Michael J. Thorpy, MD: Vikas, insomnia is often only viewed as a nocturnal problem by people. But it’s more than that, isn’t it? It’s a 24 hour problem; it’s a problem with day and night. Why do we think it’s a 24 hour problem rather than a nighttime problem?
Vikas Jain, MD, FAASM, FAAFP, CCSH, CPE: There are several reasons. One is that if you don’t sleep well at night, if you have trouble falling asleep and staying asleep if you wake up too early, then a poor night’s sleep generally results in decreased performance during the day. People with insomnia are three times more likely to have trouble concentrating during the day than people who sleep well at night. They are twice as likely to have poor energy levels and have higher levels of mood disorders in patients with insomnia. In general, especially in patients with chronic insomnia, if you don’t sleep well night after night, you worry about your sleep all day. “Will tonight be the night I’ll get some sleep?” That itself is suitable for another night of poor sleep. It can persist beyond that.
Michael J. Thorpy, MD: You are so right. There are many people who wake up in the morning and think, “If I don’t sleep well tonight, I can’t do the things I want to do the next day.” They start worrying about it in the morning. Because of this, you have symptoms all day.
Karl Doghramji, MD: Michael, if I could only intensify that. Clinically, I find that some patients who have apparently insignificant sleep disturbances only wake up a few times, or perhaps have very brief sleep latencies, complain of insomnia. When I ask them why they are so worried about a few awakenings they say, “Because I feel miserable during the day.” This seems to be the most common complaint among insomniacs. It’s not what happens at night; This is how they feel during the day.
Michael J. Thorpy, MD: Fatigue, exhaustion, and difficulty getting things done during the day are often the main complaints, not the nighttime complaints.
Nathaniel Fletcher Watson, MD: With this in mind, it is interesting that so many clinical studies examining drugs and treatments for insomnia are almost completely ignorant of diurnal function. That changes with the introduction of some newer drugs and some activity in clinical trials, but it’s remarkable how myopic we were as a field focusing on night time, sleep latency and waking up after sleep, sleep efficiency, and the number of Awakening but non-daytime problems such as drowsiness, mood-related problems, or cognition. Hopefully this will change as we move forward.
Erinn E. Beagin, MD: I ask my patients that. You come in and say, “I can’t get 8 hours of sleep.” I say, “How many do you get?” “I get 5 hours of sleep. But when I was in the military, I went to bed at 11pm and got up at 4am. ”Question # 1 I ask is,“ Are you tired during the day? How do you feel during the day? ”And they say,“ I’m going through. I have no problems. ”It’s reassuring to this patient, but you’re absolutely right. It’s the people who come in and say they can’t function the next day that I’m a lot more worried about.