What exactly is insomnia?
Insomnia is a recurring condition in which the person has difficulty getting off to sleep, staying asleep, or achieving enough sleep. Typically this pattern repeats several nights each week. However, ‘insomnia’ is a relative term. While some people believe 8 hours sleep is too little, others find that 6 hours is enough. The real test for a good sleeping pattern is the average calculated over several weeks. The ideal mean lies between 6-8 hours. You can use a smart watch to track your own figure. You may find that the number of hours you think you need differs from the amount your brain requires.
Treatment for insomnia is typically offered where the patient has most of the symptoms listed below.
What causes insomnia?
Common problems include chronic pain, respiratory disorders, heart disease, gastric reflux, restless leg syndrome, and an over-active thyroid. If you have insomnia, and suspect a physical cause you should request a medical examination. The advice given below assumes you do not have an untreated medical condition.
Poor sleeping conditions
A surprising number of insomnia cases relate to the bedroom. Poor quality beds and mattresses, noisy environments, hot/cold rooms and bright lights are amongst the most common factors. Also problematic are mobile phones, lap-tops and televisions if used while in bed, as the artificial light from these devices interferes with the circadian rhythm. A further problem is a sleeping partner who disturbs your rest. All these factors should be addressed before seeking professional treatment for insomnia.
This refers to irregular sleeping hours. This may be a problem if you work changing shifts, fly regularly (jet lag), like to party often, or if you have young children.
Alcohol, caffeine and nicotine are common sources. If you have prescription medication, check for side-effects. Lastly, recreational drugs are another hazard, especially cocaine and other stimulants.
Between 24% and 36% of adults with insomnia also have an anxiety disorder. This leads to patterns of over-thinking, worry and difficulty in switching off from thoughts. Another common problem is that sufferers can develop anxious thoughts about not sleeping, thus perpetuating the problem.
Other mental health conditions
Symptoms of chronic insomnia
- Difficulty falling asleep on going to bed (at least six months)
- Waking up more than once during the night
- Waking up in the early hours, unable to get back to sleep
- Feeling unrefreshed and tired on getting out of bed
- Daytime sleepiness
- Impaired attention and concentration (‘brain fog’)
- Feeling irritable and/or anxious as a result of poor sleep
- Worrying about insomnia, and increasing dread as bed-time approaches
The key to insomnia
Long-term insomnia leads to a breakdown in the circadian rhythm, otherwise known as the rest-activity cycle, or the ‘body clock’. As the amount of sleep we achieve becomes irregular we experience alertness at night, and tiredness during the day. As a result the body clock becomes confused and is unable to reset. This problem is made worse if the insomniac takes day-time naps, as that makes the sleep pattern still more irregular. Effective long-term resolution of sleep disorders rests on resetting the circadian rhythm (see below).
There are a variety of sleep aids that might improve sleep. However, these are best used in tandem with psychotherapy if you have an anxiety or other mental health disorder, or an impaired body clock. Some of these aids are given below.
A simple technique is progressive muscular relaxation. Beginning with the muscles around the eyes and in the eyelids, first gently tighten them, and then relax completely. Moving on to the muscles in the lower jaw, the forehead, scalp, neck, shoulders, upper arms, lower arms, and hands. Then downwards from the neck into the upper back, and lower back. Moving back to the chest and stomach, then the hips, thighs, calves and feet. End by imagining that any remaining tension anywhere in your body is flowing away through the tips of your toes like air escaping from a balloon.
Many of these involve increasing the amount of time between the in-breath and the out-breath. To do this breathe in slowly to the count of four, hold the breath briefly, then breathe out to the count of four. Then in/out to the counts of 5, 6, 7, 8 and upwards, so far as is comfortable. This works even better with the aid of a mindfulness tape.
These are sound mixings between 2-4 Hz that slow down brain waves to the Delta (sleep) wave, For a 21 minute Binaural beat program (2Hz) to promote sleep click here.
Is a tried and tested technique for sleep improvement. As the hypnotic trance develops the conscious mind is depotentiated, and thoughts become less intrusive. Meanwhile, the body goes deeper and deeper into a relaxed, comatose state. For more information on my approach to hypnotherapy click here.
Available in most pharmacies there are a wide range of plant-based remedies such as Valerian root, Skullcap, Passionflower, Kava and Chamomile tea. Three amino acids that improve sleep are GABA, Melatonin and 5-HTP. Magnesium is an important mineral the body uses to develop sleep, and is available in capsules. For something stronger try CBD oil.
Commonly prescribed tranquillisers include Temazepam, Librium, Valium and Xanax. However these drugs reduce in effectiveness when taken regularly, and cause day-time drowsiness. They can also make long-term solutions harder to achieve. For all these reasons tranquillisers will only be prescribed for most patients for a few weeks.
Therapy for insomnia
Psychotherapy mostly treats insomnia where anxiety is the main factor, although many therapists also employ techniques that improve sleep directly – using mindfulness, breathing exercises, relaxation techniques and paradoxical intention (see below). For more information on my own approach to anxiety reduction click here.
Paradoxical intention is a reversal approach, in which the person gives up trying to sleep, and instead tries to stay awake. One key factor in insomnia is that the more people consciously try to sleep, the more they inhibit the automatic shutdown mechanism that precedes sleep. A similar mechanism underlies stammering: as the person tries too hard to speak ‘normally’, the worse the stutter gets. Going into reverse reduces conscious interference with speech. In the same way trying not to fall asleep removes the anxiety that supervenes when conscious effort fails.
The now standard approach in therapy for insomnia is the model known as Cognitive Behaviour Therapy for Insomnia (CBTI), also known as the Stanford Protocol, since it was first developed at Stanford University in the United States. A key element in the protocol is sleep restriction.
In chronic insomnia the bed no longer becomes a place to sleep in, but to lie awake. Side by side with that problem is that the body clock is no longer timed to stay asleep at night. CBTI addresses this by having clients leave the bed if they have lain awake longer than 15 minutes. Instead they are asked to carry out low key activities, such as house-cleaning, creative work with their hands, or mild exercise (TVs, computers and mobile phones are disallowed). If, after 20 minutes of doing this they feel drowsy they may re-enter the bedroom. This step is repeated as many times as necessary.
In severe cases clients might find that they get no sleep at all for the first one or two nights. However, by the third night (unless there are medical problems) they will have achieved a good night’s sleep. The program continues, usually over several weeks, until the rest-activity cycle resets.