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Author: Ron Cridland, MD
Insomnia Related to Psychiatric Disorder refers to when insomnia occurs secondary to an underlying psychiatric disorder such as major depression, anxiety disorder, bipolar disorder, obsessive compulsive disorder, schizophrenia, etc. Sometimes treating the underlying psychiatric disorder will resolve the insomnia. Quite often, once the insomnia has become chronic it often develops a life of its own and persists even after the psychiatric disorder is controlled. There is a tendency to use even more medication to try and control the insomnia. However, this does not get at the underlying factors perpetuating the insomnia and often results in side effects from high dosages of sedating medication.
Once insomnia becomes chronic, it needs to be diagnosed and managed separately as a sleep disorder. In earlier editions of the “International Classification of Sleep Disorders” there was a separate diagnostic category for “Insomnia Related to Psychiatric Disorders”. Now, they have all “Insomnias” lasting longer than three months listed under the category, “Chronic Insomnia”. This combines previous sleep disorder diagnoses such as Psychophysiological Insomnia or Inadequate Sleep Hygiene together. This makes sense in that there can be many factors that contribute to chronic insomnia and they all need to be addressed. I still prefer to use the term Psychophysiological Insomnia because it helps remind us of the important underlying mechanisms contributing to chronic insomnia.
Although insomnia may initially begin as a symptom of a psychiatric disorder, quite often, chronic insomnia occurs first and is the trigger for developing a psychiatric disorder. It is well recognized that people suffering from chronic insomnia for over a year are up to 40 times more likely to develop a major depressive disorder and up to 20 times more likely to develop an anxiety disorder. It takes energy to cope with stress. If you are tired from lack of sleep, you sometimes do not have the energy to cope so “molehills turn into mountains” more easily. It is easier to feel anxious or depressed. Small problems can become overwhelming because you do not feel like you have the energy to problem solve or deal with them. In the past you may have been able to see a “light at the end of the tunnel.” Now it seems like that light has been turned out and you may wonder where you are going to find the energy to keep going. It is harder to look forward to things you used to enjoy when you do not have the energy to do those things anymore.
There are a number of factors that can precipitate depression or anxiety. Most people with anxiety will have trouble sleeping which will then in turn contribute to perpetuating the anxiety even after the factors that triggered the anxiety have improved or resolved. Most people with depression will have some disturbance of their sleep too. They may develop insomnia. Sometimes they feel extra tired and start sleeping more than usual.
There are many factors that can trigger panic attacks in a susceptible person. However, one factor that is often overlooked is fatigue. When you are tired you have to push yourself to function and get through your day. The stress of this increases the “fight or flight” response and the stress hormones like cortisol and adrenalin. Adrenalin speeds up your heart rate and makes your heart beat stronger. Given enough adrenalin you may feel palpitations in your chest or that your heart is “pounding”. If you do not understand why this is happening, you could easily start to feel anxious about what is “wrong” with your heart. In some cases, this can trigger a panic attack.
People with a tendency to bipolar disorder are more susceptible to insomnia. They may become excited about something and find it harder to sleep. The less sleep they get the more adrenalin they live on making their insomnia worse. At some point insufficient sleep can contribute to enough cognitive impairment to trigger an episode of mania.
When insomnia improves and you can get enough sleep, mild depression and anxiety may resolve on their own. However, with more severe depression, anxiety or other mental disorder, these conditions also must be managed with psychotherapy and/or medication along with strategies to manage stress in addition to managing the insomnia.
Diagnosis
At one time, insomnia that began secondary to a psychiatric disorder was diagnosed as “Insomnia Related to Psychiatric Disorders”. Now, once an insomnia becomes chronic, it is considered an entity on its own. If the insomnia persists despite adequate control of the underlying mental disorder, then the diagnosis of Chronic Insomnia or Psychophysiological Insomnia needs to be considered. Criteria for diagnosis includes the following: difficulty initiating, maintaining or returning to sleep associated with daytime symptoms of fatigue, reduced concentration or cognitive function. The sleep disturbance is not explained by other physical disorders (e.g.: pain, hyperthyroidism, hot flashes), medication effects, uncontrolled psychiatric symptoms or other primary sleep disorder.
Management
For management of Insomnia Related to Psychiatric Disorders, Chronic Insomnia, or Psychophysiological insomnia, please refer to the section on Psychophysiological Insomnia.
