A systemic approach to insomnia

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: by Chloé Subra-Yacoubovitch

Graduated with a Master of Philosophy, a DU in Relationship and Strategic Intervention Clinic and a certification in Hypnosis, Chloé SUBRA, practitioner and trainer, supports individuals, athletes and organizations. She is co-founder and educational manager of Alter Horse, leader in equicoaching since 2013.

This article presents insomnia from a new angle: that of the systemic approach. It explores the different facets of this common sleep disorder, from diagnostic criteria to interactional patterns, to better understand its mechanisms and implications.

Identify the different sleep disorders

The Diagnostic and Statistical Manual of Mental Disorders DSM-5 lists 10 disorders or groups of sleep-wake alternation disorders, including insomnia .

The other disorders being hypersomnolence, narcolepsy, sleep disorders linked to breathing, sleep-wake alternation disorders linked to the circadian rhythm, awakening disorders in non-REM sleep, nightmares, REM sleep behavior, restless legs syndrome and substance/medication-induced sleep disorders.

Insomnia: a very common sleep disorder

Some numbers

About a third of adults report symptoms of insomnia

10 to 15% of associated daytime disturbances

6 to 10% symptoms required for insomnia disorder.

The DSM-5 specifies that in general practice, approximately 10 to 20% of individuals complain of significant symptoms of insomnia (Ohayon, 2002; Roth et al., 2006).

Typically, individuals suffering from insomnia complain of: "[...] dissatisfaction linked to the quality, timing and quantity of their sleep. Distress and resulting impairment during the day are essential features of all these sleep-wake alternation disorders. »

Indeed, the deterioration in the condition of patients during the day is formalized by:

“[...] various daytime complaints and symptoms (Buysse et al. 2007), such as fatigue, decreased energy and mood disturbances. Anxiety or depressive symptoms that do not meet the criteria for a specific mental disorder may be present as well as a very high sensitivity to the daytime repercussions of a lack of sleep. »

What is insomnia?

DSM-5 diagnostic criteria

The DSM-5 establishes a list of diagnostic criteria making it possible to distinguish the aforementioned sleep-wake alternation disorders.

The classification of insomnia noted 307.42 (F51.01) meets the following criteria:

Symptoms

The main complaint concerns, in adults, dissatisfaction linked to the quantity or quality of sleep, associated with one (or more) of the following symptoms:

Difficulty falling asleep
Difficulty maintaining sleep characterized by frequent awakenings or problems returning to sleep after waking up.
Early morning awakening with inability to go back to sleep.

Sleep disturbance causes marked distress or impaired functioning in social, occupational, educational, academic, or other important areas.

Sleep difficulties occur at least 3 nights a week.
Sleep difficulties have been present for at least 3 months.
Sleep difficulties occur despite adequate sleeping conditions.
Insomnia is not better explained by another sleep-wake disorder nor does it occur exclusively during that disorder (e.g., narcolepsy, breathing-related sleep disorder, rhythm-related sleep disorder circadian, parasomnia).
Insomnia is not caused by the physiological effects of a substance (eg, substance of abuse, medication).
The coexistence of a mental disorder or other medical condition does not explain the predominance of insomnia complaints.

Consultation of the DSM-5 constitutes a clinical reference and, in this sense, makes it possible to direct the anamnesis in order to collect the elements inclusive or exclusive to the classification of the pathology. Also, it makes it possible to discriminate insomnia from other disorders through a differential diagnosis.

In-Depth Exploration of Insomnia

Enriching the history with questioning by Richard J. Schwab (MDS manual)

In order to collect all data useful for clinical diagnosis, it may be relevant

to add to the anamnesis the questions of Richard J. Schwab (2022) in the MSD manual.

Indeed, Richard J. Schwab's anamnesis compiles the following data:

the duration and age of onset of symptoms and any events (eg, life or job change, new medication, new illness) that coincide with the onset of the disorder.
Sleep and daytime symptoms should be noted.

