Diagnosis of Primary insomnia
Primary insomnia Diagnosis: Book Excerpts
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INSOMNIA:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there dyspnea? If there is a history of dyspnea, heart disease or lung disease should be suspected.
- Is there a history of drug or alcohol ingestion? There are many drugs that may cause insomnia, including the amphetamines, theophylline, caffeine, anticonvulsants, nicotine, thyroid hormones, and the sympathomimetics. Alcohol may induce sleep, but patients complain of early morning wakening.
- Is there a history of a painful condition? Abscessed teeth, arthritis, sciatica, bone metastasis, hiatal hernia, and esophagitis are just a few of the conditions that may keep a patient awake because of pain.
- Are there other psychiatric symptoms? Anxiety, loss of libido, loss of appetite, and depression may be associated with hyperthyroidism, general paresis, organic brain syndrome, chronic anxiety, and endogenous depression.
DIAGNOSTIC WORKUP
Routine studies include a CBC, sedimentation rate, urinalysis and drug screen, chemistry panel, thyroid profile, VDRL test, EKG, and chest x-ray. Arterial blood gases and pulmonary function testing should be done to rule out pulmonary disease. A venous pressure and circulation time will help rule out early congestive heart failure. Blood pressure monitoring can be used to rule out paroxysmal hypertension. If an organic brain syndrome is suspected, a CT scan or MRI of the brain should be done. If psychiatric symptoms are present, the patient should be referred to a psychiatrist. Alternatively, a therapeutic trial of psychotherapeutic agents may be initiated if the patient is not suicidal. When all of the above diagnostic tests are negative, a sleep study must be done. However, home monitors for apnea and oxygen desaturation are available and may be an inexpensive alternative to rule out obstructive sleep apnea.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Insomnia:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Unnecessary concern about deviation from “normal” sleeping patterns
-
Acute, transient insomnia (<4 weeks)
–Situational stress (most common)
–Acute illness or injury
–Medications or drugs (e.g., cocaine)
–Change in sleep environment or hours - Chronic insomnia (>4 weeks)
–Difficulty falling asleep: May be due to poor sleep hygiene, conditioned insomnia (initial acute insomnia progresses to chronic due to maladaptive distorted sleep cognitions), medications (e.g., sedatives, decongestants, oral contraceptive use, antidepressants, bronchodilators), drugs (including over-the-counter and herbal preparations, alcohol, nicotine, illicit drugs), and caffeine (e.g., coffee, soda, medications)
–Difficulty staying asleep: May be due to sleep apnea, medications and drugs (e.g., alcohol), depression, anxiety, dementia, psychosis, mania, post-traumatic stress disorder, and various medical conditions (e.g., COPD, asthma, CHF, angina, GERD, peptic ulcer disease, IBD, BPH, UTI, pregnancy, uremia, diabetes mellitus, hyperthyroidism, menopause, pain, pruritus, seizures)
-
RLS
–“Creepy-crawly” unpleasant sensations in
the legs and/or feet
–Temporarily relieved by moving limbs
-
Periodic limb movement disorder
–Arms and/or legs jerk during sleep
–May be a primary disorder or secondary to uremia, neuropathy, or iron deficiency
–Often in the elderly
–Often occurs with restless legs syndrome
Narcolepsy
REM-behavior disorder
–Rare, mostly in elderly
–Thrashing or seemingly purposeful
behaviors during sleep
Prion fatal familial insomnia
Workup and Diagnosis
-
Sleep and medication/drug history, including bed partner history
-
Sleep diary is the most effective specific assessment tool
–Should be recorded each morning
–Include time in bed, time asleep, awakenings, estimate of
sleep quality, associated symptoms (e.g., pain, dyspnea, urinary frequency)
-
A focused physical examination to evaluate cardiovascular, pulmonary, and neurologic systems and mental status will improve diagnostic accuracy
-
Polysomnography (sleep study) is useful to evaluate sleep apnea, restless legs syndrome, periodic limb movement disorder, and REM-behavior disorder
-
“Insomnia” is a self-reported condition; labs or other testing is often unnecessary unless underlying medical conditions are suspected
–ECG, chest X-ray, echocardiogram, pulmonary function
tests if suspect undiagnosed cardiac or pulmonary disease
–EEG if suspect undiagnosed seizure disorder
–TSH and free T4 if suspect thyroid disease
–Iron studies and BUN/creatinine if suspect restless legs
syndrome or periodic limb movement disorder (iron deficiency and renal failure are risk factors for both)
–Consider blood alcohol level, CBC and MCV, LFTs, and toxicology screen if suspect alcohol or illicit drug abuse
>
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
INSOMNIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
