Coping with Insomnia
Susan Bennett, PhD

Most people can relate to the occasional frustration and upset of insomnia. Late night worries, too much caffeine, or something disturbing before bedtime can make anyone struggle to fall asleep or stay asleep. For some people, however, insomnia is an all too regular occurrence.

About 10% to 20% of the general population experiences some type of insomnia. Rates
increase as people age. Some research indicates that up to 40% of older adults struggle
regularly with this threat to emotional and physical well-being (Fiorentino, Martin, 2010). Some people have occasional insomnia while others can battle this condition for years.

It is known that poor sleep has negative effects on one’s health. Research supports links to higher risks of stroke, weight gain, diabetes, depression, anxiety, and elevated stress levels. Additionally, brain research suggests that people are less able to manage stress when sleep deprived. The amygdala is the emotional center of the brain. The prefrontal cortex manages primitive fight or flight responses generated by the amygdala. When sleep-deprived, the amygdala is 60% more reactive. This can lead to irritable behavior and mood swings. We see this clearly in children but can forget that adults are also vulnerable to the negative effects of poor sleep (Epstein, 2008; Holmes, 2015).

There are several types of insomnia:
1. Sleep onset insomnia: Trouble getting to sleep
2. Sleep maintenance insomnia: Restless sleep, waking frequently throughout the night
3. Early morning awakening: Waking at 3am or later and not being able to return to sleep

Insomnia is diagnosed as a primary disorder or as secondary to another condition such as depression, anxiety, substance abuse, physical pain, or other medical issues. In order to qualify as a diagnosis of insomnia, the sleep difficulty must interfere with daytime functioning. Insomnia is a complex disorder that can be caused by one or many factors in combination.

Some typical causes are:
1. Frequent daytime napping
2. Spending too much time in bed
3. Insufficient daytime activities
4. Late evening exercises
5. Insufficient bright light exposure
6. Excess caffeine
7. Evening alcohol consumption
8. Smoking in the evening
9. Late heavy dinner
10. Watching television or engaging in other stimulating activities at night
11. Anxiety and anticipation of poor sleep
12. Clock watching
13. Environmental factors, such as the room being too warm, too noisy, or too bright. Pets on the bed or in the bedroom, and/or active or noisy bed partners

(Bloom, Ahmed, Alessi, Ancoli-Israel, Buysse, Kryger, Phillips, Thorpy, Vitiello, Zee, 2009)

Most of the factors above fall under the heading of poor "sleep hygiene". For some, just
learning about these issues can lead to behavior change that resolves sleep problems. Coping with other causes of insomnia such as anxiety, depression, substance abuse, and medical disorders usually requires more intervention. Insomnia can be a chicken and egg dilemma. For example, a vicious cycle can develop in which anxiety interferes with sleep which then leads to exhaustion and a greater susceptibility to anxiety.

People often turn to the use of sleep aides when they face insomnia. These sleep aides have great appeal because they provide immediate relief. Within a 1/2-hour, one can drift off into a peaceful slumber. However, over the counter medications such as those containing diphenhydramine or doxylamine or prescription medications such as Ambien are only designed for short-term use. Longer term use can result in worsened insomnia. Dependence on such medications can also distract people from addressing the actual causes of the insomnia.Occasionally, sleep aides can be helpful as a short-term measure to re-establish a healthy sleep pattern. However, learning and protecting good sleep hygiene and addressing other underlying causes of insomnia is essential to prevent relapse (“Cognitive Behavioral Therapy for Insomnia”, n.d.)

Currently, the most effective treatment for insomnia is Cognitive Behavioral Therapy for
Insomnia (CBT-I). This approach combines many interventions such as education about sleep hygiene, detailed assessments of current sleep patterns including using a sleep diary, stimulus control and/or sleep restriction, and cognitive restructuring.

The assessment consists of detailed questions about the client’s sleep history and current sleeping pattern. Other possible causes of sleep difficulty are ruled out such as sleep apnea (a disorder that interferes with steady breathing while sleeping), restless leg syndrome, medication side effects, and other issues. The therapist will also ask about anxiety, depression, loss and relationship stressors.

