to Fall Asleep (Sleep Latency Problem)
Falling asleep quickly is an essential component of subjectively
"good" sleep and is taken for granted by most people. A long delay in
falling asleep is experienced as dysphoric. It is now known that sleep
and wakefulness are part of a 24-hour rhythmic process, and there is
a certain time of the day when the organism begins to experience a readi-
ness for sleep. If the bedtime is not coordinated with this time, there
could be a sleep latency problem. Because this fact is not generally
understood, the sleep disorders specialist often finds that patients
tend to be somewhat casual about the regularity of their bedtime -
occasionally complaining of "insomnia" when they go to bed very early
in the evening.
Furthermore, there is very little data on what constitutes the
threshold for complaining about this problem. Many complex factors
can enter into a decision to seek medical advice: the actual number of
nights the inability to fall asleep is experienced; the presumed
etiology -- if the patient perceives an obvious cause he is less likely
to complain than if the problem appears to have no cause; convenience --
thus, if one has a routine appointment with one's physician, one is
likely to mention the perceived inability to fall asleep, whereas one
may delay bringing the problem to the attention of the physician if a
special effort is required to make an appointment; the effect on daytime
activities -- a problem may be endured on vacation when there is a possi-
bility of sleeping late in the morning, whereas if the same problem is
felt to interfere with one's working situation, a physician might
be consulted; finally, a patient's tendency to use medication pro-
phylactically could be a factor.
The Complaint of Being Unable to Stay Asleep (Sleep Maintenance Problem)
Some people complain that they have no trouble falling asleep, but
inevitably wake up during the night, either many times, or for a long
period of time, or both. Once again, this type of complaint can be very
complicated. Is there too much wine at dinner? A noisy environment?
A strange bed? A bed-partner who snores loudly, moves frequently, etc.?
Emotional upset -- especially depression? An inappropriate sleeping
time? Here again the duration and intensity of the problem are issues.
The Complaint of Daytime Consequences
Although it is remotely possible in some patients that the total
dysphoria of a sleep disturbance is the anxiety or boredom of lying
awake at night, there is general agreement among sleep disorders
specialists that a complaint of insomnia cannot be viewed as a sign
of a pathological sleep disturbance unless there is some daytime conse-
quence. However' when dealing with patients who complain of disturbed
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sleep, physicians may neglect to inquire about the effect of the pre-
sumed sleep loss upon daytime function.
Assessment of daytime problems consequent to nocturnal sleep dis-
turbance is complex. It is well known that muscular activity can
counteract sleepiness. _ / General pleasantness or unpleasantness of
the life situation interacts, as do soporific situations like a hot
room, a boring lecture, a heavy meal, use of alcohol, and so forth.
Often a most difficult medical decision involves differentiating fatigue
and tiredness due to sleep disturbance from alterations in mood and
activity changes due to depression.
B. Types of Insomnia
Only in the past few years have a number of interdisciplinary cen-
ters been established specifically to offer their services in the inten-
sive evaluation of individual patients with sleep complaints. The aim
with each patient is to make a specific etiologic diagnosis, and to
recommend or initiate the most appropriate treatment. By compiling the
results of individual cases, sleep disorders centers have thus begun
the first comprehensive empirical case series analysis of the complaint
of insomnia.
In 1978, after nearly two years of deliberations and comparisons of
case series, the Association of Sleep Disorders Centers (ASDC) proposed
a standard diagnostic classification of "Disorders of Initiating and
Maintaining Sleep" (DIMS). This is shown in Table 1, which also includes
relevant parts of their classification of "Biological Rhythms Distur-
bances" which may also give rise to the complaint of insomnia. This
nosology undoubtedly will change as further progress is made in under-
standing sleep disorders. In a few categories, data and experience were
deficient and anecdotal information was utilized for the sake of com-
prehensiveness. Several sleep disorders centers are now using this
classification. Some diagnoses do not include a specific etiology,
and in most instances no good data are available on treatment. However,
the formulation of a standard classification is an essential prelude
to further progress in cooperative case series studies and to more
specific evaluation of the efficacy of hypnotic drugs and other
therapeutic measures.
The following is a description of most of the specific diagnoses,
modified from the ASDC nosology to make the material useful to
practicing physicians.
Transient and Situational Insomnia
Acute insomnia may arise from a number of sudden changes in life,
such as medical, surgical, or traumatic conditions; admission to a
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Table 1
DIAGNOSTIC CLASSIFICATION OF INSOMNIA*
I. Disorders of Initiating and Maintaining Sleep: DIMS (The Insomnias)
1. Psvehonhv~iolo~i c~1
a. Transient Situational
b. Persistent
2. Psychiatric Disturbances
associated with
a. Personality and Neurotic Character Disorders
b. Affective Disorders
c. Acute Schizophrenia and Other Psychoses
3.
