For people who sleep well, sleep is effortless. If you ask anyone who is a great sleeper how it is that they developed this amazing habit, they will likely be challenged to give a solid explanation.
Their capacity to sleep is innate, and they may make some efforts at keeping their sleep stable, but it is unlikely that they put much thought into their sleep. For folks who experience insomnia, sleep can start to feel like the enemy.
It is a failure to perform the essential task required for daytime functioning. It is a repetitive experience of distress, which often generalizes to other important areas.
Insomnia is a problem of insufficient or inadequate sleep, related to the inability to initiate sleep, maintain sleep or both. For many people, insomnia can start as problems falling asleep, and then move into a pattern where the problems with sleep occur throughout the entire night.
Insomnia affects between 30% and 50% of the United States population based upon subjective self-report and approximately 10% of the population when using the strictest diagnostic criteria for chronic insomnia disorder.
Insomnia tends to occur most often in women and risk of insomnia increases with age. Insomnia tends to have a relapsing/ remitting pattern, in that people who struggle with insomnia will have periods of high-intensity insomnia and periods where it is less intense.
Definition of Insomnia
In the past, we used to differentiate types of insomnia based upon where the sleep struggle had manifested and whether it could be related to something else in the individual. Insomnia was believed to be either primary (no other causes can be attributed to sleep disorder) or secondary (caused by another medical or psychological condition).
“Insomnia is a problem of insufficient or inadequate sleep, related to the inability to initiate sleep, maintain sleep or both.”
We also used to classify insomnia as sleep initiation insomnia (problem falling asleep), early insomnia (wakefulness early in sleep pattern), late insomnia (insomnia occurring at the end of the sleep period), and disorder of initiating and maintaining sleep (DIMS). The most recent revision of the International Classification of Sleep Disorders, the ICSD-3, eliminated insomnia typing and focused on more of a general presentation.
Currently, to be diagnosed with an insomnia disorder, you would have the following signs or symptoms:
|• Report of problems falling asleep or staying asleep|
• Less sleep than what is needed despite adequate opportunity for sleep
• Daytime consequences as a result of lack of sleep, which include:
○ Attentional issues
○ Mood disturbance
○ Daytime sleepiness
○ Social or vocational effects
○ Concerns or worries about sleep
○ Tension headaches
○ Problems with motivation, energy, or proneness to making errors
If the problem persists for more than three months, it is considered to be chronic insomnia, and less than three months is called acute insomnia.
Why Do People Develop Insomnia?
Our model for understanding insomnia is that it arises from predisposing, precipitating, and perpetuating factors, which work in concert to disrupt the normal drives toward sleep.
Predisposing factors for insomnia include potential genetic and familial factors that increase the likelihood of high states of arousal and tendency toward excessive introspection.
There is an inherited form of insomnia known as Familial Fatal Insomnia, which has been observed specifically in 40 families in the world. This is carried by a specific genetic trait that affects the production of a necessary protein.
This condition is unbelievably rare but has given us some insight into a manner through which insomnia could be inherited. More commonly, inheritance is likely related to sensitivity within the circadian system (internal clock), sleep metabolism, or tendency to be anxious.
Precipitating factors can be periods of intense stress, increased time demands, and/or major changes to routine. For many people, a stressful experience in life (good or bad) can trigger a pattern of disrupted sleep. Admittedly, some people can go through significant stress and sleep well, but most people will have some changes in their sleep pattern when they are stressed.
In my own experience, buying a house is a stressor that will definitely interrupt my sleep. I have learned that I can use some coping skills to navigate this stress, but I often also have to wait out the stress while not allowing sleep to worsen.
Perpetuating factors include the behaviors and maladaptive thought patterns that can cause insomnia to persist. These can include daytime naps, changing daytime activity to cope with poor sleep, spending excessive time in bed, and worrying excessively about sleep. Sometimes, people will become almost ritualistic in their approach to sleep out of a desire to try to control it and are devastated by their inability to force it to occur.
The more we focus on our sleep, the worse our sleep becomes. When perpetuating factors are addressed well, the drive toward homeostasis will usually correct the sleep cycle back toward a normal rhythm.
