AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Insomnia is defined as difficulty with sleep initiation, maintenance, or quality despite adequate time and opportunity that occurs on a repeat basis and results in some form of daytime impairment. It is the most commonly reported sleep-related problem, with approximately 10-15% of Americans having daytime impairment as a result of the sleep disturbance, and is associated with a variety of medical, psychiatric, and sleep disorders. A comprehensive history and physical examination is essential for determining the underlying etiology of insomnia.

A patient's report of insomnia is nonspecific and can encompass a variety of concerns, including difficulty falling asleep, awakening early or easily, problems with returning to sleep after awakening, or a general poor quality of sleep. Therefore, the patient must define what he or she means by insomnia. In order to be considered a disorder, the insomnia should be accompanied by daytime sleepiness, loss of concentration, irritability, worries about sleep, loss of motivation, or other evidence of daytime impairment that is associated with the sleep difficulty.

Insomnia is commonly divided into 3 types based on duration. The first type is transient insomnia. Transient insomnia lasts up to 1 week and is often referred to as adjustment sleep disorder because it is caused most often by an acute situational stress, such as a new job, upcoming deadline, or examination. It is often recurrent with new or similar stresses. The second type, short-term insomnia, is defined as that lasting 1-6 months and is usually associated with more persistent stressful situational (death or illness) or environmental (noise) factors. The third type is chronic insomnia. Chronic insomnia is any insomnia lasting more than 6 months and is associated with a wide variety of disorders.

Other related eMedicine articles include Insomnia (neurology focus) and Primary Insomnia. In addition, the following Medscape CME courses are available:

• Insomnia: Impact on Health and Quality of Life
• Insomnia and Comorbid Anxiety
• The Treatment of Insomnia in Older Adults

Pathophysiology

Determinants of insomnia

Insomnia is usually a result of an interaction of biological, physical, psychological, and environmental factors.

While transient insomnia can occur in any person, chronic insomnia appears to develop only in a subset of patients who may have predisposing factors. The evidence supporting this theory indicates that, compared with persons who have normal sleep, persons with insomnia (1) have higher rates of depression and anxiety, (2) score higher on scales of arousal, (3) have longer daytime sleep latency, (4) have increased 24-hour metabolic rates,¹ (5) have more night-to-night variability in their sleep, and (6) may have more beta electroencephalogram activity (a pattern observed during memory processing/performing tasks) at sleep onset.

In experimental models of insomnia, normal subjects deprived of sleep do not demonstrate the same abnormalities in metabolism, daytime sleepiness, and personality as subjects with insomnia. In an experimental model in which normal subjects were given caffeine, causing a state of hyperarousal, the normal subjects had changes in metabolism, daytime sleepiness, and personality similar to subjects with insomnia.² These results support a theory that insomnia is a manifestation of hyperarousal. In other words, the poor sleep itself may not be the cause of the daytime dysfunction, but merely the nocturnal manifestation of a general disorder of hyperarousability.

One theory holds that chronic insomnia is the result of 3 components: predisposing factors, precipitating factors, and perpetuating factors. Patients who develop chronic insomnia are thought to have predisposing factors that put them at risk. These factors may cause the occasional night of poor sleep, but, in general, the patient sleeps well until a precipitating event (eg, death or other life stress) occurs. Then, the patient develops acute insomnia. If the patient develops bad sleep habits or other perpetuating factors, chronic insomnia develops despite the removal of the precipitating factor. This theory is illustrated in Media File 1.

Frequency

United States

In a 1991 survey, 30-35% of adult Americans reported difficulty sleeping in the past year and 10% reported the insomnia to be chronic, severe, or both. Despite the high prevalence, only 5% of individuals with chronic insomnia visited a clinician specifically to discuss their insomnia, while only 26% discussed their insomnia during a visit made for another problem.

International

A study from Quebec indicated an overall prevalence rate of insomnia of approximately 20% in French Canadians. A study of young adults in Switzerland indicated a 9% rate of chronic insomnia. A World Health Organization study of 15 sites found a prevalence rate of approximately 27% for patients reporting "difficulty sleeping."

Mortality/Morbidity

Insomnia is associated with a variety of symptoms related to daytime functioning.

