Editing Insomnia (section)

== Diagnosis ==
{{Further|Ford Insomnia Response to Stress Test}}
In medicine, insomnia is measured using the [[Athens insomnia scale]] (AIS).<ref>{{cite journal | vauthors = Soldatos CR, Dikeos DG, Paparrigopoulos TJ | title = Athens Insomnia Scale: validation of an instrument based on ICD-10 criteria | journal = Journal of Psychosomatic Research | volume = 48 | issue = 6 | pages = 555–60 | date = June 2000 | pmid = 11033374 | doi = 10.1016/S0022-3999(00)00095-7 }}</ref> It measures eight parameters related to sleep, represented as an overall scale which assesses an individual's sleep quality. It has excellent internal consistency and re-test reliability.<ref>{{Cite journal |last1=Jahrami |first1=Haitham |last2=Trabelsi |first2=Khaled |last3=Saif |first3=Zahra |last4=Manzar |first4=Md Dilshad |last5=BaHammam |first5=Ahmed S. |last6=Vitiello |first6=Michael V. |date=2023-11-01 |title=Reliability generalization meta-analysis of the Athens Insomnia Scale and its translations: Examining internal consistency and test-retest validity |url=https://linkinghub.elsevier.com/retrieve/pii/S1389945723003489 |journal=Sleep Medicine |volume=111 |pages=133–145 |doi=10.1016/j.sleep.2023.09.015 |pmid=37776584 |issn=1389-9457}}</ref> The Athens Insomnia Scale for Non-Clinical Populations (AIS-NCA) has been developed and validated in English,<ref name=":0">{{Cite journal |last1=Sattler |first1=Sebastian |first2=Seddig ,Daniel |last3=and Zerbini |first3=Giulia |date=2023-08-03 |title=Assessing sleep problems and daytime functioning: a translation, adaption, and validation of the Athens Insomnia Scale for non-clinical application (AIS-NCA) |url=https://www.tandfonline.com/doi/full/10.1080/08870446.2021.1998498 |journal=Psychology & Health |volume=38 |issue=8 |pages=1006–1031 |doi=10.1080/08870446.2021.1998498 |issn=0887-0446 |pmid=34766856}}</ref> Chinese,<ref>{{Cite journal |last1=Tan |first1=Chenhao |last2=Wang |first2=Jinhao |last3=Cao |first3=Guohuan |last4=Chen |first4=Chao |last5=Yin |first5=Jun |last6=Lu |first6=Jiaojiao |last7=Qiu |first7=Jun |date=2023-09-15 |title=Reliability and validity of the Chinese version of the Athens insomnia scale for non-clinical application in Chinese athletes |journal=Frontiers in Psychology |language=English |volume=14 |doi=10.3389/fpsyg.2023.1183919 |doi-access=free |issn=1664-1078 |pmc=10540192 |pmid=37780167}}</ref> and German<ref name=":0" /> to identify subclinical manifestations of insomnia in a language simpler than the Athens Insomnia Scale and more suitable for self-report. It uses four items to assess sleep problems and three items to assess impaired daytime functioning.

A medical history and a physical examination can identify other conditions that could be the cause of insomnia. A comprehensive sleep history should include sleep habits and sleep environment, medications (prescription and non-prescription, including supplements), alcohol, nicotine, and caffeine intake, and co-morbid illnesses.<ref name="Passarella, S 2008">Passarella, S, Duong, M. "Diagnosis and treatment of insomnia." 2008.</ref> A [[sleep diary]] can be used to track time to bed, total sleep time, time to sleep onset, number of awakenings, use of medications, time of awakening, and subjective feelings in the morning.<ref name="Passarella, S 2008"/> The sleep diary can be replaced or validated by the use of out-patient [[actigraphy]] for a week or more, using a non-invasive device that measures movement.<ref name=Schutte-Rodin>{{cite journal | vauthors = Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M | title = Clinical guideline for the evaluation and management of chronic insomnia in adults | journal = Journal of Clinical Sleep Medicine | volume = 4 | issue = 5 | pages = 487–504 | date = October 2008 | pmid = 18853708 | pmc = 2576317 | url = http://www.aasmnet.org/Resources/clinicalguidelines/040515.pdf | quote = Actigraphy is indicated as a method to characterize circadian patterns or sleep disturbances in individuals with insomnia, ... | access-date = 30 July 2015 | url-status = live | archive-url = https://web.archive.org/web/20150209031235/http://www.aasmnet.org/Resources/clinicalguidelines/040515.pdf | archive-date = 9 February 2015 | doi = 10.5664/jcsm.27286 }}</ref>