The quality and quantity of sleep are identified by determining the following:

Bedtime (bedtime events).
Sleep latency (time from bedtime to falling asleep)
Number and times of awakenings
Final morning wake-up time and number of lifts
Frequency and duration of naps
Quality of sleep (whether it is restful)
Consumption and withdrawal of medications, alcohol, caffeine and nicotine as well as the level and duration of physical activity should also be noted.

If we note that Richard J. Schwab's anamnesis does not note the frequency of insomnia, nor its recurrence or possible comorbidities, it nevertheless has the advantage of introducing the notion of events. Thus it allows us to see how the disorder unfolds, namely: how it exists.

What is psychophysiological insomnia?

According to the DSM-5: “This type of insomnia persists well beyond the resolution of the precipitating factors, usually because patients then exhibit anticipatory anxiety of another sleepless night followed by another day of fatigue. Typically, sufferers spend hours in bed ruminating about their insomnia and have more difficulty falling asleep in their own room than when sleeping outside. »

In addition, although it is noted that insomnia comes from environmental, genetic or physiological factors, it is however noted that temperamental factors generally maintain the disorder: “A personality or cognitive style that is anxious or quick to worry, a Predisposition to high levels of alertness and the tendency to repress emotions may increase vulnerability to insomnia. »

In A logic of mental disorders (2016, p.31), Wittezaele and Nardone point out the limits and disadvantages of a medical classification of mental disorders.

“For the systemic therapists that we are, what is especially lacking in the DSM is the description of patients' reactions when they are confronted with the situations that generate the symptoms. »

And to add: "[...] the DSM gives a photograph of the person where we would need a film which shows the interactions between the patient and himself and his life context. »

However, we note in the DSM-5, and even if this is insufficient, that:

“Factors that perpetuate the disorder, such as poor sleep habits, irregular sleep schedules and fear of not sleeping, fuel the problem of insomnia and can contribute to a vicious cycle that can lead to the persistence of insomnia. »

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A systemic view of insomnia

The clinical approach to insomnia introduces the idea that fear (or fear of not sleeping) could be a central axis within the subject's perceptual-reactive system, fueling the problem of insomnia by maintaining a " vicious circle ".

If the essential for the systemicist , namely the behavioral reactions to the fear of not sleeping, is missing from the diagnosis, this “anticipatory anxiety” is introduced at the same time as contextual elements (“patients spend hours in bed by ruminating on their insomnia"), which in our opinion go beyond the scope of pathophysiology and possibly open a window onto a systemic vision of insomnia.

Doing a system: introduction to the fundamental principles of the systemic approach

The systemic approach developed by members of the Palo Alto School describes the disorder as the rigidification of the subject's perception-reaction system maintained and fueled by repeated attempts at dysfunctional solutions.

The fundamental properties of systems justify their natural tendency to maintain themselves through a self-regulation phenomenon which increases resistance to change.

Homeostasis , first of all, justifies the propensity of the system to avoid changes to maintain its environment. Its regulatory mechanisms allow it to maintain a stable state according to a physical principle of Newtonian inertia: change is movement. It requires strength, energy and risk. This homeostasis is epistemological and not axiological: a system can be dysfunctional and seek to maintain itself. The effects of this dysfunctional regulation are then reused to fuel the dysfunctional system in a loop previously described as a vicious circle .

Then the principle of equifinality The structure of a system's interactions at a time explains its functioning better than the history of the system. The current system is its own justification. As a result, and following a circular principle rather than linear causality, the clarification of the current modes of operation or dysfunction of the system makes it possible to resolve the dysfunctions and not the study of previous causes.

Finally, the principle of totality The circularity of causes constitutes a whole which, by virtue of the emergent and unpredictable properties of the related parts, is more than the sum of its parts. The system itself explains the behavior of individuals and not the other way around.

