INSOMNIA (SLEEPLESSNESS)

  Insomnia is the most prevalent sleep disorder in the general population, defined as repeated difficulty with falling and staying asleep, and with achieving sleep consolidation or good-quality sleep despite adequate time and opportunity. An insomnia diagnosis requires the presence of both suggestive symptomatology and associated daytime dysfunction. Insomnia often presents with comorbid conditions, including psychiatric, sleep, and substance use disorders.

 

    Females are at higher risk of developing insomnia than are males. The higher prevalence of insomnia among females begins in adolescence but becomes particularly notable during menopause. Insomnia is also more prevalent among elderly patients.

Patients with comorbid psychiatric conditions are at particularly increased risk for insomnia. Another risk factor for sleep disorders is shift work.

Insomnia can also occur as a symptom of another sleep disorder, such as obstructive sleep apnea (OSA). Patients with obesity are also at increased risk of developing OSA.

 

The third edition of the International Classification of Sleep Disorders (ICSD-3) revised the definition of insomnia in 2014, subclassifying insomnia as short-term, chronic, or other.

In the past, chronic insomnia was defined as either primary or comorbid. This system was updated because it did not sufficiently guide diagnosis or treatment options. Calling insomnia comorbid may suggest that it is a secondary condition that will resolve upon treatment of the primary condition; in reality, however, the cognitions and behaviors that manifest in insomnia must be addressed whether or not a patient is diagnosed with another co-occurring medical or psychiatric disorder.

Insomnia can also be classified as either chronic insomnia, which is present for at least a month, or acute or transient insomnia, which may last days to weeks.

 Drawing data from a national sample of health plan members, Walsh and colleagues set out to explore the distribution of the hallmark symptoms of insomnia: difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening, and nonrestorative sleep. The most prevalent symptom in this representative group was difficulty maintaining sleep (61%), followed by nonrestorative sleep (25.2%), difficulty initiating sleep (7.7%), and early-morning awakening (2.2%).

 

The diagnosis of insomnia is centered around the patient history. In addition to a detailed sleep history, a 2-week sleep log can help identify sleep patterns and maladaptive behaviors. A sleepiness assessment, such as the Epworth Sleepiness Scale, is also essential to workup.

Polysomnography and daytime multiple sleep latency testing are not indicated in the routine evaluation of chronic insomnia. Polysomnography is indicated when diagnosis remains unclear, clinical evidence suggests either breathing disorders (ie, sleep apnea) or movement disorders, or when behavioral or pharmacologic treatment fails. Actigraphy may be of diagnostic value when depression is suspected.

 

The clinical scenario in the second answer choice is the most accurate description of a patient presenting with insomnia. Perimenopause can disrupt sleep patterns, and early awakening is a cardinal presenting symptom of insomnia.

A diagnosis of insomnia can be made when the following requirements are met: a patient experiences difficulty initiating or maintaining sleep, is waking up too early, or is getting nonrestorative sleep. These issues must persist despite adequate opportunity for sleep. In addition, at least one form of daytime impairment must be reported, such as attention impairment, poor school performance, irritability, daytime sleepiness, headaches or gastrointestinal symptoms in response to sleep loss, or concerns about sleep.

 Medscape