Chronic Insomnia

Abstract

Insomnia is characterized by difficulty falling asleep or staying asleep, with consequent daytime impairment of mental and/or physical function. A detailed clinical history reveals the relative impact of a variety of different contributing and perpetuating factors, which then informs prioritization among different treatment options. Nonpharmacological approaches, especially the validated approach of cognitive–behavioral therapy for insomnia, are preferred over hypnotic medications. If hypnotics are chosen, the goal is short-term interventions after a careful risk-benefit assessment and shared decision-making with the patient. Although objective testing via polysomnography is not routinely indicated, such investigations can be informative in those at risk for concurrent primary sleep disorders, and in those who are treatment refractory. Circadian rhythm disorders can present with insomnia complaints, but are managed with chronotherapy. Whatever management pathway is pursued, the response to therapy should be anchored in improvements in daytime function.

Keywords

insomnia - hypnotic - phenotyping - polysomnography - cognitive–behavioral therapy

• References

• 1 Winkelman JW. Clinical Practice. Insomnia Disorder. N Engl J Med 2015; 373 (15) 1437-1444
• 2 Perlis ML, Corbitt CB, Kloss JD. Insomnia research: 3Ps and beyond. Sleep Med Rev 2014; 18 (03) 191-193
• 3 Levenson JC, Kay DB, Buysse DJ. The pathophysiology of insomnia. Chest 2015; 147 (04) 1179-1192
• 4 Bonnet MH, Arand DL. Hyperarousal and insomnia: state of the science. Sleep Med Rev 2010; 14 (01) 9-15
• 5 Weber F, Dan Y. Circuit-based interrogation of sleep control. Nature 2016; 538 (7623): 51-59
• 6 Buysse DJ, Germain A, Hall M, Monk TH, Nofzinger EA. A neurobiological model of insomnia. Drug Discov Today Dis Models 2011; 8 (04) 129-137
• 7 Desseilles M, Dang-Vu T, Schabus M, Sterpenich V, Maquet P, Schwartz S. Neuroimaging insights into the pathophysiology of sleep disorders. Sleep 2008; 31 (06) 777-794
• 8 Harvey AG, Tang NK. (Mis)perception of sleep in insomnia: a puzzle and a resolution. Psychol Bull 2012; 138 (01) 77-101
• 9 Shekleton JA, Rogers NL, Rajaratnam SM. Searching for the daytime impairments of primary insomnia. Sleep Med Rev 2010; 14 (01) 47-60
• 10 Roth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med 2007; 3 (5, Suppl) S7-S10
• 11 Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 2002; 6 (02) 97-111
• 12 Taylor DJ, Mallory LJ, Lichstein KL, Durrence HH, Riedel BW, Bush AJ. Comorbidity of chronic insomnia with medical problems. Sleep 2007; 30 (02) 213-218
• 13 Roth T. Comorbid insomnia: current directions and future challenges. Am J Manag Care 2009; 15 (Suppl): S6-S13
• 14 Riemann D. Insomnia and comorbid psychiatric disorders. Sleep Med 2007; 8 (Suppl. 04) S15-S20
• 15 Sarsour K, Morin CM, Foley K, Kalsekar A, Walsh JK. Association of insomnia severity and comorbid medical and psychiatric disorders in a health plan-based sample: Insomnia severity and comorbidities. Sleep Med 2010; 11 (01) 69-74
• 16 Bianchi MT. Sleep Deprivation and Neurological Diseases. New York, NY: Springer; 2014
• 17 Zee PC, Attarian H, Videnovic A. Circadian rhythm abnormalities. Continuum (Minneap Minn) 2013; 19 (1 Sleep Disorders): 132-147
• 18 Saline A, Goparaju B, Bianchi MT. Sleep fragmentation does not explain misperception of latency or total sleep time. J Clin Sleep Med 2016; 12 (09) 1245-1255
• 19 Alameddine Y, Ellenbogen JM, Bianchi MT. Sleep-wake time perception varies by direct or indirect query. J Clin Sleep Med 2015; 11 (02) 123-129
• 20 Vgontzas AN, Fernandez-Mendoza J, Liao D, Bixler EO. Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder. Sleep Med Rev 2013; 17 (04) 241-254
• 21 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 2008; 4 (05) 487-504
• 22 Suh S, Nowakowski S, Bernert RA. , et al. Clinical significance of night-to-night sleep variability in insomnia. Sleep Med 2012; 13 (05) 469-475
• 23 Carney CE, Buysse DJ, Ancoli-Israel S. , et al. The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep 2012; 35 (02) 287-302
• 24 Luyster FS, Buysse DJ, Strollo Jr PJ. Comorbid insomnia and obstructive sleep apnea: challenges for clinical practice and research. J Clin Sleep Med 2010; 6 (02) 196-204
• 25 Walters AS, Rye DB. Review of the relationship of restless legs syndrome and periodic limb movements in sleep to hypertension, heart disease, and stroke. Sleep 2009; 32 (05) 589-597
• 26 Ustun B, Westover MB, Rudin C, Bianchi MT. Clinical prediction models for sleep apnea: the importance of medical history over symptoms. J Clin Sleep Med 2016; 12 (02) 161-168
• 27 Moro M, Goparaju B, Castillo J, Alameddine Y, Bianchi MT. Periodic limb movements of sleep: empirical and theoretical evidence supporting objective at-home monitoring. Nat Sci Sleep 2016; 8: 277-289
• 28 Collop NA, Anderson WM, Boehlecke B. , et al; Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med 2007; 3 (07) 737-747
• 29 Bianchi MT, Goparaju B. Potential underestimation of sleep apnea severity by at-home kits: rescoring in-laboratory polysomnography without sleep staging. J Clin Sleep Med 2017; 13 (04) 551-555
• 30 Morin CM, Benca R. Chronic insomnia. Lancet 2012; 379 (9821): 1129-1141
• 31 Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D. Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med 2015; 163 (03) 191-204
• 32 Cheng SK, Dizon J. Computerised cognitive behavioural therapy for insomnia: a systematic review and meta-analysis. Psychother Psychosom 2012; 81 (04) 206-216
• 33 Sarris J, Byrne GJ. A systematic review of insomnia and complementary medicine. Sleep Med Rev 2011; 15 (02) 99-106
• 34 Buscemi N, Vandermeer B, Friesen C. , et al. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med 2007; 22 (09) 1335-1350
• 35 Kripke DF. Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit. F1000 Res 2016; 5: 918
• 36 Bianchi MT, Westover MB. Insomnia and morning motor vehicle accidents: a decision analysis of the risk of hypnotics versus the risk of untreated insomnia. J Clin Psychopharmacol 2014; 34 (03) 400-402
• 37 Bianchi MT, Thomas RJ, Ellenbogen JM. Hypnotics and mortality risk. J Clin Sleep Med 2012; 8 (04) 351-352
• 38 McKinney SM, Dang-Vu TT, Buxton OM, Solet JM, Ellenbogen JM. Covert waking brain activity reveals instantaneous sleep depth. PLoS One 2011; 6 (03) e17351
• 39 Tang NK, Harvey AG. Correcting distorted perception of sleep in insomnia: a novel behavioural experiment?. Behav Res Ther 2004; 42 (01) 27-39
• 40 Russo K, Goparaju B, Bianchi MT. Consumer sleep monitors: is there a baby in the bathwater?. Nat Sci Sleep 2015; 7: 147-157