National Sleep Foundation

Chapter 2: Insomnia

Diagnostic Features

The diagnosis of insomnia is given whether the condition occurs as a comorbid condition to another mental or physical disorder, such as depression or pain.1  Insomnia can continue even after the primary condition has improved.2,3,4

Insomnia disorder is described by the following diagnostic criteria:5

  1. Predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
    1. Difficulty initiating sleep.
    2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
    3. Early morning awakening with limited ability to return to sleep.
  2. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
  3. The sleep difficulty occurs at least three nights per week.
  4. The sleep difficulty is present for at least three months.
  5. The sleep difficulty occurs despite adequate opportunity for sleep.
  6. The insomnia is not better explained by, and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
  7. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
  8. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

Insomnia is deemed to be “episodic” if it lasts from one up to three months; “persistent” if it last longer than three months; and “recurrent” if the individual experiences two or more episodes within a year.6

Insomnia can worsen the clinical outcomes for the comorbid disorder, or predispose patients to experience a recurrence of their primary condition. For this reason, both the insomnia and the comorbid condition should be treated at the same time.

Insomnia often co-occurs with:

  1. Psychiatric disorders such as depression, substance abuse, or anxiety;7,8,9,10,11
  2. General medical conditions including diabetes, cardiopulmonary disease, musculoskeletal conditions, gastrointestinal disease, endocrine conditions, chronic renal failure, and neurological disease;12,13
  3. Substance use and abuse, including use/abuse of alcohol, tobacco, prescription medication such as prednisone, and over-the-counter (OTC) medications such as pseudoephedrine.14

References:

  1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association, 2013.
  2. Katz DA, McHorney CA. The relationship between insomnia and health-related quality of life in patients with chronic illness. J Fam Pract. 2002;51:229-235.
  3. Chang PP, Ford DE, Mead LA, Cooper-Patrick L, Klag MJ. Insomnia in young men and subsequent depression. The Johns Hopkins Precursors Study. Am J Epidemiol. 1997;146:105-114.
  4. Ohayon MM, Roth T. Place of chronic insomnia in the course of depressive and anxiety disorders. J Psychiatr Res. 2003;37:9-15.
  5. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association, 2013.
  6. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association, 2013.
  7. Mai, E. and Buysse, D., Insomnia: Prevalence, impact, pathogenesis, differential diagnosis, and evaluation. Sleep Med Clin. 2008;3(2):167-174.
  8. Knutson, KL. The association between pubertal status and sleep duration and quality among a nationally representative sample of U.S. adolescents. Am J Hum Biol. 2005;17:418-424.
  9. Hyyppa MT, Kronholm E. Quality of sleep and chronic illnesses. J Clin Epidemiol. 1989; 42:633-638.
  10. Ohayon MM. Prevalence of DSM-IV diagnostic criteria of insomnia: distinguishing insomnia related to mental disorders from sleep disorders. J Psychiatr Res. 1997;31:333-346.
  11. Buysse D, Reynolds C, Kupfer D, et al. Clinical diagnoses in 216 insomnia patients using the International Classification of Sleep Disorders (ICSD), DSM-IV and ICD-10 categories: a report from the APA/NIMH DSM-IV Field Trial. Sleep. 1994;17:630-637.
  12. Katz DA, McHorney CA. Clinical correlates of insomnia in patients with chronic illness. Arch Intern Med. 1998;158:1099-1107.
  13. Sutton DA, Moldofsky H, Bradley EM. Insomnia and health problems in Canadians. Sleep 2001;24:665-670.
  14. Schweitzer PK, “Drugs that disturb sleep and wakefulness,” In: Kryger MH, Roth T, Dement WC, (eds.), Principles and Practice of Sleep Medicine. 5th ed. Philadelphia, Pa: Elsevier Saunders; 2011:542-560.