Anxiety About Sleep
Sleep is defined as the essential inactive state human beings undertake, where our bodies and minds switch off, allowing us to rest and restore the energy we require for daily functioning. There are five different stages of sleep the body undertakes, and within these, deep sleep has been shown to be the most critical. During deep sleep, most of our blood supply is directed away from the brain, and towards our muscles- restoring the muscular energy we require. It is also a time where the immune system is activated to defeat illnesses. Surprisingly though, deep sleep only lasts around 30-45 minutes, and we experience the greatest physical impairment and functioning from its deficiency.
Our sleep is controlled by two systems in the brain, known as the wakefulness system and the sleep system. In healthy sleepers, the “wakefulness” system works effectively during the day by keeping individuals awake and alert for approximately 16 hours. This is up until it weakens, which is when the “sleep” system takes over, keeping us asleep for the remaining 8 hours of the night. The strength of the sleep system is dependent on the accumulation (based on each hour spent awake) of the neuromodulator in the brain, adenosine. As the hours spent awake during the day increase, so too does the accumulation of adenosine- therefore making it easier to fall asleep at night.
Put simply, insomnia is defined as sleep deprivation- caused by both reduced sleep quantity and quality, that significantly impedes individuals’ daily life functioning. There are over 70 different types of sleeping disorders, but insomnia is one of the few most common and more severe. It can cause irritability, fatigue, disrupted concentration and memory, trigger physical sickness, induce a state of “mental fog”, and decrease productivity.
There are three main types of insomnia, these include:
- Sleep onset insomnia: problems falling asleep, taking 30 minutes or longer to fall asleep
- Sleep maintenance insomnia: waking up multiple times during the night or early in the morning and staying awake for 30 minutes or longer after waking
- Poor quality of sleep
Individuals may find that their insomnia is a combination of the three, or that it chops and changes over time. They may also experience insomnia on and off in bouts, with some weeks worse than others.
Extensive research has found that around one third of adults experience insomnia, with around 50% of these chronically. Other research has estimated that almost 60% of adults experience insomnia at least two nights per week. In Australia, it is estimated that insomnia affects approximately one quarter of the population. However, it is important to understand that insomnia is not simply diagnosed based upon the duration or quality of sleep, it is when these factors begin impacting their daily life functioning, that problems arise. If individuals sleep lightly, experience disrupted sleep, or do not get the recommended 7-8 hours, and it doesn’t impair their daily functioning, it does not mean that they have insomnia- they may just require less sleep.
The general observation is that insomniacs have a heightened arousal and increased mental activity (overworking wakefulness system). Part of CBT’s effectiveness is slowing down this mental activity- therefore helping to regulate healthy sleeping patterns.
Sleep studies have consistently shown that a significant decrease in body temperature is associated with falling asleep, with the biggest drop in temperature occurring within a two-hour period before each of the longest sleep cycles. Research has shown that individuals with insomnia have little variation in their daily body temperature, and have a warmer core body temperature, compared to that of healthy sleepers. Additionally, studies have also shown that the body temperature in sleep onset insomniacs (difficulties initiating sleep at the start of the night; more common in the 20-30 year old age range) does not drop for several hours prior to sleeping. As for sleep maintenance insomniacs (difficulties staying asleep despite falling asleep easily; more commonly seen in the elderly and retirees), their body temperature does not drop to the standards seen in healthy sleepers either. This is again, where several of the methods used in CBT can help to re-regulate normal body temperatures in these individuals.
There are two main types of insomnia: acute and chronic.
Acute insomnia lasts from a few days up to a month. It can either be transient (lasting a few days) or short term (lasting up to 3-4 weeks).
Common causes for acute insomnia:
- Increased arousal: due to experiencing grief, excitement, anxiety, physical illness or pain due to injury, relationship changes, or family/work related stressors
- Change in sleeping habits: due to environmental factors, or physical stimuli preventing sleep
- Decreased sleep hygiene: due to excessive consumption of substances that heighten arousal/ delay sleep, or self-induced lack of sleep due to busy lifestyle/ work commitments/ travelling.
Chronic insomnia is indicated when the insomnia persists longer than one month, usually well after the original triggering factor has been resolved or has significantly faded in thought domination. Acute insomnia develops into chronic insomnia when a combination of factors combine, including periods of increased stress or worry, anxiety about lack of sleep, and abnormal behaviours around sleeping that become habits. Often when these occur, individuals develop negative thought patterns and associations with sleep and bedtime, such that the thought of sleeping itself becomes a learned cue, triggering wakefulness. This is when individuals usually begin to partake in a variety of behaviours, in a bid to help alleviate their insomnia, which unfortunately, over time, reinforce and perpetuate insomnia.
Some of these thoughts and behaviours include:
- Thinking that sleep can be “forced”
- Taking naps throughout the day
- Trying to go to bed early or sleeping in to catch up on sleep
- Reducing or ceasing physical exercise due to feeling too fatigued
- Consuming substances such as alcohol to induce sleep and caffeine to cope with fatigue during the day
- Engaging in activities in bed (before planning to sleep) to try and promote sleep (such as watching a movie or reading)
- Thinking that insomnia can be cured by external factors
Up until quite recently, the most frequently prescribed treatment for insomnia and sleep related disorders has been sleeping medications. However, extensive research conducted over the years have found the effectiveness of Cognitive Behavioural Therapy (CBT) as an alternate treatment to the variety of sleeping medications on offer for individuals with sleeping disorders. The success of treating insomnia with CBT, is based around the theory that insomnia can be addressed by dealing with the underlying causes– the majority of which are rooted in cognitions (thoughts) and behaviours (habits) that have been learnt (and can therefore be unlearnt) over time which maintain insomnia.
