F U N D A M E N T A L S 37
Evaluation of Insomnia
Insomnia is defined as sleep difficulty (difficulty
initiating or maintaining sleep, early morning
awakening, or both) that is associated daytime con-
sequences because of night time sleep difficulty,
with the proviso that the nighttime or daytime
problems are not explained by an inadequate
opportunity to sleep. The International Classifica-
tion of Sleep Disorders, Second Edition (ICSD-2)
defined eight insomnia disorders (Tables F37-1
and F37-2).1 Other classifications such as that
by Diagnostic and Statistical Manual of Mental Dis-
orders, Fourth Edition (DSM-IV) classified
insomnia as primary insomnia and secondary
insomnia (insomnia associated with a mental dis-
order, medical disorder, or a drug or substance).2
The term comorbid insomnia has often been used
to refer to “secondary” insomnias, as it is often
difficult to define the relationship between
insomnia and the associated disorder (which dis-
order is primary and which is secondary?). For
example, insomnia may precede depression,
worsen during depression, and persist after
remission from depression. The ICSD-3 defines
only three insomnia disorders (see Table F37-1;
Box F37-1),3 and the ICSD-2 insomnia disorders
have been consolidated into these three disorders.
The rationale is that previously used subtypes
could not reliably be diagnosed.4 The same
TABLE F37-1 Insomnia Disorders
International Classification of
Sleep Disorders, 3rd Edition
Chronic insomnia disorder (CID)
- Frequency: on at least 3 nights per week
- Duration
3 months
Short-term insomnia disorder (STID)
- Duration <3 months
Other insomnia disorder
- Difficulty initiating or maintaining sleep but does not meet criteria for
CID or STID
584
patient may be diagnosed with different subtypes
by different experienced clinicians. This is not
surprising, as many patients manifest overlapping
symptoms.
Chronic insomnia disorder (CID) is defined
in the ICSD-3 and encompasses elements of
psychophysiologic insomnia, idiopathic insom-
nia, paradoxical insomnia, insomnia associated
with mental disorder, inadequate sleep hygiene,
as well the behavioral insomnias of childhood
(limit setting or sleep association disorders)
(Box F37-2 and see Table F37-2). The ICSD-
3 states that CID is characterized by “frequent
and persistent difficulty initiating or maintain-
ing sleep that results in general sleep dissatisfac-
tion.” CID may occur in isolation or be a
comorbid condition with a mental disorder,
medical condition, or substance use. Duration
of at least 3 months is required for the diagnosis
of CID, and symptoms must occur on at least
3 nights per week. Note that in ICSD-2, only
a 1-month duration was required for many of
the insomnia disorders. More details on CID
are provided below. A number of other sleep
disorders are associated with insomnia com-
plaints (Table F3-3). These included sleep
apnea syndromes, circadian rhythm sleep-wake
disorders, and the restless legs syndrome.
International Classification of
Sleep Disorders, 2nd Edition
Psychophysiologic insomnia
Paradoxical insomnia
Idiopathic insomnia
Insomnia due to mental disorder
Inadequate sleep hygiene
Behavioral insomnia of childhood
Insomnia due to drug or substance
Insomnia due to medical condition
Adjustment insomnia (acute
insomnia)
 FUNDAMENTALS 37 EVALUATION OF INSOMNIA 585

TABLE F37-2 Major Characteristics of Insomnia Types in International Classification of