• Individuals with insomnia report an impaired ability to concentrate, poor memory, difficulty coping with minor irritations, and decreased ability to enjoy family and social relationships.
• Individuals with insomnia are more than twice as likely to have a fatigue-related motor vehicle accident.
• The mortality rate appears to be higher in patients who sleep fewer than 5 hours each night.

Sex

The prevalence rate of reported insomnia is higher in women than in men (approximately 40% vs 30%).

Age

Frequency increases with age.

CLINICAL

Section 3 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

The history is the most important part of the evaluation for insomnia. It must include a complete sleep history, medical history, social history, and careful medication review.

• Sleep history
• • As part of the sleep history, the examiner must determine the timing of insomnia, the patient's sleep habits (commonly referred to as sleep hygiene), and the symptoms of the sleep disorders associated with insomnia.
  • To determine the timing of insomnia, several types of questions should be asked. At what time is the sleep difficulty occurring? Is the difficulty with falling asleep, frequent awakenings, or early morning awakening? If the problem is at sleep onset, is the patient sleepy when he or she gets into bed?
  • Try to determine the patient's sleep schedule. What time does the patient go to bed and wake up in the morning? Do these occur at the same times every day? Have any recent changes occurred in this schedule? Does the patient take daytime naps?
  • Inquire about the patient's sleep environment. What are the temperature, bed comfort, and noise and light levels? Does the patient sleep in his or her own bed? Does the patient sleep better in a chair or when away from home (eg, hotel)?
  • Sleep habits can also be determined with questioning. Individuals with insomnia often have poor sleep hygiene. Does a period of relaxation occur prior to bedtime or does the patient work until bedtime? Does the patient read or watch television in bed? Is the television or a light kept on during the night? What does the patient do if he or she cannot fall asleep? If he or she wakes up in the middle of the night, does the patient fall back to sleep easily? If not, what does the patient do? Does the patient take daytime naps? Does the patient exercise and when?
  • Symptoms of other sleep disorders should be elicited. Symptoms of obstructive sleep apnea include snoring, witnessed apneas, and gasping. Symptoms of restless legs syndrome (RLS) or periodic limb movement disorder (PLMD) include a restless feeling in the legs upon lying down that improves with movement, rhythmic kicking during the night, and very crumpled or disrupted sheets in the morning.
• Daytime history
• • Daytime effects should be present if the patient is truly not sleeping at night. In fact, if no daytime effects are present, the patient is likely getting adequate sleep and the report of insomnia is truly subjective.
  • Common symptoms include fatigue, tiredness, lack of energy, irritability, reduced work performance, and difficulty concentrating.
  • These should be distinguished from reports of excessive sleepiness, which is rare in persons with insomnia.
• Medical history: Perform a thorough medical history and review of systems, with particular emphasis for those disorders mentioned in Causes.
• Psychiatric history: Perform a thorough psychological review to screen for a psychiatric disorder (see Causes).
• Social history
• • For adjustment (also known as transient, short-term, or acute) insomnia, inquire about recent situational stresses such as a change in job/school or bereavement.
  • For chronic insomnia, attempt to relate the onset of insomnia to past stresses or medical illnesses.
  • Perform a thorough history of the use of tobacco, caffeinated products, alcohol, and illegal drugs.
• Medication history: Medications that commonly cause insomnia include beta-blockers, clonidine, theophylline (acutely), certain antidepressants (eg, protriptyline, fluoxetine), decongestants, and stimulants.

Physical

The physical examination may be helpful in the evaluation because findings may offer clues to underlying medical disorders predisposing the patient to insomnia.

• If the patient reports sleep apnea, perform a careful head and neck examination. Common anatomic features associated with sleep apnea include lateral narrowing of the oropharynx, oropharyngeal crowding secondary to increased tongue and soft tissue volume, enlarged tonsils, micrognathia, and retrognathia.
• If the patient reports symptoms of RLS or any other neurologic syndrome, perform a careful neurologic examination.
• If the patient reports daytime symptoms consistent with any of the medical causes of insomnia listed below, a careful examination of the affected organ system (eg, lungs in chronic obstructive pulmonary disease) may be helpful.

