Clinical Vignette
Patient: "Mrs. K," 45-year-old accountant, presenting with 8-month history of difficulty falling asleep and staying asleep despite adequate opportunity.
Chief Concern: "I lie in bed for 2 hours before I fall asleep. Then I wake up at 3 AM and can't get back to sleep. I'm exhausted all day, making mistakes at work, and snapping at my kids. I've tried melatonin, chamomile tea, and sleep podcasts. Nothing works."
History of Present Illness: Mrs. K reports an 8-month history of sleep difficulty that began after a stressful tax season. Initial trigger resolved, but sleep difficulty persisted. Current pattern: goes to bed at 10 PM, lies awake until midnight (sleep onset latency 2 hours), falls asleep, wakes at 3 AM (sleep maintenance difficulty), remains awake until alarm at 6:30 AM. Total sleep: approximately 3.5 hours. She experiences: daytime fatigue, concentration difficulty (accounting errors at work), irritability, and anxiety about sleep ('I start dreading bedtime at 5 PM'). Sleep hygiene behaviors (maladaptive): watches TV in bed for 1-2 hours, uses phone in bed scrolling social media, stays in bed when awake ('hoping I'll fall asleep'), takes long daytime naps (1-2 hours on weekends), irregular weekend schedule (stays up until 2 AM, sleeps until noon). She has adequate opportunity for sleep (bedroom is dark, quiet, temperature-controlled). She does not have sleep apnea symptoms (no snoring, no witnessed apneas, normal BMI). She does not have restless legs. No substance use contributing (no caffeine after noon, no alcohol).
Past Psychiatric History: Treated for GAD 5 years ago (resolved with CBT). Current worry is sleep-focused rather than generalized.
Mental Status Exam: Appears fatigued. Dark circles under eyes. Yawned 3 times during interview. Speech normal. Mood 'exhausted and frustrated.' When discussing bedtime routine, affect became anxious ('I just know I won't sleep'). Describes 'racing thoughts about not sleeping' when she gets into bed. No depression beyond fatigue-related irritability. No psychotic symptoms.
Step 1: Insomnia Disorder DSM-5-TR Criteria
Criterion A: Predominant complaint of dissatisfaction with sleep quantity or quality, associated with ≥1: (1) difficulty initiating sleep, (2) difficulty maintaining sleep, (3) early-morning awakening with inability to return to sleep.
(1) 2-hour sleep onset latency. (2) 3 AM awakening with inability to return to sleep. Both sleep onset AND maintenance insomnia present. MET — onset AND maintenance.
Criterion B: Sleep disturbance causes clinically significant distress or impairment.
Work errors. Irritability affecting family relationships. Daytime fatigue. Anxiety about sleep. MET.
Criterion C: Occurs ≥3 nights per week.
Occurs 5-7 nights per week. MET.
Criterion D: Persists for ≥3 months.
8-month duration. MET.
Criterion E: Occurs despite adequate opportunity for sleep.
Adequate opportunity: dark, quiet bedroom; goes to bed at 10 PM; 8.5-hour sleep opportunity. MET.
Criterion F: Not better explained by another sleep-wake disorder.
No sleep apnea symptoms. No restless legs. No narcolepsy. No circadian rhythm disorder. MET.
Criterion G: Not attributable to physiological effects of a substance.
No caffeine after noon. No alcohol. No medications affecting sleep. MET.
Criterion H: Coexisting mental disorders and medical conditions do not adequately explain the insomnia.
Prior GAD resolved. Current anxiety is specifically about sleep (conditioned arousal), not generalized worry. MET.
Step 2: Perpetuating Factors (Spielman's 3P Model)
| Factor Type | Description | This Patient |
|---|---|---|
| Predisposing | Traits that increase vulnerability to insomnia | History of GAD (anxiety trait) |
| Precipitating | Events that trigger the initial insomnia episode | Stressful tax season 8 months ago (RESOLVED) |
| Perpetuating | Behaviors/cognitions that MAINTAIN insomnia after trigger resolves | TV/phone in bed, staying in bed awake, daytime naps, irregular schedule, anxiety about sleep (conditioned arousal) |
Treatment Target
The precipitating stressor has resolved; the insomnia is maintained by PERPETUATING factors (maladaptive sleep behaviors and conditioned arousal). CBT-I targets these perpetuating factors directly: sleep restriction, stimulus control, and cognitive restructuring of sleep-related anxiety.
Diagnostic Formulation
Diagnostic Conclusion
Insomnia Disorder, Chronic, with Non-Sleep Disorder Mental Comorbidity (G47.00): All DSM-5-TR criteria met. Combined sleep onset + maintenance insomnia. 8-month duration. Maintained by maladaptive behaviors and conditioned arousal. Treatment: CBT-I (Cognitive Behavioral Therapy for Insomnia — FIRST-LINE, preferred over medication): (1) Sleep restriction (reduce time in bed to match actual sleep time — 4 hours initially, expand gradually). (2) Stimulus control (bed = sleep only; leave bed if awake >20 minutes). (3) Cognitive restructuring (challenge catastrophic sleep thoughts). (4) Sleep hygiene (no screens in bed, consistent wake time). (5) Relaxation training if needed. Pharmacotherapy: only if CBT-I is insufficient or unavailable — short-term sedative-hypnotic (zolpidem) or melatonin-receptor agonist (ramelteon).
Teaching Points
- CBT-I (Cognitive Behavioral Therapy for Insomnia) is the FIRST-LINE treatment for chronic insomnia, recommended OVER pharmacotherapy by the American Academy of Sleep Medicine, the American College of Physicians, and the European Sleep Research Society. CBT-I has equivalent short-term efficacy to medication AND superior long-term outcomes (benefits persist after treatment ends; medication effects cease when medication stops).
- Sleep restriction therapy is the most powerful component of CBT-I. It works by creating mild sleep deprivation, which increases sleep drive and consolidates sleep. If a patient sleeps 3.5 hours, their 'sleep window' is initially restricted to 4 hours (e.g., 2 AM-6 AM). As sleep efficiency improves (>85%), the window is expanded by 15-30 minutes.
- Stimulus control addresses conditioned arousal: when the bed becomes associated with wakefulness rather than sleep, the bed itself becomes a cue for wakefulness. Stimulus control rules: (1) use bed only for sleep (and sexual activity), (2) go to bed only when sleepy, (3) leave bed if unable to sleep within 20 minutes, (4) maintain consistent wake time regardless of sleep quality.
- Spielman's 3P model (Predisposing, Precipitating, Perpetuating) explains why insomnia becomes chronic: the initial trigger (precipitating factor) may resolve, but maladaptive compensatory behaviors (perpetuating factors) maintain the insomnia. Treatment targets the perpetuating factors, which is why CBT-I is effective even when the original trigger is long gone.
- Long-term use of benzodiazepine receptor agonists (zolpidem, eszopiclone) for insomnia carries risks: tolerance, dependence, rebound insomnia, next-day impairment, and complex sleep behaviors (sleep-walking, sleep-driving). These medications should be used only short-term and when CBT-I is insufficient or unavailable.