Insomnia: Causes and Recommendations for Treatment
Written by: Dr. Pamela Heilman, PsyD, LCP
What is sleep?
The sleep cycle is comprised of 4 stages and all play a role in getting quality rest. One of the 4 stages is referred to as REM (rapid eye-movement) and the other 3 stages are part of the NREM (non-REM). Stage 1, also referred to as N1 is a very light sleep and typically lasts about 1-5 minutes. It is easy to wake a person up during this stage. Stage 2 (N2) is a deeper, more restorative sleep and lasts for approximately 10-60 minutes. During this stage, body temperature drops, muscles relax, and breathing and heart rate slow down. Stage 3 (also known as N3, Slow wave or Delta Sleep) is the deepest stage of sleep that helps consolidate memories and typically lasts for 20-40 minutes. Muscle tone, pulse, and breathing rate continue to decrease during this stage. Experts suggest that this stage is crucial for recovery and growth. Finally, REM is the 4th stage of sleep and lasts for 10-60 minutes. Much of dreaming happens during REM sleep.
Research suggests that REM sleep is essential for functions such as learning and creativity (Suni, 2022).
In a normal sleep period, a person will experience 4-6 sleep cycles. Most of deep sleep occurs during the first half of the sleep cycle. Evidence suggests that not only is it important to obtain a certain amount of sleep per night (approximately 7-8 hours), but proper cycling through the 4 stages is essential as well. Individuals who do not get enough deep sleep or REM sleep may experience more impairment in functioning that impacts thinking, emotions, and physical health (Suni, 2022).
Processes that Affect Wakefulness and Sleepiness
The sleep drive and circadian rhythm/body clock are biological processes that promote wakefulness and sleep. Sleep drive refers to a person’s likelihood of falling asleep at a given time. A person’s body accumulates sleep drive every hour that they are up and moving. It takes approximately 16-18 hours of alertness/activity to build up enough sleep drive to go to sleep (Danforth, 2017).
The circadian rhythm/body clock refers to internal processes which schedule bodily functions and activities. Our circadian rhythm responds to outside cues to keep our body in sync. When the sun goes down, it signals our body clock. Anything we do on a regular schedule helps to keep our body clock in sync. Regular bed times, wake times, light exposure and even meal times help to set our internal clock (Danforth, 2017).
What Causes Insomnia?
The arousal system allows us to respond to dangerous threats and can override the processes controlling sleep. Individuals who have experienced trauma may experience physiological hyperarousal which interferes with ability to fall asleep. An overactive mind (cognitive hyperarousal) is often associated with depression and anxiety disorders and can disrupt sleep processes. Some individuals who experience insomnia become conditioned over time to develop anxiety about being able to sleep (Danforth, 2017).
When people experience difficulty getting quality sleep, they will often use “compensatory behaviors” such as going to bed early, drinking alcohol, worrying about sleep, sleeping in, and napping. These behaviors can actually worsen sleep over time because they disrupt proper cycling through the 4 stages of sleep.
Factors that negatively impact your sleep drive such as excessive time in bed, inactivity, napping, and sleeping in can all lead to insomnia. Variable bed times/wake times and jet lag can disrupt your circadian rhythm and impair sleep quality (Danforth, 2017).
Treatment for Insomnia
There are important considerations when determining appropriate treatment for insomnia. A sleep specialist will assess your symptoms, other co-occurring conditions, and possible causes for your insomnia. Typically, you will be asked to log at least 1 week (ideally 2 weeks) of sleep activity to help assess what treatment is right for you. If you report symptoms associated with Obstructive Sleep Apnea (a medical condition which blocks your airway during sleep), you will be encouraged to participate in a sleep study and to work with a medical doctor to determine the appropriate course of treatment. The following is a list of treatments utilized in CBT for insomnia (CBT-I).
Stimulus Control Therapy
Individuals with insomnia often spend too much time in bed lying awake. Over time the brain begins to associate the bed with wakefulness. This type of therapy involves strategies to
re-establish the connection between bed and sleep and helps to reset the circadian rhythm. Examples might include having the individual wait until they are tired before going to bed, having a regular wake time, and getting out of bed if they have been awake past a certain period of time.
Sleep Restriction Therapy
This type of therapy is meant to help individuals who are experiencing problems with sleep drive and overall sleep quality. The individual’s sleep diary is used to help calculate a “time in bed prescription.” The goal is to shorten time spent in bed until sleep quality improves.
These are strategies that help target thoughts and beliefs about sleep. An individual will be taught healthy ways to manage worry and rumination around bed time.
Relaxation therapy is most appropriate for individuals with sleep onset difficulties. Examples include progressive muscle relaxation and diaphragmatic breathing (Danforth, 2017).
Sleep hygiene refers to lifestyle habits that may impact sleep quality. Healthy sleep hygiene may include some of the following:
Therapy for insomnia is not a one-size-fits-all approach. The above-mentioned therapies may be contraindicated for some individuals. It is important to get a thorough assessment with your therapist and possibly, primary care physician in order to determine what treatment may be most beneficial.
Danforth, M. (2017). Treating Insomnia: Evidence-based strategies to help your clients sleep. PESI.
Suni, E. (2022, August 10). Stages of Sleep. Sleepfoundation.org
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