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Psychophysiological Insomnia

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Cognitive Behavioral Therapy (CBT)

What is it?

Psychophysiological insomnia is a type of insomnia that is associated with excessive worrying. These thoughts are specifically focused on not being able to sleep.

This insomnia may begin suddenly following an event. It may also develop slowly over many years. People with this sleep disorder worry too much about their insomnia. They also worry about being tired the next day. As a result, they learn to become tense and anxious as bedtime approaches.

They may have racing thoughts that all relate to insomnia and trying to fall asleep. As they worry about falling asleep, they become more and more tense. This makes it less likely that they will be able to fall asleep. This tension and worrying about sleep increases through the night. It sets up a cycle for ongoing insomnia.

Even a simple bedtime routine may be a cue that causes tension to worsen. In fact, people with this insomnia may sleep better away from home. Focused and excessive worrying about sleep is the hallmark of this form of insomnia.

People with psychophysiological insomnia have the following symptoms:

  • Focused and excessive worrying about sleep and the effects of insomnia
  • Difficulty falling asleep
  • Increasing agitation and tension as bedtime approaches
  • No other apparent cause of insomnia except for worrying about sleep
  • No medical, psychological or neurologic problem that would explain the insomnia
  • No behaviors, medications or substances that would explain the insomnia

People with this disorder think too much about sleep. As a result, they may engage in bad behaviors to try to fall asleep. This includes taking sleeping pills or drinking alcohol. They might spend too much time in bed hoping to get more sleep.

The lack of sleep also makes them very tired during the day. They may try to cope by drinking excessive amounts of caffeine. This in turn only makes it harder for them to fall asleep at night. Even though they are very tired from a lack of sleep, they do not tend to fall asleep during the day. They are usually unable to take a nap when they try.

They may fall asleep more quickly when they are not trying so hard. They may also fall asleep easier when away from the bedroom. The worry of being unable to control sleep may lead to other problems. It can cause feelings of helplessness or result in drug or alcohol use. The risk for depression increases with persistent insomnia.

Who gets it?

This form of insomnia affects about 1% to 2% of people. About 10% to 15% of sleep center patients have it. It is more common in women than men. It is uncommon in children. Teens and adults of all ages may have it.

People with this insomnia may have a prior history of being a light sleeper. They may also be anxious about their health. A genetic factor has not been found. It does seem to run in families. This link may not be related to genetics. Worrying too much about sleep may simply be learned from others in the home.

How do I know if I have it?

  1. Do you worry too much about your sleep?
  2. Are sleep and your insomnia a major concern? Is your mind consumed with your sleep as bedtime approaches?
  3. Do you mentally become more tense and agitated as bedtime approaches?
  4. Do you physically become more tense and agitated as bedtime approaches?
  5. While waiting in bed to fall asleep, are you plagued by worries about being able to sleep?
  6. Are there no other obvious causes of your insomnia? This includes possible causes such as the following:
  • Stress
  • Medication use
  • Other behaviors
  • Medical problems
  • Psychological causes

If you answered yes to these questions, then you might have psychophysiological insomnia.

Do I need to see a sleep specialist?

This insomnia can be ongoing and can grow in its intensity. It may cause you to engage in bad behaviors. This includes excessive medication or alcohol use. Ongoing insomnia also increases the risk for depression. Due to these reasons, you should discuss your sleep problems with your family doctor.

Tell him or her how you worry too much about sleep. You may be so tired that you are unable to function well during the day. In this case, you may ask your doctor to refer you to a sleep specialist. Your doctor will likely ask you many sleep and medical questions. He or she may first suggest that you change any behaviors that make your insomnia worse. You may sleep better by simply following the practices of good sleep hygiene.

Sleep hygiene consists of basic habits and tips that help you develop a pattern of healthy sleep. Your doctor may also suggest that you take a medication. On the other hand, he or she may refer you to a sleep specialist.

What will the doctor need to know?

The doctor will ask you about the following:

  • Sleep symptoms (such as whether or not you snore)
  • Your sleep schedule (such as your bedtime, number of awakenings, when you get out of bed, naps)
  • If you are very sleepy or have problems functioning normally during the day
  • Any medical problems or any psychological problems
  • If you take any prescription or over-the-counter medications, including herbs
  • Alcohol, caffeine, or substance use

Your family history may also provide important details. The doctor will do an exam. You may be asked to complete a sleep diary. This will monitor your progress before and after treatment. You may be asked to rate your sleep with the Epworth Sleepiness Scale. This will help show how your sleep is affecting your daily life.

Will I need to take any tests?

Your family doctor may want to perform routine blood tests. He or she may also want to get a thyroid blood test. A sleep study is not generally needed for people with this form of insomnia. Your doctor may have you do an overnight sleep study if you are suspected of having another sleep disorder. This study is called a polysomnogram.

It charts your brain waves, heart beat, and breathing as you sleep. It also records how your arms and legs move. This shows if there are other disorders that are related to your sleep problems. Examples of these disorders include sleep apnea and periodic limb movement disorder. The best sleep study will also record your sleep on video. This will show if you get out of the bed and do anything unusual during the night.

How is it treated?

Treatment is similar to that of other forms of insomnia. Doctors often treat insomnia in the three ways that follow:

1. Sleep hygiene

Sleep hygiene consists of good things that you can do to improve sleep. For example, you should get up at the same time every day. You should also avoid drinks with caffeine that disturb sleep.

2. Cognitive behavioral therapy

This involves relaxation exercises and other methods that help improve your sleep. Some people listen to relaxing tapes. Others learn breathing exercises from a psychologist. Other methods teach you to do things such as limiting the time you spend in bed.

3. Sleeping pills and sleeping aids

Doctors sometimes prescribe sleeping pills to treat insomnia. These are called hypnotics. At times insomnia is related to depression and anxiety. In these cases, medications may be prescribed by doctors to help insomnia.

Some people with insomnia try to treat themselves with nonprescription sleep aids that they find on drugstore shelves. Others may try vitamins or herbs. Some people even use alcohol to help them fall asleep. Doing this actually makes their sleep worse. The alcohol causes them to wake up during the night.

There are many ways to treat insomnia that are common and effective. You should talk to your primary care doctor to discuss these options. You may also want to visit a sleep center to get more expert advice. You should see a sleep specialist if your insomnia causes you to nod off during the day.

By Sharon L. Schutte-Rodin, MD
Updated on November 28, 2005

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