Sleep Disorders, 2nd Edition
Insomnia Types Essential Features Clinical Clues
Psychophysiologic Duration at least 1 month Better sleep in novel environment (away
Anxiety about sleep from home)
Heightened arousal when in bed Can fall asleep outside bedroom or when
Conditioned sleep-preventing associations not trying to sleep
(bedroom as a stimulus for wake not
sleep)
Paradoxical Duration at least 1 month Objective sleep duration (PSG,
Extreme and physiologically improbable actigraphy) is much greater than
complaints: “I never sleep.” reported
Despite report of little sleep, relatively No or rare naps
minor daytime impairment
Idiopathic Onset in infancy or childhood Lifelong insomnia without remissions
No identifiable precipitant Insidious onset
No period of sustained remission
Associated with a Insomnia present for at least 1 month Insomnia waxes and wanes with mental
mental disorder Mental disorder has been diagnosed disorder
Temporally associated with mental
disorder (may precede by a few days or
weeks)
Inadequate sleep Improper sleep scheduling Variable bedtime and wake times
hygiene Use of products that disturb sleep near Napping
bedtime
Stimulating activities near bedtime
Use of the bed for nonsleep activities
Behavioral Falling asleep is an extended process Nighttime awakenings require caregiver
insomnia of Sleep-onset associations demanded intervention for return to sleep
childhood In absence of associated factors, sleep
sleep association onset delayed
type
Behavioral Difficulty initiating or maintaining sleep Caregiver demonstrates insufficient limit
insomnia of Refusal to go to bed or return to bed after setting to establish appropriate
childhood awakening behavior
limit-setting type
Adjustment Temporally associated with identifiable Recent psychological, psychosocial,
Insomnia stressor environmental, or physical stressor
Duration <3 months
Expected to resolve

Adapted from Schutte-Rodin S, Broch L, Buysee D, et al: Clinical guideline for the evaluation and management of chronic
insomnia in adults, J Clin Sleep Med 4:487-504, 2008.

SHORT-TERM INSOMNIA DISORDER

This disorder encompasses what was previously
termed adjustment insomnia. The duration must
be less that 3 months.
OTHER INSOMNIA DISORDER
This diagnosis is reserved for individuals who
complain of difficulty initiating and maintaining
sleep yet do not meet the full criteria for
either CID or short-term insomnia disorder.
MAJOR COMPONENTS OF CHRONIC
INSOMNIA DISORDER
1. Sleep difficulty: In adults, the major com-
plaints are difficulty initiating sleep (sleep
onset insomnia), difficulty maintaining sleep
(frequent awakenings, sleep maintenance
insomnia), and early morning awakening.
In children, sleep difficulty is defined by
caregiver observation of resistance to going
to bed at an appropriate time and difficulty
maintaining sleep without parent or care-
giver intervention.
2. Daytime difficulty caused by sleep
difficulty: Multiple complaints may be
present, including fatigue, attention or con-
centration difficulty, impaired social or aca-
demic performance, irritability, daytime
sleepiness, and reduced motivation. In chil-
dren, behavioral problems such and hyper-
activity, aggression, or impulsivity may be
prominent. Often, patients express dissatis-
faction with sleep or concerns about the
effects of poor sleep on their health.
586 FUNDAMENTALS 37 EVALUATION OF INSOMNIA
BOX F37-1 Chronic Insomnia Disorder—Diagnostic Criteria ICSD-3
Criteria A-F must be met
A. The patient reports or the patient’s parent or
caregiver observes one or more of the following:
1. Difficulty initiating sleep
2. Difficulty maintaining sleep
3. Waking up earlier than desired
4. Resistance to going to bed on appropriate
schedule
5. Difficulty sleeping without parent or care-
giver intervention
B. The patient reports or the patient’s parent or
caregiver observes one or more of the following
related to the nighttime sleep difficulty:
1. Fatigue/malaise
2. Attention, concentration, or memory
impairment
3. Impaired social, family, occupational or aca-
demic performance
4. Mood disturbance/irritability
Adapted from American Academy of Sleep Medicine: International classification of sleep disorders, ed 3, Darien, IL, 2014, American
Academy of Sleep Medicine.
BOX F37-2 Short-Term Insomnia
Disorder
ICSD-3 DIAGNOSTIC CRITERIA
(Criteria A to E must be met)
A, B, C. As in Chronic Insomnia Disorder
D. The sleep disturbance and associated daytime
symptoms have been present for less than
3 months.
E. The sleep/wake difficulty is not better explained
by another primary sleep disorder.
3. Frequency, duration, adequate sleep
opportunity or environment: A frequency
of at least 3 nights per week, a duration of

