Patients with insomnia have impaired daytime function due to difficulty initiating sleep, difficulty maintaining sleep, or waking up early in the morning without ability to return to sleep [7]. They complain of fatigue, loss of energy, depression and irritability during the day and disturbed sleep during the night. A detailed history may reveal the use of certain medication that may point towards an underlying disease. If the patient is suffering from a psychological condition, it may present with characteristic symptoms like delusions, hallucinations, confusion, anxiety, depression and personality changes. If the insomnia is associated with other diseases, presenting complains of insomnia will be accompanied with systemic signs and symptoms.

• Fatigue

  The most common one is insomnia, which can exacerbate other post-injury symptoms, including fatigue, impaired cognition, depression, anxiety, and pain. [ncbi.nlm.nih.gov]

  Risk factors associated with insomnia were milder TBIs, and higher levels of fatigue, depression, and pain. [doi.org]

  Sometimes in the depressed phase of bipolar disorder and in seasonal affective disorder, sleep is uninterrupted, but patients complain of unrelenting daytime fatigue. [merckmanuals.com]

• Weakness

  (Grade: weak recommendation, low-quality evidence). [ncbi.nlm.nih.gov]

  Many drugs are too weak ... benadryl, unisom, hydroxyzine, clonidine etc. The drugs which have worked have caused munchies and weight gain ... mirtazapine (Remeron), quetiapine (seroquel) and even trazodone. [reddit.com]

  Tiredness, lethargy, dyspnoea, pruritus, insomnia, weakness and deterioration in mobility are common and have significant impact on the quality of life. The judge recognized the solicitor of the criminal who was suffering from insomnia. [dictionary.cambridge.org]

• Congestive Heart Failure

  Medical conditions - chronic pain, chronic fatigue syndrome, congestive heart failure, angina, acid-reflux disease ( GERD ), chronic obstructive pulmonary disease, asthma, sleep apnea, Parkinson's and Alzheimer's diseases, hyperthyroidism, arthritis, [medicalnewstoday.com]

  The many medical conditions that may cause insomnia include: Breathing problems, e.g. asthma, chronic obstructive pulmonary disease Congestive heart failure Obesity Acid reflux (heartburn) Hyperthyroidism Urinary problems (e.g. urinary incontinence) Chronic [southerncross.co.nz]

  For example, COPD, GERD and congestive heart failure can all make it difficult to fall asleep. But physical conditions are not the only culprit. [sleepassociation.org]

• Chronic Fatigue Syndrome

  Medical conditions - chronic pain, chronic fatigue syndrome, congestive heart failure, angina, acid-reflux disease ( GERD ), chronic obstructive pulmonary disease, asthma, sleep apnea, Parkinson's and Alzheimer's diseases, hyperthyroidism, arthritis, [medicalnewstoday.com]

  Such "acute" fatigue is different yet again from the "chronic" fatigue experienced by cancer patients, sufferers of chronic fatigue syndrome or fibromyalgia. [scientificamerican.com]

  Chronic fatigue syndrome (CFS). Some early research shows that taking melatonin in the evening might improve some symptoms of CFS, including fatigue, concentration, and motivation. [webmd.com]

• Unconsciousness

  Insomnia, the inability to sleep, is for Eluned Summers-Bremner the “embodiment of a double negative, the absence of unconsciousness” (p. 70). [doi.org]

  At the house, Finch knocks Burr unconscious just as Dormer arrives. Dormer is too disoriented from lack of sleep to fight off Finch. Burr revives and saves Dormer, while Finch escapes. [en.wikipedia.org]

  That when we can't sleep we are granted valuable insight 'into the unconscious mind.' [amazon.com]

  While inducing unconsciousness, benzodiazepines actually worsen sleep quality as they promote light sleep and decrease time spent in deep REM sleep. [healthengine.com.au]

  Sleep can seem like quite a mysterious process that takes us from consciousness to unconsciousness. In fact, some of its complexities are still not fully understood. [idorsia.com]

• Constipation

  Sometimes, doctors recommended taking a magnesium supplement to combat constipation or leg cramps. [whattoexpect.com]

  Side effects include constipation, dizziness, nausea, exacerbation of sleep apnea, and the risk of addiction; however, very low doses are often effective in controlling symptoms of RLS. Benzodiazepines. [ninds.nih.gov]

  Side effects include daytime sedation, dry mouth, constipation, and difficulty urinating. Prescription medications. [health.harvard.edu]

