Psychophysiological insomnia

Deirdre A Conroy PhD (Dr. Conroy of the University of Michigan has no relevant financial relationships to disclose.)
Antonio Culebras MD, editor. (Dr. Culebras of SUNY Upstate Medical University has no relevant financial relationships to disclose.)
Originally released October 1, 1993; last updated May 17, 2016; expires May 17, 2019

This article includes discussion of psychophysiological insomnia, conditioned insomnia, and learned insomnia. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

In this article, the author discusses diagnosis, complications, and treatment of psychophysiological insomnia. New updates include drugs coming down the research pipeline, new neurophysiologic information regarding the hyperarousal theory of insomnia, and the relationship of insomnia and short sleep duration to the development of chronic disease such as hypertension.

Key points

 

• Three types of factors play a role in the development of psychophysiological insomnia: (1) predisposing or constitutional factors, eg, the tendency to worry excessively and the tendency to be hyperaroused; (2) precipitating factors, eg, a transient stressor; and (3) perpetuating factors, eg, the individual's expectation of a poor night's sleep that becomes a self-fulfilling prophecy.

 

• Psychophysiological insomnia usually begins as a somaticized response to a stressful event and then, depending on genetic and other environmental variables, becomes a more chronic condition because of negative conditioning.

 

• Many studies have reported hyperarousal in cognitive, somatic, autonomic, hormonal, and EEG domains in patients with primary insomnia. Hyperarousal and its concomitants may be a link to the association of primary insomnia to such complications as hypertension, diabetes, and increased mortality.

 

• The administration of sedative-hypnotic drugs and cognitive behavioral therapy are 2 effective tools for the management of psychophysiological insomnia.

 

• This form of insomnia occurs in 1% to 2% of the general population and 12% to 15% of patients presenting to a sleep disorders center (American Academy of Sleep Medicine 2014).

Historical note and terminology

Although it had been suspected earlier that faulty sleep hygiene or maladaptive learning may cause some insomnia (Bettolo 1931; Strauss 1948), the 1979 Diagnostic Classification of Sleep and Arousal Disorders, published by the Association of Sleep Disorders Centers, first created the diagnostic category of persistent psychophysiological insomnia. This category was defined as "insomnia that develops as a result of the mutually reinforcing factors of chronic, somatized tension anxiety and negative conditioning to sleep." Hauri then showed that a cluster analysis could identify psychophysiological insomnia on the basis of polysomnographic variables, psychological questionnaires such as the Minnesota Multiphasic Personality Inventory, and a sleep history. In another study, Hauri and Fisher compared psychophysiological insomniacs, normal sleepers, and insomniacs with dysthymic disorder. The 2 insomnia groups (psychophysiological and dysthymic) showed similar degrees of sleep impairment. Psychologically, however, patients with persistent psychophysiological insomnia were similar to normal and different from dysthymic patients, except that psychophysiological patients were more likely to be repressors or sensation avoiders than normal. In addition, the psychophysiological patients suffered more than either normal or dysthymics from tension-related symptoms such as muscle tension headaches.

The International Classification of Sleep Disorders, 3rd edition, defines "psychophysiological insomnia" as a clinical and pathophysiological subtype of an insomnia disorder and as "heightened arousal and learned sleep-preventing associations that result in a complaint of insomnia and associated decreased functioning during wakefulness" (American Academy of Sleep Medicine 2014). The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders replaces the term primary insomnia with insomnia disorder to avoid implying directionality when this disorder is co-occurring with other conditions (American Psychiatric Association 2014).

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