The VA should cease and desist using their flawed insomnia disorder disability guidance:
How did the VA get insomnia disorder disability claims so wrong?
The VA is wrong. More specifically: The VA’s guidance related to insomnia disorder disability claims is wrong.
- This shouldn’t be a huge surprise since they made a big change related to insomnia without going through a public comment period.
The VA’s incorrect guidance perpetuates an outdated view related to primary insomnia that the field has moved away from- including the DSM-5. This primary insomnia view is not reflected in the DSM-5.
- What is the DSM-5? It is the current edition of the diagnostic manual for mental disorders (published in May of 2013). It is the book that sets the rules for how we diagnose mental disorders.
The VA’s guidance actually misquotes and dramatically mischaracterizes what the DSM-5 actually says. What does the VA’s guidance say that the DSM-5 says?
You can read it here M21-1, Part V, Subpart iii, Chapter 13 – Mental Disorders
Notes:
DSM-5 revised the diagnostic terminology from “primary insomnia” to “insomnia disorder.” In both the current and prior versions of DSM, the diagnostic criteria includes ruling out all other potential causes. Accordingly, a valid diagnosis of insomnia disorder meeting DSM-5 criteria means that the insomnia condition is not caused by (or secondary to) any other condition.
This statement above is actually false. The VA’s guidance dramatically misrepresents what the DSM-5 actually says. It is true that the DSM-5 got rid of primary insomnia, but the statement “In both the current and prior versions of DSM, the diagnostic criteria includes ruling out all other potential causes” is incorrect. This ignores the whole reason the DSM-5 got rid of the concept of primary insomnia. Had the VA done a proposed rulemaking for this big change, they would have heard from actual experts about how wrong they are.
On page 410 of the DSM-5-TR you can see the DSM-5 actually contradicts what the VA is pretending the DSM-5 says. The DSM-5 actually says things like:
The diagnosis of insomnia disorder is given whether it occurs as an independent condition or is comorbid with another mental disorder (e.g. major depressive disorder), medical condition (e.g. pain), or another sleep disorder (e.g. breathing-related sleep disorder). For instance, insomnia may develop its own course with some anxiety and depressive features without those features meeting criteria for any one mental disorder. Insomnia may also manifest as a clinical feature of a more predominant mental disorder. Persistent insomnia is a risk factor for depression, anxiety disorders, and alcohol use disorder and is a common residual symptom after treatment for these conditions. When insomnia is comorbid with a mental disorder, treatment may need to target both conditions. Given these different courses, it is often impossible to establish the precise nature of the relationship between these clinical entities, and this relationship may change over time. Therefore, in the presence of insomnia and a comorbid disorder, it is not necessary to make a causal attribution between the two conditions. Rather, the diagnosis of insomnia disorder is made with concurrent specification of the comorbid conditions. A concurrent insomnia diagnosis should only be considered when the insomnia is sufficiently severe to warrant independent clinical attention; otherwise, no separate diagnosis is necessary.
The DSM-5 literally includes specifiers for insomnia disorder that include “with mental disorder;” “with medical condition;” and “with another sleep disorder” (see pg. 410). This is dramatically different from the incorrect guidance from the VA noting that an insomnia disorder diagnosis in DSM-5 means “the insomnia is not associated with any other underlying disease or injury.” The VA’s guidance is inconsistent with the DSM-5 and is clearly and unmistakably wrong.
Under the Development and Course section for Insomnia Disorder (see DSM-5-TR pg. 413); the DSM-5 notes:
Insomnia can be situational, persistent, or recurrent. Situational or acute insomnia usually lasts a few days or a few weeks and is often associated with life events or rapid changes in sleep schedules or environment. It usually resolves once the initial precipitating event subsides. For some individuals, perhaps those more vulnerable to sleep disturbances, insomnia may persist long after the initial triggering event, possibly because of conditioning factors and heightened arousal. The factors that precipitate insomnia may differ from those that perpetuate it. For example, an individual who is bedridden with a painful injury and has difficulty sleeping may then develop negative associations for sleep. Conditioned arousal may then persist and lead to persistent insomnia. A similar course may develop in the context of an acute psychological stress or a mental disorder.
