Insomnia Clinical Presentation
- Author: Jasvinder Chawla, MD, MBA; Chief Editor: Selim R Benbadis, MD more...
The patient history is the most important part of the evaluation for insomnia. It must include a complete sleep history, medical history, psychiatric history, social history, and medication review. The 2008 American Academy of Sleep Medicine (AASM) guideline consensus is that at a minimum, patients should complete the following evaluations :
A general medical and psychiatric questionnaire to detect comorbid disorders
A sleepiness assessment, such as the Epworth Sleepiness Scale
A 2-week sleep log to define sleep-wake patterns and their variability
For the sleep history, the examiner must determine the timing of insomnia, the patient's sleep habits (commonly referred to as sleep hygiene), and whether the patient is experiencing the symptoms of the sleep disorders associated with insomnia.
To determine the timing of insomnia, ask the patient the following questions:
Is the difficulty with falling asleep, frequent awakenings, or early morning awakening?
If the problem is at sleep onset, are you sleepy when you get into bed?
To determine the sleep schedule, ask the patient questions such as the following:
What time do you go to bed and get up in the morning?
Do you go to bed and get up at the same times every day? How about during off days?
Has this schedule changed recently?
Inquire about the patient's sleep environment, as follows:
What are the temperature, bed comfort, and noise and light levels?
Do you sleep better in a chair or when away from home (eg, hotel) than in your own bed?
Sleep habits can also be determined with questioning. Individuals with insomnia often have poor sleep hygiene. Questions regarding sleep hygiene are as follows:
Before bedtime, do you relax or do you work?
Do you read or watch television in bed?
Is the television or a light kept on during the night?
What do you do if you cannot fall asleep?
If you wake up in the middle of the night, do you fall back to sleep easily? If not, what do you do?
Do you take daytime naps?
Do you exercise? If so, at what time?
Ask patients about symptoms of other sleep disorders, such as obstructive sleep apnea (eg, snoring, witnessed apneas, gasping) and restless legs syndrome/periodic limb movement disorder (eg, restless feeling in legs on lying down, which improves with movement; rhythmic kicking during the night; sheets in disarray in the morning).
Ask about daytime effects, which should be present if the patient is truly not sleeping at night. In fact, a patient who has no daytime effects is probably getting adequate sleep and may have sleep-state misperception insomnia (sometimes called paradoxical insomnia). This rare condition, which appears to constitute less than 5% of insomnia cases, is defined by a marked discrepancy between the subjective complaint of insomnia and the objective polysomnographic findings.
Common complaints of daytime effects in patients with insomnia are as follows:
Lack of energy
Reduced work performance
These complaints should be distinguished from the complaint of excessive sleepiness, which is uncommon in insomnia. If a patient complains of excessive daytime sleepiness (ie, Epworth Sleepiness Scale Score >10), another sleep disorder should also be considered. (See the image below for the Epworth Sleepiness Scale.)
Medical and psychiatric history
Perform a thorough medical history and review of systems. Also perform a thorough psychological review to screen for psychiatric disorders. In particular, assess for signs and symptoms of anxiety or depression. Diagnostic criteria for generalized anxiety disorder are listed in the image below.
A 2-question case-finding instrument can help screen for depression. The questions are as follows:
During the past month, have you often been bothered by feeling “down,” depressed, or hopeless?
During the past month, have you often been bothered by having little interest or pleasure in doing things?
A patient who answers “No” to both questions is unlikely to have major depression. A patient who answers “Yes” to either should receive diagnostic testing for depression.
A family history should be obtained in all patients with insomnia. Though rare, fatal familial insomnia (FFI) should be considered if first-degree relatives are affected, because this disorder is inherited in an autosomal dominant pattern. A family history can also be helpful in identifying patients at risk for heritable conditions that may contribute to more common causes of insomnia, including psychiatric disorders.
For transient or short-term insomnia, inquire about recent situational stresses, such as a new job, new school, relationship change, or bereavement. For chronic insomnia, attempt to relate the onset of insomnia to past stresses or medical illnesses. Inquire about the use of tobacco, caffeinated products, alcohol, and illegal drugs.
Medications that commonly cause insomnia include the following:
Certain antidepressants (eg, protriptyline, fluoxetine)
Also inquire about over-the-counter and herbal remedies that the patient may be taking.
The physical examination may be helpful because findings may offer clues to underlying medical disorders that predispose the patient to insomnia. It may also facilitate the differential diagnosis or classification of insomnia.
If the history suggests sleep apnea, perform a careful head and neck examination. Common anatomic features associated with obstructive sleep apnea/hypopnea syndrome include the following:
Large neck size (ie, >17 in. in men)
Mallampati airway score of 3 or 4 (see the image below)
Low-lying soft palate, particularly in patients with hypertension or cardiac disease
Other features include an enlarged tongue, retrognathia, micrognathia, or a steep mandibular angle. An elevated body mass index (BMI) of 30 kg/m2 or higher is also common.
If the patient reports symptoms of restless legs syndrome or any other neurologic disorder, perform a careful neurologic examination. If the patient reports daytime symptoms consistent with any of the medical causes of insomnia, a careful examination of the affected organ system (eg, lungs in chronic obstructive pulmonary disease) may be helpful.
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