Insomnia Disorder DSM-5 780.52 (G47.00)

Default

DSM-5 Category: Sleep-Wake Disorders

Insomnia disorder is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to individuals who experience recurrent poor sleep quality or quantity that causes distress or impairment in important areas of functioning.

Introduction

Categorized as a sleep-wake disorder, insomnia disorder is characterized by difficulty in initiating sleep, staying asleep and/or by waking early in the morning and being unable to get back to sleep.

People with insomnia disorder often experience tiredness or sleepiness in the daytime as a result, along with related inattention, irritability and trouble concentrating on tasks, sometimes to such an extreme that their work or social life suffers.

According to statistics, about one-third of adults report having experienced symptoms of insomnia, with ten to 15 per cent recording daytime impairments. Between six and ten per cent of individuals meet the criteria for insomnia disorder, which is the most common known sleep disorder.

Symptoms of insomnia disorder

Symptoms of insomnia disorder include the following:

  • Trouble falling asleep at night
  • Lying awake for long periods of time
  • Waking several times during the night
  • Waking up early unable to get back to sleep
  • Not feeling refreshed after sleeping
  • Feeling fatigued or sleepy during the day
  • Having difficultly focusing on a task
  • Feeling irritable2

Diagnostic criteria for insomnia disorder

There is no single way to test for insomnia disorder, so medical professionals will reach a conclusion based on symptoms and by ruling out other factors.

To reach a diagnosis of insomnia disorder, the following criteria need to be met:

  • Unhappiness with the quality or quantity of sleep, which can include trouble falling asleep, staying asleep or waking up early and being unable to get back to sleep
  • The sleep disturbance causes significant distress or impairment in functioning, such as within the individual’s working or personal life, behaviorally or emotionally
  • Difficulty sleeping occurs at least three times a week and is present for at least three months
  • The problem occurs despite ample opportunity to sleep
  • The difficulty cannot be better explained by other physical, mental or sleep-wake disorders
  • The problem cannot be attributed to substance use or medication

Physicians will often use a variety of techniques to support a diagnosis of insomnia disorder, such as a sleep diary and the Epworth Sleepiness Scale.

A sleep diary helps identify any potential causal elements and habits, as well as variability in sleeping patterns. The Epworth Sleepiness Scale determines how drowsy a person feels in situations like waiting at traffic signals, watching television or reading.

A physical examination is usually undertaken and bloods may be tested to check for thyroid function and other disorders.

Causes of insomnia disorder

There is no single cause of insomnia disorder but many factors may contribute to the condition’s onset, including:

Stress and anxiety
Stress or anxiety can make sleeping difficult by causing tension or feelings of worry and overstimulation. Over time, the negative associations with sleeping may make it more difficult to fall asleep and stay asleep.

Other sleep disorders
Some sleep disorders may cause insomnia, or coexist with the condition. Restless leg syndrome, for example, can hamper attempts to sleep, while sleep apnea causes the sufferer to wake briefly but repeatedly through the night.

Mental disorders
Depression and other mental conditions may contribute to the onset of insomnia disorder. Mood and hormonal changes can contribute to insomnia, while the reverse is also true.

Medical conditions
A number of medical conditions are known to cause insomnia, such as chronic pain, nasal allergies and arthritis. Reflux, asthma and thyroid disorders may also cause discomfort and make it difficult to get to sleep or stay asleep.

Medication or substance abuse
Some medicines, such as treatments for the common cold, allergies, thyroid disease and high blood pressure, are thought to cause insomnia as a side effect.

Lifestyle factors
Consuming caffeine or alcohol can disrupt sleep patterns, while working from home or late at night can make winding down difficult. Daytime napping may also result in insomnia for some people.

Comorbidity

Insomnia disorder may occur in isolation or comorbid with other conditions. Commonly, the disorder occurs with the following physical disorders:

  • Diabetes
  • Coronary heart disease
  • Arthritis
  • Fibromyalgia
  • Chronic obstructive pulmonary disease

Additionally, insomnia disorder is often found to be comorbid with various mental disorders, including:

  • Bipolar disorder
  • Anxiety disorder
  • Depressive disorder

Differential diagnosis

Insomnia disorder shares similar signs and symptoms with various other conditions; as a result, the disorder is sometimes difficult to diagnose. The most frequent differential diagnoses with insomnia disorder include:

Normal sleep variations - Insomnia symptoms may be experienced by people from time to time as variations in normal sleep. Other symptoms and factors, however, will not be present, such as daytime sleepiness or adequate opportunity to sleep.

Breathing-related sleep disorders - Up to 50 per cent of individuals suffering from breathing-related sleep disorders like sleep apnea may also report symptoms of insomnia.

