Insomnia affects as much as 40% of the population in a year, as many as a third of adults suffer sleep disorders at some time in their lives and 10-20% of the adult population suffers from chronic sleep disturbance. Sleep disruption can result from environmental factors, everyday stress, medical issues, mental health disorders and substance use. In a few people, insomnia is a primary disorder, one that is not associated with another medical or mental health disorder but most people who suffer from insomnia have a related disorder. Many medical disorders, including heart disease, diabetes, allergies and hormonal fluctuations, may affect sleep. Ingestion of stimulants, like caffeine and nicotine, prescribed medications and recreational substances, including alcohol, may all disrupt sleep. Mental health disorders, especially anxiety and depressive disorders, may both cause and be exacerbated by sleep disturbance.
Sleep difficulties may manifest as an inability to fall asleep (initial insomnia), frequent awakening (middle insomnia) and/or early awakening (terminal insomnia). Initial insomnia is often associated with anxiety, ingestion of stimulating substances and food, stimulating activities (like television and computer use) and/or exercise too close to bedtime. Both middle and terminal insomnia are often associated with depression and may be exacerbated by alcohol and drug use and withdrawal. Alcohol and some drugs may initially induce sleep, only to disrupt sleep cycles or cause awakening later on. Withdrawal from substances, especially alcohol, benzodiazepines and opioids, may cause sleep disruption long after acute withdrawal symptoms subside.
Normal sleep is divided into two types: REM (rapid eye movement) and NREM (non-rapid eye movement or quiet sleep); NREM sleep is further divided into four stages, from light to progressively deeper. During quiet sleep, the physical body is rejuvenated through tissue repair and regeneration, bone and muscle growth and strengthening of the immune system. REM sleep is characterized by dreaming and increased brain activity accompanied by muscular paralysis. Cycles of sleep lasting about 90 minutes alternate between NREM and REM sleep, with REM sleep cycles gradually lengthening from about 10 minutes in the first cycle to as long as an hour at the end of sleep. The function of REM sleep is not completely understood but seems to be related to learning, emotions and stress management.
Primary insomnia can be treated with sleep hygiene and cognitive-behavioral interventions. (See our website for sleep hygiene tips: http://www.anxiety-stresscenter.com/stress/sleep-hygiene). Insomnia associated with another medical or mental health disorder should include treatment of the primary disorder as well as direct treatment of the insomnia. A positive synergy is created with the treatment of both the primary disorder and sleep problems: reducing other symptoms of anxiety and depression will generally lead to better sleep and improving sleep will usually improve other symptoms of anxiety and depression. A number of approaches to managing insomnia can help:
- General health guidelines for diet and exercise will also help insomnia. A healthy diet, reduced use of stimulants and alcohol, and 30 minutes of aerobic exercise are all associated with improved sleep.
- A relaxing bedtime routine will help you fall asleep more easily. Turning off the computer, taking a warm bath, soothing music, prayer or reading, and a warm drink may all help you relax and let your body know it is time to prepare for sleep. Think about what routines would help you relax most and repeat these nightly.
- Stimulus control: re-learning to associate being in bed with being asleep rather than with being awake. If you can’t fall asleep within 10-15 minutes, get up and go to another spot, engage in a relaxing activity and return to bed only when sleepy. Allow another 10-15 minutes in bed to fall asleep and leave the bed again if you still don’t sleep. Repeat as often as necessary to result in sleep and be patient: it may take several nights of this process to re-learn a positive association between bed and sleep. The association bed and being awake was learned over a long period of time so it may take days or weeks to reverse it.
- Relaxation therapy: Reducing levels of arousal during the day and at night will result in improved sleep. Progressive muscle relaxation, imagery, meditation and relaxing exercise like hatha yoga can all reduce arousal and improve sleep. Activities like reading, listening to music, crafts and games may help you relax and fall asleep, as long as they are not too exciting. Television may help some people relax but beware of getting caught up in a program and staying up to finish it. Both television and music interfere with sleep if left on so use a sleep timer or, even better, only use these in another room. Computer use and work activities generally have an arousing effect and should be avoided right before bed and when trying to return to sleep.
- Cognitive intervention: On your own or with a therapist, examine your own thoughts and beliefs about sleep and insomnia, challenging the validity and adaptiveness of your beliefs and replacing them with ideas that are more evidence-based and useful in facilitating restful sleep.
- Medical intervention: Medications may be useful in some cases to disrupt insomnia and re-establish sleep/wake cycles and when used in conjunction with sleep hygiene. Discuss which medications may be best for you and your sleep symptoms with your medical provider.
Nancy R. Soro, Ph.D.
Licensed Clinical Psychologist
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