Does Insomnia Always Have an Underlying ‘Cause’?

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Does Insomnia Always Have an Underlying ‘Cause’?

“Everybody suffers from a few sleepless nights, but most people do not suffer from the disorder of insomnia,” explains Dr. Michael Thorpy, a neurologist and director of the Sleep-Wake Disorders Center at Montefiore Medical Center in the Bronx. “Insomnia disorder typically occurs when the sleeplessness occurs for at least one month, though even a few days of bad sleep may be sufficient to require treatment.”

Shelby Freedman Harris, Psy.D.
Dr. Thorpy and Shelby Freedman Harris, a psychologist and director of the center’s behavioral sleep medicine program, recently took readers’ questions about insomnia on the Consults blog. Here, Dr. Thorpy and Dr. Harris respond to a reader inquiring whether insomnia is always a result of some underlying condition like stress or pain, or whether it can exist as a standalone disorder.

Q.
Is insomnia always coupled with an underlying cause (chronic pain, stress, anxiety disorder, etc) or is it truly possible to have insomnia and not have any underlying condition? Moreover, if you solve the underlying condition of your insomnia,  is it possible to still suffer from insomnia?

A.
Dr. Harris and Dr. Thorpy respond:

Great question, and something that has caused a lot of debate in sleep medicine over the years. Briefly, you can have an underlying condition and insomnia. But once the original condition is treated, the insomnia may remain and require its own treatment.

Older schools of thought held that insomnia was always secondary to some underlying condition, such as a medical, psychiatric or psychological disorder. But sleep specialists now believe that, in a minority of patients, insomnia occurs without any known underlying disorder.

Furthermore, when a medical condition exists along with insomnia, it does not necessarily mean that the two are linked. Therefore, we sleep specialists now refer to the association as “comorbid,” or existing alongside, rather than “secondary,” which implies one condition causes the other. So someone might have insomnia comorbid with depression, but it does not necessarily mean that the depression caused the insomnia. The depression might have resulted from the insomnia, or be unrelated. Treating the “underlying” diagnosis may not alleviate the insomnia.

In many cases, we believe that insomnia often starts because of a variety of triggers. It may be the onset of a medical or psychiatric disorder, for example, or starting a new medication. Stress may also cause insomnia. The stress may be positive, such as the birth of a baby, a new job or marriage, or negative, such as financial concerns, bereavement or working odd hours.

Although many patients can link the start of their insomnia to a particular cause, others have a form of insomnia with no underlying connection to another disorder. This disorder, called psychophysiological insomnia, is often seen in patients who were light sleepers much of their lives and who tend to place great emphasis on, and worry about, sleep.

Even when an underlying medical or psychiatric disorder, such as depression, is successfully treated, resolution of the underlying condition doesn’t guarantee the sleep disturbances will go away. Continuing sleep trouble suggests that the insomnia exists as a separate disorder and is not simply a symptom of another condition.

The situation is often made worse because, over time, people who can’t sleep often develop strategies to help them either get more sleep at night or cope during the day with sleep loss. Such strategies might include increased use of caffeine, prescription or over-the-counter medications, alcohol, napping, sleeping in or going to bed early, calling in sick to work, putting extra pressure on oneself to sleep, and so on. These behaviors, which may help at first, actually serve to make the insomnia worse in the long run.

In such cases, the insomnia may require its own separate treatment. Cognitive behavior therapy, a prescription medication or a combination of the two can be very helpful. Cognitive behavior therapy is an evidence-based, nondrug approach based on the concept that chronic insomnia – or insomnia lasting longer than four weeks — is sustained by a variety of physical and behavioral factors (some of which are noted above) that are generally unrelated to short bouts of insomnia. The factors that maintain chronic insomnia then become the focus of the treatment.