Extrinsic and intrinsic disorders cause primary insomnia. Sleep hygiene, substance abuse, and stress are extrinsic disorders.
Psychophysiologic insomnia, idiopathic or primary insomnia, obstructive sleep apnea, RLS, SWSD, and circadian rhythm disorders are intrinsic. Short-term stress causes psychophysiologic insomnia. After several nights of poor sleep, the patient focuses on sleeplessness, perpetuating the problem. Circadian rhythm abnormalities include ASD and DSD. Advanced sleep phase disorder, common in the elderly, causes drowsiness in the early evening, normal sleep, and early morning awakening. These patients may have trouble staying awake until evening. Adolescents with delayed sleep phase disorder may not feel sleepy until after midnight, sleep normally, and wake up late.
Aging reduces stage 3 and 4 sleep and increases stage 1, resulting in less restorative sleep. Increasing nocturnal awakenings fragment sleep. Seniors have more sleep complaints. Many sleep complaints in the elderly are caused by medical conditions or medications that increase with age.
Arthritis, allergies, heart failure, and benign prostatic hypertrophy affect sleep. Postpartum and perimenopausal hormone shifts cause sleep disturbances. Decongestants, -agonists, corticosteroids, -blockers, diuretics, antidepressants, and H-2 blockers disrupt sleep. If a medication causes sleep problems, consider alternatives. If no other options exist, insomnia medications may be prescribed.
It’s hard to tell primary sleep complaints from psychiatric ones. Insomnia often indicates anxiety, depression, or panic disorder. 30% of insomnia patients had depression, according to an office-based physician survey. 40% of sleep patients have a psychiatric disorder, according to another study. 10% to 15% of insomniacs abuse drugs.
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A sleep complaint starts with a sleep history. If possible, the patient’s bedmate should confirm sleep-wake patterns. Family history can help. More than 30% of insomniacs have first-degree female relatives with sleep disorders. The sleep history should include psychiatric disorders, current medication regimens, and associated symptoms. Note previous treatment attempts. Physical evidence of comorbidities, such as allergies or sleep apnea, may be important.
If a sleep-related breathing disorder is suspected, polysomnography is indicated. Daytime sleepiness, snoring, witnessed apneic spells, and a BMI over 35 are all indicators of sleep apnea. Polysomnography is recommended for patients with these symptoms, narcolepsy, or sleepwalking. Pilots and truck drivers who experience daytime sleepiness should have sleep studies.
Individualized insomnia treatment should occur after other causes have been considered, diagnosed, and treated. Nonpharmacologic treatment is less expensive and has fewer side effects. If the patient will benefit from the faster effect of drug therapies while pursuing behaviour modifications, pharmacologic treatment should be used.
Effective nonpharmacologic insomnia treatments reduce sleep onset latency or increase total sleep time by 30 minutes. Most treatment studies measure outcome using sleep diaries. Sleep time, sleep-onset latency, and nocturnal awakenings are measured. A meta-analysis of 48 studies found stimulus control therapy to be more effective than progressive relaxation, imagery training, and paradoxical intention. Relaxation exercises beat placebo. A recent meta-analysis compared pharmacotherapy and behavioural therapy and found no differences, except behavioural therapy reduced sleep latency mor
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