History

Fact Explanation
Difficulty in initiating sleep This should last for at least 1 month. The patient being dissatisfied with sleep latency (at least 30 minutes) , reporting long sleep latency at sleep onset as a major sleep problem. [1]
Difficulty maintaining sleep Patient complains difficulty in resuming sleep after awakening. disrupted sleep is a major problem.[1]
Early morning awakening Short sleep duration at night with inability to resume sleep once awake. [1]
Non-restorative sleep The patient has a normal duration of sleep but is unrested upon awakening. Fatigue at awakening is a major problem.[1]
Causes clinically significant distress or impairment of the day to day functioning of the patient. Impairment of social and occupational life. [2]
Disturbance of sleep doesn't occur exclusively during the course of another sleep disorder or psychiatric disorder Psychiatric disorders such as dementia, delirium, depression, bipolar affective disorder, schizophrenia causes insomnia. [3]
Not due to the direct physiological effects of a substance or another medical disorder Physical illnesses which causes pain, shortness of breath or sleep disordered breathing, discomfort also causes disturbance of sleep. [3]
References
  1. OHAYON MM, REYNOLDS CF III. Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the International Classification of Sleep Disorders (ICSD) Sleep Med [online] 2009 Oct, 10(9):952-960 [viewed 31 May 2014] Available from: doi:10.1016/j.sleep.2009.07.008
  2. RYSTAL AD, LANKFORD A, DURRENCE HH, LUDINGTON E, JOCHELSON P, ROGOWSKI R, ROTH T. Efficacy and Safety of Doxepin 3 and 6 mg in a 35-day Sleep Laboratory Trial in Adults with Chronic Primary Insomnia Sleep [online] , 34(10):1433-1442 [viewed 30 May 2014] Available from: doi:10.5665/SLEEP.1294
  3. WILSMORE BR, GRUNSTEIN RR, FRANSEN M, WOODWARD M, NORTON R, AMERATUNGA S. Sleep Habits, Insomnia, and Daytime Sleepiness in a Large and Healthy Community-Based Sample of New Zealanders J Clin Sleep Med [online] , 9(6):559-566 [viewed 30 May 2014] Available from: doi:10.5664/jcsm.2750

Examination

Fact Explanation
Musculoskeletal examination for signs of physical illnesses that can cause insomnia i.e. conditions causing chronic pain. Conditions like peripheral vascular disease causing critical limb ischemia, rheumatoid arthritis, should be excluded in the examination. [1]
Respiratory system examination- look for barreled shape chest, rhonchi and crepitaations on auscultation Chronic Obstructive Pulmonary Disease (COPD) should be excluded. [2]
Do a cardiovascular examination - look for irregular pulse, arrhythmia on auscultation Heart diseases can cause insomnia. [2]
Look for signs of hyperthyroidism - hair loss, lid retraction, lid lag, exophthalmos, tremors, goiter, sweaty palms etc. [2] Hyperthyroidism causes insomnia. [2]
Mental State Examination: Appearance Crumpled clothes, self neglect suggests alcoholism, schizophrenia. Hunched shoulders, turned down face, vertical furrows in the brow suggest depression. [3]
Mental State Examination: Speech Speaking more slowly than usual and mutism may be seen in depression. [3]
Mental State Examination: Mood Depressed mood, anxiety associated symptoms- palpitations, tremors, dry mouth.[3]
Mental State Examination: Thinking Suicidal thoughts in severe depression. Nihilistic delusions, defamatory or accusatory auditory hallucinations in severe depressive disorder. [3]
Mental State Examination: Perception Transient hallucinations of vision and hearing in heavy alcohol drinkers usually during withdrawal. [3]
Mental State Examination: Cognitive functions Attention and concentration and memory can be impaired in depression. [3]
Mental State Examination: Insight May be lost in severe depressive disorders. [3]
References
  1. TAYLOR DJ, MALLORY LJ, LICHSTEIN KL, DURRENCE HH, RIEDEL BW, BUSH AJ. Comorbidity of chronic insomnia with medical problems. Sleep [online] 2007 Feb, 30(2):213-8 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17326547
  2. BUDHIRAJA R, ROTH T, HUDGEL DW, BUDHIRAJA P, DRAKE CL. Prevalence and Polysomnographic Correlates of Insomnia Comorbid with Medical Disorders Sleep [online] , 34(7):859-867 [viewed 31 May 2014] Available from: doi:10.5665/SLEEP.1114
  3. HARVEY AG, TANG N. (Mis)Perception of Sleep in Insomnia: A puzzle and a resolution Psychol Bull [online] 2012 Jan, 138(1):77-101 [viewed 30 May 2014] Available from: doi:10.1037/a0025730

