Insomnia is a near universal experience, but can be extremely disruptive when frequent and persistent. Insomnia is often driven by the development of maladaptive behaviors and thoughts surrounding the sleep disturbance. Such behaviors include naps, irregular sleep schedules, or excessive time in bed. Typical maladaptive thoughts include excessive worry about the inability to sleep or concern about the impact of the sleep disturbance on daytime function. These behaviors and thoughts can perpetuate the insomnia cycle. Patients with insomnia should be distinguished from “short sleepers” who average less than 6 hours of sleep per night but lack any sleep disturbances or functional impairment, and from those who lack an adequate opportunity for sleep but, when given sufficient time and circumstances to sleep, achieve normal sleep without disruptions or impairment.
- A.
Short-term insomnia is often due to a precipitating event or identifiable stressor, such as a change in environment or schedule, or medical or psychiatric illness. Often as the precipitating event resolves or diminishes, so does the insomnia. If there are maladaptive behaviors or thoughts surrounding the sleep disturbance, cognitive behavioral therapy for insomnia (CBT-I) can be helpful. Depending on the degree of distress or impairment, short-term hypnotic use may be appropriate.
- B.
Environmental factors, such as noise, light, uncomfortable temperatures, or safety concerns, may contribute to insomnia, with improvement when these factors are addressed.
- C.
Stimulants can interfere with sleep and cause insomnia, including caffeine, nicotine, amphetamines, and cocaine. Activating antidepressants, such as bupropion, and other medications such as corticosteroids, can also interfere with sleep. Withdrawal from hypnotics, anxiolytics, and sedating substances such as alcohol or marijuana may cause rebound insomnia.
- D.
Insomnia is frequently comorbid with psychiatric, medical, and other sleep disorders. If comorbid disorders are present, treatment should focus on the underlying condition as well as the insomnia as there is likely a reciprocal relationship between the two.
- E.
Obstructive sleep apnea, parasomnias, periodic limb movements, and narcolepsy may present with insomnia complaints due to nighttime awakenings or fragmented sleep. Restless legs syndrome may present with difficulty falling asleep, but this disorder can be differentiated from sleep-onset insomnia by the clinical history. Circadian rhythm sleep-wake disorders such as advanced sleep-wake phase disorder, delayed sleep-wake phase disorder, and shift work disorder should be considered in the setting of insomnia complaints. Advanced sleep-wake phase disorder should be differentiated from insomnia with early morning awakening, as individuals with an advanced endogenous circadian rhythm tend to go to bed early and wake up early but otherwise sleep normally, unlike someone with insomnia. Early morning awakening may also be common in individuals with depression. Delayed sleep-wake phase disorder can present as sleep-onset insomnia if an individual attempts to go to bed earlier than their endogenous circadian clock. However, when allowed to have a later bedtime and wake time, these individuals sleep normally without difficulty falling asleep.
- F.
CBT-I is the first-line treatment for chronic or persistent insomnia. CBT-I is a nonpharmacological therapy that targets both the maladaptive behaviors and thoughts that contribute to chronic insomnia; it has more durable long-term benefits after treatment completion compared to hypnotic medications. If CBT-I is not effective, available, or feasible, pharmacotherapy for insomnia can be considered ( Table 78.1 ). Hypnotic medications for insomnia can be associated with side effects, drug-drug interactions, dependency, and habituation. If needed, hypnotic medications should be used on a short-term basis and supplemented with CBT-I when possible.
Algorithm 78.1
Flowchart for the treatment of a patient with insomnia. CBT-I, Cognitive behavioral therapy.Related posts:
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