Many people struggle with sleep at various points in their lives. There are various definitions of insomnia, but in general we refer to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)1 to make an accurate diagnosis.
DSM-5 criteria state that in order to diagnose a person with insomnia, the person must be concerned about their sleep quality and/or quantity, along with one or more of the following:
- Trouble falling asleep. We generally interpret this as it taking more than 30 minutes for someone to fall asleep when they first lay down for the night.
- Trouble staying asleep. This refers to waking up during the night and not being able to fall back asleep for at least 30 minutes.
- Waking up too early and not being able to fall back asleep. This usually shows up as waking up more than 30 minutes before your alarm and not being able to fall back asleep.
The sleep difficulties must be present at least 3 nights per week, for at least 3 months.
The sleep issues must cause significant dysfunction in the person’s social, occupational, academic, behavioural, or other important areas of functioning. This might look like poor performance or frequent mistakes at work, getting into car accidents because of delayed reaction time and/or falling asleep, avoiding social activities because of feeling too tired, difficulty completing homework or other projects because of fatigue, being very irritable with other people (friends, partners, children), or other issues.
If someone is just not giving themselves the opportunity to sleep, this is not insomnia. We call this chronic sleep restriction. For example, the college student who pulls “all-nighters” during the week to get a last-minute project done, or a parent who wakes up frequently in the night due to caring for their child but is otherwise generally able to fall asleep when given the opportunity.
Similarly, if someone is sleeping a relatively short amount of time each night (eg. 5-6 hours), but they are able to feel generally well-rested and function well during the day, this is not insomnia either. This is short duration sleep.
Another point in the DSM-5 states that “the insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder.” In other words, we need to make sure we rule out the possibility that the person with trouble sleeping doesn’t have narcolepsy, sleep apnea, or other sleep disorder which can sometimes “mimic” insomnia.
We also need to make sure that we evaluate a person for any coexisting mental health disorders, such as depression, anxiety, attention deficit hyperactivity disorder (ADHD), or bipolar disorder, which can also cause issues with falling or staying sleep. Patients should also be evaluated for other medical disorders which can present with troubles falling asleep, such as gastroesophageal reflux disease (GERD), thyroid disorders, asthma, neurological disorders, or nasal / sinus issues.
The last point on the DSM-5 criteria for insomnia state that the sleep difficulties are not due to the effects of a drug (such as cocaine or marijuana), or a medication (such as stimulant medication, some anti-histamines, some anti-depressant medications, steroids, or certain asthma medications).
Things can get a bit tricky when someone has both depression and insomnia, or both sleep apnea and insomnia. There can be overlap amongst different conditions, and one condition can impact the other. It’s important to work with your health team to sort out an accurate diagnosis, so that you can get the help you need and get back to sleeping well and feeling better as quickly as possible.
If you’d like to learn more about getting a restful sleep from a holistic perspective, contact Pacific Sleep to book an in-person, phone, or virtual appointment with Dr. Houwing.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596