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Insomnia

Insomnias

Insomnia is defined as a state of sleeplessness.


Presentation

Patients with insomnia have impaired daytime function due to difficulty initiating sleep, difficulty maintaining sleep, or waking up early in the morning without ability to return to sleep [7]. They complain of fatigue, loss of energy, depression and irritability during the day and disturbed sleep during the night. A detailed history may reveal the use of certain medication that may point towards an underlying disease. If the patient is suffering from a psychological condition, it may present with characteristic symptoms like delusions, hallucinations, confusion, anxiety, depression and personality changes. If the insomnia is associated with other diseases, presenting complains of insomnia will be accompanied with systemic signs and symptoms.

Fatigue
  • Risk factors associated with insomnia were milder TBIs, and higher levels of fatigue, depression, and pain.[ncbi.nlm.nih.gov]
  • The most common one is insomnia, which can exacerbate other post-injury symptoms, including fatigue, impaired cognition, depression, anxiety, and pain.[ncbi.nlm.nih.gov]
  • It is associated with daytime symptoms such as irritability and fatigue. The February 20, 2013, issue of JAMA includes an article about insomnia.[doi.org]
Weakness
  • Given the methodological weaknesses of studies reviewed, additional research is needed to determine the efficacy of insomnia treatment in improving rates of alcohol relapse within this population. Copyright 2017 Elsevier B.V. All rights reserved.[ncbi.nlm.nih.gov]
  • (Grade: weak recommendation, low-quality evidence).[ncbi.nlm.nih.gov]
  • Many drugs are too weak ... benadryl, unisom, hydroxyzine, clonidine etc. The drugs which have worked have caused munchies and weight gain ... mirtazapine (Remeron), quetiapine (seroquel) and even trazodone.[reddit.com]
  • Tiredness, lethargy, dyspnoea, pruritus, insomnia , weakness and deterioration in mobility are common and have significant impact on the quality of life. The judge recognized the solicitor of the criminal who was suffering from insomnia .[dictionary.cambridge.org]
  • Sleep Maintenance Insomnia: Strengths and Weaknesses of Current Pharmacologic Therapies Rosenberg,Russell P. Annals of Clinical Psychiatry (2006),18(1):49[doi.org]
Chronic Fatigue Syndrome
  • Medical conditions - chronic pain, chronic fatigue syndrome, congestive heart failure, angina, acid-reflux disease ( GERD ), chronic obstructive pulmonary disease, asthma, sleep apnea, Parkinson's and Alzheimer's diseases, hyperthyroidism, arthritis,[medicalnewstoday.com]
  • Such "acute" fatigue is different yet again from the "chronic" fatigue experienced by cancer patients, sufferers of chronic fatigue syndrome or fibromyalgia.[scientificamerican.com]
  • Chronic fatigue syndrome (CFS). Some early research shows that taking melatonin in the evening might improve some symptoms of CFS, including fatigue, concentration, and motivation.[webmd.com]
  • Sleep studies are not helpful for insomnia caused by mental health problems, fibromyalgia, or myalgic encephalomyelitis/chronic fatigue syndrome.[healthlinkbc.ca]
Nocturnal Awakening
  • Thus, the presence of a long sleep latency, frequent nocturnal awakenings, or prolonged periods of wakefulness during the sleep period or even frequent transient arousals are taken as evidence of insomnia. 1 Thus, insomnia has been thought of both as[ncbi.nlm.nih.gov]
  • Delayed sleep phase disorder can be misdiagnosed as insomnia, as sleep onset is delayed to much later than normal while awakening spills over into daylight hours.It is common for patients who have difficulty falling asleep to also have nocturnal awakenings[en.wikipedia.org]
  • awakenings, or early morning awakenings with an inability to return to sleep. 6 Older adults report primarily, although not exclusively, difficulty in maintaining sleep.[doi.org]
  • Other information should include the time the patient went to bed, time spent falling asleep, number of nocturnal awakenings, and rising time. A bed partner's observations of the patient's sleep behavior can also help.[web.archive.org]
  • They may also have frequent nocturnal awakenings because of nocturia.[emedicine.com]
Progressive Dementia
  • We report here a Chinese case of FFI with a D178N/Met129 genotype of the PRNP gene, who exhibited rapidly progressive dementia combined with behavioral disturbances and paroxysmal limb myoclonus.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: This case is a compelling example that even with evidence of leukoencephalopathy, prion disease should be an important differential diagnosis of rapidly progressive dementia and related diseases.[ncbi.nlm.nih.gov]
Heart Disease
  • Also, deterioration in depression and heart disease status and increased number of conditions over time increased the risk for insomnia incidence.[ncbi.nlm.nih.gov]
  • People with chronic insomnia reported more of the following than did people without insomnia: heart disease (21.9% vs 9.5%), high blood pressure (43.1% vs 18.7%), neurologic disease (7.3% vs 1.2%), breathing problems (24.8% vs 5.7%), urinary problems[ncbi.nlm.nih.gov]
  • Results: People with chronic insomnia reported more of the following than did people without insomnia: heart disease (21.9% vs 9.5%), high blood pressure (43.1% vs 18.7%), neurologic disease (7.3% vs 1.2%), breathing problems (24.8% vs 5.7%), urinary[doi.org]
  • RESULTS: The primary insomnia cohort had a higher prevalence of diabetes, dyslipidemia, hypertension, coronary heart disease, chronic liver disease, and chronic kidney disease at baseline.[ncbi.nlm.nih.gov]
Sleep Disturbance
  • Most of these changes have been observed primarily in patients who have objective sleep disturbance seen on the polysomnogram, as opposed to the very interesting group who complain of sleep disturbance but who manifest minimal objective sleep changes.[web.archive.org]
  • This case report aims to illustrate the possibility of rectifying sleep disturbances comorbid with social phobia, using a brief cognitive behaviour therapy for insomnia (CBT-I).[ncbi.nlm.nih.gov]
  • Recent research suggests that sleep disturbance amplifies the effect of maladaptive emotional processes on PTSD symptom severity.[ncbi.nlm.nih.gov]
  • Overview of current management of sleep disturbances in children: I-pharmacotherapy . Curr Ther Res Clin Exp 2002 ;63(suppl B): B18 – 37 . Google Scholar Crossref ISI 4. .[doi.org]
  • Overview of current management of sleep disturbances in children: I-pharmacotherapy. Curr Ther Res Clin Exp 2002 ;63(suppl B): B18 – 37. Google Scholar Crossref ISI 4..[doi.org]
Neglect
  • This study highlights that it is a major public health concern, albeit neglected, which needs to be dealt as a priority. Copyright 2018 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • For example, adverse childhood experiences, such as abuse or neglect, have been linked to poor sleep in adulthood. 29 – 31 Additionally, other characteristics of childhood such as socioeconomic difficulty 32 and family conflict 33 have been shown to contribute[doi.org]

