Insomnia is trouble falling asleep, staying asleep or waking too early, with daytime effects, despite enough chance to sleep. Chronic insomnia lasts at least 3 nights a week for 3 months, and cognitive behavioral therapy for insomnia is the first-line treatment.
Key symptoms
- Taking a long time to fall asleep
- Waking often at night or too early in the morning
- Daytime tiredness, poor focus, irritability
- Worry about sleep and time spent awake in bed
- Snoring, leg discomfort or low mood as clues to a cause
What you find on exam
- Sleep history: schedule, habits, naps, screens, caffeine, alcohol
- Screen for depression, anxiety and substance use
- Neck size, BMI and airway for sleep apnea
- Medication review for drugs that disturb sleep
Tests
- Diagnosis is clinical
- Sleep diary for 1 to 2 weeks
- Sleep study only if sleep apnea or another sleep disorder is suspected
- Thyroid tests or iron studies if history suggests
Treatment basics
- Cognitive behavioral therapy for insomnia
- Sleep hygiene: regular schedule, dark quiet room, no screens in bed
- Stimulus control and sleep restriction
- Short-term medicine if needed, such as zolpidem or low-dose doxepin
- Treat the cause: depression, pain, sleep apnea, restless legs
Red flags
- Loud snoring with pauses in breathing or sleepiness while driving
- Suicidal thoughts or severe depression
- Complex sleep behaviors on sleep medicine, such as sleep driving
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.