Insomnia

🔍 When to Suspect

Difficulty initiating or maintaining sleep, or non-restorative sleep, causing significant daytime distress or functional impairment

From the full topic in The Ocean Library: Insomnia

🧭 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, or 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, while chronic insomnia lasts ≥ 3 months and is sustained by learned, perpetuating factors.

The key primary-care skills are threefold: separate short-term from chronic, actively exclude a secondary cause (depression or anxiety, obstructive sleep apnoea, restless legs syndrome, pain, nocturia, medicines or substances), and 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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