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Insomnia Disorder
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Good evening.
Today we will discuss one of the most common yet misunderstood sleep disorders:
Insomnia Disorder
This is not simply “bad sleep.”
It is a clinical condition that affects brain function, health, and quality of life.
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Definition
Insomnia Disorder
Insomnia Disorder is defined as:
- Difficulty falling asleep
- Difficulty staying asleep
- Waking up too early and unable to return to sleep
Despite having adequate opportunity for sleep
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Diagnostic Criteria
For a clinical diagnosis:
- Occurs at least 3 nights per week
- Persists for ≥ 3 months
- Causes daytime impairment
This distinguishes chronic insomnia from short-term sleep problems.
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Types of Insomnia
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Acute Insomnia
- Short-term
- Triggered by stress or life events
- Lasts days to weeks
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Chronic Insomnia
- Long-term
- Persists ≥ 3 months
- Often maintained by behavioral and physiological factors
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The Sleep System
To understand insomnia, we must understand normal sleep regulation.
Sleep is controlled by:
- Circadian rhythm
- Sleep pressure
In insomnia:
These systems become dysregulated
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Hyperarousal Theory (High Yield)
The most accepted explanation:
Insomnia is a state of hyperarousal
This includes:
- Increased brain activity
- Elevated cortisol
- Increased sympathetic activation
The brain is too awake to sleep
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What Happens in the Brain
In insomnia:
- Increased metabolic activity
- Reduced sleep drive effectiveness
- Difficulty transitioning into sleep
Even when patients feel exhausted, the brain remains alert.
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Common Causes
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Psychological
- Stress
- Anxiety
- Depression
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Behavioral
- Irregular sleep schedule
- Excessive screen time
- Poor sleep habits
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Medical
- Chronic pain
- Medications
- Other sleep disorders
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The Insomnia Cycle
A key concept:
- Poor sleep → worry about sleep
- Worry → increased arousal
- Arousal → worse sleep
This creates a self-perpetuating cycle
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Symptoms
Nighttime:
- Difficulty falling asleep
- Frequent awakenings
- Early morning awakening
Daytime:
- Fatigue
- Poor concentration
- Irritability
- Mood changes
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Objective vs Subjective Sleep
Important concept:
Patients may perceive worse sleep than measured.
However:
The distress is real and clinically significant.
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Impact on Health
Chronic insomnia is associated with:
Hypertension
Depression
Anxiety disorder
It affects both mental and physical health.
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Sleep Architecture Changes
In insomnia:
- Reduced total sleep time
- Increased awakenings
- Reduced deep sleep
- Altered REM patterns
Sleep becomes fragmented and non-restorative.
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Diagnosis
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Clinical Evaluation
- Sleep history
- Symptom pattern
- Duration
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Sleep Diary
Tracks:
- Sleep timing
- Awakenings
- Patterns over time
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Polysomnography (PSG)
Not always required unless:
Another sleep disorder is suspected
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Differential Diagnosis
Important to rule out:
- Obstructive Sleep Apnea
- Restless Legs Syndrome
- Circadian rhythm disorders
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Treatment
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First-Line: Cognitive Behavioral Therapy
Cognitive Behavioral Therapy for Insomnia
CBT-I includes:
- Stimulus control
- Sleep restriction
- Cognitive restructuring
This is the most effective long-term treatment
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Sleep Hygiene
- Consistent schedule
- Avoid caffeine late
- Limit screen exposure
- Comfortable sleep environment
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Medications
Used when necessary:
- Short-term use
- Sleep aids under supervision
Not first-line for chronic insomnia.
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Why CBT-I Works
It addresses:
- Thoughts about sleep
- Behaviors that maintain insomnia
It breaks the insomnia cycle.
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Prognosis
With proper treatment:
Significant improvement is possible
Without treatment:
Chronic insomnia can persist for years
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Key Clinical Insight
Insomnia is not a lack of sleep opportunity.
It is a dysregulation of the sleep system
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Summary
Insomnia Disorder is:
- Difficulty initiating or maintaining sleep
- With daytime impairment
- Driven by hyperarousal and behavioral factors
Treatment focuses on:
- Behavioral therapy
- Addressing underlying causes
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Final Message
Sleep is a natural process.
In insomnia, the brain interferes with its own ability to sleep.
Understanding and retraining the bran is the key to recovery.