The Truth About Insomnia

Can’t sleep? Here’s Why. 

What exactly is insomnia?

Having trouble falling asleep? Waking up and can’t go back to bed? Thinking you are awake when you are actually sleeping??? Insomnia is a common phrase in this day and age, and with many people having go-go-go lifestyles, who has time to sleep anyways? But there is more to the term insomnia than just folklore will tell you. On average about ten percent of the population has chronic insomnia according to a wide variety of studies (Roth, Journal of Clinical Psychiatry 2005). That’s 1/10 people you see during the day. Chances are you or someone you know has it.

To get scientific, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes insomnia as:

1. Difficulty initiating or maintaining sleep or non-restorative sleep for at least one month
2. Causes significant distress or impairment in social, occupational, or other important areas of functioning
3. Does not occur exclusively during the course of another sleep disorder
4. Does not occur exclusively during the course of another mental disorder
5. Is not due to the direct effects of a substance or general medical condition

(American Psychiatric Association, 2000)

Besides that general definition there are two types of insomnia: sleep onset insomnia and sleep maintenance insomnia. Sleep onset insomnia is trouble falling asleep while sleep maintenance is trouble staying asleep or going back to sleep after waking up.

So what causes insomnia?

Psychologists believe a combination of precipitating factors can lead to insomnia, these include:

1. Circadian Factors

Ever travel to another country and can’t sleep your first couple of nights there? It turns out jet lag, shift work, and irregular sleep schedules disturb your body’s natural sleep rhythms and can, if taken to an extreme, lead to insomnia.

1. Psychiatric Factors

These include depression, other mood and anxiety disorders, and the medications used to treat them.

1. Medication, Drugs, and Alcohol

Not only the acute effects of drugs but also, developing tolerance, and withdrawing from medications can hurt your sleep significantly.

1. Medical and Neurological Illnesses

Lots of mental illnesses have a big impact on the brain which can lead to major sleep disturbances.

(Buysse and Reynolds, Handbook of Sleep Disorders, 1990:380)

Inside an Insomniacs Head

All of the previous factors contribute to what are called Psychophysiology and Conditioning Factors. These factors are the activity inside the body and mind of an insomniac that causes them to be unable to sleep:

1. Psychological factors such as anxiety and low mood
2. Physiological tension and arousal such as mind racing, tense muscles, or being sensitive to sound or light
3. Negative conditioning such as negative sleep habits which include staying in bed late, irregular bed times, or trying too hard to sleep

(Buysse and Reynolds, Handbook of Sleep Disorders, 1990:380)

Sleep/Wake Discrimination

 

Ever wake up in the middle of the night and feel like you haven’t been sleeping at all? An interesting fact is that insomniacs have trouble distinguishing between sleep and wake states. A study by Mercer et al. (Sleep 2002) found that when insomniacs were woken up in the middle of the night, they had a much harder time knowing if they had just been sleeping or just been awake. The study also showed that insomniacs often think they are getting much less sleep than objective measures show they are getting. What this means is not that insomniacs cannot keep track of how long they have slept, it is that they actually think they are awake half the time when they are really sleeping. This in turn, can contribute to the physiological tension and psychological factors that perpetuate insomnia to begin with. As you can see, insomnia can be the result of a cognitive downward spiraling loop, which brings psychologists to believe changing insomniac’s thoughts can help stop the loop and lead to more sleep (more on that later).

Consequences, the Life of an Insomniac

You can probably imagine that living with insomnia has all sorts of consequences. Here’s a list of the most common ones that affect an individual with insomnia:

• Mental health problems
• Daytime fatigue
• Irritability
• Reduced concentration
• Memory impairments
• Gastrointestinal problems
• Frequent headaches
• Muscle, neck or back pain
• Overall poorer quality of life

(Roth, Journal of Clinical Psychiatry 2005

Berry et al., Clinical Sleep Disorders 2005)

Societal Impact

Besides being hard on the individual, insomnia affects society as a whole. Here are just a few ways:

• Increased occurrence of accidents: insomniacs were found to be 2.5 to 4.5 times more likely to have a motor or industrial accident
• Mental health problems
• Lower job performance
• Increased disability of functions of daily life
• Increased health care utilization: this includes increased cost to individual and to society. In 1995 it was found that the direct costs of insomnia in the U.S. totaled 13.96 billion dollars!

