Psychophysiological insomnia is a sleep disorder where anxiety and associations you’ve learned keep you awake, even when you want to sleep. Cognitive behavioral therapy (CBT) can help.
Psychophysiological insomnia (PPI) is a type of chronic insomnia. However, medical professionals no longer typically use the term.
PPI is characterized by hyper arousal states – times when your emotions, mind, and sometimes body are active even when you want them to be relaxed and calm. It may also have associations with your typical sleeping place.
In this article, we detail the causes, symptoms, and treatments of PPI.
Typically, PPI occurs when stress about trying to fall asleep prevents you from falling asleep, and when you associate the inability to fall asleep and the distress surrounding it with the place you typically sleep.
In this type of insomnia, the sleeping difficulties may resolve when you sleep in a different place or when you aren’t trying to fall asleep. The learned associations are related to the distress you feel about not being able to sleep, and that distress becomes linked to your sleeping environment as well.
The main symptoms of PPI are all related to trying to fall asleep or sleep in general, and they include:
- difficult falling asleep or frequent waking (lasting more than 3 months and occurring at least 3 times per week)
- racing thoughts and worrying about not being able to fall asleep
- hyperarousal (racing thoughts, elevated heart rate, higher body temperature, being tired but too aroused to fall asleep)
- daytime fatigue, irritability, and brain fog
- being overly aware or focused on anything to do with falling asleep and having negative feelings about trying to fall asleep
Researchers developed a theory to explain why PPI happens, called the attention-intention-effort model. Based on this idea, PPI is caused by these steps:
- Selective attention to sleep: Examples of this include focusing exclusively on trying to fall asleep but failing to do so, making excessive attempts to relax, and trying to suppress thoughts while in bed.
- Hyperarousal: This step involves elevated heart rate, physical activity, racing thoughts, and excessive worry or anxiety that are triggered by acute or chronic stress, creating a vicious cycle where worry about not sleeping prevents sleep.
- Conditioned arousal: The bedtime environment becomes a trigger for psychological and physiological wakefulness
- Emotional dysregulation involving abnormal activity in the brain: Regions of your brain, like the amygdala, may have irregular activity, causing impaired REM sleep that may prevent one key function of sleep – the soothing and relaxing of your mind that typically occurs during REM sleep.
Some past experiences or current feelings may increase your likelihood of experiencing PPI. Individuals who may have PPI include people who:
- feel anxiety more often
- have experienced a trauma
- have significant stress
- have ineffective or poor sleep routines or habits – like an inconsistent bedtime, taking long naps, or staying in bed while doing other things like working
- have other mental health conditions like depression, PTSD, or anxiety
Older adults and females report experiencing insomnia more often than other groups, as do people who are genetically predisposed to having a difficult time sleeping.
A sleep specialist, psychologist, or psychiatrist can help determine if you have a sleep disorder. During an evaluation for PPI or other sleep disorders, a healthcare professional may:
- Take a sleep hygiene history: Take a detailed history, paying close attention to your experiences with chronic sleep difficulties, daytime impairment, and patterns surrounding familiar versus new or novel sleep environments.
- Screen for sleep-related symptoms: Record any symptoms of hyperarousal and any thoughts you have surrounding not being able to sleep or trying to sleep.
- Use validated sleep and insomnia measures or assessments: Ask you to complete a test or tool like:
- Insomnia Severity Index (ISI)
- sleep diaries
- actigraphy
- polysomnography (to rule out other disorders)
- Rule out other medical conditions: Refer you for testing and physical exams to rule out things like sleep apnea and restless leg syndrome.
The main treatment options for PPI include:
- Cognitive behavioral therapy for Insomnia (CBT-I): This targets unhelpful beliefs, sleep behaviors, and learned associations. (Research suggests digital CBT-I and multimodal emotional regulation therapy may be effective options.)
- Stimulus control therapy and sleep restriction: These approaches may help reset the negative associations you have developed between your bed and sleep.
- Mindfulness-based strategies: Gentle activities to help interrupt hyperarousal states and break negative associations you have between trying to sleep and your bed.
- Medication: If other options aren’t working, sleep medications may be prescribed for short-term use, such as melatonin, orexin receptor antagonists, or others.
Chronic insomnia, including PPI, may contribute to or worsen these conditions:
- PTSD
- anxiety
- depression
- brain fog (cognitive impairment)
- danger from daytime sleepiness
- lower quality of life
- increased pain
- a higher risk of illness
With effective treatment and early intervention, the outlook is good for resolving PPI and improving your sleep quality. Treatment options such as CBT-I have been found to be highly effective for many people.
If left untreated, chronic insomnia may worsen and is associated with health complaints and increased stress, depression, and anxiety.
Psychophysiological insomnia is a type of insomnia that involves hyperarousal – racing thoughts, increased heart rate, and other physical symptoms, along with negative associations with the place you typically sleep. If left untreated, it can worsen and contribute to adverse health conditions and declining mental health.
There are effective treatment options, like CBT-I, to help you address your PPI symptoms. A mental health professional or sleep specialist can help.