Summary: “Hyperarousal” is a cornerstone of many mental health conditions, from insomnia and ADHD to depression and PTSD. However, the term has historically been used as a “catch-all,” leading to imprecise diagnoses and treatments. Researchers have now identified that there are actually seven distinct types of hyperarousal.
By analyzing data from nearly 500 participants across multiple disorders, the team discovered that while these tension types overlap between conditions, their “signature” varies for each individual. This breakthrough has led to a new, comprehensive questionnaire that could allow psychologists to provide more targeted, personalized care.
Key Facts
- Seven Hidden Types: The study moves beyond the vague concept of “tension” to identify seven specific categories of hyperarousal that manifest differently across mental disorders.
- Cross-Disorder Presence: Most types of hyperarousal occur in multiple conditions (insomnia, anxiety, PTSD, ADHD), but the relative severity of each type is unique to the specific disorder and the individual patient.
- The New Tool: Researchers developed a concise, freely accessible questionnaire to replace the “patchwork” of surveys previously used to measure hyperarousal.
- Brain Mechanism Search: Lead author Tom Bresser is now investigating which specific brain regions are responsible for each of the seven types of tension.
- Clinical Impact: The tool aims to help clinicians identify when a patient with “Disorder A” may actually have an underlying predisposition for “Disorder B or C,” allowing for a more holistic treatment plan.
Source: KNAW
Hyperarousal plays an important role in mental disorders. It influences the severity of insomnia, depression, anxiety, post-traumatic stress disorder (PTSD), and ADHD. Yet it is striking that researchers do not always mean exactly the same thing when they use the term “hyperarousal.”
Researchers at the Netherlands Institute for Neuroscience therefore investigated whether different forms of hyperarousal exist.
“Within sleep research, we already know a great deal about the role of hyperarousal in insomnia,” says first author Tom Bresser. “But hyperarousal also plays a major role in many other mental disorders.”
Bresser and his colleagues therefore wondered whether all these forms of hyperarousal are actually the same, or whether different types of hyperarousal exist. “If we better understand what hyperarousal really is, we can also better understand insomnia, anxiety, and depression,” he explains.
To gain more insight into this question, the researchers combined a large number of questionnaires for different mental disorders into one comprehensive survey. Nearly five hundred participants from sleepregister.nl completed all the questions.
Seven types of hyperarousal
The study revealed seven different types of hyperarousal. Almost every type of hyperarousal occurred across multiple disorders. However, the relative severity of each type of hyperarousal differed among people with insomnia, depression, anxiety, panic disorder, post-traumatic stress, and ADHD.
Tool for future research
Based on these findings, the researchers developed a new, concise questionnaire to measure the different types of hyperarousal. “Instead of having to search for the right combination of questionnaires, researchers can now use this tool to map hyperarousal much more easily and comprehensively,” says Bresser. The sleep lab is already using the questionnaire in several of its own studies on insomnia and anxiety.
In addition, Bresser is investigating which brain mechanisms are involved in the different types of hyperarousal. “We hope to better understand which brain regions are involved in which type of hyperarousal.” In this way, the researchers aim to more precisely map how hyperarousal works in the brain.
Better treatment
Bresser hopes that the questionnaire will also be used in clinical practice in the future. “Often someone comes to a psychologist with disorder A, but it turns out they also have a predisposition for disorder B or C,” he explains. “By using the combined questionnaire, the underlying forms of hyperarousal can hopefully become clearer.”
This could help psychologists provide more targeted treatment. Instead of addressing only one problem, a treatment plan could focus simultaneously on the types of hyperarousal that are most important for the individual patient. “We therefore hope that healthcare professionals will be willing to try out the questionnaire in practice,” Bresser concludes.
Key Questions Answered:
A: That’s how it was often treated! But this research shows that hyperarousal is a “spectrum,” not a single feeling. Just as “pain” can be sharp, dull, or throbbing, hyperarousal can manifest in seven different ways. Understanding which type you have is the key to figuring out why you can’t sleep or why your mind is racing.
