Towards quantitative cut-offs for insomnia: how current diagnostic criteria mischaracterize remission.

Publication date: Available online 13 February 2016
Source:Sleep Medicine
Author(s): Vivek Pillai, Thomas Roth, Christopher L. Drake
ObjectiveThough sleep symptoms of insomnia can be quantified, none of the current diagnostic systems stipulate quantitative cut-offs for sleep-onset-latency (SOL) or wake-time-after-sleep-onset (WASO). Diagnoses are based instead on idiographic patient reports of 'difficulty' falling/staying asleep. Therefore, we examined whether remission of insomnia per diagnostic criteria results from a normalization of quantitative sleep disturbance, or if it is simply reflective of tolerance to sleep symptoms.MethodsThis study involved a year-long prospective investigation of 649 adults (48.1±11.6 y; 69.3% female) with DSM-5 based insomnia. Participants completed measures of sleep disturbance, perceived sleep-related distress, daytime sleepiness, functional impairment, and workplace productivity at baseline and follow-up one year later.Results271 participants no longer met DSM-5 based insomnia criteria at follow-up. However, 66% of these remitters reported ≥ 31 minutes of SOL and/or WASO. Importantly, daytime impairment in this subgroup of remitters was no different than among individuals who met diagnostic criteria at both baseline and follow-up (i.e., chronic insomniacs). By contrast, follow-up impairment was significantly lower (F = 12.3; p < .01) among remitters whose sleep disturbance returned below empirically-derived quantitative cut-offs (both SOL & WASO < 31 minutes) than in chronic insomniacs.ConclusionThis is the first study on the long-term course of insomnia based on the newly established DSM-5 criteria. A troubling implication of findings is that a majority of insomniacs stop meeting diagnostic criteria despite continued sleep disturbance and impairment. 'Remission' in these cases is attributable instead to tolerance of sleep symptoms. Incorporating quantitative criteria into current diagnoses may offer a more sensitive assay of treatment needs.



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