Psychophysiological insomnia

Deirdre A Conroy PhD (Dr. Conroy of the University of Michigan has no relevant financial relationships to disclose.)
Antonio Culebras MD FAAN FAHA FAASM, editor. (

Dr. Culebras of SUNY Upstate Medical University at Syracuse received an honorariums from Jazz Pharmaceuticals for a speaking engagements.

Originally released October 1, 1993; last updated February 27, 2021; expires February 27, 2024


In this article, the author discusses diagnosis, complications, and treatment of psychophysiological insomnia. Updates include new information regarding the pathophysiology and unique electroencephalogram characteristic of psychophysiological insomnia. The article also discusses additional data to support cognitive behavioral therapy for insomnia as first-line treatment for psychophysiological insomnia.

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

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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