Primary Insomnia

What is primary insomnia?

Primary insomnia is a sleep disorder characterized by frequent waking or the inability to sleep. It is referred to as primary to denote that the disorder is not linked to any other mental or physical condition. This disorder does not result from any medical, psychiatric, or environmental condition or disease. Instead, this disorder, in particular, is usually the result of psychophysiological, idiopathic, unknown, or a sleep state misperception condition.

Up to 10 per cent of adults experience this disorder and 25 per cent of the elderly. It is also slightly more dominant among women. People who suffer from this disorder may have irregular sleep patterns. They may experience one night of restful sleep accompanied by many sleepless nights or restless sleep. As a result of poor or insufficient sleep, people with this disorder are often tired during the daytime, have a hard time focusing and performing normal functions, and are irritable and moody.

This disorder usually affects most adults at some point in their lifetime. Physicians use the International Classification of Sleep Disorders to diagnose this disorder. Medication and lifestyle changes are generally the suggested treatment for this disorder. Sleep hygiene, as well as the elimination of caffeine and alcohol, are both focus areas when it comes to treatment. The most important distinguishing characteristic regarding primary insomnia is the fact that it is not caused as a result of any medical or psychiatric condition. Even environmental factors are not a consideration for this disorder.

From a psychological standpoint, people with this disorder tend to repress their feelings instead of expressing them. They also tend to sleep well in other areas besides their bedroom. These symptoms are considered psychophysiological, however, idiopathic symptoms of primary insomnia are distinguished by early onset insomnia that may begin in childhood.

Primary insomnia symptoms

This disorder is marked by tension headaches, worry, daytime sleepiness, difficulty focusing, general anxiety, and fatigue upon waking. These symptoms persist for at least a month. It may take up to 30 minutes or more to fall asleep and you may wake several times during the night.

In essence, the affected person will have trouble falling to sleep, maintaining sleep, and getting restful restorative sleep. This disorder has to cause difficulty with functions to be considered primary insomnia. However, episodes of this disorder are not the result of some other underlying medical, psychiatric, or environmental condition.

There are five basic criteria that distinguish primary insomnia from other forms of insomnia.

5 criteria include:

  • The inability to initiate or maintain sleep without wakefulness
  • An impairment that significantly hinders social and occupational areas of function
  • It does not occur as a result of some other medical condition or drug
  • It is not the result of some clinical mental disorder
  • The sleep disturbances are not the result of some physiological factor

These five criteria help differentiate primary insomnia from other forms of the disorder.

Primary insomnia causes

Research has uncovered proof that this disorder is caused primarily by mood disorders and dysfunctions with the hypothalamic-pituitary-adrenal (HPA) axis, in terms of overactivity as well as excess secretion of corticotropin-releasing factor (CRF).

Additionally, the stress hormones adrenocorticotropin and cortisol play an important role in this disorder. This disorder tends to be lifelong and is aggravated by stress and tension. Individuals may also suffer from the false perception that they have insomnia although they get adequate rest and are not fatigued. Primary insomnia falls into three predominant categories:

Psychophysiological insomnia

This form of primary insomnia is marked by excessive worry or stress. This is usually the result of prolonged stress. In most cases, the individual used to sleep well, however, tension from the stress starts to upset the sleep cycle, resulting in bouts of insomnia.

Under normal circumstances, this type of insomnia is temporary. As the stress subsides the normal sleep patterns return. However, it can go the other direction as well. The stress and worry can create a pattern of chronic insomnia that can last for years. This is perhaps why this form of primary insomnia is referred to as learned insomnia or behavioral insomnia.

Idiopathic insomnia

This type of primary insomnia is distinguished by an abnormal sleep/wake cycle. This can be attributed to neurological causes. This form of insomnia can start in childhood and continue into adulthood. The causes of this type of sleep disturbance can be both neurological or neurochemical and is the result of some kind of imbalances in the sleep/wake cycle.

However, it’s important to note that this disorder is not derived from a classified clinical neurological disorder. Idiopathic symptoms include an extreme sensitivity to medications or no reaction at all to prescribed medications.

Sleep state misperception or Paradoxical Insomnia

Last but not least, sleep state insomnia is characterized by a false perception of sleep insomnia. This problem is attributed to a perceived rather than actual problem with sleep. This type of primary insomnia is based on the false belief that the individual cannot sleep. However, the individual gets adequate sleep and is not unusually tired.

