History

History

The history is the most important part of evaluating insomnia. It must include a complete sleep history, medical history, psychiatric history, social history, and careful medication review.

Sleep history

Determining the timing of insomnia, the patient's sleep habits (commonly referred to as sleep hygiene), and symptoms of sleep disorders associated with insomnia is important.

• Timing of insomnia: Patients should be asked about any difficulty falling asleep, frequent or early morning awakening, problems in sleep onset, and whether they feel sleepy when getting into bed.
• Sleep schedule: Patients must be asked what time they go to bed and rise from bed in the morning. Determine whether the sleep schedule is consistent and if the schedule has changed recently.
• Sleep environment: Patients should be asked about temperature, bed comfort, noise, and light levels. Ask whether the patient sleeps better in his or her own bed or in a chair or a foreign environment (like a hotel).
• Sleep habits: Patients with insomnia often have poor sleep hygiene. They should be asked about activities prior to bedtime (ie, relaxation or work), whether they read or watch TV in bed, and whether the TV or light is kept on during the night. Also, ask patients what they do if unable to fall asleep and whether they fall asleep after waking up in the middle of the night. Ask patients about daytime naps and whether they exercise and the time of exercise.
• Patients should be asked about symptoms of other sleep disorders such as obstructive sleep apnea (eg, snoring, witnessed apneas, gasping) and restless legs syndrome/periodic limb movement disorder (ie, restless feeling in legs on lying down, which improves with movement; rhythmic kicking during the night; sheets in disarray in the morning).
• Daytime effects: Patients should experience daytime effects if they truly are not sleeping at night. In fact, if a patient is having no daytime effects, he or she is probably getting adequate sleep and the complaint of insomnia is truly subjective. Common complaints are fatigue, tiredness, lack of energy, irritability, reduced work performance, and difficulty concentrating. These complaints should be distinguished from the complaint of excessive sleepiness, which is uncommon in insomnia. For example, if a patient complains of excessive daytime sleepiness (ie Epworth Sleepiness Scale Score >10), another sleep disorder should also be considered. (See Media file 12 for the Epworth Sleepiness Scale.)

Medical history

A thorough medical history and review of systems should be performed, with particular emphasis on those disorders mentioned in Causes.

Psychiatric history

A review of signs and symptoms of anxiety or depression should be sought. A 2-question case-finding instrument can help screen for depression.

Diagnostic algorithm for major depression.

Diagnostic criteria for generalized anxiety disorder.

Social history

For transient or short-term insomnia, inquire about new situational stresses such as a new job, new school, relationship change, or bereavement. For chronic insomnia, attempt to relate the onset of insomnia to past stresses or medical illnesses. Inquire about tobacco, caffeinated products, alcohol, and illegal drug use.

Medication history

Medications that commonly cause insomnia include beta-blockers, clonidine, theophylline (acutely), certain antidepressants (protriptyline or fluoxetine), decongestants, and stimulants. Also inquire about over-the-counter and herbal remedies that the patient may be taking.