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]

• Weakness

  (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]

• 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, brain [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]

• 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 a [ncbi.nlm.nih.gov]

  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.medscape.com]

• Non-Cardiac Chest Pain

  Carla Maradey-Romero and Ronnie Fass, New Therapies for Non-cardiac Chest Pain, Current Gastroenterology Reports, 16, 6, (2014). [doi.org]

• Orthostatic Hypotension

  Another group of agents used off label to treat insomnia, heterocyclic and tricyclic antidepressants (TCAs; ie, trazodone and amitriptyline) may also increase risk of falls secondary to orthostatic hypotension, a side effect seen in association with treatment [primarypsychiatry.com]

  Important side effects of these drugs include orthostatic hypotension and anticholinergic effects, which are of particular concern in the elderly. [doi.org]

• Motor Restlessness

  These include loud snoring and witnessed breathing pauses, which might suggest sleep apnea, and motor restlessness and involuntary leg movements, which might suggest restless legs syndrome. [doi.org]

• Hearing Impairment

  Cognitive-behavioral therapy for insomnia co-morbid with hearing impairment: a randomized controlled trial. [doi.org]

• 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]

  Learning and conditioning are also involved in the maintenance or exacerbation of sleep disturbances. [scholarpedia.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]

• Irritability

  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]

  Insomnia is a common clinical condition characterized by difficulty initiating or maintaining sleep, accompanied by symptoms such as irritability or fatigue during wakefulness. [ncbi.nlm.nih.gov]

• Poor Coordination

  However, accidents may result from poor coordination and attention lapse seen with sleep deprivation. Worsening pain or increased difficulty breathing at night also may indicate your need to seek emergency medical care. [web.archive.org]

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]

• Reduced Sleep Latency

  Z drugs were more likely to be effective in reducing sleep latency in studies published earlier, those including more younger and/or female patients, and those using zolpidem. [bmj.com]

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.

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.

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.

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].

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.

• Primary 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.

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.

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.

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. 

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.