Clinical features and diagnosis of insomnia
- Michael H Bonnet, PhD
Michael H Bonnet, PhD
- Professor, Department of Neurology
- Wright State University Boonshoft School of Medicine
- Donna L Arand, PhD
Donna L Arand, PhD
- Research Associate Professor
- Wright State University Boonshoft School of Medicine
Insomnia is the one of the most common medical complaints. It frequently coexists with medical, psychiatric, sleep, or neurological disorders. It may also be associated with acute stress, medication or substance, poor sleep habits, or changes in the sleep environment. A separate diagnosis of insomnia should be given when the insomnia symptoms show independent onset or variation in relation to a psychiatric or medical condition such as depression or chronic pain, or when the insomnia symptoms persist after adequate treatment of the comorbid condition. However, insomnia can also exist without an associated psychiatric or medical disorder . The diagnosis of insomnia requires three main components: persistent sleep difficulty, adequate sleep opportunity, and associated daytime dysfunction.
The clinical features, diagnosis, and differential diagnosis of insomnia are reviewed here. The epidemiology, consequences, and treatment of insomnia are discussed separately. (See "Overview of insomnia" and "Treatment of insomnia".)
Symptoms — Patients with insomnia complain of difficulty initiating sleep, difficulty maintaining sleep, or waking up too early. Although insomnia can be a presenting complaint, it may also be reported during the evaluation of another complaint or during health maintenance screening.
Patients with insomnia describe difficulty falling asleep, difficulty staying asleep, or waking up too early, despite adequate opportunity and circumstances for sleep. The degree of the sleep disturbance reported varies, but typically occurs at least three times per week and is not related to an inadequate opportunity for sleep (ie, not related to sleep restriction), an inappropriate sleep environment, or another sleep disorder. Patients may also describe variable sleep, such as one or several nights of poor sleep followed by a night of better sleep. Occasionally, patients may report having minimal sleep for several consecutive nights.
These complaints are accompanied by a report of compromised daytime function :
- American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
- The International Classification of Sleep Disorders, 2nd edition, Diagnostic and Coding Manual, 2nd ed, Hauri PJ (Ed), American Academy of Sleep Medicine, Westchester 2005.
- Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 2002; 6:97.
- 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.
- Ohayon MM, Roth T. Place of chronic insomnia in the course of depressive and anxiety disorders. J Psychiatr Res 2003; 37:9.
- Breslau N, Roth T, Rosenthal L, Andreski P. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry 1996; 39:411.
- Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA 1989; 262:1479.
- Krystal AD. Psychiatric comorbidity: the case for treating insomnia. Sleep Med Clin 2006; 1:359.
- Fava M, McCall WV, Krystal A, et al. Eszopiclone co-administered with fluoxetine in patients with insomnia coexisting with major depressive disorder. Biol Psychiatry 2006; 59:1052.
- Currie SR, Clark S, Rimac S, Malhotra S. Comprehensive assessment of insomnia in recovering alcoholics using daily sleep diaries and ambulatory monitoring. Alcohol Clin Exp Res 2003; 27:1262.
- Brower KJ, Aldrich MS, Robinson EA, et al. Insomnia, self-medication, and relapse to alcoholism. Am J Psychiatry 2001; 158:399.
- Drummond SP, Gillin JC, Smith TL, DeModena A. The sleep of abstinent pure primary alcoholic patients: natural course and relationship to relapse. Alcohol Clin Exp Res 1998; 22:1796.
- Maher MJ, Rego SA, Asnis GM. Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management. CNS Drugs 2006; 20:567.
- Lamarche LJ, De Koninck J. Sleep disturbance in adults with posttraumatic stress disorder: a review. J Clin Psychiatry 2007; 68:1257.
- Taylor DJ, Mallory LJ, Lichstein KL, et al. Comorbidity of chronic insomnia with medical problems. Sleep 2007; 30:213.
- George CF, Bayliff CD. Management of insomnia in patients with chronic obstructive pulmonary disease. Drugs 2003; 63:379.
- Douglas N. Asthma and chronic obstructive pulmonary disease. In: Principles and practice of sleep medicine, 4th ed, Kryger M, Roth T, Dement WC (Eds), Saunders, New York 2005. p.1122.
- Lanfranchi PA, Pennestri MH, Fradette L, et al. Nighttime blood pressure in normotensive subjects with chronic insomnia: implications for cardiovascular risk. Sleep 2009; 32:760.
- Fernandez-Mendoza J, Vgontzas AN, Liao D, et al. Insomnia with objective short sleep duration and incident hypertension: the Penn State Cohort. Hypertension 2012; 60:929.
- Vgontzas AN, Liao D, Pejovic S, et al. Insomnia with objective short sleep duration is associated with type 2 diabetes: A population-based study. Diabetes Care 2009; 32:1980.
