The Scope of the Problem
Insomnia is a common problem in the United States, affecting 5% to 10% of the population. Insomnia is dissatisfaction with sleep quality or quantity. Insomnia symptoms can occur for a variety of reasons, and can be very debilitating. The problem can be acute (lasting a few days or weeks) or chronic (lasting more than a couple of months).
Sometimes we have trouble sleeping for a few nights in a row. There can be many reasons for this. Often the problem will improve on its own, and treatment is not necessary. Acute insomnia can become chronic, and should be treated if it does.
When sleep problems persist for more than three months, they are considered chronic. Chronic insomnia can have significant effects on our quality of life, and can affect our health.
Causes of insomnia
There are many reasons why people have trouble sleeping. Some are emotional, some are behavioral, and some are physical.
Stress: Being under a lot of stress can affect our sleep although stress is more likely to affect sleep by creating anxiety or affecting sleep hygiene (see below).
Anxiety: sometimes racing thoughts and uncontrolled worry can affect our sleep. Anxiety affects our ability to fall asleep as well as our ability to get back to sleep after sleep is interrupted. People with PTSD often have a lot of difficulty with sleep. Sometimes this is due to nightmares, but sometimes not.
Depression: Depression is often characterized by changes in our sleep patterns. Interestingly, it can cause us to sleep either more or less than usual.
Substance use: Many commonly used substances can impact our ability to fall asleep and stay asleep. In particular, caffeine, alcohol and cocaine are all likely to interfere with sleep. Common prescription stimulants like Adderall, Concerta and Ritalin can also cause insomnia.
Jet lag: travelling from one time zone to another can affect our circadian sleep/wake cycle. Even if your trip was a few days ago, jet lag may still be affecting you. By some estimates it can take up to 12 days to recover from a trip to Europe or Africa. A trip to Asia can take two to three weeks for total recovery!
Medical conditions: Several common medical conditions can affect sleep, including hyperthyroidism, chronic pain, and heartburn/GERD.
Medication side effects: many prescription medications can affect our sleep by either making it difficult to fall asleep or waking us up during the night. In particular, some medications for high blood pressure, some antidepressants, and some asthma medications can cause insomnia.
Environmental factors: Noise levels, temperature, and light all have very significant effects on our ability to sleep.
Sleep apnea: this common sleep disorder has the effect of waking us up very briefly but very frequently when we sleep – up to 20 to 30 times per hour! This condition leads to daytime sleepiness, which can lead to napping. Napping can in turn affect nighttime sleep.
The three primary difficulties for insomnia sufferers are:
- Problems falling asleep
- Problems staying asleep
- Early waking
Treatment for insomnia
Insomnia is closely tied to behavior. For this reason, cognitive-behavioral therapy (CBT) is considered a primary treatment option. Sleep medications can be effective to treat some aspects of trouble sleeping, but do not address the cause. For those suffering from poor sleep who would like to use non-medication treatment, CBT can be an excellent option.
What is CBT-I?
Cognitive-behavioral therapy for insomnia (CBT-I) is a form of CBT that is specifically tailored to help people suffering from chronic insomnia. It is more effective than medication in improving sleep. Additionally, CBT-I’s effects are typically longer lasting than those of medication.
The foremost authority on sleep problems is the American Academy of Sleep Medicine. In their 2017 guidelines, they recommended CBT-I as the first-line treatment for insomnia. This means that CBT-I’s effectiveness and lack of side effects make it the best first option for insomnia treatment.
What’s involved with doing CBT-I?
CBT-I typically involves up to 10 sessions with a CBT therapist trained in CBT-I. The sessions focus on the following steps:
- Learning about the physiology of sleep and circadian rhythms
- Learning how your environment and behavior affect sleep
- Making helpful changes to your environment and behavior
- Making changes to the times you get in bed and wake up
- Monitoring your progress
Your CBT-I therapist may recommend changes that seem counterintuitive. For example, sometimes you may be asked to set an alarm to wake up before you get what feels like enough sleep. Rest assured that changes like this one are part of what it takes to establish good sleep habits. Having healthy sleep habits is often the most important part of addressing insomnia.
Doctors will sometimes prescribe sedatives and hypnotics to help with sleep. Remember, these medications are typically not recommended for long term use. Some of these medications can be habit-forming. In the short term they may be helpful, but over time they can erode our natural abilities to fall asleep. This can actually make insomnia worse. These medications are best used rarely, and only for short-term purposes. Most people with insomnia can benefit from changes to their habits and from addressing any anxiety problems that affect their ability to get to sleep.
How to sleep better if you have chronic insomnia:
- Set a consistent wake time each day, and stick to it
You can sleep in a big longer on weekends but only 30-60 minutes maximum!
- Avoid alcohol close to bedtime
For each drink, count on 1-2 hours to metabolize it. So if you like a glass of wine at night, finish it at least one hour before bedtime.
- Get exercise during the day
Make sure exercise is complete by 3-4 hours before you plan to go to sleep.
- Limit caffeine intake after lunch
Caffeine affects people differently; if your insomnia is bad, avoid caffeine altogether in the afternoon and evening.
- Spend no more than 8 hours in bed per day
Sticking to this rule will fix most cases of insomnia (but not all). Even if you’re tired when the alarm goes off, adhere to this guideline if you can.
- Ensure your sleep environment is as dark and quiet as possible
Try to limit light from electronic devices and alarm clocks.
- If you can’t fall asleep for 20-30 minutes, get out of bed
Go in another room of possible and do something sitting or standing. Do not lie down on the couch!
- If you have trouble sleeping, do not have a clock visible near your bed
Seeing how long you’ve been awake will only upset you and make sleep more difficult.
Updated: May 15, 2020