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Insomnia and VA disability

The VA disability guidance for insomnia disorder is wrong.

Thie page contains some of my thoughts on “clarifications” to the insomnia guidance by the VA :(below is a quote from the VA related to insomnia claims)

V.iii.13.1.l.  Considering SC for Insomnia

Carefully consider the evidence of record when deciding SC for insomnia.  Insomnia is generally considered a symptom of another disability due to coexisting medical or neurological conditions.  Insomnia can occur as an independent condition or can be a symptom associated with another mental disorder (for example, major depressive disorder), medical condition (for example, pain), or another sleep disorder (for example, a breathing-related sleep disorder).
When insomnia is adequately identified as a symptom of another underlying disability, SC should be established for that diagnosis rather than for “insomnia,” and the insomnia symptoms should be included in the evaluation for the primary SC disability.  A separate evaluation is not warranted for insomnia that is considered secondary to, or a symptom of, another disability.

However, SC can be established on a direct basis for “insomnia” in the absence of a known or established underlying etiology if there is an event in service (such as a diagnosis of primary insomnia or insomnia disorder in service)
a current diagnosis of insomnia disorder meeting DSM-5 diagnostic criteria a nexus establishing insomnia disorder post service is connected to the event in service, and the condition is not associated with any other disease or injury.

Important:  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. 

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.

When evaluating insomnia disorder, rate analogously under an appropriate DC in 38 CFR 4.130.
Reference:  For more information on analogous ratings, see
38 CFR 4.20
M21-1, Part V, Subpart iv, 1.C.2, and
M21-1, Part V, Subpart ii, 3.D.1.c.

The clarification from the VA above oversimplifies and misrepresents what is actually in the DSM-5-TR about insomnia disorder as well as what is in the international classification of sleep disorders, third edition- text revision (but an extensive discussion of that is a bit academic for my point here- though I will go on some more about it further below). What is even worse– it assumes that the chronic sleep impairment from insomnia is already considered in the rating of other disorders– however, at times it may not be (particularly with some physical conditions). I have some thoughts below based on the guidance above.

The VA guidance on insomnia above can make sense in relation to mental health cases where chronic sleep impairment is actually evaluated and considered, but it can potentially lead to times when it isn’t adequately reflected in the rating when it is secondary to physical conditions. This is in part due to misguided cautions against pyramiding- rating the same symptom/disorder more than once. I personally believe that the caution against pyramiding can often be abused and misused by VA raters and VA policy in general (I addressed this more in my response to the proposed changes for the mental disorders rating schedule).

Just one example of the consequences of this: If insomnia is caused by a physical condition the impact of that insomnia on a Veteran’s daily life is often not considered in the rating for that physical condition- thus there is no threat of pyramiding. The impact of the insomnia had never been considered under that physical condition. The impact of insomnia is different from those physical symptoms alone. The Veteran with only an insomnia disorder diagnosis (instead of also a mental health disorder) could therefore be out of luck in having the VA recognize the impairment from that.

An example of a physical condition which sometimes leads to chronic sleep impairment is tinnitus. Not everyone with tinnitus has chronic sleep impairment, however some people with tinnitus experience significant chronic sleep impairment (insomnia disorder) associated with their tinnitus. At the moment of writing this (early 2024) tinnitus is still around and being rated by the VA at 10%. It is telling that tinnitus currently only gets a 10% rating, yet chronic sleep impairment under the mental disorders rating schedule falls in the 30% rating. The impact of any chronic insomnia caused by tinnitus is therefore clearly not reflected by default on a tinnitus case and there is no pyramiding supported given that chronic sleep impairment from tinnitus was not considered and certainly isn’t reflected in the tinnitus rating alone. All of the impact of tinnitus defaults to 10%, yet the symptom of chronic sleep impairment such as chronic insomnia is at the 30% level in the current (as of early 2024) mental disorders rating schedule. So taking the above guidance “the insomnia symptoms should be included in the evaluation for the primary SC disability. A separate evaluation is not warranted for insomnia that is considered secondary to, or a symptom of, another disability” and applying it to something like tinnitus, for example, where there is no real mechanism in the rating to also rate chronic sleep impairment like insomnia, subjectivity and inconsistency can get introduced which likely will harm the Veteran. Raters may also be asked to function like a medical professional when they aren’t medical professionals. The wording of the above guidance goes a bit overboard, so it makes sense to be aware of that in relation to insomnia claims until a more appropriate and nuanced update is provided.

