Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Insomnia Clinical Presentation

  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Selim R Benbadis, MD  more...
 
Updated: Jul 06, 2016
 

History

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[1] :

  • 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

Sleep history

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.[6]

Common complaints of daytime effects in patients with insomnia are as follows:

  • Fatigue
  • Tiredness
  • Lack of energy
  • Irritability
  • Reduced work performance
  • Difficulty concentrating

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.)

Epworth Sleepiness Scale. 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.

Diagnostic criteria for generalized anxiety disord Diagnostic criteria for generalized anxiety disorder.

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.

Family history

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.

Social history

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.

Medication history

Medications that commonly cause insomnia include the following:

  • Beta blockers
  • Clonidine
  • Theophylline (acutely)
  • Certain antidepressants (eg, protriptyline, fluoxetine)
  • Decongestants
  • Stimulants

Also inquire about over-the-counter and herbal remedies that the patient may be taking.

Next

Physical Examination

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.[1]

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)
  • Enlarged tonsils
  • 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.

Mallampati airway scoring. Mallampati airway scoring.

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.

Previous
 
 
Contributor Information and Disclosures
Author

Jasvinder Chawla, MD, MBA Chief of Neurology, Hines Veterans Affairs Hospital; Professor of Neurology, Loyola University Medical Center

Jasvinder Chawla, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Erasmo A Passaro, MD, FAAN Director, Comprehensive Epilepsy Program/Clinical Neurophysiology Lab, Bayfront Health System, Florida Center for Neurology

Erasmo A Passaro, MD, FAAN is a member of the following medical societies: American Academy of Neurology, American Society of Neuroimaging, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: UCB; Sunovion.

Youngsook Park, MD Co-Director in SLEEP Lab, Hines Veterans Affairs Medical Center; Assistant Professor of Neurology, Loyola University, Chicago Stritch School of Medicine

Youngsook Park, MD is a member of the following medical societies: American Academy of Neurology, Willis-Ekbom Disease Foundation, American Academy of Sleep Medicine

Disclosure: Received none from Hines VA Hospital for none.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cyberonics; Eisai; Lundbeck; Sunovion; UCB; Upsher-Smith<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cyberonics; Eisai; Glaxo Smith Kline; Lundbeck; Sunovion; UCB<br/>Received research grant from: Cyberonics; Lundbeck; Sepracor; Sunovion; UCB; Upsher-Smith.

Acknowledgements

Carmel Armon, MD, MSc, MHS Professor of Neurology, Tufts University School of Medicine; Chief, Division of Neurology, Baystate Medical Center

Carmel Armon, MD, MSc, MHS is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American College of Physicians, American Epilepsy Society, American Medical Association, American Neurological Association, American Stroke Association, Massachusetts Medical Society, Movement Disorders Society, and Sigma Xi

Disclosure: Avanir Pharmaceuticals Consulting fee Consulting

Kendra Becker, MD, MPH Sleep Medicine Department, Kaiser Permanente Fontana Medical Center

Kendra Becker, MD, MPH is a member of the following medical societies: American Academy of Sleep Medicine, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Jose E Cavazos, MD, PhD, FAAN Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, Program Director of the Clinical Neurophysiology Fellowship, University of Texas School of Medicine at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center, University Hospital System; Director of the San Antonio Veterans Affairs Epilepsy Center of Excellence and Neurodiagnostic Centers, Audie L Murphy Veterans Affairs Medical Center

Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and American Neurological Association

Disclosure: GXC Global, Inc. Intellectual property rights Medical Director - company is to develop a seizure detecting device. No conflict with any of the Medscape Reference articles that I wrote or edited.

Zab Mosenifar, MD Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

James A Rowley, MD Professor, Fellowship Program Director, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine

James A Rowley, MD is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Silverio M Santiago, MD Clinical Professor of Medicine, University of California at Los Angeles School of Medicine; Chief, Department of Pulmonary and Critical Care Medicine, Medical Director, Sleep Disorders Center, Veterans Affairs Medical Center of West Los Angeles

Silverio M Santiago, MD is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Ron A Shatzmiller, MD, MSc Assistant Clinical Professor, Department of Neurology, Keck School of Medicine of the University of Southern California; Specialty Lead Physician, Healthcare Partners Medical Group, Arcadia, California

Ron A Shatzmiller, MD, MSc is a member of the following medical societies: American Academy of Neurology and American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

Peter Smethurst, MD Attending Physician, Pulmonary, Critical Care and Sleep Medicine, St Joseph's Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gregory Tino, MD Director of Pulmonary Outpatient Practices, Associate Professor, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Medical Center and Hospital

Gregory Tino, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

References
  1. [Guideline] Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008 Oct 15. 4(5):487-504. [Medline]. [Full Text].

