Insomnia / Problems Sleeping

This page provides a comprehensive overview of insomnia and other types of sleep problems, along with strategies to improve sleep. Sections include:

General Description of Insomnia and Other Sleep Problems
The Mechanics of Sleep – Five Stages
The Most Common Types of Sleep Problems
Causes of Sleep Problems
Cross Cultural Reflections on Sleep
Assessing Sleep Disorders
Ways to Improve Sleep
Blog Posts about Insomnia/Sleep Problems
Insomnia and Sleep Problems Info from National Institute of Mental Health and Centers for Disease Control

General Description of Insomnia and Other Sleep Problems

More than 25% of the US population does not get enough sleep!

While some may think of sleep as a luxury, science now shows that it’s far from that. Ample sleep is what recharges our bodies and minds. And, unfortunately, inadequate sleep can actually have a profound impact on our health, contributing to maladies like depression, high blood pressure, diabetes, anxiety, neurological disorders like dementia, and other conditions. ^1.5One study published in the journal Neurology suggests that sleep deprivation may contribute to brain shrinkage – yikes!

Like any challenge in life, sleep problems can range from mild to severe. Signs of inadequate sleep include:

Difficulty getting out of bed in the morning
Sluggishness or sleepiness in the afternoon
Falling asleep rather quickly (either at night, in front of the TV or when doing something else relaxing like meditation)
Brain fog, difficulty concentrating
Increased irritability or moodiness

Most experts recommend getting between 7 and 9 hours of sleep per night, with the amount needed varying by individual and often changing over the lifespan¹². Furthermore, young people need even more sleep, with experts recommending 10 hours for children and somewhere between 9-10 for teens. Some people claim they can get by on little sleep, but the data appears to prove otherwise.¹³

A good night’s sleep offers many health benefits. When well rested, we think better, feel more energized and are better able to fight off illness.

If you are like the millions of Americans that don’t get an adequate amount of sleep read on, as you’ll find in-depth information here on the mechanics of sleep, sleep disorders, and ways to overcome them.

The Mechanics of Sleep – Four Stages

There are four different stages of sleep: stages 1, 2, 3 of non-REM (NREM) sleep, with stage 4 being that of REM (rapid eye movement) sleep. It takes about 90 minutes to cycle through the first 3 stages before arriving at REM sleep and one spends different amounts of time in each cycle as the night goes on.

Brainwaves (i.e., Alpha, Beta, Theta, and Delta, from higher to lower frequency) are studied during sleep with electroencephalography (EEG), by placing painless surface electrodes on one’s scalp. During normal sleep, an individual will proceed through stages 1-3 of NREM sleep, culminating in stage 4 of REM sleep (note: in the past, the sleep stages were divided into 5 stages, but now are categorized as 4 only).

Stage 1: Light sleep; individual is easily awakened. Serves as a transitional role in sleep stage cycling.

Stage 2: Heart rate slows and body temperature lowers. More stimulation required to awaken the individual. EEG shows mixed frequency activity as well as “sleep spindles,” or spikes of electrical activity, which are currently thought to indicate memory consolidation.⁵

Stage 3: This is known as “slow-wave sleep” or SWS. Stage 3 is often referred to as “deep sleep” and/or “restorative sleep,” but normally constitutes only 3-8% of sleep.⁶ The EEG shows mixed frequency, high voltage activity during this stage. Of the non-REM sleep cycles, it is most difficult to awaken someone from stage 3 sleep.

Stage 4/REM sleep: As you probably already know, the term REM stands for rapid eye movement, as bursts of rapid eye movement literally occur during this stage of sleep. This is the stage in which dreaming is most commonly thought to occur, and is also associated with an increase in heart rate and blood pressure.⁷

There’s more to sleep than brain waves, however. During the day, our bodies produce a compound called adenosine, which builds up during the daytime hours and regulates our slow-wave sleep⁸ (as mentioned, this is related to “deep sleep,” an important aspect of sleep). Also, the hormone melatonin is an “internal sleep facilitator” in humans and closely associated to our circadian rhythms, a kind of biological clock that regulates the timing of our need for sleep.⁹ Circadian patterns (translated from Latin, circa means “around” and dia means “day”) explain why most people naturally feel sleepy late at night and in the middle of the afternoon¹⁰. In addition to our circadian rhythms, we have a sleep/wake homeostasis, which lets us know we’ve been awake for a long time.¹¹

The Most Common Types of Sleep Problems

There are several different kinds of sleep problems, including insomnia, hypersomnia, sleep apnea, restless leg syndrome, narcolepsy, and parasomnias.

