EU_Psychiatry_Mignot_Capasso_quark6.qxp 3/7/08 02:32 Page 45
Diagnosis and Management of Common Sleep Disorders – An Overview for the Psychiatrist
Insomnia improve primary insomnia or insomnia associated with medical or psychiatric
Insomnia refers to a complaint of difficulty falling asleep, frequent and/or disorders, both objectively and subjectively. Studies have found that
prolonged awakenings, early-morning awakenings or non-restorative, improvements may be achieved more quickly with drug treatment, but are
poor-quality sleep in an individual who has adequate opportunity for more sustained with cogitive behavioural therapy (CBT).
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One limitation of
sleep. Insomnia is not defined by sleep laboratory measures or any specific behavioural therapies is not a lack of efficacy, but the need for repeated
sleep duration. Chronic, serious insomnia affects 10% of the population,
with a higher predisposition among females.
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As insomnia occurs only
when there is adequate opportunity for sleep, it must be distinguished from
sleep deprivation, in which the individual’s short sleep duration results from
Studies have found that improvements
inadequate opportunity.
may be achieved more quickly with drug
The most common daytime impairments associated with insomnia include
treatment, but are more sustained with
complaints of fatigue, mood disturbance and impaired cognitive function.
Actual daytime sleepiness is not common among individuals with
cognitive behavioural therapy.
insomnia.
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Medical conditions, most importantly those associated with pain
and almost all psychiatric disorders, are also linked to insomnia. A thorough
medication history is essential, including prescription drugs (antidepressants
or antihypertensives commonly cause insomnia), over-the-counter follow-up and coaching of patients for several weeks to ensure compliance
medications, substances such as caffeine and alcohol and illicit drugs. and stable behavioural changes, a difficult endeavour in countries where
Insomnia is commonly described as being secondary to other conditions, care is rationed. The components of behavioural treatments for insomnia are
associated with other sleep disorders (sometimes due to sleep apnoea) or summarised below.
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primary (when no other aetiology can be identified). Secondary insomnia
refers to the insomnia syndrome when it is thought to be due to a medical Sleep Restriction
or psychiatric disorder, or to the effects of a substance or medication. This involves limiting time in bed to that spent actually sleeping, creating
However, recently a consensus conference has rejected this simple a mild sleep deprivation and increasing homeostatic pressure for sleep;
dichotomy due to insufficient evidence, especially in the neuropsychiatric this reduces poor sleep and enhances regularity of sleep/wake. ‘Quality
context.
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Why some depression cases are associated with insomnia or first, than quantity’ is the motto of sleep restriction therapy. This
excess sleep is unknown, and a causal relationship from depression to component may be the most essential. In extreme cases, the fear of not
insomnia or hypersomnia is not established. Interestingly, several studies sleeping is so intense that patients may stay in bed for 10 hours trying to
have shown that the presence of insomnia predicts the development of sleep more, thereby producing sleep disruption and insomnia.
depression years later, suggesting that insomnia could participate in the
development of depression.
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Poor sleep quality is reported in up to 90% Cognitive Therapy
of patients with depression.
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Fava and colleagues demonstrated that Based on Beck’s model, this psychotherapeutic approach seeks to modify
patients with co-morbid insomnia and depression experience a faster, more sleep-related dysfunctional beliefs and thoughts and the maladaptive
effective antidepressant response when treated with a sleep agent and cognitive processes involved in the exacerbation and perpetuation of
antidepressant combination than when treated with either a sleep agent or insomnia. One example is the belief that one may need eight to nine
hours of sleep based on what family and friends report, while in fact
there is great individual variability in the required number of hours for a
restful night of sleep.
The most common daytime impairments
Sleep Hygiene
associated with insomnia include Sleep hygiene therapy aims to provide patients with education about
complaints of fatigue, mood disturbance
how to improve their sleeping habits. One example would be to avoid
caffeine or alcohol consumption for four to six hours before bedtime.
and impaired cognitive function.
Another piece of advice is to have a dark bedroom and to avoid bright
light exposure when going to the bathroom in the middle of the night,
as this may disrupt circadian rhythms (a dimmer switch is recommended).
an antidepressant alone.
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Generalised anxiety disorder patients complain Stimulus Control
of ‘trouble sleeping’ in 60–70% of cases, and there is an overlap between Stimulus control therapy is based on the principles of conditioning. It aims
interventions that target insomnia and those that are used in treating to re-establish the bed and bedroom as stimuli for sleep, creating a
anxiety disorders, including medications and cognitive strategies that target consistent sleep/wake schedule. Therapists advise: “If you are unable to fall
worry, tension and maladaptive cognitions.
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asleep in 15–20 minutes, get out of bed and engage in a quiet, non-striving
activity. Only return to bed when you are sleepy again.”
Behavioural Treatments of Insomnia
The treatment of insomnia has recently evolved, as insomnia has been Relaxation and Sleep Management
shown to often benefit greatly from non-pharmacological interventions. Sleep management therapy aims to reduce the cognitive and emotional
Psychological and behavioural therapies have consistently been shown to hyperarousal that is incompatible with sleep.
EUROPEAN PSYCHIATRIC REVIEW 45
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