Insomnia 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 and/or behavioral)
  • Occurs ≥3 nights per week
  • Last for ≥3 months
  • Occurs even though there is sufficient opportunity for sleep
• The insomnia is not due to and does not happen during another sleep-wake disorder (eg narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder or a parasomnia)
• The symptoms are not caused by effects of substance or medication
• The disturbance is not associated with coexisting mental disorders and 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 and/or impairment should be considered under the other specified insomnia disorder

• Comprehensive clinical history and physical examination that evaluate sleep and waking function of the patient
  • Sleep history includes sleep habits, sleep environment, work schedules and circadian factors
  • Determine the onset, duration, frequency, severity, course and perpetuating factors
  • Ask about past and current treatments and response of the patient
  • Screen for physical symptoms such as pain, nocturia, shortness of breath, itch, paresthesia, reflux, restlessness or general discomfort, which may disrupt sleep
• Common medical, psychiatric, and medication/substance-related comorbidities should also be assessed

• Self-administered questionnaires, sleep log, symptom checklists, psychologic screening tests and interviews with bed partner are some of the instruments that help arrive at the proper diagnosis
  • Ask patient to keep a sleep diary
  • May use questionnaires such as Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI) or Morningness-Eveningness Questionnaire (MEQ)
    • ISI is a self-report tool which measures perceived severity of insomnia and has been shown to be a valid and reliable tool to detect patients with insomnia
    • PSQI may be used to evaluate subjective sleep during the previous month
    • MEQ is for assessment of circadian factor
• Polysomnography can be used:
  • To evaluate other suspected sleep disorders (ie periodic limb movement disorder)
  • In treatment-resistant insomnia
  • For professional at-risk populations
  • When substantial sleep state misperception is suspected

Short-Term Insomnia Disorder

• Symptoms are present for <3 months
• Also referred to as adjustment insomnia or acute insomnia
• Presence of insomnia associated with an identifiable stressor
• Sleep disturbance has a relatively short duration, occurring days to weeks, and 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 or short-term circadian rhythm disorders including particularly by jet lag and rotating shift work

Chronic Insomnia Disorder

• Insomnia persisting for at least 3 months with a frequency of at least 3 times per week
• Consists of the former terms primary insomnia, secondary insomnia and comorbid insomnia
• Patients with chronic insomnia should be evaluated for depression

Common Comorbid Medical Disorders and 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
    • Screen for obstructive sleep apnea using STOP Bang screening questionnaire: Ask about snoring, tiredness during the day, observed apneic episodes, high blood pressure, body mass index >30 kg/m², age >50 years, neck circumference >40 cm, and male gender

Common Comorbid Psychiatric Disorders

• Mood disorders
  • Major depressive disorder, bipolar 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

Common Medications or Substances Contributing to Insomnia

• Antidepressants
  • Fluoxetine, Paroxetine, Sertraline, Venlafaxine, Duloxetine, monoamine oxidase inhibitors (MAOIs)

• Stimulants
  • Caffeine, Methylphenidate, amphetamine derivatives, Ephedrine and derivatives, cocaine

• Decongestants
  • Pseudoephedrine, Phenylephrine, Phenylpropanolamine

• Narcotic analgesics
  • Oxycodone, Codeine

• Cardiovascular medications
  • Beta-blockers, alpha-receptor agonists and antagonists, diuretics, lipid-lowering agents

• Respiratory medications
  • Theophylline, albuterol

• Alcohol
• Corticosteroids