Chapter 77 Insomnia

Diagnosis, Assessment, and Outcomes

Abstract

The evaluation of insomnia should take place within two general frameworks: The one is the 3P model that classifies case material into predisposing, precipitating, and perpetuating factors, and the other is the context of the insomnia, considering stage of development, social situation, and culture. The sleep history can be facilitated by the use of a formatted questionnaire that systematically surveys key issues. A sleep diary filled out each day is one of the most useful ways to evaluate the problem and track the effect of interventions. The use of polysomnography and actigraphy are not routinely recommended.

A dual approach to assessment is suggested that uses a wide lens to establish the broad thematic structure of the problem (e.g., what part of the night is disturbed, daytime activities that affect sleep, thoughts about sleep, worries about the daytime functional deficits, sleep–wake habits). The other approach is pointedly personal and uses a focused lens that dissects a particular night of insomnia—and the subsequent day—to catch the weave of events and mental responses that locate the targets for treatment within the vicious cycle created by the interaction between poor sleep and psychological reactions.

Attention needs to be paid in the evaluation to comorbid conditions such as psychiatric, sleep and medical disorders. Consistent with the consensus of the field it is assumed that these disorders can trigger, contribute to, or be unrelated to the insomnia.

During and after treatment, conducting an evaluation of progress refines our understanding of effectiveness.

The goal of this chapter is to provide a comprehensive overview of the diagnosis of insomnia, the clinical assessment of insomnia, and the measurement of outcome and to provide a guide as to how to select from the growing array of assessment tools available. The focus is on the adult insomnia patient. The full assessment described here takes between 60 and 120 minutes, depending on the complexity of the patient’s insomnia. Given that many professionals needing to assess insomnia are time pressed, a quick assessment guide is included as Box 77-1. The information within Box 77-1 is elaborated in the text and can be used as a checklist or guide for the broad domains that should be covered during an assessment.

Box 77-1 Quick Assessment Guide

Circumstances Surrounding Onset

Age of onset

Precipitating event(s)

Sudden or gradual onset

Duration

Daytime Consequences

Fatigue

Sleepiness

Napping

Cognition, performance, and mood

Past Treatments

Type

Adequacy of trial

Efficacy

Factors That Ameliorate

Sleep in nonhabitual environments

Sleep before a day with no commitments

Other factors

Factors That Exacerbate

Sleep on Sunday nights

Anxiety when seeing the clock at night

Other factors

Medical Factors

Pain, discomfort

Treatments that interfere with sleep

Pharmacologic Considerations

Activating drugs or sedating drugs that break down the regularity of the sleep–wake cycle

Side effects

History of using hypnotics

Work Factors

Stress

Work schedule incompatible with sleep schedule

Perpetuating Factors

Other

Alcohol

Noise

Pets sleeping in the same bed

Clock watching during the night

Getting home late without enough time to wind down

Insomnia is an ongoing difficulty getting to sleep, staying asleep, waking up too early, or waking up and feeling that the sleep obtained is not restorative. In addition to the sleep complaint, the person with insomnia reports daytime impairment and has an adequate opportunity for sleep.¹ Three classification systems offer specific diagnostic criteria for insomnia. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR)² and the International Classification of Diseases, 10th revision (ICD-10),³ offer a small number of broad categories based on current symptoms and functioning, but the International Classification of Sleep Disorders, second version (ICSD-2),⁴ offers a larger number of subtypes that require the assessor to make judgments about the causes of the insomnia. Table 77-1 lists the key features of the ICSD-2 diagnoses, and Table 77-2 summarizes the diagnostic codes of the ICSD-2 and the DSM-IV-TR. Research is needed to determine the validity and reproducibility of both the broad categories and the subtypes.

