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July 9, 2015

Insomnia: Looking for answers to a common problem

White male caucasian young adult on bed with head on pillow with eyes wide open staring off into space at the camera. Afraid of the dark.

Insomnia — the inability to fall asleep or stay asleep, despite having adequate opportunity for sleep — is the most common of all sleep disorders, affecting about 12 million people in the United States.

Daniel Buysse received a medallion in recognition of his appointment as the UPMC Endowed Chair in Sleep Medicine.

Daniel Buysse received a medallion in recognition of his appointment as the UPMC Endowed Chair in Sleep Medicine.

The condition takes a financial toll in lost productivity as well as in the cost of medication and doctor visits. It’s also a risk factor for other important health conditions including hypertension, cardiovascular disease and even mortality, said sleep medicine expert Daniel Buysse, who delivered an inaugural lecture and received a medallion in recognition of his appointment as the UPMC Endowed Chair in Sleep Medicine.

Patients with insomnia describe feeling out of control and frustrated by the inability to do something that should come naturally, said Buysse in his July 2 talk, “Where in the Brain Is Insomnia? How in the World Should We Treat It?”

“What our patients are experiencing is a distressing condition about how their brain works when they’re trying to fall asleep. When they talk about treatment, they talk about things like acupuncture or over-the-counter remedies, but they’re not talking about behavioral treatments that we know are efficacious,” said Buysse, professor of psychiatry and clinical and translational science and director of the Neuroscience Clinical and Translational Research Center in the School of Medicine.


Sleep research is showing that insomnia isn’t merely a disorder of not getting enough sleep, he said.

A traditional view of sleep as an either-or condition may see insomnia as a problem of the sleep switch being too often in the “wake” position, but another hypothesis suggests that rather than having one overall sleep-wake switch, “we may have a lot of sleep-wake switches throughout the brain and the experience of sleep may depend on which of those switches are in which position at a particular point in time,” he said.

This local sleep hypothesis has led researchers to propose a new view of insomnia as a disorder of sleep-wake regulation characterized by increased activation in specific neuronal structures that during sleep are in more of a wake-like position, he said.


Sleep studies show few physiologic differences between people with insomnia and people who are sleeping well, he said.

“Insomniacs don’t seem to have a broken sleep homeostat,” he said. Like good sleepers, insomniacs feel sleepier the longer they’ve been awake, and they tend to get deeper sleep after a period of sleep deprivation. Their circadian “clock” systems also appear similar, with insomniacs and good sleepers alike showing greater degrees of sleepiness in the middle of the night.

However, researchers have found that people with insomnia differ from control subjects in how their brain deactivates during sleep, Buysse said. “Those differences relate to regions of the default mode network (DMN) as well as areas that are part of the executive control and salience network.”

The DMN is a resting-state network in the brain that is active between tasks. “It is the area of the brain that’s activated when you’re not doing something more specific,” he said, adding that it is associated with subjective descriptions of mind-wandering, autobiographical thoughts and rumination — the kinds of uncontrollable thoughts that keep insomniacs lying awake at night.

The executive control network is associated with cognitively demanding tasks. Other studies have found that people with insomnia have deficits in performing cognitively challenging tasks, suggesting they may have some dysfunction of this network, he said.

The salience network is another set of brain regions that “perk up” in response to a physical or emotional stimulus that may be important. Insomnia patients often describe noticing noises or other distractions that disrupt their rest, he said.

“From these studies in general, what we conclude is that insomnia, rather than being a sleep-wake disorder, per se, it may really be perceived as a disorder of network dysregulation across sleep and wake states,” he said.

“What we’re left with is a view of insomnia not just as a disorder of not getting enough sleep, but something a bit different,” said Buysse.

“What we now suggest is that genetic and other predispositions operating through some precipitating factors can lead to network dysregulation and sleep disruption, which seem to reinforce each other: That is, the more sleep disruption you get, the more dysregulated those networks become.

“And the more dysregulated the networks, the more sleep deprivation. Ultimately that results in the clinical condition that we call insomnia,” he said.

This also has implications for treatment. “You usually think of insomnia treatments as focusing on sleep disruption, but this new view suggests that actually treatments may be targeted as well to network dysregulation or a combination of sleep problems and network dysregulation. And that together those things may result in improving insomnia symptoms.”

Meditation and mindfulness techniques have been shown to affect the DMN. And while transcranial magnetic stimulation hasn’t been used in insomnia studies, TMS has been found to help suppress self-referential thoughts, which are common in insomnia patients.


If we leave those more speculative treatments aside and focus on what we actually have today, in many ways we already know how to treat insomnia, Buysse said.

Cognitive-behavioral therapy for insomnia, or CBT-I, has been found effective. This treatment, which doesn’t involve medications, stresses good sleep routines centered on four basic principles:

• Reduce your time in bed.

• Get up at the same time every day of the week, no matter how much you slept the night before.

• Don’t go to bed unless you’re sleepy.

• Don’t stay in bed unless you’re asleep.

The problem in delivering CBT-I is one of supply and demand, because the number of patients far exceeds the number of trained providers, Buysse said.

At present, there are 213 certified behavioral sleep medicine providers, he said. That would leave each one with 57,000 patients to treat, using a conservative estimate that 5 percent of the adults in the United States have insomnia.

“There is a mismatch between what we know is effective and what we can really deliver to patients,” he said.

Shortening CBT-I treatment to a focused four-session “brief behavioral treatment of insomnia” was found effective in older adults — between half and two-thirds were either cured or improved.

Still, that treatment was delivered one-on-one. “With 12 million patients out there, we’re not going to reach them all,” he said.

A new trial funded through the National Heart, Lung and Blood Institute is studying ways to more broadly deliver behavioral insomnia treatments: a self-contained online CBT-I; a videoconference version, or an educational video.

Promoting sleep health

The relationship between good sleep and good health extends beyond Buysse’s focus on insomnia research. Other sleep disorders are associated with adverse health outcomes. “We know that sleep apnea increases the risk of stroke, and we have lots of other examples like that,” he said.

“Sleep health clearly fits into national agendas that are aimed at promoting overall health,” he said.

Similar to the familiar notion of what constitutes cardiovascular health, better awareness of the characteristics of “sleep health” is needed.

Using the acronym “RU-SATED,” Buysse offered a definition of sleep health that focuses on sleep that is appropriate in terms of Regularity – Satisfaction – Alertness – Timing – Efficiency – Duration.

“We’re trying to help people build something positive to improve their health,” he said.

“Sleep medicine focuses on disorders, but what people really want is good sleep: That’s where we need to move.”

—Kimberly K. Barlow   

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