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History
Sleep history
including sleep habits, sleep environment, work schedules, and circadian
factors is documented. Determine the onset, duration, frequency, severity,
course, and perpetuating factors. Ask about past and current treatments and
response of the patient. Screen for physical symptoms such as pain, nocturia,
shortness of breath, itch, paresthesias, reflux, restlessness or general
discomfort which may disrupt sleep. Common medical, psychiatric, and
medication/substance-related comorbidities should also be assessed.
Self-administered questionnaires, sleep log, symptom checklists, psychological
screening tests, and interviews with bed partner are some of the instruments
that may help one arrive at the proper diagnosis.
Asking the patient to
keep a sleep diary and/or use questionnaires such as Insomnia Severity Index
(ISI), Pittsburgh Sleep Quality Index (PSQI) or Morningness-Eveningness
Questionnaire (MEQ) may also aid in the diagnosis. ISI is a self-report tool
which measured perceived severity of insomnia and has been shown to be valid
and reliable tool to detect patients with insomnia. The PSQI may be used to
evaluate subjective sleep during the previous month. Lastly, MEQ is used to
assess circadian factor.
Diagnosis or Diagnostic Criteria
A comprehensive clinical history and physical examination evaluating the sleep and waking function of the individual must be done.
Based on the DSM-5-TR criteria, a diagnosis of insomnia is made if there is a predominant complaint of dissatisfied sleep related to its quantity or quality associated with at least one of the following symptoms:
- Having trouble with sleep initiation; in children, this is manifested as having trouble with sleep without the caregiver’s intervention
- Struggling in maintaining sleep usually seen as frequent awakenings or problems in returning to sleep after awakening; in children, this is manifested as having trouble returning to sleep without the caregiver’s intervention
- Early morning awakening with difficulty returning to sleep afterwards
Furthermore, the sleeping difficulty:
- Causes distress or impairment in significant areas of functioning (eg social, occupational, educational, academic and/or behavioral)
- Occurs ≥3 nights per week
- Lasts for ≥3 months
- Occurs even though there is sufficient opportunity for sleep
Insomnia is not due to and does not happen during another sleep-wake disorder(eg narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder or a parasomnia). The symptoms are not caused by effects of substance or medication. The disturbance is not associated with coexisting mental disorders and medical conditions.
May specify insomnia if with nonsleep disorder mental comorbidity, with other medical comorbidity, or with other sleep disorder.
Insomnia may be specified further as:
- Episodic where symptoms occur for at least a month but <3 months
- Persistent where symptoms occur for ≥3 months
- Recurrent where ≥2 episodes occur for ≥3 months
Insomnia lasting for <3 months that meets criteria for insomnia disorder in regards to frequency, intensity, significant distress and/or impairment should be considered under the other specified insomnia disorder.
Screening
Polysomnography can be used:
- To evaluate other suspected sleep disorders (ie periodic limb movement disorder)
- In treatment-resistant insomnia
- For professional at-risk populations
- When substantial sleep state misperception is suspected