🧭 When to suspect

Insomnia is dissatisfaction with sleep quantity or quality despite adequate opportunity to sleep, with one or more of:

• Difficulty getting to sleep

• Difficulty staying asleep

• Early-morning waking

• Sleep that is non-restorative

The diagnosis requires associated daytime impairment – fatigue, poor concentration or memory, low or irritable mood, or reduced performance – and is made clinically; no investigation is needed to make it.

Suspect a clinically significant disorder when symptoms occur on ≥ 3 nights per week and cause significant distress or impair daytime functioning.

The most useful distinction is duration:

• Short-term (acute) insomnia lasts < 3 months and usually follows an identifiable trigger.

• Chronic insomnia lasts ≥ 3 months and is sustained by learned, perpetuating factors.

In practice:

• Separate short-term from chronic

• Actively exclude a secondary cause (depression or anxiety, obstructive sleep apnoea, restless legs syndrome, pain, nocturia, medicines or substances)

• Prioritise cognitive behavioural therapy for insomnia (CBT-I) over hypnotics, in line with National Institute for Health and Care Excellence (NICE) guidance

Feature

Short-term (acute) insomnia

Chronic insomnia

Duration

< 3 months

≥ 3 months, on ≥ 3 nights/week

Typical context

Identifiable precipitant – stress, bereavement, acute illness, shift change

Perpetuating factors – excess time in bed, napping, clock-watching, anxiety about sleep

First-line approach

• Sleep hygiene and address the trigger

• Brief hypnotic only if daytime impairment is severe

• CBT-I (digital or face-to-face)

• Avoid long-term hypnotics

🧠 Clinical pearl

• Think in terms of the three Ps: predisposing traits, a precipitating trigger, and the perpetuating behaviours that keep insomnia going long after the original stressor has passed.

• Acute insomnia becomes chronic when the perpetuators – longer time in bed, daytime naps, and worry about sleeplessness – take over.

• CBT-I works precisely because it dismantles those perpetuating factors, which is why it outlasts any hypnotic.

Source: NICE

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