Insomnia Assessment
The assessment of insomnia is not markedly different from the assessment of sleep disorders in general, and a good insomnia history will necessarily include a good sleep history, psychiatric history and medical history. However, it is also possible to tak
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Insomnia Assessment Hugh Selsick
7.1
Introduction
The assessment of insomnia is not markedly different from the assessment of sleep disorders in general, and a good insomnia history will necessarily include a good sleep history, psychiatric history and medical history. However, it is also possible to take a brief history that will ascertain the cardinal features of the disorder and allow one to formulate a management plan. In this chapter I will examine the aspects of history taking that are specifically important in insomnia patients, when to order investigations, what investigations are useful and the limitations of those investigations. I will conclude with a suggested formula for conceptualizing the patient’s insomnia and organizing the information you have gleaned so that the appropriate treatments can be selected.
7.2
Taking an Insomnia History
When taking an insomnia history, it can be helpful to bear in mind the ‘Three P’ theory of disease: predisposing, precipitating and perpetuating factors. In this model each patient has certain inherent factors that predispose them to getting insomnia. Certain personality traits, socio-economic variables, medical conditions and psychiatric disorders can increase the susceptibility to insomnia. Many of these predisposing variables will be beyond the ability of the clinician to modify. However, many people with a high predisposition to developing insomnia will never get it; therefore there must be some precipitating factor which initiates the illness. Unlike most other sleep disorders, insomnia may have a very definite onset and clear precipitant, and many patients will be able to identify specific events that caused the insomnia. H. Selsick Insomnia Clinic, Royal London Hospital for Integrated Medicine, London, UK e-mail: [email protected] © Springer-Verlag GmbH Germany, part of Springer Nature 2018 H. Selsick (ed.), Sleep Disorders in Psychiatric Patients, https://doi.org/10.1007/978-3-642-54836-9_7
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Clearly, if that precipitant is still present, then this should be explored and, if possible, addressed. However, in chronic insomnia patients, it is commonly the case that the precipitant will have resolved by the time the patient presents to a clinician, yet the insomnia persists, and so there must be separate perpetuating factors driving their insomnia. To a large extent, it is these perpetuating factors that need to be teased out by the history.
7.2.1 Main Complaint A common perception is that insomnia describes difficulty getting to sleep and so patients who have no problems with sleep initiation, but struggle with sleep maintenance or early morning waking, may not report that they have insomnia. It is also important to remember that patients’ broad descriptions of their problems may not always correspond with the picture elicited when a more detailed history is taken. For example, it is not uncommon for patients to say ‘I don’t sleep’ or ‘I haven’t slept in years’. Often this is a figure of speech, and what they mean is that they slee
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