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Writer's pictureMarcus Hunt

Day # 153: Insomnia - Assessment

Today, we will be focusing on the first part of our Insomnia curriculum. This session will include an overview, definitions, a comparison of primary and secondary insomnia, and an assessment framework.



A man struggling to sleep

Introduction to Insomnia 1, 2


•Insomnia(s) = condition(s) that result in inadequate quality or quantity of sleep, characterized by difficulties in ≥ 1 of the following:

  • Falling asleep (sleep initiation).

  • Staying asleep (sleep maintenance).

  • Waking up too early in the morning (early morning awakenings).


•The most common symptom of insomnia is difficulty maintaining sleep, followed by difficulty falling asleep, with a combination of these symptoms being the most common presentation overall.


•Poor quality of sleep = "non-restorative" sleep. Possible symptoms include tiredness, daytime sleepiness (less common), decreased cognitive function, and changes in mood such as irritability or mood swings.


•Numerous factors can lead to a disturbance in regular sleep patterns. These factors encompass habits and behaviors such as exposure to light and phone usage too close to bedtime, shift work, medications, psychiatric disorders, substance abuse, medical conditions, and more.


•Being overly focused on sleep and feeling upset about not being able to sleep can create a harmful cycle: the harder someone tries to sleep, the more frustrated they become, which in turn makes it even harder to sleep. Moreover, people experiencing chronic insomnia might develop unhealthy sleep habits (such as staying in bed for extended periods, having an irregular sleep routine, or taking naps) and negative thoughts (like being afraid of not sleeping, worrying about daytime consequences, or constantly checking the clock) as the disorder progresses. These behaviors, occurring in an environment where sleeplessness is common, can intensify conditioned arousal and prolong sleep problems.



Epidemiology 3, 4


•Insomnia disorder is the most common sleep disorder. About 33% of adults have symptoms, with 10%-15% experiencing daytime impairments, and 6%-10% meeting the full criteria for the disorder. In primary care settings, 10%-20% of individuals report significant insomnia symptoms.


Gender: Insomnia is somewhat more common in females with a gender ratio of about 1.5:1.


Age: Insomnia symptoms can start at any age, but the first episode is more common in young adults. Overall, complaints are more common in middle-age and older adults. Late-life onset is often linked to other health conditions. Symptoms vary with age: trouble falling asleep is typical in young adults, while difficulty staying asleep is more frequent in older individuals.




Secondary Insomnia 5, 6


•Secondary insomnia refers to difficulty falling asleep or staying asleep due to an underlying cause, such as a medical condition, mental health disorder, medications, or substance use.


•Although insomnia can be a symptom of an independent disorder, it is most frequently observed as a comorbid con­dition. For instance, 40%-50% of indi­viduals with insomnia also present with a comorbid mental disorder.


•Common causes of secondary insomnia include:

  • Medical conditions: chronic pain (e.g., fibromyalgia, arthritis, cancer), asthma or other respiratory issues, heart disease, GERD, hyperthyroidism, prostate disease, urinary frequency/urgency, neurodegenerative disorders, pregnancy.

  • Mental health conditions: depression, anxiety disorders, bipolar disorder, PTSD, OCD.

  • Medication adverse effects: corticosteroids, antidepressants, stimulants, beta-blockers, bronchodilators, decongestants (e.g., pseudoephedrine).

  • Substance use: caffeine (especially in large amounts or late in the day), nicotine, alcohol (initially sedating but disrupts sleep cycles), cocaine, methamphetamines, marijuana (can affect sleep architecture and cause disruptions).


•Identifying the primary disorder causing secondary insomnia is crucial for creating a holistic treatment plan addressing both conditions simultaneously. Also, note the bidirectional relationship between sleep disturbances and the development of mental illnesses and substance us disorders. This highlights the importance of recognizing the interconnected nature of secondary insomnia with other health conditions for optimal patient care.



Primary Insomnia 7, 8


•In contrast to secondary insomnia, primary insomnia refers to sleep disturbances that are not directly attributable to any underlying health condition.


Diagnostic Criteria


A predominant complaint of dissatisfaction with sleep quantity or quality, associated with ≥1 of the following symptoms:

  • Difficulty initiating sleep (initial or sleep-onset insomnia).

  • Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings (middle or sleep-maintenance insomnia).

  • Early-morning awakenings with inability to return to sleep (late or sleep-offset insomnia).

  • Occurs ≥ 3 days a week for ≥ 3 months

  • Causes clinically significant distress or impairment in functioning.

  • Occurs despite adequate opportunity to sleep.

  • Does not occur exclusively during the course of another sleep-wake disorder.

  • Not due to the physiologic effects of a substance or medication.

  • Coexisting mental and medical disorders do not adequately explain the insomnia.


