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Definition of insomnia—diagnostic classification systems

  • For the diagnosis of insomnia, the diagnostic categories ‘Non-organic insomnia’ (F51.0) and ‘Disorders of initiating and maintaining sleep (insomnias)’ (G47.0) are relevant. The definition for non-organic insomnia is presented in Table 1.
Table 1: Diagnostic criteria for non-organic insomnia (F51.0) according to ICD-10
  • Disturbance of sleep onset or sleep maintenance, or poor sleep quality
  • Sleep disturbances occur at least three times a week over a period of 1 month
  • The afflicted individuals focus extremely on their sleep disorder (especially during the night) and worry about the negative consequences of insomnia
  • The insufficient sleep duration and quality is coupled with a high degree of suffering or impairs daily activities.

Diagnostic procedure

  • The recommended procedure for the diagnostic management of insomnia disorder, and its co-morbidities, is shown in Table 2.
Table 2: Diagnostic management of insomnia and its co-morbidities

1. Medical history and examination (strong recommendation)

  • The anamnesis should include caregivers if necessary
  • Former and present somatic disorders (including pain)
  • Substance use (medication, alcohol, caffeine, nicotine, illegal drugs)
  • Physical examination
  • Additional measures (if indicated): 
    laboratory testing including, e.g. blood count, thyroid, hepatic and renal parameters, CRP, haemoglobin, ferritin and vitamin B12 
    ECG, EEG, CT/MRT
    Circadian markers (melatonin, core body temperature)

2. Psychiatric/psychological history (strong recommendation)

  • Former and present mental disorders
  • Personality factors
  • Work and partnership situation
  • Interpersonal conflicts

3. Sleep history (strong recommendation)

  • History of the sleep disorder, including triggering factors
  • Information from bed partner (periodic limb movements during sleep, pauses in breathing)
  • Work time/circadian factors (shift- and night-work, phase advance, delay)
  • Sleep–wake pattern, including daytime sleep (sleep diary, sleep questionnaires)

4. Actigraphy

  • In case of clinical suspicion of irregular sleep–wake schedules or circadian rhythm disorders (strong recommendation)
  • To assess quantitative sleep parameters (weak recommendation)

5. Polysomnography

  • In case of clinical suspicion of other sleep disorders like periodic limb movement disorder, sleep apnoea or narcolepsy (strong recommendation)
  • Treatment-resistant insomnia (strong recommendation)
  • Insomnia in occupational at-risk groups, e.g. professional drivers (strong recommendation)
  • In case of clinical suspicion of large discrepancy between subjectively experienced and polysomnographically measured sleep (strong recommendation)
CRP=C-reactive protein; CT=computed tomography; ECG=electrocardiogram; EEG=electroencephalogram; MRT=magnetic resonance tomography.
  • A medical and psychiatric/psychological anamnesis is mandatory, and has to be tailored to the clinical picture of the patient and his/her symptomatology. With respect to the assessment of medical disorders, it needs to be borne in mind that some somatic causes of insomnia can be specifically treated, for example hyperthyroidism.
  • Patients with chronic insomnia often suffer from a co-morbid mental disorder, which they do not spontaneously report. This may be due to the fact that it is easier for some patients to talk about sleep than to talk about emotional distress. Thus, the presence of mental disorders should also be actively examined.
  • Table 3 summarises the major somatic and mental co-morbidities of insomnia.
Table 3: Major co-morbidities of insomnia   

Psychiatric

Medical 

Neurological 

Substance use/dependence

  • Depressive disorders
  • Bipolar disorders
  • Generalised anxiety disorder
  • Panic disorder
  • Post-traumatic stress disorder
  • Schizophrenia

 

  • Chronic obstructive pulmonary diseases
  • Diabetes mellitus
  • Chronic kidney diseases
  • Human immunodeficiency virus infection
  • Malignancy
  • Rheumatic disorders
  • Chronic pain
  • Sleep apnoea
  • Neurodegenerative diseases 
  • Fatal familial insomnia
  • Cerebrovascular diseases
  • Multiple sclerosis
  • Traumatic brain injury
  • RLS
  • Alcohol
  • Nicotine
  • Caffeine
  • Marijuana
  • Opioids
  • Designer drugs
  • Cocaine
  • Amphetamine 
RLS=restless legs syndrome.

