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Andrew Krystal, MD, discusses his recent publication, 

Cost-effectiveness of digital CBT (Sleepio) for insomnia: A Markov simulation model in the United States

is a psychiatrist who cares for adults with all types of sleep disorders, with particular expertise in insomnia. He also treats patients who have mood and anxiety spectrum disorders in addition to sleep disorders. An internationally renowned expert on sleep and mood disorders, he has more than 25 years of experience in patient care and research. He is president of the Sleep Research Society and a member of the American Academy of Sleep Medicine, American Psychiatric Association and American College of Neuropsychopharmacology. He serves on the examination committee of the American Board of Sleep Medicine, which allows medical professionals to pursue certification in sleep medicine.

How cost-effective is fully automated digital cognitive behavioral therapy (CBT) intervention for insomnia?

Digital Cognitive Behavior Therapy for Insomnia 

At the recent Virtual SLEEP 2020 Meeting, Eisai gave 2 presentations. One of these was on lemborexant, which was recently launched in the US for the treatment of adult patients with insomnia, characterized by difficulties with sleep onset and/or sleep maintenance.

In these presentations, data on the following topics were shared:

1. Long-term results evaluating lemborexant efficacy and safety in adults ages 65 and older, in measures of time to sleep onset, sleep efficacy, and sleep maintenance.

2. Efficacy and safety results of lemborexant in female subjects of perimenopausal age from SUNRISE 2.

3. An open-label pilot study evaluating the ability of patients with insomnia disorder to directly transition from zolpidem to lemborexant. 

4. The impact of lemborexant on fatigue severity.

is the International Project Team Lead for the lemborexant clinical development program at Eisai. 

The International Project Team Lead for the lemborexant clinical development program shares insights from their presentations at the Virtual SLEEP 2020 Meeting. 

An Inside Look at 2 Presentations from the Virtual SLEEP 2020 Meeting

If you were to poll physicians and ask which specialty usually takes the lead in the management of chronic pain, no doubt an overwhelming majority would say anesthesiology, with a smaller number saying neurology and physiatry. However, probably few would say psychiatry.

It is odd considering the recent revision of the 

 by the International Association for the Study of Pain, the leading worldwide organization for medical professionals involved in the field of pain: “Pain is always a subjective experience that is influenced to varying degrees by biological, psychological, and social factors.”

 This appears to be almost precisely with what psychiatry deals.

We already know that there is a high degree of comorbidity between 

 with chronic pain and, although it is commonly thought that the mental disorders are always secondary to the pain, research has shown that pain is a common presenting symptom of these disorders.

The papers in this Special Report discuss 2 other problems that frequently occur in those with chronic pain: 

 (PTSD). We have known about the relationship between sleep disorders and chronic pain for years; however, the relationship between pain and PTSD is a more recent finding.

As with depressive and anxiety disorders, it is usually thought that if a sleep disorder is present in a person with chronic pain, the sleep issue is always secondary to the pain. However, this oversimplifies the relationship. The interaction between pain and sleep disorders is often a 2-way street, with each exacerbating the other. Both the pain and the sleep disorder need to be addressed.

Of course, the presence of any type of pain can impair sleep. Patients with peripheral diabetic neuropathic pain often report worse pain in their lower extremities during the night when they are trying to sleep. Those who suffer from complex regional pain syndrome in their lower extremities may complain that it is it painful to have sheets touch their skin due to allodynia, in which stimuli that do not usually cause pain do so. Patients with back pain often report problems with sleep due to pain although, curiously, laying down is the position they usually find most comfortable. In fact, if the pain is worse lying down, it is considered a red flag indicative of serious underlying pathology.

Similarly, disruption in normal sleep cycles can cause pain. More than 45 years ago, research found disruptive sleep in some healthy individuals precipitated the symptoms of fibromyalgia and resulted in widespread pain.

There are few studies on the treatment of comorbid pain and sleep disorders. Although both are commonly treated with medications, there is limited research on using pharmacologic agents when both problems are present. Most of the studies have looked at pregabalin in patients with fibromyalgia.