The DSM-5 diagnostic criterion H. (see pg. 410 of the DSM-5-TR) for insomnia disorder recognizes that there can be “coexisting mental disorders and medical conditions.” It notes that to diagnose insomnia disorder these should not “adequately explain the predominant complaint of insomnia.” This is very different than what the VA’s guidance says. The diagnostic criteria DOES NOT include “ruling out all other potential causes” or that “a valid diagnosis of insomnia disorder meeting DSM-5 criteria means that the insomnia condition is not caused by (or secondary to) any other condition.” In fact, many times a mental disorder or medical condition alone does not “adequately explain the predominant complaint of insomnia.” The adequate explanation includes perpetuating factors caused by the medical condition or mental disorder (as noted above the DSM-5 gave the example of “conditioned arousal”). The example above clearly indicates the DSM-5 intends for someone having “a painful injury” can also be diagnosed with insomnia disorder as “conditioned arousal may then persist and lead to persistent insomnia.”
The DSM-5 isn’t the only diagnostic manual we can consult for expertise; we can look at the International Classification of Sleep Disorders, third edition (ICSD-3-TR). The ICSD-3-TR is the diagnostic manual from the American Academy of Sleep Medicine (AASM). It was published around 10 years after the DSM-5 was first published. It contains the current perspective and scientific advances from experts in the field of Sleep Medicine. The wording for chronic insomnia disorder includes the phrasing that “the sleep disturbance and associated daytime symptoms are not solely due to another current sleep disorder, medical disorder, mental disorder, or medication/substance use.” The inclusion of solely can be seen as a similar approach to DSM-5’s indication that the insomnia is not adequately explained by another condition.
- In relation to this criterion of not “solely” being due to another disorder, the AASM provided notes (see pg 34). They noted that “comorbidity does not preclude the independent diagnosis of chronic insomnia disorder. Evidence has clearly shown that even when a co-occurring disorder has instigated the insomnia, the sleep disturbance often transforms into an independent, self-sustaining disorder. By the time such a patient presents with an insomnia complaint to a health care provider, the insomnia is usually either independent of the comorbidity or shares a reciprocal relationship with it. It is therefore difficult to determine, in practice, if an insomnia disorder is solely due to” another disorder.
- On pg. 30-31 of the ICSD-3-TR, the American Academy of Sleep Medicine notes “insomnia symptoms often accompany comorbid medical illnesses, mental disorders, and other sleep disorders. Insomnia symptoms may also arise with the use, abuse, or exposure to certain substances. A separate insomnia disorder diagnosis is warranted when the insomnia symptoms are persistent and result in distress or impairment.” This statement from the American Academy of Sleep Medicine also contradicts the incorrect policy guidance the VA gave.
- The AASM noted on pg. 31 that the nosology for ICSD-3 is a “marked departure” from the ICSD-2’s conceptual framework; the AASM “the previous insomnia nosology of the ICSD-2 promoted the concept that insomnia can exist as a primary sleep disorder or arise as a secondary form of sleep disturbance related to an underlying primary psychiatric, medical, or substance use disorder. However, differentiation between primary and secondary subtypes is difficult, if not impossible. More importantly, even when another condition initially causes the insomnia, it often develops into an independent disease entity that merits clinical attention… insomnia disorder seems best viewed as a comorbid disorder that warrants separate treatment attention.”
- On pg. 42 of the ICSD-3-TR the AASM clearly indicates that other disorders can be precipitating factors for a chronic insomnia disorder. For example, the AASM notes “…medical disorders such as gastroesophageal reflux disease or conditions that result in chronic pain, breathing difficulties, or immobility can also lead to chronic insomnia disorder.”
