Q3. Insomnia can both be a symptom and a disorder.

The symptom of insomnia is the complaint of difficulty falling asleep, difficulty staying asleep, or poor quality sleep. In the DSM-IV (APA, 2000), insomnia symptoms are part of the diagnostic criteria for a number of mental disorders, including major depressive disorder and generalised anxiety disorder. Primary insomnia disorders are characterised by insomnia symptoms along with significant distress or impairment. In the DSM-IV, for a diagnosis of primary insomnia to be given, the symptom must last for at least 1 month and do not occur exclusively during the course of another sleep disorder, mental disorder, or medical disorder or result from the use of substances or medications. Insomnia can also occur in the presence of another disorder. That is, insomnia that causes significant distress or impairment or warrants independent clinical attention but is believed to be directly related to a coexisting mental disorder or medical disorder or to the effects of substances of medications. Insomnia was reported to be the most common psychological health problem (Canals, 1997). The prevalence of insomnia in the general population was found to be 18.6% (Ohayon et al., 1996). Ohayon and colleagues (1996) conducted a study where lay interviewers telephoneinterviewed 5622 subjects from the French population. 12.7% of the sample had insomnia complaints that affected their daytime alertness and lasted for at least a month. According to the DSM-IV diagnostic criteria, 5.6% of the sample was identified to have insomnia related to another mental disorder (mostly insomnia related to a major depressive episode), and 1.3% of the sample diagnosed with primary insomnia. Out of the sample that had insomnia complaints, 8.4% of them were also diagnosed with a primary mental disorder; the most common diagnosis was GAD. The DSM-IV field trial for sleep disorders (Buysse 1994) reported that the most common sleep diagnosis was insomnia related to mental disorders (46%), and the next most common diagnosis was primary insomnia (22%). The clinicians agreement on the diagnosis for these two disorders however, is only modest. This indicates that clinicians may not always clearly identify the boundaries between the two disorders. The findings from these studies underscore the importance of needing to distinguish the difference between primary insomnia and insomnia related to another medical disorder. Howell et al., 1997 conducted a study to examine the difference between primary insomnia and insomnia related to mental disorders. 216 participants were referred or self referred to 5 different sites and were interviewed by 5 sleep disorder specialists. After the interview, the clinicians rated how much they thought different factors were important to the sleep complaint each client presented. Poor sleep hygiene and negative conditioning were found to be related to primary insomnia. Good sleep hygiene is daily living activities that help to maintain good quality sleep and daytime alertness. Examples of poor sleep hygiene may include excessive alcohol use, spending excessive amounts of time awake in bed, and not allowing time for relaxation before bedtime. Negative conditioning is the worries about not being able to fall asleep, frustration related to sleeplessness and external cues that can elicit arousal. For insomnia related to mental disorders, psychiatric disorder was the only contributing factor that was significantly different to the primary insomnia. Amongst the psychiatric disorders, the identified disorders were mood disorders (63%), anxiety (10%), personality disorder (10%), adjustment disorder (4%), a psychotic disorder (4%) and various other diagnoses (8%). Perlis (2001) compared EEG activity of participants in three different groups (primary insomnia, insomnia related to major depression, and controls who had no sleep disturbances and found sleep to be restorative). These groups each had nine participants and they were matched for age, body mass and gender. This study reported that individuals with primary

insomnia displayed more beta-1, beta-2 and gamma activity at/around sleep onset and during NREM sleep than individuals from the other two groups. For the total sleep time and sleep latency (time to fall asleep), the PI subjects reported less sleep and longer time needed to fall asleep than the polysomnographic (PSG) measures of sleep. The beta activity significantly correlated with these subject-objective discrepancy scores. This suggests that high frequency EEG activity evident in individuals with insomnia is related to perception of sleep quantity and quality. Although Gamma activity is also related to cognitive processes, it may be associated with different aspects of information processing to Beta. E.g. Beta may be related to long term memory while Gamma relates to sensory processing and attention. Further research is required to identify the brain regions that generated these Beta and Gamma activities. Similarly, another study (Staner et al., 2003) compared individuals with primary disorder to healthy controls and insomnia related to major depression. It was found that during sleep onset individuals with primary insomnia did not have a progressive reduction of their alpha and beta power, and five minutes before sleep onset, they had a lower delta activity than the other two experimental groups. During the first non-REM period, participants with insomnia related to depression had fewer changes in slow wave activity. These results suggest that hyperarousal may explain the difficulties primary insomniacs face when trying to fall asleep. The reason why depressive insomniacs have trouble with sleep initiation may be due to the lower sleep pressure (early appearance of REM sleep and lowering of slow wave activity in non-REM sleep). Benca (2008) outlined how different psychiatric disorders can have varying patterns of sleep disturbances. It was reported that mood disorders have a reduced total sleep time, reduced sleep continuity, reduced slow wave sleep and increased REM sleep. Summary: Better understanding of the difference between primary insomnia and insomnia related to another medical disorder will help ensure correct diagnoses and identification of the most appropriate treatment. Preliminary findings from studies using EEG and PSG have revealed the presence of distinctive brain activity and sleep structure in individuals with primary insomnia compared to individuals who have insomnia related to major depression. The use of EEG and or PSG may then aid future diagnosis of insomnia