Dissatisfaction with sleep quantity/quality, >=3 nights/week for >=3 months, with daytime impairment.
Also known as: insomnia, sleep disorder, chronic insomnia
Overview
Predominant complaint of dissatisfaction with sleep quantity or quality — difficulty initiating sleep, maintaining sleep, or early-morning awakening with inability to return to sleep — occurring >=3 nights/week for >=3 months despite adequate opportunity for sleep, with associated daytime impairment.
Epidemiology
Symptomatic insomnia in ~30% of adults; chronic insomnia disorder in ~6-10%. Female-to-male ratio ~1.5:1. Prevalence increases with age and medical comorbidity.
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Question 1PsychiatryMedium
A 54-year-old man presents with 8 months of nonrestorative sleep and excessive daytime sleepiness despite spending 8 hours in bed nightly. His wife reports loud snoring and several episodes per night when he appears to stop breathing and then gasps awake. BMI is 36 kg/m2, neck circumference is 44 cm, and blood pressure is 148/92 mm Hg. He drinks no caffeine after noon and denies an urge to move his legs at night. A trial of sleep-hygiene counseling has not helped. Which of the following is the most appropriate next diagnostic study?
AMultiple sleep latency test
BOvernight pulse oximetry
CTwo-week sleep diary
DPolysomnography study
Reveal answer & full explanation
Correct answer: D — Polysomnography study
AMultiple sleep latency test
BOvernight pulse oximetry
CTwo-week sleep diary
DPolysomnography study✓
Why Polysomnography study is correct
Although polysomnography is not routine for uncomplicated insomnia, it is the appropriate next study when the history points to another primary sleep disorder.
Loud snoring, witnessed apneas with gasping, obesity (BMI 36), large neck circumference, hypertension, and daytime hypersomnia are classic features of obstructive sleep apnea.
Attended in-laboratory polysomnography (or validated home sleep apnea testing) confirms OSA, and treating it often resolves the apparent insomnia and chronic fatigue. AASM reserves polysomnography for suspected OSA, periodic limb movement disorder, narcolepsy, parasomnias, or treatment failure.
Why the others are wrong
Overnight pulse oximetry — records oxygen desaturation only, without airflow, respiratory effort, or arousal data, so it cannot confirm obstructive sleep apnea or grade its severity, and a normal tracing would not exclude it.
Two-week sleep diary — a low-cost tool to characterize insomnia patterns, but it is non-discriminating here and would not detect or confirm obstructive sleep apnea.
Multiple sleep latency test — quantifies pathologic sleepiness and evaluates narcolepsy, but it is valid only after polysomnography the preceding night has excluded untreated obstructive sleep apnea as the cause of the sleepiness.
Question 2PsychiatryMedium
A 42-year-old woman reports 5 months of difficulty falling asleep and frequent nighttime awakenings, occurring nearly every night and leaving her fatigued and irritable at work. She lies in bed worrying for over an hour before sleep onset. For the past 4 years she has had excessive, difficult-to-control worry about her job, her finances, and her family's health, accompanied by muscle tension and restlessness. She drinks alcohol socially, has one cup of coffee with breakfast, and works a standard daytime schedule. BMI is 23 kg/m2, and physical exam is unremarkable. She meets criteria for chronic insomnia disorder. Which of the following is the strongest risk factor for her condition?
AFamily history of insomnia
BFemale sex and age over 40
CIrregular bedtime routine
DGeneralized anxiety disorder
Reveal answer & full explanation
Correct answer: D — Generalized anxiety disorder
AFamily history of insomnia
BFemale sex and age over 40
CIrregular bedtime routine
DGeneralized anxiety disorder✓
Why Generalized anxiety disorder is correct
Comorbid psychiatric conditions — anxiety, depression, and PTSD — are among the strongest and most consistently linked risk factors for chronic insomnia disorder.
The hyperarousal model explains the mechanism: heightened cognitive and somatic arousal (here, ruminative bedtime worry) drives both sleep-onset and sleep-maintenance difficulty and conditions arousal to the bed.
Her 4 years of excessive, difficult-to-control worry with muscle tension and restlessness meet criteria for generalized anxiety disorder, and that anxiety-driven hyperarousal is the dominant contributor in her presentation.
Why the others are wrong
Family history of insomnia — insomnia does aggregate in families and is a recognized predisposing factor in the 3P model, but its effect is modest next to an active comorbid anxiety disorder.
