At a glance
- Explore the patient’s sleep-wake schedule, which includes a 24-hour history and patterns of sleep and daytime activity.
- Be alert for signs of other sleep disorders.
- Evidence-based treatment of insomnia can involve psychotherapy, pharmacotherapy, or both.
- Schedule pharmacotherapy re-evaluations at least every six months to evaluate for efficacy and adverse effects.
Insomnia is a common symptom; when accompanied by distress or daytime impairment, it is a disorder that affects 10%-15% of the adult population. In its Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults, the American Academy of Sleep Medicine elucidates some complexities of its diagnosis and treatment.
The Guideline focuses on primary insomnias, which are most often characterized by sleeplessness with no identifiable cause (idiopathic insomnia) or linked to heightened arousal and learned behaviors (psychophysiological insomnia). The Guideline also suggests how these insomnias can be assessed and treated in a broad context of other sleep, medical, and psychiatric disorders.
“Primary-care practitioners have a difficult task at hand when they see a patient with insomnia. The diagnosis rests on a very good history, and that takes time,” says Sharon Schutte-Rodin, MD, Clinical Outcomes Program director at the Penn Sleep Centers at the University of Pennsylvania, in Philadelphia, and chairperson of the task force that wrote the Guideline.
“As with any history, the clinician starts by defining the chief complaint,” Dr. Schutte-Rodin explains. In addition to the usual questions—when the insomnia started, what makes it better or worse—this means exploring the patient’s sleep-wake schedule in depth, which includes a 24-hour history and patterns of sleep and daytime activity.
“A patient who is sleepy at bedtime is different from one who has physical or mental anxiety as bedtime approaches,” she says. “The clinician needs to focus on what goes on before bedtime, at bedtime, and what the patient feels while waiting to fall asleep.”
Be alert for signs of other sleep disorders. Loud snoring should raise suspicion of sleep apnea; clues to sleep-movement disorders often come from bed partners’ reports; a highly skewed schedule suggests a circadian rhythm disorder. While fatigue is common in primary insomnia, pronounced sleepiness (particularly if it includes a tendency to nod off during the day) points toward other sleep or medical disorders and indicates the need for a more thorough evaluation.
Comorbidity is common: the Guideline lists a wide range of medical and psychiatric conditions that can interfere with sleep. Such medications as antidepressants, stimulants, cardiovascular drugs, decongestants, and bronchodilators frequently contribute to insomnia, as do caffeine and alcohol.
Even if comorbid disorders are managed, medication regimens adjusted, and offending substances eliminated, the insomnia may still require treatment. “Over the course of these disorders, numerous psychological and behavioral factors develop which perpetuate the insomnia problem,” the authors write. These include negative, conditioned associations and unrealistic expectations about sleep.
Polysomnography and other laboratory studies are not generally indicated for primary insomnia (although they may be to rule out or evaluate other conditions such as sleep apnea). However, such simple tools as two-week sleep logs or diaries help identify sleep-wake patterns and establish a baseline against which treatment effectiveness can be measured. The Epworth Sleepiness Scale, an eight-item self-report questionnaire, is also useful.
Treating insomnia—psychological and behavioral therapies
Evidence-based treatment of insomnia can involve psychotherapy, pharmacotherapy, or both.
“Even if treatment is limited to pharmacotherapy without cognitive or behavioral therapies, the clinician needs to discuss the patient’s expectations and goals. If patients expect a pill to cause them to magically fall asleep, perfectly every night, they will likely be disappointed,” Dr. Schutte-Rodin says. “Patients need to restructure their thinking about sleep.”
Among specific psychological and behavioral therapies, the efficacy of stimulus control, relaxation training, and cognitive behavioral therapy for insomnia (CBT-I) are well supported by data.
The first of these therapies aims to replace associations that perpetuate insomnia (e.g., linking the bed with wakefulness and worry) with positive ones, and to establish a stable sleep-wake schedule over time. Relaxation training is designed to reduce elevated levels of cognitive and physical arousal that commonly interfere with sleep. CBT-I may include one or both of the above modalities, combined with a program to change the patient’s dysfunctional beliefs and unrealistic expectations about sleep.
Such other modalities as biofeedback, paradoxical intention, and sleep restriction may be helpful for certain patients, but there is less evidence of their efficacy.