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Insomnia Overview

Symptoms & Diagnosis: Insomnia

Symptoms

There are many signs and symptoms that patients with insomnia may exhibit. The list below describes many of the symptoms that are common amongst patients with insomnia. For more information on the individual symptoms, please visit one of the websites listed on the left-hand side of the page.

  • Difficulty falling and/or staying asleep and/or early morning awakening
  • Feeling unrefreshed on awakening, or daytime sleepiness
  • Morning headaches, eye irritation
  • Difficulty with concentration/memory
  • Impaired physical function (slow reaction time, clumsiness, poor balance)
  • Irritability, depressed or volatile mood

Diagnosis

The diagnosis of insomnia is made entirely on the basis of reported symptoms. The important exclusion, based on history, is of inadequate sleep opportunity (patients whose schedules allow only foreshortened sleep). Beyond this, the important initial issue is the identification of causal or contributing factors of which can be addressed and minimized. This is done in three steps:

  1. Identification of comorbid medical and psychiatric conditions. In most cases, these are known to the patient and clinician, e.g. depression, COPD, rheumatoid arthritis. Still, the patient with a chronic pain syndrome whose sleep complaints worsen may be signaling the need for adjustment of the pain control regimen. In some cases, insomnia complaints can be the first manifestation of a comorbid condition that may itself be difficult to recognize such as depression or substance abuse.
  2. Identification of potentially contributing medications or substances. This step may be complex in patients on complicated medical regimens, but recently added, deleted or adjusted medications are the most likely candidates.
  3. Consideration of other primary sleep disorders. Insomnia can be the presenting symptom of sleep disorders such as sleep apnea syndrome (SAS) which generally requires specialized procedures for diagnosis and treatment. SAS should be suspected when insomnia complaints occur in patients with hypertension, obesity, a history of snoring, and sleepiness. One helpful distinguishing feature is the relative prominence of nocturnal and diurnal symptoms. While many patients with insomnia complain of sleepiness, the dominant feature of insomnia is typically the disrupted nocturnal sleep. By contrast, in the typical patient with sleep apnea, the dominant problem is daytime sleepiness.

While the majority of patients with insomnia can be diagnosed and managed based entirely on the symptomatic presentation, specialized testing and assessments may be necessary to rule out other primary sleep disorders or less common causes of disrupted sleep.

Polysomnogram

A polysomnogram, or PSG, is a painless and procedure which requires the patient to go to sleep as they normally would, except sensors will be placed on the finger, limbs, chest, face, and scalp. These sensors will record brain activity, eye movement, muscle activity, breathing rate, heart rate, blood oxygen levels, and the amount of air that is being inhaled and exhaled. Using this information a sleep specialist can then make a plan for treatment. This test is generally necessary to the diagnosis of sleep apnea syndromes.

Multiple Sleep Latency Test

The Multiple Sleep Latency Test, or MLST, is a machine that is used to measure how long it takes for the patient to fall asleep. This test provides an objective measure of daytime sleepiness that can be important in assessing daytime impairment in patients with sleep disorders.

Physical Exam

While the physical exam is generally normal in patients with insomnia, specific findings may help with identification of specific comorbid conditions. Hypertension is very common in untreated sleep apnea, for example. Thyroid abnormalities are commonly associated with insomnia (hyperthyroidism) and sleep apnea (hypothyroidism).

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