Sleep disorders are a common reason for seeking medical attention, particularly difficulty achieving regular, restorative, or uninterrupted sleep (insomnia). The management of this problem must take into account an important initial factor, namely the diagnosis. Insomnia can rarely be classified as an isolated disorder, that is, without other symptoms suggesting disorders of a different kind. Above all, even when it appears to be an isolated phenomenon, it can be a sign of vulnerability to other disorders that may develop over the following months.
Insomnia is usually classified as initial insomnia (difficulty falling asleep), middle insomnia (broken sleep with one or more interruptions of varying duration), and terminal insomnia (early awakening with an inability to fall back asleep). This distinction does not identify different diseases, but it is useful because these patterns are characteristic of different disorders.
The disorders in which insomnia most commonly occurs as a current, preliminary, or residual symptom include various anxiety disorders (panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and others) and mood disorders (bipolar disorder and depression).
Sometimes it is not so much the duration of sleep that is altered, but rather its timing. Instead of roughly coinciding with nighttime hours, sleep is shifted later: the person is awake and active at night, or simply cannot fall asleep even though they are not doing anything particularly stimulating, while they are tired and sleep in the morning. This can interfere with work, study, social life, and the need to plan activities during the day.
At other times, both the duration and timing of sleep are within the normal range, but the sleep is not restorative. It does not provide sufficient rest, regardless of whether the person goes to bed earlier or later in the evening, or of the type of activities they engage in during the day.
Excessive sleep is less common. It occurs mainly in certain forms of depression, traditionally described as atypical depression, as a residual symptom following episodes of elevated or activated mood that have subsided, or as a side effect of certain medications. Beyond the abnormal duration of sleep—whether it is short, delayed, or fragmented—the characteristic feature of depressive sleep is that it is not restorative.
It is often disturbed by nightmares that remain very “vivid” even after awakening, as though they had left an anxious or depressed imprint on the day, or by dreams that reproduce the worries and fears experienced during the day.
Waking up, often prematurely at dawn, with anxious thoughts and distress about the day ahead makes nighttime feel threatening: it becomes a period that is useless for resting, but rather an illusion before awakening to face the same fears and negative thoughts.
People experiencing depression often seek sleep, sometimes even artificially, as a way of escaping from the day, during which they feel unable to do anything and are forced to think anxiously. The evening may therefore become a moment of relative tranquility, but this tranquility tends to disappear after the first few hours of the night.
Anxiety-related sleep can involve various disturbances, but it often causes difficulty falling asleep and repeated awakenings accompanied by thoughts about ongoing, unresolved problems or about things that are looming in the days ahead.
There is also a different condition that is not technically insomnia: the “fear of insomnia,” or nighttime anxiety.
In the first case, the person is worried about being unable to sleep, fearing that they will not function properly mentally the following day, that they need to sleep in order to cope with the day, or that they must fall asleep by a certain time because otherwise they will no longer be able to fall asleep, and so on.
All of this develops into an obsessive attempt to control sleep, which obviously only delays sleep onset and facilitates dependence on sleeping pills.
Nighttime anxiety, on the other hand, refers to the presence of anxiety symptoms during nighttime hours, including difficulty initiating a continuous sleep process, even though the person may in fact sleep and function normally during the daytime.
Awakenings are particularly distressing and agitated, often sudden, and may be accompanied by “empty” nightmares—falling, suffocating, being unable to go back, fleeing, and so forth—which seem to represent a primitive expression of a state of alarm.
Insomnia is, of course, the main reason for the use of sleep-inducing medications.
Using these medications for several weeks often leads to “sleeping-pill dependence,” meaning a tendency to use these products with the belief that they are controlling one’s sleep, even though their actual effect may have worn off and sleep remains problematic.
Dependence is generated by two factors.
The first is that, after becoming accustomed to the medication, stopping the sleeping pill produces a temporary withdrawal syndrome, meaning anxiety and insomnia that are worse than they were initially.
Although withdrawal is temporary, the person may become strongly attached to the fear of not sleeping and may find it difficult to let that fear pass, or to gradually reduce the medication while trusting that normal sleep will eventually return without it.
The second reason is that some sleeping pills can automatically convince the brain of their “goodness,” so that the person comes to perceive them as something they cannot do without.
Officially, the explanation is that “without it I don’t sleep,” but in reality the thought of taking the medication may arise even before the person knows whether they will sleep or not, or even if they continue to sleep just as poorly as before: the mind simply says that it is better to take it.
In most cases, doses remain within the “normal” doses specified in the package instructions. In some cases, however, they are increased dramatically, with side effects affecting mood, anxiety, memory, and aggression.
A particular form of sleeping-pill dependence, associated with fast-acting, short-duration sleeping pills, is “sleeping-pill insomnia.”
A fast-acting sleeping pill is particularly appealing because it initially makes the person sleep “on command,” and if it is short-acting, it allows them to wake up without feeling groggy in the morning.
After the first few weeks, however, tolerance develops. Before taking the sleeping pill, the person tends to become anxious, and when its effect wears off, they tend to wake up and become anxious again.
At this point, they often take another dose.
When the effect of the second dose wears off, the anxiety and awakening coincide with morning. Sleep is nevertheless often fragmented and non-restorative, and anxiety is greater during the day.
In this situation, the person alternates between a relative nighttime normality—which they attribute to the effect of the medication—and daytime withdrawal, which is then interrupted by the next dose in the evening.
The actual effect is that the sleeping pill suppresses its own withdrawal symptoms at night, but not during the day. It therefore no longer has a genuine therapeutic effect and may instead produce a “up-and-down” pattern of arousal and wakefulness that worsens the quality and continuity of spontaneous sleep.