3 months, and the requirement of an ade-
quate opportunity and environment for sleep
are requirements for the diagnosis of CID.
The ICSD-3 states that patients with chronic
insomnia characterized by recurrent epi-
sodes of sleep/wake difficulties lasting several
weeks at a time (<3 months) over several
years may also qualify for the CID diagnosis.
INSOMNIA EVALUATION
A detailed sleep history is the cornerstone of
evaluation of insomnia.5–9 First, the nature of
the primary sleep complaint (problems with sleep
onset, sleep maintenance, or quality) should be
5. Daytime sleepiness
6. Behavioral problems (e.g., hyperactivity,
impulsivity, aggression)
7. Reduced motivation/energy/initiative
8. Proneness for errors/accidents
9. Concerns about or dissatisfaction with sleep
C. The reported sleep/wake complaints cannot be
explained purely by inadequate opportunity (i.e.,
enough time is allotted for sleep) or inadequate
circumstances (i.e., the environment is safe, dark,
quiet, and comfortable) for sleep.
D. The sleep disturbance and associated daytime
symptoms occur at least three times per
week.
E. The sleep disturbance and associated daytime
symptoms have been present for at least
3 months.
F. The sleep/wake difficulty is not better explained
by another primary sleep disorder.
defined and the duration of the complaint deter-
mined. The history of the origin of the complaint,
including age of onset should be explored, and
particular life events or stressors at the start of
the problem should be identified. For example,
patients with the subtype idiopathic insomnia
report problems since childhood or adolescence
with an insidious onset. Patients with psycho-
physiologic subtype of insomnia may report that
chronic insomnia began after a severe illness.
Presleep conditions or activities that could affect
sleep, including the bedroom environment,
activities near bedtime, or mental state near bed-
time should be explored. The bedroom environ-
ment should be characterized for factors that
might disturb sleep (noise, clock easily seen from
the bed, extreme hot or cold temperature). Activ-
ities near bedtime, including working late on the
computer, drinking caffeinated beverages or
alcohol in the evening, or exercise near bedtime,
may impair the ability to sleep. The mental status
at bedtime should be explored. Often, patients
began worrying about their stresses and prob-
lems when retiring for the night. The presence
or absence of nocturnal symptoms, including snor-
ing, gasping during sleep, symptoms of restless
legs syndrome (RLS), and body movements
should be evaluated.
The sleep-wake schedule should be determined
by report including variability of bedtime and
rise time as well as the frequency and duration
of naps. Factors that worsen or improve sleep
should be detailed. For example, some patients
 FUNDAMENTALS 37
with insomnia report sleeping better in a novel
environment (reverse first-night effect).10
Patient recall may be supplemented by sleep
logs, actigraphy, or both, as discussed in a fol-
lowing section. Daytime function should be dis-
cussed with emphasis on possible consequences
of insomnia. Reports of daytime fatigue or
impaired cognition and mood are more
common than true daytime sleepiness. True day-
time sleepiness should trigger suspicion for additional
sleep problems such as sleep apnea, narcolepsy, or
depression. Daytime activities that may affect sleep
such as the amount of caffeine, alcohol, exercise,
sunlight exposure, and napping should be
detailed. A general medical and psychiatric history
is important to identify mental or medical condi-
tions that may affect sleep. A detailed medication
history including over-the-counter medications
and substances of abuse is extremely important.
A physical examination and appropriate labo-
ratory testing if not recently performed should
rule out obvious medical causes of insomnia.
Examination of the upper airway showing a high
Mallampati score (upper airway narrowing)11
might trigger suspicions of obstructive sleep
apnea (OSA).
DIFFERENTIAL DIAGNOSIS
Major characteristics of the insomnia types listed
in the ICSD-2 are listed in Table F37-2. Patients
with CID often have characteristics of more
than one type. A number of non CID sleep dis-
orders may be associated with insomnia com-
plaints (Box F37-3). Sleep apnea syndromes
may be associated with repetitive arousal and
sleep-maintenance problems. In patients with
BOX F37-3 Other Sleep Disorders
Associated with Insomnia
Complaints
1. Sleep apnea syndromes
2. Circadian rhythm sleep/wake disorders
a. Delayed sleep/wake disorder type—sleep-
onset insomnia
b. Advanced sleep/wake disorder—early AM
awakening
c. Irregular sleep phase type—at least three
sleep episodes per 24 hours
d. Non-24 hour sleep phase type—alternating
periods of insomnia and hypersomnia
3. Restless legs syndrome/periodic limb move-
ment disorders
From American Academy of Sleep Medicine: International
classification of sleep disorders: diagnostic and coding manual, ed
3, Darien, IL, 2013, American Academy of Sleep Medicine.
EVALUATION OF INSOMNIA 587
sleep apnea, insomnia symptoms are more likely
to be present in women than in men.1 The circa-
dian sleep-wake rhythm disorders (CSWRDs)
may also be associated with insomnia com-
plaints, including delayed sleep phase syndrome
(sleep-onset insomnia) and advanced sleep phase
syndrome (early morning awakening). In delayed
sleep phase syndrome, once the affected indi-
viduals are able to fall asleep, they have fairly
normal sleep. In advanced sleep phase syndrome,
individuals fall asleep early but then awaken in the
early morning hours. In non–24-hour CSWRD,
patients may report periods of insomnia alternating
with hypersomnia.1,3 RLS or periodic limb move-
ment disorder (PLMD) may be associated with
symptoms of insomnia or nonrestorative sleep.
A number of medications may also disturb sleep
quality (e.g., caffeine).
QUESTIONNAIRES, SLEEP LOGS,
AND ACTIGRAPHY
Supporting information from questionnaires
(mood, cognition about insomnia), sleep logs,
and actigraphy may be helpful in evaluating
patients with insomnia (Box F37-4 and Box
F37-5). These may supplement other information
obtained from the sleep history. Assessing the
patient’s attitudes about sleep and the sleep prob-
lem is as important as documenting the degree of
sleep disturbance. In addition, some patients are
hesitant to admit to feelings of depression. Sleep
logs and actigraphy provide a more accurate esti-
mate of the patient’s sleep quantity than is possi-
ble from patient recall.
The Epworth Sleepiness Scale (ESS; see
Fundamentals 17) is used to assess subjective
estimates of the propensity to fall asleep in
common situations.12 The Pittsburgh Sleep
Quality Index (PSQI) is a 24-item self-report
measure of general sleep quality that specifically
addresses the preceding 1-month period. The
PSQI evaluates seven domains, including the
duration of sleep, sleep disturbance, sleep-onset
latency, daytime dysfunction because of sleepi-
ness, sleep efficiency, need for medications to
sleep, and overall sleep quality. The PSQI
yields a global score and seven component
scores (poor sleep: global score > 5).13,14 The
questionnaire has been shown to distinguish
among healthy patients, patients with depres-
sion, and patients with sleep disorders. It was
not designed specifically for insomnia but
has been used in insomnia assessment and treat-
ment studies. Detailed instructions for use and
scoring of the PSQI are available at the
588 FUNDAMENTALS 37 EVALUATION OF INSOMNIA

