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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:
  • 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:
  • 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

Treatment approach

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]