Workup

Physical examination may offer clues to underlying medical disorders predisposing to insomnia [8]. A detailed history is imperative in making the right diagnosis.

Laboratory tests

  • Arterial blood gases
  • Blood oximetry
  • Routine blood tests like complete blood count (CBC), prothrombin time, thyroid function tests, liver function tests, kidney function tests to rule out underlying disease.

Imaging

  • ECG
  • Polysomnography
  • Actigraphy
  • Radiography and CT scan to exclude other diseases

Test results

The diagnosis of insomnia is a difficult one and is easily confused with sleep apnea. A detailed history and the use of a sleep diary or log book can aid in making the right diagnosis.

Epileptiform Activity
  • PURPOSE: We report a novel case of "grand mal on awakening" from sleep presenting with intractable insomnia associated with interictal epileptiform activity (IEA) during sleep.[ncbi.nlm.nih.gov]

Treatment

Medication

Since insomnia can precipitate, exacerbate, or prolong comorbid conditions, treatment of insomnia may improve comorbidities [9]. Treatment is based on chemotherapy that includes sedatives like benzodiazepines, and non-benzodiazepines receptor agonists like Zolpidem and Eszopiclone. Other drugs that can be used to treat or at least provide symptomatic relief include Melatonin, or Melatonin-receptor agonists like Ramelteon, Orexin receptor antagonist like Suvorexant, sedative anti-depressants like Doxepin, and antihistamines.

Non-pharmalogical treatment

It includes hypnotic treatment to induce and improve sleep and cognitive behavioural therapy (CBT). CBT is a good way of treating insomnia and is recommended along with pharmacological treatment.

Prognosis

Insomnia may disappear on its own if the predisposing factor is removed or treated. In cases where the predisposing factor(s) or underlying condition persists, insomnia is a progressive disease. It may begin with disturbed sleep and progress to severe depression, loss of memory and a reduced quality of life. People who are able to sleep for only 5 hours or less on long term basis have high mortality rates.

Etiology

Insomnia has a diverse range of potential causes. First and foremost is stress. Stress could be due to personal, professional, social or financial conditions which would make the person anxious and depressed, causing insomnia. Some patients may be insomniacs due to a genetic predisposition. A missense mutation has been found in the gene encoding the GABAA beta 3 subunit in a patient with chronic insomnia [3].

Other causes include preexisting medical conditions like heart disease, gastrointestinal problems, urinary problems, persistent pain, hypertension or respiratory problems. Restless legs syndrome or periodic limb movement disorder may be causing insomnia and so can be mental disorders like PTSD, schizophrenia and bipolar disorder. Hormone shifts, like those occurring during premenstrual syndrome (PMS) or pregnancy, increased use of nicotine and caffeine, and some stimulant medications like amphetamines may cause insomnia.

