The evaluation of the patient complaining of sleeplessness begins with a careful history and physical exam that addresses both sleep and waking behaviors. The history should include questions designed to evaluate the possibility of common medical, psychiatric and medication, or substance abuse-related issues [2]. Taking a good history from a patient with sleeplessness or restless sleep can be time consuming, but is critical to making a correct diagnosis and in guiding the treatment plan.

A good sleep history includes characterizing the insomnia complaints such as the type of complaint (falling asleep, staying asleep, early morning wakings, or non-restorative sleep), severity, impact on daytime functioning, frequency (how many nights a week), duration (how long has this been occurring), type of course (intermittent or progressive), aggravating or ameliorating symptoms, treatment attempts, and response to therapy [2]. Discussing the patient’s bedtime behaviors such as characterizing the sleeping environment, the patient’s emotional state, and whether the patient senses dread regarding sleep and sleep behaviors can provide insight [2]. Understanding the patients’ sleep-wake cycle to include sleep latency (time to fall asleep), number of awakenings, length of awakenings, sleep duration, and napping can all provide clues to the patient’s insomnia. Day-to-day variability should also be examined [2]. Patterns of sleep can be ascertained which may provide clues to circadian rhythm disorders, and assessing the amount of sleep can provide clues that the patient has too much or too little sleep opportunity [2].

In assessing insomnia, it is important to screen for comorbid sleep disorders such as restless leg syndrome, obstructive sleep apnea, and parasomnias (sleep walking/sleep talking) [2]. Comorbid medical complaints such as chronic pain, untreated reflux, uncontrolled nocturnal asthma, headaches, and paroxsysmal nocturnal dyspnea may contribute to the patient’s complaint of insomnia [2].

A complete insomnia history includes medical, psychiatric, medication/substance, and family/social/occupational histories (Table 8.2). Not only are medical and psychiatric illnesses often comorbid or even causative for insomnia, but direct effects of prescription or over-the-counter medications may impact sleep and daytime functioning [2]. For example, a patient taking an over-the-counter sleep headache remedy containing caffeine may be sabotaging their ability to fall asleep. A careful evaluation of their caffeine intake and smoking/tobacco history can be illuminating. Many patients with insomnia use cigarettes before bed as a way to “relax,” yet few patients realize the simulating effects of the nicotine. Alcohol is commonly used prior to bed to help initiate sleep by many suffering with insomnia, without realizing that alcohol can cause frequent and prolonged nighttime awakenings. Finally, evaluating and offering suggestions regarding waking and bedtime behaviors may improve symptoms. For example, the light from using electronic devices in bed is counterproductive to sleep and may cause or perpetuate insomnia.