Insomnia Insomnia

146 Duntley
The patient’s primary care physician had tried several medications for insomnia
including zolpidem, zaleplon, nortriptyline, and trazodone, but nothing
helped. The patient’s primary care doctor suspected that he was depressed;
however, he himself thought that his fatigue and depression were secondary
to the insomnia.
The patient denied uncomfortable lower extremity sensations. He denied
loud snoring or observed apneas, loss of muscle tone with any particular emotion,
sleep paralysis, or hallucinations. He had no past medical history. He
was not on any medications on initial presentation and had no family history
of insomnia. He did not drink coffee or consume any caffeine in the late afternoon.
He did not drink alcohol, did not use illicit drugs, and he quit smoking.
His physical exam was normal. His polysomnogram (PSG) was normal and his
MSLT showed a mean sleep latency of 3.9 minutes with sleep onset REM periods
on three out of five naps.
He was started on modafenil and his nighttime sleep improved and insomnia
resolved at a dose of 300 mg taken in the morning. His daytime sleepiness
improved significantly at a dose of 600 mg per day.
starts are typically aware of the sudden jerk. They may also experience a sensation
of falling, or brief sensory symptoms such as flashes.
DIFFERENTIAL DIAGNOSIS
The symptoms of primary sleep disorders are often nonspecific and the sleep
disorders must be differentiated from each other. For instance, periodic limb jerks
can occur with PLMD or in OSA syndrome. Sleep paralysis is a prominent manifestation
of narcolepsy, but can also occur in any disorder causing sleep fragmentation
or severe sleep restriction. It is sometimes difficult to distinguish insomnia
secondary to a primary sleep disorder from psychophysiological insomnia. Of 116
patients with sleep-disordered breathing and insomnia in one series, 20 presented
with a chief complaint of insomnia only (5). Many patients with insomnia initiated
by a primary sleep disorder will develop a component of conditioned insomnia as a
secondary phenenomenon. This emphasizes the need for careful evaluation so that
symptoms suggestive of a primary sleep disorder are not missed. Patients may
develop poor sleep habits such as irregular hours and excessive caffeine intake as
an attempt to compensate for symptoms of their sleep disorder, and these features
may be so prominent as to suggest that the insomnia is secondary to inadequate
sleep hygiene. In primary sleep disorders with longstanding symptoms from an
early age, idiopathic insomnia may be the differential diagnosis.
DIAGNOSTIC WORKUP
A thorough history to elicit symptoms of an underlying sleep disorder is essential.
Because patients may be unaware of snoring, apneas, and other nocturnal signs,