One thing to consider is if there are also other mental health diagnoses or symptoms like depression and anxiety associated with the physical condition causing insomnia, it may make sense to also be reporting those symptoms and not just insomnia, so that the VA will be sure to take the chronic sleep impairment you have secondary to physical conditions seriously and evaluate it (even if they have to do that as depression/anxiety with chronic sleep impairment secondary to a physical condition rather than insomnia secondary to that physical condition).

If you have thoughts or questions let me know.

The diagnostic criteria for Insomnia Disorder under DSM-5-TR (pg. 410) includes “coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.”

This is NOT the same thing as the VA guidance would suggest. The VA guidance suggests “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.” However, this statement in the VA guidance is a gross mischaracterization of DSM-5.

DSM-5 notes that the mental disorder or medical condition alone should not adequately explain the insomnia.

To continue with our example of tinnitus, the scientific evidence supports that tinnitus alone does not adequately explain insomnia disorder or chronic sleep impairment.

  • (remember “adequately explain” is what the DSM-5-TR actually says)
  • (it also describes mental and medical conditions as “coexisting” and not the same impairment)

For example, Barry & Marks (2023) note “a significant proportion of individuals with distressing tinnitus also report insomnia. Limited, but emerging, evidence suggests that tinnitus-related insomnia cannot be explained only by the presence of tinnitus and that sleep-related cognitive-behavioral processes may play a key role in exacerbating tinnitus-related insomnia.”

[Barry G, Marks E. Cognitive-behavioral factors in tinnitus-related insomnia. Front Psychol. 2023 Mar 17;14:983130. doi: 10.3389/fpsyg.2023.983130. PMID: 37008859; PMCID: PMC10064054].

The physiological effects of tinnitus do not lead to insomnia disorder. The impact of tinnitus, in some but not all people, can trigger significant cognitive and behavioral effects which lead to insomnia/ chronic sleep impairment. This is NOT the same thing as tinnitus alone. Tinnitus can trigger thoughts and behaviors, in some individuals, which promote the development of an insomnia disorder. This includes “dysfunctional beliefs” and “catastrophization.”

The impact of physical conditions (ex: tinnitus) can be a precipitating factor for insomnia, but it is not necessarily a perpetuating factor that prolongs chronic sleep impairment/ an insomnia disorder.

According to the three-factor (3P) model of insomnia, there are three primary factors that contribute to the development of chronic insomnia: (1) predisposing factors — traits or conditions (e.g., high emotional reactivity) that increase one’s vulnerability to developing insomnia; (2) precipitating factors — situational conditions (e.g., stressful life events) that trigger the onset of insomnia; and (3) perpetuating factors — behaviors and cognitions that contribute to the transition from acute to chronic insomnia and maintain the disorder long term.

[Walker J, Muench A, Perlis ML, Vargas I. Cognitive Behavioral Therapy for Insomnia (CBT-I): A Primer. Klin Spec Psihol. 2022;11(2):123-137. doi: 10.17759/cpse.2022110208. PMID: 36908717; PMCID: PMC10002474].

Tinnitus itself isn’t the perpetuating factor- that is the mental health/sleep disorder piece reflected in the insomnia disorder diagnosis (i.e. “behaviors and cognitions”). The 10% tinnitus rating reflects that trigger, but the perpetuating factors that can develop (ex: 30% chronic sleep impairment) are not reflected in that alone.

Some conclusions:

  • To sum up it up to make this not go on forever– the VA’s guidance related to insomnia disorder mischaracterizes what is actually in the DSM-5-TR diagnostic criteria. 
  • It reflects a clear misunderstanding of chronic sleep impairment and insomnia disorder
  • It misuses and confuses pyramiding
  • It confuses precipitating factors– triggers– like tinnitus (10%) with the perpetuating factors that subsequently can develop in some cases (behaviors and cognitions) that lead to chronic sleep impairment (30%)/  insomnia disorder.
  • Insomnia disorder secondary to physical conditions like tinnitus should be something the VA addresses in order to reflect the chronic sleep impairment– perpetuating factors– that can sometimes but not always develop.

Fun Fact: One thing I like about the VA is that they have provided some of their mental health employees with training in Cognitive Behavioral Therapy for Insomnia (CBT-I). It is a brief psychotherapy focused on a non-medication related way to improve chronic insomnia. The American Academy of Sleep Medicine even suggests using CBT-I for chronic insomnia. If you are going for treatment primarily related to chronic insomnia it may make sense to see if someone with training in CBT-I is available for you. The VA also has some free apps you can use either in conjunction with psychotherapy or as a standalone. You can learn more about those here:

You can watch a YouTube video I recorded about this as well.

I am no attorney or policy expert, but the changed guidance related to insomnia was so different and impactful (and incorrect), that it should have gone through an official rulemaking process.