Insomnia: When You Just Can't Sleep The literal meaning of insomnia is "not sleeping," and that fits

its modern definition perfectly. Insomnia occurs hen you ha!e trou"le going to sleep, staying asleep once you finally fall asleep #including a$ing up too early%, or you sleep "ut are not refreshed "y the e&perience. 'ccording to the International Classification of Sleep (isorders #ICS(%, the continuum of insomnia, as e&perienced "y the patient, identifies three stages #mild, moderate, and se!ere%. Mild insomnia means the patient often complains of either not getting enough sleep or not feeling as though sleep as restful. It isn't associated ith functional impairment, "ut the patient can feel tired, restless, irrita"le, or an&ious. Moderate insomnia is !ery similar ith t o differences. It occurs hen the patient al ays feels sleep as insufficient or unsatisfactory, and it causes mild to moderate impairment of daytime functioning. In severe insomnia, the impairment itself is also se!ere. )any factors can or$ together to produce insomnia, and researchers ha!e identified physical, psychological, and e!en social causes as contri"utors to the pro"lem. The t o main types of insomnia are differentiated as primary #not caused "y any identifia"le medical, psychiatric, or e&ternal en!ironmental influence% and secondary #resulting from a physical or mental illness, or a defined sleep disorder%. Primary Insomnias *sychophysiological Insomnia 'lso called "conditioned insomnia," this is a particularly interesting condition, "ecause not only does the patient complain of insomnia, "ut also of a high le!el of an&iety regarding the insomnia. In this disorder, a stressful e!ent produces "oth somatized tension, hich is a comple& of physical stress responses #for e&ample, increases in muscle tension and "lood !essel constriction%, plus a conditioned response to the ina"ility to sleep. The patient transfers orry a"out the stress to orry a"out the sleep pro"lem, that orry ma$es the sleep pro"lem orse, and the conditioned response occurs hen the failure to sleep and the orry "ecome self+reinforcing. ,!erything an unaffected person associates ith sleep #the "edroom, lying in "ed, thin$ing a"out sleep% "ecomes associated for the insomniac ith a$efulness instead, completely the opposite of the desired effect. Sleep State )isperception 'lso called "pseudoinsomnia," this condition is diagnosed hen a patient complains of insomnia, "ut that complaint cannot "e o"-ecti!ely !erified # hich is not true of psychophysiological insomnia%. When the patient spends a night in the sleep la", the polysomnography re!eals no insomnia, "ut the patient insists the insomnia as present. There's no suspicion of malingering, "ecause the complaints seem sincere and straightfor ard, and the patient presents no history or appearance of mental distur"ance. It is clear the patient is con!inced he is not sleeping, and e.ually clear he is sleeping. What is not clear is hy sleep state misperception occurs. Idiopathic Insomnia 'lso called "childhood+onset insomnia," this type of insomnia lasts a patient's lifetime, and is thought to stem from faulty iring of some neurologic component responsi"le for sleeping and a$ing. *ossi"le culprits include o!eracti!ity on the part of the system that responds to stimuli, or insufficient acti!ity in the parts that usually "ring sleep on and prolong it. It is e!en possi"le some idiopathic insomniacs fall at the lo end of the normal distri"ution in terms of sleeping hours. These patients are called "natural short sleepers," and their sleep span is less than /01 of hat is considered the normal amount "ased on age. Secondary Insomnias 'd-ustment Insomnia 'lso called "short+term insomnia," this type of insomnia is caused "y some emotional distur"ance, hich can "e a stress, personal conflict, or e!en a change in en!ironment that has emotional importance. These en!ironmental triggers are "y no means al ays catastrophic or e!en negati!e. They can include e!ents li$e starting a ne school or -o", pre+test an&iety, or "eing married the ne&t day. 2or a diagnosis of ad-ustment insomnia, the change in sleep has to "e sudden and drastic, and it needs to coincide ith the timing of the stressful occurrence. When the e!ent is anticipated, insomnia appears, and hen the e!ent goes a ay, the insomnia goes ith it. 3eha!ioral Insomnias of Childhood This category is actually t o disorders, according to ICS(: limit+setting insomnia and sleep+onset association insomnia. Limit-setting insomnia is .uite simple: a child manages to delay his "edtime "y !arious "eha!iors, and no one pre!ents him from doing so. The more often the child succeeds in

