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Stanford Sleep Epidemiology Journal Stanford Sleep Epidemiology Research Center (SSERC) Psy-EVAL Research
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First created | 12/01/2000
Last edited | 05/11/2012
Writtten by Maurice M. Ohayon, MD, DSc, PhD
Reference to cite:1) Ohayon MM. Prevalence of DSM-IV diagnostic criteria of insomnia: distinguishing insomnia related to mental disorders from sleep disorders. J Psychiatr Res 1997; 31: 333-46. 2)
Although insomnia complaints are reported by nearly one third of the general population, the diagnosis of insomnia is only made in 6–15%. Similarly, excessive daytime sleepiness is reported by approximately one in five people but only 2% of the general population are diagnosed with hypersomnia, narcolepsy, or behaviorally induced insufficient sleep syndrome.
In the vast majority of individuals, sleep disturbances are caused by or associated with various medical or neurological diseases, psychiatric disorders, or environmental factors.
Sleep disturbances encompass a broad range of phenomena, such as
insomnia, hypersomnia, sleep apnea, and restless legs syndrome
(RLS). The latest edition of the
International Classification of Sleep
Disorders describes criteria for the diagnosis of >100 sleep
disorders, divided into eight categories [1]:
· Insomnia
·
Sleep related breathing disorders
·
Hypersomnias of central origin
·
Circadian rhythm sleep disorders
·
Parasomnias
·
Isolated symptoms, apparently normal variants, and unresolved
issues
·
Other sleep disorders
Insomnia symptoms are present in approximately 30% of the general population; however, insomnia is diagnosed in only 6% [2].
Therefore, it can be estimated that approximately 75
million people in the US and 150 million in Europe are affected
by insomnia.
Insomnia is usually chronic [3,4,5, 6,7], with most insomnia patients (85%) reporting that their symptoms have lasted ³1 year.
In fact, in one study, 68% of subjects reported their
symptoms lasting ³5 years, while only 5% had symptoms that
lasted 6–12 months, 6% 1–6 months, and just 4% had symptoms for
≤1 month [16].
Insomnia has many different causes of insomnia and, according
to the origin of the condition, insomnia may be divided into
three main categories (Fig. 1):
·
Comorbid with another physical and/or mental illness.
·
Induced by use of psychoactive substances.
·
Caused by lifestyle or without apparent cause.
Sleep-related breathing disorders (SRBD), such as obstructive sleep apnea syndrome (OSA) or hypoventilation, account for 5–9% of insomnia complaints (Fig. 2) [8–10].
Periodic limb movement disorders (PLMD), RLS, or both conditions are diagnosed in approximately 15% of individuals who present with insomnia complaints [9, 10, 11, 12], while medical or neurological conditions are observed in 4–11% [4, 5, 9, 10].
Poor sleep
hygiene or environmental factors are responsible for
approximately 10% of insomnia complaints and these symptoms are
substance-induced in 3–7% [13,5, 9, 10].
Epidemiological studies have consistently reported that
mental disorders are associated with 30–40% of insomnia
complaints and symptoms of mental disorders have been reported
to be present in ³60% of individuals with insomnia symptoms
[4,14–17].
In the general population, people with symptoms of insomnia have consistently been found to perceive their health to be poorer than the rest of the population [5,17–22] and ³50% do have recurrent, persistent, or multiple health problems [14,23].
The most frequently reported associations are with upper airway
diseases [5,24,25], rheumatic diseases [5,24,26,27], chronic
pain [26,28], and cardiovascular diseases [5,29,30].
Several studies have attempted to determine whether insomnia can be responsible for cardiovascular accidents; however, the results have been inconclusive (Fig. 3).
One retrospective study found that insomnia was significantly predictive of myocardial infarction [31] and a prospective study reported that the relative risk (RR) of an individual with insomnia developing a cardiovascular accident was 3.1 [29].
Despite these results,
three other prospective studies found no association between
insomnia and the risk of developing a cardiovascular disease
[32–34] while another found that there was a greater
likelihood of developing insomnia after a cardiovascular
accident [30]
Four longitudinal studies have examined the relationship between the persistence of insomnia symptoms and the appearance of mental disorders [35–38].
