One of the most well-known basic models of insomnia pathogenesis is called the “3-P” model. It was developed in 1987 by the American researcher Arthur Spielman and considers 3 groups of factors, “guilty” in the development of insomnia:
The first “P”: predisposing factors – serve as a background for the development of insomnia. They can accompany a person throughout his life, growing and weakening, but without causing significant sleep disturbances. These include:
- Biological factors that reflect the hyperactivity of the stress systems of the body (they can be recorded using instrumental and laboratory research methods, but this does not have much clinical meaning, rather it is of scientific interest. Although it may be possible in the future, by assessing these factors, it will be possible to reveal the degree of predisposition to insomnia).
- Psychological factors are the most studied of the factors that predispose to the development of insomnia. These include such personality traits as emotional instability, increased anxiety, perfectionism, hypochondriasis, a tendency to rumination (obsessive thoughts), a reduced ability to cope with stress, characteristic of manifestations of mental hyperactivation.
- Social factors include shift and night work, frequent jet lag; low socioeconomic status (poverty) and family history of insomnia. A mode of operation that does not correspond to the natural daily rest-activity cycle can cause both circadian rhythm disturbance and insomnia. In 2015, a statistically significant relationship was found between low socioeconomic status and a decrease in satisfaction with night sleep, as well as a decrease in the effectiveness of night sleep in a polysomnographic study.
- Behavioral factors , such as habitual disturbance of sleep hygiene, alcohol abuse, smoking, low level of physical activity (physical inactivity), have shown their contribution to the development of insomnia as predisposing factors.
Second “P”: provoking factors. In the case of insomnia, stress is always the trigger.
- Biological stress: exacerbation or debut of the disease.
- Psychological stress: increased psycho-emotional stress (positive or negative): problems in the family, personal life, conflicts at school or work, a wedding, a successfully passed exam, etc. Moreover, the cause of the development of insomnia may be not one strong stress, but several weak, almost imperceptible stress factors, the actions of which were summed up.
The fact is that for the body, both of these types of stress proceed completely alone and according to absolutely the same mechanisms: the adrenal glands begin to produce stress hormones – adrenaline, cortisol and others … And as a result, a non-specific reaction of the body to stress occurs.
In the meantime, there is no need to know about it. ”
Third “P”: supporting factors. Any stressful effect is naturally accompanied by emotional hyperactivation. In the acute period, sleep disturbances are directly related to the reaction to a stressful situation; after its resolution, sleep can be restored. However, in the presence of predisposing factors, with a high intensity of stress, or if the stressful situation is prolonged, supportive factors appear, which are represented by manifestations of somatic and cortical hyperactivation. All this leads to the formation in a person of misconceptions about sleep, the emotional experience of insomnia and its consequences.
Dysfunctional sleep beliefs are often caused by not knowing how many hours a day an average person needs to sleep in order to get enough sleep and function properly. Patients tend to associate insomnia with impaired daytime functioning, the development of somatic diseases, and insanity. The behavior of a person suffering from insomnia is based on misconceptions about sleep and its disturbances, emotional experiences of insomnia and its consequences. In turn, misbehavior only aggravates insomnia and its attendant beliefs and emotions. Thus, the “vicious circle” of self-excitation is closed. The desire to improve the quality of sleep by increasing its amount, i.e. an increase in the time spent in bed. Attempts to “sleep off” after a sleepless night or during the day lead to a weakening of the “sleep pressure” by the next evening. Thus, there is an increasing discrepancy between the time spent in bed and the actual sleep time, which increases the patient’s dissatisfaction. At the same time, excess time spent in bed, as a rule, is spent on activities not related to sleep: reading, watching TV, working at the computer, eating. This destroys the correct association between bed and sleep.
Fourth “P”: “Pavlovsk reinforcement.” In recent years, the classic Spielman model has been refined – a fourth supporting factor has been added to it: “Pavlovsk reinforcement”. Probably everyone remembers the story about Pavlov’s dogs: a light bulb came on in front of the experimental dogs, and then the animals were given food. After a while, they stopped giving food, but the dogs continued to produce saliva on the light bulb – the dogs were waiting for food to appear. Since a person, in fact, is an animal, it is also possible to develop certain conditioned reflexes in him. Therefore, with long-term sleep disturbances, conditioned reflexes are formed and consolidated at a subconscious (ie, independent of the person’s will) level: fear of not falling asleep, fear of bed, disappearance of the normal reflex “bed = sleep” and the formation of a pathological reflex “bed = insomnia ” . This additional acquired source of hyperactivation in chronic insomnia is triggered when a person finds himself in the evening in the same environment where he spent the previous sleepless nights.
What can insomnia lead to? The consequences of insomnia are many:
- The presence of insomnia is an independent risk factor for the development of depression (a 2-fold increase in the risk), anxiety disorders, drug and alcohol abuse, and suicide.
- The abuse of sleeping pills is noted in 0.8% of the general population (abroad), according to the data of a domestic epidemiological study conducted in 2011, this value is estimated at 4.5%.
- It was shown that the presence of insomnia is accompanied by an increase in the risk of developing hypertension (3-5 times), diabetes mellitus (1.5 times), myocardial infarction and heart failure.
- The most dangerous social consequence of insomnia is a 2.5-4.5-fold increase in the risk of getting into an accident in patients with insomnia. This is due to a decrease in attention level and reaction time in this disorder during the daytime. It was shown that in terms of the effect on the driver’s reaction speed, a decrease in sleep duration by 4 hours is equivalent to the content of alcohol in the exhaled air 0.95 ‰ (which corresponds to a mild degree of intoxication).
- The social consequences of insomnia are manifested in an increase in the incidence of absenteeism (absence from the workplace due to poor health) or presenteeism (decrease in productivity with the formal presence of a person at the workplace). The working capacity of patients with insomnia is 2 times lower than that of healthy people.
- A decrease in attention and reaction speed in patients with insomnia increases the risk of developing accidents at work 8 times.
In the meantime, there is no need to know about it. ”