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Chronic Insomnia
behavioural patterns destructive to sleep, medication and substance use,
Table 1: Diagnostic Criteria of Insomnia
circadian dysynchrony, intrinsic sleep pathologies (including sleep
apnoea and limb movement), consumption of medication, alcohol or
1. The patient complains of
illegal drugs, inadequate lifestyle or even the environment.
21
In total,
• difficulties falling asleep;
more than 50 major categories of disorders may cause the
• difficulties staying asleep;
• waking up too early; and/or
symptomatology of insomnia.
2
There is a considerable overlap between
• sleep that is non-restorative or of poor quality.
the types of insomnia, and where to draw the line between the
2. The sleep difficulty occurs at least three times per week and has been a problem for
categories in order to diagnose patients is often arbitrary. However,
at least one month.
the physician is asked to cover all pathogenetic aspects in his or her 3. This difficulty is present despite adequate opportunity and circumstances for sleep.
therapeutic approach.
4. This impairment in sleep is associated with daytime impairment or distress, and some
of the following forms of daytime impairment related to the night-time sleep difficulty
An assessment of lifetime prevalence
22
found markedly increased rates
are reported by the patient:
• fatigue or malaise;
of psychiatric disorders in individuals with insomnia (71%) in
• attention, concentration or memory impairment;
comparison with individuals with no sleep complaints (41%). In one
• social or vocational dysfunction or poor school performance;
other representative example
23
of a large number of studies on
• mood disturbance or irritability;
psychiatric co-morbidity, a psychiatric disorder was rated as a • daytime sleepiness;
contributing factor for 77% of patients who received a first diagnosis • reduction of motivation, energy or initiative;
of primary insomnia.
• prone to errors or accidents at work or while driving;
• tension, headaches or gastrointestinal symptoms in response to sleep loss; and
• concerns or worries about sleep.
Pathophysiology of Chronic Insomnia
Insomnia can present as an isolated disorder (primary insomnia) or as a
Definition adapted from criteria given by the Diagnostic and Statistical Manual of Mental
Disorders, 4th edition, text revision (DSM-IV-TR),
1
the International Classification of Diseases,
condition that co-exists with medical and psychiatric disorders. Widely
10th Revision (ICD-10),
3
the International Classification of Sleep Disorders
2
and the
Classification of the American Academy of Sleep Medicine.
10
independent from its initial origin, chronic insomnia can be characterised
as a psychological and physiological state of hyperarousal, manifesting in and physiological changes observed when an individual is in a state of
psychological symptoms such as excessive worry or mental hyperactivity arousal. A major association between insomnia and psychiatric
as well as physiological hyperactivity.
24
Several lines of evidence support disorders such as depression, anxiety, alcohol abuse and drug abuse
central nervous hyperarousal of the sleep–wake system and include has been demonstrated repeatedly, showing odds ratios that range
physiological changes such as increased central nervous system metabolic from a relative risk of two to 10 for the increased likelihood of major
rate
25
and elevated electroencephalographic activity.
26,27
This is paralleled depression if a patient has insomnia.
19,43
by changes in peripheral compartments, for example increased levels of
plasma catecholamines,
28
increased basal metabolic rate
29
and elevated There is also evidence for links between insomnia and organic disease.
core body temperature.
30
The pathophysiology of hyperarousal in Epidemiological data suggest that insomnia is related to heart
insomnia has been linked to overactive hypothalamic–pituitary–adrenal disease.
44
In industrial workers insomnia served as a predictor for
axis function, suggesting neuroendocrine similarities between insomnia arterial hypertension.
45
This is in line with data, some of which were
and major depressive disorders.
31–33
gathered in prospective studies, suggesting increased mortality in
patients with chronic insomnia, especially in the elderly.
46–48
Sleep
Health Burden and Social Consequences problems in community elderly have been found to act as predictors
The effects of insomnia on patients can result in a substantial amount not only of death, but also of nursing home placement.
49
of morbidity for those suffering from insomnia. A reasonable number of
studies have demonstrated that insomnia leads to impaired memory and The possible link between stress, insomnia, depression and other
reduced cognitive and psychomotor functioning. A recent study clearly co-morbidities includes decreased immune function and increased
indicated that hippocampal volumes are smaller in patients with chronic pro-inflammatory activity. Increased secretion of pro-inflammatory
insomnia compared with healthy controls.
34
This sits well with the finding cytokines has been observed in normal sleepers experiencing sleep
that insomniacs have impairment in sleep-dependent nocturnal memory deprivation.
19,50
Short sleep and sleep deprivation have also been
consolidation as well as in procedural and declarative learning.
35,36
found to be related to disturbed glucose metabolism
51
and increased
mortality.
48
It is important to recognise that these are data in sleep
Patients with insomnia also have a well demonstrated increased risk of deprivation and, thus, confirmatory data in insomnia are needed.
psychiatric disorders (especially depression),
37,38
decreased quality of life,
increased healthcare utilisation and costs and an increase in falls and Insomnia either directly or via secondary diseases may have
accidents.
7,39
The overall state of wellbeing that individuals with considerable impact in the workplace, leading to decreased work
insomnia experience – as assessed by subjective and objective measures performance and increased risk of accidents and absenteeism.
7,23,52
of functioning, health and satisfaction with the important dimensions of Insomnia patients averaged 15.8 days absent from work per year
their lives
40
– is worsened to almost the same extent as in patients with compared with 1.6 days absent in a control group.
53
Similarly, patients
chronic conditions such as congestive heart failure and depression.
41,42
with a sleep problem had a higher percentage rate of missing work
than patients with no sleep problem.
54
In addition to the sleep–wake system being in a state of hyperarousal,
other systems and disorders are likely to be affected. Mood, anxiety Furthermore, patients with insomnia are 2.5–4.5 times more likely to
levels and pain thresholds may also be affected by the psychological have an accident than individuals with normal sleep patterns.
7
EUROPEAN PSYCHIATRIC REVIEW 37
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