Insomnia Insomnia

Primary Sleep Disorders 145
suspicion of the disorder. Nocturnal symptoms include snoring, usually with a crescendo
pattern or interruption with snorting or choking noises, witnessed apneas or
pauses in snoring, arousals with choking or dyspnea, motor restlessness and limb
jerking, night sweats, nocturia, gastroesophageal reflux, and dry mouth and drooling.
Daytime symptoms include fatigue, excessive daytime sleepiness, morning
headaches, impaired concentration, decreased libido or impotence, and personality
changes such as irritability. Although patients present with varying combinations
of these symptoms, most of which are very nonspecific, most patients with insomnia
secondary to sleep-disordered breathing will give enough symptoms in a careful
history to raise suspicion of apnea. Accompanying symptoms may be less
prominent in central sleep apnea, but evidence of respiratory failure or underlying
CNS or cardiopulmonary disease may be present.
RLS is characterized by four essential features: (1) a desire to move the limbs
that is usually associated with dysesthesias or paresthesias, (2) motor restlessness,
(3) symptoms that are exclusively present or worsened by rest and relieved at least
partially or temporarily by movement, and (4) a circadian rhythm with symptoms
that are worse in the evening or night, usually near the patient’s habitual bedtime
(39). Additionally, most patients have PLMs during sleep and may have involuntary
limb movements while awake and at rest. Patients with PLMs without RLS
may be unaware of their limb movements. A disheveled bed may provide clues to
movements during sleep.
Narcolepsy is characterized by excessive daytime sleepiness accompanied by
manifestations of dysregulated REM sleep, including cataplexy, hypnogogic hallucinations,
and sleep paralysis (1). Cataplexy is the only symptom that is pathognomonic
for narcolepsy but does not occur in all patients. Patients with nightmares
are aware of vivid dreaming with anxiety-provoking content. Patients with sleep
Case 1: Narcolepsy Presenting with Insomnia
A 25-year-old man presented with difficulty falling asleep for the past 4
months. Some nights he did not fall asleep until 4 or 5 AM, causing him to be
unable to get up in the morning, causing concentration problems during the
day, and leading him to frequently fall asleep unintentionally in sedentary
situations. The sleepiness affected his life significantly. He had to repeat his
second year of medical school because of frequent episodes of falling asleep
in class and a lack of concentration.
He did not have a regular bedtime. He reported that some nights he went to
bed around 10 PM, some nights 4 AM. Regardless, most nights it took him an
hour or more to fall asleep. Even when he got 8 hours of nighttime sleep, he
still felt tired in the morning. He was as likely to fall asleep during the day
when he got a few hours of sleep as when he got 8 hours of sleep. He did not
take naps routinely, but a couple of times per week he fell asleep studying on
the couch and usually napped for 1 to 3 hours.