Opioids and benzodiazepines, medications that are frequently prescribed for patients with chronic pain, may actually exacerbate pain because they can cause hyperalgesia (eg, lower pain threshold). These agents can also exacerbate sleep disorders because of their disruption of normal sleep architecture. Sadly, many lay people and medical professionals mistakenly believe that the sedative side effects of these medications mean they will be beneficial for sleep.

There is much less research on chronic pain and PTSD, although there has been a growing interest in the past few years. 

A limiting factor of the data is that much of the research involves veterans. Due to the nature of our recent wars, many veterans suffer from painful injuries caused by explosions. They frequently suffer from traumatic brain injuries (TBI) of varying severity. In fact, both pain and sleep disorders have both been associated with TBI.

 Of course, few civilians who suffer PTSD have similar experiences, so the role TBI may play in the development of comorbid PTSD and chronic pain remains to be determined. 

In addition, research has shown that PTSD may not only be associated with both pain and sleep disorders, but also play a role in acute pain becoming chronic pain.

Since we have yet to identify a markedly efficacious treatment for PTSD, adding chronic pain as a factor further complicates care decisions. Furthermore, although there has been much speculation as to which factors predispose people to develop PTSD and chronic pain separately, we still have no final answer, and we have limited ability to predict who is at increased likelihood for developing both.

For all 3 problems—PTSD, sleep disorders, and chronic pain—psychologically based therapies appear to be among the most promising treatments. They also do not carry the same risks of exacerbating another condition as do medications.

Since psychiatrists often treat PTSD and even sleep, there is little doubt they will see patients with comorbid chronic pain. Unless psychiatrists also are knowledgeable about pain and its management, we will not be able to provide optimal care for our patients.

 is in private practice in Philadelphia.

This article was originally posted on October 21, 2020, and has since been updated. Scroll down for the 

 of the full print issue in which it appeared. -Ed

The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises.

2. Moldofsky H, Scarisbrick P, England R, et al. Musculoskeletal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and health subjects. 

3. Husak AK, Bair MJ. Chronic pain and sleep disturbances: a pragmatic review of their relationships, comorbidities, and treatments. 

4. Lavigne G, Khoury S, Chauny JM, et al. Pain and sleep in post-concussion/mild traumatic brain injury. 

5. Burns JW, Janssen, Lillis T, et al. The transition from acute to persistent pain: the identification of distinct trajectories among women presenting to an emergency department. 

Pain may not often be considered within the realm of psychiatry; however, chronic pain's relationships with sleep disorders and PTSD make it an issue psychiatrists can—and should—address.  

Psychiatry’s Role in the Management of Chronic Pain

Pain has a substantial impact on sleep, and an insufficient amount of restful sleep can increase pain susceptibility. Brief bouts of pain—such as pain due to a traumatic injury or a short-lived medical issue—can cause almost immediate adverse effects on daytime functioning and alertness. The symptoms can begin to manifest as soon as the day after a night of inadequate sleep. Chronic pain can lead to prolonged sleep deprivation that can have physical, emotional, and behavioral complications. For example, in the rheumatologic literature, it has long been noted that there is an association between chronic musculoskeletal pain, sleep disruption, and depression.

 More recent research attempts to elucidate the contributing factors and address treatment planning.

 is a benefit of effective pain management. A pain management strategy may also require dedicated attention to sleep quality and sleep quantity. Evaluation of sleep disturbances in the context of chronic pain requires a comprehensive assessment of subjective symptoms and objective tests, such as sleep questionnaires and an 

. Treatment of sleep issues caused by chronic pain is individualized and multifaceted and must take the chronic pain condition, the specific sleep disturbance, and the psychiatric sequalae into account.

Sleep disturbances caused by chronic pain

It is estimated that between 50% to 80% of those living with chronic pain experience sleep disruption. For example, a study revealed 53% of participants with chronic pain met criteria for insomnia, while only 3% of the pain-free controls met the criteria.

 There is also a potential a dose-response link between the intensity of pain and its impact on sleep.

Insomnia is the most commonly noted sleep disorder associated with chronic pain. A large meta-analysis noted a high prevalence of other sleep disruptions as well, with the 3 most common being insomnia at 72%, restless leg syndrome with a prevalence of 32%, and obstructive sleep apnea with a prevalence of 32%.

 It is notable that the 3 most commonly observed sleep disorders added up to greater than 100%, underscoring the fact that chronic pain can be associated with more than 1 type of sleep disturbance at a time (

There are several mechanisms by which pain interferes with sleep. Pain is an obvious distraction that makes it hard to fall asleep and can lead to waking up at night, especially when pain medication wears off. However, pain also interferes with the physiology of sleep in targeted ways that go beyond the conscious distraction caused by the discomfort. There is a variability in chronic pain diagnoses, and the distinctive types of pain syndromes affect sleep differently. Furthermore, the impact of chronic pain on sleep appears to be multidimensional. Research into various pain syndromes and their physiological impact on sleep provide a range of insights into the ways that pain interferes with sleep.

For example, acute post-surgical pain also has quantifiable effects on sleep, including a measurable decrease in the time spent in the 

 (REM) of sleep. Changes are noted not only after general anesthesia, but also after regional anesthesia.

 This observation suggests that the pain itself (rather than the general anesthetic wearing off) is at least a contributing factor to post-operative pain-associated sleep disturbances.

Fibromyalgia is frequently associated with sleep disturbances.

 Patients with fibromyalgia have reduced short-wave sleep and abnormal α-rhythms, with episodes of wakefulness during non-REM sleep.

 Daytime fatigue and non-restorative sleep are common complaints among patients who have fibromyalgia, and these polysomnogram findings are consistent with inadequate sleep quality, even when patients might seem to have slept for an adequate number of hours.

Neuropathic pain is also associated with sleep disturbances, and there is a strong bidirectional relationship between sleep disturbances and neuropathic features of pain.

Sleep disturbances are common among patients who have chronic, recurrent headaches. Common headache types, including tension headaches and migraines, often have associated symptoms besides pain, including sleep disturbances.

 As with fibromyalgia, the amount of time spent sleeping is not necessarily diminished in patients who have headache-associated sleep disturbances. Instead, it is the restorative effects of sleep that are impacted by chronic headache pain, rather than the total amount of sleep per night. The features of sleep disturbances can also vary with different types of headaches.

Sleep disturbance also can affect a person’s response to pain. As sleep stages are compromised, daytime pain increases through a process of hyperalgesia, in which lower pain stimuli result in higher pain perception and greater pain-associated impairment than would be expected otherwise.

According to research in patients with fibromyalgia, sleep deprivation impairs pain-inhibition pathways that normally help control pain.

 Studies also suggest that sleep deprivation can lead to systemic inflammation that can amplify pain.

 The evidence does not suggest that sleep deprivation can independently cause pain; rather, sleep deprivation may amplify the perception of pain that is already occurring as a result of underlying causes.

It is important to note that, while there is a strong association between sleep disorders and chronic pain and mood disorders, it is very difficult to determine which of these has a stronger impact on the others.

Psychiatric consequences of pain-related sleep disturbances

A number of psychiatric sequelae can complicate pain-induced sleep disturbances. There is a strong relationship between chronic pain that is associated with sleep disturbances and subsequent diagnoses of depression and anxiety.

 Other psychiatric issues, such as delusions, hallucinations, or mania are not commonly noted with pain-induced sleep disturbances.

Studies looking at neuropathic pain suggest that inflammation may be associated with psychiatric changes and behavioral alterations.

 However, experts are not completely sure whether there may be other contributory factors as well, and future research regarding the etiology of psychiatric disturbances in pain-induced sleep disturbances may answer some of the currently unanswered questions about these complex relationships.

