RespiratoryTier 1Disease (DEADMAN)

Sleep disorders - insomnia

Description

Persistent difficulty initiating, maintaining sleep, or early waking, with daytime impairment, despite adequate opportunity for sleep
Chronic insomnia disorder - symptoms >=3 nights/week for >=3 months; short-term/acute insomnia - less than 3 months, usually a clear precipitant (stress, illness, jet lag)
Primary vs secondary/comorbid - insomnia is now framed as comorbid with, rather than simply secondary to, conditions like depression/anxiety/pain, given it often persists independently and needs its own treatment

Insomnia symptoms reported by ~30-40% of adults; chronic insomnia disorder in ~10%
F>M, increases with age; higher prevalence with shift work, chronic pain, psychiatric comorbidity

3P model: Predisposing (trait anxiety, female sex, family history, hyperarousal tendency) + Precipitating (acute stressor, illness, shift change) + Perpetuating (maladaptive behaviours - excessive time in bed, daytime napping, watching the clock, caffeine/alcohol use) - the perpetuating factors are what chronic insomnia treatment (CBT-I) directly targets
Cognitive/physiological hyperarousal - the core mechanism in chronic insomnia, not simply "not enough sleep drive"
Secondary/comorbid contributors: depression, anxiety, chronic pain, menopause, medications (stimulants, some antidepressants, corticosteroids), other sleep disorders (OSA, restless legs) masquerading as or coexisting with insomnia

Clinical - a history-based diagnosis

Sleep diary/actigraphy over 1-2 weeks - characterises the pattern (onset, maintenance, early waking) and daytime impact objectively
Screen for and exclude/identify comorbid conditions - depression/anxiety screening, OSA screening (snoring, witnessed apnoeas, STOP-BANG), restless legs symptoms, medication/substance review (caffeine, alcohol, stimulants)
Polysomnography is not routinely needed for insomnia alone - reserved for suspected coexisting sleep-disordered breathing or parasomnia

Distinguish from

Circadian rhythm disorders (delayed/advanced sleep phase) - timing problem, not difficulty sleeping per se once the preferred window arrives
Insufficient sleep syndrome - behavioural sleep restriction, not a disorder of sleep initiation/maintenance itself

A. First-line for chronic insomnia - CBT-I, not medication

Cognitive behavioural therapy for insomnia (CBT-I) is first-line for chronic insomnia disorder, including in patients with comorbid conditions - endorsed over pharmacotherapy given durable benefit without the risks of long-term hypnotic use
Components: stimulus control (bed only for sleep/sex), sleep restriction therapy (initially reduces time in bed to consolidate sleep), cognitive restructuring (unhelpful beliefs about sleep), sleep hygiene education (least effective alone, but included)
Digital/app-delivered CBT-I - reasonable option where face-to-face access is limited, evidence supports efficacy

B. Pharmacotherapy - adjunct, not routine first-line

2026 AASM guideline: combining medication with CBT-I is generally NOT recommended over CBT-I alone - CBT-I alone often achieves durable benefit without added pharmacological risk
Reserve pharmacotherapy for short-term use, severe/acute distress, or where CBT-I is inaccessible/ineffective - shared decision-making incorporating patient preference
If used: short courses of a non-benzodiazepine hypnotic (e.g. zolpidem) or a melatonin receptor agonist; dual orexin receptor antagonists (e.g. suvorexant, lemborexant) - newer option, targets sleep-maintenance insomnia specifically
Avoid long-term benzodiazepine/Z-drug use - tolerance, dependence, falls/cognitive risk in older adults, rebound insomnia on cessation

C. Comorbid insomnia

Treat insomnia as its own target alongside, not only after, managing the comorbid condition (depression, chronic pain, menopause) - resolving the comorbidity alone often does not resolve the insomnia
Screen for and treat OSA/restless legs if identified - a different pathway to insomnia management

Depression, anxiety disorders - bidirectional relationship, insomnia is both a symptom and an independent risk factor for future episodes
Chronic pain, menopause, shift work
Restless legs syndrome, OSA - can coexist or masquerade as insomnia
Substance use - caffeine, alcohol (disrupts sleep architecture despite sedating initially), stimulant medications

Untreated chronic insomnia - associated with increased risk of depression, reduced quality of life, cognitive impairment, and workplace/road safety incidents
CBT-I produces durable improvement that typically persists after treatment completion, unlike medication effects which often do not persist after cessation
Chronic hypnotic use - risk of tolerance, dependence, and rebound insomnia on withdrawal; falls and fracture risk particularly in older adults
With effective CBT-I, the majority achieve clinically meaningful improvement, though a minority have a more treatment-resistant course requiring ongoing multidisciplinary management

6 more sections, plus exam facts

Premium unlocks every note across every specialty, and the full exam fact library behind it.