Psychophysiologic insomnia: This was my diagnosis when I finally decided to see a doctor about my sleep. I didn’t like the sound of it. “Psycho” came before “physiologic,” and to me the implication was that my trouble sleeping was mostly in my head.
My insomnia felt physical, accompanied by bodily warmth, muscle tension, and a jittery feeling inside. I was anxious about sleep, too, and my thoughts weren’t exactly upbeat. But surely putting the psycho before the physiologic was putting the cart before the horse?
Don’t let the terminology put you off the way I did. Psychophysiologic insomnia (I’ll call it PPI) is a problem in which constitutional vulnerabilities, situational factors, habits, and dysfunctional thinking are so intertwined that it’s hard to sort them out. Here’s a brief description and recommendations on how to manage it.
A Diagnosis Based on Symptoms
No objective test can reliably distinguish between normal sleepers and people with PPI. So the diagnosis is made based on symptoms alone. In PPI as in other types of insomnia, the wakefulness may occur at the beginning, in the middle, or at the end of the night. But people with PPI also:
- have a lot of anxiety about sleep
- are prone to intrusive thoughts and involuntary rumination
- feel physically wound up
- fall asleep at unusual times and places
- experience daytime impairments such as fatigue, moodiness, and trouble thinking
Polysomnography (PSG)—the test administered overnight in a sleep lab—is not usually recommended because it doesn’t discriminate well between people with PPI and normal sleepers. But PSG results show that overall, people with PPI sleep less, and spend more time in lighter stages of sleep, than people who sleep well. (In contrast, the PSG results of people with paradoxical insomnia look normal, even though sufferers may feel like they’re getting 1 or 2 hours of sleep at best.)
How PPI Develops
Often it begins in adolescence or early adulthood, showing up as light sleep or periodic episodes of poor sleep.* Some people are naturally more susceptible than others. This may be true, sleep expert Peter Hauri has written, because of “an inherent, mild defect in the sleep-wake system, i.e., either excessive strength of the reticular activating system [the arousal system] or a weakness in the inhibitory, sleep-inducing circuits. Because the sleep-wake balance in such patients might lean toward wakefulness, such people would be suffering from an occasional, neurologically based poor night of sleep long before developing serious insomnia.”
Stressful situations lead to more extended bouts of poor sleep. Sooner or later, concern about sleep sets in. This is when insomnia starts to get “serious,” to use Hauri’s word. Looking for ways to reestablish better sleep, people change their habits—trying harder to sleep, going to bed early, taking naps—in ways that actually make sleep worse. The bed and the bedroom come to be associated with not sleep but rather with wakefulness and worry about sleep.
Thus begins the vicious cycle where long stretches of wakefulness in bed, accompanied by feelings of tension, begin to condition arousal of the brain, in turn fueling more bodily arousal. What began as light sleep or an occasional stress-related bout of insomnia has become a chronic affair.
Once the PPI train pulls away from the station, it’s hard to get off. For decades I tried every trick in the book—sleeping on the couch, watching nature programs, listening to white noise, scenting my pillows, rhythmic breathing, drinking tea made from Chinese herbs. Nothing worked for long or without cost.
The good news is that PPI, unlike some other types of insomnia, responds well to treatment with cognitive behavioral therapy for insomnia (CBT-I). (While the name might suggest that it’s similar to conventional talk therapy, CBT-I is mainly focused on helping people modify habits.) For me, sleep restriction therapy, a treatment offered as part of CBT-I, was especially useful. Sleep restriction led to an awareness that my sleep could be reliable if I timed it right.
Equally important, though, for people whose insomnia feels physical (like mine) is finding a way to tamp the physiological arousal down. What works best for me is daily aerobic exercise. Research also suggests that mind-body therapies such as yoga, tai chi, and mindfulness meditation are helpful in this regard.
If this sounds like the type of insomnia you’ve got, check into CBT-I and physical training. There’s nothing to lose and much to gain.
How do you manage your insomnia? Has your strategy worked?
* Lee-Chiong T. Sleep Medicine: Essentials and Review. New York: Oxford University Press; 2008: 84.