Regardless of the exact molecular cause, psychiatric diagnoses of anxiety or depression can cause severe patient distress and may also lead to behavioral changes. These issues must be addressed in the clinical setting so that patients can have access to symptom relief and an improved quality of life.

Because of the bidirectional relationship between pain and sleep disturbances, experts recommend evaluating patients who have chronic pain for undiagnosed sleep disorders.

 Evaluation can include commonly used sleep questionnaires, such as the Mini Sleep Questionnaire (MSQ), the Pittsburgh Sleep Quality Index (PSQI), and the Epworth Sleepiness Scale. Objective measures include polysomnogram, Multiple Sleep Latency Test (MSLT), and Maintenance of Wakefulness Test (MWT). Additionally, screening tests for depression and anxiety are often necessary as well. Key components of the evaluation include diagnosing the sequelae of pain in addition to diagnosing the pain syndrome.

The treatment of pain has far reaching effects beyond pain control. Yet, managing pain-related sleep disturbance is not based on pain management alone. Interventions directly aimed at treating sleep disturbance are associated with a better outcome than interventions aimed at only treating the pain.

Currently, very little research has been done on the optimal treatment of sleep disorders in patients with chronic pain, and there is a lack of formal guidelines for approaching the problem. Research is emerging, however, and some experts recommend tailoring sleep care to the specific patient, rather than using a general approach to managing sleep disturbances for patients in whom chronic pain is believed to be the cause of the sleep problem.

 Some authors even suggest that chronic pain is a triad that includes pain, sleep disturbance, and depression.

There are a number of different treatment approaches for pain-associated sleep disturbances, including cognitive behavioral therapy, medication, and respiratory support during sleep for patients who need it.

 Treatment of chronic pain should always take sleep issues into consideration. Opioids, for instance, can alter sleep architecture, and while there are many disadvantages to long-term use of opioids for treating chronic pain, there are rare situations in which they are prescribed. This treatment can be especially problematic for patients who have respiratory sleep disorders, like sleep apnea. Given the complicated balance involved in chronic pain management, opioids might still be an appropriate part of the treatment plan for certain patients who have respiratory side effects. In these cases, the use of respiratory assistance, such as continuous positive airways pressure (CPAP) during sleep, may be an effective solution.

The overall approach to pain management that is complicated by sleep and psychiatric issues requires a tailored plan. It might or might not involve treatments for more than 1 diagnosis of the pain/sleep disturbance/depression triad. For instance, antidepressants might help with pain control and with mood stabilization. And anticonvulsants may help with pain control while also improving sleep.

 But, despite these obvious potential overlaps in treatment, some patients might benefit from optimal treatment approaches tailored to each diagnosis, even if completely separate treatments for each condition are required to achieve control of symptoms. Pharmacological interventions often must be selected based on the targeted symptoms. Even conservative management approaches, such as counseling, cognitive behavioral therapy, and physical therapy are most effective when they are symptom-specific, because the conservative approaches for treating each condition are not identical.

is Associate Editor Humanities in Neurology, Clinical Assistant Professor Case Western Reserve University School of Medicine, Div. of Medical Education, and Editor in Chief Emeritus of 

This article was originally posted on September 21, 2020, and has since been updated. Scroll down for the 

1. Moldofsky H. The significance of the sleeping-waking brain for the understanding of widespread musculoskeletal pain and fatigue in fibromyalgia syndrome and allied syndromes. 

2. Cheatle MD, Foster S, Pinkett A, et al. Assessing and Managing Sleep Disturbance in Patients with Chronic Pain. 

3. Mathias JL, Cant ML, Burke ALJ. Sleep disturbances and sleep disorders in adults living with chronic pain: a meta-analysis. 

4. Dette F, Cassel W, Urban F, et al. Occurrence of rapid eye movement sleep deprivation after surgery under regional anesthesia. 

5. Choy EH. The role of sleep in pain and fibromyalgia. 

6. Stocks J, Tang NK, Walsh DA, et al. Bidirectional association between disturbed sleep and neuropathic pain symptoms: a prospective cohort study in post-total joint replacement participants. 

