Understanding Insomnia

What exactly is insomnia

Psychologists and other health professionals use the Diagnostic and Statistical Manual of Mental Disorders (DSM) to determine if someone meets criteria for a sleep disorder. In order to be diagnosed with insomnia, an individual must experience the following symptoms:

• Have difficulty falling asleep, staying asleep, or waking up early without being able to get back to sleep
• The sleep problems occur at least 3 nights per week, and persists for more than 3 months
• The sleep disturbance interferes with the individual’s ability to function in daily life
• The sleep problems are not better explained by other medical or psychological problems
• Sleep difficulties exist despite adequate opportunities for sleep.

What causes sleep problems

There are many different factors that can contribute to sleep problems. Identifying the specific causes that are contributing to your sleep problems can help you tailor your treatment.

Mental Health Problems: Many psychological problems can interfere with sleep, including depression, anxiety, worry, and posttraumatic stress disorder. If your sleep problems are secondary to a mental health condition, these underlying problems should be treated which is likely to resolve the insomnia.

Medical Conditions: Medical problems such as chronic pain, sleep apnea, asthma, allergies, or Parkinson’s disease can also interfere with sleep. Speak with your family doctor about your symptoms so that medical conditions can be identified and treatment recommendations can be made.

Medications: Both prescription and non-prescription medications can contain ingredients that interfere with sleep. Speak to your doctor or pharmacist about how your medications could be impacting your sleep. It is often possible to make changes that can resolve this issue (e.g., by taking medication at a different time of day).

Sleep behaviours and habits: Sometimes there is no underlying psychological or medical cause for insomnia. Instead, our difficulties sleeping can be explained by unhelpful thoughts and behaviours that we have developed over time. The strategies outlined below can help you identify some of these unhelpful patterns so that you can begin developing healthier sleep habits.

Stop watching the clock when you can’t fall sleep. This only increases anxiety and makes sleep less likely.

What you can do to combat insomnia

Stop trying to sleep well. This sounds counter-intuitive, but if you ask any good sleeper what they do to fall asleep, they will probably find it hard to answer the question. Good sleepers just go to bed, and they eventually fall asleep. They don’t need to put effort into falling asleep, they just do. In contrast, poor sleepers often develop various strategies designed to promote sleep. For example, they may use white noise machines, play special sounds, read or watch TV in bed to wind down, or drink sleepy time tea in order to help them relax. The are two problems with these strategies. First, they take effort. Poor sleepers often spend a lot of time and energy doing things to help them get to sleep. However, our bodies have a built-in system for regulating sleep, and such efforts actually get in the way of that system. The second problem with strategies designed to promote sleep is that they focus our attention on our sleep problems and drive up anxiety. This can leave us feeling stressed and agitated before bed, which is bad news for sleep.

Develop healthier sleep habits. Sometimes we engage in behaviours that we don’t realize are interfering with our sleep (or even worse, we think they’re helping). For example, alcohol is a common culprit of sleep problems. Although alcohol can in fact help us fall asleep, it actually interferes with our sleep system reducing the quality of our sleep and making it more likely that we will wake up part-way through the night. It is therefore important to develop good sleep habits to promote a good night’s sleep. The Centre for Clinical Interventions provides a list of helpful sleep strategies (http://www.cci.health.wa.gov.au/docs/Info-sleep%20hygiene.pdf)

Increase your sleep drive: Our bodies have an internal system that regulates our sleep and wakefulness, called our sleep drive. Our sleep drive starts to build from the second we wake up, and the longer we are awake the more our need for deep sleep increases. Our sleep drive is determined by how long we have been awake and how active we have been. This has two important implications for promoting sleep. First, since sleep drive is determined by how long we have been awake, naps will reduce our sleep drive and make night-time sleep more difficult. While some people can have naps without any repercussions, people with insomnia should avoid naps. If you feel sleepy during the day, a short burst of exercise can help wake you up (e.g., go for a walk, run up and down the stairs a few times). Second, since daytime activity contributes to sleep drive, daily exercise is a fantastic way to encourage sleep (just make sure you avoid exercise before bedtime).

It’s not just about quantity. Despite the popular belief that we need 8 hours of sleep, there is little scientific evidence to support that 8 is the magic number. People vary in their sleep needs and furthermore, these needs vary across the lifespan (e.g., babies need much more sleep than adults). Although quantity does matter (few people could function on 1-2 hours of sleep per night for extended periods) the quality of one’s sleep is just as important. 6 hours of deep restorative sleep will leave you feeling much better than 8 hours of light, disrupted sleep.

Stop catastrophizing. Have you ever caught yourself saying things like “if I don’t get a good night’s sleep, I won’t be able to function tomorrow” or “I can’t take another sleepless night”. Statements like these increase pressure to fall asleep, which only makes us anxious and sleep less likely. It’s therefore important to challenge thoughts like this and remind yourself that although it might be unpleasant, you will probably be able to get through tomorrow.

Create a Buffer. One common sleep mistake people make is trying to go from a busy day full of activity to sleep, without any wind-down time (e.g., like responding to work emails in bed or finishing up a project that is due tomorrow). However, our minds take time to shut down and working until bedtime is likely to keep your mind active making sleep much more difficult (regardless of how exhausted you might feel). Try creating a buffer zone before bed where you do calming activities to give yourself a chance to wind down and relax. This could include a warm shower, a relaxing book (stay away from anything too arousing), knitting, colouring, breathing exercises, meditation, or preparing lunch for tomorrow.

Treatment

If the above strategies aren’t working for you, consider seeking professional help. Although medications are often used to treat sleep problems, they are generally recommended for short-term use only (e.g., recovering from an illness, travelling across time-zones). Using sleeping pills long-term can cause your body to get used to them so that they no longer work for you. Sleeping pills can also be addictive, meaning that your body gets used to them so you can no longer sleep without them. The treatment of choice for insomnia is a type of psychological treatment known as cognitive behavioural therapy (CBT). In CBT, you learn skills to challenge negative thinking patterns and unhelpful behaviours that are maintaining your sleep problems. For a video on insomnia and CBT see https://www.youtube.com/watch?v=T3SqiE9cZ7s&t=246s

Want more information?  Check out our list of resources including books on insomnia as well as other topics here: https://waterloocbt.ca/resources/

Author: Dr. Dubravka Gavric, C. Psych.