BOX F37-4 Evaluation of Insomnia

1 SLEEP HISTORY
A. Define primary complaint:
• Delayed sleep onset
• Sleep maintenance problems
• Frequent awakenings/early morning awakening
• Nonrestorative sleep
B. Define time course of complaint:
• Age of onset
• Precipitating event or stressor
C. Evaluate presleep conditions:
• Pre-bedtime activities
• Bedroom environment
• Physical and mental status before sleep
D. Nocturnal symptoms (awakenings, physical or mental
symptoms, including snoring or body movements)
E. Sleep-wake schedule—by patient report includ-
ing variability, naps
F. Daytime function—consequences of insomnia:
• Sleepiness versus fatigue
• Impairment of mood, cognitive dysfunction,
quality of life
G. Daytime activities relevant for sleep:
• Sunlight exposure, exercise
• Napping
• Work schedule and disturbance
• Caffeine and alcohol intake
H. Medical and psychiatric conditions (e.g., chronic
pain, depression) or medications that may affect
sleep
2 PHYSICAL AND MENTAL STATUS
EXAMINATION
A. Narrow upper airway (high Mallampati score),
retrognathia
3 SUPPORTING INFORMATION
A. Sleep/mood questionnaires:
• Epworth Sleepiness Scale
• Dysfunctional Beliefs and Attitudes about
Sleep
• Pittsburgh Sleep Quality Index
B. Sleep log for 2 weeks—attention to sleep and
wake time variability, general patterns
C. Actigraphy
4 SLEEP STUDY—NOT ROUTINELY INDICATED
A. Indicated when another sleep disorder such as
sleep apnea is suspected.

