Why Can’t I Sleep? Insomnia: A Daytime Problem with Night Time Consequences

If you’re having trouble sleeping you are not alone. While insomnia is a common problem, only ten percent of those with insomnia seek professional help for it. Many people self-treat, e.g. with alcohol. Some of these self-treatments exacerbate insomnia over the long-run.

Research into insomnia reveals it’s not just a disorder of sleep. It’s rooted in excess stress during the day, and how we perceive and manage that stress.

Lack of sleep can have serious long-term consequences such as weight gain, high blood pressure, and anxiety/depression.

The resolution of insomnia is within our control and hinges on developing sustainable techniques to quiet our physical arousal system through modifying our mental/emotional response to stress.

Insomnia Produces Fatigue, Not Sleepiness

Ironically, insomnia causes daytime “fatigue” which may actually inhibit “sleepiness”.

• “Sleepiness” is a feeling of physical and mental tiredness associated with a desire and ability to sleep.
• “Fatigue” is a feeling of physical and mental tiredness not associated with increased tendency to sleep. Fatigue can produce a sensation of agitated wakefulness.

The physical changes caused by stress during daytime cause excess arousal and that arousal energy is manifested as:

• delayed onset of sleep,
• frequent awakenings,
• and poor sleep quality.

Once insomnia is established, it produces physical changes that make it self-perpetuating and independent from it’s original origins. Insomnia increases the body’s inflammatory response. Normally our “inflammation molecules” peak shortly after onset of sleep. However, with insomnia our inflammation molecules peak in the early evening, remain sustained throughout the night and day, contributing to a sensation of restlessness and fatigue.

“Clinically significant insomnia” is defined as insufficient sleep on 3 or more nights/week. Adults need 7.5-8 hours of sleep; while children and adolescents require 9-10 hours.

Types of Insomnia

• Transient: precipitated by life stress, situational, lasts less than one month
• Sub-Acute: Persists 1-6 months
• Chronic: Persists 6 months or more

Stress and Our Reaction to It Cause/Perpetuate Insomnia

Stress activates the body’s emergency system, the hypothalamic-pituitary-adrenal axis, or HPA, and our stress-management cascade is thrown into action:

• We perceive stress from work, family, financial, social situations
• Brain gets notice: “Attention: Stress!”
• Nerve impulses in brain trigger pituitary gland in brain to make stress-coping hormone signals (hypothalamus activates pituitary)
• The stress-hormone-coping signals travel via the blood stream to the adrenal glands which respond by making adrenaline and cortisol

The adrenaline and cortisol “activate” the body’s nerve and metabolic system. These are manifested in:

• increased heart rate
• increased blood vessel constriction—>high blood pressure
• increased body temperature
• increased body movements before onset of sleep–>agitation
• change in metabolism which increases fat deposition around the middle

Life Transitions Increase Our Vulnerability to Insomnia

Certain hormonal changes and aging increase our susceptibility to insomnia.

Dramatic hormonal transitions such as peri-menopause and post-partum are associated with insomnia. Post-menopausal women who use hormone replacement have a shorter sleep latency than those who don’t (more on this later).

As we get older our body becomes more “reactive” to similar amounts of stress because we grow more physically sensitive to the stress-modulating hormones.

Treating Insomnia

Recent evidence shows severe insomnia responds best to cognitive behavioral therapy. When initiating treatment for chronic insomnia the effects of cognitive behavioral therapy are increased if a sleep aid is initially used in conjunction with CBT (see JAMA article cited below).

Sustained management of insomnia requires continued employment of cognitive behavioral techniques to manage worry and rumination, and use of exercise such as yoga, breathing techniques, and other body-quieting mechanisms to decrease daytime activation of the HPA axis or stress management cascade.

Cognitive Behavioral Therapy, Sleep Hygiene, Daytime Quieting of Stress Pathways

Cognitive behavioral therapy (CBT) consists of using the mind to redirect worry, automatic negative thoughts, and rumination. Elements of CBT include:

• mindfulness to one’s emotional state
• consciously interrupting “runaway” anxiety, rumination, worry, negative thoughts and replacing them with neutral or positive thoughts
• incorporation of physical relaxation with the conscious process of slowing down the mind

Sleep hygiene

• engaging in relaxing activity to prepare for bed (e.g. reading, listening to soft music, relaxation exercises, deep breathing)
• lying in bed only when sleepy; get out of bed if awake–redirect focus if worrying, ruminating, e.g. read a book
• avoid caffeine after noon (can increase arousal through evening)
• avoid alcohol (can increase stomach acid reflux which causes episodic awakening)

Daytime quieting of stress pathways

• Yoga: very effective at reducing heart rate, breathing rate and silencing “the chattering monkey” of the mind, reduces metabolic by-products of stress
• Physical exercise, e.g. walking: reduces blood pressure, heart rate, stress-metabolic by-products.
• Breathing/Relaxation Exercises: deep breathing, can be done throughout the day in brief (e.g. 2-5 minute) episodes to mitigate daily stress

Sources and Resources

Scientific Articles

Morin et al. Cognitive Behavioral Therapy, Singly and Combined with Medication, for Persistent Insomnia: A Randomized Controlled Trial JAMA May 20, 2009—Vol 301, No, 19, page 2005.

Basta, M et al. Chronic Insomnia and Stress System Sleep, Med Clin. 2007 June 2(2): 279-291.

Cognitive Behavioral Therapy, Relaxation Techniques

Bourne, Edmund J. The Anxiety and Phobia Workbook, Fourth Edition New Harbinger Publications, Inc. Oakland, CA, 2005.

Spradlin, Scott E. Don’t Let Your Emotions Run Your Life New Harbinger Publications, Inc. Oakland, CA, 2003.

Yoga

Shiva Rae, Flow Yoga for Beginners

Questions

• Do you have insomnia? If so for how long?
• What long-term strategies have you found reduce your insomnia?

Tagged as: chattering monkey, cognitive behavioral therapy, fatigue, insomnia, sleep aids, sleep deprivation, sleep hygiene, sleepiness, sleeplessness