CES in the Treatment of Insomnia: A Review and Meta-analysis

Cranial Electrotherapy Stimulation (CES) is an effective, established treatment for insomnia that avoids polypharmacy interactions for pain patients taking medications while simultaneously reducing anxiety, depression, and pain.
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Primary insomnia is a complaint lasting for at least one month, of difficulty initiating and/or maintaining sleep or of the presence of nonrestorative sleep as defined by the Diagnostic and Statistical Manual of Mental Disorders.1 Primary insomnia is categorized as a Primary Sleep Disorder, under the category of “Dyssomnias” in the DSM-IV-TR. The diagnostic criteria for primary insomnia is summarized in Table 1.2

The International Classification of Sleep Disorders Revised (ICSD-R) uses the term “psychophysiologic insomnia” for a complaint of insomnia, and for the associated decreased functioning during wakefulness. The ICSD-R defines insomnia of six months duration as chronic.3

The DSM criteria also reflects the now widely-accepted use of polysomnography (PSG) which has enlarged the scope of differential diagnosis when assessing insomnia. The DSM-IV-TR categorizes all sleep disorders as either dyssomnias or parasomnias.4 Parasomnias include diagnoses of Nightmare Disorder, Sleep Terror Disorder, Sleep-walking Disorder, or “not otherwise specified” conditions such as REM sleep behavior disorder and sleep paralysis. Sleep paralysis can be an exaggeration of a relatively nonpathologic hypnagogic event, or can be a common component of Narcolepsy, which itself is one of the dyssomnias. A list of some common dyssomnias is shown in Table 2.

Estimates of the number of people in the U.S. who suffer from insomnia range from 18 million to 24 million in adulthood, and up to 20% in later life, or 7 million in people 65 years of age and older, with women being about two times as likely to develop insomnia as men.5,6

Theoretically, “nonrestorative” or nonrefreshing sleep is definable as some impairment in daytime functioning but is not always easy to demonstrate clinically. It has been difficult to demonstrate systematic impairment of daytime function in insomniacs. Some PSG studies have shown clear differences between the sleep of insomniacs and normal subjects.7 However, there is one large study which shows extensive overlap in PSG indicators of sleep between insomnia patients and normal controls.8 So controversy exists whether patients with insomnia complaints and response to hypnotics differ from controls in any PSG measures of sleep and daytime function.9

Table 1. DSM-IV-TR Diagnostic Criteria for Primary Insomnia
A. Difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least one month
B. Sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
C. Sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-Related Sleep Disorder, Circadian-Rhythm Sleep Disorder, or a Parasomnia
D. Sleep disturbance does not occur exclusively during the course of another mental disorder such as Major Depressive Disorder, Generalized Anxiety Disorder, or a delirium.
E. The disturbance is not due to the direct physiological effects of a substance (such as a drug of abuse or a medication) or a general medical condition

The significance of insomnia also relates to whether it occurs at the beginning, the end, or in the middle of the course of the usual sleep period. Traditionally, insomnia has been classified into three main types: delayed sleep onset, impaired sleep continuity, and early-morning awakening.10 Insomnia can be a feature of many major psychiatric disorders but is not regarded as a necessary diagnostic criterion for any particular disorder. Insomnia can be the sole symptom of depression, and can be a risk factor for the development or recurrence of some psychiatric disorders. Paradoxically, sleep loss can be both a symptom and a treatment of major depression.11

The primary function of sleep is to ensure adequate cortical function when awake.12 According to one theory, two processes interact in normal sleep production. The sleep homeostat drives the sleep-wake schedule toward a balanced requirement (prolonged wakefulness incurs a “sleep debt”), and an internal circadian timer regulates the 24 hour biological clock’s sleep-wake cycle.13 Together, the two processes regulate not only the amount of sleep but the quality of sleep as well. The two processes also differ across the life span, with young children requiring longer periods of sleep with more rapid eye movement (REM) sleep than do adults as the homeostatic drive declines with age.14

There is no absolute technique for falling asleep and staying asleep. Sleep is generally regarded as a passive process in which internal and external cues enable autonomic conditions for sleep. According to the inhibition model, there is both a physiological de-arousal, and a cognitive de-arousal, allowing sleep to occur.15,16

Table 2. Listing of DSM-IV-TR Main Dyssomnias
A. 307.42 Primary Insomnia
B. 307.44 Primary Hypersomnia
C. 347.00 Narcolepsy
D. 780.57 Breathing-Related Sleeping Disorder
E. 327.xx Circadian Rythm Sleep Disorder
.31 Delayed Sleep Phase Type
.35 Jet Lag Type
.36 Shift Work Type

Sleep will usually not occur during cognitive arousal. According to Freud, the first step in becoming an insomniac is to worry that one will not sleep when one goes to bed. Recent research has borne out the fact that worries of any kind—but certainly a fear of not falling asleep and worrying about the resulting consequences of this for one’s life the next day—clearly deactivates the cognitive de-arousal required for sleeping.17

When asked what kinds of thoughts they have when they attempt to sleep, insomniacs provide a long list, typically including planning, thinking things out—especially with a negative emotional content, fear of not sleeping, plus concentrating on worrisome changes that are operative in their lives. When people who have no problems falling asleep are asked what they think about when they go to bed at night, many answer, “nothing especially.”

While medications are often used to treat insomnia, those in the class of benzodiazepine and related chemical structures have limited usefulness over the long range since they tend towards tachyphylaxis (rapidly decreasing response following initial doses) and produce tolerance. The use of cognitive behavior therapy for enhancing sleep is often suggested since it may identify the things that the insomniac is doing to defeat the brain’s attempt to de-arouse.18

First published on: October 1, 2007