“Our model for understanding insomnia is that it arises from predisposing, precipitating, and perpetuating factors, which work in concert to disrupt the normal drives toward sleep.”
The lack of control over sleep is really the core of why this is such a significant problem for so many people. You can want to sleep, you can recognize its importance, and you can do everything you can to sleep well, yet you cannot make your brain turn off and let you become unconscious. We actually see that there are some unique characteristics of the brains of people who struggle with insomnia.
These differences include additional electrical activity during sleep, which we think actually allows for a small degree of possible consciousness when you are actually sleeping. This additional activity also supports the idea that people who struggle with insomnia tend to be much more focused on their sleep, paying more attention to nighttime wakefulness.
There are also deficits in the production of the neurotransmitter, gamma-aminobutyric acid (GABA) which is the neurotransmitter that is tasked with inhibition in the brain, primary function of which is sleep.
Another common difference is a tendency to be much more agitated or reactive during the day and the night. My dissertation work focused specifically on the co-occurrence (or comorbidity) of insomnia and depression because the talk at the time was that the combination of insomnia and depression was uniquely difficult to treat a condition that had increased risks to health and relapse over each of the independent conditions.
In my clinical work, I find that anxiety and insomnia work like opposite sides of the same coin. They share the same pathways in the brain and are essentially the same problem at different times of day or periods in life. The way this is often described is that thoughts can be experienced as a constant reel of chatter.
Sometimes people will know exactly where their brain is going with worries, and other times people say that it can skip topics quickly. When a person who is experiencing insomnia and anxiety has an awaking at night, they are much more likely to feel very worried about the awakening and the effect it will have on their day.
“Insomnia affects between 30% and 50% of the United States population based upon subjective self-report.”
Some people in this state will actually wake in the midst of a panic attack or extreme nightmare. The distress that preceding their awakening turns into a big hurdle to overcome because we simply cannot turn the distress back off and go back to sleep. It is not uncommon for people to then start to engage in their anxious thought reel, which will keep their brain agitated and engaged for hours.
Sleep disorders tend to have a high degree of comorbidity (co-occurrence) with other psychological disorders, physical disorders, and even other sleep disorders. Lack of sleep significantly affects daytime mood, which tends to increase vulnerability to developing anxiety or depression.
Anxiety and insomnia share the same pathways in the brain, so really are different presentations of the same problem. In both conditions, there is a high degree of central nervous system activity of the sympathetic nervous system.
The daytime effects of heightened sympathetic activity include vulnerability to panic attacks, high heart rate, shallow breathing, hyper-reactivity (e.g. high startle reflex), gastrointestinal discomfort, and even heightened sensory information.
The nighttime effects of heightened sympathetic activity are much the same, but people are more aware of racing thoughts, urges to move, and inability to fall asleep.
In the day, these symptoms are characterized as anxiety or panic disorder, at night these symptoms would be a firm diagnosis of insomnia.
How Does Insomnia Affect People?
There are many short- and long-term effects that are associated with insomnia. Sleep disruption creates physical and psychological agitation, which includes low mood, temper issues, and will inhibit healthy coping strategies.
“Sleep disorders tend to have a high degree of comorbidity with other psychological disorders, physical disorders, and even other sleep disorders.”
Someone who might run to help boost their mood may feel that they don’t have the energy to run, so may find themselves, yet again, eating the donut in their office to satisfy the brain’s call for extra carbohydrates, and then have an additional helping of disappointment over their poor coping.
This cycle increases both physiological and psychological agitation, which worsens the probability that they will be able to settle as the evening approaches.
In pediatrics, we often speak of a condition called “tired and wired” where a child is self-stimulating like crazy to try to sustain attention and wakefulness. The way that this can appear in adults is that their body is overwhelmingly tired, but their mind is so wired that they can’t settle down.
Caffeine is not always the culprit, but it can play a significant role in developing this state; it can take people up to 12 hours to metabolize caffeine fully. Using too much caffeine too late in the day will intensify the experience of sleeplessness for many people.
Insomnia is associated with mood disorders, and sleep changes tend to be key in diagnosing both depression and bipolar disorder. Many people experience excessive sleepiness with depression, but there are individuals who have depression and insomnia; this group is particularly vulnerable to suicide, so needs to be watched with extra precaution.