Acute insomnia: < 3 months. Often linked to stress or changes in sleep patterns and typically resolves on its own.


Chronic insomnia: ≥3 months to years. Linked to lower quality of life and higher psychiatric illness risk.


The "3 P's" Model of Insomnia


•Psychologist Arthur Spielman proposed the "3 P's" model of insomnia to explain its development and maintenance. The model includes Predisposing, Precipitating, and Perpetuating factors, which respectively increase the likelihood of insomnia, trigger its onset, and prolong the issue.


Predisposing: These are biological, psychological, or social traits that make a person more vulnerable to insomnia. They create a predisposition for insomnia but do not directly cause it. Examples include:

  • Tendencies towards anxiety or hyperarousal.

  • A family history of sleep difficulties.

  • Personality traits like perfectionism or heightened stress response.


Precipitating: These refer to particular events or situations that trigger the beginning of insomnia. While they may temporarily disturb sleep, if left unresolved, they can progress to chronic insomnia.. Examples include:

  • Stressful life events (e.g., job loss, death of a loved one, divorce)

  • Illness or injury (e.g., pain, a new medical diagnosis)

  • Changes in sleep environment or schedule (e.g., travel, moving to a new home, shift work, birth of a new child)


Perpetuating: These are behaviors, beliefs, or environmental factors that sustain insomnia after the initial cause is gone. They turn a temporary sleep problem into a chronic one. Examples include:

  • Poor sleep habits (e.g., irregular sleep schedules, napping during the day).

  • Worrying about not being able to sleep or preoccupation with a perceived inability to sleep.

  • Using stimulants like caffeine or overuse of sleeping pills.

  • May involve 'paradoxical insomnia,' a condition where individuals misperceive their sleep state, leading to a significant underestimation of their actual amount of sleep.



Assessment Framework


Sleep History


  • Start by obtaining a thorough sleep history from the patient, including patterns, duration, quality, and any related symptoms like daytime fatigue or irritability.

  • Nighttime symptoms: Timeline of symptoms (acute vs chronic), time to fall asleep (sleep latency), amount and duration of nightime and early morning awakenings, restless leg symptoms, abnormal sleep behaviors (e.g. sleepwalking, sleep talking, sleep paralysis, confusional arousals, night terrors or nightmares, acting out dreams), and sleep apnea symptoms.

  • Daytime symptoms: Drowsiness upon awakening (non-restorative sleep), headache on awakening, drowsiness and fatigue later in the day, concentration problems, and naps (frequency, length, duration, time of day).

  • Sleep habits/hygiene: Level of activity during the day, exercise (type of exercise and what time of day), substances (alcohol, caffeinated drinks, cold medicines, OTC sleep aids, etc.), evening routine, types of activities in bed (homework, TV watching, reading), and sleep environment (noise, light, temperature, sleep partner).

  • Previous sleep assessments, treatments, and response to treatments.


Medical History + Physical Exam


  • Screen for medical conditions that are known to be associated with insomnia (see secondary insomnia heading for list of common conditions).

  • Include a thorough medical review of systems.

  • Medications, supplements, and substance abuse.

  • Include a thorough physical exam.


Psychiatric History


  • Conduct a comprehensive psychiatric assessment, paying particular attention to depressive disorders, bipolar disorder, anxiety disorders, neuropsychiatric conditions (e.g. dementia), and substance use disorders.

  • Keep in mind the bidirectional relationship between mental health problems and insomnia: these issues can both contribute to insomnia disorder and result from prolonged sleep disturbances..


Sleep Logs, Questionnaires, and Testing


  • Sleep Logs (Sleep Diaries): Tool used to track sleep-wake patterns and behaviors. The patient fills out the log every morning upon waking to ensure accuracy. Typically filled out daily for 1-2 weeks to capture an accurate picture of sleep habits.

  • Epsworth sleepiness scale (ESS): Simple, self-administered questionnaire used to assess an individual's level of daytime sleepiness.

  • Actigraphy: Small wearable device, usually worn on the wrist, that continuously records movement over an extended period (days or weeks). This data helps estimate sleep parameters like total sleep time, sleep efficiency, and periods of wakefulness during the night. It can provide objective data rather than relying solely on patient reports.

  • Polysomnography (PSG): Consider PSG ("sleep study") for patients with refractory insomnia or suspected underlying sleep disorders such as sleep apnea or periodic limb movements. Patients spend a night in the sleep laboratory, where they are connected to a number of sensors that provide objective data related to brain activity, eye movements, heart rhythm, breathing patterns, oxygen saturation, and leg movements.



Conclusion


In the upcoming lesson, we will cover the management of insomnia, which will include behavioral approaches, cognitive behavioral therapy for insomnia (CBT-I), and the use of medications.


Resources for today's post include:

The articles referenced above


See our full list of book recommendations for the most up-to-date editions.

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