  Some research shows that melatonin works better in people with IBS in which constipation rather than diarrhea is the main symptom. Menopausal symptoms. Limited research shows that melatonin does not relieve menopausal symptoms. [webmd.com]

• Back Pain

  OBJECTIVE : To present the seventh in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. [ncbi.nlm.nih.gov]

  Don’t initially obtain X-rays for injured workers with acute non-specific low back pain. X-ray is unnecessary for the initial routine management of low back pain unless red flags are present. [web.archive.org]

• Low Back Pain

  OBJECTIVE : To present the seventh in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. [ncbi.nlm.nih.gov]

  X-ray is unnecessary for the initial routine management of low back pain unless red flags are present. Even when red flags are suspected, it should not be mandatory to order an X-ray in all cases. [choosingwisely.org]

  Don’t initially obtain X-rays for injured workers with acute non-specific low back pain. X-ray is unnecessary for the initial routine management of low back pain unless red flags are present. [web.archive.org]

  back pain Medications such as those taken for the common cold and nasal allergies, high blood pressure, heart disease, thyroid disease, birth control, asthma, and depression can also cause insomnia. [sleepfoundation.org]

  Adam D Bramoweth, Jenna G Renqvist, Anne Germain, Daniel J Buysse, Angela Gentili, Gary Kochersberger, Eric Rodriguez, Michelle I Rossi and Debra K Weiner, Deconstructing Chronic Low Back Pain in the Older Adult—Step by Step Evidence and Expert-Based [doi.org]

• Hyperhidrosis

  […] pose a serious risk to respiratory function even when taken alone, this is due to its much higher toxicity index relative to other benzodiazepines) Blurred vision (in higher doses) Confusion Lack of concentration Slurred speech Less Common Side Effects Hyperhidrosis [web.archive.org]

• Suggestibility

  Several research groups have suggested that these patients should initially receive treatment for their insomnia before the sleep apnea is targeted. [ncbi.nlm.nih.gov]

  In contrast, the clinical trial data for diphenhydramine, immediate-release melatonin, and valerian suggested limited beneficial effects. [doi.org]

• Psychiatric Symptoms

  CONCLUSION: Clinical insomnia in outpatients with schizophrenia is highly prevalent and has a negative impact on quality of life and psychiatric symptoms. [ncbi.nlm.nih.gov]

  Psychiatric symptoms — such as anxiety and depression — are known to be associated with changes in sleep. [sleepfoundation.org]

  There were 7,954 respondents questioned at baseline and again 1 year later about sleep complaints and psychiatric symptoms. [primarypsychiatry.com]

  Approximately half of all diagnosed insomnia is related to psychiatric disorders.[62] In depression in many cases "insomnia should be regarded as a co-morbid condition, rather than as a secondary one;" insomnia typically predates psychiatric symptoms. [en.wikipedia.org]

• Compulsive Disorder

  Insomnia is a common problem among patients with obsessive-compulsive disorder (OCD), and patients suffering from acute insomnia with psychiatric comorbidity are more likely to develop chronic insomnia without appropriate intervention. [ncbi.nlm.nih.gov]

  Many anxiety disorders are associated with difficulties sleeping. Obsessive-compulsive disorder (OCD) is frequently associated with poor sleep. Panic attacks during sleep may suggest a panic disorder. [nami.org]

  […] but now used with a range of problems including anxiety, depression, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and anger problems. [en.wikipedia.org]

• Nocturnal Polyuria

  Nocturnal polyuria, excessive nighttime urination, can be very disturbing to sleep.[22] Subjectivity[edit] Some cases of insomnia are not really insomnia in the traditional sense, because people experiencing sleep state misperception often sleep for a [en.wikipedia.org]

• Polyuria

  Nocturnal polyuria, excessive nighttime urination, can be very disturbing to sleep.[22] Subjectivity[edit] Some cases of insomnia are not really insomnia in the traditional sense, because people experiencing sleep state misperception often sleep for a [en.wikipedia.org]

• Sleep Disturbance

  Most of these changes have been observed primarily in patients who have objective sleep disturbance seen on the polysomnogram, as opposed to the very interesting group who complain of sleep disturbance but who manifest minimal objective sleep changes. [web.archive.org]

  This case report aims to illustrate the possibility of rectifying sleep disturbances comorbid with social phobia, using a brief cognitive behaviour therapy for insomnia (CBT-I). [ncbi.nlm.nih.gov]

