Insomnia and how to beat it

by Maria M. Hadjimarkou, PhD Lecturer School of Psychology University of Sussex

In my last entry on sleep hygiene, I mentioned insomnia.  Today I would like to focus on insomnia, not only because of its high prevalence but also because of its implications for our overall health.  I will discuss its aetiology and how it can be a stepping-stone for various health conditions and share some tips on how it can be dealt with.

Insomnia is defined as the inability to initiate or maintain sleep.  We may toss and turn for a while before falling asleep or when we do manage to go to sleep, we may wake up during the night or early in the morning (earlier than intended) and find it very difficult to go back to sleep.  The main complaint by those suffering from insomnia is lack of restorative sleep (quantity and/or quality), but also the inability to function optimally the next day, emotional lability (switching emotions easily and lingering towards negative emotions), and cognitive difficulties. These symptoms are often part of an existing condition, such as depression or anxiety, but they can also exist independently.

Insomnia is formally diagnosed in 6-10% of people, although as many as a third of the population may report insomnia symptoms.  According to the formal criteria, insomnia is considered significant if it occurs for at least 3 nights per week and for at least three months. The onset of insomnia is primarily in adulthood with greater prevalence in women compared to men. Insomnia can be a brief episode (or acute) because of an event or change in our lives, but for some, the condition may persist.

In regard to the aetiology of insomnia, several models have been proposed. The most prevalent is Spielman’s 3P model (1987) which suggests that insomnia emerges from predisposing, precipitating and perpetuating factors.  According to this model, insomnia becomes a chronic condition in people who have certain characteristics that render them susceptible. What are those characteristics? It can be their age (those older are more susceptible), gender (women are more at risk), personality characteristics (i.e. tendency to worry and ruminate), social/environmental (social pressures, work schedule, noise, etc). These characteristics may increase the likelihood that one will develop insomnia if a precipitating event occurs. The precipitating event can be anything that leads that person to experience insomnia for a short period of time, and it may very well be a justified reason such as having a hard time at work or moving to a new place.

For the majority of people, this acute experience of insomnia will pass, however in those with predisposing factors, this insomnia episode may be the trigger that leads to increased anxiety and vigilance around sleep, accompanied by changes in the way that the person behaves, in an effort to tackle insomnia. They may start going to bed earlier to make sure they get enough sleep or nap to make up for lost sleep. However, these changes in attitude and behaviour around sleep have the opposite effect and increase the time they spend awake in bed and the worry around sleep. So, instead of tackling acute insomnia they perpetuate the condition and establish it as a chronic problem. 

A vicious cycle begins with increased arousal and negative thoughts associated with bedtime. The bedroom becomes associated with the unpleasant feeling of lying awake, unable to sleep and feeling increasingly frustrated and highly aroused.  These findings explain why insomniacs get more sleep in novel environments. Generally, people find it difficult to sleep in a new setting, like a hotel room or a sleep lab, known as the ‘first night effect’. For insomniacs, the opposite is true; they sleep better in a new setting and this ‘reverse first-night effect’, highlights the impact of the negative associations that have been established around sleep in their bedroom, with different aspects of the bedroom serving as cues, signals that increase anxiety regarding sleep. A new environment is devoid of those negative experiences (thinking of switching rooms or giving your bedroom a facelift yet?).

Insomnia is a known risk factor for cardiovascular diseases such as myocardial infarction and stroke, with the strongest association found in those having difficulty initiating sleep.  Another finding that has emerged through large studies, is that insomnia seems to be a prelude to common mental health conditions, such as depression and anxiety disorders. The first study to find this link was in 1989 and several big studies followed, looking at a large number of data from thousands of people. What was found repeatedly, is that insomnia always precedes the mental health condition and those suffering from insomnia have an increased risk, often twice as much, to develop depression in the next 1-3 years. This risk was also found in people with no pre-existing conditions who were followed over time. Those who ended up suffering from insomnia also had a significant risk of depression later on. The initial studies focused on depression but gradually the scope has expanded to other mental health conditions.  Presently, insomnia is implicated as a risk factor for depression, anxiety disorders, alcohol-related conditions and psychoses (although more evidence is needed for the last one). In the manual used for the diagnosis of mental health conditions (DSM-5, 2013), it is stated that insomnia is ‘an established risk factor for the subsequent development of mental illnesses and substance use disorders.’ 

Thus, it seems that the ball is in our hands. Knowing that insomnia is a risk factor for physical and mental health conditions, what do we do about it? We could panic and disrupt our health and well-being even more, or we could take a deep breath and tackle it head-on. The great news is that there is an effective way to tackle insomnia (besides analysing our life and identifying everything that we have been doing wrong) we could reach out for CBT-I or Cognitive Behavioural Therapy for Insomnia. Studies have shown that this intervention is highly effective in treating insomnia even if it is delivered in different formats, such as in groups or online. Even a brief single session called ‘one shot’ CBT-I also works. Of course, there is variability across people and for some, it may take more investigation and additional measures, but it may be the start.

If anxiety is the culprit, I highly recommend Carnegie Dale’s book ‘How to Stop Worrying and Start Living’ (1953) as it tackles it head-on. The two things from the book that I would like to highlight for you are: a) in order to stop worrying we need to identify what makes us worry and pinpoint its source. It is not as easy as you might think. b) in defining what it is that makes us worry we may have to face the worst-case scenario of our anxiety (perhaps losing our job or having our relationship fall apart). No matter how devastating that may be, it can be liberating, and it can make anxiety stop. Facing the worst-case scenario may help us realise that not only we can survive it, but that other opportunities may lie ahead. So, dealing with anxiety, taking care of our sleep hygiene and seeking help with CBT-I may be game-changing when it comes to sleep and beyond, as tackling insomnia may also shield us from numerous health problems in the future. 

For more on CBT-I visit this webpage: www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia