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12 Diagnosis ofInsomnia Disorder
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efciency for the practicality of an outpatient ofce visit. The following section on
useful tools for insomnia disorder diagnosis will provide strategies for both building
rapport with the patient without compromising efciency.
265
Tools forAssessment ofInsomnia Disorder
Utilizing a variety of tools and questionnaires may drastically expedite obtaining
information necessary to make an insomnia disorder diagnosis. The Insomnia
Severity Index (ISI) is useful in questioning the patient about their insomnia- specic
symptoms such as their sleep onset latency and nighttime awakenings [66]. It is
common for patients to have a sleep onset latency of ≤35minutes; however, sleep
onset latencies of >30–35 minutes should be broached by the clinician [57].
Similarly, several brief nighttime awakenings are benign, but the clinician should
address nighttime awakenings that lead to prolonged wakefulness during the night
known as wake after sleep onset (WASO). A duration of wakefulness >40minutes
is outside the normal range and indicates potential insomnia if occurring on a frequent basis [67]. In addition to measures such as sleep onset latency and WASO, the
Pittsburgh Sleep Quality Index (PSQI) asks questions such as “During the past
month, how often have you taken medicine (prescribed or ‘over the counter’) to help
you sleep?” in order to ascertain aspects of the patient’s sleep problem that may
otherwise not be addressed by the patient interview [68]. Both of these instruments
allow for the evaluation of the patient’s insomnia complaints in the context of normative data so that a clear picture of the severity of the sleep disturbance can be
obtained. Normative cutoffs for the ISI vary, but a frequently used cutoff in the community setting is ≥ 10 while the cutoff for the PSQI is >5 [68, 69].
Sleep Diary
A valuable tool for the practitioner is a 2-week “sleep diary” that the patient completes each morning immediately after awakening. The sleep diary includes the
patient’s self-reported bedtime, “lights out time,” sleep onset latency, number and
duration of nighttime awakenings, amount of wake after sleep onset, time in bed,
total sleep time, sleep efciency (total sleep time divided by time in bed), selfreported sleep quality, number and duration of naps, and any caffeine, alcohol, or
sleep aid use (prescription or over the counter). The sleep diary allows the practitioner to gain an accurate picture of the patient’s sleep habits and sense any trends in the
patient’s sleep schedule, such as a phase advance/delay or excessive use of caffeine
or alcohol. The advantage to using the sleep diary as opposed to asking the patient to
recall this information during the ofce visit is that the patient may struggle to recollect information about their sleep or may misperceive their long-term sleep habits.
Having a patient ll out a sleep diary each morning for 2weeks provides the most
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accurate picture of their sleep and should be utilized prior to full clinical evaluation
whenever possible. If the practitioner is aware in advance that a patient is scheduling
a visit for insomnia symptoms, they may request ofce staff to send a sleep diary
worksheet or recommend app-based sleep diaries to the patient to ll out for 2weeks
prior to the visit. Alternatively, it may be benecial to schedule a 2-week follow-up
visit with the patient and request that they ll out the sleep diary during this 2-week
interval to better ascertain their sleep habits and develop a successful treatment plan.
When used properly, sleep diaries are a valuable part of the treatment process as they
allow both the patient and the practitioner to track the progress of the treatment and
adjust the treatment as needed. The National Sleep Foundation is an excellent source
for obtaining a free to use standardized sleep diary [70].
Despite the rise in popularity of “wearable” devices such as Fitbits, Apple
watches, etc., their questionable validity makes them less than ideal methods for
tracking the sleep of insomnia patients. When compared to PSG sleep measures,
wearable technology demonstrated a high sensitivity of over 90% for detecting
sleep; however, its specicity for detecting wake was substantially diminished,
leading to an articially inated total sleep time and diminished WASO [71]. Sleep
onset also tended to be delayed when measured with wearable technology, with a
typical delay of about 20 minutes when compared to PSG [71]. While results
remained consistent across various categories of body mass indices and sexes,
results tended to vary across age groups [71]. Additionally, wearable technology is
generally programmed to detect a certain amount of sleep, typically at least an hour,
leading to extreme inaccuracies in detecting napping [71]. Therefore, it is important
for practitioners evaluating patients for insomnia disorder to not rely only on data
from wearable devices but rather on information presented from sleep diaries lled
out by patients themselves. In most cases, patient reports of symptoms should be
taken at face value given the frequent discrepancy between subjective and objective
sleep assessments (including actigraphy) in insomnia disorder. However, wearable
devices are particularly useful for tracking sleep in patients who may be unable to
provide accurate self-assessments (e.g., young children, cognitively impaired) or
for those with widely varying sleep schedules such as night shift workers.
Taken together, the information provided through validated questionnaires such
as the ESS, ISI, and PSQI in combination with sleep diary worksheets that track the
patient’s sleep habits will provide the practitioner with the most accurate depiction
of the patient’s insomnia symptoms.
R. Atkinson and C. Drake
Differential Diagnosis
In the differential diagnosis for insomnia disorder, a variety of other sleep and nonsleep- related disorders should be considered. Primarily, depression often presents
with symptoms of insomnia, so it is imperative that the practitioner utilizes
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267
screening questionnaires such as the PHQ-9 and ISI to establish whether the patient
is experiencing symptoms of depression, insomnia, or both. In many cases, due to
the high comorbidity between insomnia and mental illness, the patient may be experiencing both depression and insomnia, and the patient ought to have both conditions treated at the time of the ofce visit. Although certain atypical antidepressants
such as trazodone and mirtazapine have been used to treat insomnia, they are offlabel and guidance on efcacy and appropriate doses for treatment of insomnia
disorder are limited [72].
The symptoms of OSA may also present similarly to insomnia disorder, with
patients reporting fatigue during the daytime and frequent awakenings at night. To
differentiate between insomnia disorder and OSA, the practitioner should use tools
that assess risks and symptoms of sleep-disordered breathing and OSA, such as the
ESS and the four-item STOP/STOP-BANG [73, 74]. If a patient screens positive on
either or both of these questionnaires, the practitioner should schedule a diagnostic
study (home sleep apnea test or PSG) or make an appropriate referral to further
investigate a potential diagnosis of OSA.
Movement disorders such as RLS may also present similarly to insomnia disorder, as the unpleasant sensations and urge to move at nighttime may prevent the
patient from falling asleep. Questioning the patient about the symptoms of RLS and
following up with a PSG study if positive symptoms are endorsed will help the
practitioner to differentiate RLS from insomnia disorder. There are several unique
characteristics of RLS that facilitate this process including a circadian rhythm of
symptoms, unpleasant sensations in the legs, and the patient reports some relief with
movement.
As previously mentioned, circadian rhythm disorders may also present as
insomnia disorder, as a patient with phase delay may be unable to fall asleep
until far past the patient’s usual bedtime. Patients with a circadian rhythm disorder can show either a phase delay (i.e., delayed sleep onset and waketime) or a
phase advance (i.e., earlier sleep onset than desired and early morning awakenings). Therefore, closely examining a patient’s sleep diary and paying particular
attention to weekday and weekend, holiday, or vacation data will inform the
practitioner of a possible circadian rhythm disorder. When a patient presents
with a consistently extreme early or consistently extreme late bedtime additional
assessment is warranted by a sleep specialist to rule out a circadian rhythm disorder. If there is substantive discord between the objective and subjective data
and all other disorders have been ruled out, paradoxical insomnia could be considered [75].
In summary, insomnia disorder has a host of comorbid conditions that can contribute to insomnia symptoms or that may present similarly to insomnia disorder. If
the practitioner is uncertain that an insomnia disorder diagnosis is the most appropriate for a given patient, a variety of screening questionnaires and the use of a PSG
study in conjunction to sleep specialist referral are important aspects for obtaining
an accurate diagnosis.
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R. Atkinson and C. Drake
Treatment Options andGoals
Evaluation of insomnia should conclude with a discussion of treatment options and
the patient’s treatment goals. The primary goals in treating patients with insomnia
disorder are typically to improve their sleep quality, thereby improving the patient’s
subjective experience of their sleep [50] and improving their daytime functioning.
For patients wishing to discontinue the use of sleep medications, tapering and eventual discontinuation of pharmacological treatment may occur in concert with CBT-I
once the patient’s insomnia symptoms are below the threshold for severe insomnia
for several weeks (ISI<22) [50, 66]. Secondary goals of insomnia disorder treatment should be to reduce any psychological distress or correct any maladaptive
belief systems that the patient has regarding sleep by referring the patient to a CBT-I
provider [42, 50]. Importantly, when discussing treatment goals with the patient, the
practitioner ought to ask the patient for their desired outcome and any treatment
preferences they may have. Engaging in shared decision-making and goal formulation in this way will not only help to guide treatment options but also help the
patient to be actively engaged in their treatment and build rapport [42].
