Insomnia (sleeplessness) is characterized by a difficulty to initiate or maintain sleep not due to time constraints, resulting in daytime impairment, which may include sleepiness, fatigue, as well as cognitive problems (e.g., impaired memory and concentration). If you have been suffering from insomnia for at least 3 months, you would be diagnosed with Chronic Insomnia Disorder, which is a persistent form of insomnia. 1-2% of adults experience a form of primary insomnia known as Psychophysiological Insomnia (Conditioned Insomnia). It is primary because it is not caused by a secondary medical condition or substance abuse.
Do you suffer from psychophysiological insomnia?
If you’re suffering from psychophysiological insomnia, you are probably extremely concerned with your inability to sleep and the consequences that follow even though you are pretty aroused during the day and can’t usually nap even when sleepy. Even relaxing before bedtime may be difficult.
Often, sleeping in a new environment may help you sleep better.
What is psychophysiological insomnia?
Sleep scientists have limited understanding of this condition. One theory which attempts to explain it is known as the Two-Factor Model, proposed by Bonnet and Arand in 1997. The two factors are:
- Basal Arousal Level – What is your normal level of arousal relative to others? (The level of arousal reflects your level of wakefulness and alertness.) Is your basal arousal level lower of higher than that of others?
- Sleep Requirement – How much sleep do you require relative to others? Do you require a shorter or longer sleep than most other people?
Arising from different combinations of these factors are 4 distinct conditions:
- People who have a low basal arousal level and a short sleep requirement may suffer from excessive daytime sleepiness.
- People who have a low basal arousal level and a long sleep requirement may suffer from idiopathic hypersomnolence, characterized by excessive daytime sleepiness even after 7 hours or more of quality sleep.
- People who have a high basal arousal level and a long sleep requirement may suffer from paradoxical insomnia, characterized by complaints regarding sleep that are not supported by objective measures which show adequate sleep, and without the level of daytime impairment expected.
- People who have a high basal arousal level and a short sleep requirement may suffer from psychophysiological insomnia or idiopathic insomnia.
Long story short, according to the Two-Factor Theory, psychophysiological insomnia characterizes people who do not require much sleep, while having a high basal arousal level. Since they are very aroused normally, they find it difficult to fall asleep. When sleep deprivation finally overrides the overactive arousal system, sleep comes, but not for long due to the short sleep requirement of the individual’s sleep system.
Sufferers of psychophysiological insomnia may try to fall asleep when sleep is not required, and fail, making them worry about not getting enough sleep, which in turn can prevent sleep when it is needed. As such it is a “learned” insomnia. (They just don’t need much sleep and when they don’t, they are highly aroused. They simply can’t fall asleep, and shouldn’t try to sleep, unless they are very tired.)
Why does psychophysiological insomnia happen?
Psychophysiological insomnia arises from both psychological and physiological factors. Usually it begins with a stressful precipitating event, such as an illness, job loss, or bereavement, which causes short-term insomnia. The person then try to improve their sleep by adopting behaviors that actually perpetuate the insomnia, turning it into a chronic insomnia.
These behaviors, which may include changing the sleep schedule and using sleeping aids at night or stimulants to remain awake during the day, result from excessive worry regarding sleep and the consequences of not sleeping.
Eventually the sufferer of this type of insomnia may fear going to bed due to the expectation of poor sleep, thereby perpetuating the maladaptive behaviors.
Thus, both the constant focus on sleep and these maladaptive behaviors contribute to the inability to sleep.
The most probable physiological cause of psychophysiological insomnia is stress (cortisol levels). The more stressed out one is regarding sleep, the more difficult it becomes to fall asleep. Additional physiological correlates are elevated heart rate and impaired heart rate variability during the night.
Treatment of psychophysiological insomnia
I will start by stating what is not a useful treatment approach: Benzodiazepines and other sleeping pills should not be administered long-term for the treatment of psychophysiological insomnia.
Psychophysiological insomnia is treated like other primary insomnia disorders: with a combination of cognitive-behavioral strategies, including stimulus-control therapy and sleep-restriction therapy.
Cognitive-behavioral therapies in particular are highly useful in order to change the learned associations preventing sleep.
Also, lifestyle modification and sleep hygiene improvement are important in order to modify maladaptive coping strategies, such as caffeine use, drinking alcohol, watching television, playing video games, using the computer, or eating/exercising close to bedtime.
Relaxation therapy and mindfulness-based interventions (meditation) can help in bringing down stress and arousal levels. Meditation may also a good substitute for cognitive therapy as it can help with breaking down thought associations. Other possibly useful therapies include acupuncture, tai chi, hypnosis, exercise, and electrosleep therapy.
Herbs can provide a safe and efficient alternative for pharmaceutical drugs.
Learn more about treatments for insomnia.
Kryger, Meir H.; Roth, Thomas; Dement, William C.. Principles and Practice of Sleep Medicine E-Book. Elsevier Health Sciences. Kindle Edition.
Westerman, David, E., The Concise Sleep Medicine Handbook: Essential Knowledge for the Boards & Beyond. (5th ed.) GSSD Publishers, LLC.