In the approach to the diagnosis, every physician should take the time to talk to the patient about possible reasons for fear or hostility. A nagging wife or mother-in-law, financial worries, a strict boss, or fear of losing a job are just a few examples of problems that can be handled with some sympathetic professional help. A good physical and neurologic examination may reveal an organic cause. The laboratory evaluation will be based on suspicion of one or more of the diseases mentioned above and using the list of tests that follows this discussion. A skull x-ray, EEG, CT scan, and possibly a spinal tap are indicated if a neurologic disorder is strongly suspected.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Insomnia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
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 commonly 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 complaints that suggest an undiagnosed disorder, perform a physical examination.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Insomnia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
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.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Insomnia:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of insomnia. Insomnia cannot be diagnosed by the amount of time a person sleeps. Rather, it is distinguished by the daytime consequences of unsatisfactory sleep (4). A pertinent history for insomnia would include:
1. A history of restlessness, irritability, daytime somnolence, and impaired work or social functioning, which can lead to situational stress. This may be a transient problem, but it can lead to difficulties with initiation of sleep and early awakenings.
2. Use of caffeine or other stimulants, especially over-the-counter medications (e.g., decongestants) that may contain ephedrine or phenylpropanolamine. Late evening exercise can also be a stimulant. Alcohol may help induce sleep, but it interferes with REM sleep and leads to nonrestorative sleep and early awakenings.
3. Affect changes, sadness, hopelessness, and vegetative signs such as weight loss should suggest depression, the most common psychiatric disorder associated with insomnia (Chapter 3.3). This is especially true if the insomnia persists for weeks. Anxiety disorders cause difficulty with getting to sleep, whereas patients with depression may fall asleep more readily but have early awakening.
4. Medical problems such as peptic ulcer disease and heart failure have been implicated in insomnia (Chapters 7.5 and 9.6). A history of frequent nocturnal urinations can also disrupt sleep and may indicate benign prostate hyperplasia or other prostate problems. Hyperthyroidism can cause irritability and insomnia, as can thyroid replacement therapy for hypothyroidism. Other problems such as asthma, angina, back pain, and sinusitis can also cause sleep disorders.
5. Loud snoring, daytime somnolence, forgetfulness, difficulty concentrating, and a history from the bed partner of periods of discontinuation of breathing during sleep of 10 seconds or more should suggest a more thorough evaluation for obstructive sleep apnea. Daytime napping, associated findings of gastrointestinal reflux disease, and hypertension are also suggestive associations for sleep apnea.
6. The bed partner is also a good person to ask about leg movements during sleep. This could be suggestive of a periodic limb movement disorder. A similar syndrome, restless legs, is associated with a history of unpleasant sensations in the legs and a persistent desire to move them. Both conditions cause a delay in sleep onset and nocturnal awakenings.
7. Sleep phase disturbances caused by jet lag or shift work can be characterized by early awakening or by awakening later in the day.
Physical examination.
The physical examination for insomnia is more a search for other underlying disease states than for any specific signs for insomnia, although hypertension, obesity, and thick neck suggest consideration of sleep apnea.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Insomnia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Insomnia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
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, 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 commonly 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 or drug withdrawal. After reviewing complaints that suggest an undiagnosed disorder, perform a physical examination.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
INSOMNIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
In the approach to the diagnosis, every physician should take the time
to talk to the patient about possible reasons for fear or hostility. A
nagging wife or mother-in-law, financial worries, a strict boss, or fear of
losing a job are just a few examples of problems that can be handled with
some sympathetic professional help. A good physical and neurologic
examination may reveal an organic cause. The laboratory evaluation will be
based on suspicion of one or more of the diseases mentioned above and will
use the list of tests that follows this
discussion. A skull x-ray, electroencephalogram (EEG), CT scan, and possibly
a spinal tap are indicated if a neurologic disorder is strongly suspected.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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