Sleepless Nights: What to Do

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November 30th, 2020 Health & Wellness No Comments

Almost everyone has a bad night of sleep once in a while, usually during periods of stress or illness.  For about 10-15% of the U.S. population, it is a regular occurrence and has become a chronic problem.  We call this pattern insomnia, and it can take a toll.

People with insomnia often say that they feel tired or sluggish during the day, have difficulty with concentration and memory, and feel irritable.  The goal of this article is to review our current understanding of insomnia and current treatment options.

What is insomnia?

The definition of insomnia may seem obvious; it’s trouble sleeping.  But there’s more to it than that.  First, there’s the time of night that is affected.  Trouble falling asleep at the beginning of the night is called sleep onset insomnia.  Other people have difficulty with waking up in the middle of the night and then having trouble getting back to sleep, which is called sleep maintenance insomnia.  The last type is when people wake up earlier than they want to in the morning and can’t get back to sleep, or early morning awakenings.

While some people with insomnia only have trouble in one part of the night, for many it’s a combination of these patterns.  The second part of defining insomnia is often overlooked, and it has to do with the impact of poor sleep.  To receive a diagnosis of insomnia (technically, it’s called insomnia disorder), there has to be some sort of impairment or distress due to not sleeping well. There are people who take awhile to fall asleep at night, or who are up during the night, but it doesn’t bother them or affect their daily functioning so we don’t call it insomnia.

What is a Good Night Sleep

As part of understanding insomnia it’s also helpful to understand how a good night of sleep is defined.  Sometimes there is a belief that a good night of sleep means laying in bed and falling asleep right away, and then waking up 7-8 hours later without any awakenings throughout the night.  This is a very high standard that almost no one can live up to.

It’s considered normal to take 15-20 minutes or so to fall asleep at the beginning of the night. It’s also typical to wake up 1-3 times per night, perhaps to use the bathroom, as long as there isn’t significant trouble getting back to sleep.  If there are unrealistic expectations for sleep, someone may think they have insomnia when they’re really just normal.

How common is insomnia?

As suggested in the opening line of this article, having a night of insomnia here and there is just part of normal life experience.  Around 10-15% of people experience chronic insomnia, meaning it occurs several times per week or more and has lasted 3 months or longer.  Another 25-30% has bouts of insomnia here and there but it does not last for long periods of time, which is called episodic insomnia.  If you add up these statistics, somewhere between one third and one half of individuals of suffering from insomnia on a fairly regular basis. That’s a lot of people!

Factors that impact rates of insomnia

There are several factors which impact the rates of insomnia.  For example, women have insomnia at a 50% higher rate compared to men. There are several reasons for this difference, including insomnia that occurs at certain points in the menstrual cycle, and insomnia that occurs during menopause.

Age is another factor, with rates of insomnia increasing with age.  The effects of age are partly related to changes in sleep biology that occur over time, including less deep sleep.  Another major contributor is the increased rates of health problems and medications, which can both negatively impact sleep.

How does insomnia develop over time?

When people develop chronic insomnia, it usually doesn’t just happen all at once, like a light switch getting flipped.  It develops over time, and may even come and go.  Insomnia first occurs because of what are called precipitating factors, which are the things that first lead to trouble sleeping. The most common precipitating factor is stress.  Insomnia is part of the normal physical response to stress, and it is often during stress periods that most of us have difficulty with sleep.

Sometimes the precipitating factor is an injury or other cause of pain, where being in pain at night is what keeps us awake. Sometimes it can be worry or anxiety, or a period of depression.  There are many other factors that can make insomnia more likely to occur.  Sometimes I wonder that any of us sleep well.  But for most people, if the precipitating factors does away their sleep improves.

For other people, their sleep doesn’t improve over time even though the precipitating factor may be gone. For example, as mentioned before women often experience insomnia during menopause.  As menopause passes, so does insomnia for most but for others their insomnia persists even years later.

It can be very confusing trying to figure out why sleep hasn’t improved.  It’s due to what are called perpetuating factors, which are cycles that people get stuck in that keep insomnia going over time.  Let’s look at one common cycle, which is sleep-related worry.  Someone may initially have insomnia because of stressful circumstances in their life. Then, at night when they are getting ready for bed they start worrying about their ability to sleep.  The worry ends up making them feel more awake and alert, and now they can’t fall asleep. The sleep-related worry has become a perpetuating factor.

Another common perpetuating factor is what is called conditioned arousal.  When people are good sleepers, and each night when they get into bed they fall asleep, their body learns, or becomes conditioned, to associate the bed with sleep. As a result, when good sleepers get into bed, it triggers an automatic response of feeling sleepier.  For people with insomnia the opposite happens. They spend so much time lying awake in bed, tossing and turning, in a state of mental and physical arousal, that they develop an association between the bed and wakefulness that is called conditioned arousal.  When someone has developed conditioned arousal, they may feel sleepy at night, but when they get into bed they start to feel more wide awake because of this pattern.