The relationship between insomnia and bipolar disorder follows along the same pathways as depression but has the added component that insomnia can be a key indicator of the presence of a manic episode in bipolar disorder.
For people with bipolar disorder, it becomes very important to make sure that circadian rhythm is stabilized. For example, during a depressed period, they may have little activity, little sun exposure, and over-consumption of food. When they enter a manic phase, these patterns are reversed, with a high degree of activity, light exposure, and little food consumption.
We can actually have some good effects in managing bipolar disorder if we can create a stable clock system and regulate controlled behaviors like food and activity.
“Pretty much all disorders that disrupt sleep at night have the potential to create an ongoing experience with insomnia.”
Daytime adaptations to sleep loss tend to be driven by the agitated state that is both causing and continuing insomnia. Sleep disruption creates dysregulation in the neurotransmitters related to appetite, and we see a significant increase in drive for food consumption, particularly carbohydrates.
A classic example of this challenge comes when you arrive at work, not having slept well, and being greeted by the box of donuts; so much of your brain wants to eat the donuts that there is little room left for rational thought. The high that the sugar creates can eventually move to a significant crash, which reinforces drive for carbohydrates and soothing through food; it is not unusual for clients to report that they have experienced problems with poor eating habits that may have originated in their problems with sleep continuity.
We all experience some slight energy crash in the early afternoon as a normal part of our circadian rhythm, but this crash is highly amplified when we are sleep deprived and potentially suffering from dramatic swings in blood sugar. The rise in the availability of sugary coffee drinks has created an additional insult in sleep continuity- we experience blood sugar swings during the day and then have brains that are too stimulated to settle to sleep at night.
For physical health, there are many conditions that create a vulnerability to insomnia or can be intensified by sleep problems. People who are blind can have significant challenges with their circadian rhythm, and experience chronic sleep loss as a result. There has been a lot of research on the relationship between diabetes and insomnia because insulin is a key component of the circadian system.
People who have Type I Diabetes have lost their capacity to produce their own insulin and need to take insulin on a daily basis to allow their cell to utilize nutrition they eat. The development of insulin pumps has significantly helped with the regulation of blood sugar, and also provides some support to stabilizing sleep for these individuals, as the high swings in blood sugar create challenges in circadian rhythm.
Individuals who have some struggles with chronic pain may have long periods of inactivity through the day and night, which results in significant challenges with sustaining sleep.
“Sleep disruption creates physical and psychological agitation, which includes low mood, temper issues, and will inhibit healthy coping strategies.”
People who have spent prolonged periods in bed after a significant illness will also experience challenges with sleep; they may sleep excessively as their body recovers, but then find that they cannot sleep well at all.
Experience of insomnia is related to vulnerability to contracting a cold because it results in dampening of immune functioning. People who have experienced chronic insomnia tend to also have a higher risk of cardiovascular disease, cancer, metabolic syndrome, high blood pressure, diabetes, and stroke. A great summary of these and other health effects can be found here.
Lastly, people who have experienced insomnia can often also be diagnosed with additional sleep disorders. The majority of sleep disorders share the same set of symptoms: daytime sleepiness, problems with waking in the morning, fatigue, and consistent feelings that sleep needs are not being met.
Sleep apnea, which is a condition where there are problems breathing at night, will have the additional possible symptoms of snoring, choking at night, dry mouth, and frequent awakenings. Restless legs syndrome involves problems with urges to move the body and can also manifest in some limb movements that create nocturnal awakenings. Periodic limb movement syndrome involves kicking of the legs during sleep which results in nocturnal awakenings.
Pretty much all disorders that disrupt sleep at night have the potential to create an ongoing experience with insomnia. We usually hope that treating the condition that is causing the awakening will treat insomnia, but there are many cases where residual insomnia persists. Positive airway pressure (PAP) treatment is the gold standard of treatment for sleep apnea, but can also trigger an experience of claustrophobia which can intensify experienced insomnia.
When we have treated all of the potential causes of nocturnal awakening, what is left is often called “psychophysiological insomnia” and requires its own intervention.
How is Insomnia Measured?