They found that subjects with insomnia symptoms were 4–8 times more likely to develop a mental disorder during the year following the onset of these symptoms.
Two studies examining the time sequence of the appearance of insomnia symptoms in relation to that of mood and anxiety disorders reported that insomnia was present in 70% of individuals with mood disorders and that it preceded the appearance of the mood disorders in nearly 50% of cases.
Insomnia was found in one-third of patients with anxiety
disorders and preceded the anxiety disorder in approximately 20%
of cases [16,39].
Insomnia affects the daytime functioning of 20–60% of individuals with the disorder, [4, 8,40].
Individuals who sleep poorly ³3 nights per week, are
dissatisfied with their sleep, do not feel rested upon
awakening, and have hyperarousal in bed are the most likely to experience
repercussions in terms of their daytime functioning [4, 8].
In the general population, road accidents are experienced 2–3 times more frequently by drivers who are dissatisfied with their sleep, than those who report sleep satisfaction [8,18].
Such accidents are also more commonly experienced by those with short sleep times (defined as <5 h less per night) [41,42].
In the elderly,
insomnia is associated with an increased risk of hip fracture
[43], and falls [44,45]. Furthermore, the RR for fatal
occupational accidents in individuals who have difficulty in
sleeping is 1.9 [46].
Contrary to insomnia, EDS (defined as a propensity for sleep during waking hours) is not a diagnosis.
EDS can be a symptom or a consequence of a sleep disorder, physical illness, or mental disorder.
However, EDS is a disabling symptom that adversely affects various areas of quality of life and is a good indicator of the presence of health problems.
Excessive sleepiness is
nearly as prevalent as insomnia, affecting approximately 20% of
the general population [47].
Like insomnia, EDS can be comorbid with several disorders such as organic diseases, mental disorders, and sleep disorders, or can be related to the abuse of or dependency on psychoactive substances.
EDS can also be induced by the lifestyle of
individuals or can be without apparent cause (Fig. 1).
In the general population:
- physical illnesses account for approximately 20% of EDS complaints,
- mental disorders for approximately 22%, and
- sleep disorders – such as OSA, RLS, and insomnia – for nearly 50%.
EDS is an essential criterion for the diagnosis of just three sleep disorders:
- behaviorally induced insufficient sleep syndrome,
- hypersomnia (idiopathic, recurrent, or post-traumatic), and
- narcolepsy.
These conditions are
diagnosed in >3% of the general population [65] (Fig. 4).
In epidemiological, cross-sectional studies, 12.4–30% of subjects with EDS have been shown to have a depressive disorder and 20–35% an anxiety disorder [48–51].
However, unlike
insomnia, EDS has not been found to be associated with
development of a mental disorder in longitudinal studies
[35,36,52].
Several comorbid general medical and neurological disorders can cause EDS (Fig. 4).
Studies have shown that the risk of experiencing EDS is 2–4 times greater for people with diabetes than non-diabetics in the general population [51].
Other studies have observed that 16–74% of individuals with Parkinson’s disease report EDS [53–55].
Elderly people who complain
of EDS are three times more likely to have Alzheimer’s disease
[56].
In sleep clinics, OSAS is the most commonly seen cause of EDS, with ³75% of patients reporting EDS being diagnosed with OSAS.
It has been shown that up to 25% of individuals in the
general population who report EDS have OSAS [48–50, 57].
Unlike insomnia symptoms, EDS is generally not gender-related [49].
Whether its prevalence increases or decreases with age is
not clear, as both trends have been observed [65].
Some work schedules, especially shift work, have frequently been often linked with EDS.
Although some individuals may tolerate the physical strains caused by shift work, they are not immune to the fatigue, mood swings, reduced performance, and decreased mental agility caused by it.
These problems are mainly due to the desynchronization of the circadian rhythm, that is, when the normal sleep/wake rhythm, the normal circadian rapid eye movement (REM) sleep rhythm, and the rhythm of REM and non-REM sleep patterns are disrupted.
As a consequence, several shift workers complain of excessive sleepiness during working hours and of insomnia during sleeping time.
Two studies have
reported that up to 30% of night or shift workers report
excessive sleepiness at work [46,18].
