Insomnia 2020: A Primer
Insomnia is on the rise: Here’s what you should know and what you can do about it.
Recent studies (like this one from Harvard Medical School) have shown an increase in anxiety globally during the COVID-19 pandemic. Considering the known link between anxiety and insomnia, it is unsurprising that emerging research suggests higher rates of insomnia in 2020, too. Some sleep specialists have coined terms like “COVID-somnia” and “coronasomnia” to capture this phenomenon – a surefire sign that it is, indeed, a thing.
So what exactly is insomnia?
Insomnia is a problem with falling and/or staying asleep. It is associated with daytime fatigue. Clinically, we differentiate between acute and chronic insomnia. Nearly all people experience acute insomnia at some point in their life. Acute insomnia typically occurs in response to a new stressor. Fortunately, it is short-lived, lasting no more than a couple of weeks. Chronic insomnia, by contrast, is characterized by an inability to fall or stay asleep at least three times per week for at least three months. Chronic insomnia affects roughly 25 percent of people worldwide. Insomnia is especially common in females, older adults, and those with mental health and medical conditions. Whereas acute insomnia resolves quickly and has minimal impact on a person’s overall well-being, chronic insomnia is persistent and detrimental to one’s overall health and functioning. Chronic insomnia is known to affect attention, mood, decision-making, work performance, typical daily activities (e.g., driving, cleaning), and even relationships. Chronic sleep deprivation is also associated with wide-ranging negative health outcomes. It can affect cardiovascular, immune, endocrine, and nervous system functioning. The interrelations among sleep quality and various medical conditions are multi-faceted and complex. With each problem negatively impacting another, a vicious cycle can develop in which a person’s anxiety or pain, for example, interferes with their ability to sleep which, in turn, worsens their anxiety or pain, and so on and so forth. Interrupting this cycle is crucial.
Why does acute insomnia progress to chronic insomnia in some people?
A host of factors contribute to the development and continuation of insomnia. The 3P model helps explain each of the primary contributors. The first ‘P’ stands for Predisposing factors. The age-old debate in the field of mental health is that of nature versus nurture. Although the jury is still out regarding the extent to which nature and nurture each contributes to mental illness, there is near consensus that some people are more biologically predisposed than others to developing certain conditions; insomnia is no exception.
The second ‘P’ in the 3P model stands for Precipitating factors. A precipitating event is any stressor that triggers an episode of acute insomnia which may, in turn, lead to chronic insomnia. As mentioned above (and as is patently obvious to any human in 2020), this year has been immensely stressful. It has been chock full of potential precipitating events for insomnia. Like the undulating waves of COVID-19 spreading across the globe killing hundreds of thousands of people, the police killing of George Floyd in Minneapolis and subsequent civil unrest has had rippling effects worldwide. The increasing threat of global warming, an economy on the brink of collapse, and political turmoil further exacerbate mental health concerns. Nearly 20% of adults--and 34% of Gen Z respondents--in a recent study commissioned by the American Psychological Association described their mental health as worse this year than in 2019. Although insomnia may subside when the stressor(s) that precipitated it remits, in other cases it persists, taking on a life of its own.
This is where the third ‘P’ comes into play. The third ‘P’ in the 3P model refers to Perpetuating factors or certain behaviors in which people engage that unwittingly contribute to the cycle of sleepless nights. Ever scroll through your phone or watch television right before hitting the hay? Occasionally pop a Benadryl or enjoy a “night cap” before trying to catch some z’s? How about that cat nap you like to take on a Sunday afternoon? I hate to break it to you, but those seemingly helpful short-term strategies wreck your sleep quality over time. They exacerbate insomnia and they need to be addressed if you’re interested in fixing your ongoing sleep problems.
There is also a bonus ‘P’ many sleep specialists reference: Pavlovian conditioning. If you don’t remember learning about Pavlov’s dogs in your Psych 101 class, here’s a brief recap: Pavlov was a researcher who trained dogs to drool at the sound of a bell by first teaching the dogs to associate the sound of a bell with the imminent presentation of food. This is called classical conditioning. So what does this have to do with sleep? Well, humans are just like dogs in that we, too, learn through classical conditioning. If you have ever found yourself reflexively reaching for your own phone when you hear the familiar ding on your friend’s phone, that’s classical conditioning. Ever suddenly think you’re hungry or notice your mouth watering while walking past the cookie jar? That’s also classical conditioning. This comes into play with insomnia when, over time, your bed and your bedroom become associated with feelings of frustration, anxiety, restlessness, and wakefulness. A night of restful sleep, by contrast, is substantially more likely when you approach your bedroom feeling tired, calm, and relaxed. To address insomnia, we want your bed and bedroom to become associated with such feelings. This will promote better sleep quality.
How can I overcome insomnia?
Although you can’t change your biology and you can’t go back in time to erase precipitating events, there is good news on the insomnia front: you can actively address perpetuating and pavlovian factors. Cognitive behavioral therapy for insomnia (CBTi) is an evidence-based intervention offered by psychologists and other mental health professionals that helps you accomplish just that. It is recommended as a first line treatment for insomnia. Put simply, CBTi helps people develop healthier sleep habits and avoid behaviors that keep them stuck in the vicious cycle of sleepless nights and drowsy days. Below is a simplified list of techniques often used in CBTi:
Reduce the amount of time you spend in bed (awake).
Combat classical conditioning by learning to associate your bed and bedroom with sleep cues, rather than wake cues.
Make simple lifestyle changes such as reducing your intake of caffeine, alcohol, and nicotine and avoiding screen time before bed.
Promote a comfortable sleep environment that is quiet, cool, dark, and calming.
Recognize, challenge, and change overly negative thoughts you have about sleep.
Adopt a “paradoxical intention” mindset to help you stop fighting your body to sleep.
Utilize relaxation exercises such as visual imagery, progressive muscle relaxation, and diaphragmatic breathing to help your mind and body relax before bed.
Complete biofeedback training to help you notice and gain control over certain physiological processes.
Should I try CBTi or a sleep medication?
Reputable organizations like the National Institute of Health, American College of Physicians, and American Academy of Sleep Medicine recommend CBTi as a first-line treatment for chronic insomnia. Medications, by contrast, are generally recommended only for short-term use due to risks and side effects ranging from mild to severe. These include memory problems, risk of falls, depression, impaired driving, and addiction potential. Some medication classes are safer than others, however, and medications may be particularly useful when relevant co-morbid conditions exist. Although it takes more effort and sacrifice in the short-term, CBTi is more effective than medications over the long term.
If you are suffering from acute insomnia, do your best to manage stress and adopt healthy sleep habits (see tips #3 and #4 above) to prevent your condition from worsening over time. If you are experiencing chronic insomnia, however, it may be time to consult with a psychologist who specializes in treating sleep disorders. You can also talk to your primary care provider if you’d like to learn more about medication and supplement options.