Assessment of insomnia remission after initiation of treatment should include
the same measures and questionnaires used for the initial evaluation of the diagnosis
rather than exclusively asking the patient if their symptoms have improved. Of note,
many patients will learn to tolerate their symptoms or believe that poor sleep is
acceptable yet will still be displaying insomnia symptoms and experiencing daytime impairment [40]. Repeating the initial measures and questionnaires will provide a more accurate picture of the progression of the patient’s sleep pattern before
and after treatment. Importantly, emphasis should be placed on if the patient’s daytime functioning has improved, as this is one foundation of the insomnia disorder
diagnosis. If the patient is still exhibiting impaired daytime functioning or displaying other symptoms of insomnia, the practitioner should question the patient about
treatment adherence (both behavioral and pharmacological), or consider if a different diagnosis is more appropriate. In some cases where remission does not occur, it
can be effective to have the patient to use an alternative or additional treatment
approach. Furthermore, as over a quarter of individuals in remission will relapse
within 3years, it is essential that the practitioner follow-up with the patient at all
future appointments [5]. Thorough documentation in the medical record of the
insomnia disorder diagnosis and treatment efforts will help in future visits with the
patient and will aid other providers if insomnia recurrence occurs.
Summary
Insomnia disorder is a highly pervasive and persistent sleep disorder that negatively
impacts both the patient and society as a whole. The clinical management of insomnia disorder in a primary care setting can be challenging, but given the proper tools,
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269
any practitioner can be prepared to efciently and effectively treat insomnia disorder. Keeping in mind the potential etiology of the disorder, the practitioner will be
able to understand the myriad underlying reasons for the patient’s symptom presentation and use this knowledge to inform the patient of their appropriate treatment
options. Being familiar with the signs, symptoms, and treatments of insomnia disorder will allow general practitioners including those in primary care to be optimal
rst-line interventionists for these patients and deliver high-quality, compassionate
care to those suffering from this debilitating disorder.
Key Summary Points
1. Insomnia disorder is a common clinical condition impacting at least 10%
of adults.
2. Insomnia disorder is diagnosed based on a thorough clinical history; diagnosis does not require the patient to undergo polysomnography.
3. First-line treatment for insomnia disorder is cognitive behavioral therapy
for insomnia (CBT-I).
4. If left untreated, insomnia disorder can contribute to the development of
depression and increase a patient’s risk of suicidality.
5. Insomnia disorder can often present similarly to other sleep disorders such
as obstructive sleep apnea (OSA), restless legs syndrome (RLS), and circadian rhythm disorders; therefore, the practitioner must consider these
alternate diagnoses in patients presenting with sleep difculties.
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Diagnosis ofInsomnia Disorder
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Chapter 13
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Management ofInsomnia Disorder
GwendolynC.Carlson, MichelleR.Zeidler, andJenniferL.Martin
Keywords
Insomnia · Sleep medicine · Clinical practice guidelines · CBT-I
Management ofInsomnia Disorder
Insomnia disorder is characterized by difculty initiating and maintaining sleep. It
is estimated that 10–30% of the population experiences insomnia [1–3]. There are
two primary diagnostic systems for the identication of clinically signicant insomnia symptoms: (1) the American Psychiatric Association’s (APA) Diagnostic and
Statistical Manual of Mental Disorder-fth Edition (DSM-5) [4] and (2) the
International Classication of Sleep Disorders-Third Edition (ICSD-3) of the
American Academy of Sleep Medicine (AASM) [5]. A diagnosis of insomnia
G. C. Carlson
Department of Mental Health, VA Greater Los Angeles Healthcare System, VA Health
Services Research and Development Service (HSR&D) Center for the Study of Healthcare
Innovation, Implementation and Policy, Los Angeles, CA, USA
Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine,
University of California, Los Angeles, Los Angeles, CA, USA
M. R. Zeidler
Sleep Disorders Center, VA Greater Los Angeles VA Healthcare System, Department of
Medicine, David Geffen School of Medicine, University of California, Los Angeles,
Los Angeles, CA, USA
J. L. Martin (
Geriatric Research, Education and Clinical Center, Veteran Affairs Greater Los Angeles
Healthcare System, Department of Medicine, David Geffen School of Medicine, University
of California, Los Angeles, Los Angeles, CA, USA
e-mail: Jennifer.martin@va.gov
*)
M. S. Badr, J. L. Martin (eds.), Essentials of Sleep Medicine,
Respiratory Medicine, https://doi.org/10.1007/978-3-030-93739-3_13
275© Springer Nature Switzerland AG 2022
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