Not everyone who suffers from insomnia should routinely have a [[polysomnography]] study to screen for sleep disorders,<ref name="ACOEMfive">{{Citation |author1=American College of Occupational and Environmental Medicine |author1-link=American College of Occupational and Environmental Medicine |date=February 2014 |title=Five Things Physicians and Patients Should Question |publisher=American College of Occupational and Environmental Medicine |work=[[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url=http://www.choosingwisely.org/doctor-patient-lists/american-college-of-occupational-and-environmental-medicine/ |access-date=24 February 2014 |url-status=live |archive-url=https://web.archive.org/web/20140911001813/http://www.choosingwisely.org/doctor-patient-lists/american-college-of-occupational-and-environmental-medicine/ |archive-date=11 September 2014 }}</ref> but it may be indicated for those with risk factors for [[sleep apnea]], including obesity, a thick neck diameter, or fullness of the flesh in the [[oropharynx]].<ref name="ACOEMfive"/> For most people, the test is not needed to make a diagnosis, and insomnia can often be treated by changing their schedule to make time for sufficient sleep and by improving [[sleep hygiene]].<ref name="ACOEMfive"/>

Some patients may need an overnight sleep study in a sleep lab. Such a study will commonly involve assessment tools including a polysomnogram and the [[multiple sleep latency test]]. Specialists in [[sleep medicine]] are qualified to diagnose disorders within the, according to the [[International Classification of Sleep Disorders|ICSD]], 81 major sleep disorder diagnostic categories.<ref>{{cite journal | vauthors = Thorpy MJ | title = Classification of sleep disorders | journal = Neurotherapeutics | volume = 9 | issue = 4 | pages = 687–701 | date = October 2012 | pmid = 22976557 | pmc = 3480567 | doi = 10.1007/s13311-012-0145-6 }}</ref> Patients with some disorders, including [[delayed sleep phase disorder]], are often misdiagnosed with primary insomnia; when a person has trouble getting to sleep and awakening at desired times, but has a normal sleep pattern once asleep, a circadian rhythm disorder is a likely cause.

In many cases, insomnia is co-morbid with another disease, side effects from medications, or a psychological problem. Approximately half of all diagnosed insomnia is related to psychiatric disorders.<ref name="Wilson" /> For those who have depression, "insomnia should be regarded as a co-morbid condition, rather than as a secondary one;" insomnia typically predates psychiatric symptoms.<ref name="Wilson" /> "In fact, it is possible that insomnia represents a significant risk for the development of a subsequent psychiatric disorder."<ref name=Th2007 /> Insomnia occurs in between 60% and 80% of people with depression and can be a side effect of medications that treat depression.<ref name=Luca2013>{{cite journal | vauthors = Luca A, Luca M, Calandra C | title = Sleep disorders and depression: brief review of the literature, case report, and nonpharmacologic interventions for depression | journal = Clinical Interventions in Aging | volume = 8 | pages = 1033–39 | date = 2013 | pmid = 24019746 | pmc = 3760296 | doi = 10.2147/CIA.S47230 | doi-access = free }}</ref>

The determination of causation is not necessary for a diagnosis.<ref name="Wilson">{{cite journal | vauthors = Wilson SJ, Nutt DJ, Alford C, Argyropoulos SV, Baldwin DS, Bateson AN, Britton TC, Crowe C, Dijk DJ, Espie CA, Gringras P, Hajak G, Idzikowski C, Krystal AD, Nash JR, Selsick H, Sharpley AL, Wade AG | title = British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders | journal = Journal of Psychopharmacology | volume = 24 | issue = 11 | pages = 1577–1601 | date = November 2010 | pmid = 20813762 | doi = 10.1177/0269881110379307 | s2cid = 16823040 }}</ref>

=== DSM-5 criteria ===

The [[DSM-5]] criteria for insomnia include the following:<ref>{{cite book | chapter = Sleep Wake Disorders | title = Diagnostic and statistical manual of mental disorders: DSM-5 | location = Washington, D.C. | publisher = American Psychiatric Association | date = 2013 }}</ref>

"Predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms":
*Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
*Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
*Early-morning awakening with inability to return to sleep.
In addition:
*The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
*The sleep difficulty occurs at least three nights per week.
*The sleep difficulty has been present for at least three months.
*The sleep difficulty occurs despite adequate opportunity for sleep.
*The insomnia is not better explained by and does not occur exclusively during another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
*The insomnia is not attributable to the physiological effects of a substance (e.g., a [[drug of abuse]], a medication)."

The [[DSM-IV TR]] includes insomnia but does not fully elaborate on the symptoms compared to the DSM-5. Instead of early-morning waking as a symptom, the DSM-IV-TR listed “nonrestorative sleep” as a primary symptom. The duration of the experience was also vague in the DSM-IV-TR. The DSM-IV-TR stated that symptoms had to be present for a month, whereas the DSM-5 states that symptoms must be present for three months and occur at least three nights a week (Gillette).

