Editors

ChristerHublin

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 factorshttp://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:
- pain Chronic Pain
- restless legs syndrome
- reflux disease and other causes of abdominal symptoms Gastro-Oesophageal Reflux Disease
- conditions causing dyspnoea, such as chronic obstructive pulmonary disease and cardiac insufficiency Chronic Obstructive Pulmonary Disease (COPD) Chronic Heart Failure
- prostate and menopause symptoms Benign Prostatic Hyperplasia Menopausal Symptoms and Hormone Therapy
- hyperthyroidism Hyperthyroidism
- diabetes.
- Note: sleep apnoea Sleep Apnoea in the Adult may also manifest itself as insomnia (the patient is woken by episodes of disturbed breathing).
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 http://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:
- symptoms at least on three days per week
- impairs daytime functional capacity.
- The severity of insomnia can be assessed with Insomnia Severity Index (ISI) http://mapi-trust.org/questionnaires/isi/.
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 http://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 http://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) http://www.dynamed.com/condition/insomnia-in-adults#SLEEP_HYGIENE
- Sleep environment, sleep habits and regular sleep schedule
- Functioning during awake hours and timing of the awake period
- Stimulants http://www.dynamed.com/condition/insomnia-in-adults#DIET
Non-pharmacological treatment
- Includes mapping out the patient's sleep patterns and insomnia-perpetuating factors as well as active interventions:
  - lifestyle check-up
  - physical exercise http://www.dynamed.com/condition/insomnia-in-adults#EXERCISE
  - relaxation http://www.dynamed.com/condition/insomnia-in-adults#RELAXATION_TRAINING
  - sleep stimulus control http://www.dynamed.com/condition/insomnia-in-adults#STIMULUS_CONTROL_THERAPY
  - limiting the time spent in bedhttp://www.dynamed.com/condition/insomnia-in-adults#OTHER_BEHAVIORAL_INTERVENTIONS.
- Cognitive behavioural interventions http://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
- The maximum dose must not be exceeded, and the medicine should be taken as a single dose at bedtime.
- The half-life of the medicine should be considered and the patient informed about possible residual effects that persist until the following morning or day (e.g. accident proneness, fatigue and other cognitive disturbances, fitness to operate in traffic).
- Insufficient data exist on hypnotic use exceeding 3 months, and it is not possible to estimate the efficacy (or safety) of long-term use.
- In individuals aged over 60 years, the disadvantages of long-term use of hypnotics outweigh the benefits Sedative Hypnotics in Older People with Insomniahttp://www.dynamed.com/condition/insomnia-in-adults#CAUTIONS_AND_ADVERSE_EFFECTS_WITH_HYPNOTIC_SEDATIVE_USE.
- Benzodiazepine derivatives (zolpidem and zopiclone) http://www.dynamed.com/condition/insomnia-in-adults#NONBENZODIAZEPINES do not alter the sleep structure as much as benzodiazepines http://www.dynamed.com/condition/insomnia-in-adults#BENZODIAZEPINES themselves.
- A small dose of a sedating antidepressant (doxepin, trimipramine, mirtazapine, trazodone) may be used as an alternative http://www.dynamed.com/condition/insomnia-in-adults#NONBENZODIAZEPINES Antidepressants for Insomnia in Adults.
- Antipsychotics are mainly used to treat insomnia associated with psychotic disorders.
- Melatoninhttp://www.dynamed.com/condition/insomnia-in-adults#MELATONIN is effective in chronic primary insomnia. It should be taken at the same time every evening.

Treatment approach

Transient (< 1 month) and short-term (1-3 months) insomnia http://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)
- Cognitive interventions are the treatment of choice since they address the perpetuating factors, and their efficacy persists even after the treatment is stopped http://www.dynamed.com/condition/insomnia-in-adults#TOPIC_MNT_T4C_VGB.
- Non-pharmacological treatment can effectively be carried out also in primary care http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC6663098&blobtype=pdf
- The treatment of any underlying conditions may also be considered as insomnia treatment (e.g. an antidepressant for depression, an analgesic for pain or a dopamine agonist for restless legs syndrome).

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]

section name header

Information

Editors

Insomnia

Essentials

Prevalence

Causes

Diagnosis

Treatment

Treatment approach

References