Insomnia – Diagnosis, Symptoms, and Treatment

What is Insomnia?

Insomnia is a medical condition characterized by the impaired ability to initiate or maintain restorative sleep.  If this lasts longer than one month, it is called chronic insomnia.  This often leads to daytime fatigue, impaired concentration, and irritability.  Insomnia is often related to another medical or psychiatric disorder.  This may include anxiety, depression, mania, bipolar disorder, hyperthyroidism, cocaine or amphetamine abuse, alcohol dependence, and medication withdrawal.  Work is also a frequent contributor to insomnia, especially shift-work sleep disorder.

What Causes Insomnia?

Insomnia can be a primary disorder or caused by other conditions.  The most common diseases associated with insomnia include:

• Psychiatric disorders - anxiety, depression, PTSD, mania, & bipolar disorder
• Chronic pain - osteoarthritis
• Chronic heart (congestive heart failure) and lung (COPD) conditions
• Hyperthyroidism
• Benign prostatic hyperplasia – frequent urination at night (nocturia)
• Alcohol dependence
• Caffeine
• Cocaine or amphetamine abuse
• Obesity & obstructive sleep apnea
• Medications – Adderall, selective serotonin reuptake inhibitors (SSRIs)
• Medication withdrawal - benzodiazepines

Insomnia can also be caused by erratic work schedules and shift-work sleep disorder.

How Common is Insomnia?

Insomnia is a common condition that is frequently evaluated in the primary care clinic.  This disease often requires referral to a sleep specialist.

Chronic insomnia has a prevalence of about 10-15% in the United States.  It more often affects women, the elderly, and individuals with chronic medical or psychiatric disorders.

Signs and Symptoms

The most common symptom of insomnia include:

• Inability to initiate sleep
• Inability to maintain sleep
• Abnormal sleep quality
• Problems getting restorative sleep
• Daytime fatigue
• Mental fogginess – impaired concentration
• Irritability

Your doctor will often evaluate for specific findings on your physical examination, such as:

• Symptoms or signs of anxiety or depression
• Finding suggestive of chronic heart or lung disease
• Signs of thyroid disease
• Signs of being overweight or obese

They will also examine your medications in detail to see if their use or withdrawal could be contributing to your symptoms.

Diagnosis

Insomnia is diagnosed based on symptoms and physical examination.  Your doctor may obtain blood tests such as a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and thyroid function studies (TSH, free T4).

Your doctor may refer you to a sleep specialist, where you will typically undergo a study called polysomnography.  During this overnight test, your doctor will monitor vital signs and oxygen levels as you sleep to assess whether you may have obstructive sleep apnea (OSA).  Obstructive sleep apnea is characterized by periodic decreases in oxygen levels correlated with increased brain activity, meaning the brain is waking up when oxygen levels drop.  This condition is typically seen in obese individuals who snore at night. It frequently leads to daytime sleepiness, elevated blood pressure, pulmonary hypertension, and heart failure.

Insomnia Medication and Treatment0

The first step in treating insomnia is to reverse any underlying cause such as - psychiatric disorders, chronic pain, hyperthyroidism, prostate issues, and obesity.  Patients with obstructive sleep apnea (OSA) typically benefit from a CPAP (continuous positive airway pressure) mask at nighttime.  Weight loss is also typically encouraged in these individuals.

Another critical component of insomnia treatment is education about proper sleep hygiene.  Your doctor will likely recommend the following strategies:

• Go to bed and wake up at consistent times
• Do not look at the clock or your phone in the middle of the night
• If you don’t fall asleep in 15 minutes, go to a quiet area where you can rest and participate in relaxing activities such as reading or listening to music.
• Only use your bedroom for sleep and sexual activity
• Avoid taking daytime naps
• Perform physical activity and exercise earlier in the day
• Avoid coffee or caffeinated beverages after noon
• Avoiding eating a late dinner

Patients with severe insomnia or symptoms that do not improve with the measures above may benefit from the sedative and hypnotic medications.  These most often include one of the following drugs:

Benzodiazepines:

• Ativan (lorazepam)
• Xanax (alprazolam)
• Klonopin (clonazepam)
• Valium (diazepam)
• Librium (chlordiazepoxide)

Non-benzodiazepine hypnotics:

• Ambien (zolpidem)
• Lunesta (eszopiclone)
• Sonata (zaleplon)
• Antidepressants
• Oleptro (trazodone)

These drugs should generally be used at the lowest doses possible and for the shortest period, some (especially benzodiazepines) may lead to dependence and drug withdrawal. This is especially true in the elderly as they may cause confusion and increase the risk of falls.

References:

1. Silber MH. Clinical practice. Chronic insomnia. N Engl J Med. 2005 Aug 25;353(8):803-10. - https://www.ncbi.nlm.nih.gov/pubmed/16120860
2. Maness, D, Khan, M. Nonpharmacologic Management of Chronic Insomnia. Am Fam Physician. 2015 Dec 15;92(12):1058-1064. - https://www.aafp.org/afp/2015/1215/p1058.pdf