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  FUNDAMENTALS  37 Evaluation of Insomnia Insomnia is defined as  sleep difficulty  (difficulty initiating or maintaining sleep, early morningawakening, or both) that is associated  daytime con- sequences   because of night time sleep difficulty, with the proviso that the nighttime or daytimeproblems are not explained by an inadequateopportunity to sleep. The  International Classifica-tion of Sleep Disorders  , Second Edition (ICSD-2)defined eight insomnia disorders ( Tables F37-1 and F37-2). 1 Other classifications such as that by   Diagnostic and Statistical Manual of Mental Dis-orders  , Fourth Edition (DSM-IV) classifiedinsomnia as primary insomnia and secondary insomnia (insomnia associated witha mental dis-order,medicaldisorder,oradrugorsubstance). 2  The term  comorbid insomnia  has often been usedto refer to “secondary” insomnias, as it is oftendifficult to define the relationship betweeninsomnia and the associated disorder (which dis-order is primary and which is secondary?). Forexample, insomnia may precede depression, worsen during depression, and persist afterremission from depression. The ICSD-3 definesonly three insomnia disorders (see Table F37-1; Box F37-1), 3 and the ICSD-2 insomnia disordershave beenconsolidatedintothese three disorders. The rationale is that previously used subtypescould not reliably be diagnosed. 4  The samepatient may be diagnosed with different subtypesby different experienced clinicians. This is not surprising, as many patients manifest overlappingsymptoms.Chronic insomnia disorder (CID) is definedin the ICSD-3 and encompasses elements of psychophysiologic insomnia, idiopathic insom-nia, paradoxical insomnia, insomnia associated with mental disorder, inadequate sleep hygiene,as well the behavioral insomnias of childhood(limit setting or sleep association disorders)(Box F37-2 and see Table F37-2). The ICSD- 3 states that CID is characterized by “frequent and persistent difficulty initiating or maintain-ing sleep thatresultsingeneral sleep dissatisfac-tion.” CID may occur in isolation or be acomorbid condition with a mental disorder,medical condition, or substance use.  Durationof at least 3 months   is required for the diagnosisof CID, and symptoms must occur on at least 3 nights per week. Note that in ICSD-2, only a 1-month duration was required for many of the insomnia disorders. More details on CIDare provided below. A number of other sleepdisorders are associated with insomnia com-plaints ( Table F3-3). These included sleepapnea syndromes, circadian rhythm sleep-wakedisorders, and the restless legs syndrome. TABLE F37-1  Insomnia Disorders International Classification of Sleep Disorders  , 3rd Edition International Classification of Sleep Disorders  , 2nd Edition Chronic insomnia disorder (CID)- Frequency: on at least 3 nights per week- Duration  3 monthsPsychophysiologic insomniaParadoxical insomniaIdiopathic insomniaInsomnia due to mental disorderInadequate sleep hygieneBehavioral insomnia of childhoodInsomniaduetodrugorsubstanceInsomniaduetomedicalconditionShort-term insomnia disorder (STID)- Duration < 3 monthsAdjustment insomnia (acuteinsomnia)Other insomnia disorder- Difficulty initiating or maintaining sleep but does not meet criteria forCID or STID 584  SHORT-TERM INSOMNIA DISORDER  This disorder encompasses what was previously termed  adjustment insomnia . The duration must be less that 3 months. OTHER INSOMNIA DISORDER  This diagnosis is reserved for individuals whocomplain of difficulty initiating and maintainingsleep yet do not meet the full criteria foreither CID or short-term insomnia disorder. MAJOR COMPONENTS OF CHRONICINSOMNIA DISORDER 1.  Sleep difficulty  : In adults, the major com-plaints are difficulty initiating sleep (sleeponsetinsomnia),difficultymaintainingsleep(frequent awakenings, sleep maintenanceinsomnia), and early morning awakening.In children, sleep difficulty is defined by caregiver observation of resistance to goingto bed at an appropriate time and difficulty maintaining sleep without parent or care-giver intervention.2.  Daytime difficulty caused by sleepdifficulty  : Multiple complaints may bepresent,includingfatigue,attentionorcon-centrationdifficulty,impairedsocialoraca-demic performance, irritability, daytimesleepiness, and reduced motivation. In chil-dren, behavioral problems such and hyper-activity, aggression, or impulsivity may beprominent. Often, patients express dissatis-faction with sleep or concerns about theeffects of poor sleep on their health. TABLE F37-2  Major Characteristics of Insomnia Types in  International Classification of Sleep Disorders  , 2nd Edition Insomnia Types Essential Features Clinical Clues Psychophysiologic Duration at least 1 monthAnxiety about sleepHeightened arousal when in bedConditioned sleep-preventingassociations(bedroom as a stimulus for wake notsleep)Better sleep in novel environment (awayfrom home)Can fall asleep outside bedroom or whennot trying to sleepParadoxical Duration at least 1 monthExtreme and physiologically improbablecomplaints: “I never sleep.”Despite report of little sleep, relativelyminor daytime