Diagnostic management of insomnia and its co-morbidities

  • The diagnostic procedure for insomnia should include a clinical interview consisting of a thorough evaluation of the current sleep–wake behaviour and sleep history as well as questions about somatic and mental disorders, a physical examination, the use of sleep questionnaires and sleep diaries, and, if indicated, additional measures (blood tests, ECG, EEG, CT/MRT, circadian markers; strong recommendation, moderate- to high-quality evidence).
  • It is recommended to actively ask for medication and other substance use (alcohol, caffeine, nicotine, illegal drugs), which may disturb sleep (strong recommendation, high-quality evidence).
  • Sleep diaries or actigraphy can be used in case of clinical suspicion of irregular sleep–wake schedules or circadian rhythm disorders (strong recommendation, high-quality evidence), and actigraphy can be used to assess quantitative sleep parameters (weak recommendation, high-quality evidence).
  • Polysomnography is recommended when there is clinical suspicion of other sleep disorders, like periodic limb movement disorder, sleep apnoea or narcolepsy, treatment-resistant insomnia, insomnia in occupational at-risk groups, or suspicion of a large discrepancy between subjectively experienced and polysomnographically measured sleep (strong recommendation, high-quality evidence).

Treatment of insomnia

  • In the presence of co-morbidities, clinical judgement should decide whether the insomnia or the co-morbid condition is treated first, or whether both are treated at the same time.

Cognitive behavioural therapy for insomnia (CBT-I)

  • Cognitive behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence).

Pharmacological interventions

  • A pharmacological intervention can be offered if CBT-I is not effective or not available.

Benzodiazepines and benzodiazepine receptor agonists

  • Benzodiazepines (BZ) and benzodiazepine receptor agonists (BZRA) are effective in the short-term treatment of insomnia (≤4 weeks; high-quality evidence).
  • The newer BZRA are equally effective as BZ (moderate-quality evidence).
  • BZ/BZRA with shorter half-lives may have less side-effects concerning sedation in the morning (moderate-quality evidence).
  • Long-term treatment of insomnia with BZ or BZRA is not generally recommended because of a lack of evidence and possible side-effects/risks (strong recommendation, low-quality evidence). In patients using medication on a daily basis, reduction to intermittent dosing is strongly recommended (strong recommendation, low-quality evidence).

Sedating antidepressants

  • Sedating antidepressants are effective in the short-term treatment of insomnia; contraindications have to be carefully considered (moderate-quality evidence). Long-term treatment of insomnia with sedating antidepressants is not generally recommended because of a lack of evidence and possible side-effects/risks (strong recommendation, low-quality evidence).

Antihistaminics

  • Because of insufficient evidence, antihistaminics are not recommended for insomnia treatment (strong recommendation, low-quality evidence).

Antipsychotics

  • Because of insufficient evidence and in light of their side-effects, antipsychotics are not recommended for insomnia treatment (strong recommendation, very low-quality evidence).

Melatonin

  • Melatonin is not generally recommended for the treatment of insomnia because of low efficacy (weak recommendation, low-quality evidence).

Phytotherapy

  • Valerian and other phytotherapeutics are not recommended for the treatment of insomnia because of poor evidence (weak recommendation, low-quality evidence).

Light therapy and exercise

  • Light therapy and exercise regimes may be useful as adjunct therapies (weak recommendation, low-quality evidence).

Complementary and alternative medicine

  • Acupuncture, aromatherapy, foot reflexology, homeopathy, meditative movement, moxibustion and yoga are not recommended for the treatment of insomnia because of poor evidence (weak recommendation, very low-quality evidence).

Clinical algorithm for the diagnosis and treatment of insomnia

Clinical algorithm for the diagnosis and treatment of insomnia v2

Clinical algorithm for the diagnosis and treatment of insomnia

Full guideline:

doi.org/10.1111/jsr.12594

Riemann D, Baglioni C, Bassetti C et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res 2017; 26: 675–700.