=== Types ===

Insomnia can be classified as transient, acute, or chronic.
*''Transient insomnia'' lasts for less than a week. It can be caused by another disorder, by changes in the sleep environment, by the timing of sleep, severe [[Major depressive disorder|depression]], or by [[stress (biology)|stress]]. Its consequences&nbsp;– sleepiness and impaired psychomotor performance&nbsp;– are similar to those of [[sleep deprivation]].<ref name="Roth">{{cite journal | vauthors = Roth T, Roehrs T | title = Insomnia: epidemiology, characteristics, and consequences | journal = Clinical Cornerstone | volume = 5 | issue = 3 | pages = 5–15 | year = 2003 | pmid = 14626537 | doi = 10.1016/S1098-3597(03)90031-7 }}</ref>
*''[[Acute (medicine)|Acute]] insomnia'' is the inability to consistently sleep well for less than a month. Insomnia is present when there is difficulty initiating or maintaining sleep or when the sleep that is obtained is non-refreshing or of poor quality. These problems occur despite adequate opportunity and circumstances for sleep, and they must result in problems with daytime function.<ref>{{cite web |url=http://articles.directorym.com/Insomnia-a352.html |title=Insomnia&nbsp;– sleeplessness, chronic insomnia, acute insomnia, mental ... |access-date=29 April 2008 |archive-url=https://web.archive.org/web/20080329155902/http://articles.directorym.com/Insomnia-a352.html |archive-date=29 March 2008}}</ref> Hyperarousal can be linked to acute insomnia since it activates the body's fight-or-flight response. When we encounter stress or danger, our bodies naturally become more alert, which can interfere with our capacity to both fall asleep and remain asleep. This heightened state of arousal can be useful in the short term during threatening situations, but if it continues over an extended period, it can result in acute insomnia.<ref name="Acute and Chronic Insomnia: What Ha">{{cite journal | vauthors = Vargas I, Nguyen AM, Muench A, Bastien CH, Ellis JG, Perlis ML | title = Acute and Chronic Insomnia: What Has Time and/or Hyperarousal Got to Do with It? | journal = Brain Sciences | volume = 10 | issue = 2 | pages = 71 | date = January 2020 | pmid = 32013124 | pmc = 7071368 | doi = 10.3390/brainsci10020071 | doi-access = free }}</ref> Acute insomnia is also known as ''short term insomnia'' or ''stress related insomnia''.<ref name=r1>{{cite web |url=http://sleepdisorders.about.com/od/commonsleepdisorders/a/Acute_Insomnia.htm |title=Acute Insomnia – What is Acute Insomnia |publisher=Sleepdisorders.about.com |access-date=10 March 2013 |url-status=live |archive-url=https://web.archive.org/web/20130329185735/http://sleepdisorders.about.com/od/commonsleepdisorders/a/Acute_Insomnia.htm |archive-date=29 March 2013 }}</ref> 
*''[[chronic (medical)|Chronic]] insomnia'' lasts for longer than a month. It can be caused by another disorder, or it can be a primary disorder. Common causes of chronic insomnia include persistent stress, trauma, work schedules, poor sleep habits, medications, and other mental health disorders.<ref>{{Cite web |date=2020-08-31 |title=Types of Insomnia |url=https://www.sleepfoundation.org/insomnia/types-of-insomnia |access-date=2022-07-15 |website=Sleep Foundation |language=en |archive-date=2022-07-14 |archive-url=https://web.archive.org/web/20220714180512/https://www.sleepfoundation.org/insomnia/types-of-insomnia |url-status=live }}</ref> When an individual consistently engages in behaviors that disrupt their sleep, such as irregular sleep schedules, spending excessive time awake in bed, or engaging in stimulating activities close to bedtime, it can lead to conditioned wakefulness contributing to chronic insomnia.<ref name="Acute and Chronic Insomnia: What Ha"/> People with high levels of stress hormones or shifts in the levels of [[cytokine]]s are more likely than others to have chronic insomnia.<ref>{{cite news | vauthors = Simon H |title=In-Depth Report: Causes of Chronic Insomnia |url=http://health.nytimes.com/health/guides/symptoms/sleeping-difficulty/causes-of-chronic-insomnia.html |newspaper=The New York Times |access-date=4 November 2011 |url-status=live |archive-url=https://web.archive.org/web/20111108185210/http://health.nytimes.com/health/guides/symptoms/sleeping-difficulty/causes-of-chronic-insomnia.html |archive-date=8 November 2011 }}</ref> Its effects can vary according to its causes. They might include muscular weariness, [[hallucination]]s, and/or [[mental fatigue]].<ref name="Roth"/>