Espie and others have emphasized the increased attention to sleep and effort to control sleep that paradoxically increases rather than decreases alertness in the bedroom ( 16). An increased effort around sleep is often part of the description. “As soon as I climb the stairs, the lights go on in my head” are typical statements heard in clinic. The typical example is people who nap during the day and disrupt the natural drive to night sleep.Ī hypervigilant phenotype is typical with a “racing mind” that finds it hard to switch off. One of the most widely accepted models for chronic insomnia is based on the Spielman three ‘P’s model ( 15) with predisposing factors (certain personality traits), a precipitating trigger (the acute stressor) but then perpetuating or maladaptive behaviours that worsen sleep and disrupt both the normal homeostatic and circadian drivers to sleep. However for chronic insomnia to develop, there usually have to be perpetuating factors. This usually resolves when the stressor is removed ( 14). Persistent insomnia remains the single biggest risk factor for depression ( 13).Īcute stressors are a common cause of acute insomnia, for example an argument at work or a systemic illness. (Insomnia disorder is now called comorbid insomnia if it is associated with another physical or mental health problem). It is more common in women and it is commonly comorbid with other mental and physical health problems ( 12). Increasing age is a risk factor due in part to the natural tendency for a more fragmented night and decreasing melatonin output. In addition there may be a tendency to attribute insomnia in those with mental or physical health problems to an existing diagnosis, rather than consider insomnia as a distinct and treatable disorder. This may be at least part of the reason that insomnia and other sleep disorders remain under diagnosed and undertreated ( 6). At least 30% of US adults sleep less than 6 hours a night on a regular basis ( 5). First the industrial revolution and then, more recently, the digital revolution have led to shift work and sleep restriction as a widespread phenomenon across society. In modern life, we manipulate our light levels to disrupt and confuse our circadian rhythm. There is increasing sleep fragmentation and increased time to fall asleep in otherwise healthy older adults with and without sleep complaints ( 4). There is phase advance (i.e., falling asleep earlier) with every decade that passes with adults falling asleep by 30 minutes earlier a decade on average from the third decade onwards. Teenagers and young adults need 8–9 hours of sleep on average with a delay in sleep phase such that many fall asleep after rather than before midnight ( 3). Both total sleep time and the circadian rhythm change over the course of our lives and tend to fragment and weaken over time ( 2). The homeostat drives an increasing pressure to sleep after every hour awake and the circadian rhythm drives alertness in the day and sleep at night with light intensity as the strongest external timekeeper ( 1). Normal sleep relies upon two distinct but overlapping neuronal circuits. Finally, the review will cover evidence for different modes of delivery (online, self, help, group or individual face to face) in a variety of clinical settings. Therefore, this review will cover the initial assessment of insomnia, including insomnia mimics, the selection of patients for treatment and the key components of CBT therapy. This is a simple CBT to deliver with better and safer outcomes than prescription hypnotics. Over 25 years of high quality research have shown evidence for sustained improvements in sleep in those with insomnia alone or insomnia comorbid with other conditions. The first line treatment is now well established as insomnia-specific cognitive behavioural therapy (CBTi) in the most recent US and European treatment guidelines. Patients and health professionals have often had limited teaching about effective strategies for insomnia which leaves many untreated and insomnia can be unfairly perceived as a challenging symptom to manage. If it is the patient’s main concern, it warrants treatment. While it is commonly comorbid with other physical and mental health problems, the new diagnostic classification has been helpfully simplified such that it is considered a disorder in itself. Insomnia disorder (“immoderate watchfulness”) remains the commonest sleep disorder in primary and secondary care with an estimated 5–10% of the adult population affected. Disrupted sleep for any reason has immediate and long term consequences on physical and mental health. Hippocrates recognized the importance of asking about sleep as long ago as 400 BC when he wrote “ sleep and watchfulness, both of them when immoderate, constitute disease”.
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