Review Articles
INSOMNIA: CASE STUDIES IN FAMILY PRACTICE
Kamil Mohd Ariff FAFPM MFamMed(Monash), Klinik Kamil Ariff, Arau, Perlis
Zailinawati Abu Hassan FRACGP GradDipFamMed(Monash), Klinik Keluarga, Kuala Lumpur
Kamil MA, Zailinawati AH. Insomnia: Case studies in family practice. Malaysian Family Physician. 2006;1(1):11-14INTRODUCTION
Sleep disorders can be broadly classified into: (a) insomnia, (b) parasomnia, (c) sleep disorders associated with psychiatric, neurologic and other medical disorders, and (d) proposed sleep disorders (e.g. pregnancy and menstrual related sleep disorders).1 Insomnia is a common encounter in primary care consultations2 and constitutes the commonest sleep problem3,4 that presents to the general practitioner.
Based on the National Center for Sleep Disorders Research Classification,5 insomnia symptoms can be defined as subjective complaints of difficulty falling asleep, difficulty maintaining sleep, early awakening and non refreshing sleep despite an adequate opportunity to sleep. An important consideration is whether the presence of one or more of these symptoms causes significant impairment to the patient’s social, occupational or other important areas of functioning.
Insomnia can be due to primary or secondary causes. Primary insomnia refers to insomnia that appears to be unrelated to any identifiable underlying medical or psychiatric disorder.6,7 Secondary causes of insomnia include conditions where another disorder contributing to or aggravating the insomnia can be diagnosed (Table1). The diagnosis of sleep disorders is often based on obtaining a detailed sleep history, a neuropsychiatric evaluation, a physical examination looking for medical and other disorders, mental status examination and relevant investigations. A sleep diary that the patient maintains in which sleep-relevant behaviours such as bedtime and waking times, awakenings, total sleep time, napping, medications, alcohol and mood on waking often provides valuable information for the patient and physician. Patients with sleep-disordered breathing, sleep-related motor disorders and those with severe, chronic insomnia for which an obvious cause cannot be found may require referral for sleep laboratory evaluation.Table 1. Common causes of insomnia
Primary causes:
- Adjustment disorder e.g. job loss, brief anxiety states, hospitalization and other stressful life events
- Psychophysiological insomnia
- Sleep state misperception
- Idiopathic insomnia
Secondary causes:
- Environmental sleep disorder - noise, temperature, humidity
- Inadequate sleep hygiene
- Psychiatric disorders- anxiety, depression, panic attacks, mania, schizophrenia, alcoholism
- Medical illness- respiratory disorders (chronic obstructive airway disease, asthma), rheumatologic disease, neurological disorders (parkinsonism, dementia, fatal familial insomnia)
- Medications – nicotine, bronchodilators, steroids, beta-blockers, alcohol
- Sleep wake cycle disorders- jet-lag, shift work, delayed or advanced sleep phase syndrome
- Sleep-related motor disorders - restless legs and periodic limb movements of sleep
- Sleep related breathing disorders - sleep apnoea, chronic obstructive pulmonary disease
The following four case vignettes illustrate common and uncommon cases of insomnia that may present to the primary care physician.
CASE 1
Mr Tan, a 40-year-old man with difficulty falling asleep and maintaining sleep.
Mr. Tan, a 45-year-old man presents with difficulty falling asleep and staying asleep. The problem started after the death of his sister 2 months previously. He is unable to fall sleep until at least an hour after going to bed. He has no previous sleep problems. A general practitioner (GP) he consulted had prescribed low-dose dothiepin (tricyclic antidepressant) as sedation but Mr. Tan was unable to tolerate the drowsiness and dry mouth caused by the medication. He consumes 4 cups of coffee during the day and lately takes alcohol at night to aid sleep. The patient’s wife has noted that his legs jerk occasionally during the sleep though Mr. Tan is not aware of these movements.
What are the likely causes of Mr. Tan’s sleep problem?
The most likely causes for Mr Tan’s sleep problem are
- Adjustment sleep disorder: This is insomnia related to acute stress, conflict, or recent environmental change. The precipitating event in this case is the death of his sister. Adjustment sleep disorder is usually a