135 Primary Insomnia (307.42)

Diagnostic Criteria

A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least one month.

B. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-Related Sleep Disorder, Circadian Rhythm Sleep Disorder, or a Parasomnia.

D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, a delirium).

E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Associated features

• Many individuals with Primary Insomnia have a history of light sleep prior to the development of this disorder. Anxious over concern with general health and increased sensitivity to the daytime effects of mild sleep loss have been noticed within Primary Insomnia. Also, interpersonal, social, and occupational problems may develop as a result of over concern with sleep, increased daytime irritability, and poor concentration.
• Individuals with severe Primary Insomnia may have concentration problems and greater functional impairment, lower productivity, and increased health care utilization.
• Individuals with this disorder may have a history of mental disorder, particularly Mood and Anxiety Disorders.

Child vs. adult presentation

Complaints of Insomnia are more prevalent with increasing age. Young adults more often complain of difficulty falling asleep, whereas midlife and elderly adults are more likely to have difficulty with maintaining sleep and early morning awakening.

Gender and cultural differences

Primary Insomnia is more prevalent in females than in males.

Epidemiology

• One-year prevalence rates are as high as 30%-45% in adults. The prevalence rates for the general adult population is approximately 1%-10% and up to 25% in the elderly.
• Primary Insomnia typically begins in young adulthood or middle age and is very rare in children or adolescents.

Etiology

Most cases of Primary Insomnia develop after a sudden onset of psychological, social, or medical stress, and typically persist long after the original causal factors resolve, due to the development of heightened arousal and negative conditioning.

Treatment

Orexin-A and -B (also known as hypocretin-1 and -2) are neuropeptides produced in the lateral hypothalamus that promote many aspects of arousal through the OX1 and OX2 receptors. In fact, they are necessary for normal wakefulness, as loss of the orexin-producing neurons causes narcolepsy in humans and rodents. This has generated considerable interest in developing small-molecule orexin receptor antagonists as a novel therapy for the treatment of insomnia. Orexin antagonists, especially those that block OX2 or both OX1 and OX2 receptors, clearly promote sleep in animals, and clinical results are encouraging: Several compounds are in Phase III trials. As the orexin system mainly promotes arousal, these new compounds will likely improve insomnia without incurring many of the side effects encountered with current medications (Scammel & Winrow, 2010). Acupuncture and cupping have shown significant effects in treating insomnia in college students (Zhang, Ren, & Zhang, 2010).

PROPOSED CHANGES IN DSM-5 (DSM5.org)

Insomnia Disorder

A. The predominant complaint is dissatisfaction with sleep quantity or quality made by the patient (or by a caregiver or family in the case of children or elderly).

B. Report of one or more of the following symptoms:

• Difficulty initiating sleep; in children this may be manifested as difficulty initiating sleep without caregiver intervention
• Difficulty maintaining sleep characterized by frequent awakenings or problems returning to sleep after awakenings (in children this may be manifested as difficulty returning to sleep without caregiver intervention)
• Early morning awakening with inability to return to sleep
• Non restorative sleep
• Prolonged resistance to going to bed and/or bedtime struggles (children)

C. The sleep complaint is accompanied by significant distress or impairment in daytime functioning as indicated by the report of at least one of the following:

• Fatigue or low energy
• Daytime sleepiness
• Cognitive impairments (e.g., attention, concentration, memory)
• Mood disturbance (e.g., irritability, dysphoria)
• Behavioral problems (e.g., hyperactivity, impulsivity, aggression)
• Impaired occupational or academic function
• Impaired interpersonal/social function
• Negative impact on caregiver or family functioning (e.g., fatigue, sleepiness

D. The sleep difficulty occurs at least three nights per week.

E. The sleep difficulty is present for at least three months.

F. The sleep difficulty occurs despite adequate age-appropriate circumstances and opportunity for sleep.

Duration:

1. Acute insomnia (<1 month)
2. Sub acute insomnia (1-3 months)
3. Persistent insomnia (> 3 months)

Clinically Comorbid Conditions:

• Psychiatric disorder (specify)
• Medical disorder (specify)
• Another disorder (specify)

