OVERVIEW

What is chronic insomnia disorder?

Chronic insomnia disorder refers to prolonged (≥ 3 months) and frequent (≥ 3 times per week) difficulty sleeping at night, accompanied by significant subjective dissatisfaction with sleep. It is associated with daytime negative experiences related to sleep difficulties, such as fatigue, emotional instability, difficulty concentrating, etc., which significantly impair daily life, work, study, and other aspects.

How common is chronic insomnia disorder?

Approximately 10% of the population is affected by chronic insomnia disorder, which can occur in any age group except infants. It is relatively more common among women, the elderly, individuals with physical illnesses, mental disorders, or substance dependence, as well as those from lower socioeconomic backgrounds.

Which department should patients with chronic insomnia disorder visit?

In areas with adequate resources, patients are advised to first seek a sleep specialist clinic. If such a clinic is unavailable locally, they may consider departments such as psychiatry, psychosomatic medicine, or similar specialties. In regions where psychiatric services are less accessible, neurology or general internal medicine may also be viable options.

SYMPTOMS

What are the clinical characteristics of chronic insomnia disorder?

The manifestations of chronic insomnia disorder mainly include difficulty falling asleep and difficulty maintaining sleep. Among them, difficulty maintaining sleep includes: difficulty falling back asleep after waking up during the night and early morning awakenings.

• The judgment of difficulty falling asleep generally refers to an excessively long time between going to bed (or waking up during the night) and falling asleep (sleep onset latency), and the influence of different age groups needs to be considered. For example, for children and adolescents, a sleep onset latency > 20 minutes, and for middle-aged and elderly people > 30 minutes, may indicate difficulty falling asleep.
• Early morning awakenings need to consider individual differences in bedtime, as early sleepers who wake up early may not necessarily have early morning awakenings.
• It can manifest solely as difficulty falling asleep or difficulty maintaining sleep, but the simultaneous presence of both is more common. Additionally, the two may shift and change over time.
• Poor sleep quality and lack of restorative sleep are often present alongside difficulty falling asleep and difficulty maintaining sleep.
• Common daytime negative experiences related to sleep difficulties include: fatigue, decreased energy, difficulty concentrating, impaired memory, irritability, low mood, or emotional instability.
• Complaints of daytime sleepiness or drowsiness are also common, but a frequent observation is that even when given the opportunity and conditions to sleep during the day, individuals still struggle to fall asleep.
• The frequency of sleep difficulties and daytime symptoms is ≥ 3 times/week, lasting ≥ 3 months.

Patients with chronic insomnia disorder may also experience emotional distress. While focusing on symptom relief, it is important not to neglect emotional well-being. Lifestyle changes such as meditation and exercise can help improve mood, and psychological counseling can assist in resolving emotional difficulties.

Additionally, these patients often need support and understanding, so care from family and friends can be very helpful.

Is chronic insomnia disorder related to chronic rhinitis and chronic sinusitis?

There is a certain relationship between chronic rhinitis, chronic sinusitis, and sleep disorders. Studies have found that 32.16% of patients with chronic rhinosinusitis experience sleep problems, a proportion higher than that in the general population. Sleep disorders are one of the top five health issues affecting patients with chronic rhinosinusitis.

CAUSES

Why do people suffer from insomnia?

The exact causes and pathological mechanisms of insomnia are not yet fully understood. Current research suggests that the occurrence and development of insomnia may be related to factors such as genetics, neurobiology, sleep-wake regulation, as well as individual behavioral and cognitive patterns.

Under what circumstances is insomnia more likely to occur?

• Sleep environment, habits, or sleep-related behaviors may contribute to insomnia. Examples include noisy surroundings, unsuitable sleep temperature, irregular sleep schedules, hunger or overeating before bed, consumption of coffee/alcohol/tea, and other behaviors detrimental to sleep;
• Objective environmental factors and changes in circadian rhythms may also trigger insomnia, such as night shifts, overtime work, moving, traveling by car or boat, jet lag from air travel, etc. These are usually adaptable in the short term;
• High-stress events (e.g., breakups, promotions, career challenges), emotional issues (e.g., anxiety, depression), and certain significant psychological problems;
• Individual attitudes toward sleep and cognitive behavioral patterns (e.g., excessive focus on or anxiety about poor sleep) may lead to the persistence or worsening of insomnia;
• Certain physical illnesses and mental disorders, such as heart disease, emphysema, hyperthyroidism, gastrointestinal discomfort, joint pain, depression, mania, substance abuse and dependence, etc. Additionally, some medications (e.g., aminophylline, diuretics) may also cause insomnia.

