Sleep Disorders

Chronic insomnia: poor sleep at least 3 days a week for at least 3 months duration (Kay-Stacey and Attarian, 2016)

- Precipitating / predisposing factors:

• stress
• personality features
• psychiatric conditions
• sleep disorders (RLS)
• medical issues
• substances
• undesirable sleep environment
• poor sleep hygiene

- Another obstacle is sleep report, as most people are inaccurate reporters of how many hours of sleep they are getting in a night. Furthermore, their mood might bias them to a more pessimistic outlook. This issue has not been improved by wearable devices, as these have not yet reached the level of accurately recording sleep.

Treatment

- Overall, the first line of therapy should be psychotherapy, specifically CBT for insomnia is recommended. Out of all the components of CBT-I, they report sleep restriction (reducing the time allowed in bed) as the most powerful intervention (Kay-Stacey and Attarian, 2016)

Components of CBT for insomnia (Trauer et al, 2015)

• Cognitive therapy: aims to identify, challenge, and replace dysfunctional beliefs and attitudes about sleep and insomnia. Such misconceptions may include unrealistic expectations of sleep, fear of missing out on sleep, and overestimation of the consequences of poor sleep
• Stimulus control: behavioral instructions aimed at strengthening the association between bed and sleep and preventing conditioning of the patient to associate bed with over stimulating activities. Such instructions include avoiding nonsleep activities in the bedroom; going to bed only when sleepy; and leaving the bedroom when unable to sleep for 15-20 min, returning to bed only when sleepy
• Sleep restriction: behavioral instructions to limit time in bed to match perceived sleep duration in order to increase sleep drive and further reduce time awake in bed. Time allowed in bed is initially restricted to the average time perceived as sleep per night and then adjusted to ensure sleep efficiency remains > 85%
• Sleep hygieneL general recommendations relating to environmental factors, physiologic factors, behavior, and habits that promote sound sleep. Specific instructions include advice on control of the bedroom environment, including avoiding visual access to a clock, regular sleep scheduling, and avoiding long daytime naps; and limited alcohol, caffeine, nicotine intake
• Relaxation: any relaxation technique that the patient finds effective can be used to limit cognitive arousal and reduce muscular tension to facilitate sleep. Specific techniques that may be used include meditation, mindfulness, progressive muscle relaxation, guided imagery, and breathing techniques

Pharmacotherapy

If one must use medications for chronic insomnia they should be used in short-term. The impact of sleep medications beyond 6 months generally return to pretreatment values (Kay-Stacey and Attarian, 2016) (unfortunately, then they have insomnia plus a medication dependence).

References

Kay-Stacey, M. & Attarian, H. Advances in the management of chronic insomnia. BMJ i2123 (2016) doi:10.1136/bmj.i2123. https://pubmed.ncbi.nlm.nih.gov/27383400/

Trauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M. W. & Cunnington, D. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann. Intern. Med. 163, 191–204 (2015). https://pubmed.ncbi.nlm.nih.gov/26054060/