Irregular bedtime routine — variable sleep timing perpetuates insomnia and is a target of CBT-I, but she keeps a standard daytime schedule and behavioral irregularity is a weaker driver than comorbid anxiety.
Female sex and age over 40 — female sex and older age are demographic risk factors (female-to-male ratio ~1.5:1, prevalence rising with age), but these confer only a modest increase compared with the strong effect of a comorbid mood or anxiety disorder.
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Hyperarousal model: heightened cognitive, somatic, and cortical arousal at night with conditioned arousal to bed/bedroom. Disrupted homeostatic and circadian sleep regulation.
Medical conditions — Pain, GERD, nocturia, dyspnea, hyperthyroidism, menopause
Parasomnias — Behavioral events during sleep — REM sleep behavior disorder, sleepwalking, night terrors
Diagnostic workup
Diagnostic criteria
DSM-5-TR / ICSD-3: Predominant complaint of dissatisfaction with sleep quantity or quality, with >=1 of: difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening; sleep difficulty occurs >=3 nights/week, present >=3 months, despite adequate opportunity; causes clinically significant distress/impairment; not better explained by another sleep-wake disorder, substance, or coexisting condition.
Labs
TSH, ferritin (RLS), CBC; consider iron studies if RLS suspected
Targeted labs based on comorbidities
Imaging
Polysomnography NOT routine for insomnia — reserve for suspected OSA, periodic limb movement disorder, narcolepsy, parasomnias, or treatment failure
Diagnostic algorithm
flowchart TD
A[Sleep complaint] --> B[History + sleep diary<br/>screen for OSA, RLS, mood]
B --> C{Comorbid sleep<br/>or psychiatric disorder?}
C -->|Yes| D[Treat comorbidity<br/>polysomnography if OSA]
C -->|No| E[Chronic insomnia disorder]
E --> F[CBT-I first-line]
F --> G{Response?}
G -->|Yes| H[Taper and maintain]
G -->|No| I[Add medication:<br/>orexin antagonist, low-dose doxepin,<br/>Z-drug or ramelteon]
I --> J[Reassess at 4-6 wks<br/>shortest effective duration]
Insomnia evaluation and stepped management.
Treatment
First-line
Cognitive behavioral therapy for insomnia (CBT-I) — first-line per ACP and AASM; components include stimulus control, sleep restriction, sleep hygiene, cognitive restructuring, relaxation training
Sleep hygiene alone has limited efficacy as monotherapy but is foundational
Treat comorbid conditions (depression, pain, OSA)
Second-line / adjunct
Pharmacotherapy as adjunct or when CBT-I unavailable/insufficient; use lowest effective dose for shortest duration
Non-benzodiazepine 'Z-drugs' — zolpidem, zaleplon, eszopiclone (limit chronic use; FDA boxed warning for complex sleep behaviors)
Ramelteon — melatonin receptor agonist; useful for sleep-onset insomnia
Doxepin 3-6 mg — selective H1 antagonist for sleep maintenance
AVOID: chronic benzodiazepines (dependence, falls in elderly, cognitive effects), diphenhydramine and other anticholinergics (Beers criteria — avoid in older adults)
Melatonin (OTC) — modest evidence; useful for circadian misalignment
Complications
Increased risk of depression, anxiety, substance use
Cardiovascular morbidity (HTN, CAD)
Workplace and motor vehicle accidents
Falls and cognitive impairment (especially elderly with sedative-hypnotics)
Complex sleep behaviors with Z-drugs
PANCE pearls
CBT-I is first-line and superior to pharmacotherapy in long-term outcomes — many digital and self-help options available where in-person access is limited.
Avoid diphenhydramine and benzodiazepines in older adults (Beers criteria); orexin antagonists or low-dose doxepin preferred when medication is needed.
Z-drugs carry FDA boxed warning for sleepwalking, sleep-driving, complex sleep behaviors — counsel patients.
Treating OSA (CPAP, dental appliance, surgery) often resolves apparent insomnia and chronic fatigue.
AASM 2017/2021 — Sateia MJ et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults. J Clin Sleep Med 2017; 2021 update
ACP 2016 — Qaseem A et al. Management of Chronic Insomnia Disorder in Adults: ACP Clinical Practice Guideline. Ann Intern Med 2016
DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)
ICSD-3 — American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed.
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