Primary Insomnia (learned Insomia)

In the past it was common to make the distinction between primary and secondary insomnia. In primary insomnia the difficulty with sleep is the “core” problem. In secondary insomnia, the disturbed sleep is due to other specific problems, for example body clock disorder, substance abuse or depression. The distinction is however somewhat artificial and blurred. As mentioned in the previous chapters a component of “learned insomnia” is common to all forms of insomnia.

Primary insomnia describes a chronic insomnia where the psycho-physiological mechanism explained in the previous chapter (IO) is a predominant issue. This refers to a state of increased arousal that tends to interfere with continuity of sleep. This kind of insomnia is also referred to as learned insomnia.

Mr. SP is a 37 year old father of 2 boys and a manager of a local club. He is a non-smoker and he drinks up to 10 standard drinks/week. He is on 2-3 coffees/day. He is a fairly healthy man otherwise who at the time of the assessment has been using intermittently Restavit™ or Phenergan™ (both have an anti-histamine effect to help sleep). He presented complaining of lack of sleep, poor sleep quality and daytime fatigue. He is on no regular medication. He describes being unable to initiate sleep and stay asleep on and off for many years but more prominent in the last 12 months. It was obvious that the worsening of his sleep problem was linked to his job. Because of reduction in the activity and the earning of the club there was concern about the future of the industry and most uncertainty about his own future in the job. It was not uncommon for SP to have difficulty switching off at night and waking up through the night and thinking about his work.

He would normally go to bed between 9-10pm falling asleep sometimes within 30 minutes but sometimes it would take a few hours to fall asleep. He rarely fell sleep after midnight. He would wake up 3-4 times per night usually for prolonged periods and he had difficulty going back to sleep. He was a snorer but there were no features suggestive of sleep apnoea (snoring and stopping breathing). He was a restless sleeper who would get up between 6.15-6.45am depending on the day of the week. He would not take a nap through the day but he could occasionally on weekends. He has been drowsy driving long distances and watching television.

Despite the reported difficulties at work he had no evidence of anxiety or depression.

One of the main complaints from SP was the level of tiredness mostly mental tiredness during the day, with inability to concentrate for prolonged periods.

We spent a good time of our meeting discussing how, in his case, sleep was more likely to be affected by the circumstances he was finding himself in compounded by his personality, being a person who tends to be hyper-alert and with difficulty switching off. We also discussed how, in his case, circumstances during the day, specifically the uncertainty in his job, the pressure from management to make the club profitable, the potential risk of losing his job and his income were the primary movers of his poor feeling during the day and indirectly affecting his night time sleep. By the same token not being able to sleep well would make him feel worse during the day in what becomes a vicious cycle.

We stressed the importance of awareness of the daytime issues expressed above. He implemented restriction of time in bed going to bed around midnight and getting up no later than 6am for the first two weeks together with the use of Melatonin (3mg) about 9pm. He also understood the importance of relaxation and meditation. An appointment was made to review him in about 4 weeks.

At follow-up there was some improvement in his sleep continuity but not as satisfactory as he would have expected. He was unable to spare the time for relaxation and meditation because he was too busy and he relied on the medication more than we had planned. The issues discussed in the first encounter were revisited and in particular the importance of having some strategy and some alternative in case his occupation as a manager of a club was in doubt and at risk.

Although he felt that his job was not at risk, we discussed the importance of having a strategy and alternative in the worst case scenario. Again the importance of a critical review of daytime in order to improve bedtime and sleep was emphasized. He continued with restriction of time in bed and the use of Melatonin. After a further 4 weeks he underwent a formal sleep study that showed regular bedtime around 11.30pm and sleep until 6.30am. There were a couple of awakenings in the middle of the night for about 10 minutes but he perceived he had been awake for almost an hour on both occasions. This is not uncommon and is referred to as sleep misperception. This is to say that the subjective feeling of the person of being awake is much longer than what actually happened which is very much in keeping with an element of hyper-arousal (see page).

Mr. SP continued with restriction of time in bed maintaining bedtime no earlier than 11.30pm.