Chronic Insomnia

Chronic insomnia is technically insomnia lasting over a month, although doctors usually won’t consider the condition chronic until it has gone on for several months, and has not been alleviated by attention to sleep hygiene or by elimination of obvious causes.

two people lying downHow bad is chronic insomnia? Some find it a mere irritation and others find it debilitating. Some people think they have chronic insomnia, but really don’t. (If you don’t have daytime sleepiness, you don’t formally have insomnia.)

Management

Chronic insomnia poses a challenge for doctors. They are discouraged from prescribing hypnotic drugs for the long term. (Doctors have discretion to do so if they feel it is warranted, but the professional guidelines and FDA labeling generally oppose long-term drug use.) Chronic insomnia has been understudied partly because of its long-term nature. The longest clinical trials of treatments last less than a year, while chronic insomnia can go on for decades, leaving the patient to fend for themselves and find ways to cope.

One strategy some insomniacs employ (either with their doctor’s approval or not) is to rotate sleep aid medications. Spend a few weeks on an over-the-counter antihistamine followed by a few weeks on melatonin followed by a few weeks on a prescription Z-drug. With the occasional drug holiday, people continue like this for years.

Cognitive behavioral therapy (CBT) has been shown time and again to work for insomnia. The main rap against it is the time and expense which compare unfavorably to quick pills. But for chronic insomnia, the calculation works in favor of CBT. The up front investment pays dividends in better sleep and no drug cost in the long run. CBT doesn’t work for everyone, but a good therapist can often help the problem sleeper.

Periodic reviews of sleep behavior and hygiene are a good idea for the chronic insomniac. Sleep journals are also useful for those with chronic insomnia.

“There is only one thing people like that is good for them; a good night’s sleep.” - Edgar Watson Howe

A Wicked Problem

The federal government’s Sleep Disorders Research Plan (2011) says "Chronic insomnia affects nearly one out of five adults,” Sociologists and urban planners coined the term wicked problem to describe difficult situations with conflicting requirements and intractability to solutions. Chronic insomnia could be considered a wicked problem.

Chronic insomnia often sneaks up on people. As we get older, it is common for sleep quality to decline. And the drugs that people take as they get older can interfere with sleep - thyroid preparations, corticosteroids, and blood pressure medications do this. Comorbidities include chronic pain (eg, osteoarthritis, fibromyalgia), gastroesophageal reflux disease (GERD), heart failure, renal disease, diabetes, neurologic problems, and psychiatric disorders.

The pathophysiology of insomnia may be a hyperactivated or hyperaroused state. If this is true, it explains partly the chronic nature. The arousal does not easily diminish and does not go down at night. People describe it as feeling they can't downshift. Hypnotic drugs induce sleep, but the next day the person feels unrefreshed. People feel the only way to really come down is to take a vacation, and indeed, vacations often "cure" chronic insomnia, at least for a short time. For insomniacs like this, drugs are almost certainly not a good long-term choice. CBT and other behavioral programs are the best method for addressing chronic insomnia.

Biomarkers for stress such as cortisol and ACTH tend to run higher in insomnicas.

This type of dilemma for the patient and doctor - that the insomnia can apparently be stopped only by a vacation - is tough. It is one reason people retire earlier than they otherwise would and one reason we at Sleepdex want to spread the word about good sleep. We want people to find a way to sleep better to make their waking lives better and more productive.

Another plausible idea is that chronic insomniacs have "impaired plasticity of the sleep-wake system". While a normal person or someone with insomnia from another cause might be able to recover from a bad night with extra sleep the next night, the chronic insomiac can’t and accumulates a sleep debt and is stuck with excessive daytime sleepiness.

Costs of insomnia

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