What is Insomnia?
 

Insomnia is a persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, resulting in significant daytime impairment or distress.
 

• Diagnostic Criteria:
   

  • Difficulty falling asleep, staying asleep, or waking too early occurring at least 3 nights per week.

  • Persistence of symptoms for at least 3 months (classifying it as chronic/persistent insomnia).

  • Presence of associated daytime impairment (fatigue, mood disturbance, cognitive deficits, or reduced work performance).
     

• Clinical Presentation Categories:
   

  • Sleep-Onset Insomnia: Difficulty falling asleep at the beginning of the night (latency typically exceeding 30 minutes).

  • Sleep-Maintenance Insomnia: Frequent or prolonged awakenings during the night, or difficulty returning to sleep after waking.

  • Early Morning Awakening (Terminal Insomnia): Waking up significantly earlier than desired and being unable to fall back asleep.

Primary Causes of Insomnia
 

• Psychophysiological (Learned) Insomnia: Conditioned arousal where the patient associates the bed and bedroom with frustration, wakefulness, and anxiety about sleeping.

• Paradoxical Insomnia (Sleep State Misperception): A complaint of severe lack of sleep where objective polysomnography shows near-normal sleep architecture and duration.

• Idiopathic Insomnia: A lifelong, chronic sleep-onset and maintenance disorder of presumed neurological or developmental origin beginning in childhood without clear triggering events.

Secondary Causes of Insomnia = Most Cases
 

• Psychiatric Disorders: Major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder (PTSD), and bipolar disorder (frequently driving both onset and maintenance insomnia).

• Medical & Neurological Conditions: Chronic pain syndromes, chronic obstructive pulmonary disease (COPD), congestive heart failure, gastroesophageal reflux disease (GERD), hyperthyroidism, and neurodegenerative disorders (e.g., Alzheimer's or Parkinson's disease).

• Sleep-Related Breathing & Movement Disorders: Obstructive sleep apnea (OSA) and restless legs syndrome (RLS) / periodic limb movement disorder (PLMD).

• Stimulants: Caffeine, nicotine, and illicit stimulants.

• Medications: SSRIs, corticosteroids, decongestants, beta-blockers, and the withdrawal or tolerance effects of alcohol, sedatives, or hypnotics.

• Environmental Disruptors: Shift work, chronic circadian misalignment, excessive noise, or poor sleep hygiene.

Diagnostics
 

• Clinical History & Detailed Sleep History: Sleep hygiene habits, sleep-wake schedule (bedtimes, rise times, daytime napping), bedpartner reports of snoring or apneas, and a complete medication and substance review.

• Validated Sleep Questionnaires: Utilizing tools such as the Insomnia Severity Index (ISI) to quantify symptom severity and track treatment response.

• Two-Week Sleep Diary: Tracking exact bedtimes, sleep-onset latency, nighttime awakenings, total sleep time, subjective sleep quality, and daytime functioning.

• Laboratory & Objective Diagnostics:

  • Thyroid-stimulating hormone (TSH) and a comprehensive metabolic panel if a systemic or metabolic etiology is suspected.

  • Polysomnography (PSG): Not routinely required for uncomplicated chronic insomnia, but indicated if a comorbid sleep disorder like obstructive sleep apnea or periodic limb movement disorder is suspected.

  • Actigraphy: Wrist-worn device to objectively monitor rest-activity cycles over 1 to 2 weeks when sleep state misperception or circadian rhythm disorders are suspected.

Management 
 

​Non-Pharmacological Management (First-Line Treatment)
 

• Cognitive Behavioral Therapy: The first-line treatment

• Stimulus Control Therapy: Re-associating the bed and bedroom exclusively with sleep (e.g., getting out of bed if unable to sleep for 20 minutes).

• Sleep Restriction Therapy: Temporarily restricting time spent in bed to match actual sleep duration, building homeostatic sleep pressure and consolidating sleep.

• Sleep Hygiene Education: Optimizing the sleep environment (dark, quiet, cool) and eliminating disruptive behaviors (screen time, late caffeine, alcohol).
   

Pharmacological Management

*Some of these medications are only indicated for short-term use and for sleep onset and/or maintenance. 
 

• Z-Drugs: Non-benzodiazepine receptor agonists (e.g., zolpidem, eszopiclone) 

• Dual Orexin Receptor Antagonists: lemborexant, suvorexant, or daridorexant

• Melatonin Receptor Agonists: ramelteon, utilized primarily for sleep-onset insomnia

• Sedating Antidepressants (Off-Label): Low-dose trazodone, doxepin, or mirtazapine
   

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