Insomnia assessment and treatment
Insomnia assessed against the diagnostic criteria: history, sleep diary, ruling out other sleep disorders, and only then choosing a direction. In person or by video.
Key points
- Insomnia is a clinical diagnosis based on history and a sleep diary, not on laboratory tests.
- The most important task of the first consultation is RULING OUT: sleep apnoea, restless legs syndrome, circadian rhythm disorders and physical illness can all look like insomnia.
- International guidelines place CBT-I first line for chronic insomnia. Medication is an adjunct or a short-term option, not the starting point.
- Video consultation suits this condition: most of the diagnosis comes from history and the diary, and both work over video.
Who this is for
- Insomnia lasting more than 3 months, on 3 or more nights a week.
- You have tried many remedies and many sleep aids without improvement.
- You are taking sleeping pills and want to know whether there is another way.
- Insomnia alongside stress, anxiety or low mood.
- You sleep enough hours but are still exhausted during the day. This situation needs other sleep disorders ruled out.
Why the first consultation takes longer than you expect
There is no confirmatory test for insomnia. No blood marker, no scan that says "this is insomnia". The whole diagnosis lies in reconstructing your sleep in enough detail to see the pattern, then ruling out other conditions that produce a similar pattern. That is the work of taking a history, and it takes time.
A ten-minute appointment ending in a prescription for sleeping pills does not solve this. It may get you a few nights of sleep, which is why that approach is common. But if the cause is sleep apnoea the medication makes it worse; if the cause is a circadian rhythm disorder the medication does not touch the cause; and if it genuinely is psychophysiological insomnia, the medication covers the symptom while the maintaining mechanism stays exactly where it was.
Three patterns of insomnia, three directions
| Pattern | What patients usually say | Main intervention |
|---|---|---|
| Trouble falling asleep | I lie there for an hour, my mind will not stop | Stimulus control, relaxation techniques, working on worry about sleep itself |
| Trouble staying asleep | I get to sleep, then wake at 2 or 3am and lie there until morning | Sleep restriction, review of physical causes and evening alcohol |
| Waking too early | I am awake at 4am and cannot get back to sleep | Consider circadian rhythm and low mood. This pattern often travels with depression |
What to bring to the consultation
- A sleep diary if you have kept one. Even a few days beats trying to remember.
- A list of EVERYTHING you take: prescriptions, over-the-counter medicines, supplements, herbal teas.
- Recent test results if you have them, thyroid function and full blood count above all.
- Information from whoever sleeps next to you: do you snore, do you stop breathing, do your legs move a lot. Patients almost never know these things themselves.
How long until it improves
With behavioural therapy, most people see a clear change after 4 to 6 weeks, and a full course usually fits into 6 to 8 sessions. The first week is harder rather than easier, because sleep restriction deliberately creates a little sleep loss in order to concentrate sleep pressure. Knowing this in advance is part of the treatment: people who drop out almost always drop out in week one.
How it works
- Taking a sleep history
Reconstructing a typical night of yours by the clock: when you go to bed, how long until you fall asleep, how many times you wake, when you wake for good, when you get up. This part decides the direction of treatment more than any test, because the three patterns of insomnia - trouble falling asleep, trouble staying asleep, waking too early - are handled differently.
- Ruling out other sleep disorders
Loud snoring, witnessed pauses in breathing, a restless urge to move the legs at night, unusual behaviour during sleep, excessive daytime sleepiness: each points to a different condition with a different treatment. Skipping this step is the most common reason insomnia treatment does not work.
- Reviewing other conditions and current medication
Thyroid disease, chronic pain, reflux, waking to urinate, lung disease, the perimenopausal years, depression and anxiety all cause insomnia. So do many commonly used medicines. The list of what you are taking is valuable information, supplements included.
- A sleep diary for 1 to 2 weeks
This is standard practice, not paperwork. International guidelines do not use polysomnography to diagnose ordinary insomnia; the diary gives exactly what is needed: sleep efficiency and the factors keeping the problem going.
- Choosing a direction and setting follow-up
For chronic insomnia, international guidelines place cognitive behavioural therapy (CBT-I) first line, ahead of medication. Follow-up is scheduled from the first visit, because this approach is measured in weeks rather than days.
Frequently asked questions
- Do I need a sleep study?
- Usually no. The American Academy of Sleep Medicine guideline states clearly that polysomnography is not used routinely to diagnose insomnia. That test is needed when sleep apnoea, periodic limb movement disorder or unusual behaviour during sleep is suspected.
- Is a video consultation enough?
- For insomnia it is enough in most cases, because the diagnosis rests on history and the diary. Where a sleep study or a physical examination is needed, you will be directed to an appropriate facility.
- I am taking sleeping pills. Should I stop before the consultation?
- No, and do not stop on your own. Stopping some of them abruptly can cause worse rebound insomnia and carries other risks. Come as you are and bring the name, the dose and how long you have been taking it.
References
- Behavioral and psychological treatments for chronic insomnia disorder in adults: an AASM clinical practice guideline - American Academy of Sleep Medicine, 2021 · DOI 10.5664/jcsm.8986
- International Classification of Sleep Disorders, 3rd edition, Text Revision (ICSD-3-TR). Darien, IL - American Academy of Sleep Medicine, 2023
- Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults - American Academy of Sleep Medicine, 2008 · DOI 10.5664/jcsm.27286
- Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline from the American College of Physicians - American College of Physicians, 2016 · DOI 10.7326/M15-2175