cognitive behavioral therapycognitive behavioral therapy for insomniainsomnia

What type of insomnia do I have? Narrowing it down.

By October 24, 2019 No Comments

Before sharing how you can narrow things down in terms of what type of insomnia you have I want to double down on one thing:

Insomnia is a symptom and not a disorder.

I’ve used the analogy of cough in the past. For those of you who are new to the blog coughing is a symptom, a symptom that could be of pneumonia, dust mite allergy, foreign body and a whole host of other underlying conditions. Insomnia is also a symptom and could be caused by many underlying factors. If those underlying factors are not adressed then your insomnia will not resolve.

That said it is meaningful in my opinion to have some type of framework and categorize insomnia for several reasons including:

1. Allowing you to educate yourself about your specific type of isnomnia.

2. Giving you a target to focus your efforts at sleeping better on.

Most of the time knowing what type of insomnia you have does not change treatment, CBTi is first line therapy for almost all types of insomnia. In medical school there was a saying that dermatologists have 1000 diagnoses and 1 treatment, almost everything was treated with a steroid cream. Insomnia is somewhat similar but again knowing what type of insomnia you have I think can make you feel a bit less alone and empower you to learn more about your type of insomnia.

So what types of isomnia are there?

A common general classification that has fallen out of favor is sleep onset versus sleep maintenance insomnia. I mention it because you may have heard about this. This classification is not used much anymore because most people with insomnia (not eveyrone, I am very aware!) have problems with both. More importantly however, braking down insomnia into problems falling and staying asleep does not tell you much about why you are having trouble sleepin and that is why this classification is not very useful.

There has been a recent trend towards simply categorizing insomnia as acute and chronic in the sleep medicine field. Acute meaning less than 3 months and chronic lasting for more than 3 months. I think this has mostly to do with billing and I don’t find this classification very helpful as again it does not tell you much about why you have insomnia.

A broad categorization that I think is meaningful is into primary and secondary insomnia.

Secondary insomnia

Insomnia is caused by an ongoing identifiable trigger. Common reasons are stress, pain and obstructive sleep apnea.

Primary insomnia

Insomnia occurs without any ongoing trigger.

Most people can tell if they have secondary or primary insomnia. Both are very common but if I had to guess I would think stress related secondary insomnia is the most common type of insomnia.

If you have a secondary insomnia then your main focus should be to try to address the root cause of your insomnia. If it is stress then relieving that should be your primary goal. If you can’t sleep because your cat wakes you up well then you have to figure that one out etc. This being said, CBTi is likely to be helpful to you even if you cannot completely resolve the underlying trigger.

I have had many patients with all kinds of triggers for insomnia respond well to CBTi. There are no particular modifications to the CBTi you need if your insomnia is secondary except again trying to work on the underlying trigger.

If there is no ongoing trigger for your insomnia then it is probably primary. There are three types of insomnia and this is where it gets really interesting IMHO.

Psychophysiological insomnia

A now resolved trigger originally caused insomnia. Although the trigger is no longer active the insomna never resolved.

Paradoxical insomnia

A usually big discrepancy exist between how much someone sleeps and how much they percieve sleeping.

Idiopathic insomnia

Insomnia starts in childhood and the cause is unknown

By far the most common type of primary insomnia is psychophysiological insomnia. The typical history is that someone had a bit of a tendency towards insomnia and/or never need very much sleep but was coping and sleeping well. Something stressful happened like loosing a job or a loved one and now insomnia became a big problem. Although the stress or grief is no longer an problem difficulties sleeping remain.

People with psychophysiological insomnia are ideal candidates for CBTi. This is becuse they often have habits such as going to bed early, spending more time in bed than needed and associating the bedroom with insomnia. All things that can be effectively reversed with bedtime restriction and stimulus control.

Every now and then I see a person that says that her or she does not sleep. At all. They have gone days, weeks sometimes even months without sleeping. This is off course not physiologically possible so what is going on. People with paradoxical insomnia, aka sleep state misperception severtly underestimate how much they sleep. Although the classical patient is someone who reports not sleeping at all symptoms are more subtle usually. Often someon feels that they sleep 2-3 hours when (if you have EEG data) they sleep 5-6 hours. They sometimes have superficial and fragmented sleep because they spend too much time in bed. If this is the case they do better with bedtime restriction.

Another thing that I have found is often a clue that someone has paradoxical insomnia is that they are unsure of a lot of things. When I ask how long it takes them to fall asleep they are not sure. When I ask them to estimate how much sleep they get at night they have a hard time answering. If you feel as if you have a very poor grasp of how long it takes you to fall asleep or how much you sleep you may have paradoxical insomnia. Using a fitbit or other sleep tracker may help find out how much you actually sleep and compare to how much you think you sleep. If you did not read my blog on how to read your fitbit you may read it here.

CBTi can help with paradoxical insomnia because it is worse when sleep efficiency is low.

Finally we have idiopathic insomnia. If you have had difficulties sleeping your entire life, since childhood for no apparent reasongn then you have idioathic insomnia. It is a diagnosis of exclusion and poorly understood. I find that most of my patients with idiopathic insomnia have a family history of poor sleep. Often one of their parents had significant insomnia so it may be a genetic component.

The longer someone has suffered from insomnia the harder it typically is to treat so idiopathic insomnia is usually more of a challenge then other insomnias. However, if you think you have idiopathic insomnia your best bet is CBTi.

I want to say one last time that although I have described here different types of insomnia :

Insomnia is not a disorder but it is a symptom.

Insomnia can be a symptom of an ongoing trigger like stress and is then a secondary insomnia. It can also be a symptom ofof a previous stressor as in psychophysiological insomnia, a symptom of difficulties estimating how much one sleeps as in paradoxical insomnia or a symptom of a poorly understood condition that manifests as idiopathic insomnia.

As always please share your thoughts and experiences and I hope this was helpful.