Narcolepsy - Insomnia disorder and narcolepsy share some characteristics but the latter often includes other features like sleep paralysis and sleep-related hallucinations.

Parasomnias - Sufferers of narcolepsy may awaken and struggle to fall asleep again but these incidences are behavior related.

Living with insomnia disorder

Insomnia disorder usually develops in young adulthood and often occurs comorbid with another condition, either medical or mental. Sleep is essential to health and wellbeing - both the symptoms and effects of insomnia disorder can be challenging for sufferers in a variety of ways.

Daytime functioning can suffer, which may make it difficult for an individual with insomnia disorder to carry out their usual daily tasks, or to perform well at work. Complex tasks and cognitive performance may require more effort.

The irritability associated with sleep deprivation can cause problems in a person’s social and home life, making relationship maintenance difficult and affecting those close to the sufferer.

Long-term insomnia disorder is also associated with an increased risk of other conditions, such as hypertension, major depressive disorder and myocardial infarction, as well as lower quality of life. However, there are various forms of treatment for insomnia disorder that can help in managing symptoms and working on the root cause of the disorder.

Treatment

Insomnia disorder may be treated through medication or with therapy. Often, a comprehensive approach is taken that incorporates two or more of the following:

Medication

Sleeping pills that treat insomnia are known as hypnotics. Eszopiclone (Lunesta), ramelteon (Rozerem), zaleplon (Sonata) and zolpidem (Ambien, Ambien CR) are prescription medications that may be used to treat insomnia disorder with varying efficacy.

Sleep hygiene education

Sleep hygiene is the habits and practices that contribute to getting a good night’s sleep and include factors like diet and exercise, as well an environmental elements like light and sound levels at bedtime.

Cognitive behavioral therapy (CBT)

A person’s attitudes and beliefs about sleep may be contributing to the insomnia - CBT challenges sufferers to rethink their beliefs and behaviors in order to bring about positive change.

Someone suffering from chronic insomnia may be advised to try a specific type of cognitive behavioral therapy called CBT-I. This type of treatment may include the following:

Relaxation therapy - Sufferers of insomnia disorder are often highly aroused - relaxation therapy may help deactivate the arousal system through techniques like imagery training and progressive muscle relaxation.

Stimulus control therapy - This type of treatment encourages the patient to associate their bedroom with sleeping and establish a sleep/wake pattern.

Biofeedback - Designed to help the sufferer recognize when they are not relaxed, biofeedback sensors are attached to the body and connected to a machine, measuring functions like heart rate and muscle tension.

Sleep restriction therapy – Limiting the time spent in bed to bring about a state of mild sleep deprivation, which should, theoretically, promote more rapid and efficient sleep.

Paradoxical intention - Challenging the sufferer to try to stay awake. This is used for patients who have trouble falling asleep but not for sufferers who struggle to maintain being asleep.

With the right treatment, individuals suffering from insomnia disorder may find their condition improves and symptoms can be managed or brought under full control.


Dr. Kevin Fleming obtained his PhD from Notre Dame and is the Founder of Grey Matters International (www.greymattersintl.com) a neuroscience-based behavior change consulting firm.

References

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

NHS (2015) Insomnia: Introduction http://www.nhs.uk/Conditions/Insomnia/Pages/Introduction.aspx Date Accessed: 21/03/2017

Saddichha, S (2010) Diagnosis and Treatment of Chronic Insomnia Ann Indian Acad Neurol. Apr-Jun; 13(2): 94–102 doi: 10.4103/0972-2327.64628 Cited at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924526/ Date Accessed: 21/03/2017

National Sleep Foundation (2017) What causes insomnia? https://sleepfoundation.org/insomnia/content/what-causes-insomnia Date Accessed: 21/03/2017.

Fortier-Brochu E, Beaulieu-Bonneau S, Ivers H, Morin CM Insomnia and daytime cognitive performance: a meta-analysis (2012) Sleep Med Rev. Feb;16(1):83-94. doi: 10.1016/j.smrv.2011.03.008. Epub 2011 Jun 1. Cited at https://www.ncbi.nlm.nih.gov/pubmed/21636297 Date Accessed: 21/03/2017

Dean, L (2010) Comparing Newer Drugs for Insomnia PubMed Clinical Q&A [Internet] Cited at: https://www.ncbi.nlm.nih.gov/books/NBK45586/ Date Accessed: 21/03/2017

NHS (2-15) Insomnia: Treatment http://www.nhs.uk/Conditions/Insomnia/Pages/Treatment.aspx Date Accessed: 21/03/2017.


Help Us Improve This Article

Did you find an inaccuracy? We work hard to provide accurate and scientifically reliable information. If you have found an error of any kind, please let us know by sending an email to contact@theravive.com, please reference the article title and the issue you found.


Share Therapedia With Others