Sleepless Nights: Hypersomnia and Insomnia

In South Korea, there is a saying, “if you sleep now, you will dream. But if you study now, you will make your dream come true.” It sounds interesting, but this is only one among the handful of “daily-life propagandas” for South Korean students to control their sleepiness. However, to be honest, it is hard to deny that they were mostly not so successful – that is just how basic desire our sleepiness really is. Thus, it will be redundant to say how painful it is when one gets a problem in sleep.

Sadly, many people in the world, even at this moment, have hard time controlling their sleep, whether their problem is caused by the lack of it, or by the inundation of it. But if there is action, there must be reaction. Just as much as sleep disorders are painful problems, there is also much study on the sleep disorders so as to help the patients diagnosed with them. Here, we are going to focus on the very basic element – the amount of sleep and disorders related to this concept. This will lead us to focus mainly on two disorders, hypersomnia and insomnia. Though they look as if they are on the two extremes, hypersomnia and insomnia actually have a lot in common when it comes to treatments against them, and their relationship with schizophrenia and neurocognitive disorders. They are also in common in the fact that a lot has been revealed about them, while it is still necessary for more to be discovered.

First, hypersomnolence disorder is characterized by several diagnostic criteria. It is characterized by self-reported excessive sleepiness (hypersomnolence) despite a main sleeping period lasting at least 7 hours. In order to be diagnosed with hypersomnolence disorder, the excessive sleepiness must occur at least three times per week, for at least three months. As much as the disorder is characterized by “self-reported” hypersomnolence, this will be followed by the accompaniment of significant distress or impairment in cognitive, social, occupational, or other important areas of functioning. The diagnostic criteria of the disorder also emphasizes that one can be diagnosed with hypersomnolence disorder only when one’s hypersomnolence, or excessive sleepiness in other words, cannot be well explained by other predictable causes, such as another psychological or physiological impairment. (APA, 2013)

The risk factors for hypersomnolence disorder include viral infections, such as the ones by HIV pneumonia, infectious mononucleosis, and Gullain-Barré syndrome. Such viral infections refer to 10% of all reported cases of hypersomnolence disorder. When it comes to the genetic risk factor, there does exist genetic inheritance of hypersomnolence disorder, in an autosomal-dominant mode. (APA, 2013) When it comes to prevalence of the disorder, 1% of the European and US general population has episodes of sleep inertia. Among the individuals who consult in sleep disorder clinics with complaint of daytime sleepiness, 5% ~ 10% of them are diagnosed with hypersomnolence disorder. The disorder occurs with relatively equal frequency in males and females. (APA, 2013)

Insomnia is characterized by several diagnostic criteria. It is chracterized by dissatisfaction with sleep quality and/or quantity, which causes disruption of daily functioning. In order to be diagnosed with insomnia, one has to have a trouble sleeping at least three nights per week, and disruption has to occur despite sufficient opportunities to sleep. The diagnostic criteria of the disorder also emphasizes that one can be diagnosed with insomnia only when one’s trobule sleeping cannot be well explained by other predictable causes, such as another psychological or physiological impairment. (APA, 2013)

The risk factors for insomnia include temperamental factors such as anxiety and worry, predisposition for high arousal, and repression of emotions. Environmental risk factors such as extreme temperature, altitude, light and noise also should be noted importantly. Genetically, insomnia seems to be shared in first-degree family members, even though the extent to which this link is inherited through a genetic predisposition, learned by observations of parental models, or established as a by-product or another shared disorder remains undetermined. (APA, 2013) When it comes to prevalence of the disorder, population-based estimates indicate that about one-third of adults report insomnia symptoms, 10% ~ 15% of them experience associated daytime impairments, and 6% ~ 10% have symptoms that meet criteria for insomnia disorder. Insomnia is reported to be more common among females and the elderly. (APA, 2013)

The most common feature shown in both hypersomnia and insomnia is that the treatment against them is mainly based on oral medications. In the case of hypersomnolence disorder, the most common forms of treatment include oral medications such as antidepressants, modafinil, and xyrem (sodium oxybate). (Living with Insomnia, 2013) Antidepressants are especially preferred since they can cope with the most common form of comorbidity shown by hypersomnolence disorder: the accompaniment of depression. (Living with Insomnia, 2013) In the case of insomnia, there are myriads of commercial oral medications for treating insomnia, which is in accordance with the high prevalence related to the disorder. Yet, the most popular chemical for treating insomnia is zolpidem tartrate, which is, in the market, sold in many commercial forms such as Ambien, Stilnox, and Konics. Though initially an antipsychotic for schizophrenia, quetiapine is also commonly used for treating insomnia. Especially, since quetiapine is prescribable both by neurology department and psychiatry department, unlike many other antipsychotics, quetiapine is being commonly prescribed for more serious patients who had not been much affected by other sleeping pills.

