Psychophysiological Insomnia

For some people, insomnia isn’t just about not sleeping — it becomes a learned pattern where anxiety and hyperarousal keep the brain stuck “on.” In the past, this was referred to as psychophysiological insomnia. However, the term is no longer used in formal diagnoses.

While the terminology has changed, the underlying symptoms of psychophysiological insomnia still impact many people. Worrying about sleep has the potential to worsen sleeping problems, which already affect as many as 50% of people Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source and can dramatically impact quality of life Trusted Source Medline Plus MedlinePlus is an online health information resource for patients and their families and friends. View Source .

What Is Psychophysiological Insomnia?

Although the term is no longer part of the formal medical lexicon, psychophysiological insomnia has been used to refer to sleeping problems linked to stress about sleep itself Trusted Source American Academy of Sleep Medicine (AASM) AASM sets standards and promotes excellence in sleep medicine health care, education, and research. View Source Trusted Source Journal of Clinical Sleep Medicine (JCSM) JCSM is the official, peer-reviewed journal of the American Academy of Sleep Medicine. View Source .

At the most basic level, insomnia occurs when a person has trouble falling asleep or staying asleep. But while many people use the term loosely in everyday conversation, doctors and researchers rely on formal definitions crafted by the American Academy of Sleep Medicine (AASM) in the International Classification of Sleep Disorders (ICSD).

“When sleep becomes a struggle, the resulting increased arousal leads to a spiral of negative emotions that are simply not conducive to sleeping. It occurs often in insomnia, and is not restricted to the prior subtype.”

Brandon R. Peters, MD, FAASM

Sleep Physician, Sleep Psychiatry Expert

In prior versions of the ICSD, psychophysiological insomnia was one of many subtypes of insomnia distinguished by their suspected cause. Under the old categorization, psychophysiological insomnia involved worrying excessively about the negative effects of not getting enough sleep, which prevented a person from being able to relax at bedtime. Racing thoughts and physical tension could make it seem impossible to sleep. As a result, the home bedroom could take on stressful associations, actually making it easier to sleep in in an unfamiliar setting like a hotel room.

Over time, doctors and researchers noted that psychophysiological insomnia often overlapped with other types of insomnia. As a result, the AASM chose to remove the separate definitions of insomnia, including psychophysiological insomnia, in the most recent version of the ICSD. The ICSD now distinguishes between short-term insomnia and chronic insomnia, with chronic insomnia defined as occurring at least three times a week for at least three months.

What Is the Difference Between Psychophysiological Insomnia and Primary Insomnia?

Though the terms are no longer used for diagnosing sleep disorders, in past editions of the ICSD, primary insomnia described any cases of insomnia that were not directly caused by other medical, psychiatric, or sleep disorders, and psychophysiological insomnia was categorized as a type of primary insomnia. Other formerly used subtypes of primary insomnia included:

• Idiopathic insomnia: insomnia with no obvious cause
• Paradoxical insomnia: cases in which a person thinks they’re not sleeping but is objectively measured to be sleeping
• Inadequate sleep hygiene: insomnia linked to habits and routines that interfere with sleep
• Behavioral insomnia of childhood: insomnia stemming from improper sleep training in children

There were also separate categories for people with insomnia triggered by another medical, psychiatric, or sleep disorder or substance use, grouped under the name “secondary insomnia.” 

Today, these categories are no longer recommended. Instead, doctors primarily may use the categories of either short-term or chronic insomnia without reference to a specific underlying cause.

Symptoms of Insomnia

By definition, insomnia in adults must involve at least one of the following symptoms:

• Trouble falling asleep
• Waking up excessively throughout the night with difficulty returning to sleep
• Waking up earlier than intended in the morning

These problems occur even though a person has sufficient time to sleep and a bedroom environment that is adequate for good sleep. In other words, people with insomnia have the time and opportunity to sleep, but they still can’t sleep well.

Additionally, a person is only considered to have insomnia if their sleep troubles cause symptoms during waking hours, such as:

• Daytime sleepiness or fatigue
• Trouble concentrating or remembering things
• Problems with coworkers, classmates, family members, or friends
• Mood swings or behavioral problems
• A higher-than-expected rate of accidents and errors
• Lack of motivation
• Worrying about sleep

The last criterion, worrying about sleep, is the one that applies most closely to what in the past would have been called psychophysiological insomnia. But in the current version of the ICSD, worrying about sleep is considered a common component of insomnia for many people.

“Pervasive worry that seems excessive, beyond a normal reaction to a trigger, or cannot be controlled may prompt further evaluation and treatment by a medical professional.”

Brandon R. Peters, MD, FAASM

Sleep Physician, Sleep Psychiatry Expert

People with insomnia often spend time during the day worrying about their sleep and experience anxiety at bedtime. Because of past sleep difficulties, the familiar bedroom setting or the knowledge that it’s time to go to sleep can act as triggers for stress and worrying. It can build gradually as bedtime approaches.

What Causes Psychophysiological Insomnia?

Traditionally, psychophysiological insomnia was understood to develop in people whose sleeping problems were caused or amplified by stress about sleep. As they start to get anxious about what will happen if they don’t get enough sleep – such as the fear of performing badly on an exam or making a mistake during work – these worries make it even more difficult to fall asleep, causing a vicious cycle.

Since researchers no longer divide insomnia into the old subtypes, there isn’t much recent research on the specific causes of psychophysiological insomnia. But the general belief among many experts is that insomnia is linked to hyperarousal of the nervous system Trusted Source Science Direct The leading platform of peer-reviewed literature that helps you move your research forward. View Source . 

During both the day and night, people with insomnia may exhibit a faster heart rate, heightened metabolism, higher stress hormone levels, faster brain waves, and higher body temperature. These characteristics are part of the body’s fight-or-flight system, and they indicate that the body and mind are having trouble relaxing. Continued activation of the nervous system at night is believed to interfere with the ability to fall asleep and stay asleep. 

“People with insomnia may be described as being tired but wired,” says sleep medicine specialist Brandon Peters, MD.

Scientists are still in the process of researching how genes, lived experiences, and brain structure and function can influence the risk of developing insomnia . Insomnia often occurs alongside other health conditions such as depression and anxiety, and some experts believe these conditions may share certain underlying connections.

“It may also coexist with sleep apnea, associated with the increased cortisol levels that trigger awakenings and occur due to the breathing disruptions,” Dr. Peters says.

How Can You Treat Psychophysiological Insomnia?

There are many different treatments for insomnia, including therapy, sleep hygiene changes, and prescription medications Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source .

Cognitive Behavioral Therapy for Insomnia (CBT-I)

Cognitive behavioral therapy for insomnia (CBT-I) is one of the most common and effective treatments for insomnia Trusted Source UpToDate More than 2 million healthcare providers around the world choose UpToDate to help make appropriate care decisions and drive better health outcomes. UpToDate delivers evidence-based clinical decision support that is clear, actionable, and rich with real-world insights. View Source Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source . Over the course of six weeks or more, CBT-I aims to change a person’s sleep-related thoughts and behaviors through a set of different techniques under the guidance of a trained professional or learned through self-guided online courses, apps, and books.

Relaxation techniques like breathing exercises, progressive muscle relaxation, and guided imagery are a common component of CBT-I, and learning to relax may help counteract worries about sleep that are common in people with symptoms of psychophysiological insomnia. It may also help as a distraction to reduce racing thoughts at night. Talk therapy may also help decrease anxiety related to sleep.

“Sleep consolidation (or sleep restriction) and stimulus control are two other important aspects of CBT-I,” Dr. Peters says. “And scheduled worry time, a buffer zone, and morning light exposure are also key features.”

Evidence suggests CBT-I can help with falling asleep faster and sleeping more soundly, with benefits lasting over the long term. It also has a low risk of side effects. CBT-I techniques are thought to work best when used in conjunction with each other, rather than using one technique on its own. It’s important to know that it may take multiple sessions of CBT-I before sleep starts to improve.

“CBT-I is the gold standard for the treatment of chronic insomnia and it is meant as a first-line intervention, even prior to the use of sleeping pill. It is highly effective, teaching a set of skills that will provide lifelong benefit.”

Brandon R. Peters, MD, FAASM

Sleep Physician, Sleep Psychiatry Expert

Sleep Hygiene

Sleep hygiene refers to a set of both daytime and nighttime behaviors and routines that help pave the way for better sleep. These might include setting a regular sleep schedule, exercising regularly, reducing caffeine and alcohol intake, and ensuring the bedroom is a proper temperature and free of excess light and noise. 

While improving sleep hygiene alone is not usually enough to cure insomnia, it often works in concert with other aspects of CBT-I.

Medication

For some people, prescription medications may improve insomnia symptoms. Since medication can lead to side effects, sleep doctors recommend trying CBT-I first. Sleep medication is designed for short-term use of around two weeks but potentially up to four or five weeks.

Can You Prevent Psychophysiological Insomnia?

There’s no single way to prevent insomnia or the worrying about sleep that is associated with psychophysiological insomnia. However, establishing good sleep hygiene can help promote better nightly sleep Trusted Source National Heart, Lung, and Blood Institute (NHLBI) The NHLBI is the nation's leader in the prevention and treatment of heart, lung, blood and sleep disorders. View Source .

Practicing healthy sleep habits, including finding ways to relax before bed, can help get your sleep on  track and may prevent sleep-related worries from leading to chronic insomnia Trusted Source National Heart, Lung, and Blood Institute (NHLBI) The NHLBI is the nation's leader in the prevention and treatment of heart, lung, blood and sleep disorders. View Source . If sleeping problems start affecting your daily life and activities, talk to your healthcare provider for more specific guidance and recommendations.