Insomnia demystified - A Sleep Psychologist's Guide (Part 2)

This is the second in a series of four articles explaining how chronic insomnia develops and what you can do to get relief from it.

In the first article in this series, we learned an important paradox about sleep: that putting in effort to sleep can make it much harder for sleep to come. In this installment, I’ll describe how this principle explains why some people develop chronic insomnia, the kind that can last for months or years.

First, some basic information. Insomnia is diagnosed when an individual has difficulty falling asleep (taking more than 30 minutes), staying asleep (waking up 3 or more times a night, or for a period of more than 30 minutes), or waking up earlier than the desired time.

In addition, these difficulties must occur more than 3 times a week and affect a person’s functioning during the day. Insomnia sufferers commonly have difficulty concentrating, decreased mood and motivation, and fatigue. Short-term, or adjustment insomnia is diagnosed in someone who has had these problems for at least a month. Longer durations of insomnia (3 months or more) would qualify as being chronic.

Insomnia most commonly starts because of a stressor: an exam period, illness, or a difficult life event. Stressful events are inescapable, and poor sleep during these trying periods can be very hard to avoid. As such, having some nights of bad sleep during a stressful period is not usually of great concern. Once the problem is solved or a person copes with and adjusts to their new situation, their sleep quality will gradually return to normal.

In contrast, people with chronic insomnia continue to experience sleep difficulties long after the initial stressor has been resolved. For this reason, the problem can be tough to understand – if there’s nothing going on to be anxious about, what is keeping the insomnia going?

Here’s where we come back to our basic lesson: trying to sleep is counterproductive. As it turns out, chronic insomnia is often sustained by habits that are picked up when people worry excessively about their short-term sleep problem and overcompensate to fix it. These habits can be behavioural and/or cognitive. Let’s break some of them down.

1)    Continuing to lie in bed when sleep isn’t happening.

The classic image of someone suffering from insomnia is of them lying in bed, eyes wide open and bloodshot, hoping for sleep to come. Interestingly, this behaviour is not just the result of insomnia, it is the engine that keeps it going.

We are not always conscious of this, but our brains are wired to quickly create associations between places, actions, and emotions. For example, someone who is afraid of going to the dentist may start to feel anxious while they are sitting in the waiting room, simply because they have associated that environment with the nerve-wracking experience of having their teeth prodded and examined.

Healthy sleepers associate the bedroom and lying in bed with feelings of relaxation, peace, and safety, making it easy for them to drift off quickly into slumber. Those with insomnia do just the opposite, they learn to associate the bed with feelings of restlessness and dread. “Oh no,” they think as soon as it’s time to turn the lights out, “another night of tossing and turning.” Anxiety kicks in, and the fear becomes a self-fulfilling prophecy.

2)    Spending more time in bed to make up for lost sleep.

As insomnia sufferers get increasingly frustrated and worried about their sleep habits, it seems logical to try and spend more time in bed in the hope that this extra sack time will yield more rest. This comes in different flavours – taking a long time in the morning to get out of bed or scheduling long daytime naps are two common ones.

By indulging this habit, many people do indeed get a greater absolute amount of sleep. However, this extra shuteye comes with a steep price. First, time spent in bed becomes highly inefficient. Healthy sleepers spend more than 90% of the time they are in bed asleep; those with insomnia have sleep efficiency that is way below that. Sleep quality is lower because it is broken up into small chunks rather than one consolidated block. As we’ve already discussed earlier, all that extra wake time in bed is training the body to associate the bedroom with alertness and anxiety.

3)    Coming up with false beliefs about sleep.

People with insomnia often spend a lot of time thinking about sleep (and how to get it) and can end up with a set of beliefs about sleep that are either untrue or unhelpful. Here are some common ones:

• “If I don’t get 8 good hours of sleep, I’m going to be a wreck tomorrow.”

• “All the stars need to align so that I have the perfect conditions to get satisfying sleep tonight.”

• “Insomnia is going to ruin my health if I don’t get it under control soon.”

• “My mind keeps running when I’m trying to sleep and there’s nothing I can do about it.”

As you can imagine, constantly running that script does very little to make a person less anxious about bedtime. In chronic insomnia, these thought patterns can become automatic and habitual, adding more fuel to the fire of the problem.

In short, long-term insomnia is often the ironic result of worrying excessively about poor sleep and its consequences and putting in unnecessary effort to counteract the sleeplessness. How do we unknot this problem? In the next article, I’ll write about some of the tools that psychologists use to treat this sticky and troublesome condition.

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