insomnia
INSOMNIA

Insomnia can be either having difficulty in initiating sleep, maintaining sleep or experiencing early morning awakening wherein returning to sleep is not easily attained.

These disturbances can cause significant distress and impairment in daytime functioning.

It is the most prevalent sleep disorder in the general population thus accurate diagnosis and effective treatment is necessary.

Diagnosis

  • Based on DSM-5 criteria, a diagnosis of insomnia is made if there is a predominant complaint of dissatisfied sleep related to its quantity or quality associated with at least one of the following symptoms:
    • Having trouble with sleep initiation or maintenance; in children, this is manifested as having trouble with sleep without the caregiver’s intervention
    • Interrupted sleep (eg frequent awakenings or early-morning awakening) with difficulty returning to sleep afterwards
  • Also, DSM-5 criteria stated that the sleeping difficulty:
    • Causes distress or impairment in significant areas of functioning (eg social, occupational, educational, academic, behavioral)
    • Occurs ≥3 nights per week
    • Duration of ≥3 months
    • Occurs even though there is sufficient opportunity for sleep
  • The insomnia is not due to & does not happen during another sleep-wake disorder (eg narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia)
  • The symptoms are not caused by effects of substance or medication
  • The disturbance is not associated with coexisting mental disorders & medical conditions
  • May specify insomnia if with non-sleep disorder mental comorbidity, with other medical comorbidity or with other sleep disorder
  • Insomnia may be specified further as:
    • Episodic where symptoms occur for at least a month but less than 3 months
    • Persistent where symptoms occur for ≥3 months
    • Recurrent where ≥2 episodes occur within a span of a year
  • Insomnia lasting for <3 months that meets the criteria for insomnia disorder in regards to frequency, intensity, significant distress &/or impairment should be considered under the other specified insomnia disorder

Evaluation

Evaluation

  • Comprehensive clinical history & physical examination that evaluates sleep & waking function of the patient
  • Common medical, psychiatric, & medication/substance-related comorbidities should also be assessed
  • Characterize primary insomnia complaint
    • Eg difficulty falling asleep, awakenings, or poor & unrefreshing sleep
    • Determine the onset, duration, frequency, severity, course & perpetuating factors
    • Ask about past & current treatments & response of the patient
  • Self-administered questionnaires, sleep log, symptom checklists, psychologic screening tests & interviews with bed partner are some of the instruments that help arrive at the proper diagnosis

Classification

Primary Insomnia

  • Predominant complaint is difficulty in initiating or maintaining sleep, or non-restorative sleep for at least 1 month
  • Sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational or other important areas of functioning
  • Sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia
  • Disturbance does not occur exclusively during the course of another mental disorder (eg major depressive disorder, generalized anxiety disorder)
  • Disturbance is not due to the direct physiological effects of a substance (eg drug of abuse, medication) or a general medical condition

Primary Insomnia Disorders

Adjustment insomnia

  • Presence of insomnia associated with an identifiable stressor
  • Sleep disturbance has a relatively short duration, occurring days to weeks, & is expected to resolve when the stressor resolves or when individual is able to adapt
  • Associated with unfamiliar sleep environment, situational stress, acute medical illness or pain, shift work, or caffeine or alcohol use
  • Diagnosis can only be firmly made retrospectively after it has been relieved
  • Usually triggered by: changes in sleep environment, high arousal states, poor sleep hygiene, short-term circadian rhythm disorders including particularly by jet lag & rotating shift work

Psychophysiological insomnia

  • Involves heightened arousal & learned sleep-preventing associations
  • Arousal is characterized by muscle tension, “racing thoughts”, or increased awareness of environment
  • Patients have increased concern about sleep difficulties & their consequences

Paradoxical insomnia

  • Important feature is the complaint of severe or nearly “total” insomnia that greatly exceeds objective evidence of sleep disturbance & is not equivalent with the reported daytime dysfunction
  • Best diagnosed with polysomnography & self-reports

Idiopathic insomnia

  • Has an insidious onset during infancy or early childhood; also called childhood-onset insomnia or life-long insomnia
  • No associated precipitating or perpetuating factors
  • Diagnosed only after concomitant medical, neurologic, & psychiatric problems have been ruled out

Inadequate sleep hygiene

  • Associated with voluntary sleep practices or activities that typically produce increased arousal or directly interfere with sleep
  • Such activities include irregular sleep scheduling; use of alcohol, nicotine or caffeine; mentally or physically stimulating activities before bedtime; & use of the bed or bedroom for activities not related to sleep (eg snacking, studying, reading)

Secondary Insomnia (Comorbid Insomnia)

Common comorbid medical disorders & conditions

  • Neurological
    • Stroke, Parkinson’s disease, dementia, seizure disorders, headache disorders, traumatic brain injury, chronic pain disorders, peripheral neuropathy, neuromuscular disorders
  • Cardiovascular
    • Angina, congestive heart failure
  • Pulmonary/Respiratory
    • Chronic obstructive pulmonary disease (COPD), emphysema, asthma, laryngospasm
  • Gastrointestinal
    • Reflux, peptic ulcer disease, cholelithiasis, colitis, irritable bowel syndrome
  • Genitourinary
    • Incontinence, benign prostatic hypertrophy, interstitial cystitis
  • Endocrine
    • Hyperthyroidism, hypothyroidism, diabetes mellitus
  • Musculoskeletal
    • Rheumatoid arthritis, osteoarthritis, fibromyalgia, Sjogren syndrome, kyphosis
  • Reproductive
    • Pregnancy, menopause, menstrual cycle variations
  • Sleep disorders
    •  Obstructive sleep apnea, central sleep apnea, restless legs syndrome, periodic limb movement disorder, circadian rhythm sleep disorders, parasomnias

Common comorbid psychiatric disorders

  • Mood disorders
    • Major depressive disorder, bipolar mood disorder
  •  Anxiety disorders
    •  Generalized anxiety disorders, panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder
  • Psychotic disorders
    • Schizophrenia, schizoaffective disorder
  •  Amnestic disorders
    • Alzheimer’s disease, other dementias
  • Other disorders
    • Attention-deficit disorder, adjustment disorders, personality disorders, bereavement, stress

Common medications or substances contributing to insomnia

  • Antidepressants
    • Fluoxetine, Paroxetine, Sertraline, Venlafaxine, Duloxetine, monoamine oxidase inhibitors
  • Stimulants
    • Caffeine, Methylphenidate, amphetamine derivatives, Ephedrine & derivatives, cocaine
  • Decongestants
    • Pseudoephedrine, phenylephrine, phenylpropanolamine
  • Narcotic analgesics
    • Oxycodone, Codeine
  • Cardiovascular medications
    • Beta-blockers, alpha-receptor agonists & antagonists, diuretics, lipid-lowering agents
  • Respiratory medications
    • Theophylline, albuterol
  • Alcohol
  • Corticosteroids

Chronic Insomnia

  • Insomnia persisting for >4 weeks & is usually associated w/ the above comorbid medical &/or psychiatric conditions
  • Patients w/ chronic insomnia should be evaluated for depression
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