eMedicine Specialties > Psychiatry > Adult

Primary Insomnia

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

Introduction

Background

Primary insomnia is sleeplessness that is not attributable to a medical, psychiatric, or environmental cause. The diagnostic criteria for primary insomnia (307.42) from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) are as follows:

  • The predominant symptom is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month.
  • The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia.
  • The disturbance does not occur exclusively during the course of another mental disorder (eg, major depressive disorder, generalized anxiety disorder, a delirium).
  • The disturbance is not due to the direct physiological effects of a substance (eg, drug abuse, medication) or a general medical condition.1

The International Classification of Sleep Disorders (ICSD-2) diagnostic and coding manual consists of 3 primary insomnia categories: 

  • Psychophysiological insomnia
  • Idiopathic insomnia
  • Paradoxical insomnia2,3

Case study
A 56-year-old woman reports difficulty falling asleep and staying asleep. She reports intermittent episodes of sleep difficulty during periods of stress. However, for the past 3 weeks she has not been able to sleep well and frequently takes 90 minutes to fall asleep and then wakes within 2 hours and is not able to return to sleep. Her excessive daytime sleepiness has interfered with her work as an artist. She denies stress and depression and has no significant medical history.

Pathophysiology

The pathophysiology of primary insomnia is not well understood and essential features assist with diagnosis. The focus of management is on symptoms.
 
Psychophysiological insomnia
 
The essential features include learned or behavioral insomnia and heightened arousal.
 
The primary components involved are intermittent periods of stress that result in poor sleep and maladaptive behaviors. These include (1) a vicious cycle of trying harder to sleep and becoming tenser (ie, patients “trying too hard to sleep”) and (2) bedroom habits and routines (eg, brushing teeth) that actually condition the patient to become frustrated and aroused. Patients often report "racing thoughts" and sensitivity to their environment. 
 
Bad sleep habits such as those naturally acquired during periods of stress are occasionally reinforced. These are therefore not resolved and become persistent. Insomnia continues for years after the stress is abated and is labeled persistent psychophysiological insomnia. 
 
Idiopathic insomnia
 
The essential feature of idiopathic insomnia is lifelong sleeplessness with onset in infancy or childhood. 
 
Lifelong sleeplessness is attributed to an abnormality in the neurologic control of the sleep-wake cycle for many areas of the reticular activating system (which promotes wakefulness) as well as in areas such as supra nuclei, raphe nuclei, and medial forebrain areas (which promote sleep).
 
Possibly, a so-called neuroanatomic, neurophysiologic, or neurochemical lesion exists in the sleep state that patients tend to be on the extreme end of the spectrum toward arousal.
 
Paradoxical insomnia
 
Paradoxical insomnia is also called sleep state misperception. The essential feature is reports of severe insomnia without supporting objective evidence such as daytime sleepiness.

Frequency

United States

Primary insomnia is diagnosed in approximately 15-25% of patients with insomnia who are referred to sleep disorder centers following exclusion of other predisposing conditions. However, true incidence is not known. Primary insomnia is estimated to occur in 25% of all patients with chronic insomnia.

Mortality/Morbidity

Whether the consequences associated with chronic insomnia outweigh the costs of treatment remains debatable. Despite that, the following associations have been noted:

  • Increased risk of mortality is associated with short sleep lengths.
  • Insomnia is the best predictor of the future development of depression.
  • Catastrophic worry about the consequences of not sleeping is common among patients with chronic insomnia and serves to maintain the sleep disturbance.
  • Increased risk exists of developing anxiety, alcohol and drug use disorders, and nicotine dependence.
  • Poor health and decreased activity occur.
  • Onset of insomnia in older patients is related to decreased survival.

Sex

Primary insomnia is more common in women than in men.

Age

Persons of any age may be affected, although primary insomnia is more common in the older population.

Clinical

History

A thorough clinical interview with the patient and his or her sleep partner is critical in making the correct diagnosis of primary insomnia.

  • Psychophysiological insomnia
    • Sleep disturbance varies from mild to severe.
    • Insomnia may manifest as difficulty falling asleep or as frequent nocturnal awakenings.
    • Patients often find that they can sleep well anywhere else but in their own bedroom (see Pathophysiology).
    • Patients with this type of insomnia tend to be more tense and dissatisfied compared to people who sleep well. Emotionally, they typically are repressors, denying problems.
  • Idiopathic insomnia
    • Insomnia is long-standing, typically beginning in early childhood.
    • Patients often present with other hard-to-localize neurologic signs and symptoms such as difficulties with attention or concentration, hyperactivity, and mild nonfocal electroencephalographic abnormalities.
    • Emotionally, persons with childhood-onset insomnia are often repressors, denying and minimizing emotional problems.
    • These individuals often show atypical reactions, such as hypersensitivity or insensitivity, to medications.
    • Insomnia tends to persist over the entire life span and can be aggravated by stress or tension.
  • Sleep state misperception: Patients report insomnia subjectively, while sleep duration and quality are completely normal.

Physical

Physical findings that indicate sleep deprivation and fatigue may include features such as eye redness. Depending on the origin of the sleep dysfunction, other physical findings would be included to rule out secondary causes (ie, weight, neck circumference, thyroid). A complete neurologic examination is included in the evaluation of insomnia to assess for comorbid conditions. Recognition of mental disorders that may be contributing to insomnia is key to effectively manage symptoms.4

When performing a complete Mental Status Examination, drowsiness and mood changes such as irritability, anxiety, and sad feelings from underlying depression may be noted. The clinician should also note the patient's orientation, memory, judgment, insight, and the presence of any hallucinations or delusions.5

As with any mental status (but especially with the concern about depression), assess the patient's suicide potential. For completeness, assess the patient's homicidal potential as well.

Causes

Exclusion of other common causes is required to make the diagnosis of primary insomnia.

  • Medical causes
    • Chronic pain, especially neuropathic pain
    • Primary sleep disorders (eg, sleep apnea, periodic limb movements, restless legs syndrome)
    • Dyspnea from any cause
    • Pregnancy
    • Drug use or withdrawal (eg, selective serotonin reuptake inhibitors, stimulants, antihistamines, caffeine, diet pills, herbal preparations containing ma huang, anticonvulsants, steroids)
  • Psychiatric and/or psychological causes
    • Mood disorders (eg, depression, mania): Recent findings have strengthened the evidence that primary insomnia may be linked with mood disorders and is associated with hypothalamic-pituitary-adrenal (HPA) axis overactivity and excess secretion of corticotropin-releasing factor (CRF), adrenocorticotropin-releasing hormone, and cortisol.
    • Anxiety disorders (eg, generalized anxiety, panic attacks, obsessive–compulsive disorder)
    • Substance abuse (eg, alcohol or sedative/hypnotic withdrawal)
    • Major life stressors and/or events
  • Environmental causes
    • Noise
    • Jet lag or shift work
    • Bedroom too hot or cold

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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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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