7. Fernández-de-Las-Peñas C, Fernández-Muñoz JJ, Palacios-Ceña M, et al. Sleep disturbances in tension-type headache and migraine. 

8. Kundermann B, Krieg JC, Schreiber W, Lautenbacher S. The effect of sleep deprivation on pain. 

9. Marshansky S, Mayer P, Rizzo D, Baltzan M, Denis R, Lavigne GJ. Sleep, chronic pain, and opioid risk for apnea. 

Prog Neuropsychopharmacol Biol Psychiatry

10. Nicholson B, Verma S. Comorbidities in chronic neuropathic pain. 

11. Nijs J, Mairesse O, Neu D, et al. Sleep disturbances in chronic pain: neurobiology, assessment, and treatment in physical therapist practice. 

Sleep disturbance and chronic pain work together to cause misery for patients, with one exacerbating the other. Here: Tips to address both and bring peace to patients.

Sleep Disturbances as a Sequalae of Chronic Pain 

Pear Therapeutics has announced the availability of Somryst, the only US Food and Drug Administration-authorized digital therapeutic for chronic insomnia to date. (Read 

, MD, chief medical officer at Pear Therapeutics.)

“We’re excited to offer patients who have been struggling to find a long-term solution for chronic insomnia with a meaningful, first-line treatment,” Corey McCann, president and chief executive officer of Pear Therapeutics, said in a statement.

A prescription digital therapeutic (PDT), Somryst offers 6 to 9 weeks of cognitive behavioral therapy (CBT) via a tablet or smartphone. Clinical studies on the efficacy of this therapeutic have appeared in 

The prescription reduced the time needed to fall asleep by 45%, time spent awake during the night by 52%, and the severity of insomnia symptoms by 45%. Improvement continued 6 and 12 months after treatment.

At present 30 million Americans suffer from chronic insomnia, but McCann noted that treatment options are especially “important now, more than ever, as we continue to navigate the COVID-19 pandemic.”

Indeed, sleep disorders have soared during the pandemic. Nearly half of respondents to a Pear Therapeutics survey reported pandemic-related sleep loss. The number reporting poor sleep almost doubled (from 15% to 27%), and younger generations have been especially affected, with nearly one-third of Gen Z and Millennials admitting to poor sleep quality.

Digital prescriptions may be good options for patients who cannot access a clinician. “Despite CBTi being the recommended first line treatment for chronic insomnia, there aren’t enough clinicians who are trained to deliver CBTi therapy,” Michelle Primeau, MD, medical director of the Palo Alto Medical Foundation Sleep Medicine Center in San Carlos, CA, told the press. “Somryst has been shown to address the underlying issues of chronic insomnia by training the brain and body to fall asleep faster and stay asleep longer.”

Are your patients experiencing increased insomnia? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and may be edited for style.

Ritterband LM, Thorndike FP, Ingersoll KS, et al. Effect of a web-based cognitive behavior therapy for insomnia intervention with 1-year follow-up: a randomized clinical trial

Christensen H, Batterham PJ, Gosling JA, et al. Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial. 

Batterham P, Christensen H, Mackinnon A, et al. Trajectories of change and long-term outcomes in a randomized controlled trial of internet-based insomnia treatment to prevent depression. 

Potential relief for millions of Americans with pandemic-related sleep issues. 

A New Digital Therapeutic for Chronic Insomnia

The US Food and Drug Administration (FDA) granted a De Novo clearance to a prescription Apple watch and iPhone app meant to improve sleep quality for those with nightmare disorders or posttraumatic stress disorder-related nightmares.

 uses the watch’s sensors to track the user’s heart rate and movement as they sleep. A baseline profile is created for the patient within 1 to 2 nights of sleep. In this short time frame, the learning algorithm will spot heart rate of movement abnormalities likely caused by a nightmare. If the app senses a disturbance, the Apple watch will vibrate enough to interrupt the dream, but not enough to fully wake them up and disturb their sleep cycle.

