Psychophysiologic insomnia definition9/13/2023 ![]() ![]() Little is known about how CBT-I exerts its effects on sleep-related attentional bias in PI patients. ![]() Thus, after successful CBT-I, PI patients are expected not to experience hyperarousal in bed and not to overreact to SS. CBT-I techniques try to decrease the potential conditioned pairing between awakening and sleep-related information 14. CBT-I is intended to correct the psychophysiological component of the insomnia. The treatment of choice for PI is cognitive behavioral therapy for insomnia (CBT-I) 11, 12, 13. These authors showed increased amygdala activity in insomnia patients in response to insomnia-related pictures, but they were unable to find any differences in brain activity between insomnia patients and good sleepers (GS) in response to sleep-related words. However, only two functional magnetic resonance imaging (fMRI) studies of insomnia investigating brain activation in response to SS have been conducted by a single research group 9, 10. In a recent review 8, the majority of research comparing good sleepers and insomnia patients reported sleep-related attentional bias in insomnia patients. Insomnia patients pay more attention 4, 5, 6 and show elevated cognitive and psychological arousal to SS 7. Previous neurophysiological research has shown that patients with insomnia usually show hyperarousal in response to SS. For both models, selective or exaggerated attention to SS can be produced in PI patients due to excessive preoccupation with sleep. Another cognitive model of insomnia 3 suggests that excessive worry and fear over disrupted sleep renders individuals anxious and aroused. Excessive attention, intent, and effort to achieve good sleep increase sleep-related anxiety, thus maintaining insomnia. The AIE pathway model argues that PI develops and is maintained by three processes: 1) attention to sleep-related stimuli (SS), 2) intention to sleep, and 3) effort to sleep. The attention-intention-effort (AIE) pathway model has been proposed as a cognitive model for PI 2. Through repeated experiences of sleepless nights, patients with PI become more preoccupied with ‘good’ sleep 2. Poor sleep in PI increases sleep-related anxiety, which further exacerbates hyperarousal. Psychophysiological insomnia (PI), one such example of an independent insomnia that has its own pathophysiology, is known to be a learned insomnia, caused by a conditioning process whereby sleep-related conditions and hyperarousal are paired. The diagnosis of insomnia disorder can be made when sleep difficulties and related daytime dysfunctions are present despite adequate time and opportunity for sleep. However, the International Classification of Sleep Disorders (ICSD) regards insomnia disorder as an independent illness rather than as merely dependent on other conditions 1. Insomnia symptoms can be accompanied by various psychiatric and medical illnesses. CBT-I may exert its treatment effects on PI by reducing hyper-responses to SS in the precentral cortex and insula. PI showed hyper-responses to SS in the precentral cortex, prefrontal cortex, and default mode network and these brain hyper-responses were normalized after CBT-I. Clinical improvements after CBT-I were correlated with BOLD reduction in the right insula and left paracentral cortex in response to SS. The increased response to SS in the precentral cortex was associated with longer wake time after sleep onset (WASO), and its reduction after CBT-I was associated with improvements in WASO. The increased responses to SS were reduced after CBT-I. PI patients showed higher BOLD activation to SS in the precentral, prefrontal, fusiform, and posterior cingulate cortices before CBT-I. BOLD changes after CBT-I in patients were also examined. Blood oxygen level dependent (BOLD) signal differences in response to SS and neutral stimuli (NS) were compared between 14 drug-free PI patients and 18 good sleepers (GS) using functional magnetic resonance imaging (fMRI). The present study was an exploratory, prospective intervention study that aimed to explore brain response to visual SS in PI before and after CBT-I. Psychophysiological insomnia (PI) includes arousal to sleep-related stimuli (SS), which can be treated by cognitive behavioral therapy for insomnia (CBT-I).
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