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Chronic Insomnia / Insomnia Disorder

Co-morbid Insomnia

Management of insomnia disorder needs to address any co-morbid medical or mental health condition, substance use or other sleep disorder that shares bi-directional relationships with the insomnia.

Insomnia can present as an independent condition, or co-morbid with other conditions:1, 2, 3, 4, 5

Even in the presence of co-morbid mental and physical health conditions, insomnia disorder warrants targeted assessment and treatment.

  • Other mental health conditions:

i. Depression

ii. Anxiety

iii. Post-Traumatic Stress Disorder (PTSD)

  • Physical conditions:

i. Gastroesophageal reflux

ii. Chronic pain

iii. Arthritis

iv. Dementia

v. Chronic obstructive pulmonary disease (COPD)

vi. Nocturia

vii. Hyperthyroidism

viii. Hypertension

ix. Insulin resistance

x. Menopause

xi. Obesity

  • Other sleep disorders

i. Obstructive Sleep Apnoea (OSA) (approximately one third of individuals with insomnia fulfil diagnostic criteria for OSA) 6

ii. Restless legs syndrome (an urge to move the limbs in the evening, that is partially or completely relieved by movement, which may cause difficulties with sleep onset)

iii. Narcolepsy

iv. Circadian rhythm sleep disorders

v. Parasomnias

vi. Periodic limb movement disorder

vii. Nightmares

  • Substance abuse

  • Drug or substance use/withdrawal

  • Alcohol dependence

While more intensive treatment of the above mentioned co-morbid chronic conditions should be carefully considered, insomnia often develops its own course (e.g. perpetuating factors) such that treating the other condition does not necessarily alleviate the insomnia. As well as being a potential result of having these comorbidities, insomnia is associated with increased risk of developing co-morbidities. Furthermore when co-occurring with other conditions, insomnia is responsive to targeted insomnia-treatment, which often improves management of the other condition too.(e.g. depression, pain). For example, untreated insomnia increases risk of future depression, while CBTi improves symptoms of depression. Therefore, it is recommended that insomnia is conceptualised as a ‘co-morbid’ condition when it presents with other disorders, to ensure adequate diagnostic and treatment attention for the insomnia.1, 7 Conceptualisations of ‘secondary insomnia’ (e.g. insomnia secondary to depression) are not supported by scientific evidence and should be avoided.


AHI - Apnoea-Hypopnoea Index
BBTi - Brief Behavioural Therapy for Insomnia
BMI - Body Mass Index (kg/m2)
BQ - Berlin Questionnaire
CBTi - Cognitive Behavioural Therapy for Insomnia
CELL - Coblation Endoscopic Lingual Lightening
COPD - Chronic Obstructive Pulmonary Disease
CVA - Cerebrovascular Accident
CPAP - Continuous Positive Airway Pressure
CSA - Central Sleep Apnoea
DASS - Depression Anxiety Stress Scale
DBAS - Dysfunctional Beliefs and Attitudes about Sleep
DBP - Diastolic Blood Pressure
DIMS - Difficulties Initiating and/or Maintaining Sleep
DISE - Drug-Induced Sleep Endoscopy
DISS - Daytime Insomnia Symptom Scale
ENT - Ear Nose and Throat
ESS - Epworth Sleepiness Scale
FOSQ - Functional Outcomes of Sleep Questionnaire
FSH - Follicle-Stimulating Hormone
FTP - Friedman Tong Position
GP - General Practitioner
HANDI - RACGP Handbook of Non-Drug Interventions
HGNS - Hypoglossal Herve Htimulation
ISI - Insomnia Severity Index
K10 - Kessler Psychological Distress Scale
MAD - Mandibular Advancement Device
MAS - Mandibular Advancement Rplint
MBS - Medicare Benefits Schedule
MMA - Maxillomandibular Advancement Surgery
MRA - Mandibular Repositioning Appliance
ODI - Oxygenation Desaturation Index
OSA - Obstructive Sleep Apnoea
PLMD - Periodic Limb Movement Disorder
PT - Positional Therapy
PTSD - Post-Traumatic Stress Disorder
PSG - Polysomnography
QSQ - Quebec Sleep Questionnaire
REM - Rapid Eye Movement
RFTB - Radiofrequency Thermotherapy of the Tongue Base
SBP - Systolic Blood Pressure
SCI - Sleep Condition Indicator
SE - Sleep Efficiency
SF36 - Short-Form (36) Health Survey
SMILE - Submucosal Minimally Invasive Lingual Excision
SNRIs - Serotonin-Norepinephrine Reuptake Inhibitors
SOL - Sleep Onset Latency
SSRI - Selective Serotonin Reuptake Inhibitors
TFTs - Thyroid Function Tests
TIB - Time In Bed
TORS - Transoral Robotic Surgery
TST - Total Sleep Time
UPPP - Uvulopalatopharyngoplasty
WASO - Wake After Sleep Onset

Quick links


  1. International Classification of Sleep Disorders, 3rd ed. Darien, IL: American Academy of Sleep Medicine. 2014
  2. Krystal AD. Psychiatric comorbidity: the case for treating insomnia. Sleep Med Clin 2006;1:359
  3. Katz DA, et al. Clinical correlates of insomnia in patients with chronic illness. Arch Intern Med 1998;158(10):1099–107
  4. GrimaNA, et al. Insomnia management. Australian Journal of General Practice, Formerly Australian Family Physician (AFP) 2019;48(4)
  5. Winkelman JW. Overview of the treatment of insomnia in adults. In UpToDate, Benca R (ed). Waltham, MA: UpToDate 2020
  6. Sweetman A, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with co-morbid insomnia: A randomized clinical trial. Sleep 2019;42(12)
  7. Buysse DJ. Insomnia. JAMA. 2013;309(7):706–16