Epidemiological studies have reported higher risks of EDS in
individuals who use antidepressants, anxiolytics, hypnotics,
antihistamines, or alcohol (OR 2–6.7) [4,48,50].
Two epidemiological studies have linked EDS to cognitive deficits.
In a study involving 2346 Japanese American men aged between 71 and 93 years, Foley et al. found that men who reported EDS at baseline were twice as likely to be diagnosed with dementia 3 years later than those who did not suffer from daytime sleepiness [58].
Ohayon and Vechierrini performed another study involving 1026 subjects aged ³60 years and controlled for age, gender, level of physical activity, occupation, organic diseases, use of sleep or anxiety medication, sleep duration, and psychological well-being [59].
They found that subjects with EDS were twice as likely to have
attention–concentration deficits, difficulties in orientation,
and memory problems than those without EDS.
Some population-based studies have investigated the mortality risks associated with EDS.
Hays et al. assessed mortality risk
in a sample of 3962 elderly individuals (³65 years) and defined
EDS by the presence of naps during the daytime [60]. They found
that individuals who reported napping most of the time had a
mortality risk of 1.73.
In another study by Rockwood et al., a small increased mortality risk (1.89) from daytime sleepiness was found in their elderly sample [61].
However, this risk did not retain significance when the model
was adjusted for age, depression, cognitive deficits, and
illness.
EDS has been found to be a direct or contributing factor in 17–21% of road accidents [62,63].
Similarly, road accidents have
been found to be experienced 2–3 times more frequently by
drivers who have EDS [49,63].
Sleep disturbances are frequently associated with various medical or neurological conditions and psychiatric disorders.
Therefore, it is crucial to explore the possibility of comorbid conditions in patients who complain of sleep disturbances.
This should be the first step in the planning of an appropriate treatment strategy.
Treatment of the comorbid condition may decrease sleep disturbances.
However, in several instances,
specific treatment of the sleep disturbances will be necessary
and can contribute the management of the comorbid condition.
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Figure 1. Causes of insomnia and EDS.
EDS: excessive daytime sleepiness.
Figure 2. Common causes of
insomnia complaints [2]
[AU: Please reference. – Ref #2]
[AU: Do you have a copy of this
figure that has not been converted into a picture so that we can
edit it? – Yes, new format]
Figure 3. Time sequence for insomnia
symptoms and development of cardiovascular diseases.
[AU: Do you have a copy of this
figure that has not been converted into a picture so that we can
edit it? – yes, new format]
[AU: please provide the full
reference for koskenvuo et al. 1986 - done]
Figure 4. Most common causes of excessive
daytime sleepiness
[AU: Please reference. – derived from
several studies]
[AU: Do you have a copy of this figure
that has not been converted into a picture so that we can edit it? –
yes new format
Medical & Psychiatric Correlates
Smoking is positively related to difficulties
in initiating sleep and estimated sleep latency.
Although often
reported in clinical studies, the association between the use of
antihypertensive drugs and insomnia was seldom reported in
epidemiological studies.
On sleep patterns, alcohol at bedtime accelerates the sleep onset, increases
the amount of slow-wave sleep, decreases the amount of REM sleep and causes
sleep disruption in the second half of the sleep period.
About
four out of 10 insomnia subjects medicate themselves with
over-the-counter medications or alcohol.
Other medications,
such as serotonergic reuptake inhibitors (SSRIs), some neuroleptics,
some antiparkinsonians and amphetamines may all provoke insomnia among
patients using these kinds of medications. Hypnotics and anxiolytics
may cause insomnia
Waking up with a headache is traditionally associated with sleep disorders
Obstructive Sleep Apnea Syndrome
is an independent risk factor (odds ratio: 9.7) for hypertension.
Snoring and breathing pauses during sleep appeared to be
non-significant predictive factors.
Surprisingly, few studies have
attempted to determine if a comorbid medical condition in individuals with
chronic painful physical disease increased the likelihood of having a major
depressive disorder
Depression with Psychotic Features
There are little data regarding the prevalence of associated psychotic features in subjects with major depressive disorders in the general population
Sleep Apnea
and Depression
Some clinical studies have attempted to
determine whether depression limits the recognition and treatment of
breathing-related sleep disorders, or if breathing-related sleep disorders play
a role in the etiology or course of depressive disorder
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