Primary insomnia treatments

There are a variety of different health practitioners that can treat this disorder. This disorder is often diagnosed and treated by family practitioners and internists. However, this disorder can also be diagnosed by sleep medicine specialists, neurologists, and psychiatrists. The test involved in diagnosing primary insomnia can be wide and varied. However, two common tests that a doctor may perform are blood tests and physical examinations. A doctor will also explore your sleep history as another way of gaining insight into the reasons behind your insomnia. You may be required to maintain a sleep diary and monitor your diet as well. Your doctor will be looking for any behavioral issues that may be present also.

The treatment approach that your doctor will prescribe will have a lot to do with the underlying causes for your condition. However, medications and behavioral therapies are common approaches. Behavioral therapies help you to gain control of unwanted behaviors. Some of these therapies include breathing and relaxation techniques, replacing negative thoughts with positive thoughts about bedtime, limiting your bed for sleep and other nighttime activities only, and talk therapies if necessary.

Anti-anxiety and anti-depression medications are commonly prescribed as well. However, care should be exercised with OTC sleep medications. They can be habit forming and lead to blurred vision as well as many other side effects. Another common approach used by many physicians is the polysomnography. This is basically a sleep study that requires patients to rest in a sleep lab so that their sleep patterns can be monitored.

The Academy of Sleep Medicine has several medications that are recommended for the treatment of primary insomnia. Their first preferred medication is short/intermediate-acting benzodiazepine receptor agonists (BzRAs). There are several medications that fall into this recommended category. If this medication is unsuccessful, the second line of defense is often short/intermediate-acting BzRAs or ramelteon. This is often followed by a sedating low-dose antidepressant.

It is common for BzRA or ramelteon to be used in combination with a sedating antidepressant. In general, the approved approach for prescribing medication for the treatment of insomnia is to use the lowest effective dose, administer dosing 2-3 times weekly, take medications for short periods of time, and gradually discontinue or taper regularly used medications. In addition, the approved approach is to use medications with a short/intermediate half-life to decrease daytime drowsiness.

Medications prescribed for the treatment of insomnia in older people should be sensitive to reactions that older people are more predisposed to. However, there are some medications that are not suggested for older people who suffer from primary insomnia. This is mainly because of the high anticholinergic side-effect profile. Amitriptyline, in particular, is one such medication. In fact, many FDA approved medications have the potential of having adverse effects on older people who suffer from primary insomnia.

These medications include: Chloral hydrate, barbiturates, and nonbarbiturate nonbenzodiazepine drugs, antiepileptic gabapentin, tiagabine, and atypical antipsychotics, quetiapine, olanzapine. Conversely, the safest most effective medications that are currently available are nonbenzodiazepines and melatonin receptor agonists. Primary insomnia is most prevalent among older people, however, this disorder can affect anyone.

The initial approach to treating this disorder is conservative. Information and history about personal sleep behavior is gathered. Even sleep partners are involved in enabling a clearer view of the problem. The suggested treatment usually involves changes in a person’s sleep hygiene. Often times, making changes in a person’s lifestyle and sleep environment are sufficient enough to eliminate or diminish the problem.

However, when lifestyle changes are unsuccessful, medications and therapy are often prescribed. The medications and therapies are customized to fit what the physician feels the underlying problems are. Medication is often the last resort, however. Therapy is often substantial enough to bring about a change in this disorder.

Primary insomnia prevention

There are many things that you can do to avoid developing primary insomnia. Developing better sleep habits or sleep hygiene can be helpful. Going to bed and getting up at the same time is also a good way to avoid insomnia. Training your body to get used to sleeping and waking at the same time every day is a healthy habit.

It’s also a good idea to eliminate naps after 3pm and make sure that they are no more than 30 minutes long. Sometimes naps are eliminated altogether to ensure a person is fatigued enough to sleep. This is helpful in protecting sleep patterns and making sure that your sleep schedule is not disturbed. The elimination of caffeine and other liquids right before bedtime is also suggested. Caffeine has the tendency to keep a person up and consuming water before bedtime may cause wakefulness in the middle of the night for bathroom trips.

The room you sleep in should be cool, dark, and quiet. Turn the TV and video games off and don’t exercise three hours before bed. Stimulating activities will make it difficult to sleep. Start slowing down within a three-hour window of your bedtime. If lifestyle changes or better sleep hygiene don’t help you it’s a good idea to see a doctor for medical attention. However, these tips will help you develop a better sleep hygiene. They will also help train your body to rest more peacefully and without wakefulness.

People that suffer from primary insomnia generally don’t enter the rapid eye movement (REM) or deep level of sleep. This would explain why their sleep may not be restorative or why they may wake frequently throughout the night. Any factors that may present a stumbling block to creating restorative uninterrupted sleep are removed. Sometimes it takes more than just lifestyle changes to correct primary insomnia. However, lifestyle is the first area that is tweaked in an attempt to diminish primary insomnia.