postponing the enforcement of sleep rules #in "ed, lights out, no tal$ing, and so on%, the more strongly ""edtime" is associated ith not sleeping. Sleep-onset association insomnia occurs hen certain conditions ha!e to "e met in order for a child to fall asleep. 4i!en a "ottle or pacifier, or "eing roc$ed, may induce sleep any here, hile "eing placed in "ed ithout the other stimuli does not cause sleep. Inade.uate Sleep 5ygiene Simply put, this refers to "ad sleep ha"its. 5uman "eings really are creatures of ha"it, and if any of those ha"its are oppositional to sleep that can create a pro"lem. There are a large num"er of factors causing this type of insomnia, "ut here are some e&amples. Su"stances li$e nicotine and caffeine can ma$e it hard to fall asleep, hereas alcohol can alter the .uality of sleep or interrupt sleep. If your or$ re.uires deep thought or you e&ercise !igorously too close to "edtime, those practices ma$e it hard to sleep. Is your "edroom temperature uncomforta"le, do your pets "other you at night, or does your "edroom lac$ curtains6 2ailure to correct those conditions may cause trou"le sleeping. Insomnia Caused 3y a (rug or Su"stance, or a )edical or *sychiatric *ro"lem There are a num"er of insomnias grouped under this heading. There are three main types of drug or su"stance insomnia. Food allergy insomnia is defined as an allergic reaction producing at least t o of these symptoms: agitation, torpor during the day, "reathing pro"lems, gastrointestinal distur"ance, or irritated s$in. It's often associated ith co 's mil$, and the patient finds it hard to fall asleep or stay asleep. When the allergen is remo!ed from the patients' diet, the symptoms a"ate. Nocturnal eating/drinking syndrome seems to "e a conditioned response. Children gro accustomed to "eing fed -ust "efore "ed, and then a$e in the night e&pecting another "ottle "efore falling asleep again. The "eha!ior is also seen in adults ho a$e for midnight snac$s, and once the "eha!ior is learned it "ecomes ha"itual. 2urther distur"ance of sleep occurs hen the patient must a$e up to go to the "athroom. In dependency insomnias #specifically, hypnotic+, stimulant+, and alcohol+dependent insomnias%, a drug the patient ta$es continually disrupts normal sleep. Sleeping medication that causes a re"ound effect must "e ta$en e!ery night, or the patient ill remain a a$e "ecause the drug is missing. The longer the drug has "een used, the harder it is to ithdra and still sleep. Central ner!ous system stimulants li$e caffeine, amphetamines, or cocaine act directly to $eep the patient a a$e. Some stimulants, li$e decongestants, are used for other medical purposes, and the a$efulness is an un anted side effect. Some people drin$ alcohol in order to "e a"le to sleep, then de!elop a tolerance for it. The more they ha!e to drin$ "efore "ed, the more li$ely it is they'll suffer mild ithdra al symptoms #s eating, the head pain and dry mouth of mild dehydration% during the night that a$e them up. There are numerous medical illnesses that produce insomnia as a side effect. The ICS( di!ides these up into t o categories, neurologic disorders and other illnesses. The neurologic disorders often affect the "rain #as in dementia or cere"ral degenerati!e disorder% or the central ner!ous system #li$e *ar$inson's disease%. Some are genetically lin$ed #the fatal familial insomnias%. Sleep+related epilepsy and sleep+related headaches can also cause insomnia. 7ther diseases that cause lac$ of sleep include sleeping sic$ness, nocturnal cardiac ischemia, chronic o"structi!e pulmonary disease, sleep+related asthma or sleep+related . reflu&, and fi"romyalgia. 2inally, there are se!eral categories of psychiatric disorder that can also interfere ith proper sleep. 'lcoholism, mood, an&iety, or panic disorders, and psychoses are all commonly associated ith pro"lems in the sleep+ a$e cycle, and in diagnosing any insomnia it is important to separate the psychiatric disorder itself from the disruption in sleep.