Author: Ron Cridland, MD
If you go through a period of time when your sleep is significantly disturbed and it goes on long enough, you may become conditioned to sleep that way. This may occur even after the original factors that caused your insomnia have resolved or significantly improved. We call this “conditioned insomnia” or Psychophysiological Insomnia.
As the name suggests, Psychophysiological Insomnia consists of psychological and physiological factors that interfere with your ability to sleep. The physiological factors are sometimes obvious like pain or hot flashes. Sometimes they are not so obvious like an underlying sleep disorder such as sleep apnea or periodic limb movement disorder. If we suspect an underlying sleep disorder, we will usually order a sleep study or Nocturnal Polysomnogram to more objectively evaluate your sleep. Also, if you are tired and have to push yourself to get through the day, you are essentially “living on adrenalin”. This makes it hard to fall asleep. Even when you fall asleep your body is still in “fight or flight” mode which causes your sleep to be lighter and more easily disturbed.
The psychological component of Psychophysiological Insomnia is primarily due to conditioning. You may have developed a habit of thinking, worrying, planning or problem solving in bed, or just spending long periods of time awake. These habits tend to be mentally stimulating and not conducive to good sleep. Watching the clock and feeling anxious or frustrated about your inability to sleep can also make your sleep worse. Ultimately, you may become conditioned to associate the bed with mental activity, alertness, and frustration rather than relaxation and sleep.
The classic example is the new mother who immediately learns to sleep with “one ear open” to listen for the needs of her precious newborn baby. She is so alert during the night that she not only hears the baby when it cries, she is aware of everything else going on at night such as the house creaking, the wind blowing or the dog walking down the hall. Unfortunately, long after the baby is old enough to leave home, the mother is often still sleeping this way. She has become conditioned to be a light, vigilant sleeper. The good news is that once we understand what we are dealing with, we know how to change conditioning.
The diagnosis of Psychophysiological Insomnia is based on a history of difficulty initiating, maintaining and/or returning to sleep often associated with a habit of thinking, worrying, planning or problem solving in bed. It is often triggered by an event such as childbirth, painful illness or injury, or a stressful event. Although it can coexist with any other medical, psychiatric or sleep disorder, these disorders do not appear to be the primary cause of the difficulty sleeping. If there is significant pain, anxiety, depression, restless legs, etc., then these conditions need to be controlled before you should expect success at managing the insomnia. However, once these aggravating conditions have been controlled, any residual insomnia is most likely the result of poor sleep conditioning after a long period of disturbed sleep and should respond to the non-pharmacological insomnia treatment program.
If the insomnia symptoms began after an obvious trigger like childbirth or a stress like a loss of a job which has since resolved, then a Nocturnal Polysomnogram is probably not necessary. However, if there is a history compatible with a possible underlying sleep disorder such as obstructive sleep apnea, then a nocturnal polysomnogram would be useful to rule out other conditions contributing to poor sleep. Although people with insomnia are tired during the day from lack of sleep, they are not usually very sleepy. If you are significantly sleepy as well, then this raises the possibility of another underlying sleep disorder and a nocturnal polysomnogram should be performed.
To successfully manage Psychophysiological Insomnia, you need to manage the underlying psychological and physiological factors contributing to poor sleep.
The psychological factors are primarily related to conditioning. Many of the recommendations in the section on sleep hygiene help to address a number of these factors. For example, maintaining a regular sleep schedule, using a relaxation technique to fall asleep and return to sleep, setting the alarm so you do not look at the clock during the night, getting out of bed if you cannot sleep, are all recommendations that help condition good sleep.
However, if there is significant anxiety or depression, then these issues need to be treated as well. Sometimes, anxiety and depression are secondary to difficulty coping and feeling overwhelmed triggered by fatigue due to insomnia. If these symptoms are mild enough, just improving sleep with a non-pharmacological sleep program may be enough to improve anxiety and depression. However, if the individual is feeling more desperate, short-term use of a sleeping pill like zopiclone may be necessary while at the same time following the sleep program to address the underlying insomnia conditioning. Once the individual is sleeping well and feeling rested, then they can follow the protocol for Getting Off Your Sleeping Medication. However, sometimes the anxiety and depression are significantly contributing to the insomnia to the degree that these symptoms must also be treated at the same time using cognitive behavioral therapy (CBT) or anti-depressant medication.
Managing the physiological factors that contribute to Psychophysiological Insomnia is also important in order to be successful at achieving restorative sleep. If a nocturnal polysomnogram shows a significant underlying sleep disorder contributing to poor sleep, then this condition needs to be treated. Good sleep hygiene needs to be followed, such as winding down before bed to allow the adrenalin to wear off, avoiding TV and computer the last hour to remove the stimulating effect on the brain, avoiding caffeine after 12 noon, avoiding alcohol within 3 hours of bedtime, etc.
To become a good sleeper, you need to address the possible underlying sleep disorders and other issues identified with the Online Sleep Disorders Questionnaire. If you have been following the recommendations for good sleep hygiene and are still having problems with insomnia, then you should ask for a referral to a sleep disorders physician or a psychologist trained in Cognitive Behavioral Therapy for Insomnia (CBTi). Alternatively, you can follow the recommendations on this web site for a customized sleep program through the Online Insomnia Management Program (OIMP).
For more information you can go to the section on The Principles and Process for Reconditioning Good Sleep.