Differential Diagnoses

Fact Explanation
Short sleepers They naturally awake after few hours of sleep. Distinguished from primary insomnia by the absence of characteristic symptoms: intermittent wakefulness, fatigue, irritability, concentration problems. [1]
Primary hypersomnia Hypersomnia can occur in primary insomnia. In hypersomnia disorders, the primary complaint is daytime sleepiness. The cause of the primary symptom is not disturbed nocturnal sleep or misaligned circadian rhythms. [2]
Circadian rhythm sleep disorder Persistent or recurrent misalignment between the patient’s sleep pattern and the pattern that is desired as the societal norm. The patient can not sleep when the sleep is desired or expected. [2]
Narcolepsy This may cause insomnia but distinguished from the primary insomnia by excessive day time sleepiness that is typically associated with cataplexy, sleep paralysis, hypnagogig hallucinations. [3]
Breathing related sleep disorder Disordered ventilation during sleep. This can be due to : Central apnea syndromes- Respiration is disturbed in an intermittent pattern due to a dysfunction in the central nervous system. They include, primary central sleep apnea, central sleep apnea due to Cheyne-Stokes breathing pattern, central sleep apnea due to high-altitude periodic breathing, secondary form of central sleep apnea due to drug or substance ( seen in long therm opioid users). Or, obstructive sleep apnea syndromes- obstruction in the air way causes inadequate ventilation. [2]
Parasomnias Parasomnias are undesirable physical or experiential events that accompany sleep. They consist of abnormal sleep-related movements, behaviors, emotions, perceptions, dreaming, and autonomic nervous system functioning, which may lead to intermittent awakening. [2]
Mental disorders that causes insomnia Major depressive disorder, anxiety disorders, schizophrenia causes insomnia. Primary insomnia is not diagnosed when the insomnia exclusively occurs during the course of another mental disorder. [2]
Insomnia due to general medical conditions Conditions like hyperthyroidism, pheochromocytoma, conditions causing chronic pain. [2]
Substance induced insomnia Caffeine induced sleep disorder. [2]
References
  1. KNUTSON KL, VAN CAUTER E, RATHOUZ PJ, DELEIRE T, LAUDERDALE DS. Trends in the Prevalence of Short Sleepers in the USA: 1975-2006 Sleep [online] 2010 Jan 1, 33(1):37-45 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2802246
  2. THORPY MJ. Classification of Sleep Disorders Neurotherapeutics [online] 2012 Oct, 9(4):687-701 [viewed 31 May 2014] Available from: doi:10.1007/s13311-012-0145-6
  3. NISHINO S. Clinical and Neurobiological Aspects of Narcolepsy Sleep Med [online] 2007 Jun, 8(4):373-399 [viewed 31 May 2014] Available from: doi:10.1016/j.sleep.2007.03.008

