Hyperarousal in insomnia disorder: Current evidence and potential mechanisms
Open accessAbstract
Summary: Insomnia disorder is among the most frequent mental disorders, making research on its aetiology and pathophysiology particularly important. A unifying element of many aetiological and pathophysiological models is that they support or even centre on the role of some form of hyperarousal. In this theoretical review, we aim to summarise the current evidence on hyperarousal in insomnia. Hyperarousal is discussed as a state of relatively increased arousal in physiological, cortical and cognitive‐emotional domains. Regarding physiological hyperarousal, there is no conclusive evidence for the involvement of autonomous variables such as heart rate and heart rate variability, whereas recent evidence points to a pathophysiological role of neuroendocrine variables. In addition, current literature supports a central involvement of cortical arousal, that is, high‐frequency electroencephalographic activity. An increasingly important focus in the literature is on the role of other microstructural sleep parameters, especially the existence of microarousals during sleep. Beyond that, a broad range of evidence exists supporting the role of cognitive‐emotional hyperarousal in the form of insomnia‐related thought and worries, and their concomitant emotional symptoms. Besides being a state marker of insomnia, hyperarousal is considered crucial for the predisposition to insomnia and for the development of comorbid mental disorders. Thus, beyond presenting evidence from cross‐sectional studies on markers of hyperarousal in insomnia, hypotheses about the mechanisms of hyperarousal are presented. Nevertheless, longitudinal studies are needed to further elucidate the mechanism of hyperarousal throughout the course of the disorder, and future studies should also focus on similarities and differences in hyperarousal across different diagnostic entities.
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The relationships between pre-sleep arousal, the primary anxiety factor underlying insomnia, and the six individual processes making up PI remain unexplored.
“However, the relationships between pre‐sleep arousal, the primary anxiety factor underlying insomnia (Dressle & Riemann, 2023) and the six individual processes making up PI remain unexplored to the best of our knowledge.”
From Associations between psychological inflexibility processes, pre‐sleep arousal and sleep quality. (2025) · cites this paper as Dressle & Riemann, 2023
Section 6.2.4 describes cognitive arousal, often intensified before sleep, as central to many insomnia models and linked to worry and rumination. It does not establish pre-sleep arousal as the primary anxiety factor underlying insomnia. The statement that its relationships with six PI processes remain unexplored is the citing authors’ own qualification, not a finding attributed to this source. (LLM, conf=0.82)
Experimental — accuracy not yet measuredOver time, this leads to a conditioned state of heightened alertness and tension in response to sleep-related cues, making it even harder to fall asleep.
“Over time, this leads to a conditioned state of heightened alertness and tension in response to sleep‐related cues, making it even harder to fall asleep (Dressle & Riemann, 2023; Espie et al., 2006).”
From Associations between psychological inflexibility processes, pre‐sleep arousal and sleep quality. (2025) · cites this paper as Dressle & Riemann, 2023
Section 3 identifies conditioning effects in the bed environment as a potential cause of hyperarousal, and section 6.2.4 says attention to sleep-related cues can amplify cognitive arousal. The paper also links arousal to difficulty initiating sleep, but it does not establish that a conditioned response to those cues develops over time; the claim presents that proposed mechanism as fact. (LLM, conf=0.82)
Experimental — accuracy not yet measuredMetacognitive beliefs can amplify the emotional salience of primary sleep-related cognitions, increase attentional bias toward sleep-related threats, and paradoxically intensify pre-sleep arousal when individuals attempt to suppress unwanted thoughts.
“Metacognitive beliefs can amplify the emotional salience of primary sleeprelated cognitions, increase a entional bias toward sleep-related threats, and paradoxically intensify pre-sleep arousal when individuals a empt to suppress unwanted thoughts [15,16].”
From Pre-Sleep Anxiety: Mechanisms and Therapeutic Approaches in Clinical Practice. (2026) · cites this paper as [15]
Section 6.2.4 (page not provided) says that metacognitions and thought suppression influence pre-sleep cognitive arousal, and describes selective attention to sleep-related cues. It does not say that metacognitive beliefs specifically increase the emotional salience of sleep-related thoughts or cause that attentional bias, nor does it explicitly describe a paradoxical increase in arousal from suppressing unwanted thoughts. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe hyperarousal model of insomnia suggests that when people overthink and focus excessively on trying to sleep, they create mental and physical associations that interfere with sleep.
“The hyperarousal model of insomnia suggests that when people overthink and focus excessively on trying to sleep, they create mental and physical associations that interfere with sleep.”
From Associations between psychological inflexibility processes, pre‐sleep arousal and sleep quality. (2025) · cites this paper as Dressle & Riemann, 2023
Increased pre-sleep arousal plays a key role in the maintenance of insomnia.
“increased pre‐sleep arousal plays a key role in the maintenance of insomnia.”
From Associations between psychological inflexibility processes, pre‐sleep arousal and sleep quality. (2025) · cites this paper as Dressle & Riemann, 2023
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Self-citationSleep EEG characteristics associated with sleep onset misperception
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Self-citationEvent-related potentials in insomnia reflect altered perception of sleep
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The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023
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“Finally, the guideline was approved by the guideline committee of the ESRS and by the ESRS board, before submission to Journal of Sleep Research (JSR).”
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Hyperarousal features in the sleep architecture of individuals with and without insomnia
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The Psychoneurobiology of Insomnia: Hyperarousal and REM Sleep Instability
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Self-citationInvestigating the Role of BDNF in Insomnia: Current Insights
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A continuous approach to explain insomnia and subjective-objective sleep discrepancy
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Transcutaneous Auricular Vagus Nerve Stimulation in Insomnia: A Systematic Review and Meta-Analysis
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Petak, A., & Maričić, J. (2025) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph22071001 · Cited by 20 · see citing works
Insomnia disorder is associated with 24-hour cortical hyperarousal
Dai, Y., Ma, J., Vgontzas, A. N., Chen, B., Chen, L., Wu, J., Zheng, D., Zhang, J., Karataraki, M., & Li, Y. (2024) · Sleep Medicine · doi:10.1016/j.sleep.2024.11.002 · Cited by 22 · see citing works
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Hyperarousal dynamics reveal an overnight increase boosted by insomnia
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Sleep EEG in chronic insomnia disorder
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Sleep Medicine—What's in a Name?
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- Authors
- Dressle, R. J., & Riemann, D.
- Affiliations
- University of Freiburg (DE)
- Corresponding author
- Dressle, Raphael J.
- Venue
- Journal of Sleep Research
- Publisher
- Wiley
- Published
- 2023-05-14
- Volume
- 32
- Issue
- 6
- Pages
- e13928-e13928
- ISSN
- 0962-1105 (ISSN-L)
- 1365-2869
- OpenAlex
- W4376631032
- Cited by
- 218
- References
- 164
- Citations by year
- 2026: 108 · 2025: 70 · 2024: 32 · 2023: 8
- FWCI
- 9.20
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Journal of Sleep Research (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Life Sciences › Neuroscience › Cognitive Neuroscience › Sleep and Wakefulness Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- insomnia, hyperarousal, insomnia pathophysiology, heart rate variability, cortical arousal, microarousals, comorbid mental disorders
- MeSH terms
- Arousal, Cross-Sectional Studies, Emotions, Humans, Sleep Initiation and Maintenance Disorders, Sleep
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