- The AASM notes on pg. 43 “among adults, the onset of chronic insomnia disorder often has a clear precipitating major life event.” These can be medical or psychological conditions.
The VA’s guidance is a misquote based on an archaic view of primary insomnia. The field has left the VA’s guidance behind (even before the publication of the DSM-5 back in May 2013). As noted by Perlis, et. al. [see Cognitive Behavioral Treatment of Insomnia: A session-by-session guide; Springer; 2005] “In the early 1980s, as the Sleep Medicine movement was just gathering steam, there was perhaps no rallying cry as popular as ‘insomnia is a symptom, not a disorder.’ Presumably, this position was adopted because it was genuinely believed that the polysomnographic (PSG) study of sleep was destined to reveal all the underlying pathologies that give rise to the ‘symptoms’ of not only insomnia but fatigue and sleepiness as well. After more than two decades of sleep research and sleep Medicine, it is interesting to find that ‘all things old are new again’: Insomnia is once again considered a distinct nosological entity.”
The VA’s own expert from the National Center for PTSD (Elissa McCarthy, PhD) also contradicts the VA’s guidance on insomnia disorder disability claims. In the CE presentation “PTSD and Insomnia: Cultural and Clinical Considerations,” the VA’s own expert notes (and you can hear it yourself starting at the 13 minute and 39 second mark of this video) that:
“We know that insomnia disorder is common in comorbidities with other mental health disorders and conditions and that should not preclude you from making the diagnosis. In the past insomnia was viewed as a symptom of other disorders and was not thought to require its own clinical attention or intervention. We’ve learned that maladaptive coping strategies that individuals develop to deal with these sleep disruptions often lead to an independent disorder such as insomnia disorder that doesn’t resolve by simply addressing the other comorbid condition. Given the information we have now and what we know about insomnia disorder, these sleep disturbances warrant an independent evaluation to determine if it is a sleep disorder or a symptom- and I can’t emphasize enough the presence of another mental health disorder such as PTSD should not preclude the diagnosis of insomnia disorder.”
What can we conclude?
- The VA’s guidance essentially requiring that service connection be only on a direct basis for insomnia is contrary to the actual scientific consensus in the field.
- The VA’s guidance requiring that the condition is not associated with any other disease or injury is contrary to the actual scientific consensus in the field.
- The “Important:” guidance from the VA noting “A separate SC evaluation for a diagnosis of insomnia disorder is only warranted if all other potential causes are ruled out and SC can be established on a direct basis” is contrary to the scientific consensus in the field. It is blatantly wrong and mischaracterizes what the DSM-5 actually says. These are the types of errors that would have been caught had the VA not tried to sneak these changes in as clarifications rather than the big, major changes that they are. These errors would have been caught and corrected if they had been done through the rulemaking process.
What should happen next?
- The VA should return to evaluating insomnia disorder under the mental disorders rating schedule as an independent disorder. Under the current mental disorders rating schedule the symptom of chronic sleep impairment falls at the 30% level.
- VA employees—who aren’t doctors—shouldn’t be the ones evaluating whether something is a symptom or a disorder; a doctor should be.
- For example, insomnia from tinnitus should be evaluated by an appropriate healthcare professional and addressed under mental disorders (not tinnitus). It is absurd to think that something that falls at the 30% level on the VA’s mental disorders rating schedule (chronic sleep impairment) has already been considered under something that is capped at 10% (tinnitus). There is no mechanism for actually and fairly addressing the insomnia disorder except by evaluating it under the mental disorders rating schedule.
The VA should cease and desist using their flawed insomnia disorder guidance.
- It was a big change– contrary to the DSM-5– that never went through the proposed rulemaking procedure.
If you have questions feel free to contact psychologist Dr. Todd Finnerty- [email protected]
Learn more at https://nexusletters.com/insomnia-and-va-disability/