Insomnia Insomnia

Psychophysiological Insomnia 71
up around 4:30–5 AM she stays in bed, dozing on and off until about 11 AM.
Prior to this, she used to go to bed around 10–11 PM, fall asleep within an hour
or so, and then wake up at 4 AM and stay in bed tossing and turning until about
7 AM when she had to get up to go to work. She tried drinking alcohol just
before bedtime to help her fall asleep. She does not use caffeine during the
day. She denies snoring, observed apneas, cataplexy, sleep paralysis, hypnagogic
hallucinations, and choking spells. She denies waking up gasping for
air. She denies symptoms of restless legs.
DIFFERENTIAL DIAGNOSIS
Psychophysiological insomnia lies on a continuum with a number of other diagnostic
categories.
Idiopathic insomnia is diagnosed if the predisposition toward poor sleep by itself
is severe enough to cause insomnia. Psychophysiological insomnia is assumed to
start with a somewhat milder predisposition toward poor sleep that usually develops
into insomnia only with the occurrence of some other, identifiable stressor acting
as the trigger (1).
A sleep state misperception (SSM) is when the patient sleeps adequately but
does not perceive it as sleep (28). In this disorder, complaints of insomnia occur
without any objective evidence of sleep disturbance. Patients may report that they
have not slept at all in weeks, months, or years. However, on objective sleep studies,
they sleep several hours per night. When results of sleep evaluation are presented,
patients with SSM may vehemently insist that the studies are in error
because they are convinced that they sleep very little, if at all.
Idiopathic, or childhood-onset, insomnia is a rare condition presenting as a
chronic, serious inability to initiate and maintain sleep, which can often be traced
back to the first few weeks of life.
Circadian rhythm abnormalities occur when the patient sleeps well but not at
socially acceptable times (28). Those with the advanced sleep-phase syndrome have
excessive sleepiness in the evening and undesired early morning awakening. Those
with the delayed sleep-phase syndrome have sleep-onset insomnia, excessive daytime
sleepiness (particularly in the morning), or both.
Inadequate sleep hygiene is the diagnosis when insomnia is maintained primarily
by neglecting sleep hygiene and engaging in behaviors that are not conducive for
sleep (e.g., drinking too much coffee, exercising too close to bedtime, napping, staying
in bed too long, drinking alcohol too close to bedtime). To the extent that the
insomnia is independent of the precipitating causes and also independent of the quality
of sleep hygiene, psychophysiological insomnia is the preferred diagnosis (28).
Generalized anxiety disorder is the preferred diagnosis when anxiety permeates
most aspects of a patient’s functioning (anxiety in social interactions, about job
performance, etc.). Psychophysiological insomnia is preferred when the anxiety is
focused almost exclusively on poor sleep and its consequences on daytime functioning
(28).