University of Pittsburgh Sleep Medicine Institute

BOX F37-5 Questionnaires to Evaluate
Patients with Insomnia
Epworth Sleepiness Propensity to fall asleep in
Scale eight situations (0 never, 1
slight, 2 moderate, 3 high
chance) with a total score
0 to 24. Normal
10
Beck Depression BDI or BDI-II is a 21-item
Inventory self-report inventory used
to measure depression.
BDI-1 scores: Minimal or
no depression BDI < 10,
moderate to severe
depression BDI
19
BDI-II scores: Minimal or
no depression BDI < 14,
moderate to severe
depression BDI
20
Pittsburgh Sleep A 24-item self-report
Quality Index measure of sleep qualities
(poor sleep: global score
>5)
Dysfunctional Beliefs DBAS is a self-rating of 30
and Attitudes About statements that is used to
Sleep Questionnaire assess negative cognitions
about sleep. Shorter
version the DBAS-16 also
exists (see Appendix 1).
BDI, Beck Depression Inventory; DBAS, Dysfunctional
Beliefs and Attitudes about Sleep; PSQI, Pittsburgh Sleep
Quality Index.
web site http://www.sleep.pitt.edu/content.asp?
id¼1484&subid¼2316.
The Beck Depression Inventory (BDI-I
or BDI-II) is a 21-item self-report inventory
(Box F37-5) used to measure manifestations of
depression, each item being scored from 0 to
3.15,16 Higher total scores indicate more severe
depressive symptoms. The BDI-II is a revision of
the original BDI-I. Because primary insomnia
and major depression share some daytime symp-
toms, the usual cutoff scores for the BDI might
be less specific for depression in insomnia
patients.17 The Dysfunctional Beliefs and Atti-
tudes about Sleep (DBAS) Questionnaire is a
self-rating survey to assess negative cognitions
about sleep.18,19 Reversal of these cognitions is a
goal of the cognitive component of cognitive
behavioral therapy (CBT). The original DBAS
was a 30-item questionnaire, in which patients
responded using an analog scale (0, strongly dis-
agree; 1, 2, 3. . . , to 10, strongly agree). A shorter
version (DBAS-16)19 has recently been validated
and is less time-consuming for patients to complete
(Figure F37-1).
SLEEP LOGS
A sleep log (sleep diary) for at least 2 weeks is
recommended when evaluating patients with
 FUNDAMENTALS 37 EVALUATION OF INSOMNIA 589

Strongly Strongly
Disagree Agree
Name 1 2 3 4 5 6 7 8 9 10
1. I need 8 hours of sleep to feel refreshed and function well during the day.

2. When I don’t get a proper amount of sleep on a given night, I need to catch up on the
next day by napping or on the next night by sleeping longer.

3. I am concerned that chronic insomnia may have serious consequences

on my physical health.

4. I am worried that I may lose control over my abilities to sleep.

5. After a poor nights sleep I know that it will interfere with my

daily activities on the next day.

6. In order to be alert and function well during the day, I believe would be
better off taking a sleeping pill rather than having a poor nights sleep.

7. When I feel irritable, depressed, or anxoius during the day

it is mostly because I did not sleep well the night before.

8. When I sleep poorly on one night, I know it will distrub my sleep schedule
for the whole week.

9. Without an adequate night’s sleep I can hardly function the next day.
10. I can’t ever predict whether I’ll have a good or poor night’s sleep.

11. I have little ability to manage the negative consequences of distrubed sleep.

12. When I feel tired, have no energy, or just seem not to function well
during the day, its generally because I did not sleep well the night before.

