31 Mar., 2021

“In the future, everyone will sleep for 15 minutes”

It occurs to me that in the 8 months I’ve had this blog up, I’ve been assuming everyone is familiar with the term “insomnia,” first of all; second, that we’re all more or less working with the same idea of what I’m prattling on about.

storyboard from Andy Warhol’s film Sleep

I just had one of those “Oh, crap,” moments, at which I realized that, in fact, perhaps we may not all be as one with what insomnia is. So, in order that everyone understands what I mean, here I go—to those who may have a different understanding of the word, I’m not proselytizing—I’m simply saying what’s in my head when I use the word, which, for what it’s worth, does come out of a lot of conversations with doctors and psychologists, and some reading of medical journals. But for now, is just here to make sure that my posts aren’t confusing.

So: insomnia is used to refer to sleep disorders. These disorders have in common that the affected person is not sleeping enough, or sleeping ineffectively, despite having the opportunity to sleep well. The end result? a sleep-deprived state affecting the person’s waking hours. That last bit is important. Some people naturally don’t need a lot of sleep. Someone for whom it is normal to sleep 6 hours a night, and functions optimally that way, is not an insomniac.

Insomnia may be a disorder in and of itself, or may be a symptom of a variety of other problems—a symptom of a symptom, in strict point of fact. A doctor considering a diagnosis of insomnia is looking for several things; not all need to be present, but some must.

The patient must first of all, have one of the following, although two, or even all three may be present: difficulty falling asleep, difficulty staying asleep (ie, sleeping in fits and starts), or waking too early (ie, sleeping in a single block that is not long enough for adequate rest).

Most patients will also show suboptimal sleep patterns; these can happen in a number of ways: there may not be enough REM sleep as a ratio of total sleep hours (the DSM-5, sometimes spelled DSM-V, calls this “non-restorative sleep”); or the patient may fail to experience full sleep paralysis, resulting in a lot of movement, possibly including (but not necessitating) sleep-walking; there are others, known as parasomnias, and even occasionally sui generis sleep problems.

The problem must persist despite a change in environment: this also is important; a problem that is specific to an environment is a problem with that environment, not true insomnia.

Finally, to be termed “insomnia,” a sleep problem must persist for more than a week, at the very least (except for the acute variety—see below).

Insomnia that lasts for more than a month; for years; or even a lifetime, is “chronic,” or “persistent.” Insomnia that lasts less than a month is “transient.” A single episode of between one to three months that appears to have resolved completely, may be called “episodic.” Insomnia may also be described as “recurrent,” if a patient experiences many transient occurrences over a long period, with at least two in a year. Two transient or episodic occurrences more than a year apart are considered separate and unrelated events.

If insomnia has a sudden, severe onset, in that the patient is getting literally no, or nearly no, sleep at all, for two nights or more in a row, this is “acute” insomnia. Non-acute, episodic insomnia, during which a patient may be getting 6.5 hours of sleep a night, instead of an optimal 8, for a week or so, may be allowed to run its course; acute insomnia, even if it is episodic, needs to be treated.

It is possible to be sleep-deprived without having insomnia. This distinction is important. People who are being scheduled for shifts at work that do not allow them enough time to sleep in between; people not sleeping because they have a newborn; or people having an especially difficult time adjusting to a different time zone (ie, jet lag) may all experience sleep-deprivation, but not insomnia. These people do not have enough opportunity to sleep. It’s a critical factor in insomnia that the patient has the opportunity to sleep adequately, and simply cannot.

Insomnia may be primary or secondary.

Primary insomnia, renamed “Insomnia Disorder” in the DSM-5, is a condition that appears to be endemic to the patient’s neurological make-up: something is “off” in the patient’s brain structures, or ability to form neurotransmitters, or has some other native cause that may never be known, but in any event, does not arise from the environment, and is not situational.