Rationale For Changes

This new terminology reflects a change in paradigm, recommended by NIH (2005), and widely adopted in the sleep community. Making a reliable differential diagnosis between “Primary Insomnia” and “Insomnia related to another disorder” implies that a clinician can identify the cause and the consequence of the main condition, a determination that is often difficult, if not impossible to make. We recommend using “Insomnia Disorder” whenever diagnostic criteria are met, whether or not there is a co-existing psychiatric, medical, or another sleep disorders. The presence of any of these disorders can still be coded separately. Adopting this new paradigm/terminology would preclude using criteria C, D, E from DSM-IV.

CRITERION A

The addition of dissatisfaction to the insomnia definition may improve detection of clinically significant insomnia relative to a single focus on insomnia symptoms. Also, dissatisfaction is more strongly related to daytime impairments compare to insomnia symptoms alone.

References:

• Ohayon, M. M. (2002). “Epidemiology of insomnia: What we know and what we still need to learn.” Sleep Medicine Reviews 6(2): 97-111.
• Ohayon, 2009. Secondary analyses.
• Early morning awakening can be the only presenting insomnia symptom and this does not necessarily have the same presentation or significance as nocturnal awakenings with difficulty returning to sleep. This addition may enhance specificity of symptoms/diagnosis and, potentially, treatment.
• References:
• Hohagen, F., C. Kappler, et al. (1994). “Sleep onset insomnia, sleep maintaining insomnia and insomnia with early morning awakening–temporal stability of subtypes in a longitudinal study on general practice attenders.” Sleep17(6): 551-554.
• Morin, C. M., M. LeBlanc, et al. (2006). “Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors.” Sleep Medicine 7(2):
• CRITERION B
• The examples of impairments may facilitate assessment of the impact of insomnia on daytime functioning.
• References:
• Buysse, D. J., W. Thompson, et al. (2007). “Daytime symptoms in primary insomnia: a prospective analysis using ecological momentary assessment.” Sleep Medicine 8(3): 198-208.
• Edinger, J. D., M. H. Bonnet, et al. (2004). “Derivation of research diagnostic criteria for insomnia: report of an American Academy of Sleep Medicine Work Group.” Sleep 27(8): 1567-96.

CRITERION C

The frequency of occurrence of insomnia symptoms is an important determinant of morbidity/impairment. Although arbitrary, the proposed cut-point is consistent with ICD-10 and with those typically used in clinical research. This change would contribute to harmonizing criteria across diagnostic nosologies.

References:

• Ohayon (2009). Secondary analysis

CRITERION D

The 1-month threshold is a very short period of time to define insomnia as chronic and persistent. Insomnia lasting only 1 month might be better conceptualized as an episode of insomnia rather than an insomnia disorder. Morbidity may also increase with insomnia duration longer than one month.

References:

• Ohayon (2009). Secondary analyses.
• Morin, C. M., Belanger, L. et al. (2009). “The natural history of insomnia: a population-based 3-year longitudinal study.”Arch Intern Med 169(5): 447-53.

CRITERION E

Consistent with the Research Diagnostic Criteria, this specification can be helpful to distinguish clinical insomnia from volitional sleep deprivation.

References

• Edinger, J. D., M. H. Bonnet, et al. (2004). “Derivation of research diagnostic criteria for insomnia: report of an American Academy of Sleep Medicine Work Group.” Sleep 27(8): 1567-96.

COMORBID CONDITIONS

Although we wish to move away from the previous conceptualization of insomnia as primary or secondary, it would be helpful to still code the presence of any comorbid psychiatric, medical, or other sleep disorders.

Relationship to International Classification of Diseases 10

Nonorganic Insomnia F 51.0, Disorders of initiating and maintaining sleep (insomnias) G 47.0

Relationship to International Classification of Sleep Disorders 2nd Edition

Psychophysiological, paradoxical and idiopathic insomnia 307.42

Severity

1. Insomnia Severity Index

2. PROMIS Sleep-Wake Disurbance Self-Report (preliminary in development now)

3. Women’s Health Initiative Insomnia Rating Scale