Identifying subtypes of insomnia for personalised treatment

Insomnia is characterised by problems falling asleep, staying asleep, and/or early morning awakening. It is estimated that up to a third of people suffer from sleep problems with most people experiencing a ’bout of insomnia’ sometime during their life. Insomnia is particularly problematic as it is associated with an increased risk of several physical and mental health problems. For example, it increases the risk of cardiovascular disease, metabolic conditions, chronic pain conditions, and mental health disorders such as depression.

Insomnia is often treated with psychological therapy (e.g., cognitive behaviour therapy) and/or pharmaceutical medications. While these treatments can be helpful, there remain a significant portion of people who obtain minimal or no benefit from these treatments.

One way to increase treatment success is to match or personalise, treatments based on a person’s presenting complaints or other unique characteristics. This is a key principle of PI Therapy. Targets for treatment are personalised based on a person’s presenting complaints. Ultimately, it is about identifying a persons’ unique cause(s) of depression and/or anxiety and then targeting these causes.

While insomnia has been traditionally considered a single disorder, in a recent study, it was actually shown to comprise five different subtypes [1]. These subtypes of insomnia are characterised by measurable differences in brain (EEG) activity. They also differ in their responsiveness to pharmaceutical and psychological treatments. Some subtypes are also associated with a greater risk of depression compared to others. Interestingly, these subtypes do not differ based on their sleep-related symptoms (e.g., trouble falling asleep, staying asleep, or early-morning awakening)

Identifying subtypes of depression is important as it may help practitioners implement the most effective treatment for a specific individual. The 5 insomnia subtypes included:

1. Type 1: highly distressed insomniacs
2. Type 2: moderately distressed insomniacs who are able to experience pleasurable emotions
3. Type 3: moderately distressed insomniacs who struggle to experience pleasurable emotions
4. Type 4: slightly distressed insomniacs who are highly reactive to environmental and lifetime events. These people have chronic insomnia in response to life events.
5. Type 5: slightly distressed insomniacs who are minimally-reactive to the environmental and lifetime events. These people have short-duration insomnia in response to life events.

Based on these insomnia subtypes it is possible that the following treatments will be the most effective:

1. Type 1 & 2: use meditation, relaxation and other emotional regulation strategies to lower levels of distress. Medication may also be helpful (pharmaceutical and/or natural).
2. Type 3:  use meditation, relaxation and other emotional regulation strategies to lower levels of distress. Medication may also be helpful (pharmaceutical and/or natural). It is also important to improve positive mood by increasing engagement in pleasurable activities. It will also be important to identify causes for this lack of positive emotional response. For example, are there nutritional deficiencies (e.g., low iron levels), medical conditions, or other lifestyle and environmental factors that are impacting this lack of emotional response?
3. Type 4: Identify causes of emotional reactivity to stress and lifetime events. For example, is there trauma, unhelpful thoughts and beliefs, or unhelpful coping responses? Cognitive-behaviour therapy (CBT) may be helpful for such individuals. Learning alternative coping responses will be important.
4. Type 5: Increase engagement in positive events and utilise positive psychology techniques such as keeping a gratitude journal. Also identify and treat any medical or physical factors that may be impacting on the lack of emotionally reactivity (including identifying nutritional deficiencies or other lifestyle factors).

Ultimately, the most effective treatments are going to be those that are matched to an individual. A one size fits all approach is simply not working so we need to modify our approach by reducing the over-reliance on over-generalised labelling and diagnoses.

References

1. Blanken, T.F., et al. Insomnia disorder subtypes derived from life history and traits of affect and personality. The Lancet Psychiatry, 2019. link to article