Patients with insomnia commonly complain that they are unable to turn off their thoughts long enough to go to sleep. Many also describe someone else in their family with similar complaints. Is it possible for patients to learn insomnia from a family member?

About 30% to 48% of adults experience symptoms of insomnia, and 10% complain of persistent or chronic insomnia. There are various forms of the disorder. One form consists of being a light-sleeper awakened by any noise. Worrying about not getting enough sleep and sometimes complaining about not sleeping at all are other characteristic symptoms.

These patients have psychophysiological insomnia, a disorder that results from physiological arousal and learned sleep-preventing behaviors. Also called learned insomnia, conditioned insomnia, chronic insomnia or primary insomnia, these patients “try hard to go to sleep, but nothing works!”

Most of these patients recall a stressful event, pain or illness resulting in an initial period of  insomnia. After the precipitating factor is removed, these patients experience continued anxiety and fear about not being able to sleep.

Psychophysiological insomnia is a perfect example of a mind/body experience. Psycho refers to mind issues and physiological refers to the body’s reaction. The stress and anxiety associated with going to sleep keeps the patient from what he or she wants the most.

Psychophysiological sleep rarely occurs in children but can occur in adolescence. It is more prevalent in women than men. Predisposing factors include being overly concerned with health or general wellbeing.

Because this form of insomnia is seen in families, there is concern that perhaps a patient has developed an idea of what good and bad sleep is from a family member with sleep issues. The patient may compare their sleep to the family member and then decide that they also have a sleep problem.

Even general environmental clues like brushing teeth before bed, or putting on pajamas can prompt these patients to worry about whether they are going to be able to sleep.

Patients with psychophysiological insomnia often report sleeping better when they sleep away from home. It is very common for them to report having “the best sleep they have had in a long time” when they come for a sleep study.

Unfortunately, many of these patients develop a long history of sleep aid use, and stopping medications abruptly tends to increase their anxiety and reinforce their view of poor sleep.

Slowly weaning sleep aids, sometimes over months, and initiating cognitive behavioral therapy can be beneficial. Reducing stress is also important as these patients often have issues with anxiety in other areas of their life.                                                                              

Be sure to rule out other sleep disturbances that could be causing the problem, including other sleep disorders, medical illnesses, mental disorders, medication use or substance abuse.

Psychophysiological insomnia can be difficult to distinguish from idiopathic insomnia, which has a more persistent pattern of poor sleep. Paradoxical insomnia can also be considered but is usually easier to distinguish because of the mismatch of objective and subjective sleep measures.

It is important that patients with pyschophysiological insomnia understand how anxiety is worsening their ability to sleep. It is also important that they do not feel that you are telling them the problem is all “in their head.”

I explain psychophysiological insomnia as a manifestation of the effect of stress on the body. Most patients understand this concept and relate it to their anxiety and worry about sleeping.

There is some clinical data that reveals patients with psychophysiologic insomnia have increased cortical arousal before bed and throughout the night. Questions remain as to whether patients with this form of insomnia are able to deactivate this cortical stimulation. In either case, there is more research to be done in this area of sleep medicine.

Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.

References

  1. American Academy of Sleep Medicine. The International Classification of Sleep Disorders, 2nd ed.: Diagnostic and Coding Manual. Westchester, Illinois: American Academy of Sleep Medicine, 2005.
  2. Bastien CH et al. “Chronic Psychophysiological Insomnia: Hyperarousal and/or Inhibition Deficits? An ERP’s Investigation.” Sleep. 2008.;31(6):887-898.