Use of Drugs and Alcohol
.
associated with
a. Tolerance to or Withdrawal from CNS Depressants
b. Sustained Use of CNS Stimulants
Sustained Use or Withdrawal of Other Drugs
d-. Habitual Use or Withdrawal of Alcohol
Sleep Induced Ventilatory Impairment
.
a. Sleep Apnea
b. Hypoventilation Syndromes
Nocturnal lIyoclonus and "Restless Legs" Syndromes
-
associated with
a. Nocturnal Myoclonus
b. "Restless Legs"
Restless Legs with Nocturnal Myoclonus
6. associated with
Other Medical, Toxic, and Environmental Conditions
7. Childhood Onset
Centers
*Adapted from the Nosology Committee, Association of Sleep Disorder
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Table 1 (continued)
Other DIMS Conditions
associated with
a. Parasomnias (specify conditions)
b. Repeated REDS Interruptions
Atypical Polysomnographic Features
Not Otherwise Specified
9. No DIMS Abnormality
a. Short Sleeper ("Healthy Insomniac")
b. Subjective DIMS Complaints without Objective Findings
c. Not Otherwise Specified
II. Dyssomnias Associated with Disruptions of 24-Hour Sleep-Wake Cycle
1.
Phase Shift
associated with
a. Rapid Time Zone Change ("Jet Lag" Syndrome)
b. Unconventional or Changing Sleep-Work Schedule (Shift Work)
Delayed Sleep Phase
2. Non-24 Hour Sleep-Wake ~y~-~drome
-
3. Irregular Sleep-Wake Pattern
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hospital or sleeping in any new environment; personal stress and anxiety,
as in bereavement; or disturbances of biological rhythms, such as "jet
lag" or shift work. Other commonly stressful conditions include occupa-
tional changes, moving to a new location, severe illness in a close rela-
tive or friend, termination of a romantic relationship, and test anxiety.
Acute forms of insomnia usually respond to the passage of time, patient
education, or the judicious use of hypnotics. However, firmly established
treatments are lacking in some situations. In the case of jet lag, for
example, administration of a hypnotic may increase total sleep time
without improving subjective well being. 18/ In this condition, the
actual loss of sleep is probably less disruptive than the deviation
from the schedule imposed by one's internal biological clock.
Insomnia Associated with Mental Disorders
Psychological symptoms -- varying degrees of depression, anxiety,
concern about physical well-being, and "nervousness" are common in
insomniac patients. In a standard psychological screening test, such
as the Minnesota Multi-Personality Inventory (MMPI), most insomniac
patients show evidence of psychopathology, particularly on the depres-
sion and hypochondriasis scales. 1/,13/,19/,20/ Before treating the
patient, therefore, the physician must gauge the severity of the
psychological disturbances, if any, and decide whether these distur-
bances are sufficient to make a psychiatric diagnosis, such as depres-
sion, mania, organic brain syndrome, alcoholism, drug addiction,
schizophrenia, hypochondriasis, anxiety, neurosis, or personality
disorder. This involves a careful history and mental status examina-
tion, as well as additional history from relatives, friends and
co-workers when appropriate.
Not only do psychiatric illnesses fail to respond to hypnotics,
but also hypnotics may be used by disturbed individuals for suicide.
In one study, more than half of those who committed suicide by overdose
had received a medical prescription for lethal amounts of a hypnotic
within one week of death. 21/ A British study found that many patients
who committed suicide by hypnotic ingestion had been taking sleeping
pills for years, often renewing their prescriptions by telephone calls
to the doctor's receptionist without any regular physician contact. 22/
Depressive illness may be classified as primary or secondary.
Primary depression occurs in patients with primary affective illness,
that is, in the absence of another primary psychiatric or medical
illness. Primary affective illness includes unipolar (one or more
depressive episodes) and bipolar depressive illness (a history of both
depressive and manic episodes). Secondary depression may occur in
patients with alcoholism, drug addiction, schizophrenia, obsessive-
compulsive disorders, hysteria, passive dependent and pas sive-agressive
disorders, and other psychiatric illnesses. It may also occur in
patients with primary medical illnesses, such as Addison's Disease,
hyperparathyroidism, or pancreatic carcinoma.
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In recognizing depression, the physician should be alert to the
mental, physiological, and social symptoms seen in depressed patients
(Table 2~. The duration of symptoms is important in establishing the
diagnosis of a depressive illness since many of these same symptoms
may occur briefly in acute situational reactions, such as mourning
or severe disappointment.
The physician's recognition of suicidal risk is of particular
importance not only in patients with symptoms of depression, but also
those who display signs of anxiety, irritability, hysteria, sociopathy,
impulsiveness, alcoholism, or schizophrenia. As Murphy 23/ points out,
the first and most important step is for the physician to ask himself
"Can this patient commit suicide?" Once this is a consideration in
the physician's mind, he should ask the patient several broad but tactful
questions, such as "How has your mood been lately?" or "How badly have
you been feeling?" He must ask specific questions about suicidal ideas,
such as "Have you felt badly enough to wish you were dead?" "Have you
ever thought of doing anything to yourself?" The patient with a specific
suicide plan, and the means to carry it out, is at grave risk, and prompt
hospitalization should be considered. Factors that increase risk of
successful suicide include male sex, age greater than 40, social isola-
tion, history of prior suicide attempts, delusions of somatic illness,
troublesome physical illness, and uncontrolled drinking. 23/ Although
men are more likely to successfully commit sucide than women, women
are more likely to use drugs when they attempt or suceed in suicide.
