Insomnia for clinicians

Insomnia symptoms, where people have difficulty getting to sleep or staying asleep or where sleep is non-restorative or poor quality, occur in around 30% of adults.

Symptoms

Around 10% of the population have insomnia symptoms and experience various forms of daytime distress or impairment, such as:

  • fatigue
  • memory or concentration problems
  • reduced motivation
  • being accident-prone.

See Mai E, Buysse DJ. Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis, and Evaluation. Sleep medicine clinics. 2008;3(2):167-174. doi:10.1016/j.jsmc.2008.02.001.

Clinical definition

Clinical definitions of insomnia also involve daytime distress or impairment related to the nighttime sleep difficulty, including:

  • fatigue or malaise
  • attention, concentration, or memory impairment
  • social or vocational dysfunction or poor school performance
  • mood disturbance or irritability
  • daytime sleepiness
  • motivation, energy, or initiative reduction
  • proneness for errors or accidents at work or while driving
  • tension, headaches, or gastrointestinal symptoms in response to sleep loss
  • concerns or worries about sleep

See International Classification of Sleep Disorders (ICSD-2) (American Academy of Sleep Medicine, 2005.

Risk factors

Insomnia can be associated with a number of medical and mental health conditions. Risk factors for insomnia include:

  • female sex
  • advanced age
  • depressed mood
  • snoring
  • low levels of physical activity
  • comorbid medical conditions
  • nocturnal micturation
  • regular hypnotic use
  • onset of menses
  • previous insomnia complaints
  • high level of perceived stress.

Insomnia can be precipitated by life events, work or school stresses and job dissatisfaction. Hyperarousal is thought to be the underlying physiological impairment in insomnia.

Assessment

Assessment of the individual should include discussion of the sleep-wake routine, daytime routine, including work eating and exercise times.

Sleep habits, including sleep conditions and environment, sleep times and pre-sleep routine, as well as overnight behaviour, especially clock-watching and anxiety levels, should be discussed.

Daytime functioning and symptoms (see above), including safety issues need to be considered. Other conditions, including other sleep disorders such as restless legs and sleep apnoea, other medical or psychiatric conditions should be assessed.

Use of substances, such as nicotine, alcohol and caffeine as well as previous treatments for insomnia tried, also need to be reviewed.

Sleep diaries over 1-2 weeks can be a useful way to track sleep-wake patterns.

Management of insomnia

Management of insomnia can include cognitive behavioural therapy (CBT). 

This can involve the following:

  • Sleep hygiene training - correcting habits around sleep;
  • Sleep restriction - initially limiting time in bed then gradually increasing sleep time;
  • Stimulus control - regular wake times, going to bed when sleepy, avoiding naps, avoiding computers, tablets, phones, TV in bed (“use the bed only for sleep and sex”), getting up from bed if not sleeping;
  • Cognitive therapy - exercises to change attitudes and beliefs hindering sleep;
  • Relaxation training - to relax mind and body.

CBT can be delivered in person individually, in groups or online and on devices.

Some people may benefit from sedatives as an adjunct to CBT.

This information has been developed by SA Health and The University of Adelaide