By far the most frequent source of insomnia is some form of mental or emotional disquiet. Since one primary biological reason for sleep is to provide the brain with a chance to rest, it is perhaps not surprising that one consequence of a troubled mind should be troubled sleep.

I must hasten to point out that in using such terms as "mental disquiet" or "psychological disturbance" I am not suggesting, by any stretch of the imagination, that people with insomnia are thereby crazy, or that their sleep troubles are "all in their minds." Quite the contrary. Insomnia is a very real, and very widely experienced, phenomenon. Insomniacs really do sleep less than other people, as measured not just by their own perceptions but clinically and scientifically in sleep laboratories. Nor do victims of insomnia have unrealistic expectations or beliefs about what constitutes a good night's sleep; studies have shown that insomniacs desire only the same amount of sleep as other people.

While it is true that insomnia is a feature of a number of severe mental disorders, including clinical depression, it may also appear when a psychologically healthy person's life is unusually stressful or tension-filled. Often people with sleep disorders have endured troubling situations over which they had no control—an unhappy home life during childhood, for example/ And the increasing pressure and pace of today's society adds to everyone's mental load. The primary purpose of labeling insomnia as largely psychiatric in origin is not to suggest that the disorder is illusory or that its victims are mentally disturbed but to call attention to the types of therapy that have the greatest chance of succeeding.

With that in mind, then, let me proceed to describe some of the behavioral patterns and mental attitudes that are frequently associated with insomnia. Perhaps you will recognize one or more of these traits in yourself or in a loved one who suffers from sleepless nights. If so, you will be better able to focus on the cause of the problem—the first step toward resolving it.


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Another less common stress-related sexual problem is vaginismus. Women with vaginismus would like to be able to achieve normal sexual intercourse, but find that involuntary contraction of the muscles surrounding the vagina make penetration painful or impossible.

Flora told her doctor that she thought she had no vaginal opening. Although she had never examined herself with a mirror, she could not feel an orifice with her finger nor insert a tampon. Her doctor attempted a pelvic exam, but found that although her vulva was normal, Flora's involuntary contractions of the pubococcygeus muscles were so strong that she could not be dilated for an internal examination or a Pap smear.

A number of stresses can be responsible for vaginismus, including fear of pain, fear of pregnancy, fear of intimacy, fear of punishment, fear of intrusion, fear of "contamination," fear of dependency, and fear of rape. Vaginismus is, in fact, very often the product of an early rape—by a stranger, date, husband, or even family member. The contractions that were meant to protect the victim from the stress of unwanted intercourse can remain and prevent desired intercourse.

In cases such as this, both the symptom and the stress need treatment. Helen Kaplan recommends gradual dilation and accommodation of the vagina to the patient's own fingers, in the privacy of her own home. If the inhibition seems unyielding, clinical psychologists and psychiatrists trained as sex therapists can help women deal with the underlying fear and stress.