![]() Such classifications may provide clues to the cause of insomnia. Duration-based classifications (acute, short-term, and chronic) have also been suggested ( 4). ![]() Moreover, a majority of patients present with some combination of symptoms. However, longitudinal studies suggest that these specific symptoms have limited stability over time ( 3) patients who present with sleep-onset insomnia at one time may present with frequent awakenings at a later time. For instance, symptom-based classifications distinguish between sleep-onset and sleep-maintenance insomnia. Other classification schemes for insomnia have also been used. For most purposes, the general insomnia criteria proposed in ICSD-2 serve as a useful basis for discussing insomnia as a clinical disorder.ĪAdapted from the International Classification of Sleep Disorders, Second Edition ( 2). ICSD-2 describes general criteria that are common to all insomnia disorders ( Table 1) as well as eight specific insomnia disorders (in addition to “unspecified” and “not otherwise specified” categories), each of which meets the general criteria along with more specific diagnostic criteria. Sleep medicine specialists use the International Classification of Sleep Disorders, Second Edition (ICSD-2) ( 2), to diagnose sleep disorders. Finally, DSM-IV-TR includes diagnoses of “secondary” insomnia disorders, that is, insomnia that causes significant distress or impairment or warrants independent clinical attention but is believed to be directly related to a coexisting mental disorder or medical disorder or to the effects of substances or medications. In DSM-IV-TR the specific diagnosis of primary insomnia is further defined by a duration of at least 1 month and by symptoms that do not occur exclusively during the course of another sleep disorder, mental disorder, or medical disorder or result from use of substances or medications. Insomnia disorders are characterized by insomnia symptoms accompanied by significant distress or impairment. In DSM-IV-TR ( 1), insomnia symptoms are included among the diagnostic criteria for several other mental disorders, including major depressive disorder and generalized anxiety disorder. The symptom of insomnia is defined as a subjective complaint of difficulty falling asleep, difficulty staying asleep, or poor quality sleep. “Insomnia” is used to refer to both a symptom and a disorder. F be evaluated? What medical testing, if any, would be appropriate? What factors should be considered in formulating a treatment plan? What treatments would be appropriate? She has been treated with levothyroxine for the past 15 years. Her medical history is unremarkable other than a past history of Graves’ disease. In fact, she believes that her cognitive difficulties and irritability are most noticeable after nights of particularly poor sleep. She denies pervasive sadness or loss of interest, but she is very frustrated with her inability to function more effectively, which she attributes to her insomnia. Her current symptoms are distinct from those that were associated with her episode of major depression. At that time she was diagnosed with major depression and was started on a successful trial of escitalopram, which she continues at a dose of 10 mg/day. Her insomnia began approximately 5 years ago during a period of increased life stress related to a difficult divorce and a job change. She says that she has “no energy for anything extra,” that her house is a mess, and that she routinely declines invitations to join social and even family activities. Her nighttime sleep problems result in daytime irritability and difficulty focusing and organizing her thoughts, which subjectively impair her work as an administrative assistant, although her performance evaluations have been satisfactory. to give herself adequate time for sleep, and she gets out of bed around 7:00 a.m. ![]() She typically goes to bed around 10:00 p.m. These symptoms occur nearly every night, with only one or two “good” nights per month. She complains of difficulty falling asleep, often 30 minutes or longer, and difficulty maintaining sleep during the night, with frequent awakenings that often last 30 minutes or longer. F, a 42-year-old divorced woman, presents for evaluation of chronic insomnia. ![]()
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