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vivabest psychiatry

Insomnia

A sleep disorder characterized by difficulty falling or staying asleep, leading to daytime impairment, fatigue, and distress despite having adequate opportunity to sleep.

What Is Insomnia?

Insomnia is a common sleep disorder marked by difficulty falling asleep, staying asleep, or waking too early with unrefreshing sleep and daytime impairment (fatigue, poor concentration, mood changes, safety risks).

Types of Insomnia

  • By duration
  • Acute (short-term): days to weeks, often linked to stress, life events, travel, or shift changes.
  • Chronic (ongoing): ≥3 nights/week for ≥3 months despite adequate time/opportunity for sleep.
  • By cause
  • Comorbid (secondary): occurs with medical/psychiatric conditions, other sleep disorders, medications/substances.
  • Primary: no clear external cause; often tied to long-standing stress, conditioned arousal, or circadian factors.

Other Conditions

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Who’s at Risk?

  • Ongoing stress or major life changes
  • Anxiety, depression, PTSD, or nocturnal panic
  • Irregular schedules (shift work), frequent travel across time zones
  • Medical issues (pain, reflux, cardiopulmonary/neurologic disease), pregnancy/perimenopause
  • Substances/medications (caffeine, alcohol, nicotine, stimulants, some antidepressants/steroids)
  • Older age; sleep disparities also exist across populations due to social and health factors

Symptoms

  • Long sleep latency (lying awake), frequent awakenings, early-morning awakenings
  • Unrefreshing sleep; daytime sleepiness, low energy
  • Cognitive/mood effects: poor focus, memory lapses, irritability, anxiety or low mood
  • Functional impact: reduced work/school performance, driving risks
  • Chronic insomnia features: symptoms ≥3 nights/week, ≥3 months, not explained by another sleep disorder, substances, or insufficient opportunity to sleep.
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Diagnosis of Insomnia

  • A clinician will typically:
  • Review medical/psychiatric history, sleep history, and a sleep diary or questionnaires
  • Perform a physical exam and targeted labs if indicated (e.g., thyroid)
  • Consider actigraphy for sleep timing/regularity
  • Order polysomnography (sleep study) if another sleep disorder is suspected (e.g., sleep apnea, parasomnias, limb movements); MSLT in selected cases

Possible Complications

Daytime sleepiness and accidents (including drowsy driving), depression/anxiety, hypertension, cardiovascular and metabolic risks, and reduced quality of life.

When to Seek Care

  • Symptoms ≥3 months, significant daytime impairment, or safety concerns (e.g., drowsy driving)
  • Loud snoring, witnessed apneas, or acting out dreams
  • Persistent insomnia despite good sleep habits

Treatment of Insomnia

Best practice: Start with behavioral therapy; add medications when needed and appropriate.

1. Cognitive Behavioral Therapy for Insomnia (CBT-I) — First-Line

  • Stimulus control: bed only for sleep/intimacy; consistent wake time; leave bed if unable to sleep after ~20 minutes
  • Sleep restriction/compression: match time in bed to actual sleep, then gradually expand
  • Cognitive strategies: reduce worry/rumination and catastrophic sleep beliefs
  • Relaxation training: breathing, progressive muscle relaxation, biofeedback
  • Paradoxical intention: reduce performance anxiety by “trying to stay awake”
  • Circadian strategies: fixed wake time, bright light timing, and timed melatonin when phase-shifted
  •  

2. Sleep Hygiene (Foundations)

  • Regular schedule (including weekends), wind-down routine
  • Cool, dark, quiet bedroom; limit screens/light in the evening
  • Avoid late caffeine, nicotine, heavy meals, and alcohol close to bedtime
  • Daytime activity/exercise (not right before bed); brief early-day naps only if needed

3. Medications (when CBT-I is unavailable/insufficient)

Use the lowest effective dose for the shortest duration; combine with CBT-I.

  • Orexin receptor antagonists (e.g., suvorexant, lemborexant, daridorexant)
  • Ramelteon (melatonin-receptor agonist) or low-dose doxepin
  • “Z-drugs” (eszopiclone, zaleplon, zolpidem) or benzodiazepines (e.g., temazepam) when appropriate, with caution for dependence, falls, next-day impairment
  • Sedating antidepressants (e.g., trazodone, amitriptyline) in selected cases for comorbid symptoms
  • OTC antihistamines are not for regular use due to side effects (daytime sedation, confusion, urinary retention), especially in older adults
  • Melatonin: use appropriate timing/dose; discuss with your clinician

Treat underlying contributors (pain, mood/anxiety, apnea, restless legs, medication effects) to sustain improvement.

Vivabest Psychiatry PLLC: Our Approach

  • Comprehensive evaluation (medical/psychiatric review, sleep diary, targeted labs; sleep study referrals when indicated)
  • CBT-I–centered care with circadian and relaxation strategies
  • Medication management when appropriate, with careful monitoring
  • Measurement-based follow-up and coordination with primary care/sleep medicine

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