impairmentObjective sleep duration (PSG,actigraphy) is much greater thanreportedNo or rare napsIdiopathic Onset in infancy or childhoodNo identifiable precipitantNo period of sustained remissionLifelong insomnia without remissionsInsidious onsetAssociated with amental disorderInsomnia present for at least 1 monthMental disorder has been diagnosedTemporally associated with mentaldisorder (may precede by a few days orweeks)Insomnia waxes and wanes with mentaldisorderInadequate sleephygieneImproper sleep schedulingUse of products that disturb sleep nearbedtimeStimulating activities near bedtimeUse of the bed for nonsleep activitiesVariable bedtime and wake timesNappingBehavioralinsomnia of childhoodsleep associationtypeFalling asleep is an extended processSleep-onset associations demandedIn absence of associated factors, sleeponset delayedNighttime awakenings require caregiverintervention for return to sleepBehavioralinsomnia of childhoodlimit-setting typeDifficulty initiating or maintaining sleepRefusal to go to bed or return to bed afterawakeningCaregiver demonstrates insufficient limitsetting to establish appropriatebehaviorAdjustmentInsomniaTemporally associated with identifiablestressorDuration < 3 monthsExpected to resolveRecent psychological, psychosocial,environmental, or physical stressor Adapted from Schutte-Rodin S, Broch L, Buysee D, et al: Clinical guideline for the evaluation and management of chronicinsomnia in adults,  J Clin Sleep Med   4:487-504, 2008. 585 FUNDAMENTALS 37  E  VALUATION OF  I NSOMNIA   3.  Frequency, duration, adequate sleepopportunityor environment : A frequency of   at least 3 nights per week, a duration of    3 months,  and the requirement of an ade-quateopportunityandenvironmentforsleepare requirements for the diagnosis of CID. TheICSD-3statesthatpatientswithchronicinsomnia characterized by recurrent epi-sodesofsleep/wakedifficultieslastingseveral weeks at a time ( < 3 months) over several yearsmayalsoqualifyfortheCIDdiagnosis. INSOMNIA EVALUATION  A detailed sleep histor y is the cornerstone of evaluation of insomnia. 5–9 First, the nature of the  primary sleep complaint   (problems with sleeponset, sleep maintenance, or quality) should bedefined and the  duration of the complaint   deter-mined.Thehistoryofthe srcin ofthecomplaint,including age of onset should be explored, andparticular life events or stressors at the start of the problem should be identified. For example,patients with the subtype idiopathic insomniareport problems since childhood or adolescence with an insidious onset. Patients with psycho-physiologic subtype of insomnia may report that chronic insomnia began after a severe illness. Presleep conditions   or activities that could affect sleep, including the bedroom environment,activities near bedtime, or mental state near bed-time should be explored. The  bedroom environ-ment   should be characterized for factors that might disturb sleep (noise, clock easily seen fromthe bed,extreme hot or cold temperature).  Activ-ities near bedtime , including working late on thecomputer, drinking caffeinated beverages oralcohol in the evening, or exercise near bedtime,may impair the ability to sleep. The  mental status at bedtime  should be explored. Often, patientsbegan worrying about their stresses and prob-lems when retiring for the night. The presenceor absence of   nocturnal symptoms  , including snor-ing, gasping during sleep, symptoms of restlesslegs syndrome (RLS), and body movementsshould be evaluated. The  sleep-wake schedule  should be determinedby report including variability of bedtime andrise time as well as the frequency and durationof naps. Factors that worsen or improve sleepshould be detailed. For example, some patients BOX F37-1 Chronic Insomnia Disorder—Diagnostic Criteria ICSD-3 Criteria A-F must be met  A. The patient reports or the patient’s parent orcaregiver observes one or more of the following:1. Difficulty initiating sleep2. Difficulty maintaining sleep3. Waking up earlier than desired4. Resistance to going to bed on appropriateschedule5. Difficulty sleeping without parent or care-giver interventionB. The patient reports or the patient’s parent orcaregiver observes one or more of the followingrelated to the nighttime sleep difficulty:1. Fatigue/malaise2. Attention, concentration, or memory impairment 3. Impaired social, family, occupational or aca-demic performance4. Mood disturbance/irritability 5. Daytime sleepiness6. Behavioral problems (e.g., hyperactivity,impulsivity, aggression)7. Reduced motivation/energy/initiative8. Proneness for errors/accidents9. Concerns about or dissatisfaction with sleepC. The reported sleep/wake complaints cannot beexplained purely by   inadequate opportunity  (i.e.,enough time is allotted for sleep) or  inadequatecircumstances   (i.e., the environment is safe, dark,quiet, and comfortable) for sleep.D.  Thesleepdisturbanceandassociateddaytimesymptoms occur at least three times per  week. E. The sleep disturbance and associated daytimesymptoms have been present for at least 3 months.F. The sleep/wake difficulty is not better explainedby another primary sleep disorder.  