  2. Montagna P, Gambetti P, Cortelli P, Lugaresi E. Familial and sporadic fatal insomnia. Lancet Neurol. 2003 Mar. 2(3):167-76. [Medline].

  3. Edinger JD, Means MK. Cognitive-behavioral therapy for primary insomnia. Clin Psychol Rev. 2005 Jul. 25(5):539-58. [Medline].

  4. Chesson AL Jr, Anderson WM, Littner M, Davila D, Hartse K, Johnson S, et al. Practice parameters for the nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 1999 Dec 15. 22(8):1128-33. [Medline].

  5. Morgenthaler T, Kramer M, Alessi C, Friedman L, Boehlecke B, Brown T, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report. Sleep. 2006 Nov 1. 29(11):1415-9. [Medline].

  6. American Academy of Sleep Medicine. ICSD2 - International Classification of Sleep Disorders. Diagnostic and Coding Manual. 2nd. Westchester, Ill: American Academy of Sleep Medicine; 2005. 1-32.

  7. Buysse DJ. Diagnosis and Classification of Insomnia Disorders. In: Insomnia: Principles and Management. Szuba MP, Kloss JD, Dinges DF, Eds. Cambridge University Press, Cambridge UK, 2003, et al.

  8. Chokroverty S. Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects, 3rd edition, p361. WB Saunders, Philadelphia, et al.

  9. The Gallup organization. The Gallup study of sleeping habits. Princeton, NJ,: The Gallup Organization; 1979.

  10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth. Arlington, VA: American Psychiatric Association; 2013.

  11. Edinger JD, Means MK, Carney CE, Krystal AD. Psychomotor performance deficits and their relation to prior nights' sleep among individuals with primary insomnia. Sleep. 2008 May 1. 31(5):599-607. [Medline]. [Full Text].

  12. Zammit GK, Weiner J, Damato N, Sillup GP, McMillan CA. Quality of life in people with insomnia. Sleep. 1999 May 1. 22 Suppl 2:S379-85. [Medline].

  13. Daley M, Morin CM, LeBlanc M, Grégoire JP, Savard J. The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers. Sleep. 2009 Jan 1. 32(1):55-64. [Medline]. [Full Text].

  14. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep. 2005 Sep 1. 28(9):1049-57. [Medline].

  15. Smith MT, Huang MI, Manber R. Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clin Psychol Rev. 2005 Jul. 25(5):559-92. [Medline].

  16. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Psychological and behavioral treatment of insomnia:update of the recent evidence (1998-2004). Sleep. 2006 Nov 1. 29(11):1398-414. [Medline].

  17. Czeisler CA, Cajochen C, Turek FW. Melatonin in the regulation of sleep and circadian rhythms. Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. New York: McGraw-Hill; 2000. 400-6.

  18. Saper CB, Scammell TE, Lu J. Hypothalamic regulation of sleep and circadian rhythms. Nature. 2005 Oct 27. 437(7063):1257-63. [Medline].

  19. Saper CB, Chou TC, Scammell TE. The sleep switch: hypothalamic control of sleep and wakefulness. Trends Neurosci. 2001 Dec. 24(12):726-31. [Medline].

  20. Baumann CR, Bassetti CL. Hypocretins (orexins) and sleep-wake disorders. Lancet Neurol. 2005 Oct. 4(10):673-82. [Medline].

  21. Lu J, Greco MA. Sleep circuitry and the hypnotic mechanism of GABAA drugs. J Clin Sleep Med. 2006 Apr 15. 2(2):S19-26. [Medline].

  22. Nutt D. GABAA receptors: subtypes, regional distribution, and function. J Clin Sleep Med. 2006 Apr 15. 2(2):S7-11. [Medline].

  23. Krystal A. Pharmacological Treatment: Other Medications. Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 5th ed. St. Louis, Mo: Elsevier Saunders; 2010. 916-30.

