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A 52-year-old woman comes to your office complaining of persistent insomnia and requests a prescription for a sleeping pill that she saw on a television advertisement.

  • What are the major diagnostic considerations for this patient with insomnia?
  • What further information do you need to know about her sleeping problems?
  • What questions should you ask to determine if the insomnia is related to a serious condition?

Insomnia is a very common complaint. Between 30% and 50% of adults have insomnia at some time, and it is a persistent problem in about 20% of adults. The prevalence increases with age, and it is more common in women. About 10% of the population has insomnia with significant daytime consequences, including daytime sleepiness or fatigue, diminished energy, poor concentration, memory impairment, irritability, depressed or anxious mood, and interpersonal difficulties.1

Although definitions of insomnia vary, most patients describe problems with initiating sleep, frequent or prolonged awakenings, a feeling of nonrestorative sleep, or some combination of these symptoms. Negative impacts on daytime social and/or occupational functioning are present in 20% to 60% of insomnia patients.2 Insomnia precedes the development of mood disorders in 50% of cases and anxiety disorders in 20% of cases.2 The risk of developing depression over 1 to 3 years is approximately 5-fold in patients with insomnia.3 Thus, insomnia can be a harbinger of future psychiatric illness. Lastly, patients with insomnia have an increased risk of industrial accidents (3- to 4-fold risk), road accidents (2- to 3-fold risk), and falls and hip fracture in the elderly population.2,3

Insomnia is most often precipitated by other medical or psychiatric disorders, primary sleep disorders, and medication use. This type of insomnia is called comorbid insomnia. Insomnia without any identifiable comorbid cause is called idiopathic or primary insomnia. The history is the most important diagnostic tool in establishing the underlying comorbid disorders. There are few helpful physical findings, and only rarely are specialized studies (eg, polysomnography or actigraphy) necessary. Because eliminating or mitigating the causes of insomnia remains the cornerstone of treatment, the history is critical to successful treatment.

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Adjustment sleep disorderInsomnia associated with acute life events (eg, medical or surgical illnesses, bereavement, divorce, stress).
Advanced sleep phase syndromeA circadian rhythm disorder in which persons have difficulty with early awakenings but no difficulty initiating sleep early at night, with normal quality and duration of sleep.
Comorbid insomnia

Insomnia resulting from comorbid medical and psychiatric illnesses, medication use, or other primary sleep disorders.

Delayed sleep phase syndromeA circadian rhythm disorder in which persons have difficulty falling asleep but have normal sleep quality and duration once sleep is initiated.
InsomniaAn experience of inadequate or poor quality sleep characterized by 1 or more of the following: difficulty falling asleep, difficulty maintaining sleep, waking up too early in the morning, or nonrefreshing sleep.
Periodic ...

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