Insomnia & Sleep Disorders
Sleep-Wake Disorders (DSM-5-TR)
Persistent difficulty initiating or maintaining sleep, early morning awakening, or nonrestorative sleep that impairs daytime functioning. Includes insomnia disorder, circadian rhythm disorders, and sleep disturbances secondary to anxiety, depression, PTSD, or chronic pain. One of the most common complaints in primary care and therapy.
Prevalence: ~10-15% chronic insomnia; ~30% intermittent insomnia symptoms in US adults
Clinical Picture
Insomnia is one of the most common clinical presentations and one of the most undertreated, often overshadowed by the conditions it co-occurs with (depression, anxiety, PTSD, chronic pain). CBT for Insomnia (CBT-I) is one of the most effective psychological treatments for any condition, with large effect sizes and durable gains — yet most therapists don't know how to deliver it. The mechanism is primarily behavioral: sleep restriction and stimulus control break the conditioned arousal that maintains insomnia, while cognitive components address the catastrophic thinking about sleeplessness that perpetuates the cycle.
Treatment Considerations
CBT-I is the clear first-line treatment, recommended over medication by the American College of Physicians. It typically requires 4-8 sessions and can be delivered in person, via telehealth, or through guided digital programs. For insomnia co-occurring with other conditions, treating the insomnia directly (rather than assuming it will resolve when the 'primary' condition improves) often produces better outcomes for both. Mindfulness-based approaches and ACT adaptations for insomnia are showing promise as alternatives or adjuncts. Sleep difficulties in PTSD may require trauma-specific interventions (e.g., Imagery Rehearsal Therapy for nightmares).
5 Therapeutic Approaches
Sorted by evidence tier: guideline-recommended first, then RCT-supported, then emerging/limited evidence.
Related Clinical Vignettes
Sources & References
Prevalence data from NIMH, WHO, and DSM-5-TR field trial publications. Evidence tiers reflect guideline status (APA, NICE, VA/DoD, WHO) and meta-analytic findings as of early 2025. Individual modality citations are listed on each modality page. Full bibliography available on the Sources page.