Insomnia refers to the complaint of difficulty falling asleep, frequent or prolonged awakenings, inadequate sleep quality, or short overall sleep duration in an individual who has adequate time available for sleep. Insomnia is not defined by polysomnography or a specific sleep duration. Because insomnia occurs only when there is adequate opportunity for sleep, it must be distinguished from sleep deprivation, in which the individual has relatively normal sleep ability but inadequate opportunity for sleep. An insomnia disorder is a syndrome consisting of the insomnia complaint together with significant impairment or distress. Common daytime impairments associated with insomnia include mood disturbances (irritability, mild dysphoria, or difficulty tolerating stress), impaired cognitive function (difficulty concentrating, completing tasks, or performing complex, abstract, or creative tasks), and daytime fatigue (Moul et al. 2002). Clinicians are often taught that insomnia is a symptom rather than a disorder and that it is almost always "secondary." However, based on consistencies in clinical features, course, and response to treatment, a recent National Institutes of Health conference suggested that "comorbid" insomnia may be a more appropriate term than "secondary" (National Institutes of Health 2005).

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FIGURE 22–6. Heuristic model of the development of insomnia.This behavioral model of insomnia proposes that individuals have varying predisposition for insomnia and that specific precipitating factors will lead vulnerable individuals to cross the insomnia "threshold." Behavioral factors lead to perpetuation of the insomnia after the original precipitants have receded. The y axis indicates sleep disturbance (higher numbers = worse), and the x axis represents successive stages of insomnia.Source. Adapted from Spielman AJ: "Assessment of Insomnia." Clinical Psychology Review 6:11–25, 1986.
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TABLE 22–5. Cognitive-behavioral interventions for insomnia
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TABLE 22–6. Benzodiazepine receptor agonists: pharmacokinetics
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TABLE 22–7. Summary of other drugs used to treat insomniaa


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