DIAGNOSIS

How is chronic insomnia disorder diagnosed?

The diagnosis of chronic insomnia disorder requires meeting the following criteria:

• At least one of the following symptoms of sleep difficulty must be present:

  1. Difficulty falling asleep;
  2. Difficulty maintaining sleep;
  3. Early morning awakening;
  4. Subjective resistance to going to bed at the appropriate bedtime;
  5. Difficulty sleeping without the presence of a parent or caregiver.

Among these, items 4 and 5 are more common in children or elderly individuals requiring care (e.g., dementia).

• At least one of the following daytime symptoms related to sleep difficulty must be present:

  1. Fatigue or lack of energy;
  2. Difficulty concentrating or memory impairment;
  3. Reduced physical energy or stamina;
  4. Mood disturbances such as irritability, impulsivity, or instability;
  5. Daytime sleepiness;
  6. Concern or dissatisfaction with sleep;
  7. Significant negative impact on daily life, work, or studies.

• The frequency of sleep difficulties and daytime symptoms must be ≥ 3 times per week and persist for ≥ 3 months.

• The sleep difficulties are not directly caused by insufficient sleep opportunity (e.g., shift work leading to inadequate nighttime sleep), unfavorable sleep environment (e.g., dangerous conditions, extreme temperatures), physical illness, mental disorders, or other sleep disorders.

Are tests needed to assist in diagnosing chronic insomnia disorder? Why?

The diagnosis of chronic insomnia disorder is primarily based on detailed sleep history and sleep rhythm information provided by the patient and informants, such as bedtime, time taken to fall asleep, nighttime awakenings, final wake-up time, rise time, daytime mental state, and daytime naps.

At the same time, it is necessary to differentiate insomnia caused by physical illness, mental illness, medications, or other factors. In addition to detailed physical and mental examinations, relevant blood tests, imaging studies, electrocardiograms (ECG), electroencephalograms (EEG), psychological assessments, and other auxiliary tests may aid in differential diagnosis.

Does experiencing sleep difficulty mean having insomnia disorder?

Not necessarily.

Apart from the situations described in diagnostic criterion (4), which should not be diagnosed as chronic insomnia disorder, patients who report only poor sleep quality and lack of restored energy without difficulty falling or staying asleep should be further evaluated for other potential conditions affecting nighttime sleep quality (e.g., sleep apnea syndrome).

For such cases, polysomnography (PSG) and multiple sleep latency tests (MSLT) may help clarify the diagnosis.

TREATMENT

How to Treat Chronic Insomnia Disorder?

The treatment of chronic insomnia disorder mainly includes pharmacotherapy and cognitive behavioral therapy.

For short-term efficacy, pharmacotherapy may be superior to cognitive behavioral therapy, while for long-term benefits and side effects, the importance of cognitive behavioral therapy for insomnia may outweigh pharmacotherapy. Therefore, it is generally recommended that combining pharmacotherapy with cognitive behavioral therapy yields better outcomes.

The choice of specific treatment plan may require individualized consideration based on factors such as the patient's insomnia condition, physical health, accompanying symptoms or diseases, attitude toward cognitive behavioral therapy, and financial situation.

• Pharmacotherapy: Currently, medications used to treat chronic insomnia disorder mainly include benzodiazepines, non-benzodiazepines, sedating antidepressants, melatonin receptor agonists, and others.

  • Non-benzodiazepines: Commonly used drugs in this category include zolpidem, zopiclone, eszopiclone, and zaleplon. Compared to "Valium"-type drugs, their side effects (e.g., tolerance, dependence, hangover effects) are relatively milder, making them the first-line pharmacological treatment for insomnia disorder.

  • Benzodiazepines: Commonly referred to as "Valium"-type drugs, these include midazolam, oxazepam, alprazolam, lorazepam, estazolam, diazepam, and clonazepam. In principle, long-term use is not recommended. Some long-acting types may cause daytime drowsiness and fatigue the next day ("hangover" effect). Long-term or high-dose use may lead to reduced efficacy ("tolerance") and dependence, with withdrawal symptoms or rebound insomnia possible upon dose reduction or discontinuation.