  Learning and conditioning are also involved in the maintenance or exacerbation of sleep disturbances. [scholarpedia.org]

  The nature of sleep disturbance is related more to NREM sleep, especially SWS and sleep continuity, as well as efficiency parameters. [doi.org]

• Irritability

  It is associated with daytime symptoms such as irritability and fatigue. The February 20, 2013, issue of JAMA includes an article about insomnia. [doi.org]

  Mood swings, irritability, and anxiety are common associated symptoms. Insomnia has also been associated with a higher risk of developing chronic diseases. [medicalnewstoday.com]

  Because alcohol is absorbed directly through the stomach, the cells that line the organ become irritated. [web.archive.org]

• Memory Impairment

  While transient insomnia produces sleepiness and impairment in psychomotor performance, chronic insomnia is associated with absenteeism, frequent accidents, memory impairment, and greater health care utilization. [ncbi.nlm.nih.gov]

  Daytime problems caused by insomnia include the following: Poor concentration and focus Difficulty with memory Impaired motor coordination Irritability and impaired social interaction Motor vehicle accidents because of fatigued, sleep-deprived drivers [web.archive.org]

  Withdrawal can be associated with anxiety, depression, nausea, rebound insomnia, nightmares and impaired memory. Gradual drawing back of the dose alone is ineffective in achieving long-term cessation of benzodiazepine use. [healthengine.com.au]

  Daytime problems caused by insomnia include the following: Poor concentration and focus Difficulty with memory Impaired motor coordination (being uncoordinated) Irritability and impaired social interaction Motor vehicle accidents because of fatigued, [emedicinehealth.com]

Physical examination may offer clues to underlying medical disorders predisposing to insomnia [8]. A detailed history is imperative in making the right diagnosis.

Laboratory tests

• Arterial blood gases
• Blood oximetry
• Routine blood tests like complete blood count (CBC), prothrombin time, thyroid function tests, liver function tests, kidney function tests to rule out underlying disease.

Imaging

• ECG
• Polysomnography
• Actigraphy
• Radiography and CT scan to exclude other diseases

Test results

The diagnosis of insomnia is a difficult one and is easily confused with sleep apnea. A detailed history and the use of a sleep diary or log book can aid in making the right diagnosis.

Medication

Since insomnia can precipitate, exacerbate, or prolong comorbid conditions, treatment of insomnia may improve comorbidities [9]. Treatment is based on chemotherapy that includes sedatives like benzodiazepines, and non-benzodiazepines receptor agonists like Zolpidem and Eszopiclone. Other drugs that can be used to treat or at least provide symptomatic relief include Melatonin, or Melatonin-receptor agonists like Ramelteon, Orexin receptor antagonist like Suvorexant, sedative anti-depressants like Doxepin, and antihistamines.

Non-pharmalogical treatment

It includes hypnotic treatment to induce and improve sleep and cognitive behavioural therapy (CBT). CBT is a good way of treating insomnia and is recommended along with pharmacological treatment.

Insomnia may disappear on its own if the predisposing factor is removed or treated. In cases where the predisposing factor(s) or underlying condition persists, insomnia is a progressive disease. It may begin with disturbed sleep and progress to severe depression, loss of memory and a reduced quality of life. People who are able to sleep for only 5 hours or less on long term basis have high mortality rates.

Insomnia has a diverse range of potential causes. First and foremost is stress. Stress could be due to personal, professional, social or financial conditions which would make the person anxious and depressed, causing insomnia. Some patients may be insomniacs due to a genetic predisposition. A missense mutation has been found in the gene encoding the GABAA beta 3 subunit in a patient with chronic insomnia [3].

Other causes include preexisting medical conditions like heart disease, gastrointestinal problems, urinary problems, persistent pain, hypertension or respiratory problems. Restless legs syndrome or periodic limb movement disorder may be causing insomnia and so can be mental disorders like PTSD, schizophrenia and bipolar disorder. Hormone shifts, like those occurring during premenstrual syndrome (PMS) or pregnancy, increased use of nicotine and caffeine, and some stimulant medications like amphetamines may cause insomnia.

Incidence

It is a very common medical complaint in primary care patients and the same is true for patients in palliative care, which is illustrated by studies that report the prevalence of insomnia is over 70 percent [4].

Age

Insomnia is very rare in children, unless it is accompanied with a medical condition that disturbs sleep. Acute insomnia can affect adolescents and old aged people alike but is generally a frequent complain of people in the prime of life. Chronic insomnia on the other hand is much more common in the elderly.