Epidemiology

Incidence

It is a very common medical complaint in primary care patients and the same is true for patients in palliative care, which is illustrated by studies that report the prevalence of insomnia is over 70 percent [4].

Age

Insomnia is very rare in children, unless it is accompanied with a medical condition that disturbs sleep. Acute insomnia can affect adolescents and old aged people alike but is generally a frequent complain of people in the prime of life. Chronic insomnia on the other hand is much more common in the elderly.

Sex

Insomnia is 40% more common in women than in men [5].

Sex distribution
Age distribution

Pathophysiology

The DSM-5 criteria for insomnia include the following [6]:

Difficulty initiating and maintaining sleep, and difficulty going back to sleep after awakening early. The symptoms must be present at least 3 times a week for 3 months to be declared insomnia. The symptoms should also persist despite adequate opportunities to sleep and without any effects of drugs, narcotics or alcohol.

Types

Although insomnia can be classified into many subtypes, it can be divided into 3 broad categories:

  • Acute insomnia

It lasts for less than a month and then goes away on its own. It is triggered by either environmental factors such as travelling, change in environment, change in routine, or stress and depression. It is also known as transient insomnia (symptoms lasting for less than a week) and adjustment insomnia.

This condition fits the DSM-5 criteria for insomnia. It is characterized by inability to sleep during desired time or inability to maintain sleep for a longer time. The duration of sleep may be punctuated by periods of heightened awareness of the surroundings, heightened somatic tension and intrusive thoughts.

  • Chronic insomnia

This condition lasts for more than 1 month and is mostly due to a medical condition such as heart disease, breathing problems, conditions causing nocturia, diseases associated with persistent pain like arthritis, hypertension or gastrointestinal problems. If chronic insomnia exists without an underlying medical condition, it is due to high stress.

Prevention

Good sleep hygiene plays an important role in preventing insomnia. It includes setting up and maintaining a regular sleep schedule with regular sleep and wakening timings, avoiding caffeinated drinks and high sugar containing food a few hours before going to bed. A calm quiet environment and a healthy diet and lifestyle also go a long way in helping attain good sleep.

Summary

Insomnia was previously viewed as a sleep disturbance that was secondary to a medical condition, psychiatric illness, sleep disorder, or medication, and would improve with treatment of the underlying disorder [1]. But now, insomnia is recognized as an independent disorder [2]. It is a common complaint in outpatient care departments and is most frequently associated with stress.

Patient Information

Definition

Insomnia is defined as a condition of sleeplessness. There may be inability to fall asleep, maintain sleep or to go back to sleep after awakening early. 

Cause

Insomnia is primarily due to stress. Other causes include heart, gastrointestinal and urinary diseases, breathing problems, pain, mental conditions, disrupted sleep schedule or lifestyle, environmental change, drug side effects and genetic factors.

Signs and symptoms

Insomnia often coexists with other symptoms, such as pain, depression, and anxiety and the presence of one often exacerbates the other, contributing to a decrease in quality of life [10]. It presents with inability to fall asleep or maintain sleep for longer than a few hours at night, and irritability, tiredness and loss of energy during the day. 

Diagnosis

Insomnia is diagnosed by excluding other underlying diseases that may be causing sleep disturbances. A thorough physical examination and laboratory tests aid in that endeavour. A detailed history helps in making the right diagnosis.

Treatment

Treatment includes the use of prescribed drugs along with cognitive behavioural therapy. Lifestyle changes also help. 

References

Article

  1. National Institutes of Health. 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; 28:1049.
  2. Katz DA, McHorney CA. Clinical correlates of insomnia in patients with chronic illness. Arch Intern Med 1998; 158:1099.
  3. 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. Aug 2002;111(2):154-60
  4. Hugel H, Ellershaw JE, Cook L, et al. The prevalence, key causes and management of insomnia in palliative care patients. J Pain Symptom Manage 2004; 27:316.
  5. "Several Sleep Disorders Reflect Gender Differences". Psychiatric News 42 (8): 40. 2007.
  6. "Sleep Wake Disorders." Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013
  7. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014
  8. 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. Oct 15 2008;4(5):487-504 
  9. Sack RL, Auckley D, Auger RR, et al. Circadian rhythm sleep disorders: part II, advanced sleep phase disorder, delayed sleep phase disorder, free-running disorder, and irregular sleep-wake rhythm. An American Academy of Sleep Medicine review. Sleep 2007; 30:1484.
  10. Glynn J, Gale S, Tank S. Causes of sleep disturbance in a specialist palliative care unit. BMJ Support Palliat Care 2014; 4 Suppl 1:A56.

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Last updated: 2019-07-11 22:48