The condition of insomnia: Etiopathogenetic considerations and their impact on treatment practices

Insomnia is conceived as the subjective complaint of reduced sleep quantity and/or quality, even in the absence of objective verification of sleep loss; it is the outcome of the interplay of many environmental, biological, and psychological factors, which can be distinguished into predisposing, precipitating and perpetuating. Predisposing and precipitating factors include various demographic characteristics and the occurrence of psychiatric or somatic illnesses as well as other stressful life events. The perpetuating factors, responsible for the development of chronicity of the complaint of insomnia, mainly involve a 24-hour state of hyperarousal and a vicious cycle of sleeplessness causing fear of sleeplessness which in turn leads to further hyperarousal and more sleeplessness. Particular psychological characteristics, including excessive use of denial and repression as well as a strong propensity for internalisation of emotions, are also among the main factors contributing to the psychophysiological activation and state of hyper-arousability commonly encountered among insomniac patients. The treatment should not only focus on ameliorating sleeplessness, it should also address all those factors that cause and maintain insomnia. An integrative management of insomnia includes education on sleep hygiene measures, behavioural, cognitive and psychodynamic psychotherapies, and the utilization of sleep-promoting drugs. Among the latter, only for the use of benzodiazepine or benzodiazepine-like hypnotics exists sufficient evidence for efficacy as well as adequate information on their side-effect profiles. Thus, these compounds are considered as the drugs of choice for the treatment of insomnia. It is recommended that the use of hypnotic drugs is restricted to the initial period of treatment; they should be rationally utilized within the context of a broad therapeutic program, which is based on a sound doctor-patient relationship and includes sleep hygiene education and the application of certain psychotherapeutic techniques in an individualized manner.