By definition, insomnia is difficulty falling asleep, staying asleep or both that manifests in daytime consequences for the sufferer. These consequences may include fatigue, malaise, excessive sleepiness, concentration and memory impairment, irritability and mood disturbance, strained personal and professional relationships, impaired vocational or academic performance, enhanced accident risk and occurrence and preoccupation with worries related to sleep.
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Acute versus Chronic Insomnia
Primary insomnia is diagnosed when symptoms persist longer than one month, and insomnia is classified as “chronic” when symptoms exceed six months in duration. While 90 percent of U.S. adults will report at least one incident of insomnia during their lifetime (acute), the vast majority of these cases are triggered by sudden trauma, loss or situational stress and typically self-resolve in days to weeks.
Insomnia risk is 1.4 times higher in women than men, and the sex difference further increases during and after menopause. Individuals over 60 years old, those with chronic health problems, shift workers, patients of color or poor socioeconomic status and cancer sufferers are also at increased risk for developing insomnia.
The “3-P” Model of Chronic Insomnia
The so-called “3-P model” of chronic insomnia, which encompasses “predisposing,” “precipitating” and “perpetuating” factors, is widely accepted as the presumed mechanism through which “acute” insomnia morphs into a “chronic” insomnia state.
A “predisposing” factor usually underlies the development of chronic insomnia. These traits range from hyperarousal, as evidenced by enhanced subcortical brain activation, and coexisting depression and anxiety to genetic, environmental and familiar precursors. “Precipitates,” such as illness, trauma, stress, loss or geographic change, typically trigger the insomnia incident, and an individual’s initial reaction to the incident in terms of degree of worry and rumination may also predict whether the acute insomnia incident transforms into a chronic insomnia condition. Finally, certain “perpetuating” behavioral factors and sleep habits solidify the maladaptive insomnia response. These include clock watching, irregular sleep-wake cycles, use of blue-light-emitting devices, such as tablets, phones and computers in proximity to bedtime, and caffeine and nicotine exposure. Preoccupation with poor sleep and misperception of actual sleep time may add to the worry surrounding insomnia and perpetuate the condition.
Prevention and Early Intervention
Preventative strategies hinge on early identification of acute insomnia and interventions aimed at normalizing sleep patterns. Sadly, timely recognition of insomnia is a true challenge. The typical medical student receives only about 2.5 hours of sleep education during their four-year medical school curriculum, and primary care providers are often woefully under-resourced to dedicate time during patient encounters to evaluate and treat sleep disorders like insomnia. Insomnia remains a largely unrecognized and untreated problem.
Recent research supports the cost-effectiveness and efficacy of early intervention for the prevention of chronic insomnia. Although pharmacologic agents are often prescribed for insomnia patients, a new study demonstrated that one 60-minute session of cognitive behavioral therapy targeted at addressing acute insomnia lead to resolution of insomnia symptoms in 60 percent of the intervention group.
Public awareness of the risks associated with insomnia and insufficient sleep is also needed. In recent years, national advocacy groups, such as the American Academy of Sleep Medicine (AASM) and National Sleep Foundation (NSF), have increased efforts aimed at insomnia education and outreach to patients and providers.