Causes

Insomnia is a disorder; an accurate differential diagnosis is essential for proper management in a particular patient.

• Adjustment insomnia (also known as transient, short-term, or acute insomnia): Etiologies for these disorders can be divided into 2 broad categories.
• • Environmental etiologies result from an unfamiliar or nonconducive sleep environment due to factors such as too much noise or light, extremes of temperature, or an uncomfortable bed or mattress.
  • Stress-related etiologies primarily result from life events such as new job or school, deadlines or examinations, or deaths of relatives and close friends.
• Chronic insomnia: The differential diagnosis is broader and includes the categories below.
• • Medical disorders may include chronic pain syndromes from any cause (eg, arthritis, cancer), advanced chronic obstructive lung disease, chronic renal disease (especially if on hemodialysis), chronic fatigue syndrome, and fibromyalgia.
  • Neurologic disorders may include Parkinson disease, other movement disorders, and headache syndromes, particularly cluster headaches, which may be triggered by sleep.
  • Most chronic psychiatric disorders are associated with sleep disturbances.
  • • Depression is most commonly associated with early morning awakenings and an inability to fall back asleep; studies have also demonstrated that insomnia can lead to depression. Insomnia of more than 1-year duration is associated with an increased risk of depression.
    • Schizophrenia and the manic phase of bipolar illness are frequently associated with sleep-onset insomnia.
    • Anxiety disorders (including nocturnal panic disorder and posttraumatic stress disorder) are associated with both sleep-onset and sleep-maintenance complaints.
• Drug-related insomnia: Sleep disruption is common with the excessive use of stimulants, alcohol, or sedative-hypnotics. The sleep disturbance may be related to periods of use or discontinuation of the substance or substances.
• Primary sleep disorders
• • RLS and PLMD: RLS is a sleep disorder characterized by unpleasant physical sensations in the legs; relief of the symptoms with movement; worsening of the symptoms during periods of rest or inactivity; and the presence of symptoms primarily in the evening and at night. RLS may be associated with PLMD (repetitive periodic leg movements that occur while asleep). If RLS is predominant, sleep-onset insomnia is generally present; if PLMD is predominant, sleep-maintenance insomnia is more likely.
  • In obstructive sleep apnea, a small subset of patients report insomnia rather than hypersomnolence. They frequently report multiple awakenings or sleep-maintenance difficulties.
  • Circadian rhythm disorders may include advanced sleep-phase syndrome (patient goes to bed early and rises early) and delayed sleep-phase syndrome (patient goes to bed late and rises late). They can manifest as insomnia when the patient wants to either stay in bed later or go to bed earlier but cannot and then believes he or she has a problem sleeping. Shift workers also frequently have problems with insomnia, particularly when required to sleep during the day.
• Psychophysiological insomnia: This is a disorder of somatized tension and learned sleep-preventing associations resulting in a complaint of insomnia and daytime fatigue.
• • Insomnia begins with a prolonged period of stress in a person with previously adequate sleep. The patient responds to stress with somatized tension and agitation, causing physiologic arousal. The bedroom routine, sleep routine, or both become associated with frustration and arousal; poor sleep hygiene follows.
  • In a person experiencing normal sleep, as the initial stress abates, the bad sleep habits are gradually extinguished because they are not reinforced nightly. However, in a patient with a tendency toward occasional poor nights of sleep, the bad habits are reinforced, the patient "learns" to worry about his or her sleep, and chronic insomnia follows.
  • History in these patients frequently reveals excessive daily worries about not being able to fall asleep. They have difficulty falling asleep at bedtime, but they may fall asleep unintentionally during monotonous pursuits (eg, watching television, reading) or in inappropriate situations (eg, at a lecture, while driving) but not when desired. The patient may sleep better when outside of his or her usual sleep environment (eg, away from home). The patient may also report increased arousal, agitation, and muscle tension at or prior to bedtime.
• Infrequent causes: Rarely, insomnia is caused by idiopathic insomnia (long-standing insomnia beginning in childhood without antecedent psychiatric or medical cause) or paradoxical insomnia, a sleep-state misperception for which the patient reports insomnia but does not have objective evidence of a sleep disorder.

