Doctor's Notes on Primary Insomnia
Primary insomnia is sleeplessness, insufficient sleep, or the perception of poor quality sleep not caused by medical or psychiatric diseases, conditions, genetics, illnesses, or environmental causes (such as drug abuse, medication, or shift-work). Insomnia can be classified as primary, which is caused by either psychological factors, sleep state misperception, or is idiopathic (no known cause). When insomnia is caused by another disease, condition, or illness it is considered secondary insomnia.
Symptoms of primary insomnia may range from mild to severe and include difficulty falling asleep, frequent awakenings in the night, and an inability to sleep well anywhere else but in one’s own bedroom. Symptoms that may accompany insomnia include difficulties with attention or concentration, hyperactivity, hypersensitivity or insensitivity to medications, tension, dissatisfaction, and repression (denial or minimization) of emotional problems.
Primary Insomnia Symptoms
Psychophysiological insomnia symptoms:
- Sleep disturbance varies from mild to severe.
- Sleeplessness may manifest as difficulty falling asleep or as frequent awakenings in the night.
- Persons with insomnia often find that they can sleep well anywhere else but in their own bedroom.
- Persons with this type of insomnia tend to be more tense and dissatisfied compared to good sleepers. Emotionally, they are typically repressors (suppress their feelings), denying problems.
Idiopathic insomnia symptoms:
- Insomnia is long-standing, typically beginning in early childhood.
- Persons with idiopathic insomnia often complain of difficulties with attention or concentration or hyperactivity.
- Emotionally, persons with childhood-onset insomnia are often repressors, denying and minimizing emotional problems.
- Individuals often show atypical reactions, such as hypersensitivity or insensitivity, to medications.
- Insomnia tends to persist over the entire life span and can be aggravated by stress or tension.
Sleep state misperception: Persons complain of insomnia subjectively, while sleep duration and quality are completely normal. They typically do not display daytime sleepiness or other signs of poor-quality sleep. These people may be described as having "sleep hypochondriasis." They may subsequently develop anxiety and depression.
Treatment with medicine usually provides rapid symptomatic relief.
The mainstays of short-term treatment of primary insomnia include: hypnotics (agents that promote sleep) and benzodiazepines (compounds with antianxiety, hypnotic, anticonvulsant, and muscle relaxant properties).
Hypnotics for primary insomnia
Basic principles for the treatment of insomnia include the following:
- Use the lowest effective dose of medication.
- Use intermittent dosing (2 to 3 nights per week).
- Use for a short term (2 to 3 weeks at a time).
- Discontinue after slow taper if the person has been taking it regularly.
- Use drugs with short and/or intermediate half-life to minimize daytime sedation.
|Flurazepam (Dalmane)||15 to 30 mg||0.5 to 1 hr|
|Quazepam (Doral)||7.5 to 15 mg||2 hr|
|Eszopiclone (Lunesta)||Nonelderly: 2 to 3 mg|
Elderly: 1 to 2 mg
|Estazolam (ProSom)||1 to 2 mg||2 hr|
|Temazepam (Restoril)||7.5 to 30 mg||1.2 to 1.6 hr|
|Lorazepam (Ativan)||0.5 to 2 g||2 to 4 hr|
|Oxazepam (Serax)||10 to 15 mg||3 hr|
|Triazolam (Halcion)||0.125 to 0.5 mg||1 to 2 hr|
|Zolpidem* (Ambien)||5 to 10 mg||1.6 hr|
|Zaleplon* (Sonata)||5 to 10 mg||0.9 to 1.5 hr|
*Zolpidem and Zaleplon are not structurally related to benzodiazepines.
Common side effects of hypnotics are as follows:
- Amnesia (total or partial inability to recall past experiences) and withdrawal effects may occur, especially with short-acting benzodiazepines (not with zolpidem and zaleplon).
- Residual daytime sedation with intermediate-acting and long-acting drugs may occur, depending on dosage.
- Rebound insomnia may occur with short-acting and intermediate-acting benzodiazepine after discontinuation.
- Short-acting agents are recommended for persons with difficulty falling asleep, while intermediate-acting drugs are indicated for problems with sleep maintenance.
- Avoid long-acting agents, especially in older people, because they cause daytime sedation, impair cognition, and, thereby, increase the risk of falls.
Not everyone should take hypnotic medications. Contraindications of hypnotics are as follows:
Caution and close monitoring is needed in older people and in persons with hepatic, renal, or pulmonary disease.
Belsomra (suvorexant) is an orexin antagonist, a newer classification of insomnia medication. Orexion antagonists work by decreasing activity in the wake center of the brain and helping individuals transition to sleep. The other hypnotic medications typically act on the sleep promoting centers of the brain by attempting to increase activity in these areas. Dosage for Belsomra is 5 to 20 mg/2 hr. Belsomra is completely unrelated to both the benzodiazepine and non-benzodiazepine sedative-hypnotic drugs.
- The primary side effect of this drug class is increased sleepiness during the day.
- Overall it is considered relatively safe in early studies.
- As with other sleep medications, caution should always be considered when other CNS depressants are being used.
- At least 7 hours for sleep should be available after taking this medication, and any side effect such as abnormal behaviors during sleep, increased depressive symptoms, suicidal thoughts, daytime sleepiness, or breathing problems should be reported to your doctor.
Primary Insomnia Causes
Sleeplessness without any medical, psychological, or environmental cause can be divided into the following three subgroups:
In a person with previously adequate sleep, sleeplessness begins because of a prolonged period of stress. Tension and anxiety resulting from the stress causes awakening. Thereafter, sleep in such persons becomes associated with frustration and arousal, resulting in poor sleep hygiene. In most people, as the initial stress decreases, normal sleep habits are gradually restored because the bad sleep habits are not reinforced. However, in some people, the bad habits are reinforced, the person "learns" to worry about his or her sleep, and sleeplessness continues for years after the stress has subsided. Therefore, it is also called learned insomnia or behavioral insomnia.
Lifelong sleeplessness is attributed to an abnormality in the neurologic control of the sleep-wake cycle involving areas of the brain responsible for wakefulness and sleep. It may begin in childhood. Those affected may have a dysfunction in the sleep state that predisposes the person towards arousal.
Sleep state misperception
The person complains of insomnia without objective evidence or symptoms of any sleep disturbance.
Smart phones, e-readers, tablets, computer screens, TVs, and digital clocks emit blue light, a short frequency of light that may be harmful to the eyes and disrupt sleep. Minimize screen time for several hours before bedtime to get a good night's rest. Wearing orange tinted glasses that block out blue light may also be helpful. Apps are available for your computer, tablet, and smartphones that prevent the screens from emitting blue light. Besides blue light exposure, it makes sense to power down several hours before bedtime to maximize your chances of getting a good night's rest. Cover up any displays that may be visible from your bed, like a digital clock. Black out curtains can block out ambient light from outside.
Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.