There are a number of these perpetuating factors, and they all end up doing the same things, which is to turn insomnia into a chronic problem that does not improve on its own.

Treatment options

Fortunately, there are several treatment options for managing chronic insomnia, each of which has pros and cons.  The most common way that insomnia is treated is with prescription medication.  There are many medications used to treat insomnia, some of which are FDA-approved for this use and other that are used off-label.  For example, trazodone is a medication commonly used to treat insomnia but that’s not what it was developed for. It is approved as an antidepressant, but it was found to make people feel sleepy. So now it’s mainly used to treat insomnia rather than for depression.

Wide availability of medications

The wide availability of a variety of medications is an advantage of this treatment approach. Another advantage is that, when they work well, they work right away; you take the medication before bed and that night you feel the benefits.

There are also several disadvantages of sleeping medications. First, they often don’t work as well as we would like them to.  People experience some relief but they still do not get a full night of good quality sleep.  Or, they work at first but become less effective over time. Another disadvantage is the potential for side effects.  A common side effect for sleep medication is grogginess in the morning because it is still in the person’s system. So it helps them sleep at night but then they feel lousy for some of the day.

Sleep medications have the potential for dependence to form.  Most of the medications don’t have significant risk for physical addiction, but someone can develop a psychological dependence if they believe they have to take the medication in order to sleep. Once dependence forms, there can be significant anxiety about sleep is they don’t take it.  Finally, a disadvantage of medications is that they treat insomnia but usually don’t fix the underlying problem, so they have to be used for long periods of time.

Cognitive behavioral treatment

The other proven method for the treatment of insomnia is cognitive behavioral treatment for insomnia (CBT-I).  CBT-I is a form of talk therapy that is focused specifically on sleep. In CBT-I, individuals meet with a psychologist or other provider, usually once per week, for 4-8 weeks.  Throughout treatment people are asked to keep a daily record of how the slept each night by completing a sleep diary in the morning.  The sleep diary is reviewed each week in CBT-I to learn more about an individual’s sleep patterns and to track their progress over the course of treatment.  Each week, they are taught specific strategies that are designed to target the perpetuating factors that maintain insomnia over time.

Set a sleep schedule

Strategies include setting a set sleep schedule, ways to decrease worrying or racing thoughts at night, reducing napping or caffeine use during the day, and learning to change sleep-related thoughts.  Since CBT-I is designed to address the perpetuating factors that maintain insomnia, it has the huge advantage of producing better long-term effects, so the individual does not need to remain in treatment to continue getting the benefits.  Another advantage is that it avoids a lot of the side effects and risks of dependence that can come with medication.

However, it has disadvantages as well.  CBT-I takes work, and it usually means following the strategies for several weeks before they start to make a difference.  So there’s more work up front than with taking medication.  Another disadvantage is that CBT-I is not always widely available.  There are not a lot of providers trained in this type of treatment, so it can sometimes be difficult to find someone who offers it.

Sleep medications and CBT-I are the treatments that have the most research demonstrating that they are effective. There are lots of other treatments that have less evidence, but that may be helpful. For example, there is some research demonstrating that acupuncture can help alleviate insomnia.  Some studies have found that forms of meditation, such as mindfulness meditation, can also improve sleep.

There are different products on the market that claim to be effective treatments for insomnia, but that often don’t have much evidence to back up these statements.  This is certainly true for many over-the-counter sleep aids. Most of these contain an antihistamine called diphenhydramine, which does tend to make us feel sleepy but it is notorious for making someone feel “hung over” the next morning.  Other over-the-counter sleep aids contain melatonin, which is a hormone our brain produces at night that is involved in regulating sleep. There have been many research studies on melatonin for insomnia, but often they find that it works no better than a sugar pill.

Hopefully this provides you with some useful information on insomnia in terms of what it is, where it comes from and what you can do about it.  If you suffer from insomnia, talk with your primary care provider about treatment options that may be a good fit for you.  There are different options available, so even if one treatment doesn’t work as well as you would like there are others to try.

Contributed by:

Philip Gehrman, PhDDr. Philip Gehrman is an Associate Professor of Psychology in the Department of Psychiatry of the University of Pennsylvania School of Medicine, and a clinical psychologist at the Philadelphia VA Medical Center.  He directs the Sleep, Neurobiology and Psychopathology lab at Penn.  He has an active research program exploring the mechanisms and treatment of sleep and circadian dysregulation in the context of mental health disorders.  Dr. Gehrman’s clinical specialization is on the delivery of cognitive behavioral and chronotherapeutic interventions for insomnia, circadian rhythm disorders, and other sleep disorders.  The overarching goal of his work is to advance the understanding of the links between sleep and mental illness through translational research that spans biology to therapeutics.

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