Sex

Insomnia is 40% more common in women than in men [5].

The DSM-5 criteria for insomnia include the following [6]:

Difficulty initiating and maintaining sleep, and difficulty going back to sleep after awakening early. The symptoms must be present at least 3 times a week for 3 months to be declared insomnia. The symptoms should also persist despite adequate opportunities to sleep and without any effects of drugs, narcotics or alcohol.

Types

Although insomnia can be classified into many subtypes, it can be divided into 3 broad categories:

• Acute insomnia

It lasts for less than a month and then goes away on its own. It is triggered by either environmental factors such as travelling, change in environment, change in routine, or stress and depression. It is also known as transient insomnia (symptoms lasting for less than a week) and adjustment insomnia.

• Primary insomnia

This condition fits the DSM-5 criteria for insomnia. It is characterized by inability to sleep during desired time or inability to maintain sleep for a longer time. The duration of sleep may be punctuated by periods of heightened awareness of the surroundings, heightened somatic tension and intrusive thoughts.

• Chronic insomnia

This condition lasts for more than 1 month and is mostly due to a medical condition such as heart disease, breathing problems, conditions causing nocturia, diseases associated with persistent pain like arthritis, hypertension or gastrointestinal problems. If chronic insomnia exists without an underlying medical condition, it is due to high stress.

Good sleep hygiene plays an important role in preventing insomnia. It includes setting up and maintaining a regular sleep schedule with regular sleep and wakening timings, avoiding caffeinated drinks and high sugar containing food a few hours before going to bed. A calm quiet environment and a healthy diet and lifestyle also go a long way in helping attain good sleep.

Insomnia was previously viewed as a sleep disturbance that was secondary to a medical condition, psychiatric illness, sleep disorder, or medication, and would improve with treatment of the underlying disorder [1]. But now, insomnia is recognized as an independent disorder [2]. It is a common complaint in outpatient care departments and is most frequently associated with stress.

Definition

Insomnia is defined as a condition of sleeplessness. There may be inability to fall asleep, maintain sleep or to go back to sleep after awakening early. 

Cause

Insomnia is primarily due to stress. Other causes include heart, gastrointestinal and urinary diseases, breathing problems, pain, mental conditions, disrupted sleep schedule or lifestyle, environmental change, drug side effects and genetic factors.

Signs and symptoms

Insomnia often coexists with other symptoms, such as pain, depression, and anxiety and the presence of one often exacerbates the other, contributing to a decrease in quality of life [10]. It presents with inability to fall asleep or maintain sleep for longer than a few hours at night, and irritability, tiredness and loss of energy during the day. 

Diagnosis

Insomnia is diagnosed by excluding other underlying diseases that may be causing sleep disturbances. A thorough physical examination and laboratory tests aid in that endeavour. A detailed history helps in making the right diagnosis.

Treatment

Treatment includes the use of prescribed drugs along with cognitive behavioural therapy. Lifestyle changes also help. 

1. National Institutes of Health. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep 2005; 28:1049.
2. Katz DA, McHorney CA. Clinical correlates of insomnia in patients with chronic illness. Arch Intern Med 1998; 158:1099.
3. Buhr A, Bianchi MT, Baur R, Courtet P, Pignay V, Boulenger JP, et al. Functional characterization of the new human GABA(A) receptor mutation beta3(R192H). Hum Genet. Aug 2002;111(2):154-60
4. Hugel H, Ellershaw JE, Cook L, et al. The prevalence, key causes and management of insomnia in palliative care patients. J Pain Symptom Manage 2004; 27:316.
5. "Several Sleep Disorders Reflect Gender Differences". Psychiatric News 42 (8): 40. 2007.
6. "Sleep Wake Disorders." Diagnostic and statistical manual of mental disorders: DSM-5.. 5th ed. Washington, D.C.: American Psychiatric Association, 2013
7. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014
8. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. Oct 15 2008;4(5):487-504 
9. Sack RL, Auckley D, Auger RR, et al. Circadian rhythm sleep disorders: part II, advanced sleep phase disorder, delayed sleep phase disorder, free-running disorder, and irregular sleep-wake rhythm. An American Academy of Sleep Medicine review. Sleep 2007; 30:1484.
10. Glynn J, Gale S, Tank S. Causes of sleep disturbance in a specialist palliative care unit. BMJ Support Palliat Care 2014; 4 Suppl 1:A56.