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ULY CLINIC

11 Septemba 2025, 07:37:18

Insomnia

Insomnia is the inability to fall asleep, remain asleep, or feel refreshed by sleep. It may be acute or transient, often during periods of stress, or chronic, causing persistent fatigue, anxiety around bedtime, and psychiatric disorders. Approximately 25% of adults experience occasional insomnia, while about 10% suffer from chronic insomnia. Causes include physiologic factors (e.g., jet lag, arguing, lack of exercise) and pathophysiologic factors, including medical, psychiatric, drug-related, pain-related, or idiopathic conditions. Patient complaints are subjective and require careful evaluation, as fatigue may be mistakenly attributed to insomnia rather than an underlying disorder such as anemia.

History and Physical Examination

Sleep and lifestyle history: onset, duration, and patterns of insomnia; use or withdrawal of sedatives; consumption of CNS stimulants (amphetamines, pseudoephedrine, theophylline derivatives, phenylpropanolamine, cocaine, caffeine); travel or jet lag; daytime activity levels; exercise routines.
Medical history: chronic or acute illnesses affecting sleep, including cardiac, respiratory, endocrine, neurologic, or painful/pruritic conditions.
Behavioral and emotional assessment: emotional status, stress, personal and professional problems, hallucinations, alcohol withdrawal signs.
Collateral history: consultation with a spouse or sleep partner for behavioral observations.
Physical examination: perform a general and focused exam after reviewing complaints suggesting undiagnosed disorders.

Medical causes

Cause	Key Features
Alcohol withdrawal syndrome	Abrupt cessation of long-term alcohol use can cause insomnia lasting up to 2 years; early symptoms include diaphoresis, tachycardia, hypertension, tremors, restlessness, irritability, headache, nausea, flushing, nightmares; progression to delirium tremens includes confusion, disorientation, paranoia, hallucinations, seizures.
Generalized anxiety disorder (GAD)	Chronic insomnia with tension, fatigue, restlessness, autonomic hyperactivity (diaphoresis, dyspepsia, elevated pulse and respiratory rates), apprehension.
Mood disorders	Depression: difficulty falling asleep, early awakening, dysphoria, appetite changes, psychomotor agitation/retardation, fatigue, loss of interest, guilt, indecisiveness, recurrent thoughts of death. Manic episodes: decreased need for sleep, elevated mood, irritability, hyperactivity, fast speech, racing thoughts, risky behaviors.
Nocturnal myoclonus	Involuntary leg jerks every 20–40 seconds, disrupting sleep; may occur in seizure disorders.
Sleep apnea syndrome	Central or obstructive; apneic periods 10–90 seconds followed by gasps; cycles repeated multiple times/night with bradycardia/tachycardia; morning headache, daytime fatigue, hypertension, ankle edema, personality changes.
Thyrotoxicosis	Difficulty initiating and maintaining sleep, cardiopulmonary signs (dyspnea, tachycardia, palpitations), weight loss, diarrhea, tremors, nervousness, diaphoresis, heat intolerance, enlarged thyroid, exophthalmos.

Other Causes

Drugs and substances: sedatives, hypnotics, CNS stimulants (amphetamines, theophylline, pseudoephedrine, phenylpropanolamine, cocaine, caffeine), and certain herbal remedies (ginseng, green tea).
Idiopathic or lifestyle factors: jet lag, arguing, lack of physical activity, environmental factors.

Special considerations

Evaluate with blood and urine studies (17-hydroxycorticosteroids, catecholamines), polysomnography (EEG, electrooculography, electrocardiography), and sleep EEG.
Teach sleep hygiene and relaxation techniques, including fixed sleep/wake times, regular exercise (not near bedtime), and a comfortable sleep environment.

Patient counseling

Advise on comfort and relaxation strategies to promote natural sleep.
Discuss the appropriate use of sedatives or tranquilizers.
Refer to counseling or a sleep disorder clinic if necessary.
Emphasize management of underlying medical or psychiatric disorders.

Pediatric pointers

Insomnia in early childhood may arise with separation anxiety (ages 2–3), stress, illness, or teething.
In children aged 6–11, insomnia often results from residual excitement; some children may have bedtime fears.
Sleep problems are common among foster children.

References

Lapierre, S., Boyer, R., Desjardins, S., Dubé, M., Lorrain, D., Préville, M., … Brassard, J. (2012). Daily hassles, physical illness, and sleep problems in older adults with wishes to die. International Psychogeriatrics, 24, 243–252.
Li, S., Lam, S., Yu, M., Zhang, J., & Wing, Y. (2010). Nocturnal sleep disturbances as a predictor of suicide attempts among psychiatric outpatients: A clinical, epidemiologic, prospective study. Journal of Clinical Psychiatry, 71, 1440–1446.