  24. Drake CL and Roth T. Predisposition in the Evolution of Insomnia: Evidence, Potential Mechanisms, and Future Directions. Sleep Med Clin. 2006. 1(3):333-350.

  25. Nofzinger EA, Buysse DJ, Germain A, Price JC, Miewald JM, Kupfer DJ. Functional neuroimaging evidence for hyperarousal in insomnia. Am J Psychiatry. 2004 Nov. 161(11):2126-8. [Medline].

  26. Bonnet MH, Arand DL. 24-Hour metabolic rate in insomniacs and matched normal sleepers. Sleep. 1995 Sep. 18(7):581-8. [Medline].

  27. Bonnet MH, Arand DL. Caffeine use as a model of acute and chronic insomnia. Sleep. 1992 Dec. 15(6):526-36. [Medline].

  28. Vgontzas AN, Bixler EO, Lin HM, Prolo P, Mastorakos G, Vela-Bueno A, et al. Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications. J Clin Endocrinol Metab. 2001 Aug. 86(8):3787-94. [Medline].

  29. Lack LC, Gradisar M, Van Someren EJ, Wright HR, Lushington K. The relationship between insomnia and body temperatures. Sleep Med Rev. 2008 Aug. 12(4):307-17. [Medline].

  30. Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987 Dec. 10(4):541-53. [Medline].

  31. Crocker A, Sehgal A. Genetic analysis of sleep. Genes Dev. 2010 Jun 15. 24(12):1220-35. [Medline]. [Full Text].

  32. Rétey JV, Adam M, Khatami R, Luhmann UF, Jung HH, Berger W, et al. A genetic variation in the adenosine A2A receptor gene (ADORA2A) contributes to individual sensitivity to caffeine effects on sleep. Clin Pharmacol Ther. 2007 May. 81(5):692-8. [Medline].

  33. Hamet P, Tremblay J. Genetics of the sleep-wake cycle and its disorders. Metabolism. 2006 Oct. 55(10 Suppl 2):S7-12. [Medline].

  34. Buhr A, Bianchi MT, Baur R, Courtet P, Pignay V, Boulenger JP, et al. Functional characterization of the new human GABA(A) receptor mutation beta3(R192H). Hum Genet. 2002 Aug. 111(2):154-60. [Medline].

  35. Montagna P, Cortelli P, Tinuper P, et al. Fatal familial insomnia. Guilleminault C, Montagna P, Lugaresi E, Gambetti P, editors. Fatal Familial Insomnia: Inherited Prion Disease, Sleep and the Thalamus. New York, NY: Raven Press; 1994. 1–14.

  36. Gambetti O, Medori P, Manetto V, et al. Fatal familial insomnia: S prion disease with distinctive histopathological and genotypic features. Guilleminault C, Montagna P, Lugaresi E, Gambetti P, editors. Fatal Familial Insomnia Inherited Prion Disease, Sleep and the Thalamus. New York, NY: Raven Press; 1994. 7–32.

  37. Montagna P, Cortelli P, Avoni P, Tinuper P, Plazzi G, Gallassi R, et al. Clinical features of fatal familial insomnia: phenotypic variability in relation to a polymorphism at codon 129 of the prion protein gene. Brain Pathol. 1998 Jul. 8(3):515-20. [Medline].

  38. Goldfarb LG, Petersen RB, Tabaton M, Brown P, LeBlanc AC, Montagna P, et al. Fatal familial insomnia and familial Creutzfeldt-Jakob disease: disease phenotype determined by a DNA polymorphism. Science. 1992 Oct 30. 258(5083):806-8. [Medline].

  39. Scaravilli F, Cordery RJ, Kretzschmar H, Gambetti P, Brink B, Fritz V, et al. Sporadic fatal insomnia: a case study. Ann Neurol. 2000 Oct. 48(4):665-8. [Medline].

  40. Morin CM, Rodrigue S, Ivers H. Role of stress, arousal, and coping skills in primary insomnia. Psychosom Med. 2003 Mar-Apr. 65(2):259-67. [Medline].

  41. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention?. JAMA. 1989 Sep 15. 262(11):1479-84. [Medline].

  42. Insomnia. American Academy of Sleep Medicine. The International Classification of Sleep Disorders. 2nd ed. Westchester, Illinois: American Academy of Sleep Medicine; 2005. 1-31.

