Insomnia disorder

Insomnia Disorder - The Wide-Awake Club

• Difficulty initiating or maintaining sleep, or nonrestorative sleep, leading to daytime impairment.
• Diagnostic criteria: Symptoms ≥3 nights/week for ≥3 months, despite adequate opportunity for sleep.
• Management focuses on identifying and treating underlying causes.

⭐ Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment and is more effective long-term than medication.

Pathophysiology - The 3P Hyperarousal Model

• Core Concept: Insomnia results from a state of hyperarousal, where predisposing traits are triggered by a precipitating event, and the resulting sleep disturbance is maintained by perpetuating factors.

• The 3 Ps:

  • Predisposing: Baseline vulnerability (e.g., genetics, anxiety traits).
  • Precipitating: Acute triggers (e.g., life stressor, illness).
  • Perpetuating: Factors that maintain insomnia (e.g., poor sleep hygiene, catastrophic thoughts about sleep).

⭐ First-line treatment, Cognitive Behavioral Therapy for Insomnia (CBT-I), directly targets the perpetuating factors (maladaptive behaviors and cognitive distortions) that maintain chronic insomnia.

Diagnosis & Workup - The Sleep Detective

• Clinical Interview is Primary: Detailed history of sleep patterns (bedtime, latency, awakenings), daytime dysfunction, and psychiatric/medical history.
• Sleep Diary/Log: Patient tracks sleep for 1-2 weeks to identify patterns. The cornerstone of behavioral assessment.
• Actigraphy: Wrist-worn device provides objective data on sleep-wake cycles; useful when subjective reports are unclear.
• Polysomnography (PSG): Not routinely indicated. Reserved for suspected comorbid sleep disorders (e.g., sleep apnea, periodic limb movement disorder).

⭐ Exam Favorite: Insomnia is a major risk factor for and is frequently comorbid with Major Depressive Disorder (MDD). Always screen for mood symptoms.

📌 Mnemonic "3-3-3": Difficulty initiating/maintaining sleep for ≥3 nights/week for ≥3 months, causing significant distress/impairment.

Management - CBT-I Before Pills

• First-Line Therapy: CBT-I is the preferred initial treatment for chronic insomnia, recommended over pharmacotherapy due to its durable effects and lack of medication-related side effects.

• Core Components:

  • Stimulus Control: Re-associate the bedroom with sleep. If not asleep in 20 min, leave the room. Use bed only for sleep/intimacy.
  • Sleep Restriction: Limit time in bed to the actual time spent sleeping to improve sleep efficiency.
  • Cognitive Therapy: Challenge dysfunctional beliefs about sleep (e.g., "I need 8 hours to function").
  • Relaxation Training: Diaphragmatic breathing, progressive muscle relaxation.
  • Sleep Hygiene: Foundational but insufficient alone.

⭐ Exam Favorite: The therapeutic effects of CBT-I are more sustained over time compared to sedative-hypnotic medications, which often have waning efficacy and risk of dependence.

High‑Yield Points - ⚡ Biggest Takeaways

• Insomnia disorder is defined by difficulty initiating or maintaining sleep, occurring at least 3 nights per week for ≥3 months, causing significant functional impairment.
• Cognitive Behavioral Therapy for Insomnia (CBT-I) is the undisputed first-line treatment and is more effective long-term than pharmacotherapy.
• If medication is needed, use short-term; non-benzodiazepines (e.g., zolpidem, eszopiclone) are preferred over benzodiazepines.
• Always rule out comorbid medical or psychiatric conditions, substance use, and poor sleep hygiene.
• Associated with increased risk of depression, anxiety, and accidents.