“Sleep is an essential part of a person’s daily routine,” Carlos Peña, PhD, director of the Office of Neurological and Physical Medicine Devices in the FDA’s Center for Devices and Radiological Health, said to the press. “However, certain adults who have a nightmare disorder or who experience nightmares from PTSD are not able to get the rest they need. Today’s authorization offers a new, low-risk treatment option that uses digital technology in an effort to provide temporary relief from sleep disturbance related to nightmares.”

Data submitted to the FDA included information from a 30-day trial of 70 patients who were randomly assigned to receive either the NightWare app or a placebo app with no vibrations. While both groups self-reported improved sleep quality, the benefit was greater for those provided with the Nightware product.

Further trials are being conducted, one of which hopes to include 240 patients from several Department of Veterans Affairs hospitals. It is projected to finish in the second half of 2021.

“NightWare was founded and built to support veterans and active duty service members who have so unselfishly given of themselves to preserve our freedoms, and suffer emotional, physical and mental distress as a consequence of severe nightmares,” NightWare CEO Grady Hannah said in a statement. “Helping our current and past military members and all people with this condition is NightWare’s mission and we are excited to introduce this first and only therapeutic for nightmares. The use of the NightWare Therapeutic Platform provides an effective treatment for clinically significant nightmares; avoids drug side-effects; and reduces the need for time intensive and often-unavailable psychological therapy sessions.”

The NightWare therapy is currently available on a limited basis through physician recommendation, but will hopefully launch in the early months of 2021. It will require a prescription and is intended for use among adults aged 22 years or older. It is not recommended for patients who sleepwalk or have violent episodes during nightmares. It is also not recommended as a standalone treatment for PTSD.

1. NightWare. We won’t rest until those with PTSD can. Accessed November 13, 2020. 

2. Muoio D. FDA grants De Novo clearance to prescription Apple Watch app for nightmare disorder. 

https://www.mobihealthnews.com/news/fda-grants-de-novo-clearance-prescription-apple-watch-app-nightmare-disorder

A new prescription smartwatch app may improve sleep quality for those with nightmare disorders. 

A New Way to “Watch” Your Nightmares

Sleep apnea, according to Dr Miller, is extraordinarily common. A big takeaway of his: CPAP works, but only if you use it. 

is a physician and entrepreneur who has founded and held senior positions at 11 companies in healthcare/life sciences over the last 30 years. He is currently co-founder, CEO and Chair of Apnimed, Inc in Cambridge, MA. Previously, he was co-founder and CEO of Macrolide Pharmaceuticals, Inc. His other companies include HPR, PharMetrics, Serenex and Tetraphase; all have been acquired except Tetraphase, which is publicly traded. He has also been an investor in more than 15 healthcare/life sciences companies, first at Hambrecht & Quist Capital Management and subsequently as co-founder and partner at the Mediphase Funds. Previously, he led a neurochemistry laboratory at Tufts University and has published nearly 100 scientific papers. He received his AB and MD at Harvard and completed clinical training at the Massachusetts General Hospital and Harvard Medical School. He is Board certified in Internal Medicine, Pulmonary Disease, and Clinical Pharmacology.

Larry Miller, MD, CEO of Apnimed, discusses the ins and outs of sleep apnea.

Treating Obstructive Sleep Apnea 

Over 30 million Americans live with diagnosable chronic insomnia. It can impair their everyday functions when awake and affect their mood. Chronic insomnia is also a risk factor for other chronic illnesses and psychiatric disorders (up to 40% also have depressive symptoms).

Existing pharmacological treatments are designed for short-term use, which may not be enough to combat a long-term illness. In this Mental Health Minute, Yuri Maricich, MD introduces Somryst, the first FDA-authorized prescription digital therapeutic (PDT) for treating chronic insomnia. It is a 9-week program that is accessible through mobile devices, including smartphones and tablets. He discusses two studies on the effectiveness of this new PDT.

(Note: in the video, Dr Maricich says that the FDA authorized Somryst in 2023. The FDA authorized it in 2020.)