Necessarily relational and interactional, inspired by Bateson's cybernetic theory which highlights the existence of feedback loops in physiological and technical systems, any system is thought of in terms of feedback.

“In any system, inputs are transformed into outputs by the transformer. Inputs result from the influence of the environment on the system, and outputs from the action of the system on the environment. We then call the feedback loop, or feedback loop in English, the mechanism which returns to the input of the system, in the form of data, the results of a transformation or an action depending on the output” (Cambien, 2008, p.22).

In 1951, Bateson and Ruesch cautiously transposed the systemic conceptual approach to human relations (Wittezaele, Garcia-Rivera, 1992) in their work Communication and Society.

Systemic lighting engages an interactional reading of the communication processes between the elements of a system, plowing the furrow of contextual fields of investigation in gestalt continuity.

Interpersonal and particularly family relationships are reread in this light, particularly through the observation of the communication of schizophrenic patients.

But how can we understand this retroactive principle in the relationship with oneself?

The interactional pattern of a self-referent disorder

In the context of difficulty maintaining sleep or returning to sleep following a period of wakefulness, the study of the perceptual-reactive system through the drafting of an interactional diagram allows us to visualize the issues of intrapersonal communication . We understand by communication, the emission and reception of mutually influencing signals. In this type of disorder, the subject's perception influences his reaction which fuels his perception in an infinite process whose inevitable outcome is the rigidification of the disorder.

A first incident of insomnia can generate an uncomfortable feeling and give rise to the fear that this discomfort will persist or recur. The perceived fear must be compensated by attempted solutions – or reactions – obeying different typical logics.

Among the various types of responses to this fear, we will find, for example, not wanting to go to bed until you are extremely tired to protect yourself from future insomnia; compensating for a sleep debt with naps; the fact of developing invasive rituals or even the fact of ignoring insomnia by pretending to sleep without succeeding.

These responses or reactions are the result of past experience, generally fruitful. Seeing that in this specific and new context, the response does not work, the subject is tempted to do more of the same thing , attributing the failure of his strategy to the intensity or quantity of response rather than to its quality.

Added to the fear of not sleeping is the realization of one's powerlessness to implement a working solution. The mind stumbles over this failure; fear increases exponentially; the reaction becomes denser. This is how the self-referential feedback loop is built.

Whether these responses obey a logic of control, avoidance or belief, all are driven by a common intention which is that of wanting to sleep.

In Not sleeping , Marie Darrieussecq (2021, p.200-201), formulates the paradox this way: “To sleep, you must not want to sleep. (...) How can we want what should go without saying? We cannot decide to dance with grace... To want spontaneity is to stiffen up... To want to forget is to remember again... And to want to fall in love is the marriage of reason...

“Consciously wanting to fall asleep,” said Doctor Zhivago with common sense, “is definitely insomnia. » Insomnia feeds on the effort to sleep like ghosts feed on our fear. »

From a systemic perspective, the therapist must therefore work to identify this feedback loop and the attempts at redundant solutions otherwise used as a strategy by the patient.

However, the identification of circularity only constitutes the premises of an intervention which is thought of strategically, that is to say with the permanent concern of the patient's adhesion to this strategic about-face which will oppose, in a sense, to himself.

“How,” one asks, “can one motivate a person to accept an interpretation of “reality” that is different from one’s own? » we ask ourselves in Strategy of brief therapy (Watzlawick, Nardone , 1997, p.172)

Here we enter the field of emotions.

The about-face we are talking about, well upstream of its purpose (stopping attempts at redundant solutions then, sometimes, 180° prescription) occurs from the anamnesis in particular through reframing , and in this, on the redefinition of the issue. The determination of the objective may also be impacted.

The construction, perception, interpretation of the disorder for which the client comes to consult are impacted; the emotional compass, panicked, as if by the effect of a reversal of the magnetic field.

At this junction point, the system can no longer be thought of without strategy.