You may wonder: What is stimulus control? Stimulus control focuses on eliminating negative associations to the bedroom while simultaneously strengthening the association of sleep with the bed and bedroom. Bloom, et al (2009) recommend the following to improve sleep hygiene and practice stimulus control:

1. Develop a sleep ritual such as maintaining a 30-minute relaxation period before bedtime or taking a hot bath 90 minutes before bedtime.
2. Make sure the bedroom is restful and comfortable.
3. Go to bed only if you feel sleepy.
4. Avoid heavy exercise within 2 hours of bedtime.
5. Avoid sleep-fragmenting substances, such as caffeine, nicotine, and alcohol.
6. Avoid activities in the bedroom that keep you awake. Use the bedroom only for sleep
and sex; do not watch television from bed, or work in bed.
7. Sleep only in your bedroom.
8. If you cannot fall asleep, leave the bedroom and return only when sleepy.
9. Maintain stable bed times and rising times. Arise at the same time each morning,
regardless of the amount of sleep obtained that night.
10. Avoid daytime napping. If you do nap during the day, limit it to 30 minutes and do not
nap, if possible, after 2pm.

Sleep restriction is focused on increasing one’s “sleep hunger” or the need for sleep. Excessive napping often can lead to sleep onset insomnia. Eliminating the naps or going to bed later may resolve things. People often go to bed earlier to try and catch up on sleep but this can backfire with subsequent early morning awakening. In this case, the clinician may recommend that the client either abruptly or gradually cut back to only the number of hours of sleep per night they are already able to manage. For example, if a client would like to wake at 6am daily and usually only sleeps 5 hours a night, the bed time is temporarily moved to 1am with a 6am wake time. After this pattern is established, the client can gradually go to bed earlier in 15-minute increments until a greater length of sleeping time is established (ideally 7-8 hours or more).

Another issue can occur when a person’s circadian rhythm or natural body clock gets out of sync. In this case, the person may go to sleep early in the evening (e.g., 6-8pm) and only sleep until 3 or 4am. This more commonly occurs with older people due to age related changes in the circadian rhythm. An effective treatment for this Advanced Sleep Phase Disorder is use of a light box in the evening to reset the body clock (Bloom, et al, 2009).

Another aspect of CBT-I is an emphasis on cognitive restructuring. This involves learning to question automatic beliefs related to insomnia that increase anxiety (e.g., “I can’t handle the day if I’m tired.”). These thoughts are replaced with coping statements that promote resilience such as “I’ve been tired many times before and always gotten through it” or “I’m tired but I am building up my need for sleep tonight.”

In addition to the interventions above, psychologists use a number of other techniques.
Therapy may address grief over recent losses, chronic relationship issues, loneliness and social isolation, anxiety, or depression. Other stress management techniques such as meditation and relaxation exercises can be helpful as well. Learning new ways to manage stress can reduce levels of stress hormones in a person’s body which may perpetuate sleeping lightly and poorly.

When people have struggled with insomnia for a long time, they can become discouraged and believe there are no solutions. Current evidence suggests that a thorough sleep assessment can pinpoint individual factors that create insomnia. These factors can then be addressed singly or in a stepwise fashion to significantly reduce the occurrence of insomnia. This appears to be the case for individuals of all ages which disproves the myth that poor sleep is an inevitable consequence of aging.

Sweet dreams.

References
Bloom, H.G., Ahmed, I., Alessi, C., Ancoli-Israel, S., Buysse, D.J., Kryger, M.H., Phillips, B.A., Thorpy, M.J., Vitiello, M.V., Zee, P.C. Evidence-Based Recommendations for the Assessment and Management of Sleep Disorders in Older Persons. Journal of the American Geriatrics Society.2009 May; 57(5): 761-789.
Cognitive Behavioral Therapy for Insomnia. Retrieved from http://www.sleepfoundation.org/articles/cognitive-behavioral-therapy-insomnia.
Epstein, L.J. 2008, December, 15. Sleep and Mood. Retrieved from
http://healthysleep.med.harvard.edu/need-sleep/whats-in-it-for-you/mood
Fiorentino L., Martin J. Awake at 4am: Treatment of Insomnia with Early Morning Awakenings Among Older Adults. Journal of Clinical Psychology. 2010 Nov; 66 (11): 1161-1174.
Holmes, L. 2015, July 23. All the Ways Sleep Affects Your Happiness, In One Chart. Retrieved from https://www.huffpost.com/entry/all-the-ways-sleep-affects-your-happiness-in-onechar_n_55ae4d55e4b07af29d564a29