A new treatment has been found effective for treating a common sleep disorder.

Introducing the First FDA-authorized Prescription Digital Therapeutic for Chronic Insomnia

Primary insomnia is a decreased ability to fall asleep and/or stay asleep, with resulting daytime effects of sleep deprivation, such as fatigue, dozing off, and irritability. The sleep problems of primary insomnia are not associated with lifestyle habits or a medical or psychiatric cause. Primary insomnia is diagnosed using DSM-5 and the International Classification of Sleep Disorders, 3rd Edition (ICSD-III) classification 

 Primary insomnia is a type of chronic insomnia as defined by the ICSD-III, and it tends to persist or recur for many years throughout a person’s life, often beginning during childhood.

This type of insomnia is usually idiopathic, although it can be impacted by mild to moderate stress. Primary idiopathic insomnia occurs without any identifiable cause and in the absence of anxiety. And people who have a history of primary insomnia may also have episodes of sleep state misperception (SSM), also known as paradoxical insomnia. With paradoxical insomnia, a person feels that they are experiencing insomnia, although they are getting enough sleep and don’t experience daytime signs of sleep deprivation. SSM is believed to affect 9% to 50% of the adult population, and it is 

 among people who also have bouts of primary insomnia.

Primary insomnia has 3 subtypes: idiopathic, stress-related, and SSM. Idiopathic insomnia is truly without any identifiable contributory factor, while stress-related insomnia can be characterized by mild stress, such as rumination or other thoughts throughout the night. Someone who has had episodes of idiopathic insomniacan also experience worsening symptoms when dealing with mild stress or can experience SSM during phases of adequate sleep.

The frequency of sleep symptoms can vary—primary insomnia can occur occasionally or frequently, and it can affect someone for just 1 night at a time or for many nights in a row. An individual affected by the condition can have trouble sleeping, may toss and turn in bed, or may get up from bed at night. Symptoms can also include 1 or more episodes of waking up during the night, often for less than an hour in total. People who have primary insomnia may be very concerned about the causes and effects of not getting enough sleep, and anxiety about sleep can exacerbate the insomnia.

A diagnostic work-up of insomnia includes a medical history, physical examination, and diagnostic tests. Daytime symptoms can include restlessness, feeling tired, falling asleep easily during waking hours, trouble concentrating, moodiness, and sadness. These symptoms are not usually present in SSM. A sleep study may show delayed sleep latency, sleep fragmentation, decreased sleep efficiency, and 

total sleep time in patients who have idiopathic primary insomnia.

 A sleep study would not be expected to show any abnormalities in SSM.

Treatments for primary insomnia include lifestyle modification, therapy, and prescription medications. Non-medical therapies include counseling, cognitive behavioral therapy, biofeedback, avoiding naps or inconsistencies in sleep schedule, managing caffeine and alcohol intake, and avoiding stimulation from factors like bright lights before sleep.

 Medications commonly used for the treatment of primary insomnia 

benzodiazepines, antihistamines, and melatonin

A 42-year-old woman complains that she isn’t sleeping well at night. Although she is in good health, she reports that she has had trouble falling asleep for as long as she can remember. She recalls being tired in the mornings when she was a child, during her teenage years, and throughout her adult years. This is not related to stress, as she says she had always been even tempered and ambitious, and she isn’t prone to anxiety.

Her current sleep pattern is that she tosses and turns for hours before falling asleep, sometimes wakes up during the night around 4 AM, and generally falls back asleep until her alarm clock wakes her at 6:30 AM. At home, sounds of rain or cars outside wake her from sleep. And when she stays in a hotel, the sound of other people talking or shutting doors wakes her up.

She is a chemist and works full time as a vice president at a manufacturing company. She has a regular 8 to 5 schedule, working from home several days per week for the past several years. This practice is consistent with her company culture because most of the work involves communicating electronically. She says that sometimes she gets very tired during the day, but she works through the fatigue because she does not want to prolong her workday.