Investigations - for Diagnosis

Fact Explanation
Polysomnography Basic polysomnograms use EEG, electromyographs and electrooculograms. This measures brain and muscle activity and assesses oxygen saturation overnight. It can be used to confirm sleep apnoea and limb movement disorders or restless legs syndrome.
TSH, fT4 To exclude hyperthyroidism that can cause secondary insomnia. [2]
ECG and echocardiography Cardiac problems including arrhythmia, heart failure can cause sleep disturbances. [1]
References
  1. BUDHIRAJA R, ROTH T, HUDGEL DW, BUDHIRAJA P, DRAKE CL. Prevalence and Polysomnographic Correlates of Insomnia Comorbid with Medical Disorders Sleep [online] , 34(7):859-867 [viewed 31 May 2014] Available from: doi:10.5665/SLEEP.1114
  2. THORPY MJ. Classification of Sleep Disorders Neurotherapeutics [online] 2012 Oct, 9(4):687-701 [viewed 31 May 2014] Available from: doi:10.1007/s13311-012-0145-6

Management - General Measures

Fact Explanation
Instruction of patients about good sleep hygiene. The conditions and practices that promote circadian rhythm-appropriate, continuous, and effective sleep. This includes: Having a regular sleep and wake time.Regular exercise, increase exposure to bright light during the day, reduce exposure to bright light during the night. Avoiding heavy meals and excessive fluids within 3 hours of bed time. Avoiding alcohol, nicotine and cocaine. Improvement sleep environment (a dark, quiet place). Avoid having the television on in the bedroom during sleep time. Adopt a relaxing routine before the bedtime. [1]
Educate the patient about the importance of non pharmacological treatment in insomnia. Many patients expect to achieve a cure through medication, while the condition can be resolved maintaining good sleep hygiene and using behavioral therapy. [2]
References
  1. WITCHER LA, GOZAL D, MOLFESE DM, SALATHE SM, SPRUYT K, CRABTREE VM. Sleep Hygiene and Problem Behaviors in Snoring and Non-Snoring School-Age Children Sleep Med [online] 2012 Aug, 13(7):802-809 [viewed 31 May 2014] Available from: doi:10.1016/j.sleep.2012.03.013
  2. OHAYON MM, REYNOLDS CF III. Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the International Classification of Sleep Disorders (ICSD) Sleep Med [online] 2009 Oct, 10(9):952-960 [viewed 31 May 2014] Available from: doi:10.1016/j.sleep.2009.07.008

Management - Specific Treatments

Fact Explanation
Cognitive behavioral therapy (CBT)- sleep restriction and stimulus control, relaxation therapy. Sleep restriction - the time spent in bed is restricted to the time the patient thinks he sleeps plus a 15 minutes - minimum of 5 hours. Stimulus control- to break the negative association between being in bed and inability to sleep.The patient is advised to leave the bed if unable to sleep within few minutes of being in the bed, engage in another activity until the patient feel sleepy and then try sleeping again, get up the same time every day, keep out of the bed during the day. [1]
Pharmacotherapy: Short-intermediate acting benzodiazepine receptor agonists Pharmacotherapy is not the first line treatment in insomnia. Useful in acute insomnia ( due to stress) Drugs such as zolpidem, eszopiclone, zaleplon (z class hypnotics), and temazepam. Can be used. Commonest adverse effect experienced is dizziness. Unlike benzodiazepines,' z hypnotics' can be used long term because they don't cause dependence. Traditional Benzodiazepines such as triazolam, lorazepam- not recommended for chronic insomnia. Recommended for use in short periods.
Pharmacotherapy: Melatonin agonist Drugs such as Ramelteon, are not sedative and has no abuse potential. It reduces time to sleep onset and increases the total sleep time. [2]
Pharmacotherapy: Sedating antidepressants Drugs such as Trazodone, Amitriptyline, Doxepin, and Mirtazapine are specially useful when treating comorbid depression/anxiety. [1]
References
  1. SCHUTTE-RODIN S, BROCH L, BUYSSE D, DORSEY C, SATEIA M. Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults J Clin Sleep Med [online] 2008 Oct 15, 4(5):487-504 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576317
  2. MIYAMOTO M. Pharmacology of Ramelteon, a Selective MT1/MT2 Receptor Agonist: A Novel Therapeutic Drug for Sleep Disorders CNS Neurosci Ther [online] 2009, 15(1):32-51 [viewed 31 May 2014] Available from: doi:10.1111/j.1755-5949.2008.00066.x