Can insomnia be permanently cured, or is it a persistent disorder?

Doctor's Answers 1

What is insomnia?

Insomnia is characterised by difficulties initiating, sustaining, or obtaining qualitatively satisfying sleep despite adequate sleep opportunities and circumstances, resulting in impaired daytime functioning. Intermittent or acute insomnia is of short duration and often linked to specific events - for instance, not being able to fall asleep the night before an exam or an important job interview. Persistent or chronic insomnia is a long-term pattern of disrupted sleep on several nights a week that lasts for months and years and can be due to a number of causes, including shift-working, poor sleep habits and medication use.

Insomnia can occur across the majority of the human lifespan, from childhood years to old age. Over 33% of adults experience insomnia at least intermittently, whereas 10% to 22% suffer chronic sleep difficulties.

Another study estimates that in the US, around 20% of adults are affected by insomnia [1], half of whom suffer from persistent insomnia. While prevalence data are more sparse for younger age groups, insomnia symptoms may be seen in as many as 20% to 40% children and teenagers, with slightly higher rates among girls and those with symptoms of mood disturbance.

How will having insomnia affect you?

While its significance is often minimised, persistent insomnia is associated with

  • daytime fatigue,
  • decreased mood,
  • impairment in social/vocational functioning
  • poor school performance, and
  • reduced quality of life.

Insomnia also increases the risks for serious medical disorders, traffic and work-site accidents, alcohol/drug abuse, and major psychiatric illnesses. When insomnia is comorbid with psychiatric illnesses such as major depression, it complicates disease management and often remains as a residual symptom that enhances the risk for both suicide and relapse. Even in younger age groups such as children and teenagers, insomnia shows strong associations with comorbid conditions such as psychiatric disorders and chronic pain syndromes.

Treatment for insomnia

In the treatment of insomnia, it will be important to figure out the underlying contributing factors that affect a person’s level of arousal at night, thus affecting the quality of sleep. Oftentimes, there are many contributing factors and all of them have to be sorted out in order to enable the person’s sleep quality to improve.

The following common causes of insomnia can be remembered by using the mnemonic I.N.S.O.M.N.I.A.C.:

  • I stands for illness due to a medical condition (asthma, congestive heart failure, chronic pains, cancer, acid-reflux disease (GERD), chronic obstructive lung disease, joint pains).
  • N stands for neurologic or psychiatric disorders (depression, bipolar disorder, anxiety disorders, psychotic disorders, dementia, Parkinson’s disease, stroke, brain tumours).
  • S stands for sleep disorder (apnea, restless legs syndrome, periodic limb movements associated with sleep)
  • O stands for overconcern about falling asleep
  • M stands for medications (steroids, SSRIs antidepressants, theophylline, etc)
  • N stands for the noisy or unpleasant environment (extreme heat or cold, sleeping next to a snoring partner)
  • I for idiopathic causes
  • A for anxiety and overactive mind
  • C for circadian rhythm disruption (jet lag, job shift changes, high altitudes)

I notice that in my clinical practice, oftentimes, many persons with insomnia are anxious about their sleep quality. When they go to bed they begin to worry that they cannot sleep. As a result of this worrying, their anxiety and arousal levels go up and hence there is no way that they can fall asleep. It will be better for them to unwind and practise relaxation methods for 1 or 2 hours in the evening and to learn to go to bed only when they are sleepy and not when it is time for them to retire to bed.

For patients with severe persistent insomnia, a sleep restriction management method may be indicated. Patients are instructed to allow no more hours in bed than they estimated they slept the previous night. Initially, this period may be considerably less than 7.5 hours. When they are able to sleep for essentially all the time in bed for several nights, they are advised to increase their time in bed by half-hour increments until they achieve optimal sleep time and sleep efficiency. This modality will not be indicated in patients with bipolar disorders as sleep deprivation may worsen the mood swings, and also in persons with epilepsy, as sleep deprivation may increase the number of fits.


References:

1. Kalmbach DA, Pillai V, Arnedt JT, Drake CL. Identifying At-Risk Individuals for Insomnia Using the Ford Insomnia Response to Stress Test. Sleep. 2016;39(2):449-456. doi:10.5665/sleep.5462 ‌

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