What is the diagnosis and next step for a patient with chronic insomnia, characterized by difficulties maintaining sleep and early morning awakenings, with symptoms of fatigue and poor concentration, and a negative depression screening?

Chronic Insomnia Disorder with Sleep Maintenance Difficulties

This patient has chronic insomnia disorder characterized by sleep maintenance difficulties and early morning awakening, and the next step is to initiate Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment. 1

Diagnosis

This clinical presentation meets diagnostic criteria for chronic insomnia disorder based on the following features 2, 3:

• Sleep maintenance difficulties: Restless sleep with tossing and turning, and inability to maintain continuous sleep 1
• Early morning awakening: Consistently waking at 3:30 AM with difficulty returning to sleep 2, 3
• Duration: The term "chronic" indicates symptoms present ≥3 nights per week for ≥3 months 2, 4
• Daytime consequences: Fatigue and poor concentration are classic daytime impairments of insomnia 1
• Adequate sleep opportunity: Goes to bed at 11 PM with appropriate time allocated for sleep 1

The negative depression screening helps rule out a primary mood disorder, though insomnia and psychiatric conditions have bidirectional relationships 1.

Critical Differential Diagnoses to Exclude

Before finalizing the diagnosis, you must systematically rule out 2:

• Obstructive sleep apnea (OSA): The restless sleep with tossing and turning could suggest OSA. However, the patient reports fatigue rather than true sleepiness (tendency to fall asleep involuntarily), which is more consistent with insomnia 1, 5. If significant sleepiness were present, polysomnography would be indicated 1.

• Advanced Sleep-Wake Phase Disorder: This would present with falling asleep very easily in early evening and extreme difficulty staying awake during evening hours, which is not described here 2.

• Restless Legs Syndrome or Periodic Limb Movement Disorder: The "tossing and turning" warrants specific questioning about uncomfortable leg sensations or witnessed leg movements 1.

Essential Workup Components

Do not order polysomnography for uncomplicated insomnia—it is not indicated and wastes resources 2. Instead, perform the following 1, 2:

Detailed Sleep History

• Pre-sleep behaviors: Assess for sleep-incompatible activities in bed (TV watching, reading in bed when unable to sleep, phone use, "clock watching") 1
• Bedroom environment: Temperature, noise, light, bed partner presence 1
• Mental state at bedtime: Anxious versus relaxed, anticipatory anxiety about poor sleep 1

Medication and Substance Review

Screen specifically for 1:

• Stimulants: Caffeine intake (timing and amount), any prescribed stimulants
• Cardiovascular medications: Beta-blockers, alpha-receptor agents, diuretics (though ACE inhibitors and calcium channel blockers are generally not culprits) 5
• Antidepressants: SSRIs can contribute to insomnia 1
• Alcohol use: Evening alcohol consumption 1

Sleep Diary

• Obtain 7-14 days of sleep diary data documenting: bedtime, sleep latency, number and duration of awakenings, wake after sleep onset (WASO), time in bed, total sleep time, sleep efficiency, and any napping 1, 2
• This provides objective baseline data and engages the patient in treatment 1

Comorbidity Screening

• Medical conditions: Chronic pain, cardiovascular disease, pulmonary disease, thyroid dysfunction 1
• Psychiatric conditions: While depression screening is negative, assess for anxiety disorders which commonly co-occur with insomnia 1

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I must be initiated as first-line treatment before any pharmacotherapy 1, 6. This is the strongest recommendation across all major guidelines, with superior long-term efficacy compared to medications 1.

