Challenges with falling asleep, staying asleep, or returning to sleep are symptoms listed in the DSM 5 as the criteria of a sleep-wake disorder known as insomnia.
Almost everyone experiences periods of disrupted sleep. Worry, changes in your daily activity or routine, and temperature are all common things that can prevent a restful night.
One night of poor sleep doesn’t mean you’re living with insomnia.
But when the inability to sleep becomes a pattern over time, you may be experiencing a sleep disorder.
Insomnia is listed as a sleep-wake disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, revised text (DSM-5-TR). The condition has three primary symptoms.
- Challenges falling asleep (onset insomnia): inability to fall asleep beyond 20-30 minutes
- Inability to maintain sleep (middle insomnia): frequent waking during the night after sleep onset beyond 20-30 minutes, and difficulty returning to sleep after mid-night waking
- Early-morning wakefulness (late insomnia): waking at least 30 minutes before the desired time and before sleep reaches 6.5 hours (often accompanied by an inability to resume sleep at all)
While only these symptoms are present in the DSM-5-TR for insomnia, how those symptoms present and how long you experience them are important for determining whether you have the condition.
Because not everyone requires the same amount of sleep, a healthcare or mental health professional will take into account what your ideal sleep duration may be, based on factors such as your past sleep history, age, and activity level.
Under a DSM-5-TR insomnia diagnosis, insomnia sleep disturbances are those that impact your daily function and negatively affect you socially, occupationally, or in other important areas of life.
Other DSM-5-TR insomnia disorder criteria necessary for diagnosis include:
- sleep difficulty is present at least 3 nights per week and for a period of at least 3 months
- you’re unable to sleep even with ample opportunity
- no other sleep-wake disorder, substance, or coexisting mental health condition explains the insomnia experience
DSM-IV-TR vs. DSM-5-TR
Insomnia disorder was included in the DSM-IV-TR, the version of the DSM that predates the DSM-5-TR.
In the DSM-IV-TR, insomnia was less defined. 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. For a diagnosis, symptoms had to be present for a period of 1 month.
The DSM-5-TR elaborated on the experience of insomnia, stating that it occurred at least 3 nights a week, happened even under ideal circumstances, and was present for a period of at least 3 months.
If any of those criteria weren’t met or posed exceptions to the rule, specifiers were added to include more subtypes of insomnia disorder.
Insomnia disorder can come with diagnostic specifiers. Specifiers are conditions noted in the DSM-5-TR that set one presentation of insomnia apart from another.
In general, insomnia occurs in two forms:
- short term
Short-term insomnia, listed in the DSM-5-TR as episodic insomnia, lasts for at least 1 month but less than 3 months.
Chronic insomnia is often listed as insomnia that lasts beyond 3 months. The DSM-5-TR breaks it down into two additional categories:
- persistent (lasting 3 months or longer)
- recurrent (two or more episodes within a single year)
Several other specifiers can be added to an insomnia disorder diagnosis such as:
- with non-sleep disorder mental comorbidity (occurring alongside another condition, including substance use disorder)
- with other sleep disorders
- with another medical comorbidity (occurring alongside a physical condition)
Other specified insomnia
Several diagnoses in the DSM-5-TR include a category of “other specified” or “unspecified.”
This specifier is used when you’re experiencing almost all the symptoms of a condition, or a mixed bag of symptoms, that can’t clearly be grouped under an existing diagnosis.
If your symptoms are causing you distress but don’t meet the full criteria for an insomnia diagnosis, a healthcare or mental health professional may use this identifier moving forward.
There are other reasons you might receive an unspecified DSM-5-TR insomnia diagnosis.
Situational insomnia, aka acute insomnia, is recognized by the DSM-5-TR as insomnia symptoms that meet all the criteria except the minimum duration requirement.
This form of insomnia is often related to life events or sleep schedule changes.
Another reason for an unspecified diagnosis may be the presence of only nonrestorative sleep. This symptom was originally listed in the DSM-IV-TR as a primary symptom of insomnia disorder.
While it’s no longer included as part of the DSM-5-TR criteria, experiencing only nonrestorative sleep for an extended period of time may warrant a diagnosis of “other specified insomnia” if no other condition is identified as the cause.
Insomnia as a feature vs. a diagnosis
Insomnia can be both an independent diagnosis and a feature of other mental and physical conditions.
As a feature, insomnia represents challenges in sleeping but may not meet the full diagnostic criteria of a disorder.
When you’re living with insomnia disorder, your symptoms meet the sleep disturbance descriptions as well as the outlined time frames and levels of impairment cited in the DSM-5-TR.
If you’ve received a DSM-5-TR insomnia diagnosis, your primary symptoms will involve at least one of the following:
- difficulty falling asleep
- challenges maintaining sleep
- inability to fall back asleep after an early-morning wake up
These three symptoms define an insomnia diagnosis, regardless of type. How those symptoms manifest in your daily life is often unique.
You may experience:
- daytime sleepiness
- mood fluctuations
- declining work or school performance
- difficulty concentrating
- lack of focus
- memory lapses
- erratic sleep schedules
- excessive napping
- spending more time in bed
- preoccupation with being unable to sleep
- decreased energy
- emotional reactivity
- muscle pain
- gastrointestinal upset
Several factors can influence how insomnia affects your thoughts and actions. If you’re living with insomnia disorder and major depressive disorder, for example, you may find symptoms of low mood are more prevalent for you.
Not everyone shows symptoms that directly reflect the severity of sleep disturbance.
You may experience insomnia for years, most nights of the week, but outwardly show minimal signs to those around you.
The DSM-5-TR lists several sleep disorders in addition to insomnia. This includes:
- hypersomnolence disorder
- obstructive sleep apnea hypopnea
- central sleep apnea
- sleep-related hypoventilation
- circadian rhythm sleep-wake disorders
- non-rapid eye movement sleep arousal disorders
- nightmare disorder
- rapid eye movement sleep behavior disorder
- restless legs syndrome
- substance or medication-induced sleep disorder
- other or unspecified sleep disorder
All these sleep disorders have their own criteria that set them apart from insomnia.
For many of them, specific sleep challenges are essential to the diagnosis and are the dominant feature even if insomnia is present.
For example, central sleep apnea involves breathing patterns that are critical to the diagnosis. Similarly, restless legs syndrome has symptoms specific to leg sensations and movement that aren’t part of the diagnostic criteria for insomnia.
Insomnia can be an independent condition or a feature of another primary condition. It’s characterized by challenges with falling asleep, staying asleep, and resuming sleep in the mornings.
When you live with insomnia, sleeplessness is often only one of the tell-tale signs. Irritability, trouble concentrating, and physical aches and pains can all be a part of the insomnia experience.
Insomnia is often treatable. It may improve as other co-occurring conditions improve, and it may lessen in severity with treatment and lifestyle changes.
To learn more about insomnia disorder, treatment, or where to find support, you can visit:
- American Sleep Association
National Center on Sleep Disorders Research
- Better Sleep Council
- Find a sleep therapist through the Anxiety & Depression Association of America
If you’re wondering if you may have a sleep disorder, consider taking our sleep quiz.