One of the most common complaints of my sleep patients, especially those with insomnia, is hyperarousal. You’ve heard the complaint, “I just can’t get my mind to turn off when I’m trying to go to sleep.” What has always thought to be a nocturnal sleep disorder may be something quite different than expected: research now suggests that these patients may have a 24-hour arousal disorder.

As providers, we struggle with how best to treat our insomnia patients. We want them to have good sleep, but we are sometimes reluctant to prescribe medication as many patients end up with a lifelong dependence on sleep aids. Approximately 55% of insomnia patients prescribed sleep aids will be taking them at a 6-month follow-up visit. Cognitive behavioral therapy and sleep hygiene can be helpful, but patients are reluctant to rely on these completely when they are lying in bed staring at the ceiling.

This study noted – as I have over the years in my own practice – that patients with lower Epworth Sleepiness Scale (ESS) scores tended to have the worst difficulties with insomnia. Patients with ESS scores of less than 6 tended to be more prevalent users of prescription sleep aids compared to the patients with ESS scores greater than 11, which is consistent with excessive daytime sleepiness. This suggests that hyperarousal, which consists of anxiety and elevated alertness, is a reliable determinant of those who will chronically use prescription sleep aids.  In this study, alertness was significantly associated with both baseline and chronic prescription sleep aid use. In fact, hyperarousal was associated with a 33% increase in the odds of prescription sleep aid use.

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This new hypothesis suggests that insomnia with elevated alertness is a phenotype that is significantly associated with prescription sleep aid (PSA) use. In short order, all that these patients want is the ability to sleep, and sleep aids are often beneficial to them. Anxiety was significantly associated with PSA; interestingly, depression was not related to the likelihood of PSA use. For years, we have blamed insomnia on depression, so this study should give us pause about how we are treating insomnia patients. Hopefully, more research will give us the answers to this troubling condition that affects so many patients.

Sharon M. O’Brien, MPAS, PA-C, is a practicing physician assistant and health coach in Asheville, N.C.


  1. Pillai V, Cheng P, Kalmbach DA, et al. Prevalence and predictors of prescription sleep aid use among individuals with DSM-5 insomnia: The role of hyperarousal. Sleep. 2016;39(4):825-832; doi: 10.5665/sleep.5636