CBT-I Components to Implement 1:

Stimulus Control Therapy (addresses conditioned arousal in bed):

• Go to bed only when sleepy, not at a fixed time like 11 PM 1
• Get out of bed if unable to fall asleep within 15-20 minutes (this patient is already doing this correctly by getting up to read or watch TV) 1
• Critical modification needed: Reading and TV watching should occur in a different room, not in the bedroom or bed 1
• Use bed only for sleep and sex—no other activities 1
• Maintain consistent wake time (7:00 AM on workdays) regardless of sleep quality 1

Sleep Restriction Therapy (consolidates sleep):

• Calculate current sleep efficiency from sleep diary (total sleep time/time in bed × 100%) 1
• If sleep efficiency <85%, restrict time in bed to match actual sleep time plus 30 minutes 1
• For this patient spending 8-10 hours in bed but sleeping poorly, initial time in bed might be restricted to 6-6.5 hours 1
• Gradually increase time in bed by 15-30 minutes weekly as sleep efficiency improves to ≥85% 1
• Caution: Use carefully if patient has seizure disorder or bipolar disorder due to sleep deprivation effects 6

Cognitive Restructuring:

• Address dysfunctional beliefs about sleep (e.g., "I must get 8 hours or I can't function") 1
• Challenge catastrophic thinking about consequences of poor sleep 1

Sleep Hygiene Education (necessary but insufficient alone) 1, 6:

• Avoid caffeine after early afternoon 6
• Avoid evening alcohol 6
• Avoid late exercise (within 3-4 hours of bedtime) 6
• Optimize bedroom environment (cool, dark, quiet) 6

CBT-I Delivery Options 1, 6:

• Individual therapy with trained CBT-I specialist (gold standard)
• Group therapy sessions
• Telephone-based delivery
• Web-based/digital CBT-I programs
• Self-help books with structured programs

All delivery methods show effectiveness, making CBT-I accessible even in resource-limited settings 1, 6.

When to Consider Pharmacotherapy

Pharmacotherapy should only supplement, never replace, CBT-I 6. Consider adding medication if 6:

• CBT-I is insufficient after 4-6 weeks
• Severe symptoms require immediate relief while implementing CBT-I
• Patient cannot engage with CBT-I due to severity

First-Line Pharmacotherapy Options (if needed) 6:

For combined sleep onset and maintenance insomnia (this patient's pattern):

• Eszopiclone 2-3 mg: Addresses both sleep initiation and maintenance 6, 7
• Zolpidem 10 mg (5 mg if elderly): Effective for both components 6
• Temazepam 15 mg: Intermediate-acting benzodiazepine receptor agonist 6

For sleep maintenance specifically:

• Low-dose doxepin 3-6 mg: Specifically targets sleep maintenance 6
• Suvorexant: Orexin receptor antagonist for sleep maintenance 6

Critical Prescribing Principles 6, 7:

• Use lowest effective dose for shortest duration possible
• Prescribe only if patient can remain in bed 7-8 hours after taking medication 7
• Take immediately before bed, not with or after meals 7
• Educate about risks: complex sleep behaviors (sleep-driving, sleep-walking), morning sedation, cognitive impairment, falls 7
• Reassess after 7-10 days—if insomnia persists, evaluate for underlying sleep disorders 7

Medications to Avoid 6:

• Over-the-counter antihistamines (diphenhydramine): Lack efficacy data, cause daytime sedation and delirium risk in elderly 6
• Trazodone: Not recommended by American Academy of Sleep Medicine 6
• Long-acting benzodiazepines: Increased risks without clear benefit 6

Common Pitfalls to Avoid

• Failing to implement CBT-I alongside or before medication: Medications provide only short-term relief; CBT-I provides durable long-term benefits 1, 6

• Assuming all sleep complaints are "just insomnia": Must screen for OSA (especially with restless sleep), restless legs syndrome, and circadian rhythm disorders 2

• Ordering polysomnography for uncomplicated insomnia: Not indicated and wastes resources 2

• Allowing sleep-incompatible behaviors in bed: Reading and TV watching when unable to sleep should occur outside the bedroom 1

• Not obtaining sleep diary data: Essential for accurate assessment and monitoring treatment response 1, 2

• Prescribing medication without behavioral intervention: Violates evidence-based treatment guidelines and deprives patient of most effective long-term treatment 1

Expected Timeline and Monitoring

• CBT-I improvements are gradual but benefits are durable beyond treatment end 6
• Initial side effects (mild sleepiness, fatigue from sleep restriction) typically resolve quickly 6
• Reassess after 4-6 weeks of CBT-I implementation 6
• If adding medication, reassess after 1-2 weeks for efficacy and adverse effects 6