- Howell D, Oliver TK, Keller-Olaman S, et al. Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice. Ann Oncol 2014; 25:791.
- Tang NK, McBeth J, Jordan KP, et al. Impact of musculoskeletal pain on insomnia onset: a prospective cohort study. Rheumatology (Oxford) 2015; 54:248.
- Vitiello MV, McCurry SM, Shortreed SM, et al. Short-term improvement in insomnia symptoms predicts long-term improvements in sleep, pain, and fatigue in older adults with comorbid osteoarthritis and insomnia. Pain 2014; 155:1547.
- Katz DA, McHorney CA. Clinical correlates of insomnia in patients with chronic illness. Arch Intern Med 1998; 158:1099.
- Banno K, Kryger MH. Comorbid insomnia. Sleep Med Clin 2006; 1:367.
- Postuma RB, Lang AE, Massicotte-Marquez J, Montplaisir J. Potential early markers of Parkinson disease in idiopathic REM sleep behavior disorder. Neurology 2006; 66:845.
- Moran M, Lynch CA, Walsh C, et al. Sleep disturbance in mild to moderate Alzheimer's disease. Sleep Med 2005; 6:347.
- Schweitzer PK. Drugs that disturb sleep and wakefulness. In: Principles and practice of sleep medicine, 4th ed, Kryger M, Roth T, Dement WC (Eds), Saunders, New York 2005. p.499.
- Krell SB, Kapur VK. Insomnia complaints in patients evaluated for obstructive sleep apnea. Sleep Breath 2005; 9:104.
- Gooneratne NS, Gehrman PR, Nkwuo JE, et al. Consequences of comorbid insomnia symptoms and sleep-related breathing disorder in elderly subjects. Arch Intern Med 2006; 166:1732.
- Krakow B, Ulibarri VA, McIver ND. Pharmacotherapeutic failure in a large cohort of patients with insomnia presenting to a sleep medicine center and laboratory: subjective pretest predictions and objective diagnoses. Mayo Clin Proc 2014; 89:1608.
- Allen RP, Picchietti D, Hening WA, et al. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Med 2003; 4:101.
- Michaud M, Dumont M, Selmaoui B, et al. Circadian rhythm of restless legs syndrome: relationship with biological markers. Ann Neurol 2004; 55:372.
- Phillips B, Young T, Finn L, et al. Epidemiology of restless legs symptoms in adults. Arch Intern Med 2000; 160:2137.
- Nichols DA, Allen RP, Grauke JH, et al. Restless legs syndrome symptoms in primary care: a prevalence study. Arch Intern Med 2003; 163:2323.
- Montplaisir J, Allen RP, Walters AS, Ferini-Strambi L. Restless legs syndrome and periodic limb movements during sleep. In: Principles and Practice of Sleep Medicine, 4th ed, Kryger M, Roth T, Dement WC (Eds), Saunders, New York 2005. p.839.
- Chesson A Jr, Hartse K, Anderson WM, et al. Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep 2000; 23:237.
- Schutte-Rodin S, Broch L, Buysse D, et al. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008; 4:487.
- Monk TH, Reynolds CF, Kupfer DJ, et al. The Pittsburgh Sleep Diary. J Sleep Res 1994; 3:111.
- Hauri P, Linde S. No More Sleepless Nights, John Wiley & Sons, New York 1996.
- Spielman AJ, Yang C, Glovinsky PB. Assessment techniques for insomnia. In: Principles and Practice of Sleep Medicine, 4th ed, Kryger M, Roth T, Dement WC (Eds), Saunders, Philadelphia 2005. p.626.
- Buysse DJ, Ancoli-Israel S, Edinger JD, et al. Recommendations for a standard research assessment of insomnia. Sleep 2006; 29:1155.
- Practice parameters for the use of polysomnography in the evaluation of insomnia. Standards of Practice Committee of the American Sleep Disorders Association. Sleep 1995; 18:55.
- Sadeh A, Hauri PJ, Kripke DF, Lavie P. The role of actigraphy in the evaluation of sleep disorders. Sleep 1995; 18:288.
- Natale V, Plazzi G, Martoni M. Actigraphy in the assessment of insomnia: a quantitative approach. Sleep 2009; 32:767.
- Arand DL, Burton G, Bonnet MH. When to order a sleep study and how to read the report - Part I. Primary Care Reports 2002; 8:192.
- Arand DL, Burton G, Bonnet MH. When to order a sleep study and how to read the report - Part II. Primary Care Reports 2002; 8:200.
- CLINICAL FEATURES
- - Psychiatric disorders
- - Medical conditions
- - Medication or substance use
- - Other sleep disorders
- Physical examination
- Sleep history and sleep log
- Identification of relevant comorbidities
- Diagnostic criteria
- DIFFERENTIAL DIAGNOSIS
- ADDITIONAL TESTING
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS