Insomnia Insomnia

70 Attarian
agitation and hence the arousal and aggravates the insomnia; watching the clock
and counting the hours left before one has to get up; sleeping in in the mornings in
order to “catch up”; doing housework, homework, or office work while awake at
night; and, in rare cases, napping during the day. All these behaviors are engaged in
“in good faith” but tend to exacerbate the problem rather than alleviate it.
A deterioration of mood and motivation as well as problems with attention, vigilance,
and concentration are associated with psychophysiological insomnia (1).
Studies have shown that these symptoms are secondary to central nervous system
arousal and not to poor sleep per se (24).
Of note, patients with psychophysiological insomnia complain bitterly of fatigue
and difficulty with concentration and attention but almost never give a history of
falling asleep unintentionally during the day. Only rarely are they able to even nap
in the daytime.
Within the limits of a normal personality profile, patients with psychophysiological
insomnia tend to be more tense, generally less satisfied, and are typically
emotional repressors and deny problems (12, 25). There usually is a positive family
history of insomnia and/or light sleepers.
Acute physical and psychological stressors tend to exacerbate insomnia, as does
shift work (26). Pregnancy may aggravate psychophysiological insomnia as well,
especially in the first and third trimester (27).
According to the ICSD, the following criteria must be satisfied to diagnose psychophysiological
insomnia: (1) a complaint of insomnia and a complaint of
decreased functioning during wakefulness; (2) indications of learned, sleep-preventing
associations, such as trying too hard to sleep or showing conditioned arousal
to the bedroom; (3) evidence for increased somatized tension, such as agitation,
high muscle tension as manifest in tension headaches, or increased sympathetic
tone; (4) the PSG, if used, shows disturbed sleep; (5) no other medical or psychiatric
disorder can account for the severity of the sleep disturbance, although most
patients with psychophysiological insomnia are somewhat anxious and dysphoric;
and (6) other sleep disorders may co-exist with the insomnia (e.g., poor sleep
hygiene and obstructive sleep apnea [OSA]) (1).
Case 1
K is a 41-year-old woman who presented to the sleep center outpatient
clinic for initial evaluation of a year’s history of sleep-onset and sleep maintenance
insomnia. K was always a light sleeper, but about 1 year ago, after
the death of her mother, she started having trouble falling and staying asleep.
Prescription sleep aids help her go to sleep within a reasonable time, but she
wakes up at 4 AM unable to return to sleep.
She has tried napping during the day, but cannot. She does not fall asleep
unintentionally, although she feels fatigued during the day. At night when
she is awake, she tosses and turns in bed and never leaves the bed or the
bedroom. Currently, she is between jobs, so in the morning when she wakes