Table 77-1 Key features of ICSD-2 Insomnia Diagnoses

INSOMNIA DIAGNOSIS	KEY FEATURES
307.41 Adjustment sleep disorder	Associated with a specific stressor
307.42 Psychophysiologic insomnia	Heightened arousal and learned sleep-preventing associations
307.42 Paradoxical insomnia	Subjective report of severe sleeplessness not congruent with the absence or minor degree of daytime impairment
327.02 Insomnia due to a mental disorder	Associated with mental disorder, but the insomnia constitutes a distinct complaint
307.42 Idiopathic insomnia	Onset in infancy or early childhood
V69.4 Inadequate sleep hygiene	Associated with activities that are inconsistent with optimal sleep
V69.5 Behavioral insomnia of childhood	The result of inappropriate sleep associations or inadequate limit setting
292.85 Insomnia due to a drug or substance	Disruption to sleep due to a drug or substance (prescribed, over-the-counter, or recreational)
327.01 Insomnia due to a medical condition	Associated with a coexisting medical disorder or other physical issue
780.52 Insomnia not due to a substance or physiologic condition, unspecified	Unable to be classified elsewhere but suspected to be associated with a mental disorder, psychological factor, or sleep-disruptive practice
327.00 Physiologic (organic) insomnia, unspecified	Unable to be classified elsewhere but suspected to be associated with a medical disorder, physiologic state, or substance

Table 77-2 Diagnostic Coding of Subtypes of Insomnia

ICSD-2* INSOMNIA CATEGORIES	DSM-IV-TR^† INSOMNIA CATEGORIES
307.41 Adjustment sleep disorder	307.42 Primary insomnia
307.42 Psychophysiologic insomnia	307.42 Primary insomnia
307.42 Paradoxical insomnia	307.42 Primary insomnia
307.42 Idiopathic insomnia	307.42 Primary insomnia
327.02^‡ Insomnia due to a mental disorder	307.42 Insomnia related to another mental disorder
V69.4 Inadequate sleep hygiene
V69.5 Behavioral insomnia of childhood
292.85 Insomnia due to a drug or substance	292.89 Substance-induced sleep disorder, insomnia type
327.01^‡ Insomnia due to a medical condition	780.52 Sleep disorder due to a general medical condition, insomnia type
780.52 Other insomnia not due to a substance or physiological condition, unspecified
327.00 Organic insomnia, unspecified

* American Academy of Sleep Medicine. International classification of sleep disorders (ICSD): diagnostic and coding manual, 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005.

† American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.

‡ Code the primary condition first and the insomnia second (e.g., dysthymic disorder, 300.4, Insomnia due to a mental disorder, 327.02). Alternatively, one of the following codes may be used: ICD-10 Insomnia Categories,³ F51.0 Nonorganic sleep disorders, G47.0 Organic sleep disorders.

The Duke Structured Interview for Sleep Disorders (DSISD) is a structured series of questions that helps the clinician to efficiently establish DSM-IV-TR, ICSD-2, and research diagnostic criteria (RDC) insomnia diagnoses. Each section of the interview starts with a screening question. If this is endorsed, a series of follow-up questions are asked. If the screen is not endorsed the follow-up questions are skipped and the assessor moves to the screening question in the next category. The DSISD is divided into three sections: insomnia diagnoses, other sleep disorders (e.g., dyssomnia), and sleep disorders associated with excessive daytime sleepiness. The DSISD has been found to be effective for identifying those meeting criteria for an insomnia disorder.⁵

Note that insomnia symptoms are a feature of a range of other sleep disorders. For example, insomnia is listed as a feature of various sleep-related breathing disorders, circadian rhythm disorders, sleep-related movement disorders, and the parasomnias (e.g., nightmare disorder and sleep-related breathing disorder). Such symptoms can arise, at least in part, from the precipitating factors that are also a feature of the insomnia disorders (e.g., hyperarousal, conditioning).

Clinical Assessment

Recommendations for the standard research assessment of insomnia have been published.⁶ This was the result of a detailed review of the literature and an expert consensus process involving an evidence-based quantitative review of the available methods. Table 77-3 summarizes the measures selected by this process. Although these are recommendations for research contexts, they serve as a useful guide for clinicians to select from the vast array of instruments available.

Table 77-3 Recommended Research Measures for Insomnia ⁶