The inability to get enough sleep is termed insomnia. Moderate opinions on the relationship between insomnia and other disorders have changed over time.
While mental health authorities classify all difficulty sleeping as insomnia, there are a few different ways in which this may manifest. So what are these insomnia types?
The Diagnostic and Statistical Manual of Mental Disorders (DSM) lists three different ways someone might have difficulty sleeping.
The first is having trouble initiating sleep if there is no obvious reason why sleep might be difficult. It is important to remember that it isn’t considered a sleep disorder if there is a clear reason you are having trouble sleeping. For example, it isn’t considered an insomnia disorder if there is loud overnight construction happening right outside your window that makes it hard to initiate sleep.
The second is having difficulty maintaining or returning to sleep if there is no reason why that might be so. Again, if you keep waking up in the middle of the night because of a car alarm, it doesn’t merit a diagnosis of insomnia.
The third possibility is waking earlier in the morning than desired and being unable to return to sleep for no discernible reason. If one of these three criteria are met, then it is possible that an insomnia diagnosis is appropriate.
There are also three types of insomnia that may show some or all of the above symptoms. Episodic insomnia is insomnia which lasts 1-3 months; persistent insomnia lasts at least three months; and recurrent insomnia is insomnia in which the insomniac has two (or more) episodes within the space of one year.
There are a number of qualifications that need to be met before a diagnosis of insomnia can be made.
One or more of the above-mentioned primary signs of insomnia needs to occur at least three nights a week for at least three months, and the sleep deprivation or difficulty sleeping must cause distress or impairment in some way.
The person having trouble sleeping doesn’t have another sleep disorder such as narcolepsy, show signs of sleep apnea, or other sleep conditions. For a diagnosis of insomnia, there cannot be a coexisting medical condition that adequately explains the disruption of sleep. For example, if someone has trouble sleeping during a depressive episode, but is able to sleep without difficulty after the depression has lifted, then it would not be classified as insomnia.
Finally, if the trouble sleeping is due to drug or medication usage, it is not technically insomnia. Even drugs like alcohol which depress the nervous system can lead to sleep disruption as the body works to counteract the depressant effects.1
It is important to remember that this represents the most current understanding of insomnia. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or DSM-V, was published in 20132 and included changes from the DSM-IV regarding insomnia.3 If you received an insomnia diagnosis prior to this publication or if the doctor that made the diagnosis was practicing with the older criteria, you may have been diagnosed according to a different set of criteria. Insomnia treatments prescribed before the updates to the DSM-V may differ than current practice.
Everyone requires a different healthy amount of sleep, and the amount of sleep needed changes with age.4 This is why insomnia isn’t defined according to a set deficit in hours of sleep. A person may be an insomniac if they have trouble sleeping at least three nights a week and this results in some level of impairment. If the sleep disturbance cannot be explained by other sleep disorders, mental illness, or substance usage, then it is considered insomnia.5
Previous editions of the Diagnostic and Statistical Manual of Mental Disorders classified insomnia into primary insomnia and secondary, or comorbid, insomnia. Difficulty sleeping without any other mental illness was classified as primary insomnia. If the insomnia occurred alongside other mental illnesses that often include sleeplessness, then it was considered to be secondary, or comorbid, insomnia.6 The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders no longer recognizes this distinction.
In many cases, insomnia can be treated. Doctors may prescribe medications or advise cognitive behavioral therapy specifically for insomnia. There are also home remedies and lifestyle changes, such as good sleep hygiene and increased exercise, that can help treat insomnia.7
© 2021 American Sleep Association.