A: Absolutely. In fact, most people with mental health disorders experience a combination of several types. However, the “ratio” of these types changes depending on the condition. For example, the type of hyperarousal driving ADHD might look very different from the type causing chronic insomnia.
A: Currently, treatments are often “siloed”—one for anxiety, another for sleep. This new questionnaire allows a therapist to see the “connective tissue” between your symptoms. Instead of just treating the diagnosis, they can treat the specific underlying tension types that are fueling all your symptoms at once.
Editorial Notes:
- This article was edited by a Neuroscience News editor.
- Journal paper reviewed in full.
- Additional context added by our staff.
About this mental health and hyperarousal research news
Author: Eline Feenstra
Source: KNAW
Contact: Eline Feenstra – KNAW
Image: The image is credited to Neuroscience News
Original Research: Open access.
“Hyperarousal transdiagnostically dissected: different dimensions characterize mood, anxiety, insomnia, posttraumatic stress and attention deficit hyperactivity disorders” by Tom Bresser, Siemon C. de Lange, Lara Rösler, Tessa F. Blanken, Sophie van der Sluis, and Eus J.W. Van Someren. EClinicalMedicine
DOI: 10.1016/j.eclinm.2026.103810
Abstract
Hyperarousal transdiagnostically dissected: different dimensions characterize mood, anxiety, insomnia, posttraumatic stress and attention deficit hyperactivity disorders
Background
Hyperarousal is a common symptom key to the severity of insomnia-, depression-, anxiety-, posttraumatic stress- and attention deficit/hyperactivity disorders. Hyperarousal however remained a loosely defined construct assessed with different questionnaires in different disorders. Here we addressed the unresolved question whether hyperarousal may be one common transdiagnostic construct or rather has multiple, possibly disorder-specific, dimensions.
Methods
In this cohort study, participants were recruited through media and from the Netherlands Sleep Registry between Dec 2023 and June 2024. We included 467 adults (mean age 58.3 years [range 21–89]; 77.6% female) with a wide range of psychiatric diagnoses and severities who completed all hyperarousal questionnaires and disorder symptom severity scales (Insomnia Severity Index, Rapid Measurement Toolkit-20, and ADHD Self-Report Scale). Factor analyses evaluated potential dimensions in hyperarousal assessed with 221 items from 18 questionnaires.
Multiple regression models were used to reveal profiles of the most relevant hyperarousal dimensions associated with the symptom severity of insomnia disorder, major depressive disorder, generalized anxiety disorder, social anxiety disorder, panic disorder, posttraumatic stress disorder and attention deficit/hyperactivity disorders. We used 27 selected items representing the seven dimensions of hyperarousal to create the Transdiagnostic Hyperarousal Dimensions Questionnaire (THDQ).
A second sample was recruited between March 2025 and April 2025 for confirmation and validation (n = 592; mean age 61.0 years [range 19–89]; 65.2% female), who completed the THDQ. To examine the possibility to estimate hyperarousal dimension factor scores using available UK Biobank items, we calculated the polychoric correlation between the 27 selected items and 22 UK Biobank items in 467 adults.
Findings
Exploratory factor analysis identified 7 dimensions, explaining 50.2% of the variance and representing anxious-, somatic-, sensitive-, sleep-related-, irritable-, vigilant- and sudomotor hyperarousal. Multiple regression models showed that hyperarousal dimensions differentially correlated with the severity of insomnia, major depression, anxiety, panic, posttraumatic stress and attention deficit/hyperactivity disorder symptoms (standardized beta-coefficients = −0.10 to 0.70). We next developed and validated a 27-item THDQ, reliably assessing each dimension (CFI = 0.92, RMSEA = 0.05, Cronbach’s alpha = 0.90). Finally, we showed that UK Biobank items can estimate anxious, irritable and sleep-related hyperarousal (r = 0.75–0.85).
Interpretation
Distinguishing different hyperarousal dimensions, enabled by the THDQ, can propel our understanding of hyperarousal to provide clues for better treatment of multiple mental disorders.
Funding
European Research Council (ERC) and ZonMw (partnership between Care Research Netherlands and Dutch Research Council).
