Updated June-02-2010
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)
Insomnia Disorder
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.
References:
National Institutes of Health (2005). "National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005." Sleep 28(9): 1049-57.
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." Sleep 17(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): 123-130.
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
1. Insomnia Severity Index
2. PROMIS Sleep-Wake Disurbance Self-Report (preliminary in development now)
3. Women's Health Initiative Insomnia Rating Scale
Primary Insomnia
A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 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 courseof 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.