13. I believe insomnia is essentially the result of a chemical imbalance.

14. I feel insomnia is ruining my ability to enjoy life and prevents me from doing what I want

15. Medication is probably the only solution to sleeplessness.

16. I avoid or cancel obligations (social, family) after a poor night’s sleep.

FIGURE F37-1 n Dysfunctional Beliefs and Attitudes About Sleep (DBAS)-16. (From Morin CM, Vallières A, Ivers H:
Dysfunctional beliefs and attitudes about sleep (DBAS): validation of a brief version (DBAS-16), Sleep 30:1547-1554, 2007.)

insomnia. Sleep logs are often more accurate and
more reliable than patient recall of their chronic
sleep patterns. Sleep logs usually follow a ques-
tion format or time plot graphic format.20 An
adaptation of a basic consensus sleep log20 is
shown in Figure F37-2. The reader should look
at Patient 111 for other examples. The essential
elements of a sleep log include the ability to
assess time in bed (TIB), sleep-onset latency
(SOL), total sleep time (TST), and the amount
of wakefulness after sleep onset (WASO). The
TIB is the period from when the patient gets
in bed until the final time the patient leaves the
bed in the morning. WASO includes all wake
from sleep onset until the patient leaves the
bed in the morning. The patient need report only
three of these four parameters because they are
related (TIB ¼ SOL + TST + WASO). Sleep effi-
ciency can be computed (¼ TST  100/TIB),
with normal values exceeding 85%. Sleep logs
also typically provide space to record caffeine
consumption, bedtime activities, or medications
taken for sleep as well as estimates of sleep qual-
ity. Sleep logs are very helpful in revealing general
patterns of the sleep-wake cycle such as irregular bed-
times and wake times and the amount and frequency
of napping. A few characteristic patterns noted in
sleep logs are listed in Box F37-6.
ACTIGRAPHY
Actigraphy involves use of a portable device
(often resembling a watch and typically worn
on the wrist) that collects movement information
(activity) over an extended period (Figure F37-3).
The absence of movement is assumed to be a sur-
rogate of sleep.21 The use of actigraphy is included
in the ICSD-3 diagnostic criteria for several circa-
dian sleep wake rhythm disorders.3 Practice
590 FUNDAMENTALS 37 EVALUATION OF INSOMNIA

FIGURE F37-2 n Sleep log. (Adapted from Carney CE, Buysse DJ, Ancoli-Israel S, et al: The consensus sleep diary: standard-
izing prospective sleep self-monitoring, Sleep 35[2]:287-302, 2012.)

