Insomnia Insomnia

Idiopathic Insomnia 83
report that these patients slept much less, or required less sleep, than their siblings
when they were infants. Sleep latency is long. Sleep is riddled with many awakenings
and may show sleep-stage abnormalities, such as rapid eye movement (REM)
sleep with few eye movements or ill-formed sleep spindles during stage 2 sleep (5).
Paradoxically, idiopathic insomniacs may show fewer body movements per unit of
sleep than do normal sleepers (14). The spectrum of severity of insomnia in this
condition varies from mild (essentially a light sleeper) to severe and incapacitating,
as the presumed underlying neurological abnormality varies from mild to severe
(14). Daytime features typically include decreased attention and vigilance, low levels
of energy and concentration, and a deterioration of mood commonly described
as grim and subdued, rather than obviously depressed or anxious. In mild or moderate
idiopathic insomnia, psychological functioning is remarkably intact. In severe
cases, daytime functioning may be severely disrupted and affected patients may be
unable to hold a job. During childhood and adolescence, idiopathic insomnia is
often associated with soft neurological signs (i.e., as dyslexia or hyperactivity).
Many cases show diffuse nonspecific abnormalities on the EEG (1).
The ICSD’s diagnostic criteria for idiopathic insomnia are (1) a complaint of
insomnia combined with a complaint of decreased functioning during wakefulness;
(2) long-standing insomnia, typically beginning in early childhood or soon after
birth; (3) relentless insomnia during periods of both poor and good emotional
adjustment; (4) one or more of the following polysomnography: increased sleep
latency, reduced sleep efficiency, and increased number and duration of awakenings
often a reversed first-night effect (best sleep on the first night); (5) the diagnosis
cannot be made if medical or psychiatric disease or stress can explain the early
Case 1
Mr. T. is a 53-year-old man with lifelong history of insomnia. Mr. T. stated
that his mother told him that he had trouble sleeping even during his infancy.
He stated that as far back as he could remember he has had insomnia. Around
age 10 or 11 he started having some anxiety associated with his inability to
sleep. He stated that when he has a decent night’s sleep for several nights in a
row, he really does not feel depressed and anxious; but not getting a good
night’s sleep creates anxiety over the inability to sleep, which then becomes
reinforced when he does not sleep easily the following night.
For reasons unknown, he did not seek medical attention for his problem
until about 1 year ago when he mentioned it to his primary care physician. He
was tried on Xanax, Ambien, Trazodone, Remeron, and over-the-counter
Tylenol PM. Few medications had any impact on his sleep. Even with medication,
he had only one good night every 2–3 weeks, during which he would
sleep 6–7 solid hours.
Most of the time, Mr. T. goes to bed between 11 PM and midnight feeling
sleepy and tired, but when he lays down he is awake for at least 1 hour, some-