Chapter 028. Sleep Disorders (Part 6)

Evaluation of InsomniaInsomnia is the complaint of inadequate sleep; it can be classified according to the nature of sleep disruption and the duration of the complaint. Insomnia is subdivided into difficulty falling asleep (sleep onset insomnia), frequent or sustained awakenings (sleep maintenance insomnia), early morning awakenings (sleep offset insomnia), or persistent sleepiness/fatigue despite sleep of adequate duration (nonrestorative sleep). Similarly, the duration of the symptom influences diagnostic and therapeutic considerations. An insomnia complaint lasting one to several nights (within a single episode) is termed transient insomnia and is typically the result of situational stress or a change in sleep...
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Chapter 028. Sleep Disorders (Part 6) Chapter 028. Sleep Disorders (Part 6) Evaluation of Insomnia Insomnia is the complaint of inadequate sleep; it can be classifiedaccording to the nature of sleep disruption and the duration of the complaint.Insomnia is subdivided into difficulty falling asleep (sleep onset insomnia),frequent or sustained awakenings (sleep maintenance insomnia), early morningawakenings (sleep offset insomnia), or persistent sleepiness/fatigue despite sleepof adequate duration (nonrestorative sleep). Similarly, the duration of thesymptom influences diagnostic and therapeutic considerations. An insomniacomplaint lasting one to several nights (within a single episode) is termedtransient insomnia and is typically the result of situational stress or a change insleep schedule or environment (e.g., jet lag disorder). Short-term insomnia lastsfrom a few days to 3 weeks. Disruption of this duration is usually associated withmore protracted stress, such as recovery from surgery or short-term illness. Long-term insomnia, or chronic insomnia, lasts for months or years and, in contrast withshort-term insomnia, requires a thorough evaluation of underlying causes (seebelow). Chronic insomnia is often a waxing and waning disorder, withspontaneous or stressor-induced exacerbations. An occasional night of poor sleep, typically in the setting of stress orexcitement about external events, is both common and without lastingconsequences. However, persistent insomnia can lead to impaired daytimefunction, injury due to accidents, and the development of major depression. Inaddition, there is emerging evidence that individuals with chronic insomnia haveincreased utilization of health care resources, even after controlling for co-morbidmedical and psychiatric disorders. All insomnias can be exacerbated and perpetuated by behaviors that are notconducive to initiating or maintaining sleep. Inadequate sleep hygiene ischaracterized by a behavior pattern prior to sleep or a bedroom environment that isnot conducive to sleep. Noise or light in the bedroom can interfere with sleep, ascan a bed partner with periodic limb movements during sleep or one who snoresloudly. Clocks can heighten the anxiety about the time it has taken to fall asleep.Drugs that act on the central nervous system, large meals, vigorous exercise, or hotshowers just before sleep may all interfere with sleep onset. Many individualsparticipate in stressful work-related activities in the evening, producing a stateincompatible with sleep onset. In preference to hypnotic medications, patientsshould be counseled to avoid stressful activities before bed, develop a soporificbedtime ritual, and to prepare and reserve the bedroom environment for sleeping.Consistent, regular rising times should be maintained daily, including weekends. Primary Insomnia Many patients with chronic insomnia have no clear, single identifiableunderlying cause for their difficulties with sleep. Rather, such patients often havemultiple etiologies for their insomnia, which may evolve over the years. Inaddition, the chief sleep complaint may change over time, with initial insomniapredominating at one point, and multiple awakenings or nonrestorative sleepoccurring at other times. Subsyndromal psychiatric disorders (e.g., anxiety andmood complaints), negative conditioning to the sleep environment(psychophysiologic insomnia, see below), amplification of the time spent awake(paradoxical insomnia), physiologic hyperarousal, and poor sleep hygiene (seeabove) may all be present. As these processes may be both causes andconsequences of chronic insomnia, many individuals will have a progressivecourse to their symptoms in which the severity is proportional to the chronicity,and much of the complaint may persist even after effective treatment of the initialinciting etiology. Treatment of insomnia is often directed to each of the putativecontributing factors: behavior therapies for anxiety and negative conditioning (seebelow), pharmacotherapy and/or psychotherapy for mood/anxiety disorders, andan emphasis on maintenance of good sleep hygiene. If insomnia persists after treatment of these contributing factors, empiricalpharmacotherapy is often used on a nightly or intermittent basis. A variety ofsedative compounds are used for this purpose. Alcohol and antihistamines are themost commonly used nonprescription sleep aids. The former may help with sleeponset but is associated with sleep disruption during the night and can escalate intoabuse, dependence, and withdrawal in the predisposed individual. Antihistaminesmay be of benefit when used intermittently but often produce rapid tolerance andmay have multiple side effects (especially an ...