Awareness of this history is valuable as it may shed light on etiology and help identify targets of cognitive therapy. A history of childhood trauma or chaotic home environment at night (even in the absence of posttraumatic stress disorder ) may increase vulnerability to sleeplessness as an adult.(See 'Patients with comorbid psychiatric disorders' below.) Psychiatric disorders and insomnia have a bidirectional relationship, and concomitant treatment for both disorders is often necessary to hasten recovery and increase the likelihood of sustained response of both disorders.(See 'Patients with comorbid sleep disorders' below and "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Diagnostic evaluation'.) Suspected OSA is an indication for in-laboratory polysomnography or home sleep apnea testing. Sleep disorders other than insomnia (eg, obstructive sleep apnea, circadian rhythm disorders, restless legs syndrome ) may present with insomnia but are unlikely to improve without treatment directed at the specific sleep disorder.Insomnia precipitated or exacerbated by a symptom of medical illness (eg, pain, nocturia, or shortness of breath) is unlikely to improve without maximal treatment of the medical disorder.Such events and comorbidities are important for treatment because: (See "Evaluation and diagnosis of insomnia in adults", section on 'Common comorbidities'.) Such factors are then variably amplified in the context of an individual's underlying reactivity to sleep disturbance when under psychologic or physiologic stress ( table 1). Predisposing and precipitating factors - The sleep history should include an examination of the social, medical, and psychiatric events that may have been relevant at the time insomnia began. Each of these factors should be assessed to formulate an individualized treatment plan. INITIAL ASSESSMENT AND COUNSELING - Insomnia etiology is best conceptualized as a combination of predisposing, precipitating, and perpetuating factors that vary over time. (See "Pharmacotherapy for insomnia in adults" and "Cognitive behavioral therapy for insomnia in adults".) Specific medications and behavioral therapies for insomnia are reviewed in more detail separately. This topic is an overview of the approach to management of acute and chronic insomnia in adults.
However, successful behavioral and pharmacologic approaches to insomnia should only be implemented once all contributing factors are recognized and attempts to address them are made. Insomnia often responds only partially to treatment of sleep-impairing influences, however, and many patients require treatment directed towards sleep itself. Management of insomnia requires a stepwise approach, beginning with attempts to eliminate, or at least minimize, the multiple contributing factors and comorbid illnesses that can interfere with optimal sleep. Identification of these factors is at the core of insomnia treatment. Although sleep is a strong and highly regulated biologic drive, the ability to fall asleep at the desired time and maintain sleep without excessive waking is fragile and influenced by multiple factors. INTRODUCTION - Insomnia is one of the most common symptoms for which adults seek medical advice.
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