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: ~30-35% of adults report insomnia symptoms; ~10% meet criteria for chronic insomnia disorder, with published estimates running from 6% to 15% depending on how strictly daytime impairment is required
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. Before starting the sleep restriction component, screen for obstructive sleep apnea, which can masquerade as insomnia and worsens under restriction, and use restriction cautiously or not at all with bipolar disorder, where sleep loss can precipitate mania, and with seizure disorders, where sleep deprivation lowers the threshold. Warn clients that the first weeks bring real daytime sleepiness, which matters if they drive or operate machinery. 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).
Approaches and Evidence
Of 5 associated approaches, 1 have completed assessments for this topic, 0 have source checks awaiting assessment, and 4 have neither recorded yet. Each completed assessment states its population and rationale; source checks alone do not establish effectiveness. These categories describe different findings and review stages; they are not a ranking of treatments.
Guideline recommendation (1)
These assessments record a guideline recommendation for the stated population. Read the scope and rationale; a broad topic label does not make a recommendation applicable to everyone.
Cognitive Behavioral Therapy for Insomnia
Bootzin / Spielman / Morin / Perlis · 1987
Reviewed population: Adults with chronic insomnia disorder receiving multicomponent CBT-I. This assessment concerns insomnia, including when it co-occurs with another condition; it does not grade treatment of obstructive sleep apnea, circadian disorders or the co-occurring diagnosis itself.
AASM’s 2021 recommendation 1 and VA/DoD’s 2025 recommendation 5 strongly recommend multicomponent CBT-I for adult chronic insomnia. VA/DoD recommendation 8 only weakly favors CBT-I over medication as initial treatment. AASM’s 2026 combination guideline conditionally favors CBT-I alone over starting CBT-I and medication together, with low-certainty evidence and preference-based exceptions. The guideline label therefore applies to the defined insomnia treatment, not sleep hygiene alone, every digital program, every sleep disorder or universal superiority to medication.
Reviewed
- American Academy of Sleep Medicine (2021-02-01; JCSM 17(2):255–262; DOI 10.5664/jcsm.8986): Behavioral and psychological treatments for chronic insomnia disorder in adults — Methods and Table 1, printed p. 256 / physical PDF p. 2; Recommendation 1 and Remarks, printed p. 257 / physical PDF p. 3
- US Department of Veterans Affairs / Department of Defense (Version 3.0; January 2025; evidence through 2024-03-31; current PDF filename dated 2025-09-15): Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea — Table 4, recommendations 5 and 8, printed/PDF p. 34
- American Academy of Sleep Medicine (2026-04-13; JCSM 22:56; evidence through June 2025): Combination treatment for chronic insomnia disorder in adults — Recommendations 1 and 2 and remark to Recommendation 2, physical PDF p. 1; Methods/Introduction, physical PDF pp. 1–2; current AASM Practice Guidelines directory
Guidelines and official sources (5)
5 clinical guideline checks
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Behavioral and psychological treatments for chronic insomnia disorder in adults
Recommendation for the stated population
AASM strongly recommends multicomponent CBT-I. Its 2021 review did not directly compare psychotherapy with medication.
Scope: Adults with chronic insomnia disorder, with or without comorbidities
- Combination treatment for chronic insomnia disorder in adults
Recommendation for the stated population
AASM conditionally favors CBT-I plus medication over medication alone, and CBT-I alone over the combination; both use low-certainty evidence and allow preference-based exceptions.
Scope: Adults with chronic insomnia; concurrent initiation of medication and CBT-I
- Management of chronic insomnia disorder in adults
Recommendation for the stated population
ACP recommends CBT-I initially; after an unsuccessful course, it suggests shared decisions about adding short-term medication.
Scope: Adults with chronic insomnia disorder
- Daridorexant for treating long-term insomnia (TA922)
Discussed in the source
NICE describes CBT-I as the standard first treatment; daridorexant eligibility requires CBT-I to have failed, be unavailable or be unsuitable. This is a drug technology appraisal, so identify that context.
Scope: Adults with long-term insomnia being considered for daridorexant
- Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea
Recommendation for the stated population
VA/DoD strongly recommends CBT-I and weakly favors CBT-I over medication initially. These recommendations address insomnia, not treatment of its comorbid diagnoses.
Scope: Adults with chronic insomnia disorder; initial treatment selection.
Assessment not yet completed (4)
No completed assessment or source check for this topic is recorded yet.
Acceptance and Commitment Therapy
Steven Hayes · 1999
Clinical Hypnotherapy
Milton Erickson · 1950
Mindfulness-Based Cognitive Therapy
Segal / Williams / Teasdale · 2002
Supportive Psychotherapy
Various (Rockland, Winston) · 1950
Additional Source References (3)
These source checks also address this topic. They are listed separately from the catalogue associations above. Read each source’s scope and direction; a mention may concern a related intervention or a neutral recommendation.
Imagery Rehearsal Therapy
Guidelines and official sources (1)
1 professional reference check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Position paper for the treatment of nightmare disorder in adults
Recommendation for the stated population
AASM recommends IRT for these nightmare presentations. It calls this a position paper, not a graded CPG.
Scope: Adults with nightmare disorder or PTSD-associated nightmares
Mindfulness-Based Stress Reduction
Guidelines and official sources (1)
1 clinical guideline check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea
Discussed in the source
VA/DoD finds insufficient evidence for or against mindfulness meditation for insomnia. This is a category-level statement, not a separate grade for MBSR; evidence was not newly reviewed for this recommendation.
Scope: Mindfulness meditation as a primary treatment for adult chronic insomnia disorder.
Motivational Interviewing
Guidelines and official sources (1)
1 clinical guideline check
Read the recommendation and its scope. A source may discuss an approach without recommending it.
- Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea
Discussed in the source
The discussion advises a patient-centered motivational interviewing approach to encourage engagement in insomnia treatment. It does not grade MI as a standalone insomnia treatment.
Scope: Encouraging adults reluctant to engage in CBT-I or brief behavioral treatment for insomnia.
Cases Featuring Associated Approaches
These teaching cases share approach links with this topic. They may illustrate a different presenting concern.
Reading This Page
Why are these approaches listed with Insomnia & Sleep Disorders?
The catalogue associates 5 approaches and 0 frameworks with this topic. These links support learning and comparison; association alone is not a treatment recommendation or evidence of effectiveness.
How should I read the evidence assessments?
Assessments are specific to the population and scope stated on each card. They include a rationale, source links, and a review date. An overall review of an approach does not automatically apply to this condition, and a randomized-study label does not by itself mean that a study found benefit.
What does "Assessment not yet completed" mean?
A condition-specific assessment has not been recorded. Approaches with checked sources appear in a separate assessment-pending group; a checked source can support, oppose, or discuss an intervention without recommending it. Neither pending group means that no research exists or that the approach is ineffective. Frameworks are shown separately.
Sources and Review Scope
Source links and dates on assessment cards apply to the stated population and rationale. The clinical overview and prevalence text above are separate authored content; an approach's evidence label does not verify those statements. Recorded narrative notes and citations remain available on individual modality pages, with their review status identified. The bibliography provides further reading.