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.
🔒 Free preview limit reached
Keep reading — start your free trial
You've read your 2 free diagnosis previews. Create your free account to unlock the full Insomnia Disorder outline — plus all 514 diagnoses, 3,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
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.
Practice Psychiatry/Behavioral questions on FirstPassPA
Turn this outline into retention. 3,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants.