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By: AAST Associate Editor on March 31st, 2022

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Insomnia: Types, Diagnosis and Treatment

insomnia | CBT-I

Insomnia is a common sleep disorder that makes it difficult to fall asleep, stay asleep and/or return to sleep after waking. Insomnia can be chronic or acute, meaning long-term or short-term, and often comes and goes over time. Depending on its severity, insomnia can lead to health complications and lifestyle disruptions.

Insomnia tends to affect women more than men, and older generations more than younger ones. Individuals from racial or ethnic minorities also seem to be affected disproportionately.

Types of Insomnia1

The International Classification of Sleep Disorders-Third Edition (ICSD-3) notes that insomnia is divided into three classifications: chronic, short-term and other insomnia disorder. The "other" category applies when the patient has insomnia symptoms but does not meet criteria for the other two types of insomnia. The system of classification departs from historical systems, especially the primary versus secondary (comorbid) models.

Diagnosis1,2,3

A diagnosis of chronic insomnia disorder, according to ICSD-3, should be based upon the general criteria of: 1) difficulty entering or maintaining sleep, 2) despite an appropriate sleep time allowance and 3) results in negative impacts during the day. Chronic insomnia is characterized by sleep difficulty lasting more than three months, at a frequency of three or more times a week.

Guidelines from the American Academy of Sleep Medicine indicate insomnia is primarily diagnosed by clinical evaluation that includes a thorough sleep history and a detailed medical, substance and psychiatric history. Self-reporting by a patient of sleep quality, latency, wake time, sleep diary content and responses to a validated questionnaire, such as the Sleep Self-Report, Insomnia Severity Index or the Pittsburgh Sleep Quality Index are generally included in the sleep history.

Recent Self-Reporting Findings

The utility of patient self-reporting in an insomnia diagnosis was considered in a study of cognitive behavioral therapy (CBT) used to treat older veterans with insomnia. Researchers studied "sleep discrepancy" between recorded or observed sleep and wake times and patient reporting. They found that the perceptions of sleep difficulty changed after CBT, more accurately reflecting the recorded sleep patterns.

Treatment3,4

Some patients may require cognitive behavioral therapy for insomnia (CBT-I) to help control or eliminate negative thoughts and actions that keep them from falling asleep. CBT-I, generally being the first line of treatment for patients, is aimed at helping a patient to recognize and change beliefs that affect their ability to sleep and assisting development of good sleep habits.

Strategies include stimulus control therapy, which helps remove factors that condition a patient's mind to resist sleep, such as setting a consistent bedtime and wake time and avoiding naps. Relaxation techniques, such as progressive muscle relaxation, biofeedback and breathing exercises can be used to help reduce anxiety that may be delaying sleep's onset. For patients who fall asleep or wake too early, light therapy can be used to push back their internal clock. For some patients however, sleep aids may be necessary.

Prescription sleeping pills can help a patient fall asleep, stay asleep or both. But, doctors generally don't recommend relying on prescription sleeping pills for more than a few weeks. If prescribed medication(s) for long-term use, approved medications include eszopiclone, ramelteon, zaleplon and zolpidem. Over-the-counter sleep aids are also an option; they usually cause drowsiness because they contain antihistamines.

Conclusion

There are many things in the world today that can keep a person awake. Not all sleep problems are insomnia — but if a patient presents with long-term symptoms or with short-term symptoms having a noticeable impact on their ability to function while awake, the next step is diagnosis. If you believe a patient is suffering from insomnia, talk with and educate them on proper sleep hygiene and cognitive behavioral therapies.

References

  1. American Academy of Sleep Medicine. International Classification of Sleep Disorders – Third Edition. 2014.
  2. Insomnia Diagnosis. Sleep Foundation. https://www.sleepfoundation.org/insomnia/diagnosis
  3. Insomnia ― Diagnosis & Treatment. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/insomnia/diagnosis-treatment/drc-20355173
  4. New Guideline: February 2017. American Academy of Sleep. https://aasm.org/resources/clinicalguidelines/040515.pdf