It’s three a.m. and you need to be up by six a.m. to get to work on time. You’ve tried puzzles, music and warm milk, but nothing is working. The thought of facing the workday with aching muscles, a foggy mind and bags under your eyes is making you more alert and unable to sleep. You accept the. fact that you may be awake the entire night.
This scenario is one that most people can relate to. Trouble falling or staying asleep, or waking too early and being unable to return to sleep, is known as insomnia. The capacity for short-term sleeplessness is a protective mechanism that enables us to avoid danger, but that can easily be activated by lesser threats. These occasional wakeful nights may leave us feeling temporarily frustrated but likely won’t affect our quality of life.
In some people, short-term or occasional insomnia becomes chronic, which means that the sleep problems occur on three or more days of the week for at least three consecutive months. If the chronic insomnia is associated with emotional distress about poor sleep as well as a perception of impaired daytime functioning, we now say this person has insomnia disorder. In other words, there are people whose frequent sleep problems don’t really bother them, and they don’t feel much impact on their daily activities; therefore, by definition, they don’t have the disorder.
Ironically, the transformation of occasional insomnia into the full disorder is fuelled by the very strategies that people use to help them cope with their initial sleep loss. Examples would be resting, withdrawing socially, or spending a lot of conscious effort to sleep well. As their sleep problems continue, sufferers may establish counter-productive habits that disrupt their sleep system and promote overactivity of their nervous systems at night in bed. The insomnia is perpetuated through a vicious cycle of sleep-related anxiety, ineffective sleep efforts, and sleeplessness.
It is important to note the difference between tiredness and sleepiness. Insomnia disorder creates tiredness, which can best be described as the opposite of energy. Tired people feel they don’t have the physical or mental energy to do the things they want to, yet at the same time, they can’t fall asleep. This is known as being “tired but wired.” In contrast, sleepiness is exactly what it sounds like – a strong tendency to fall asleep. Excessive daytime sleepiness is not typical of insomnia. If you experience daily sleepiness during meals, meetings, driving or out in public you should see your doctor to rule out other sleep disorders, such as sleep apnea.
Some medical and most psychiatric conditions cause sleep disruption, which usually resolves as the original condition resolves. In those for whom insomnia persists and becomes the disorder, the direction of causality may then operate in reverse, such that the sleep difficulties now aggravate the symptoms of the initial condition. In the past, it was thought that health practitioners had to fully treat the primary mental health or medical disease before addressing the insomnia; however, research has shown that insomnia disorder, which started out as a secondary problem, can become a primary disease unto itself. It can persist for years, even after the initial condition improves.
If you have insomnia disorder, you may have received prescription sleep medication from your family doctor, but found that with regular use, it lost its effect. Your doctor may have also given you a list of sleep hygiene practices which included directives to control the use and timing of caffeine and alcohol, maintain regular schedules, and optimize the bedroom for sleep. You may have tried these measures, but found that sleep did not improve. Frequent use of sleep medications for insomnia disorder leads to reduced effectiveness over time, and can have long-term side effects. Research shows that sleep hygiene alone is not enough to normalize sleep in those with insomnia disorder: It requires a more aggressive and customized approach.
Cognitive Behavioural Therapy for Insomnia (CBT-i) is a brief, intensive and structured program for treating insomnia disorder. Clinical trials show a 70-80% success rate for suitable candidates. Sleep Specialist Physicians consider CBT-I to be the first line of treatment for insomnia disorder. It is ideally delivered one-on-one, through 4 – 5 sessions over 5-6 weeks. People can also gain benefit from CBT-i apps, workbooks, group therapy or online videos. If prescription medication is eventually required, its effectiveness will be greater if a course of CBT-i has been completed first.
If you have only occasional insomnia, sleep hygiene can help to restore and maintain good sleep habits. If you have insomnia disorder, see your doctor or therapist to address potential mental health or medical causes. Consider CBT-i if you feel that your sleep difficulties are the main reason you feel unwell. Then rest easy knowing that you have invested in an evidence based program that can help you take control of your sleep, and improve your overall health.
