Most people, especially as we age, report various inabilities to either get to sleep on a socially acceptable schedule, or to stay asleep. Many times, sleep is not “restorative”, meaning that we just do not get a good, deep quality of sleep.
There are five categories of sleep disruption: Primary, which is unrelated to any internal physical or mental problem, and secondary, which is related to physical or psychological disorder or drugs and alcohol. With the secondary causes, there are medical and psychiatric disorders that are related to insomnias and there are medications and substances that relate to insomnias. There are also parasomnias and dyssomnias. Finally there is sleep disorder related to another mental disorder.
In primary insomnia, there is either difficulty in getting to sleep, or there is waking up from sleep. The problem can be severe enough to interfere with functioning well enough to meet the demands of society, which include waking up refreshed enough to get to work and to perform well, not falling asleep during the daytime, sleeping through the night, and being sharp and wakeful at other times, such as socializing.
The individual with primary insomnia complains of not being able to get to sleep, waking up and not being able to get back to sleep, or of sleep that does not give them the rest that makes them wake up refreshed and ready to go. This is serious when the condition goes on for more than a month, according to the DSM-IV-TR.
There are five criterion, labeled A through E that are used in diagnosing primary insomnia. Criterion A involves a lot of distress and difficulty in functioning in order to work, socialize or to carry out other functions in life. Criterion B involves a “stand alone” aspect to the primary insomnia, meaning that no other sleep disorder is involved. Criterion C involves the absence of another mental disorder. Criterion D involves absence of a physiological condition or a substance, such as medications or drugs. Criterion E involves those who often report both difficulty falling asleep and waking up with an inability to get back to restful sleep.
There are great variations in the reporting of issues related to primary insomnia. The waking or inability to sleep may come or go in different variations and at different times. The issue of poor sleep that is just not good enough to restore the body may or may not be reported, or may come and go at times. Finally, there might not be extended periods of significant impairment.
The DSM reserves diagnosis for those cases where there is “significant” distress or impairment in primary insomnia.
Primary Hypersomnia involves the same one month duration of problems that are the opposite of chronic inability to get to sleep or to stay asleep. The individual complains of either daytime sleeping or of sleeping for too long that is unrelated to any other medical or drug related causes. The same criterion, A through D, that are used in diagnosing primary insomnia are used in diagnosing Primary Hypersomnia.
Criterion E applies to primary hypersomnia and involves a major sleep (usually through the night) episode where the person sleeps from 8 to 12 hours, has normal nocturnal sleep, but still has trouble waking up and getting on the go. Daytime naps can be unplanned and unintentional or unplanned sleeping. Measurements are taken to determine objectively that there is physiological evidence of sleepiness. There are not “attacks of sleep”, but sleepiness that develops over time, resulting in daytime naps that go on for an hour or more. Such naps are not refreshing or restorative, or are poor quality sleep. “Low stimulation” events, such as class, lectures, boring jobs and periods of having nothing else to do are common triggers of daytime sleep episodes. Driving long distances can trigger inappropriate sleep episodes, also.
As with the primary insomnias, “significant” distress or impairment is essential to a diagnosis.
Psychiatry Online: DSM-IV-TR: Primary Sleep Disorder
Psychiatry Online: DSM-IV-TR: Primary Hypersomnia