  43. Taylor DJ, Mallory LJ, Lichstein KL, Durrence HH, Riedel BW, Bush AJ. Comorbidity of chronic insomnia with medical problems. Sleep. 2007 Feb 1. 30(2):213-8. [Medline].

  44. Johnson EO, Roth T, Schultz L, Breslau N. Epidemiology of DSM-IV insomnia in adolescence: lifetime prevalence, chronicity, and an emergent gender difference. Pediatrics. 2006 Feb. 117(2):e247-56. [Medline].

  45. Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002 Apr. 6(2):97-111. [Medline].

  46. Liu Y, Wheaton AG, Chapman DP, Cunningham TJ, Lu H, Croft JB. Prevalence of Healthy Sleep Duration among Adults - United States, 2014. MMWR Morb Mortal Wkly Rep. 2016 Feb 19. 65 (6):137-41. [Medline].

  47. Morin CM, LeBlanc M, Daley M, Gregoire JP, Mérette C. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Med. 2006 Mar. 7(2):123-30. [Medline].

  48. Calem M, Bisla J, Begum A, Dewey M, Bebbington PE, Brugha T, et al. Increased prevalence of insomnia and changes in hypnotics use in England over 15 years: analysis of the 1993, 2000, and 2007 National Psychiatric Morbidity Surveys. Sleep. 2012 Mar 1. 35(3):377-84. [Medline]. [Full Text].

  49. Zhang B, Wing YK. Sex differences in insomnia: a meta-analysis. Sleep. 2006 Jan 1. 29(1):85-93. [Medline].

  50. Kravitz HM, Ganz PA, Bromberger J, Powell LH, Sutton-Tyrrell K, Meyer PM. Sleep difficulty in women at midlife: a community survey of sleep and the menopausal transition. Menopause. 2003 Jan-Feb. 10(1):19-28. [Medline].

  51. Strine TW, Chapman DP, Ahluwalia IB. Menstrual-related problems and psychological distress among women in the United States. J Womens Health (Larchmt). 2005 May. 14(4):316-23. [Medline].

  52. Ruiter ME, DeCoster J, Jacobs L, Lichstein KL. Sleep disorders in African Americans and Caucasian Americans: a meta-analysis. Behav Sleep Med. 2010. 8(4):246-59. [Medline].

  53. Monane M. Insomnia in the elderly. J Clin Psychiatry. 1992 Jun. 53 Suppl:23-8. [Medline].

  54. Krystal AD. Treating the health, quality of life, and functional impairments in insomnia. J Clin Sleep Med. 2007 Feb 15. 3(1):63-72. [Medline].

  55. Chien KL, Chen PC, Hsu HC, Su TC, Sung FC, Chen MF, et al. Habitual sleep duration and insomnia and the risk of cardiovascular events and all-cause death: report from a community-based cohort. Sleep. 2010 Feb 1. 33(2):177-84. [Medline]. [Full Text].

  56. Phillips B, Buzková P, Enright P. Insomnia did not predict incident hypertension in older adults in the cardiovascular health study. Sleep. 2009 Jan 1. 32(1):65-72. [Medline]. [Full Text].

  57. Gangwisch JE, Heymsfield SB, Boden-Albala B, Buijs RM, Kreier F, Pickering TG, et al. Short sleep duration as a risk factor for hypertension: analyses of the first National Health and Nutrition Examination Survey. Hypertension. 2006 May. 47(5):833-9. [Medline].

  58. Gottlieb DJ, Redline S, Nieto FJ, Baldwin CM, Newman AB, Resnick HE, et al. Association of usual sleep duration with hypertension: the Sleep Heart Health Study. Sleep. 2006 Aug 1. 29(8):1009-14. [Medline].

  59. Vgontzas AN, Liao D, Bixler EO, Chrousos GP, Vela-Bueno A. Insomnia with objective short sleep duration is associated with a high risk for hypertension. Sleep. 2009 Apr 1. 32(4):491-7. [Medline]. [Full Text].

  60. Lanfranchi PA, Pennestri MH, Fradette L, Dumont M, Morin CM, Montplaisir J. Nighttime blood pressure in normotensive subjects with chronic insomnia: implications for cardiovascular risk. Sleep. 2009 Jun 1. 32(6):760-6. [Medline]. [Full Text].