Adapted from American Academy of Sleep Medicine:  International classification of sleep disorders  , ed 3, Darien, IL, 2014, American Academy of Sleep Medicine. BOX F37-2 Short-Term InsomniaDisorder  ICSD-3 D IAGNOSTIC  C RITERIA  (Criteria A to E must be met)  A, B, C. As in Chronic Insomnia DisorderD. The sleep disturbance and associated daytimesymptoms have been  present for less than3 months. E. Thesleep/wakedifficultyisnotbetterexplainedby another primary sleep disorder. 586  FUNDAMENTALS 37  E  VALUATION OF  I NSOMNIA    with insomnia report sleeping better in a nov elenvironment (reverse first-night effect). 10 Patient recall may be supplemented by sleeplogs, actigraphy, or both, as discussed in a fol-lowing section.  Daytime function  should be dis-cussed with emphasis on possible consequencesof insomnia. Reports of daytime fatigue orimpaired cognition and mood are morecommon than true daytime sleepiness.  True day-time sleepiness should trigger suspicion for additional  sleep problems such as sleep apnea, narcolepsy, or depression.  Daytime activities that may affect sleepsuch as the amount of caffeine, alcohol, exercise,sunlight exposure, and napping should bedetailed.Ageneralmedicalandpsychiatrichistory is important to identify mental or medical condi-tions that may affect sleep. A detailed medicationhistory including over-the-counter medicationsand substances of abuse is extremely important. A physical examination and appropriate labo-ratory testing if not recently performed shouldrule out obvious medical causes of insomnia.Examination of the upper airway showing a high Mallampati score (upper airway narrowing) 11 might trigger suspicions of obstructive sleepapnea (OSA). DIFFERENTIAL DIAGNOSIS  Major characteristics of the insomnia typeslistedinthe ICSD-2 arelistedin TableF37-2.Patients with CID often have characteristics of morethan one type. A number of non CID sleep dis-orders may be associated with insomnia com-plaints (Box F37-3). Sleep apnea syndromesmay be associated with repetitive arousal andsleep-maintenance problems. In patients withsleep apnea, insomnia symptoms are more likely to be present in women than in men. 1  The circa-dian sleep-wake rhythm disorders (CSWRDs)may also be associated with insomnia com-plaints, including delayed sleep phase syndrome(sleep-onset insomnia) and advanced sleep phasesyndrome(earlymorningawakening).Indelayedsleep phase syndrome, once the affected indi- viduals are able to fall asleep, they have fairly normal sleep. In advanced sleep phase syndrome,individuals fall asleep early but then awaken in theearly morning hours. In non–24-hour CSWRD,patientsmayreportperiodsofinsomniaalternating with hypersomnia. 1,3 RLS or periodic limb move-ment disorder (PLMD) may be associated withsymptoms of insomnia or nonrestorative sleep. A number of medications may also disturb sleepquality (e.g., caffeine). QUESTIONNAIRES, SLEEP LOGS,AND ACTIGRAPHY Supporting information from questionnaires(mood, cognition about insomnia), sleep logs,and actigraphy may be helpful in evaluatingpatients with insomnia (Box F37-4 and Box F37-5).Thesemaysupplementotherinformationobtained from the sleep history. Assessing thepatient’s attitudes about sleep and the sleep prob-lem is as important as documenting the degree of sleep disturbance. In addition, some patients arehesitant to admit to feelings of depression. Sleeplogs and actigraphy provide a more accurate esti-mate of the patient’s sleep quantity than is possi-ble from patient recall. The Epworth Sleepiness Scale (ESS; seeFundamentals 17) is used to assess subjectiveestimates of the propensity to fall asleep incommon situations. 12  The Pittsburgh SleepQuality Index (PSQI) is a 24-item self-report measure of general sleep quality that specifically addresses the preceding 1-month period. ThePSQI evaluates seven domains, including theduration of sleep, sleep disturbance, sleep-onset latency, daytime dysfunction because of sleepi-ness, sleep efficiency, need for medications tosleep, and overall sleep quality. The PSQI yields a global score and seven component scores (poor sleep: global score > 5). 13,14  Thequestionnaire has been shown to distinguishamong healthy patients, patients with depres-sion, and patients with sleep disorders. It wasnot designed specifically for insomnia but has been used in insomnia assessment and treat-ment studies. Detailed instructions for use andscoring of the PSQI are available at the BOX F37-3 Other Sleep Disorders Associated with InsomniaComplaints 1. Sleep apnea syndromes2. Circadian rhythm sleep/wake disordersa. Delayed sleep/wake disorder type—sleep-onset insomniab. Advanced sleep/wake disorder—early   AM awakeningc. Irregular sleep phase type—at least threesleep episodes per 24 hoursd. Non-24 hour sleep phase type—alternatingperiods of insomnia and hypersomnia3. Restless legs syndrome/periodic limb move-ment disorders From American Academy of Sleep Medicine:  International classification of sleep disorders: diagnostic and coding manual  , ed3,Darien,IL,2013,AmericanAcademyofSleepMedicine. 587 FUNDAMENTALS 37  E  VALUATION OF  I NSOMNIA 
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