Yet, hypersomnia and insomnia also have in common that, despite the treatment through oral medications being the major preexistent treatment, the limitations of such treatment are still clear, and the importance of other forms of treatments is in the recent spotlight in accordance with such limitations. In the case of hypersomnolence disorder, though antidepressants are commonly used, it should not be forgotten that they can cause various kinds of unexpected side effects, usually because of antidepressants’ direct influence on neurotransmitters. Modafinil cannot really be a good alternative for antidepressants since modafinil is not used for children and patients with high risk for psychosis because of its even more serious side effects – serious rash on patients’ skin, which is dangerous for children, and high possibility of causing psychosis such as anxiety disorder or bipolar disorder. (Naver Medication Information, 2013) Xyrem also has its own problem – the security issue. According to US Food and Drug Administration, xyrem’s mechanism of action is just unknown. (US FDA, 2005) Also in the case of insomnia, the importance of cognitive behavioral therapy for treating the disorder is recently being noticed. Such cognitive behavioral therapy includes relaxation therapy, stimulus control therapy, sleep restriction therapy, and cognitive therapy. (Cline, 2009) Such relatively new emphasis on behavioral therapy is in accordance with the notice on “course modifiers,” such as bad sleep habits, as the important risk factors for insomnia. (APA, 2013)

In 1996, there was a study on the relationship between avolition, which is a common negative symptom of schizophrenia, and “pseudo-hypersomnia.” The result of the study showed that the comorbidity of avolition and pseudo-hypersomnia is strongly characterized by capsular infarcts at the bilateral anterior striatum in the brain, when speaking neurologically. (Rémillard et al, 1996) The relationship with schizophrenia or neurocognitive disorders is highly notable also when it comes to insomnia. The symptoms from schizophrenia, in fact, commonly cause insomnia. Anhedonia, which is a very common negative symptom of schizophrenia may cause insomnia, since repression of emotions is also an important risk factor for insomnia. (Smith et al, 2005) In addition, noise is one of the environmental risk factors for insomnia. (APA, 2013) Yet, for patients of schizophrenia, there always can be a form of noise since many of them suffer from auditory hallucinations. These auditory hallucinations actually are noise, since when these happen to the patients, the patients’ auditory section of the brain really does get activated. (Seon et al, 2013) Furthermore, schizophrenia can appear as a form of anxiety psychosis. (Seon et al, 2013) Yet, anxiety is an important temperamental risk factor for insomnia. (APA, 2013) Thus, anxiety that is caused by schizophrenia, may, in turn, cause insomnia. The possbility that insomnia might cause, or at least, have influence on neurocognitive disorders such as dementia should be noted, especially when we think that one of the most important functions of sleep includes memory consolidation. Rapid eye movement, or REM sleep elicits an increase in neuronal activity following an enriched or novel waking experience, thus increasing neuronal plasticity and therefore playing an essential role in the consolidation of memories. (Ribeiro, 1999) Yet, memory is one of the six elements that are considered the most essential components of cognition, when it comes to history taking for clinically treating dementia.

Sleep is an important part of human life. Thus, whether it is caused by the lack of it, or by the inundation of it, sleep disorders may always be a very painful set of problems for human beings. The problem becomes more intense when it comes to the relationship between sleep disorders and other important disorders such as schizophrenia and neurocognitive disorders. For the high number of prevalence who suffer from sleep disorders, the limitations with current preexistent treatments against sleep disorders must be overcome with various clincal, and scientific efforts. Here, we analyzed such characteristic of sleep disorders mainly by looking at hypersomnia and insomnia. Though causing different kinds of disruptions in our daily-life, both have in common in that much is still yet to be investigated about them, with the need from the vast number of prevalence.