insomnia, the AASM practice parameters did not

BOX F37-6 Some Typical Sleep Log
Patterns
Delayed sleep Late bedtime or long sleep
phase latency, few awakenings,
normal sleep duration on
weekends or non-work/
non-school days
Inadequate sleep Irregular wake and rise
hygiene times, naps
Psychophysiologic Long sleep latency,
insomnia decreased total sleep time,
frequent awakenings
Variability in sleep quality
Paradoxical Nights of minimal or no
insomnia sleep are reported followed
by no or few naps the
next day
parameters for use of actigraphy have been pub-
lished by the American Academy of Sleep Medicine
(AASM.22,23 Although actigraphy is indicated for
determining the circadian patterns of patients with
state that actigraphy was indicated as a routine eval-
uation of patients with insomnia.
Actigraphy does not measure sleep as defined
by electroencephalography (EEG), electroocu-
lographic (EOG), or chin electromyographic
(EMG) criteria or the subjective experience of
sleep (as measured by sleep logs and question-
naires). Therefore, it is not surprising that esti-
mates of TST, wake time, and sleep latency
from sleep logs and actigraphy may differ from
PSG findings.24,25 Algorithms have been devel-
oped to estimate TST and WASO from the
activity data. Actigraphy estimates of sleep dura-
tion, WASO, and sleep latency are more accurate
in normal individuals than in patients with
insomnia. Periods of low activity in which
patients lie quietly in bed but are awake may
be scored as sleep by actigraphy software. When
performing actigraphy, it is essential to require
patients to complete a sleep log (e.g., lights off,
lights on, out of bed, actigraph off for shower;
TST; sleep latency). This information enables
 FUNDAMENTALS 37
FIGURE F37-3 n Actigraphy from a good sleeper and a patient with insomnia. B, Bedtime ready to sleep. The patient
with insomnia had long sleep latency and two prolonged awakenings as well as a nap.
a correct interpretation of actigraphy tracings. If
the actigraphy estimate of TST far exceeds patient
estimates, this would suggest paradoxical insomnia.
Sleep logs and actigraphy provide comple-
mentary information. Actigraphy is most valu-
able in determining the pattern of wake and
sleep. It can detect irregular bedtimes and wake
times and naps. Sleep logs are always filled out by
patients wearing an actigraph. They provide
complimentary information. Sleep logs may
overestimate sleep latency while actigraphy
underestimates sleep latency (lying still but
awake). Sleep logs may underestimate total sleep
time, and actigraphy overestimate total sleep.
The relationship among PSG, actigraphy, and
sleep log findings also may differ depending on
the groups studied.
POLYSOMNOGRAPHY
PSG is not indicated for the routine assessment
of insomnia. The 2003 AASM practice parame-
ters for the role of PSG in insomnia state:
“PSG is indicated when the initial diagnosis (insom-
nia) is uncertain, treatment fails (either behavioral or
pharmacologic), or precipitous arousals occur with vio-
lent of injurious behavior (Guideline).9 When PSG
is performed, typical findings (Box F37-7) in
patients with insomnia include long sleep latency
(>30 minutes), reduced TST, increased WASO,
and reduced sleep efficiency. Long rapid eye
movement (REM) latency, a high arousal index,
increased stage N1, and decreased stage N3 sleep
may also be noted. In patients with paradoxical
insomnia, objective sleep abnormality is much
less severe than reported. It is not unusual for
such patients to report little or no sleep following
a PSG documenting only mild to moderate dec-
rements in the TST. In some patients with
EVALUATION OF INSOMNIA 591
BOX F37-7 Typical Polysomnography
Findings in Patients with
Insomnia
• Increased sleep latency (>30 minutes)
• Decreased TST
• Decreased sleep efficiency
• Increased stage N1 (%TST)
• Decreased stage N3 (%TST)
• Increased REM latency
• Decreased REM latency (depression)
REM, Rapid eye movement; TST, total sleep time.
psychophysiologic insomnia, the “reverse first-
night effect”10 may be noted. In these patients,
the sleep quality in the sleep center is better than
that reported at home. It is essential to have all
patients complete questionnaires assessing sub-
jective sleep (estimate TST, sleep latency, sleep
quality) after PSG.
CO-MORBID INSOMNIA
Many comorbid conditions such as chronic pain
disorders may cause the sleep/wake complaints.
If such conditions are the sole cause of the sleep
difficulty, a separate insomnia diagnosis may not
apply. The ICSD-3 states one should ask “How
much of the time does the sleep difficulty arise as
a result of factors directly attributable to the
comorbid condition (e.g., pain ?)” or “Are there
times that the sleep/wake complaints occur in the
absence of these factors?” If there is evidence that
the patient’s sleep/wake complaints are not
solely caused by the medical condition, and those
sleep/wake complaints seem to merit separate
treatment attention, then a diagnosis of chronic
insomnia disorder should be made.
592 FUNDAMENTALS 37 EVALUATION OF INSOMNIA

CLINICAL PEARLS
1. The diagnosis of CID requires the presence of (a) sleep difficulty, (b) daytime consequences, (c) difficulty for
at least 3 nights per week for at least 3 months, and (d) adequate opportunity and environment for sleep.
2. Sleep difficulty may include problems initiating or maintaining sleep, and early morning awakening. In chil-
dren, sleep difficulty includes resistance to going to bed and difficulty sleeping without caregiver
intervention.
3. A good sleep history is the essential tool for evaluating insomnia. PSG has only a limited role in this
evaluation.
4. Sleep logs and actigraphy provide complementary information, so the use of both can be valuable.
5. A number of insomnia disorders in ICSD-2 are now included in the ICSD-3 diagnosis of chronic insomnia
disorder.

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Practice parameters for the evaluation of chronic insom-
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