Psych · Specialty psychiatry — sleep medicine interface
Insomnia disorder
Also known as Chronic insomnia · Primary insomnia · Psychophysiological insomnia · CBT-I · Cognitive behavioural therapy for insomnia · Sleep-onset insomnia · Sleep-maintenance insomnia · Hypnotics · Z-drugs
Exam-exhaustive fellowship atlas on insomnia disorder — DSM-5-TR/ICSD-3 nosology, Spielman 3P and hyperarousal models, epidemiology and depression/suicide bidirectionality, differential from OSA/DSPD/mania, assessment and ISI/diary, CBT-I first-line with digital options, short-term hypnotics and deprescribing, elderly harm, and ACP/AASM/ESRS/BAP guideline deltas. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Severe insomnia with active suicidal ideation, plan, or near-lethal self-harm — treat sleep and suicide risk together as a psychiatric emergency
- Reduced need for sleep with elevated/irritable mood, increased energy, or grandiosity — treat as mania/hypomania pathway, not primary insomnia
- Daytime sleepiness with near-miss driving or machinery incidents — urgent fitness-to-drive and OSA/hypersomnia work-up
- Witnessed apnoeas, cyanosis, or high pretest OSA probability with treatment-resistant 'depression' — sleep medicine pathway
- Hypnotic-related falls, delirium, or intentional overdose — stop agent, medical stabilisation, deprescribe long-term benzodiazepines/Z-drugs
- Sleep restriction started without bipolar, seizure, or safety-critical work planning
Meet the patient
A 52-year-old nurse has not slept through the night for eighteen months. She lies in bed from 10 pm "trying hard," watches the clock, and is exhausted by 3 am. Her GP started zopiclone nine months ago. She is now taking two, drinks two glasses of wine to "top it up," and tells you, quietly, that she has begun to think the house would be calmer without her.[14][19]
The whole topic is hidden in that sentence. The exam questions she answers: "Is this primary insomnia, and what did you miss?" (alcohol, depression, a hypnotic with no exit plan, and suicide risk); and "What is the first-line treatment?" (CBT-I, not a third sedative).[2][10][11]
References20ShowHide
- [1]Trauer JM, Qian MY, Doyle JS, et al. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis Ann Intern Med, 2015.PMID 26054060
- [2]Qaseem A, Kansagara D, Forciea MA, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians Ann Intern Med, 2016.PMID 27136449
- [3]Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline J Clin Sleep Med, 2017.PMID 27998379
- [4]Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline J Clin Sleep Med, 2021.PMID 33164742
- [5]Riemann D, Baglioni C, Bassetti C, et al. European guideline for the diagnosis and treatment of insomnia J Sleep Res, 2017.PMID 28875581
- [6]Riemann D, Espie CA, Altena E, et al. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023 J Sleep Res, 2023.PMID 38016484
- [7]Morin CM, Vallières A, Guay B, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial JAMA, 2009.PMID 19454639
- [8]Baglioni C, Battagliese G, Feige B, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies J Affect Disord, 2011.PMID 21300408
- [9]Hertenstein E, Feige B, Gmeiner T, et al. Insomnia as a predictor of mental disorders: A systematic review and meta-analysis Sleep Med Rev, 2019.PMID 30537570
- [10]Pigeon WR, Pinquart M, Conner K Meta-analysis of sleep disturbance and suicidal thoughts and behaviors J Clin Psychiatry, 2012.PMID 23059158
- [11]Bernert RA, Kim JS, Iwata NG, et al. Sleep disturbances as an evidence-based suicide risk factor Curr Psychiatry Rep, 2015.PMID 25698339
- [12]Buysse DJ Insomnia JAMA, 2013.PMID 23423416
- [13]Sateia MJ International classification of sleep disorders-third edition: highlights and modifications Chest, 2014.PMID 25367475
- [14]Glass J, Lanctôt KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits BMJ, 2005.PMID 16284208
- [15]Espie CA, Emsley R, Kyle SD, et al. Effect of Digital Cognitive Behavioral Therapy for Insomnia on Health, Psychological Well-being, and Sleep-Related Quality of Life: A Randomized Clinical Trial JAMA Psychiatry, 2019.PMID 30264137
- [16]Morin CM, Jarrin DC Epidemiology of Insomnia: Prevalence, Course, Risk Factors, and Public Health Burden Sleep Med Clin, 2022.PMID 35659072
- [17]Freeman D, Sheaves B, Goodwin GM, et al. The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis Lancet Psychiatry, 2017.PMID 28888927
- [18]Wilson SJ, Nutt DJ, Alford C, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders J Psychopharmacol, 2010.PMID 20813762
- [19]Wilson S, Anderson K, Baldwin D, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update J Psychopharmacol, 2019.PMID 31271339
- [20]Wichniak A, Wierzbicka A, Walęcka M, et al. Effects of Antidepressants on Sleep Curr Psychiatry Rep, 2017.PMID 28791566