History and examination in patient with insomnia

History taking
Diagnosis of insomnia is primarily based on the account given by the patient (and/or family member or carer) about their sleep.

• a detailed history should be carried out to
  • assess sleep and waking function
  • identify precipitating factors
  • detect any comorbid medical or psychiatric illness

Insomnia is a subjective complaint, but as a general guide, patients with insomnia typically report taking 30 minutes or more to fall asleep (if sleep initiation difficulties are present) and/or spending 30 minutes or more awake during the night (if sleep maintenance difficulties are present) (1)

Impaired daytime function is required in order to diagnose an insomnia disorder. (2)

When obtaining history, inquire about:

• sleep itself
  • time the patient goes to bed
  • time the patient falls asleep
  • awakening - number, duration, cause, presence of associated symptoms e.g. - heartburns, shortness of breath, anxiety, full bladder
  • time out of bed in the morning
  • usual duration of sleep
  • is the routine same during weekends and holidays
• pre sleep conditions
  • bedroom, environment
  • any vigorous activity late in the evening
• impact of any sleep problems
  • on awakening does the patient feel unrefreshed or still sleepy
  • presence of symptoms such as headache and dry mouth
  • daytime sleepiness
• symptoms of obstructive sleep apnoea (inquire from bed partner as well if possible)
  • heavy snoring, pauses in breathing and grasping
• other factors which may cause insomnia
  • use of stimulants - caffeine, alcohol, cigarettes
  • drugs which may interfere with sleep e.g. - pseudoephedrine, amphetamine, antidepressants
  • important recent life events e.g. - bereavements
• naps taken during daytime
  • frequency, timing and duration of each nap
• other sleep disorder symptoms
  • depression - low mood or lack of pleasure in some or most activities
  • symptoms related to parasomnias
    • restless sleep
    • leg or body twitching
    • leg jerking - restless leg syndrome
    • shaking fits
    • sleep walking or talking
    • waking up in terror

Sleep diary
Patients record their sleep pattern for one to two weeks which may provide insight into the actual sleep habits of the patient.

• it may identify: sleep trends, such as erratic schedules, or identify predominant sleep patterns, such as taking a long time to fall asleep, frequent awakenings, early morning awakenings, or a mixture.
• can be used as a starting point for management of insomnia and can also be used to monitor progress of certain treatment (3)

Physical examination
Although cannot be used for diagnosis of insomnia, it can be useful to help identify or exclude obvious underlying causes of sleep disorder e.g. - obstructive sleep apnoea, Parkinson's disease

Polysomnography (overnight sleep study)
Can confirm sleep apnoea and limb movement disorders or restless legs syndrome

If comorbid insomnia is suspected referral to a specialist sleep centre for further evaluation may be necessary (4,5).

References:

1. Schutte-Rodin S, Broch L, Buysse D, et al. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008 Oct 15;4(5):487-504.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.
3. Natale V et al. The consensus sleep diary: quantitative criteria for primary insomnia diagnosis. Psychosom Med. 2015 May;77(4):413-8
4. Falloon K et al. The assessment and management of insomnia in primary care. BMJ. 2011;342:d2899.
5. Wilson SJ et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol. 2010;24(11):1577-601.