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Contemporary Reviews in Sleep Medicine |

The Pathophysiology of InsomniaPathophysiology of Insomnia

Jessica C. Levenson, PhD; Daniel B. Kay, PhD; Daniel J. Buysse, MD
Author and Funding Information

From the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA.

CORRESPONDENCE TO: Daniel J. Buysse, MD, University of Pittsburgh, 3811 O’Hara St, WPIC E-1127, Pittsburgh, PA 15213; e-mail: buyssedj@upmc.edu


FUNDING/SUPPORT: Dr Buysse is supported by the National Institutes of Health [Grants MH024652, MH102412, AG020677, and HL125103]. Drs Levenson and Kay are supported by the National Institutes of Health [Grant HL082610, T32, PI Buysse].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(4):1179-1192. doi:10.1378/chest.14-1617
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Insomnia disorder is characterized by chronic dissatisfaction with sleep quantity or quality that is associated with difficulty falling asleep, frequent nighttime awakenings with difficulty returning to sleep, and/or awakening earlier in the morning than desired. Although progress has been made in our understanding of the nature, etiology, and pathophysiology of insomnia, there is still no universally accepted model. Greater understanding of the pathophysiology of insomnia may provide important information regarding how, and under what conditions, the disorder develops and is maintained as well as potential targets for prevention and treatment. The aims of this report are (1) to summarize current knowledge on the pathophysiology of insomnia and (2) to present a model of the pathophysiology of insomnia that considers evidence from various domains of research. Working within several models of insomnia, evidence for the pathophysiology of the disorder is presented across levels of analysis, from genetic to molecular and cellular mechanisms, neural circuitry, physiologic mechanisms, sleep behavior, and self-report. We discuss the role of hyperarousal as an overarching theme that guides our conceptualization of insomnia. Finally, we propose a model of the pathophysiology of insomnia that integrates the various types of evidence presented.

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sleep ; insomnia

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