DIFFERENTIALS

Section 4 of 11  

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• Follow-up
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• References

Other Problems to be Considered

Restless Legs Syndrome
Periodic Limb Movement Disorder
Sleeplessness and Circadian Rhythm Disorder
Inadequate sleep hygiene

WORKUP

Section 5 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Patients with a history suggestive of chronic obstructive pulmonary disease and insomnia should have an arterial blood gas determination performed to determine if they are hypoxemic.
• • Insomnia associated with chronic obstructive pulmonary disease frequently begins with the development of nocturnal hypoxemia, although nocturnal hypoxemia is not required for insomnia to occur. Treatment with oxygen may improve the condition, but it rarely eliminates the insomnia. Nocturnal hypoxemia is present if the patient has daytime hypoxemia and frequently if he or she has exercise-related hypoxemia.
  • If the arterial blood gas result is negative for hypoxemia, an exercise desaturation study or overnight oximetry may be helpful to determine if the patient needs oxygen.

Other Tests

• Refer patients with a history suggestive of sleep apnea or RLS/PLMD to a sleep center for possible polysomnography.
• Neurologic testing may be indicated in patients with signs and symptoms of neurologic disease.

TREATMENT

Section 6 of 11  

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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

The management of insomnia varies depending on the underlying etiology.

• If the patient has a medical, neurologic, or sleep disorder, direct treatment at the disorder. In particular, adequate pain control can greatly relieve the insomnia associated with pain syndromes.
• If the patient has a psychiatric disorder, direct treatment at the disorder. This may involve medications, psychotherapy, and possible referral to a psychiatrist, psychologist, or therapist.
• If the insomnia is related to medication or drug abuse, withdrawing the offending medication or drug is appropriate therapy.
• The treatment of psychophysiologic insomnia begins with an educational discussion about sleep and adequate sleep hygiene. The elements of good sleep hygiene are described in Patient Education.
• Before instituting therapy, most patients are asked to keep a sleep log for 2-4 weeks. This log, in which the patient records bed and wake times, sleep duration, and daytime naps and activities, gives a clearer picture of the degree of sleep disturbance and allows development of a tailored treatment.
• Cognitive-behavioral therapy is now considered the most appropriate treatment for patients with primary insomnia. Therapy is based on the fact that primary insomnia is associated with physiologic, emotional, and cognitive arousal and conditioning to arousal in bed. Cognitive therapy methods include cognitive relearning in which anxiety-producing beliefs about sleep and sleep loss are targeted. The 3 primary behavioral therapies are as follows:
• • Relaxation therapies
  • • In progressive relaxation, the patient is taught to recognize and control tension through a series of exercises that consist of first tensing and then relaxing each muscle group in a systematic way.
    • Guided imagery and meditation teach the patient how to focus on neutral or pleasant targets in place of racing thoughts.
    • Biofeedback techniques can also be used. They have the advantage of providing patients with immediate feedback regarding their levels of tension and more quickly teaching them how to relax.
  • Stimulus control therapy: This therapy works to reassociate the bed with sleepiness instead of arousal. Rules for its use include the following:
  • • The patient uses the bed only for sleeping and sexual activity (no reading, television, eating, or working in bed).
    • The patient lies down only when sleepy.
    • If the patient is unable to fall asleep in 15-20 minutes, he or she leaves the bed to do something relaxing until sleepy.
    • The previous step is repeated as often as necessary.
    • The patient does not spend more time in bed than is needed.
  • Sleep-restriction therapy: This therapy is based on the fact that excessive time in bed often perpetuates insomnia. Limiting the time in bed leads to more efficient sleep that is both consolidated and more regular and predictable. Time in bed is allowed to increase as the patient demonstrates a continuing ability to sleep in an efficient and consolidated fashion.

Consultations

Primary care providers should be able to diagnose and treat transient or short-term insomnia. Chronic insomnia is often more difficult to treat, and when primary or associated with a sleep or psychiatric disorder, referral to an appropriate specialist may be indicated.