  61. Knutson KL, Van Cauter E, Rathouz PJ, Yan LL, Hulley SB, Liu K, et al. Association between sleep and blood pressure in midlife: the CARDIA sleep study. Arch Intern Med. 2009 Jun 8. 169(11):1055-61. [Medline]. [Full Text].

  62. Baglioni C, Battagliese G, Feige B, Spiegelhalder K, Nissen C, Voderholzer U, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011 Dec. 135(1-3):10-9. [Medline].

  63. Ohayon MM, Roth T. Place of chronic insomnia in the course of depressive and anxiety disorders. J Psychiatr Res. 2003 Jan-Feb. 37(1):9-15. [Medline].

  64. Chesson A Jr, Hartse K, Anderson WM, Davila D, Johnson S, Littner M, et al. Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 2000 Mar 15. 23(2):237-41. [Medline].

  65. Natale V, Plazzi G, Martoni M. Actigraphy in the assessment of insomnia: a quantitative approach. Sleep. 2009 Jun 1. 32(6):767-71. [Medline]. [Full Text].

  66. Morin CM, Hauri PJ, Espie CA, Spielman AJ, Buysse DJ, Bootzin RR. Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep. 1999 Dec 15. 22(8):1134-56. [Medline].

  67. Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004 Sep 27. 164(17):1888-96. [Medline].

  68. Irwin MR, Cole JC, Nicassio PM. Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychol. 2006 Jan. 25(1):3-14. [Medline].

  69. Manber R, Edinger JD, Gress JL, San Pedro-Salcedo MG, Kuo TF, Kalista T. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep. 2008 Apr 1. 31(4):489-95. [Medline]. [Full Text].

  70. Edinger JD, Wohlgemuth WK, Radtke RA, Coffman CJ, Carney CE. Dose-response effects of cognitive-behavioral insomnia therapy: a randomized clinical trial. Sleep. 2007 Feb 1. 30(2):203-12. [Medline].

  71. Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011 May 23. 171(10):887-95. [Medline]. [Full Text].

  72. Morin CM, Beaulieu-Bonneau S, LeBlanc M, Savard J. Self-help treatment for insomnia: a randomized controlled trial. Sleep. 2005 Oct 1. 28(10):1319-27. [Medline].

  73. Sivertsen B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, Kvale G, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006 Jun 28. 295(24):2851-8. [Medline].

  74. Morin CM, Vallieres A, Guay B, Ivers H, Savard J, Merette C, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia. JAMA. May 20 2009. 301(19):2005-15.

  75. Krystal AD, Walsh JK, Laska E, Caron J, Amato DA, Wessel TC, et al. Sustained efficacy of eszopiclone over 6 months of nightly treatment: results of a randomized, double-blind, placebo-controlled study in adults with chronic insomnia. Sleep. 2003 Nov 1. 26(7):793-9. [Medline].

  76. Walsh JK, Krystal AD, Amato DA, Rubens R, Caron J, Wessel TC, et al. Nightly treatment of primary insomnia with eszopiclone for six months: effect on sleep, quality of life, and work limitations. Sleep. 2007 Aug 1. 30(8):959-68. [Medline]. [Full Text].

  77. Roth T, Walsh JK, Krystal A, Wessel T, Roehrs TA. An evaluation of the efficacy and safety of eszopiclone over 12 months in patients with chronic primary insomnia. Sleep Med. 2005 Nov. 6(6):487-95. [Medline].

  78. Krystal AD, Erman M, Zammit GK, Soubrane C, Roth T. Long-term efficacy and safety of zolpidem extended-release 12.5 mg, administered 3 to 7 nights per week for 24 weeks, in patients with chronic primary insomnia: a 6-month, randomized, double-blind, placebo-controlled, parallel-group, multicenter study. Sleep. 2008 Jan 1. 31(1):79-90. [Medline]. [Full Text].

  79. Jeffrey S. FDA recommends lower bedtime dose for zolpidem. Medscape Medical News. Jan 10, 2013. Available at http://www.medscape.com/viewarticle/777431. Accessed: Jan 16, 2013.

  80. FDA Drug Safety Communication: Risk of next-morning impairment after use of insomnia drugs; FDA requires lower recommended doses for certain drugs containing zolpidem (Ambien, Ambien CR, Edluar, and ZolpiMist). US Food and Drug Administration. Available at http://www.fda.gov/Drugs/DrugSafety/ucm334033.htm. Accessed: January 10, 2013.

  81. Jeffrey S. FDA label changes for zolpidem products. Medcape Medical News. May 14, 2013. [Full Text].

  82. Morgenthaler TI, Silber MH. Amnestic sleep-related eating disorder associated with zolpidem. Sleep Med. 2002 Jul. 3(4):323-7. [Medline].

  83. Chiang A, Krystal A. Report of two cases where sleep related eating behavior occurred with the extended-release formulation but not the immediate-release formulation of a sedative-hypnotic agent. J Clin Sleep Med. 2008 Apr 15. 4(2):155-6. [Medline]. [Full Text].

  84. Roehrs TA, Randall S, Harris E, Maan R, Roth T. Twelve months of nightly zolpidem does not lead to dose escalation: a prospective placebo-controlled study. Sleep. 2011 Feb 1. 34(2):207-12. [Medline]. [Full Text].

  85. Zammit G, Erman M, Wang-Weigand S, Sainati S, Zhang J, Roth T. Evaluation of the efficacy and safety of ramelteon in subjects with chronic insomnia. J Clin Sleep Med. 2007 Aug 15. 3(5):495-504. [Medline]. [Full Text].

  86. Zammit G, Wang-Weigand S, Rosenthal M, Peng X. Effect of ramelteon on middle-of-the-night balance in older adults with chronic insomnia. J Clin Sleep Med. 2009 Feb 15. 5(1):34-40. [Medline]. [Full Text].

  87. Mayer G, Wang-Weigand S, Roth-Schechter B, Lehmann R, Staner C, Partinen M. Efficacy and safety of 6-month nightly ramelteon administration in adults with chronic primary insomnia. Sleep. 2009 Mar 1. 32(3):351-60. [Medline]. [Full Text].

  88. Roth T, Heith Durrence H, Jochelson P, Peterson G, Ludington E, Rogowski R, et al. Efficacy and safety of doxepin 6 mg in a model of transient insomnia. Sleep Med. 2010 Oct. 11(9):843-7. [Medline].

  89. Krystal AD, Durrence HH, Scharf M, Jochelson P, Rogowski R, Ludington E, et al. Efficacy and Safety of Doxepin 1 mg and 3 mg in a 12-week Sleep Laboratory and Outpatient Trial of Elderly Subjects with Chronic Primary Insomnia. Sleep. 2010 Nov. 33(11):1553-61. [Medline]. [Full Text].

  90. Zhang D, Tashiro M, Shibuya K, et al. Next-day residual sedative effect after nighttime administration of an over-the-counter antihistamine sleep aid, diphenhydramine, measured by positron emission tomography. J Clin Psychopharmacol. 2010 Dec;30(6):694... Zhang D, Tashiro M, Shibuya K, et al. Next-day residual sedative effect after nighttime administration of an over-the-counter antihistamine sleep aid, diphenhydramine, measured by positron emission tomography. J Clin Psychopharmacol. 2010 Dec;30(6):694-701.

  91. Brzezinski A, Vangel MG, Wurtman RJ, Norrie G, Zhdanova I, Ben-Shushan A, et al. Effects of exogenous melatonin on sleep: a meta-analysis. Sleep Med Rev. 2005 Feb. 9(1):41-50. [Medline].

  92. Buscemi N, Vandermeer B, Hooton N, Pandya R, Tjosvold L, Hartling L, et al. Efficacy and safety of exogenous melatonin for secondary sleep disorders and sleep disorders accompanying sleep restriction: meta-analysis. BMJ. 2006 Feb 18. 332(7538):385-93. [Medline]. [Full Text].

  93. Wade AG, Ford I, Crawford G, et al. Nightly treatment of primary insomnia with prolonged release melatonin for 6 months: a randomized placebo controlled trial on age and endogenous melatonin as predictors of efficacy and safety. BMC Med. 2010 Aug 16;8... Wade AG, Ford I, Crawford G, et al. Nightly treatment of primary insomnia with prolonged release melatonin for 6 months: a randomized placebo controlled trial on age and endogenous melatonin as predictors of efficacy and safety. BMC Med. 2010 Aug 16;8:51. Full text: http://www.biomedcentral.com/1741-7015/8/51.

