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more expanded definition can be found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), or secondary, which is caused by a physical condition or psychological problem such as depression. Secondary insomnia is thought to be much more common than the primary form.3

The characteristics of primary insomnia are:

• A predominant complaint of difficulty initiating or maintaining sleep for a least one month

• Sleep disturbance that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

• Sleep disturbance that does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia

• Sleep disturbance that does not occur exclusively in the course of another mental disorder (major depressive disorder, generalized anxiety disorder, a delirium)

• Sleep disturbance that is not due to direct physiological effects of a substance

A common complaint with fairly significant medical and psychologic complications, insomnia is often a symptom of an underlying medical, psychiatric, or environmental condition. More specifically, anxiety and depression are thought to be among some of the most common causes of insomnia; however, neurologic disorders like restless leg syndrome and limb movement disorder can contribute to insomnia as well. Proper management of secondary insomnia is entirely dependent on accurate diagnosis and appropriate treatment of the underlying condition whereas primary insomnia can usually be directly treated.

Insomnia tends to occur more often in those of advanced age (it is more frequent in those over 60), females, and those with a history of depression. Generally, the most common predisposing factors for primary insomnia are stress, environmental noise, changes in surrounding environment, jet lag, and medication side effects. Secondary, or chronic, insomnia is generally more complex in nature and results from underlying mental or physical disorders. These include depression (one of the most common causes of insomnia), arthritis, heart disease, asthma, hyperthyroidism, and many other diseases. Chronic insomnia can be due to behavioral factors as well, such as overuse of alcohol, caffeine, or other substances and interruptions in sleep-wake cycles from shift work or extended nighttime activities.

Behaviorally, insomnia seems to be perpetuated by the following behaviors; sometimes curtailing these activities can make a large difference.

• Drinking alcohol before bedtime

• Smoking cigarettes before bedtime

• Excessive napping in the afternoon or evening

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