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 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?
AFemale sex and age over 40
BFamily history of insomnia
CIrregular bedtime routine
DGeneralized anxiety disorder
ERecent stressful life event
Reveal answer & full explanation
Correct answer: D — Generalized anxiety disorder
AFemale sex and age over 40
BFamily history of insomnia
CIrregular bedtime routine
DGeneralized anxiety disorder✓
ERecent stressful life event
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.
Recent stressful life event — a stressful life event is the classic precipitating factor in the 3P model, and her worries about her job, finances and family can read like recent stressors, but no discrete event is described; her worry is excessive, difficult to control and has lasted 4 years, which is generalized anxiety disorder, and that comorbid disorder is a stronger and more persistent driver of chronic insomnia than a single precipitant.
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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
Dual orexin receptor antagonists — suvorexant, lemborexant, daridorexant (sleep onset and maintenance; the 2023 European Insomnia Guideline supports use for up to 3 months, or longer in some cases; AASM 2017 names no preferred class)
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); AASM 2017 also suggests against trazodone for chronic insomnia
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 — Sateia MJ et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med 2017;13(2):307-349
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.
AASM 2021 — Edinger JD et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2021;17(2):255-262
European Insomnia Guideline 2023 — Riemann D et al. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. J Sleep Res 2023;32(6):e14035
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