  94. Rondanelli M, Opizzi A, Monteferrario F, Antoniello N, Manni R, Klersy C. The effect of melatonin, magnesium, and zinc on primary insomnia in long-term care facility residents in Italy: a double-blind, placebo-controlled clinical trial. J Am Geriatr Soc. 2011 Jan. 59(1):82-90. [Medline].

  95. Bent S, Padula A, Moore D. Valerian for sleep: a systematic review and meta-analysis. Am J Med. Dec 2006. 119(12):1005-12.

  96. Fernández-San-Martín MI, Masa-Font R, Palacios-Soler L, Sancho-Gómez P, Calbó-Caldentey C, Flores-Mateo G. Effectiveness of Valerian on insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Med. 2010 Jun. 11(6):505-11. [Medline].

  97. Taavoni S, Ekbatani N, Kashaniyan M, Haghani H. Effect of valerian on sleep quality in postmenopausal women: a randomized placebo-controlled clinical trial. Menopause. 2011 Sep. 18(9):951-5. [Medline].

  98. Meolie AL, Rosen C, Kristo D, Kohrman M, Gooneratne N, Aguillard RN, et al. Oral nonprescription treatment for insomnia: an evaluation of products with limited evidence. J Clin Sleep Med. 2005 Apr 15. 1(2):173-87. [Medline].

  99. Sun JL, Sung MS, Huang MY, Cheng GC, Lin CC. Effectiveness of acupressure for residents of long-term care facilities with insomnia: a randomized controlled trial. Int J Nurs Stud. 2010 Jul. 47(7):798-805. [Medline].

  100. Anderson, P. FDA Approves New Device for Insomnia. Medscape Medical News. Available at http://www.medscape.com/viewarticle/864509. June 8, 2016; Accessed: June 9, 2016.

  101. Ancoli-Israel S, Martin JL. Insomnia and daytime napping in older adults. J Clin Sleep Med. 2006 Jul 15. 2(3):333-42. [Medline].

  102. Kryger M, Monjan A, Bliwise D, Ancoli-Israel S. Sleep, health, and aging. Bridging the gap between science and clinical practice. Geriatrics. 2004 Jan. 59(1):24-6, 29-30. [Medline].

  103. Liu L and Ancoli-Israel S. Insomnia in the Older Adult. Sleep Med Clin. 2006. 1(3):409-422.

  104. Reid KJ, Baron KG, Lu B, Naylor E, Wolfe L, Zee PC. Aerobic exercise improves self-reported sleep and quality of life in older adults with insomnia. Sleep Med. 2010 Oct. 11(9):934-40. [Medline]. [Full Text].

  105. Lowes, R. FDA OKs New Kind of Sleep Drug Suvorexant (Belsomra). Medscape Medical News. Available at http://www.medscape.com/viewarticle/829893. Accessed: August 16, 2014.

  106. Brooks M. FDA Cuts Starting Dose of Eszopiclone (Lunesta) in Half. Medscape Medical News. May 15 2014. [Full Text].

 
Previous
Next
 
Theoretical model of the factors causing chronic insomnia. Chronic insomnia is believed to primarily occur in patients with predisposing or constitutional factors. These factors may cause the occasional night of poor sleep but not chronic insomnia. A precipitating factor, such as a major life event, causes the patient to have acute insomnia. If poor sleep habits or other perpetuating factors occur in the following weeks to months, chronic insomnia develops despite the removal of the precipitating factor. Adapted from Spielman AJ, Caruso LS, Glovinsky PB: A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987 Dec;10(4):541-53.
Mallampati airway scoring.
Diagnostic algorithm for major depression.
Diagnostic criteria for generalized anxiety disorder.
Sleep diary.
GABAA receptor subunit function(s).
GABAA receptor complex subunits and schematic representation of agonist binding sites.
Sleep-wake cycle.
The ascending arousal system. Adapted from Saper et al. Hypothalamic Regulation of Sleep and Circadian Rhythms. Nature 2005;437:1257-1263.
Ventrolateral pre-optic nucleus inhibitory projections to main components of the arousal system to promote sleep.
Schematic flip-flop switch model. Adapted from Saper C et al. Hypothalamic regulation of sleep and circadian rhythms. Nature 2005;437:1257-1263.
Epworth Sleepiness Scale.
Frequency of insomnia causes.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.