• Patients should be referred to a sleep specialist in the following situations:
• • If any elements of the history suggest obstructive sleep apnea or RLS/PLMD
  • In cases of chronic insomnia, particularly if it is psychophysiological insomnia
• Many sleep centers have a staff psychologist who specializes in treating insomnia. The advantages include experience in behavioral techniques and in providing sleep education, greater available time for the often-frequent follow-up care that is needed, and the ability to ascertain if other psychological factors may need further evaluation by a psychiatrist.
• Refer patients with a history of depression to a psychiatrist based on the usual referral pattern of the primary care provider.

MEDICATION

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• Follow-up
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• References

Importantly, note that medications alone do not cure insomnia; however, they may provide symptomatic relief and should be used as an adjunct to nonpharmacologic therapy.

Historically, sedative hypnotics and antidepressants have been used as first-line prescription medications for insomnia. Over-the-counter (OTC) medications that patients may try include antihistamines and melatonin. More recently, ramelteon (Rozerem), a melatonin receptor agonist, has been approved for the treatment of insomnia.

• Therapy should be instituted with a small dose and maintained at the smallest effective dose.
• Continued nightly use should be avoided; patients should be encouraged to use them only when truly necessary.
• Use for more than 2-3 weeks should be avoided.
  
• A hypnotic free of residual effects in the morning is preferable (eg, zolpidem, zaleplon).
  
• Hypnotics with a rapid onset of action, such as zolpidem or zaleplon are preferable when the problem is falling asleep. If the problem is staying asleep, a hypnotic with a slower rate of elimination may be more appropriate (eg, temazepam, estazolam, flurazepam). If the patient is depressed, an antidepressant with sedative properties, such as trazodone or amitriptyline, may be useful.
  
• Hypnotics should never be used with alcohol.
  
  
• In general, pregnancy is a contraindication.
  
  
• Benzodiazepines should be avoided in patients with known or possible sleep apnea.
  
• Smaller doses should be used in elderly patients.
  
• In most patients, the risk of dependency is low (most rarely escalate the dose or use more frequently than prescribed). However, avoid use in patients with a history of substance abuse.
  
• Rebound insomnia may develop when the medication is abruptly withdrawn. This is more likely to occur with larger doses and with the short-acting agents. Using smaller doses and tapering the drug can avoid rebound insomnia.

Note that most studies of the efficacy of sedative-hypnotics have been short-term trials (ie, generally <4 wk). Use for longer than 4 weeks was thought to result in tolerance and decreased efficacy, though supportive findings are scarce, and epidemiologic literature suggests that patients report continued efficacy with continued use. However, because of the addictive nature of benzodiazepines, most authorities believe that the duration of use should be limited.

A newer drug, eszopiclone, was the first sedative-hypnotic to be tested over a 6-month period and showed continued efficacy over the 6-month period.³ More recent data show continued efficacy at up to 12 months.

Common OTC antihistamines (eg, diphenhydramine, hydroxyzine) are not indicated for the treatment of sleeplessness. Antihistamines are the major ingredient of OTC sleep aids and are the ingredient in cold and sinus formulas sold as bedtime-use medications. While H1 antihistamines have sedative effects in healthy individuals, no study has established a dose range over which the hypnotic effect is effective in patients with insomnia. Thus, their regular use in individuals with insomnia is not advised. These agents may have some subjective benefit, but long-term efficacy has not been demonstrated and they are not recommended.

Melatonin has also become a popular OTC sleep aid. Melatonin is a naturally occurring hormone secreted by the pineal gland. The concentration of melatonin is highest in the blood during normal times of sleep and lowest during normal times of wakefulness. The general consensus is that melatonin given during normal waking hours has hypnotic properties. Most studies of melatonin have been small and of limited duration, and the results have conflicted somewhat with several studies that have shown limited or no effect. Most of the data, however, seem to suggest that melatonin taken before bedtime decreases sleep latency and may increase total sleep time.^{4, 5}

Studies of melatonin in individuals with chronic insomnia have not demonstrated objective changes in patient sleep habits or changes in mood or alertness the day after treatment. In addition, a dose-response relationship has not been determined. OTC melatonin is also sold at doses much higher than those that naturally occur in the blood. Therefore, at this time, most authorities do not recommend melatonin for the treatment of chronic insomnia.

Ramelteon, a melatonin receptor agonist, has been approved by the US Food and Drug Administration for use in persons with insomnia. It has been shown to have no potential for abuse and, as such, is the first nonscheduled prescription drug available in the United States for the treatment of insomnia.

