INSOMNIA

It is customary to assume that the cause of the disorder is psychogenic and simply to prescribe a sleeping pill to anyone suffering from insomnia, hoping that it will go away by itself. Although this may be true in many cases, the conscientious clinician should rule out organic disease and investigate the hygiene and psyche of the patient before prescribing a medication that may launch a lifelong habit. Anatomy is the key to a differential of the many organic causes. Visualizing the many organs of the body, one can discover most of the significant causes. Beginning with the stomach and the esophagus, one should recall indigestion from alcoholic gastritis, overeating, reflux esophagitis, or hiatal hernia. Cirrhosis of the liver may cause insomnia because of nocturnal delirium. Renal diseases may cause insomnia because of nocturia or because of the toxic effects of uremia. Heart diseases, particularly those associated with pulmonary edema or arrhythmias, may awaken the patient with paroxysmal nocturnal dyspnea or palpitations. In particular, aortic regurgitation awakens the patient because of the noise of his or her own heart. Lung diseases such as emphysema interfere with breathing, and both the cerebral anoxia and the fear of not being able to breathe cause insomnia. Upper airway obstruction from rhinitis, snoring, and epiglottitis causes insomnia. The thyroid may be the site of origin of insomnia, particularly in the thyroid storm of Graves disease. Anemia of any kind will cause insomnia if it is severe enough to cause cerebral anoxia. Skeletal deformities such as rheumatoid spondylitis may cause insomnia by forcing the patient to sleep in a chair. In the nervous system, the many neurologic disorders that can cause insomnia can be remembered by using INSOMNIA as a mnemonic.

I—Intoxication results from CNS stimulants such as amphetamines and caffeine. Although drugs and alcohol initially sedate the drinker, they produce a subsequent period of excitation. N—Neuropsychiatric disorders include neurosis, manic–depressive psychosis, and schizophrenia. S—Syphilis, seizure disorders, and senile dementia are included. O—Opiate addiction may be responsible for insomnia. M—Mental retardation and malformations such as hydrocephalus may be responsible for insomnia. The hyperactive child syndrome is just one example of a brain-damaged child with potential insomnia. N—Neoplasms of the brain may cause insomnia or somnolence. When the tumor leads to increased intracranial pressure, coma may eventually occur. I—Inflammatory diseases include viral encephalitis, tuberculosis, cryptococcosis, and various parasites. A—Arteriosclerosis includes cerebral and cerebral arterial occlusions. Frequently the insomnia is related to some physiologic or environmental problem. A sagging mattress, a room that is too hot or too cold, an uncomfortable pillow (or too many pillows), and excessive noise or light all are environmental factors that may cause insomnia. Lack of exercise, mental exhaustion, muscular aches and pain from hard work or exercise, hunger, and too much sleep in the afternoon are some of the physiologic conditions that may cause insomnia.

Approach to the Diagnosis

In the approach to the diagnosis, every physician should take the time to talk to the patient about possible reasons for fear or hostility. A nagging wife or mother-in-law, financial worries, a strict boss, or fear of losing a job are just a few examples of problems that can be handled with some sympathetic professional help. A good physical and neurologic examination may reveal an organic cause. The laboratory evaluation will be based on suspicion of one or more of the diseases mentioned above and will use the list of tests that follows this discussion. A skull x-ray, electroencephalogram (EEG), CT scan, and possibly a spinal tap are indicated if a neurologic disorder is strongly suspected.

Other Useful Tests

1. Complete blood count (CBC) (anemia)
2. Chemistry panel (chronic liver disease, renal disease)
3. Circulation time (CHF)
4. Arterial blood gases (chronic pulmonary disease)
5. Drug screen (drug abuse)
6. Venereal Disease Research Laboratory (VDRL) test (neurosyphilis)
7. Thyroid profile (hyperthyroidism)
8. MRI of the brain (brain tumor, senile dementia)
9. Polysomnography (sleep apnea, e.g.)
10. Psychiatry consult

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Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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