Insomnia disorder

Insomnia shows up alone and inside nearly every other diagnosis; the exam tests whether the counselor rules out other causes, measures it, and starts CBT-I rather than sleep hygiene alone.

Criteria at exam depth (paraphrased):

• Dissatisfaction with sleep quantity or quality with one or more of: difficulty initiating sleep, difficulty maintaining sleep (frequent awakenings or trouble returning to sleep), or early-morning awakening without being able to return to sleep. In children, difficulty may appear as trouble sleeping without caregiver help.
• Causes significant distress or impairment in daytime functioning.
• Occurs at least 3 nights per week for at least 3 months, despite adequate opportunity for sleep.
• Not better explained by another sleep-wake disorder (such as sleep apnea or a circadian rhythm disorder) or the effects of a substance; coexisting mental disorders and medical conditions do not adequately explain the insomnia.
• Specifiers: with mental disorder comorbidity, with medical comorbidity, with another sleep disorder. Course: episodic (at least 1 month but less than 3), persistent (3 months or longer), recurrent (two or more episodes within a year).

Hinge differentials:

• Obstructive sleep apnea — loud snoring, witnessed pauses, and daytime sleepiness despite adequate time in bed; refer for a sleep study.
• Circadian rhythm disorder — normal sleep when allowed to follow the preferred schedule.
• Major depression or GAD — insomnia is one symptom inside sustained low mood, anhedonia, or pervasive worry; insomnia disorder can still be diagnosed when it warrants independent attention.
• PTSD — nightmares and hyperarousal tied to trauma content.
• Substance or medication effects — caffeine, alcohol, stimulants, or withdrawal.
• Short sleepers / inadequate opportunity — no distress, or no real chance to sleep.

On the NCMHCE: Take a sleep history (schedule, naps, caffeine, alcohol, screens, shift work) and consider a sleep diary and the Insomnia Severity Index to quantify severity. Screen for depression and suicide risk, because insomnia raises risk. Refer for medical evaluation when symptoms suggest apnea, pain, or another medical cause, and for medication review. First-line treatment is CBT for insomnia (CBT-I): stimulus control (use the bed only for sleep and sex, leave the bed when unable to sleep, to re-associate bed with sleep), sleep restriction, cognitive work on sleep worries, and relaxation. Sleep hygiene education supports CBT-I but is not sufficient alone. Normalizing psychoeducation about how insomnia is maintained reduces sleep effort and anxiety. Consider shift work, caregiving, and cultural sleep practices.

Clinical Pearl: At least 3 nights a week for 3 months despite adequate opportunity. Rule out apnea and substances; CBT-I with stimulus control is first-line.