Key Feature 1: In patients presenting with sleep complaints, take a careful history to:
Phase: History, Diagnosis
Key Feature 2: When assessing patients with sleep complaints, obtain a collateral history from the bed partner, if possible.
Skill: Clinical Reasoning
Later this week I'll be leading a teaching session with my resident peers on insomnia, so I need to do my due diligence and actually know a little bit about it beforehand. This is changing gears from my string of posts regarding pediatric issues lately, as this is not as common of a pediatric as adult complaint.
Like with all presentations, for any complaint of sleep disturbance for whatever reason, I need to have a list of possible differential diagnoses. The DDx for sleep-wake disorders per the LMCC, which I find to be very logical, is broken down as follows:
I like this differential because it provides a general framework, rather than listing off a series of specific causes, because there are SO MANY specific causes that may lead to sleep disturbance. Notice one of the skills for this Key Feature (#1) is "Selectivity." The clinician really needs to employ selective questioning as the patient interview unfolds to get at what truly is the disturbance and what could be causing it. That being said, general things to inquire about include
Based on clinical assessment, if a medical (including psychiatric) disease is suspected, it is important to investigate, diagnose, and treat this as indicated. Like with any psychiatric illness, insomnia cannot be diagnosed until medical illness, medication effects or substance use, or other psychiatric illness is ruled out. If this is the case, the patient may meet the DSM-5 diagnosis of Insomnia Disorder:
A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (ex: narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
G. The insomnia is not attributable to the physiological effects of a substance (ex: a drug of abuse, a medication).
H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.
An overview of the other DSM-5 sleep-wake disorder conditions:
That's just the DDx for a primary sleep-wake disorder. Now you may better appreciate my appreciation for the simplified DDx as listed by the LMCC approach to sleep-wake disturbance! At least this is a great starting point to frame one's clinical approach.