Insomnia: Symptom or Distinct Disorder?

Primary and secondary insomnia stem from different issues

/ Author:  / Reviewed by: Robert Carlson, M.D Chris Galloway, M.D. Beth Bolt, RPh

Tossing, turning, trying desperately to get to sleep but feeling wide awake. For most people, these can be signs of one poor night's sleep. But for people with insomnia, these restless feelings become all too familiar and routine.

According to the National Sleep Foundation (NSF), insomnia (the inability to fall asleep or remain asleep) is the most common sleep problem experienced by Americans. The foundation reports that around 30 to 40 percent of adults report some insomnia symptoms within any given year, and around 10 to 15 percent report chronic insomnia.

Symptoms of insomnia can include issues like trouble falling asleep, waking up often during the night, problems getting back to sleep, waking up too early the next morning, feeling unrefreshed after a night's sleep, feeling sleepy during the day, problems concentrating and issues with moods and irritability. 

In some cases, symptoms of insomnia may appear for one night or a few nights (acute insomnia), while in other cases they can linger for longer than a month (chronic insomnia).

According to NSF, it is rare for trouble sleeping to last for extended periods of months or years. "More often, people experience chronic-intermittent insomnia, which means difficulty sleeping for a few nights, followed by a few nights of adequate sleep before the problem returns," the foundation reports.

Insomnia is a wide-ranging issue; in some cases, it can be a side effect or a symptom of a different issue (called secondary insomnia), but in other cases it is a separate condition in its own right (called primary insomnia).

"In most cases insomnia is multifactorial," said Robert Rosenberg, DO (Doctor of Osteopathic Medicine), of The Sleep Disorders Centers of Prescott Valley and Flagstaff in Arizona, in an interview with dailyRx News.

"Insomnia can be associated with medical and psychiatric issues which is the case in secondary insomnia," explained Dr. Rosenberg. "Or it can be due to long term stress and the development of poor sleep habits, in the case of primary insomnia."

"If you have difficulty sleeping, it is essential to determine whether an underlying disease or condition is causing the problem," NSF reports. By discovering possible underlying issues, insomnia can be more effectively addressed.

Secondary Insomnia

When secondary insomnia is at play, the range of possible contributing issues is wide. Other medical issues, sleep disorders, neurological problems or emotional struggles can cause this form of insomnia.

According to The National Heart, Lung, and Blood Institute (NHLBI), examples of emotional disorders that can cause insomnia include depression, anxiety and post-traumatic stress disorder (PTSD).

Neurological disorders that can lead to insomnia include Parkinson's disease and Alzheimer's.

The list of other conditions that can cause insomnia is long and varied. Examples include conditions with chronic pain (like arthritis), conditions that involve difficulty breathing (like asthma), gastrointestinal disorders (like heartburn), sleep disorders (like restless legs syndrome) and menopause.

"Often times, insomnia exacerbates the underlying condition by leaving the patient fatigued and less able to cope and think clearly," NSF explains.

The foundation recommends that in cases of secondary insomnia relating to a medical issue or pain, that patients discuss the possibility of nighttime pain aids with their doctor. This may help them find some relief and sleep easier at night. 

Substances and medications can also be a cause of secondary insomnia. Certain allergy medicines, asthma medicines and medicines for heart conditions can all be involved, says NHLBI. Even everyday substances, including caffeine, tobacco and alcohol, can contribute to insomnia.

Primary Insomnia

In cases of primary insomnia, the sleeping troubles are not caused by a different condition or issue, but rather develop on their own, as a unique disorder.

According to NHLBI, the causes of primary insomnia are not well understood and researchers are still trying to learn more, like if certain people are born with a greater risk for primary insomnia. 

"Many life changes can trigger primary insomnia. It may be due to major or long-lasting stress or emotional upset," says NHLBI. "Travel or other factors, such as work schedules that disrupt your sleep routine, also may trigger primary insomnia."

According to NSF, half of people who have experienced insomnia blame issues like worry and stress. "In the case of stress-induced insomnia, the degree to which sleep is disturbed depends on the severity and duration of the stressful situation," NSF says.

Troubles like tragedies or job loss may spark insomnia, as can eager anticipation for positive events, like an upcoming wedding or trip.

Even if sleep schedules are normalized, the insomnia may persist after it has been triggered. Bad habits relating to sleep can only add to the issues. As people cope with insomnia, they may begin to worry about being able to sleep, take too many naps, go to sleep too early, etc. All of these issues can compound and make the primary insomnia persistent. 

Diagnosing Insomnia

In diagnosing the condition, doctors will likely take both potential kinds of insomnia, primary and secondary, into consideration. According to NHLBI, patients will often need to complete medical histories, sleep histories and undergo a physical exam. Sleep studies are also sometimes used to help determine the cause of insomnia. 

Medical histories may include topics like injuries, ongoing health issues, medications used, mental health issues like depression or anxiety, stressful life events and questions about daily work and lifestyle routines, including exercise, travel and substances used.

Sleep histories may cover topics like typical bed times and rising times, the number of awakenings during the night, snoring, dozing off during the day, worrying about sleep and bedroom habits like nighttime routine, bedroom lighting and TV watching. 

"To help your doctor, consider keeping a sleep diary for 1 or 2 weeks," NHLBI recommends. "Write down when you go to sleep, wake up, and take naps. (For example, you might note: Went to bed at 10 pm; woke up at 3 am and couldn't fall back asleep; napped after work for 2 hours.)"

By cooperating during this rather thorough process, patients can work with their doctors to determine any potential underlying causes for the insomnia. If secondary insomnia is determined to be at play, then the root issue can also be addressed, hopefully helping the patient get a better night's rest.

For both forms of insomnia, there are many treatment options, including medication, cognitive behavioral therapy and lifestyle changes. Patients can work with doctors to determine the best method of treatment in their unique case.

"The take home message is that with a thorough medical and sleep evaluation insomnia can be diagnosed and treated," noted Dr. Rosenberg.

Review Date: 
August 16, 2013