Insomnia Clinical Presentation

  • Author: Ron A Shatzmiller, MD, MSc; Chief Editor: Selim R Benbadis, MD   more...
 
Updated: Jan 17, 2012
 

History

The 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 AASM guideline consensus is that at minimum, patients should complete the following evaluations[3] :

  • 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 (see under Workup)

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 following questions:

  • Is the difficulty with falling asleep, frequent awakenings, or early morning awakening?
  • If the problem is at sleep onset, is the patient sleepy when he or she gets 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?
  • 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 of day?

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 (ie, restless feeling in legs on lying down, which improves with movement; rhythmic kicking during the night; sheets in disarray in the morning).

Daytime effects should be present if the patient is truly not sleeping at night. In fact, if a patient is having no daytime effects, he or she is probably getting adequate sleep and the complaint of insomnia is truly subjective.

Common complaints are fatigue, tiredness, lack of energy, irritability, reduced work performance, and 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, with particular emphasis on those disorders mentioned in Etiology. Also perform a thorough psychological review to screen for a psychiatric disorder (see Etiology). 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 disordDiagnostic 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.

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 beta-blockers, clonidine, theophylline (acutely), certain antidepressants (eg, protriptyline or fluoxetine), decongestants, and 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 differential diagnosis or classification of insomnia.[3]

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, 18 inches or greater in males)
  • 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 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. (See Etiology)

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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

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

Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Forest Honoraria Speaking and teaching

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 Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Additional Contributors

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 eMedicine 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.

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.

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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.
 
 
 
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