Comprehensive Summary
In this article, chronic insomnia is reframed as an arousal regulation issue. Many people feel energized yet tired rather than actually asleep because the brain's alertness systems remain overactive at night and flow over into the day. Instead of pointing to a specific malfunction in the brain, the authors highlight network-level problems in systems such as the executive control and salience networks, which regulate attention and emotion. Both heredity and life experiences, particularly early stress that sets up stress hormones and brain circuitry for heightened alertness, increase risk. This perspective is supported by imaging and brain wave research, which demonstrate rigid patterns of connection. The study makes the case for precision sleep medicine, which recognizes biotypes and links them to specialized care, as the causes of sleep disorders vary from patient to patient. Cognitive behavioral therapy is currently the most effective method for treating insomnia. Other alternatives include developing technologies like neurofeedback and noninvasive brain stimulation, as well as drugs that reduce wakefulness, such as orexin receptor antagonists. The objective is to transition from universally applicable relief to customized, long-lasting solutions.
Outcomes and Implications
This article can be used to develop a clear care pathway that targets an overactive alertness system and addresses insomnia as a separate condition. Screening frequently in general care and behavioral health settings, inquiring about a history of stress throughout life, and paying close attention to women and older adults who are at higher risk. Inquiring about excessive daytime alertness that appears disproportionate. Additionally, ask about sleepiness. In a step-by-step care approach, starting with cognitive behavioral therapy for insomnia, delivered in a clinic or through high-quality digital formats. Use medication only when necessary, preferably low-dose doxepin or orexin receptor antagonists, and gradually reduce short-acting hypnotics. Combining treatment with fundamental circadian practices such as morning light exposure, maintaining a consistent routine, and providing advice on alcohol and caffeine intake. Furthermore, teaching techniques to reduce anxiety and improve emotional regulation. Consider specialized interventions, such as transcranial direct current stimulation, neurofeedback, and repetitive transcranial magnetic stimulation. Since better sleep and mental health often go hand-in-hand, it is important to co-manage depression, anxiety, PTSD symptoms, pain, and substance use. Utilizing wearables and diaries to monitor sleep patterns, identify differences such as short sleep versus typical insomnia, and match individuals with the most effective treatments. Clinics can move toward more effective, long-lasting, biomarker-guided, personalized insomnia treatments as data and basic brain and sleep metrics improve.