2:  SHORT-TERM VS CHRONIC INSOMNIA           (Rev 6-14-2018)

This section focuses on brief or transient insomnia and how it can be dealt with. It follows an initial assessment (Section 1) in Step A.

It pays to divide insomnia into three types, based on how long the person has had the problem, because treatments for different types are different. However, the times listed are approximate, and treatments recommended for one time-type may be effective for a patient who appears to fit into another category.

  • Transient – lasts a few days or less
  • Short term – up to a few weeks
  • Chronic

2a: Basic Questions

Initial questions can be relatively straight-forward and direct.

  • Ask how long the patient has had this problem
  • Ask when it started, then how he/she remembers that.

The patient’s answers help define the type of insomnia and suggests possible antecedents or causes. Sometimes knowing the context of the origin of the patient’s insomnia can suggest treatments.

 

2b Transient Insomnia (Reite, Weissberg and Ruddy 47)

This kind of insomnia is usually a consequence of change or other short-term stress, and typically ends without intervention. It just passes, often because circumstances change (the precipitant gets old and ineffective, or the anticipated event comes and passes).

Possible Sources of Treansient Insomnia:

  • Stress, from worry or excitement, anticipation
  • Illness
  • Ascent to high altitudes
  • Jet lag

Treatment for Jet Lag or Clock Change

The usual suggestions (Hauri and Linde, 160-162) are to…

  • Wait it out, without using medications
  • Make a point of awakening consistently, if going from east to west, and of going to bed at a consistent time, if going from west to east. That way, sleep is lost in either direction, and the need increases on subsequent days.

Treatment for stress-related insomnia

For most people, trying to analyze the stress may not be effective enough quickly enough.

If the problem is difficulty falling asleep, try short half-life hypnotics such as Ambien [zolpidem] 5-10 mg at bedtime for 1-2 nights.

If the problem is interrupted sleep, the person can try Geodon [zaleplon] 10 mg if there are at least 4 hours before getting up

 

Change of Altitude

According to  Reite, Weissberg and Ruddy (47-48), altitude-related insomnia typically is resolved in a few days, but can be helped by acetazolamide and sleep medications.

 

2c Short-Term Insomnia

Insomnia lasting a few days to a few weeks typically resolves without treatment, and a common intervention might be to ask the person to keep track of it for the next week and see what happens.

Sleep medicine specialists see insomnia as long term only after weeks or months. In the context of ongoing psychotherapy, however, it may be worthy of treatment much sooner. Insomnia can affect mood, sense of personal effectiveness and self-esteem. It can lead to anxiety and depression, even in a relatively short time. Ignoring it could lead to misdiagnosis and ineffective treatment.

If the person is anxious, either as a source of insomnia or a consequence of lack of sleep, a brief treatment with Ambien can be helpful to some people (Reite, Weissberg and Ruddy 47-48). However, it is typically only for a day or two, it addresses the symptom directly, and it ignores underlying causes – which are expected to pass. In some cases, medication can keep the person from developing a habit of being unable to fall asleep or awakening in the middle of the night.

There is a danger of conditioned insomnia if a person can’t seem to break the pattern, because he/she develops a fear of not sleeping. (see Section 13)

Basic Treatment: Try to break the pattern. Patients should be warned that any medication is for short-term use only, lest they develop an expectation and dependency. Long term use of any sleep medication has undesirable consequences (See Section 36).

Treatment for Bereavement –  See the section on Grief in the Depression Map

 

2d Chronic Insomnia (Reite, Weissberg and Ruddy, 48-50)

When the patient’s sleep issues continue for a long time, long-term solutions are necessary. Patients with chronic insomnia are the primary focus of this map. Here, though, we may have to define “chronic” in the patient’s terms, rather than according to some absolute or scientific standard.

When the problem is chronic, it may be helpful to divide possible causes into (1) predisposing factors, (2) precipitating factors, and (3) perpetuating factors (Manber and Ong, 118-119).

Predisposing factors can be lifelong, or at least longstanding. They typically raise a person’s general level of arousal and make other stimuli more likely to keep a person awake. Physiological factors can include a generally high energy level or a medical condition that interferes with calm. Psychological factors can include chronic anxiety or a history of developmental trauma that keep a person on alert for danger.

The conditions that initiate a patient’s current round of insomnia are called the precipitating conditions. It can be helpful to identify the beginning of a person’s problem with sleep, especially when the precipitating issue (e.g.: chronic pain, family violence) is ongoing. Many people have not sought the cause of their insomnia by examining when it started, and this search may be helpful to them.

While it can be informative to know how the patient’s insomnia began, just discovering the precipitating condition is typically not sufficient for the person to start sleeping normally. For that to happen, the perpetuating conditions usually need to be addressed. These can be quite different, and may include reactions to insomnia itself – an attempt to will oneself to sleep, a medication that leads to daytime fatigue and nap-taking, which then leads to nighttime insomnia, and so on.

In this map, these distinctions will not be emphasized. However, it may pay a clinician to make note of various sources of a patient’s insomnia, and these categories may be useful in extending your search.