Insomnia
Insomnia: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Insomnia is the inability to fall asleep, remain asleep, or feel refreshed by sleep. Acute and transient during periods of stress, insomnia may become chronic, causing constant fatigue, extreme anxiety as bedtime approaches, and psychiatric disorders. This common complaint is experienced occasionally by about 25% of Americans and chronically by another 10%.
Physiologic causes of insomnia include jet lag, arguing, and lack of exercise. Pathophysiologic causes range from medical and psychiatric disorders to pain, adverse effects of a drug, and idiopathic factors. Complaints of insomnia are subjective and require close investigation; for example, the patient may mistakenly attribute his fatigue from an organic cause, such as anemia, to insomnia.
History and physical examination
Take a thorough sleep and health history. Find out when the patient’s insomnia began and the circumstances surrounding it. Is the patient trying to stop using a sedative? Does he take a central nervous system (CNS) stimulant, such as an amphetamine, pseudoephedrine, a theophylline derivative, phenylpropanolamine, cocaine, or a drug that contains caffeine, or does he drink caffeinated beverages?
Find out if the patient has a chronic or acute condition, the effects of which may be disturbing his sleep, particularly cardiac or respiratory disease or painful or pruritic conditions. Ask if he has an endocrine or neurologic disorder, or a history of drug or alcohol abuse. Is he a frequent traveler who suffers from jet lag? Does he use his legs a lot during the day and then feel restless at night? Ask about daytime fatigue and regular exercise. Also ask if he often finds himself gasping for air, experiencing apnea, or frequently repositioning his body. If possible, consult the patient’s spouse or sleep partner because the patient may be unaware of his own behavior. Ask how many pillows the patient uses to sleep.
Assess the patient’s emotional status, and try to estimate his level of self-esteem. Ask about personal and professional problems and psychological stress. Also ask if he experiences hallucinations, and note behavior that may indicate alcohol withdrawal. After reviewing any complaints that suggest an undiagnosed disorder, perform a physical examination. (See Differential diagnosis: Insomnia, pages 450 and 451.)
Medical causes
Alcohol withdrawal syndrome
Abrupt cessation of alcohol intake after long-term use causes insomnia that may persist for up to 2 years. Other early effects of this acute syndrome include excessive diaphoresis, tachycardia, hypertension, tremors, restlessness, irritability, headache, nausea, flushing, and nightmares. Progression to delirium tremens produces confusion, disorientation, paranoia, delusions, hallucinations, and seizures.
Generalized anxiety disorder
Anxiety can cause chronic insomnia as well as symptoms of tension, such as fatigue and restlessness; signs of autonomic hyperactivity, such as diaphoresis, dyspepsia, and high resting pulse and respiratory rates; and signs of apprehension.
Mood (affective) disorders
Depression commonly causes chronic insomnia with difficulty falling asleep, waking and being unable to fall back to sleep, or waking early in the morning. Related findings include dysphoria (a primary symptom), decreased appetite with weight loss or increased appetite with weight gain, and psychomotor agitation or retardation. The patient experiences loss of interest in his usual activities, feelings of worthlessness and guilt, fatigue, difficulty concentrating, indecisiveness, and recurrent thoughts of death.
Manic episodes produce a decreased need for sleep with an elevated mood and irritability. Related findings include increased energy and activity, fast speech, speeding thoughts, inflated self-esteem, easy distractibility, and involvement in high-risk activities such as reckless driving.
Nocturnal myoclonus
With this seizure disorder, involuntary and fleeting muscle jerks of the legs occur every 20 to 40 seconds, disturbing sleep.
Pain
Almost any condition that causes pain can cause insomnia. Related findings reflect the specific cause.
Pheochromocytoma
This rare disorder causes paroxysms of acute hypermetabolic activity, which can prevent or interrupt sleep. Its cardinal sign is severe hypertension, which may be sustained between attacks. Other effects include headache, palpitations, and anxiety.
Pruritus
Localized skin infections and systemic disorders, such as liver failure, can cause pruritus, resulting in insomnia.
Sleep apnea syndrome
Apneic periods begin with the onset of sleep, continue for 10 to 90 seconds, and end with a series of gasps and arousal. With central sleep apnea, respiratory movement ceases for the apneic period; with obstructive sleep apnea, upper airway obstruction blocks incoming air, although breathing movements continue. Some patients display both types of apnea. Repeated possibly hundreds of times during the night, this cycle alternates with bradycardia and tachycardia. Associated findings include morning headache, daytime fatigue, hypertension, ankle edema, and personality changes, such as hostility, paranoia, and agitated depression.
Thyrotoxicosis
Difficulty falling asleep and then sleeping for only a brief period is one of the characteristic symptoms of this disorder. Cardiopulmonary features include dyspnea, tachycardia, palpitations, and atrial or ventricular gallop. Other findings include weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, hypersensitivity to heat, an enlarged thyroid, and exophthalmos.
Other causes
Drugs
Use of, abuse of, or withdrawal from sedatives or hypnotics may produce insomnia. CNS stimulants—including amphetamines, theophylline derivatives, pseudoephedrine, cocaine, and caffeinated beverages—may also produce insomnia.
Herb Alert
Herbal remedies, such as ginseng and green tea, can also cause insomnia.
Special considerations
Prepare the patient for tests to evaluate his insomnia, such as blood and urine studies for 17-hydroxycorticosteroids and catecholamines, polysomnography (including an EEG, electro-oculography, and electrocardiography), and sleep EEG.
Pediatric pointers
Insomnia in early childhood may develop along with separation anxiety at ages 2 to 3, after a stressful or tiring day, or during illness or teething. In children ages 6 to 11, insomnia usually reflects residual excitement from the day’s activities; a few children continue to have bedtime fears. Sleep problems are common in foster children.
Patient counseling
Teach the patient comfort and relaxation techniques to promote natural sleep. (See Tips for relieving insomnia.) Advise him to awaken and retire at the same time each day and to exercise regularly. When he can’t sleep, advise him to get up but remain inactive. Urge him to use his bed only for sleeping, not for relaxation or watching television.
Advise the patient to use tranquilizers or sedatives for acute insomnia only when relaxation techniques fail. If appropriate, refer him for counseling or to a sleep disorder clinic for biofeedback training or other interventions.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "Nursing: Interpreting Signs and Symptoms" (2007)
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- "Differential Diagnosis in Primary Care" (2007)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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