CBT is now recognised as the preferred method for treating insomnia, endorsed by the National Institutes of Health, as it has been shown to produce more effective short and long term results, without the harmful side effects of medications. Findings from more than 20 studies support this, demonstrating that those who experienced insomnia fell asleep faster with CBT treatment, than those treated with sleeping medications. Related studies conducted at the Harvard Medical School, have also shown CBT to be a more effective treatment than the most commonly prescribed sleeping drug Ambien, in both short term (4 weeks) and long term (1 year) trials.
The most common forms of medications prescribed for insomnia are benzodiazepines (BZs). These medications are designed for short term use, in particular times of need, (such as physical pain, jetlag, or after a significant life event involving grief or loss) – to prevent short term insomnia from spiralling into chronic insomnia. With prolonged use, the side effects of these medications can be quite severe, and can include:
- Decreasing deep sleep and REM sleep, alongside an increased stage 2 sleep- this induces a lighter, more disrupted sleep, affecting overall sleep quality
- Impairment of daytime functioning – including decreased alertness, concentration, memory and coordination
- Dependency, both physically and psychologically- often causing additional physical and mental adverse effects when the removal of these is attempted (such as dizziness, headaches, seizures, restlessness, rebound insomnia, anxiety, depression). They may also act as a placebo, resulting in thinking like: “I won’t be able to fall asleep because I haven’t taken my sleeping pill”, which exacerbates difficulties sleeping at night
- Built tolerance – the effectiveness of these drugs reduces after a short time, which can lead to a vicious cycle of tolerance, increased drug dosage and therefore dependency, increasing the potential to experience harmful side effects, alongside severe withdrawal symptoms when medication is ceased
- Physical side effects including blurred vision, loss of appetite, high blood pressure, digestive issues, frequent urination, nausea, and weakness
What can I do right now to help?
- Avoid the use of electronic devices before bed; the blue light emitted from such devises mimic's daylight, which can trick the brain into thinking that it is not time for sleep, and throw off the body's natural clock
- Exercise in the morning or early in the evening; avoid exercising immediately before bed
- Reduce, limit, or stop the consumption of excessive amounts of caffeine or other stimulants throughout the day or before bed – including alcohol
- Ensure you have a balanced diet, filled with nutritious foods
- Get some natural sunlight exposure during the day and first thing in the morning; open windows and curtains to let natural light in or going for walks during the day
- Establish a consistent sleeping routine
- Limit artificial exposure light at night
- Have a bedtime routine
The hormone Melatonin, (produced in the brain) is controlled by our exposure to sunlight, and helps us to regulate our sleep wake cycle. Too little exposure to sunlight, and excess exposure to artificial light at night can disrupt our sleep. This is because sunlight decreases melatonin levels (increasing wakefulness), and darkness increases melatonin levels (decreasing wakefulness), thereby encouraging sleep.
For chronic insomnia, it is crucial for the larger problems to be identified before it can be resolved. If you have concerns, even in the early stages of insomnia (when the learnt sleeping patterns in chronic insomnia are developing) it is important to seek help from a healthcare professional before they progressively worsen.
At Anxiety House, we offer Cognitive Behavioural Therapy for Insomnia (CBT-I) in the treatment of insomnia. It is a 5 week course which is tailored to each individual, and teaches people with insomnia how to strengthen their sleep system. The program involves an initial assessment of the individual followed by five sessions spaced over a six week period. The initial assessment involves a series of questions regarding the sleep history of the individual, including their:
1) Current sleeping pattern
2) Cognitive/behavioural factors (thoughts/habits) causing the insomnia
3) Lifestyle & environmental factors affecting their sleep
4) Physical and psychological issues present and past –their level of anxiety and stress, other medical problems, or mental health issues
The stages of the treatment program include:
Stage one: Sleep education and cognitive restructuring for insomnia
Stage two: Sleep medication withdrawal and sleep scheduling techniques
Stage three: Stimulus control techniques
Stage four: The relaxation response
Stage five: Sleep hygiene techniques
Who we recommend
Clinical Psychologist - DPsyc (Clin); BPsycSci (Hons)
Dr. Daphne Bryan
Daphne is a doctoral qualified clinical psychologist, with a strong interest in working with adolescents and adults who experience anxiety disorders and phobias. She has worked with a broad range of presentations across a variety of public and private settings, incorporating a variety of evidence-based strategies from a variety of modalities, including Motivational Interviewing, Cognitive Behavioural Therapy, Schema Therapy, and Acceptance and Commitment Therapy.
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My Virtual Medical Centre. (2003-2014). Insomnia. Retrieved from http://www.myvmc.com/diseases/insomnia/
Jacobs, G.D. (2000-2010). Clinical Training Program For a CBT-I Training Program.
Hinter, G. (2009). Getting to the core of insomnia. Retrieved from http://w3.unisa.edu.au/unisanews/2004/June/insomnia.asp