  • Sedating antidepressants: Commonly used ones include doxepin, trazodone, mirtazapine, and agomelatine. These drugs not only aid sleep but also have anxiolytic and antidepressant effects, without the side effects of "Valium"-type drugs, such as tolerance, dependence, withdrawal, or rebound.

  • Melatonin receptor agonists: Ramelteon belongs to this category. Similarly, the antidepressant agomelatine improves sleep by activating melatonin receptors to regulate circadian rhythms. Currently, no adverse effects such as tolerance, dependence, hangover, or rebound have been observed with melatonin receptor agonists.

  • Other methods for chronic insomnia disorder: Antipsychotics (e.g., quetiapine, olanzapine), the orexin receptor antagonist suvorexant (Belsomra), certain traditional Chinese herbal preparations, and physical therapies (e.g., light therapy, repetitive transcranial magnetic stimulation, biofeedback therapy, electrotherapy) can also be used.

• Cognitive Behavioral Therapy for Insomnia (CBT-I): CBT-I primarily addresses maladaptive cognitive thoughts and behavioral patterns related to insomnia. By guiding patients to recognize their erroneous cognitive evaluations and behavioral patterns regarding insomnia and understanding how these perpetuate or solidify insomnia, therapists help gradually rebuild cognitive and behavioral models to restore sleep rhythm and quality. CBT-I can be conducted in one-on-one or group sessions, typically over 6–8 weeks. Compared to pharmacotherapy, CBT-I has a slower onset of action for short-term benefits. Additionally, the availability and insurance coverage of CBT-I in China remain relatively low, which may be limiting factors.

DIET & LIFESTYLE

Are there any suggestions for self-adjusting sleep?

In terms of self-treatment, continuous adjustments can be made from both personal mindset and sleep hygiene habits:

• Personal mindset: Some patients with insomnia disorders view sleep as extremely stressful and important. Even a single episode of insomnia can trigger persistent worry and anxiety, such as, "What if I can't sleep again tonight?" The more they focus on sleep and try to fall asleep, the harder it becomes, which in turn intensifies tension and worry, creating a vicious cycle. Adopting a calm and accepting attitude toward insomnia may help avoid such perpetuating cycles.
• Sleep hygiene habits: Cultivate healthy sleep patterns by optimizing the sleep environment, managing unfavorable behaviors, and limiting time in bed.
  • A quiet, comfortable, and safe sleep environment is the foundation for good sleep quality.
  • Stay moderately busy during the day, engage in outdoor activities or exercise to break a sweat—this benefits both sleep and alleviates restlessness. However, avoid intense exercise within 2 hours before bedtime.
  • Avoid daytime naps if possible. If napping, limit it to no more than 30 minutes. Longer naps may lead to deep sleep, making it harder to wake up refreshed and potentially disrupting nighttime sleep.
  • Regardless of how well you slept at night, wake up at a fixed time every morning, including weekends and holidays.
  • Relax the body before bedtime to promote sleep. Methods vary by individual—music, walking, yoga, calligraphy, leisurely activities, movies, deep breathing, etc. A warm glass of milk, a foot soak, or a warm bath may also help.
  • Avoid relying on alcohol or similar substances for sleep—they are detrimental in the long run. Those sensitive to caffeine should refrain from coffee or tea after 4 PM. Avoid overeating, excessive hunger, or drinking too much water before bed.

PREVENTION

What should patients with chronic insomnia disorder do when they can't sleep?

Many people with insomnia are reluctant to leave their beds, fearing that moving around will make them more alert.

Others, when unable to sleep, lie in bed overthinking problems or scrolling through their phones and social media. Before they know it, hours pass without sleep, and their minds grow even more awake.

Over time, the bed becomes associated with activities that keep the brain alert and stimulated. As a result, lying down triggers a habitual state of wakefulness and excitement, making sleep elusive.

If you haven't fallen asleep within 20–30 minutes in bed, get up and leave the bedroom. Go to the living room or study and engage in relaxing activities, such as listening to soothing music or reading a light book. Return to bed only when drowsiness sets in. If sleep still doesn’t come, repeat the process after another 20–30 minutes. This method requires long-term consistency—effects may be noticeable after four weeks of practice.

Only go to bed when sleepy, and avoid lingering in bed without sleep. Strictly limiting non-sleep time in bed helps restore its original purpose: the bed is solely for sleep. Avoid forming habits of doing anything unrelated to sleep in bed.