Insomnia
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Introduction
Insomnia is difficulty falling asleep, maintaining sleep, early-morning wakening, or non-refreshing sleep.
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
Primary insomnia can be a diagnosis.
secondary causes include:
- medical conditions: COPD, asthma, CHF, hyperthyroidism, chronic pain, BPH
- drugs: EtOH, caffeine, nicotine, b-agonists, antidepressants, steroids
- psychiatric disorders: especially mood and anxiety disorders
- lifestyle factors: stress, shift work
However, people often react to insomnia with fear or anxiety around bedtime, or with a change in sleep situations (new environment, new responsibilties, etc). This can lead to a chronic disorder, ie psychophysiological insomnia.
Pathophysiology
Signs and Symptoms
- history
- physical exam
History
A sleep diary, completed every morning for 1-2 weeks can help understand insomnia. Record:
- bedtime
- sleep latency
- total sleep time
- awakenings
- quality of sleep
Rule out specific medical problems: CBC +differential, TSH
A sleep study referral can be done to test for periodic leg movements
Physical Exam
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
Differential Diagnosis
Treatments
Treat any suspected medical or psychiatric cause
- Medications
- Non-Medication Treatments
Medications
Benzodiazepines are best avoided.
May decrease slow wave sleep.
Effects decline with chronic use (ie 1-2 weeks)
Non-benzo hypnotics, ie zopiclone, lunesta, tramadol
Avoid anti-histamines (ie diphenhydramine and benadryl)
Herbal
Valerian (indicated for agitation and sleep)
L-Tryptophan: may induce relaxation and enhance sleep; be cautious of seratonin syndrome
Melatonin: popular, but currently no evidence (recent meta-analysis of 6 RCTs)
Non-Medication Treatments
CBT
Encourage proper sleep hygiene: caffiene, nicotine, EtOH, exercise, comfortable environment, regular sleep schedule.
Relaxation therapy can be used: deep-breathing, biofeedback.
Stimulus control: re-association of bed with sleep' re-establishment of consistent sleep-wake cycle, reduce activities cuing being awake.
Sleep restriction therapy: total time in bed should closely match total sleep time
Short-term benzodiazepine use can be an option.
- zopiclone
- trazodone
- amytriptiline
- mirtazapine
Cognitive behavioural therapy, in combination with zolpidem, appears more effective than CBT alone (NNT=8 at 6 months) (Morin et al, 2009).
Consequences and Course
Insomnia can range from transient to ongoing, and from the annoying to the devestating.
Resources and References
Topic Development
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