"Understanding Sleeplessness: Perspectives on Insomnia."

In Salt Lake City at this year's major annual meeting of sleep researchers and clinicians, I recently spoke to a group of attendees about the various ways of viewing insomnia described in my book, "Understanding Sleeplessness: Perspectives on Insomnia."

Insomnia usually is caused by several different influences. Rarely is there a single answer that solves the problem. People with chronic insomnia generally improve gradually as different issues are addressed. Success usually results from some combination of behavior changes, psychotherapeutic interventions, and schedule modifications, sometimes with the aid of medications.

One way of understanding insomnia is with a motivated behavior perspective. The idea behind this perspective is that people have various natural biological drives, one of which is the drive for sleep.

After being awake long enough, we all become sleepy. However, there are times when a person might expect to be able to sleep but doesn't have a sufficient sleepiness drive.

For instance, an afternoon nap might decrease the sleepiness drive at bedtime and make it difficult for the person to fall asleep quickly. Caffeine in the evening certainly can affect the balance of wakefulness and sleepiness, contributing to insomnia.

Another point of view is called the dimensional perspective. We all have characteristics along different spectra, some of which might influence our ability to sleep well.

One continuum relates to our biological clocks. While most of us sleep beginning at about 10 p.m. to midnight until about 6 a.m. to 8 a.m., others may be early birds or night owls.

People at the extreme ends of this spectrum are more likely to have difficulty with their sleep. The night owls often have trouble getting to sleep as early as they would like, and the early birds tend to awaken much earlier than they would like.

Recently I wrote about the different ways of viewing the problem of insomnia discussed in my book "Understanding Sleeplessness: Perspectives on Insomnia." I described the motivated behavior and dimensional perspectives in my last entry. Here I'll write about the life-story and disease model views.

It's natural for us to search for meaning by trying to explain things, and that includes why we have certain problems, such as difficulty sleeping. There is a type of logic in the stories we create. We might explain insomnia as the result of an upsetting experience, a work schedule change, or a habit of drinking coffee after dinner. In other words, insomnia may make sense because of something we've done or something that has happened to us.

With the disease model we try to explain insomnia in relation to biological functioning. The disease model considers clusters of symptoms that might represent particular disorders. From this point of view, insomnia might be viewed as one feature of a mood or anxiety disorder.

Difficulty falling asleep is a characteristic of the delayed sleep phase syndrome. Some people have insomnia as a disorder that is not obviously caused by another disorder. The ultimate goal of the disease model approach is understanding the underlying biological cause of a symptom.

The motivated behavior, dimensional, life-story, and disease model perspectives all may provide valuable insights regarding a patient's sleep problems. None of them is the single right answer; rather, these four points of view complement each other. In addition to helping us understand insomnia, these types of reasoning are used in understanding many different psychiatric problems. That is the subject of the book "Perspectives of Psychiatry" by Paul McHugh and Phillip Slavney.

More points of view should help doctors highlight the different possible ways they can help their patients. Someone with an anxiety disorder may also have an advanced sleep phase "early bird" tendency and feel distressed about family problems. Addressing all of them probably will be the best solution for the insomnia.