eMedicine Specialties > Psychiatry > Adult

Primary Insomnia: Differential Diagnoses & Workup

Author: Catherine McVearry Kelso, MD,, Assistant Professor of Internal Medicine, Virginia Commonwealth University; Medical Director, Hospice and Palliative Care, Hunter Holmes McGuire VA Medical Center, Richmond
Coauthor(s): Angela Gentili, MD, Director of Geriatrics Fellowship Program, Associate Professor, Department of Internal Medicine, Virginia Commonwealth University Health System and McGuire Veterans Affairs Medical Center; Antony Fernandez, MD, FRCPsych (UK), Associate Professor, Department of Psychiatry, Medical College of Virginia, Virginia Commonwealth University; Acting Director, Sleep Disorders Clinic, McGuire Veterans Affairs Medical Center, Richmond
Contributor Information and Disclosures

Updated: Jun 5, 2009

Differential Diagnoses

Adjustment Disorders
Major Depression
Alcohol-Related Psychosis
Obstructive Sleep Apnea-Hypopnea Syndrome
Amphetamine Abuse
Parasomnias
Anxiety Disorders
Postpartum Depression
Apnea, Sleep
Posttraumatic Stress Disorder
Bipolar Affective Disorder
Schizophrenia
Caffeine-Related Psychiatric Disorders
Sleep Disorder, Geriatric
Cocaine-Related Psychiatric Disorders
Sleep Disorders
Depression
Hyperthyroidism

Other Problems to Be Considered

A number of occult medical, psychiatric, and substance abuse disorders can cause sleep disturbance. Also consider other sleep-related disorders, such as circadian rhythm sleep disorder and parasomnias, in the differential diagnosis. Substance abuse can cause insomnia during the intoxication phase, during the sustained use phase, and during withdrawal.

Workup

Laboratory Studies

  • Laboratory studies essentially are not required for the diagnosis of primary insomnia.
  • Tests required to exclude other causes of insomnia include the following:
    • Thyroid function tests (hyperthyroidism)
    • Blood alcohol levels (alcohol-related psychosis)

Imaging Studies

  • Neuroimaging studies may be helpful if a structural lesion is suspected to cause insomnia.

Other Tests

  • Sleep diary (see Media file 1)
    • This is a questionnaire completed by the patient each morning to describe the previous night's sleep.
    • Data from the sleep diary may help minimize distortions in sleep information recalled in the physician's office.

    • Primary insomnia. Evaluation of insomnia. Format ...

      Primary insomnia. Evaluation of insomnia. Format of sleep diary.

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      Primary insomnia. Evaluation of insomnia. Format ...

      Primary insomnia. Evaluation of insomnia. Format of sleep diary.

  • Actigraphy: This is a recently developed technique that makes use of an activity monitor to record activities during sleep and waking. It is useful in the diagnosis of circadian rhythm sleep disorders, sleep state misperception, and other types of primary insomnia. In older adults treated for chronic primary insomnia, the clinical use of actigraphy is still suboptimal in detecting wakefulness.

Procedures

  • The goal of insomnia management is to improve sleep quality and maintenance and limit daytime impairments.6
  • Full-night polysomnography (PSG) is indicated when suspicion of sleep apnea or movement disorders arises, when initial diagnosis is uncertain, when treatment fails, or when precipitous arousal occurs with violent or injurious behavior.7,8,6  
  • Multiple sleep latency test
    • Psychophysiological insomnia and idiopathic insomnia manifest as increased sleep latency, reduced sleep efficiency, and increased number and duration of awakenings.
    • Sleep state misperception manifests as normal sleep latency (15-20 min), normal number of arousals and awakenings, and normal sleep duration (6.5 h). The multiple sleep latency test shows normal daytime vigilance. Sleep state misperception can be diagnosed only in the laboratory because of the need to document that sleep duration and quality are normal when a person claims to have poor sleep.

More on Primary Insomnia

Overview: Primary Insomnia
Differential Diagnoses & Workup: Primary Insomnia
Treatment & Medication: Primary Insomnia
Follow-up: Primary Insomnia
Multimedia: Primary Insomnia
References
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Further Reading

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Keywords

sleeplessness, sleep disturbance, sleep apnea, psychophysiological insomnia, learned insomnia, behavioral insomnia, idiopathic insomnia, stress-related insomnia, sleep state misperception, persistent psychophysiological insomnia, sleep disorder

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Contributor Information and Disclosures

Author

Catherine McVearry Kelso, MD,, Assistant Professor of Internal Medicine, Virginia Commonwealth University; Medical Director, Hospice and Palliative Care, Hunter Holmes McGuire VA Medical Center, Richmond
Catherine McVearry Kelso, MD, is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Geriatrics Society, and American Society for Bioethics and Humanities
Disclosure: Nothing to disclose.

Coauthor(s)

Angela Gentili, MD, Director of Geriatrics Fellowship Program, Associate Professor, Department of Internal Medicine, Virginia Commonwealth University Health System and McGuire Veterans Affairs Medical Center
Angela Gentili, MD is a member of the following medical societies: American Geriatrics Society
Disclosure: Nothing to disclose.

Antony Fernandez, MD, FRCPsych (UK), Associate Professor, Department of Psychiatry, Medical College of Virginia, Virginia Commonwealth University; Acting Director, Sleep Disorders Clinic, McGuire Veterans Affairs Medical Center, Richmond
Antony Fernandez, MD, FRCPsych (UK) is a member of the following medical societies: American Society of Addiction Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jennifer S Morse, MD, Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego
Jennifer S Morse, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Aerospace Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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