Alternative and herbal medications have also been tried in the treatment of insomnia. Among the most widely used and studied of these is valerian root extract. A 2006 meta-analysis of 16 randomized controlled trials of valerian for the treatment of insomnia had conflicting results.⁶ The pooled data did seem to show evidence of improved sleep; however, the authors noted a possible publication bias that may have contributed to this result.

Drug Category: Nonbenzodiazepine hypnotics

Good choice for treatment of sleep-onset insomnia.

Drug Category: Benzodiazepine hypnotics

Hypnotics of choice for many years because of their relative safety compared with barbiturates.

Drug Category: Antidepressants

Adverse effect of drowsiness observed with some antidepressants can be used to benefit the patient in treatment of sleep-maintenance insomnia or insomnia associated with depression.

Drug Category: Melatonin agonists

Indicated for insomnia characterized by difficulty with sleep onset.

FOLLOW-UP

Section 8 of 11  

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• Follow-up
• Miscellaneous
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• References

Patient Education

• All patients with insomnia, whether transient or chronic, should be educated about sleep and the elements of good sleep hygiene. Sleep hygiene refers to daily activities and habits that are consistent with and/or promote the maintenance of good quality sleep and full daytime alertness. The elements of good sleep hygiene are as follows:
• • Develop regular sleep habits. This means keeping a regular bedtime and wake time. Sleep time should last as long as needed to feel refreshed the following day, and extra time in bed beyond what is needed should be avoided.
  • Slow down and unwind before bedtime (beginning at least 30 min before bedtime). A light snack may be helpful.
  • Keep the bedroom dark, quiet, and at a comfortable temperature.
  • Exercise daily. This is best performed in the late afternoon or early evening (but not later than 7-8 pm).
  • Do not force oneself to sleep. If unable to fall asleep within 15-30 minutes, leave the bed and do something relaxing until sleepy.
  • Do not consume alcohol for 4-6 hours before bed. Caffeine and tobacco use should also be avoided prior to bedtime.
  • Napping during the daytime should usually be avoided.
  • Do not engage in strenuous mental or physical activities just prior to bedtime.
  • Do not take one's problems to bed.

MISCELLANEOUS

Section 9 of 11  

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• Miscellaneous
• Multimedia
• References

Special Concerns

• Insomnia in elderly individuals
• • Sleep satisfaction declines with age. This is probably related to changes in sleep associated with age, such as a decrease in slow-wave sleep, increased time awake after sleep onset, and a tendency to go to bed early and rise early. However, aging should not be assumed to be the explanation for insomnia.
  • Multiple factors affect sleep in elderly individuals, including nocturia, pain syndromes, and many medical disorders (eg, heart failure, chronic obstructive pulmonary disease, Parkinson disease); RLS, PLMD, and sleep apnea (all of which have an increased frequency in elderly individuals); dementia; and frequently changing situational factors, such as retirement, bereavement, or financial difficulties, which lead to anxiety and depression.
  • As in younger patients, nonpharmacologic treatment should take precedence over pharmacologic treatment.
  • Hypnotics should be prescribed cautiously and in lower doses for elderly patients than for younger patients. Because of changes in metabolism and elimination, the drugs tend to have a longer duration of effect in elderly individuals, which can lead to an increased incidence of falls and bone fractures at night (if the patient gets up to use the bathroom when not fully awake or ataxic) and decrements in daytime alertness and performance (including an increased incidence of motor vehicle accidents).

MULTIMEDIA

Section 10 of 11  

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• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Theoretical model of the factors causing chronic insomnia. Patients who develop chronic insomnia are thought to have predisposing or constitutional factors that may cause occasional nights of poor sleep but not chronic insomnia. However, a precipitating factor, such as a major life event, causes the patient to have acute insomnia. If perpetuating factors, such as poor sleep habits, develop in the following weeks to months, the insomnia becomes chronic despite the removal of the precipitating event. Adapted from Spielman, 1987.
	View Full Size Image
Media type:  Graph

REFERENCES

Section 11 of 11

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• Introduction
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• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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Article Last Updated: Jul 25, 2008