Secondary insomnia is trouble sleeping for which a specific cause can be pinpointed. Such causes can be as varied as restless leg syndrome, interstitial cystitis, ADHD, apnea, nasal congestion caused by allergies, pain, or tinnitus; such causes are intrinsic, but not endemic which is a whisper-thin distinction, but it is there, nonetheless. When the cause is neurological, it’s inevitable. When it is a symptom of something else, such as tinnitus, which might be a symptom of Meniere’s disease, or the side effect of a medication for a blood-clotting disorder, the approach from a psychological standpoint, may need to be different, because there is not the same inevitability. How the underlying cause it dealt with can affect the symptom that is causing the insomnia.

It can also be a side effect of a medication in and of itself; it can be caused by necessary medication, such as steroids taken for asthma, in which case the medication may need to be changed, or a second medication for the insomnia may be necessary.

Stress and anxiety can interfere with sleep. When a person with an anxiety disorder has no precipitating event causing insomnia, the patient may be diagnosed with primary insomnia, although the DSM-5 discourages this; however, whether or not the patient has an anxiety disorder, when a stressful event, such as a death in the family, or money problems, precipitates insomnia, this is secondary insomnia.

Honestly, I’m not sure what a doctor would say about chronic insomnia caused by PTSD. The “chronic” state seems to me to suggest that somehow the trauma has changed the patient’s neurological make-up, allowing for a diagnosis of primary insomnia. But I am not a doctor, nor a psychologist.

Insomnia has been on the rise in the US lately, and apparently has shot up during the pandemic, but this mostly has been secondary and transient forms of insomnia. Chronic, primary insomnia which isn’t especially common to begin with, relative to transient or episodic insomnia, hasn’t risen in the wake of the problems plaguing us figuratively, as we are plagued literally.

Nonetheless, prescriptions for sleep medications have multiplied, apparently logarithmically, over the last year. I really wish I’d bought stock in pharmaceutical companies—or, I should say, more stock. I don’t have any in Johnson & Johnson, and, unfortunately, the best insomnia medications are available in generic now. Wow, if Ambien were still brand-name only, would Aventis be cleaning up.

The word “Insomnia” was created some time in the early 1600s. It is Latin-derived, but is not an organic Latin word; like many clinical words, it was invented by assembling a Latin root and Latin affixes in a lab, a little like the way new elements that don’t exist in nature are synthesized. It’s easy to break down “insomnia” even if one has not studied Latin. “Somnus” means “sleep” (cf, “somnambulist” = “sleepwalker”), “in-” means “not,” and “-ia” is a suffix that indicates the word is describing a condition (cf., “dyslexia,” “hypoxia,” “anorexia,” and “schizophrenia”).

The very first use of the word does not seem to have come down to us, and so I do not know what the index case of insomnia was—or even if there was one. I’m assuming that there was because the condition has a Latin name with a definite origin—there is a time when the term is suddenly being used with fair frequency, when just before, it was not used at all. But it is possible that there was something happening in an area causing lots of cases of insomnia, and so the word was coined, possibly not even by a physician. Where the area was, and what was the cause, I don’t know.

I wish I did. I don’t know why, but it feels important to me; I really wish I knew the event that delivered this word to the world. I’m sure insomnia has always existed, but I’d like to know what caused someone to think it was necessary to medicalize the condition—to bestow a clinical name upon it, and to reify it—to make it a “thing,” and to ultimately brand people like me “insomniacs.”

Published by Chava Freya

Insomnia is a brain-based disorder I’ve had since I was at least 16 years old. Anti-anxiety medicine doesn’t help, except when there’s external anxiety exacerbating the problem. Sleep hygiene is irrelevant, because it’s not the problem, although I have submitted to it five different times, including having sleep specialists actually come to my home and advise me on rearranging furniture, buying special pillows, forbidding TVs in the bedroom, telling me the bed was for nothing but sleep, sex and reading, and when that didn’t work, then nothing but sleep. Period. That was the biggest failure of all.

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