Key factors in insomnia assessment include:
|• Sleep efficiency, the amount of sleep time divided by time spent in bed|
• Sleep latency, the amount of time it takes a person to fall asleep
• Sleep disruption, the number of disturbances or awakenings at night
We can assess these variables based upon discussion in the clinic or draw information from sleep diaries. Sleep diaries can provide insight into patterns of sleep and also what kinds of activities they have throughout the day. The sleep diary that I like can be downloaded here.
It is good to get two weeks of information because there is a lot of variability in sleep day to day. It is normal to also collect information using questionnaires; my favorite is the Dysfunctional Beliefs About Sleep (DBAS-16) because it gives me a lot of insight into a person’s beliefs related to their sleep pattern.
“An optional assessment for insomnia is something called actigraphy, which measures sleep and wakefulness over a longer period of time.”
Sleep studies are rarely used with diagnosing insomnia because they offer very little detail to help with its treatment; it is not very meaningful to wire someone up in a sleep lab and watch them lie awake all night!
An optional assessment for insomnia is something called actigraphy, which measures sleep and wakefulness over a longer period of time (usually 2 weeks). Actigraphy is usually only beneficial if we think that the person has an additional struggle with their clock system.
How is Insomnia Treated?
According to the position paper published by the American Academy of Sleep Medicine on diagnosis and treatment of insomnia, there are two primary goals with insomnia treatment: improve sleep quality and quantity and improve daytime functioning.
Effective sleep intervention addresses the underlying physiological changes associated with insomnia (nocturnal hyperarousal, shallow sleep, decreased GABA production). The most common intervention for insomnia is hypnotic medication, and there are several classes of medications that are used for sleep.
Common hypnotic medications include:
|• Non-benzodiazepine GABA-receptor agonists|
○ Ambien (zolpidem)
○ Lunesta (eszopiclone)
○ Sonata (zaleplon)
○ Restoril (temazepam)
○ Xanax (alprazolam)
○ Klonopin (clonazepam)
○ Valium (diazepam)
○ Ativan (lorazepam)
○ Desyrel (trazodone)
○ Remeron (mirtazapine)
○ Sinequan (doxepin)
|• Other medications|
○ Belsomra (suvorexant)
○ Seroquel (quetiapine)
○ Neurontin (gabapentin)
Although medication is the most commonly used intervention for insomnia, it is really only indicated for short-term treatment. The AASM practice guidelines indicate that the goal should be lowest effective dose, and tapering off of medication as soon as is possible. The challenge that many people can face is that medications can be habit-forming and it can be hard to sleep without them once dependency has been established.
The gold standard of treatment for insomnia is Cognitive Behavioral Therapy for Insomnia (CBT-I). CBT-I was developed by Jack Edinger and colleagues and consists of several principles which are intended to address the psychological and physiological factors related to insomnia. It includes interventions intended to make the sleep environment a place that is conducive to sleep, limiting time in bed to appropriate sleep amount, regulating sleep schedule and circadian rhythm, and addressing any thoughts or behaviors that can be interfering with sleep.
CBT-I is available through books (this is a great one: End the Insomnia Struggle: A Step-by-Step Guide to Help You Get to Sleep and Stay Asleep) online programs (Sleepio, Shuti.me), and individual or group therapy. The therapy is very structured and can range from 4 to 12 sessions depending on different variables related to insomnia.
Sleep diaries are key to diagnosis and treatment, so are usually sustained throughout CBT-I. The biggest challenge people face with CBT-I is the fact that there are not a lot of practitioners who are credentialed and skilled in using the intervention. A list of providers and resources can be found here.
Most people are familiar with the standard recommendations for improving sleep, but it is good to summarize them. Some standard practices for healthy sleep include:
|• Keeping a set schedule 7 days a week|
• Sleep environment that is dark, cool, and comforting
• Eliminating exposure to light from devices 1-2 hours prior to desired sleep onset
• Avoiding caffeine 10-12 hours before desired sleep onset
• Regular daily exercise
• Regular exposure to sunlight
• Limit time in bed to a reasonable sleep period, 7-8 hours
For more sleep information, check out some more of our blogs (linked below) and the National Sleep Foundation website.