The prescription of sedatives or hypnotics in fatal doses to a
suicidal patient may be a serious lapse of medical judgment. It implies,
first, that the physician has failed to recognize the true diagnosis
of depression and suicidal risk, and, secondly, that he has provided
the patient with the means to kill himself. Since most hypnotics
can be fatal when 10 to 30 dosage units are ingested, the amount
prescribed in the modal prescription for hypnotics in this country --
30 pills -- is sufficient to cause death or prolonged coma if taken
in overdose. Even the benzodiazepines, which are rarely lethal when
ingested alone, can be fatal when combined with alcohol or other
drugs. Little justification exists for the general proposition that
the suicidal patient will kill himself by some other means if denied
the use of pills. This proposition may be true for a few patients;
however, many are clearly ambivalent about dying and the suicidal
attempt is often a "cry for help," impulsive or manipulative. Since
generally effective treatments exist for depression, every effort
should be made to recognize depression and suicidal risk and to
treat it appropriately.
Suffice it to say, treatment of depression is aimed at the
reduction of depression and prevention of further episodes of
affective illness. Among the important factors in treatment are
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that the treatment would probably be of no benefit for about four weeks.
However, the group receiving relaxation training alone also improved,
so the specificity of the desensitization aspects of the treatment
is in question.
Classical conditioning procedures have been described as useful
in the Russian 64/ and German 65/ literature. One example 66/ of
this approach was the administration of methohexital to induce
sleep in a patient with anxiety, phobias, and hyposomnia while
he listened to a metronome. The patient would then turn on the
metronome at bedtime. Although this procedure was clinically
beneficial in this and another case, 67/ there are no data from
controlled studies.
Stimulus control studies of insomnia are based on the proposition
that the insomniac has difficulty because the bedroom environment has
become associated with activities incompatible with sleep (worrying,
eating, watching television). The patient is instructed to get into
bed only when sleepy, and to immediately leave the bedroom if he
finds himself engaged in any activity except sleep or sex. A com-
parison of stimulus control, progressive relaxation, self-relaxation
and no treatment in 78 subjects disclosed the greatest reduction in
subjective sleep latencies in the stimulus control group, followed
by the progressive relaxation group; and these were both signifi-
cantly better than the other two groups. _ / This approach has fared
well in subsequent studies, _ /-70/ and might profitably be examined
further in controlled studies of insomniacs.
Attributional therapy is based on the concept that manipulation
of a subject's understanding of the source of his difficulty might
be therapeutic. In an effort to externalize the perceived source
of arousal, 71/ when patients were told that a pill they were
receiving would further stimulate them, they went to sleep more
quickly. Other subjects who were told that a pill was a sedative
stayed awake longer, presumably because they became distressed
that they were having difficulty falling asleep even when taking
a "sedative," and the resultant anxiety compounded the sleep
disturbance. This notion has suffered in replication studies,
however, and is unproved. 72/-73/
In another variation on attribution therapy, it was suggested
that an insomniac's sleep may improve if he can learn to attribute to
himself the ability to go to sleep easily. 74/ Insomniacs received
a combination treatment that included a high dose of chloral hydrate
(1000 mg), relaxation training, and practical suggestions such as
regularizing their sleep habits. Those who improved were divided
into two groups. One group was told that the dosage they received
was maximally effective and hence the implication was that their
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improvement was due to the medication. The other group was told that
their dosage was only minimally effective, and hence that their improve-
ment was due to their own efforts. The chloral hydrate was then
discontinued, and it was found that the latter group continued to do
well, while the former group became worse.
One case report suggests the possibility that self-monitoring,
in lieu of any behavioral training techniques, may be an effective
treatment in certain patients complaining of insomnia. 75/ The
case report showed dramatic improvement in one patient who was simply
asked to keep daily records of his sleep latency, the time he awoke, and
the amount of time he spent napping. Again, however, specific replica-
tion studies have not been reported.
insomnia .
Behavioral self-management emphasizes a combination of specific
techniques, such as progressive relaxation and a cognitive learning
theory approach. 76/ 77/ With the latter the patient is asked to keep
diaries and to explore and decrease the stimuli which raise the
anxiety-tension level in the daytime. Modification of work and
domestic schedules is used to decrease anxiety producing stimuli
in the evening. Specific internal arousal conditioning factors
such as internal dialogues after lights out, are discovered and
dealt with. All the techniques emphasize mastery and aid the patient
to overcome a sense of impotence in dealing with his sleep problem.
~ ~ ~ incorporated in the treatment regimen for in-
These techniques
somniacs seen at
are
the Stress Reduction Clinic at the Stanford Medical
Center. Successful results have been described in individual cases
(including some who had been drug dependent) using this multi-faceted
treatment, though a case series and controlled studies are needed
to establish the usefulness of this approach.
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,..
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Representative terms from entire chapter:
sleep research
