General Insomnia: Definition, Diagnosis, and Management
General insomnia is a sleep disorder characterized by difficulty initiating or maintaining sleep, early morning awakening, or poor sleep quality despite adequate opportunity for sleep, resulting in daytime dysfunction including fatigue, cognitive impairment, mood disturbance, and reduced quality of life. 1
Definition and Diagnostic Criteria
Insomnia can present as either a symptom or a specific disorder. When defined as a disorder, it includes:
- Difficulty with sleep initiation, sleep maintenance, or early morning awakening with inability to return to sleep 1
- Sleep difficulty occurs despite adequate opportunity and circumstances for sleep 1
- Daytime impairment related to sleep difficulties, including at least one of the following: 1
- Fatigue or malaise
- Attention, concentration, or memory impairment
- Social or vocational dysfunction
- Mood disturbance or irritability
- Daytime sleepiness
- Reduced motivation, energy, or initiative
- Proneness to errors/accidents
- Tension, headaches, or gastrointestinal symptoms
- Concerns or worries about sleep
Classification and Prevalence
- Insomnia disorder requires symptoms occurring at least 3 nights per week for at least 3 months 1
- Prevalence varies by definition stringency: 1
- Insomnia symptoms: 33-50% of adult population
- Insomnia with distress/impairment: 10-15%
- Specific insomnia disorders: 5-10%
- Risk factors include: 1
- Increasing age
- Female gender
- Comorbid medical, psychiatric, or sleep disorders
- Shift work
- Possibly unemployment and lower socioeconomic status
Clinical Impact
Insomnia has significant impacts on health and functioning:
- Associated with decline in overall and sleep-related health 1
- Impairs cognitive performance, particularly attention, concentration, and memory 1, 2
- Increases risk for errors and accidents 1
- Contributes to mood disturbances and irritability 1
- May be associated with increased risk for dementia, fractures, and major injury (based on observational studies) 1
Assessment Approach
- Sleep history to identify contributing factors and maladaptive behaviors 3
- Sleep diary or sleep log provides more accurate information than patient recall 3
- Polysomnography is not routinely indicated for diagnosis of insomnia disorder 1, 3
- Assessment tools include the Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI) 1
Treatment Options
Non-Pharmacological Approaches
- Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia 1, 4, 3
- CBT-I components include: 1
- Cognitive therapy to change dysfunctional beliefs about sleep
- Behavioral therapies (sleep restriction, stimulus control)
- Relaxation training
- Sleep hygiene education
- Multicomponent behavioral therapy has shown effectiveness, particularly in older adults 1
- Stimulus control as a single intervention may improve some sleep outcomes 1
Pharmacological Options
- FDA-approved medications for insomnia are typically indicated for short-term use 1
- Evidence supports the following medications for short-term use: 1
- Eszopiclone
- Zolpidem
- Suvorexant
- Other medication classes with varying levels of evidence include: 3, 5, 6
- Benzodiazepines
- Melatonin receptor agonists
- Selective histamine H1 antagonists
- Antidepressants (particularly sedating ones)
- Medication selection should consider: 5
- Patient age (dose reduction advised in older adults)
- Primary sleep complaint (initiation vs. maintenance)
- Proposed treatment duration
- History of substance use
- Potential for adverse effects
Important Considerations and Cautions
- Pharmacotherapies may cause cognitive and behavioral changes, including driving impairment 1
- FDA advises dose reduction in women and older adults 1
- Long-term efficacy and comparative effectiveness of medications are not well established 1
- Insomnia may be secondary to or comorbid with other conditions, including neurological disorders 4
- Untreated insomnia can exacerbate comorbid conditions and reduce quality of life 1, 2