Insomnia Disorder DSM-5
Introduction
Insomnia is a lack of sleep due to insufficient sleep quality or quantity. The insomniac’s major complaint is awakening during sleep, followed by difficulty falling asleep. An insomniac may sleep but experience poor sleep quality, also known as nonrestorative sleep. As a result of a lack of quality sleep, impairments are experienced in social and occupational functioning. The three types of insomnia are sleep insomnia involving difficulty falling asleep, sleep maintenance involving awakening during sleep, and late insomnia involving early morning awakenings. Insomnia can be episodic lasting for a period of one month within 3 months, or persistent lasting longer than 3 months. Recurrent insomnia is two or more episodes within a year. Insomnia disorder is one of the major three groupings of sleep disorders under DSM-5, together with hypersomnia and arousal disorders.
Symptoms
Insomnia is a precursor to, and comorbid with, a number of mental and medical disorders. To ensure proper treatment, DSM-5 recognizes that one or more disorders may be present at the same time. A medical condition such as chronic pain or mental disorder such as breathing-related sleep disorder may be the cause of the insomnia. However, DSM-5 does stipulate that the insomnia should be clinically significant on its own to warrant a diagnosis.
The DSM-5’s major criteria for a diagnosis of insomnia, in brief, are (APA, 2013):
- Dissatisfaction with sleep quantity or quality, with one or more of the following symptoms: difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening
- The sleep disturbance causes significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning
- The sleep difficulty occurs at least 3 nights per week, is present for at least 3 months, and despite adequate opportunity for sleep
- The insomnia does not co-occur with another sleep disorder
- The insomnia is not explained by coexisting mental disorders or medical conditions
Insomnia Disorder in Daily Life
Insomnia is often triggered by an illness, disorders, or events that cause physical or psychological distress. Patients under primary care are two times more likely to have insomnia than the general population (Mitchell, Gehrman, Perlis, & Umscheid, 2012). The onset of insomnia can be at any age but most often occurs in early adulthood. In children, it often involves irregular sleep schedules. A new baby brother or sister may awaken a child or changes to the afternoon napping schedule may upset sleep patterns. A change in sleep patterns causing insomnia may be related to other disorders. Even when these comorbid disorders are tested and resolved, the insomnia may persist.
Insomnia is a risk factor for a number of disorders, including depression and anxiety. The comorbidity of insomnia with mental disorders is 40% to 50%, according to the DSM-5 (APA, 2013). Insomniacs have a higher rate of suicide. About 45% to 75% of cases are chronic, reports the DSM-5, implying long-term disturbances to one’s daily functioning. An insomniac is more likely to worry too much and be emotional – risk factors in other mental disorders – contributing to the sleep-related stress.
In daily life, insomnia is linked to a decline in cognitive function. A person who lacks sleep is more likely to make errors and have occupational and road accidents due to the impairment of concentration and memory. Absenteeism is likely to be higher and productivity lower at work.
The body is under physical stress when it is tired and more susceptible to illness. A tired body is less able to ward off infection and disease and more likely to inflame arthritis and chronic pain. When the body is tired, the heart is under more strain. A mentally and physically stressed body is more susceptible to stress and hypertension.
Therapy for Insomnia
Medication is the most commonly used treatment for insomnia. A class of sedatives called hypnotics is typically prescribed. Benzodiazepine has a high risk of side effects and long-term dependence, and therefore is recommended for short-term use. Nonbenzodiazepines are more commonly prescribed today but still have a risk of side effects and are habit forming. Doctors will first try non-drug approaches to treat insomnia. These may include mind relaxation exercises and avoiding stimulants before bedtime such as caffeine. Despite the complications, insomnia worsens when patients go off medication for insomnia.
Cognitive behavioral therapy for insomnia (CBT-I) is the most popular nonmedication approach to treating insomnia. CBT-I is more effective than medication in treating insomnia over the long term while medication may provide stronger short-term results. CBT-I has also shown to be more effective than mindfulness-based stress reduction (MBSR) in terms of the length of the treatment and maintenance of the results (Garland et al., 2014). Approaches used by CBT-I include stimulus control to teach the association between the bed and sleeping, sleep restriction to restore sleep regulation, and cognitive restructuring to address anxiety-related thoughts that lead to a lack of sleep (Mitchell, 2012).
A major benefit of behavioral therapy is that it treats the underlying causes of a disorder. MBSR has also successfully treated psychological symptoms. While it may take several weeks for cognitive behavioral therapy and mindfulness to show results, treatment can be administered over the span of a few weeks or months. Long-term administration is not required to maintain results.
A number of CBT approaches seek to treat insomnia and comorbid medical or mental disorders, such as depression and chronic pain. A goal of DSM-5 is to support treatment planning and management of comorbid disorders alongside insomnia. Insomnia is a precursor to other mental disorders. Co-treatment can reduce the symptoms of insomnia and the co-morbid disorder plus provide early intervention for any developing disorders. One hybrid approach produced and maintained a reduction in fatigue and depression, as well as pain interference, but not chronic pain (Tang, Goodchild, & Salkovskis, 2012). Another study was effective in treating both insomnia and pain in older persons with osteoarthritis (Vitiello, 2013). CBT-I applied with image rehearsal therapy in a group setting was effective in treating depression, nightmare frequency, and insomnia, which commonly accompany posttraumatic stress disorder in war veterans (Lauren, 2013).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Garland, S. N., Carlson, L. E., Stephens, A. J., Antle, M. C., Samuels, C., & Campbell, T. S. (2014). Mindfulness-Based Stress Reduction Compared With Cognitive Behavioral Therapy for the Treatment of Insomnia Comorbid With Cancer: A Randomized, Partially Blinded, Noninferiority Trial. Journal of Clinical Oncology, JCO-2012.
Mack, L. J. (2013). Evaluating the Effects of a Group Cognitive Behavioral Therapy for Veterans with Posttraumatic Stress Disorder and Insomnia: A Pilot Study (Doctoral dissertation, Virginia Commonwealth University Richmond, Virginia).
Mitchell, M. D., Gehrman, P., Perlis, M., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC family practice, 13(1), 40.
Tang, N. K., Goodchild, C. E., & Salkovskis, P. M. (2012). Hybrid cognitive-behaviour therapy for individuals with insomnia and chronic pain: A pilot randomised controlled trial. Behaviour research and therapy, 50(12), 814-821.
Vitiello, M. V., McCurry, S. M., Shortreed, S. M., Balderson, B. H., Baker, L. D., Keefe, F. J., ... & Korff, M. (2013). Cognitive‐Behavioral Treatment for Comorbid Insomnia and Osteoarthritis Pain in Primary Care: The Lifestyles Randomized Controlled Trial. Journal of the American Geriatrics Society, 61(6), 947-956.
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