Healthcare and Medicine Reference
In-Depth Information
Inventory of Depressive Symptomatology or the Beck
Depression Inventory II and the State Trait Anxiety Inven-
tory (see Table 77-3 ).
Box 77-2 Medical and Psychiatric Conditions
Commonly Comorbid with Insomnia
Medical Conditions *
Comorbid sleep disorders (e.g., sleep apnea, restless
legs syndrome, periodic limb movement)
Neurologic (e.g., headache, stroke, seizure disorders,
brain injury, dementia, Parkinson's disease)
Cardiovascular (e.g., angina, congestive heart failure)
Reproductive (e.g., pregnancy, menopause)
Pulmonary (e.g., asthma, emphysema)
Digestive (e.g., irritable bowel syndrome, peptic
Arthritis and other musculoskeletal disorders
Endocrine disorders (e.g., diabetes mellitus)
Nocturia, incontinence, enuresis and other genitouri-
nary disorders
Patients with periodic limb movement disorder (PLMD)
commonly present with symptoms of insomnia such as
trouble staying asleep and nonrestorative sleep. Those
affected can have hundreds of movements or brisk exten-
sions of the feet during the night; it is not uncommon for
these movements to be associated with a hundred or more
brief arousals. On occasion, a limb movement produces a
shift to a full awakening. Therefore, the patient is usually
unaware of these limb movements. The clinician needs to
infer their presence from the bed partner's report, for
example that the patient is a restless sleeper or kicks during
the night. Of course, overnight polysomnographic testing
provides objective evidence of PLMD, but insurance reim-
bursement limitations can preclude ordering a sleep study
to investigate clinical suspicion of the disorder. Therefore,
in many cases PLMD underlying a complaint of insomnia
might remain covert. Research has shown that an arousal
(cortical or subcortical) might precede the leg movement. 26
This suggests that it is not the limb movement that shakes
the sleeper awake but rather that the ascent from sleep
toward waking is primary.
Restless legs syndrome (RLS) is a complaint of sensory
discomfort or restlessness in the limbs (usually the legs)
when sedentary. It commonly becomes more pronounced
in the evening, and it is relieved by movements such as
walking, tapping or stretching. In some RLS patients the
discomfort is sufficient to interfere with falling asleep.
Therefore, when these patients complain of sleep-onset
insomnia, the culprit is clear.
Although the vast majority of patients with obstructive
sleep apnea and other sleep-related breathing disorders
chiefly complain of sleepiness, some report trouble sleep-
ing as a prominent problem. Anecdotal evidence suggests
that early in the course of the development of sleep-related
breathing disorders, trouble sleeping is more likely to be
experienced compared to when these disorders have
become firmly established.
Psychiatric Conditions
Mood disorders
• Major depressive disorder
• Dysthymic disorder
• Bipolar disorder
• Seasonal affective disorder
Anxiety disorders
• Generalized anxiety disorder
• Posttraumatic stress disorder (nightmares and
flashbacks of the trauma while trying to sleep)
Attention-deficit/hyperactivity disorder
Eating disorders
• Bulimia nervosa
• Anorexia nervosa
Adjustment disorder
Personality disorder
*Adapted from Schutte-Rodin S, Broch L, Buysse DJ, et al. Clinical
guideline for the evaluation and management of chronic insomnia in
adults. J Clin Sleep Med 2008;4:487-504.
subthreshold yet clinically
A widely held assumption is that insomnia is secondary
to, or an epiphenomenon of, the so-called primary psy-
chiatric disorder. Consequently, complaints of insomnia
have tended to be dismissed or regarded as trivial by both
patients and their caregivers or, at most, seen as a byprod-
uct of the coexisting disorder. In contrast, evidence is
accruing to indicate that insomnia is an important but
underrecognized mechanism in the multifactorial cause
and maintenance of psychiatric disorders 23 , 24 and, when
present, should be targeted in treatment. The value of this
approach is illustrated by studies comparing depressed
patients who are treated only for their depression (with
an antidepressant) versus depressed patients who are
treated for both the depression (with an antidepressant)
and the insomnia (with either a hypnotic or cognitive
behavior therapy for insomnia). The combined approach
A list of some of the most common comorbid medical
conditions is summarized in Box 77-2 . Pain, discomfort,
and treatment side effects of medical disorders are often
problematic for sleep, and therefore an assessment of
medical history, current health, and medication use is
essential. For medications, obtain information about the
type, amount, time of administration, frequency of use,
side effects, withdrawal effects on discontinuation, and
degree of drug tolerance. A physical examination has been
recommended as part of the routine evaluation of insom-
nia, especially to detect comorbid disorders.
When taking a history of hypnotic use be sure to ask
how and when they decide to take the medication. If the
patient starts the night by trying to fall asleep without a
sleeping pill and then lies in bed worrying about whether
or not sleep will come and whether or not to take a pill,
the patient might wait several hours and then take a pill
and then suffer sedating effects on waking.
both depression
outcomes. 25
Current research standards recommend that comorbid
psychiatric disorders be assessed with the Structured Clini-
cal Interview for Diagnosis (SCID) or a psychiatric history
along with questionnaire measures of mood such as the
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