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Individuals who complain of insomnia report repeated difficulty with either initially falling asleep (sleep onset insomnia) or remaining asleep (sleep maintenance insomnia) despite adequate opportunity, condition, and time for sleep. Sleep disturbance is associated with an impairment of daytime function.
Insomnia is the most common sleep disorder. The prevalence of insomnia is greater among the elderly, women, in individuals of low socioeconomic status, and in those who are widowed, divorced, or separated. Many patients with insomnia have either an underlying psychiatric pathology or an increased risk of developing new-onset psychiatric illness. A recent stressor increases the risk of developing insomnia.
The daytime consequences of insomnia include fatigue, malaise, reduced energy and motivation, cognitive impairment (eg, concentration, memory, reaction time, and judgment), diminished performance at school and work, alterations in mood, increased accident rates, and diminished quality of life. Patients may express concerns about the quality of their sleep and its impact on daytime functioning.
Insomnia is a disorder with numerous and diverse etiologies, and in many individuals, more than one cause may be present. Evaluation of insomnia relies primarily on a careful history, often aided by a well-kept sleep diary. In selected patients, polysomnography may uncover causes otherwise unsuspected from clinical history.
The goals of therapy for insomnia include alleviation of nighttime sleep disturbance as well as relief of its daytime consequences. Many cases of chronic insomnia have their origins in transient disruptions of sleep that have taken root. It is essential that short-term insomnia be promptly recognized and appropriately treated before learned habits, attitudes, and coping mechanisms incongruous with sleep become established and perpetuate the sleep disturbance. Recovery will be more elusive once maladaptive patterns become established. Most patients benefit from a combination of sleep hygiene counseling, behavior modification, and the judicious administration of hypnotic agents.
Pharmacotherapeutic management is generally effective for transient insomnia. It may also be used intermittently in patients with more chronic complaints. The selection of a particular hypnotic medication should be based on the characteristics of the patient, duration and timing of insomnia, the pharmacological profile of the agent (onset of action, and rates of absorption and elimination), its abuse potential, and possible drug interactions. It is advisable to use the lowest effective dose and to monitor carefully both the therapeutic response as well as its side effects.
In this issue of the Clinics in Sleep Medicine, Dr. Thomas Roth has assembled many of the most prominent authorities in the contemporary field of sleep medicine who, collectively, have provided a truly comprehensive discussion of the basic science and clinical management of insomnia.