Information
Editors
Insomnia
Essentials
- There is usually no single cause of insomnia but, in addition to medical causes, there are a number of factors known to contribute, including certain personality traits, lifestyle habits and life situations.
- The most common form is acute insomnia triggered by a change in the patient's life situation.
- If the patient reacts to insomnia by worry, it may lead to a state of hyperalertness which in turn will perpetuate (chronic) insomnia (functional insomnia).
- A careful history is crucial in evaluation, and a sleep diary is a useful additional tool.
- A good doctor-patient relationship and a non-pharmacological approach are the primary elements oftreatment.
Prevalence
- Transient insomnia is reported to occur in one third of the adult population and chronic insomnia in just under one tenth.
- Insomnia is also common among children and adolescents.
- Insomnia is more common in women than in men and it becomes more common with age.
Causes
- Symptoms are caused by a variety of factorsEhttp://www.dynamed.com/condition/insomnia-in-adults#CAUSES:
- predisposing factors (familial history of insomnia, hyperarousability, i.e. ”a light sleeper”, personality traits, behavioural patterns)
- precipitating factors (chronic or acute strain/stress at work or other life situation, change in health status)
- perpetuating factors (the mechanisms of psychophysiological insomnia, see above, changes in sleep habits leading to insomnia, e.g. too early a bedtime or excessive amount of time spent in bed, or an increased use of stimulants such as caffeine).
- It is difficult for insomniacs to estimate accurately the duration of broken and light sleep (the average length of sleep often significantly underestimated).
- Even small amounts of stimulants can affect sleep.
- Caffeine (adenosine antagonist) may adversely affect sleep, particularly among sensitive individuals, regardless of the time of consumption.
- Smokers sleep less well than non-smokers.
- Even a fairly small amount of alcohol (< 3 units) will lighten sleep and lessen its refreshing effect.
- Insomnia is a common symptom of stressful life situations and of almost all psychiatric disorders.
- In the elderly insomnia is associated, in particular, with other concurrent illnesses (comorbid insomnia), whereas in middle-aged persons psychosocial factors (related e.g. to work or family) have a stronger impact.
- Many physical disorders are also associated with insomnia, for example:
- Psychiatric causes
- Depression
- Anxiety
- Psychoses
- Mania
- Chronobiological causes
- Irregular sleep habits (e.g. the sleep phase and duration of sleep vary excessively between the weekdays and the weekend)
- Shift work and other unusual or long work hours
- Delayed sleep phase: the patient does not fall asleep until late in the night but, if not disturbed, will sleep normally.
- Some medicines may also cause insomnia, for example:
- anxiolytics: benzodiazepines, buspirone
- statins
- NSAIDs
- antiasthmatics: beta sympathomimetics, aminophylline, theophylline
- antidementia drugs: donepezil, rivastigmine
- antiepileptics: phenytoin, lamotrigine, levetiracetam, topiramate
- CNS stimulants: amphetamine, atomoxetine, bupropion, busiprone, caffeine, methylphenidate, nicotine, pseudoephedrine, ephedrine, modafinil
- antidepressants: fluoxetine, fluvoxamine, paroxetine, trazodone and other SSRIs, MAO-A inhibitors, duloxetine, mirtazapine (over 30 mg)
- antiparkinsonian drugs: dopamine agonists, levodopa, MAO-B inhibitors
- antipsychotics: classic antipsychotics (phenthiazine derivatives)
- glucocorticoids
- thyroxine.
- Idiopathic insomnia is rare; it starts in childhood or during adolescence and has no other recognisable causes. The patient has a positive family history and the cause of the disorder is organic, originating from the central nervous system (ICD-10 classification G47.0).
Diagnosis
- The evaluation is based on a careful history Ehttp://www.dynamed.com/condition/insomnia-in-adults#HISTORY.
- Manifestation: difficulty falling asleep (initial insomnia), middle of the night awakenings (middle insomnia), waking up too early (terminal insomnia) and/or non-restorative sleep.
- Rapidity of sleep onset, repeated waking up (cause?), ability to fall back to sleep, waking up feeling refreshed?
- Time spent in bed vs. duration of sleep
- The onset, duration and development of insomnia, any changes in symptoms and their causes
- The patient's own perception of the cause of insomnia
- Sleep pattern before the onset of symptoms
- Subjective assessment of the amount of sleep needed
- Sleep environment
- Effect on well-being and performance the following day
- Degree of tiredness (dropping off to sleep, i.e. is the patient sleepy?)
- Daytime naps
- Attention, concentration, memory, proneness to accidents and mistakes
- Mood (depression or insomnia-induced dysphoria?)
- Physical perceptions.
- Assess whether the patient has symptoms that indicate an insomnia disorder:
- The clinical examination and differential diagnostics aim at detecting or excluding e.g. other sleep disorders (particularly sleep apnoea and restless legs syndrome), psychiatric illnesses, drug-induced insomnia and somatic causes.
- In normal insomnia, there is usually no need to proceed with sleep studies (a polysomnogram) or laboratory tests Ehttp://www.dynamed.com/condition/insomnia-in-adults#TESTING_OVERVIEW.
- If there are indications of possible sleep apnoea (particularly patients with overweight or a small chin, snoring or periods of apnoea occurring every night), consider overnight polysomnography Ehttp://www.dynamed.com/condition/insomnia-in-adults#TESTING_OVERVIEW
- A patient with sleep apnoea typically suffers more from unintentional sleep attacks and daytime tiredness than from insomnia.
Treatment
- A good doctor-patient relationship is central to treatment: many patients already derive benefit from a few consultations and follow-up visits.
- Self-help and environmental factors (sleep hygiene) Ehttp://www.dynamed.com/condition/insomnia-in-adults#SLEEP_HYGIENE
- Non-pharmacological treatment
- Includes mapping out the patient's sleep patterns and insomnia-perpetuating factors as well as active interventions:
- Cognitive behavioural interventions Ehttp://www.dynamed.com/condition/insomnia-in-adults#COGNITIVE_BEHAVIORAL_THERAPY explore the functions of the patient's mind, their effect on insomnia as well as the effect that treatment-induced changes in behaviour and functioning have on the patient's wellbeing.
- Stimulus control therapy is the most studied and effective method, sleep restriction may prove effective and relaxation training leads to good outcomes.
- Pharmacotherapy
Treatment approach
- Transient (< 1 month) and short-term (1-3 months) insomnia Ehttp://www.dynamed.com/condition/insomnia-in-adults#TREATMENT_OVERVIEW
- Finding out and relieving the cause of insomnia (e.g. support in life crises and, if necessary, short-term sick leave)
- Treatment according to the principles of non-pharmacological therapy may be initiated if the symptoms are not readily alleviated.
- If good sleep hygiene is not sufficient, a short course of sleep inducing medication may be considered.
- Chronic primary insomnia (> 3 months; often functional insomnia, or insomnia including apparent features of such)
References
- Kronholm E, Partonen T, Härmä M et al. Prevalence of insomnia-related symptoms continues to increase in the Finnish working-age population. J Sleep Res 2016;25(4):454-7. [PubMed]
- Davidson JR, Dickson C, Han H. Cognitive behavioural treatment for insomnia in primary care: a systematic review of sleep outcomes. Br J Gen Pract 2019;69(686):e657-e664. [PubMed]