Insomnia

Background- Daytime dysfunction due to difficulty initiating sleep or lack of good sleep. Insomnia in the emergency department is a common complaint among patients in recovery from a substance use disorder or a psychiatric disorder. Most substances of abuse affect sleep during active use, acute withdrawal, and with sustained abstinence. Specific medications for insomnia should be avoided in patients with history of substance abuse.

Clinical Features- Patients with insomnia typically complain about difficulty falling asleep and staying asleep. Impaired daytime function must also be reported for a diagnosis of an insomnia disorder. Simultaneous psychiatric, medications/substances, are usually present.

Differential Diagnosis-

alcohol use disorder
Depression/anxiety
undifferentiated Bipolar
sleep-disruptive environmental circumstances
Restless legs syndrome
short duration sleep circadian rhythm disorders
chronic sleep restriction
psychosis

Evaluation A personal medical history considering any medical conditions, any medications being taken, and any stressful life events/changes that could be causing insomnia. Insomnia can be associated with another conditions, medications, or substances. A sleep history and review of sleep and wake diaries can be helpful in determining the cause.

Management

sleep hygiene education, relaxation and stimulus control
Trazodone, gabapentin, and melatonin agonists
Benzodiazepines should be avoided due to risks of overdose when mixed with alcohol or other substances.

Disposition

discharge home unless patient acutely psychotic
follow up with primary care doctor
Polysomnography-sleep study