Evaluation and Diagnosis of Chronic Insomnia
SUMMARY
Insomnia is defined as a self-reported dissatisfaction with sleep quality or quantity. Symptoms of insomnia occur in as much as 50% of the US population, often in conjunction with other psychiatric conditions such as anxiety, depression and PTSD. Insomnia disorder occurs when insomnia symptoms cause daytime impairment, with an estimated 10 to 15% of adults suffering from insomnia disorder during their lives. The evaluation and diagnosis of insomnia disorder is critical to forming an appropriate treatment plan. For information on the treatment of chronic insomnia, please see related topics below.
DEFINITIONS
Insomnia
- Difficulty with sleep latency (falling asleep)
- Difficulty maintaining sleep
- Poor sleep quality or quantity
Insomnia Disorder
- Insomnia symptoms that causes daytime impairment or distress
Short-term Insomnia Disorder
- Typically in response to a stressor
- Symptoms last over days to weeks before resolving
Chronic Insomnia Disorder
- Insomnia symptoms that occur at least three nights a week and last for at least 3 months AND
- Symptoms must cause clinically significant functional distress or impairment AND
- Symptoms cannot be linked to other psychiatric or medical conditions
CLINICAL SIGNS AND SYMPTOMS
- Insomnia symptoms include
- Difficulty falling asleep: > 30 minutes to fall asleep is considered delayed sleep latency
- Difficulty maintaining sleep: Waking after sleep onset > 30 minutes
- Early morning awakenings: ;6.5 hours total sleep
- Sleep that does not feel restful or restorative: Sleep efficiency < 85%
- Fatigue, Malaise
- Poor concentration | Impaired cognition
- Missed days from work
- Difficulty with complex tasks
- Mood disturbance | Increased irritability
- Anxiety and worry over loss of sleep
- Mistakes or errors during daily activities
- Exacerbation of co-morbid conditions
- Daytime sleepiness
- Excessive daytime sleepiness is usually due to sleep deprivation, not insomnia
Risk Factors
- Increasing age
- Older adults more likely to report problems with sleep quality and maintaining, younger adults are more likely to have difficult falling asleep
- Female Sex
- Comorbid conditions: Depression | Anxiety | PTSD | Substance use disorders | Chronic pain | Other sleep disorders (e.g., Obstrucive Sleep Apnea, Restless Leg Syndrome) | Benign Prostatic Hyperplasia
- Shift workers | Unemployment
Differential Diagnosis
- Medications: Caffeine | Opiates | SSRIs | Beta blockers | Theophylline | Diuretics | SNRIs | Pseudoephedrine
- Alcohol use
- BPH leading to frequent awakenings
- Restless leg syndrome
- OSA
- Circadian rhythm sleep disorders
EVALUATION
- Conduct a general medical, psychiatric and substance use assessment to identify comorbid disorders or modifiable behaviors and illnesses
- If there is clinical concern, obtain laboratory evaluation to evaluate underlying medical conditions
- TSH | CMP | Iron studies | CBC
- Obtain a thorough sleep history including
- Length of symptoms
- Prior treatments tried
- Frequency of symptoms
- Severity of nighttime distress
- Daytime symptomatology
- Precipitating or perpetuating factors
- Clinical course (e.g., relapsing, intermittent, progressive)
- Conduct a sleep log over 2 to 4 weeks to define sleep-wake pattern including:
- Medications | Substance use | Caffeine use
- Daytime napping
- Bedtime activities
- Bedroom environment
- Bedtime
- Sleep latency (time to fall asleep following bedtime)
- Number of awakenings and duration of each awakening
- Wake after sleep onset
- Time in bed (time from bedtime to getting out of bed)
- Total sleep time
- Sleep efficiency percent ([total sleep time/time in bed] x 100)
- Daytime consequences (e.g., mood changes, cognitive dysfunction)
- Sleepiness assessment: Various tools exist | Should be repeated periodically to monitor clinical course | Used also as screening to identify sleepy patients and degree of sleepiness
- Epworth Sleepiness Scale
- Insomnia Severity Index
- Pittsburgh Sleep Quality Index
- Polysomnography not routinely indicated unless there is clinical suspicion for comorbid condition
KEY POINTS
- Many adults suffer from insomnia symptoms, but roughly 10 to 15% will develop insomnia disorder that interferes with their daytime activities
- Insomnia is often associated with comorbid psychiatric conditions, and tends to worsen any comorbid conditions a patient may have
- The key to diagnosis is a thorough medical, psychiatric, sleep and substance use history