She then prepares dinner for her children and husband. After dinner, she usually takes a walk or exercises and later watches television with her family. She has a daughter who is attending college abroad for the year, and two kids in high school. The family often calls their college student daughter in the evening. The patient generally goes to bed around 11 PM after picking up around the house. Overall, although she is busy, she says she doesn’t have anything especially stressful going on in her life.

The patient is having an evaluation of insomnia at the urging of her daughter, who is studying pre-health classes in college. The main concern that she expresses is whether her insomnia could be caused by a health problem or whether she could be at risk of developing chronic health issues due to lack of sleep.

The patient’s physical examination was normal. She had a complete blood count and electrolyte blood levels that were normal. She had a home sleep study, which showed diminished sleep quality and delayed sleep latency, without evidence of issues like sleep apnea. She was presumptively diagnosed with primary insomnia, which was considered to be idiopathic.

She was offered the option of taking medication for her insomnia. She instead asked about whether there are any natural therapies, such as herbs, that she could take. In fact, there have been studies suggesting that herbal treatment may have an effect on insomnia. In one 

evaluating 50 patients, use of oil extracts for 8 weeks was associated with a reduction in scores on the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI).

 However, one challenge with using herbal remedies for treatment of insomnia is that there isn’t a consistent protocol or safety and efficacy profile when it comes to the products. In fact, very 

Her doctor suggested that she begin with lifestyle strategies that include avoiding looking at electronic devices for several hours before sleep, avoiding caffeine after noon, and adopting a more consistent exercise schedule. After a month, she did not experience improvement of her symptoms and asked to try prescription medication. Her doctor gave her a prescription for temazepam. After 1 month, she was pleased with the results, but she was concerned about the potential for addiction, so she asked if she could switch to melatonin. Her doctor gave her a schedule to taper the prescription and wanted to reevaluate the situation before starting the patient on another medication. After she discontinued the medication, the patient felt she was still getting better quality sleep and felt less tired during the day. The decision was made to hold off on any new medications as long as her symptoms were not troublesome.

• Patients who have primary insomnia might be concerned about medical causes of insomnia. Often, ruling out underlying causes can be a great relief for patients.

• Herbal treatments and alternative therapies may be beneficial in the management of primary insomnia, but doses and adverse effects are not well established.

• Treatment of chronic insomnia can be more effective when the patient is given several treatment options and has a voice in the plan.

• Sometimes temporary treatment can be effective for a bout of chronic primary insomnia that’s idiopathic.

 is Adjunct Professor at John Carroll University, and Instructor, Case Western Reserve University in Cleveland, OH. She is the editor in chief emeritus of 

1. Momin RR, Ketvertis K. Primary Insomnia. 

 Treasure Island (FL): StatPearls Publishing; 2020. 

https://www.ncbi.nlm.nih.gov/books/NBK554516/

2. Martucci M, Conte M, Ostan R. Both objective and paradoxical insomnia elicit a stress response involving mitokine production. 

https://pubmed.ncbi.nlm.nih.gov/32420904/

3. Melo DLM, Carvalho LBC, Prado LBF, Prado GF. Biofeedback Therapies for Chronic Insomnia: A Systematic Review. 

https://pubmed.ncbi.nlm.nih.gov/31123938/

4. Taherzadeh Z, Khaluyan H, IranshahyM. Evaluation of sedative effects of an intranasal dosage form containing saffron, lettuce seeds and sweet violet in primary chronic insomnia: A randomized, double-dummy, double-blind placebo controlled clinical trial. 

https://pubmed.ncbi.nlm.nih.gov/32736046/

5. Akram M, Daniyal M, Munir N, et al. Medicinal Plants Combating Against Insomnia: A Green Anti-Insomnia Approach. 

https://pubmed.ncbi.nlm.nih.gov/31663928/

When provided with an array of treatment options, patients tend to feel a sense of ownership by playing a role in their care. 

Primary Insomnia: A Lifelong Problem

Ten sleep specialists assessed widely accepted beliefs and here's what they found.

Sleep Disorders