Insomnia is one of the most common complaints reported in primary care.
Diagnosis is made primarily by patient interview. Sleep diaries, actigraphy, and polysomnography may assist in confirming diagnosis.
Identification of the correct etiology is essential, as interventions differ and may be harmful in some cases if the diagnosis is incorrect.
The significant morbidity of insomnia indicates that it is a condition that warrants treatment.
Take an individualized approach to treatment, based on the patient's preferences, the severity of their insomnia, the risks versus benefits of treatment, and the availability of specialist treatment options such as cognitive behavioral therapy.
For most patients, initial treatment with a behavioral therapy such as cognitive behavioral therapy for insomnia (CBT-I) is likely to provide the best balance between efficacy and safety.
As per the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), insomnia disorder is defined as difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality. The resulting sleep disturbance leads to impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning, as well as causing significant distress. Patients experience insomnia even with adequate opportunity to sleep for at least 3 nights per week and for at least 3 months. Insomnia is not explained by the presence of mental disorders or medical conditions and is not associated with another sleep disorder.
Definitions vary, but acute insomnia is typically considered to be insomnia lasting less than 4 weeks, occuring in response to an identifiable stressor. Chronic insomnia is typically considered to be insomnia persisting beyond 4 weeks.
History and exam
Key diagnostic factors
- sleep partner complaints
- delayed sleep onset
- multiple or long awakenings
Other diagnostic factors
- impairment of functioning
- decreased sleep time
- daytime napping
- chronic pain
- restless leg syndrome
- enlarged tonsils or tongue
- micrognathia and retrognathia
- lateral narrowing of oropharynx
- female sex
- advanced age
- chronic medical conditions
- chronic pain (e.g., hip impairment)
- psychiatric illness
- alcohol or substance misuse
- stimulant usage
- poor sleep hygiene
- traumatic brain injury
- recent travel across time zones
- night work
- thyroid dysregulation
- participation in elite sport
- sedentary behavior
1st investigations to order
- Pittsburgh Sleep Quality Index (PSQI)
- Insomnia Severity Index (ISI)
- Stanford Sleepiness Scale (SSS)
- Epworth Sleepiness Scale
- Athens Insomnia Scale (AIS)
Investigations to consider
- polysomnography (PSG)
- sleep diary
- thyroid-stimulating hormone (TSH)
John W. Winkelman, MD, PhD
Chief, Sleep Disorders Clinical Research Program
Department of Psychiatry
Massachusetts General Hospital
Professor of Psychiatry
Harvard Medical School
JWW has received honoraria for consulting to Avadel, CVS, Eisai, and Merck, and research grants from Merck and the RLS Foundation.
Dr John W. Winkelman would like to gratefully acknowledge Dr Teofilo Lee-Chiong and Dr Vipin Malik, previous contributors to this topic.
TLC is the Chief Medical Liaison for Philips, a company that makes devices to treat sleep apnea. VM received research funding from Philips Respironics for a study on COPD-OSA overlap.
Karl Doghramji, MD
Sleep Disorders Center
Thomas Jefferson University Hospital
KD is a speaker for Sanofi-Aventis, King Pharmaceuticals, Takeda Pharmaceuticals, Sepracor, and Pfizer; a consultant for Sanofi-Aventis, Takeda Pharmaceuticals, Sepracor, Pfizer, and Neurocrine Biosciences; and has stock in Merck.
Chiadi U. Onyike, MD, MHS
Geriatric Psychiatry and Neuropsychiatry
The Johns Hopkins Hospital
CUO declares that he has no competing interests.
Roy Goldberg, MD
Kings Harbor Multicare Center
RG declares that he has no competing interests.
Craig Sawchuk, MD
Affiliate Assistant Professor
Department of Psychiatry and Behavioral Sciences
University of Washington Medical Center
CS declares that he has no competing interests.
David Cunnington, MD
Melbourne Sleep Disorders Centre
DC has received consulting fees from Sanofi-Aventis and Lundbeck, and honoraria for speaking from Sanofi-Aventis.
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