Evaluating insomnia in about ten minutes

Why insomnia feels harder to evaluate than it is

Most clinicians receive only a few hours of sleep medicine training across medical school and residency.

So if insomnia cases feel confusing in clinic, that’s because of a gap in training, not a reflection of your clinical skills.

The goal is not to turn your practice into a sleep lab. What helps most is a clear framework you can run through in a few minutes.

The case

A woman in her early 40s was referred to me for insomnia by her psychiatrist. She had already tried several sleeping pills without success, and by the time she reached me she was taking zolpidem regularly. It was no longer working well.

I asked her the question I now ask almost every insomnia patient: Tell me about your sleep environment.

She was living in a small studio apartment in San Francisco, sleeping in her closet, because it was the only separate room. It was unventilated. The room was hot and stuffy at night and she couldn’t breathe.

So we made one simple change: We moved her bed out of the closet and closer to the window, so that her sleeping environment was more breathable.

Her sleep improved almost immediately.

It was interesting that she had already seen several clinicians and tried several medications, but nobody had asked about the bedroom itself.

That wasn’t the whole story either. She also had subtle symptoms suggestive of obstructive sleep apnea, which had never been evaluated. We tested for it, she did have moderate OSA, and she’s now being treated.

We also applied behavioral principles from CBT-I (cognitive behavioral therapy for insomnia), particularly reducing the time she was spending awake in bed.

Over time she tapered off the zolpidem and began sleeping better than before.

What the pattern usually looks like

After evaluating hundreds of insomnia patients, there’s one thing I know for sure: Insomnia rarely has one cause or one treatment.

It’s usually a pattern across several factors at once. Once you start identifying those factors, treatment becomes much more targeted, and the interventions themselves are often surprisingly simple.

The four categories: FEEM

The contributing factors almost always fall into 4 categories. I use the acronym FEEM to remember them: food, environment, emotional factors, and medical conditions.

Food includes caffeine, alcohol, reflux from late meals, and nutritional issues such as low ferritin (under 100 ng/mL), which can contribute to restless sleep.

Environment includes bedroom temperature, light exposure, noise, and consistency of the sleep schedule. Sleep hygiene fits in this category.

Emotional factors include anxiety, rumination, trauma, and the conditioned hyperarousal that develops around sleep.

Medical conditions include sleep apnea, restless legs syndrome, circadian rhythm disorders, and other sleep and medical disorders.

Going through these systematically usually makes the underlying contributors clear.

The phrases worth listening for

Patients will point you to the diagnosis with the language they use.

A patient who says they sleep better on vacation is telling you something important, which is that their relationship with their bed at home is a likely contributing factor.

A few phrases I listen for:

• “I wake up with panic at night” may be describing sleep apnea.
• “I’ve tried everything and nothing works” often signals frustration and hyperarousal.
• “I’ve always been a bad sleeper” may signal an identity built around insomnia itself.

These small phrases can be quite revealing.

How I explain sleep drive

I use the hunger analogy. For example, if you have a snack right before dinner, you are’t going to feel as hungry when it is time to eat.

Sleep works similarly. If someone’s spending too much time in bed, the brain doesn’t build up enough sleep drive.

Sometimes we actually need less time in bed, so the brain can rebuild that natural drive to sleep.

Which forms actually save you time

Standardized questionnaires can make your evaluation more streamlined. The Epworth Sleepiness Scale, the Insomnia Severity Index, the GAD-7 and the PHQ-9 are all useful. As a psychiatrist I sometimes add the MDQ (mood disorder questionnaire).

I also have patients complete a sleep history form before the visit, so that our appointment time can focus on the evaluation itself.

The American Academy of Sleep Medicine has a free sleep history template and a free sleep diary that work well.

The part that is not a form

Sometimes the most important perpetuating factor in insomnia isn’t about sleep at all, it’s the patient’s relationship with sleep.

This is where the patient-centered interviewing model called FIFE is useful. FIFE stands for feelings, ideas, functioning and expectations.

• Feelings: how are you feeling about your sleep problem?
• Ideas: what do you think is causing it?
• Functioning: how is it affecting your daily life?
• Expectations: what are you hoping we can accomplish?

Patients often pause and say that no one has ever asked them that before.

What comes out can be so informative. You may discover that a patient believes they have to get 8 hours of perfect sleep every night, or worries that insomnia means they will develop dementia, or hopes that one supplement will finally fix everything.

These beliefs and expectations reinforce the cycle, and they usually don’t come up unless you ask.

In that patient’s case, questions like these revealed how much pressure she was putting on herself to sleep well every night. That kind of pressure keeps the nervous system activated at the exact time it needs to wind down.

Clinical pearls

• Ask every insomnia patient to describe their sleep environment. It’s the question most often skipped.
• Go through the FEEM framework before reaching for another medication: food, environment, emotional factors, medical conditions.
• Low ferritin (under 100 ng/mL) is worth checking in insomnia.
• Insomnia that hasn’t responded to several medications deserves an evaluation for sleep apnea, including in patients who don’t fit the classic picture.
• Use FIFE to surface beliefs and expectations. They are perpetuating factors in their own right.
• The hunger analogy explains sleep drive in one sentence, and patients remember it.

Insomnia stops feeling mysterious once you start seeing it as a pattern of contributing factors. In the above patient’s case, the solution didn’t require an advanced intervention or the “right” medication. It required finding what had been missed.

If you’d like a structured framework for evaluating and treating sleep issues, our free clinical sleep mini-course for practitioners walks through this process step by step.

Disclaimer: This information is for educational purposes only and is not intended to replace individualized medical advice, diagnosis, or treatment.