(Roth, Journal of Clinical Psychiatry 2005)

So How is Insomnia Treated?

Pharmacology, Drugs!

There are two common categories of drugs used to treat insomnia, Benzodiazepines and Nonbenzodiazepine hypnotics. Although shown to have some effect on insomnia, there are also other consequences of taking each.

Benzodiazepines (Normison, Valium)

These can change your sleep architecture, have day after effects, increase in tolerance, and have discontinuation effects.

Nonbenzodiazepine hypnotics (Ambien, Sonata)

These can cause memory disturbances, nightmares, and daytime drowsiness.

All of these are recommended to use nightly for less than 1 month, so although they are a solution, it is only for the short term.

Cognitive Behavioral Therapy

Besides pharmacology, a specific type of therapy called Cognitive Behavioral Therapy has been shown to be more effective than sleep medications in treating insomnia. It is also used to treat anxiety, depression, and post traumatic stress disorder. Cognitive Behavioral Therapy’s main goal is to change unhelpful thoughts, beliefs, and behaviors of the client. The following are common therapeutic techniques used to treat insomniacs:

1. Sleep diary: clients are asked to keep a sleep diary in which they write down when they sleep and wake up each day. It is used to measure the degree of sleep disturbance before starting therapy and to monitor their improvement as therapy progresses. Sleep diaries may also help reduce sleep complains and reduce anxiety around how much a client is sleeping.
2. Targeting unhelpful beliefs about sleep: clients learn about circadian rhythms, consequences of sleep loss, and other facts about sleep in order to challenge their unhelpful beliefs that they have about sleep.
3. Stimulus control and sleep restriction: In stimulus control clients are told to go to bed only when tired, only sleep and have sex in bed, and get up at the same time every morning. If they can’t fall asleep within 10 minutes of lying down they should get up and go to another room. Sleep restriction is limiting the client’s time in bed to their average amount of sleep per day. This increases the client’s drive for sleep, and makes sure they won’t lie in bed worrying about sleep.
4. Relaxation training: Clients are taught various relaxation techniques such as meditation in order to calm presleep cognitive activity.
5. Paradoxical intention: The therapist will tell the client to try to stay awake when they lie down at night. This reverse psychology has been shown to reduce the client’s anxiety about falling asleep.
6. Imagery training: Clients are told to imagine a pleasant situation that is relaxing or a common object before sleep in order to associate sleep with something positive or neutral in the clients mind.

(Harvey, Clinical Psychology Review 2005)

Targeting Negative Automatic Thoughts 

One of Cognitive Behavioral Therapy’s main goals is to eliminate negative automatic thoughts. These are thoughts that occur quickly, automatically, can be difficult to turn off, and often precede a powerful emotion (Beck, 1995). To combat these thoughts clients are given thought records, a sheet of paper that asks the client to observe their negative automatic thoughts about sleep and evaluate the validity of those thoughts. A typical thought record includes space for the following:

1. Write down what the thought is

2. Name the emotion that accompanies the thought and rate the intensity of it (1-100)

3. Evaluating the thought using questions such as: Is there an alternative explanation? What’s the worst that could happen? Could I live through it? How likely is it? What’s the best that could happen? What’s the most realistic outcome? Are my thoughts helpful? How would others see this situation? How important will this seem when I’m 80?

4. Revaluating the intensity of the emotion after evaluating the thought

5. What to remember for next time

(Harvey, A.G.)

Now What?

Though millions of years of evolution has created an intense pressure for humans to sleep, for some of us it is not as easy as you might think. Many factors in our society can contribute to anxiety around sleep and result in a life altering condition called insomnia. Although drugs and especially therapy has been shown to help, much about insomnia is still unknown and further research is needed to keep people sleeping when they want to.

(Adopted from: Meghan Miller. “Sleep in the Clinic I: Insomnia.” Psych 133 lecture. UC Berkeley. F295 HAAS School of Business, April 10^th, 2008)

Sources

Harvey et al., Cognitive approaches to insomnia. Clinical Psychology Review 25; 593-611 (2005)

Mercer et al., Insomniacs’ Perception of Wake Instead of Sleep. Sleep 25(5); 560 (2002)

Roth., Prevalence, Associated Risks, and Treatment Patterns of Insomnia. J Clin Psychiatry 66(suppl 9) (2005)

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