1.) Insomnia: More than ¼ of the US population reports not getting enough sleep, and nearly 10% experience “chronic insomnia” (i.e. problems with quality or quantity of sleep which have existed for at least a month²¹). Insomnia encompasses any of the following: difficulty falling asleep, staying asleep, getting up too early, or non-restorative sleep²². Non-restorative sleep is a subjective feeling that sleep has not been refreshing.²³Insomnia co-occurs with psychiatric conditions at the rate of 40%.²⁴Insomnia often co-occurs with other medical conditions including chronic pain and neurologic disorders like Alzheimer’s and Parkinson’s.

A distinction has been made between insomnia and sleep deprivation: insomnia is disturbed sleep in the presence of adequate opportunity to sleep, whereas in sleep deprivation, sleep is curtailed as the result of limited opportunity for sleep (i.e., choosing to stay up late for work or pleasure, instead of hitting the pillow at a reasonable time).²⁶

2.) Hypersomnia: This is a condition in which the individual sleeps excessively. Some potential causes include narcolepsy, sleep apnea, a head injury or neurologic disease, drug or alcohol abuse, medications, depression and being overweight.²⁷Hypersomnia can also be idiopathic, meaning that the cause is unknown.²⁸People with this condition may nap frequently. Many experts agree that napping can help refresh a person, but is generally not recommended past 3pm, as this may create “sleep inertia” that then interferes with nighttime sleep.

3.) Sleep apnea: Sleep apnea occurs when breathing stops or becomes very shallow during sleep. This is caused by the soft tissue in the back of the throat temporarily closing one’s air passage. People with sleep apnea rarely get enough deep, restorative sleep.²⁹ Sleep apnea is a treatable condition, and the doctor may prescribe a continuous positive airway pressure (CPAP) machine to address the problem. Also, some doctors may recommend sleeping on one’s side instead of on one’s back, though this method may not work for everyone.³⁰

4.) Restless leg syndrome: This syndrome, also called RLS, often gets confused with the benign fidgetiness that many of us experience during a meeting or while waiting for something to happen. In restless leg syndrome, the individual feels an unpleasant tingling or prickling in the legs which is relieved by moving or massaging them.³¹ This often occurs while sitting or laying down for a long time, and it can interfere with sleep. In many cases, individuals with RLS also have “periodic limb movements in sleep,” or PLMS, in which they move their limbs during sleep, often awakening themselves or their bed partner.³²

5.) Narcolepsy: This describes a neurological condition characterized by excessive daytime sleepiness and irregular REM sleep. Individuals affected by narcolepsy can experience “sleeping attacks” with no warning, which can impair work and social functioning, and may cause injury. Experts have estimated that about 350,000 people have narcolepsy, but fewer than 50,000 actually get diagnosed. Narcolepsy is sometimes confused with other conditions and symptoms, such as depression, epilepsy, or medication side effects. It is usually diagnosed by an overnight sleep recording, or polysomnograph³³. In contrast to the 90 minutes or so it takes the average person to get into the REM stage of sleep, people with narcolepsy enter that period within minutes.

6.) Parasomnias: Normally, our brain restricts certain bodily functions like walking and talking while we sleep, but this is not always the case. “Parasomnia” is the term used to describe types of sleep problems like: sleep paralysis, sleepwalking, sleep-talking, nightmares, night terrors, and “REM sleep behavior disorder” (acting out dreams).³⁴ These conditions are often seen in children, who tend to outgrow them. These conditions can also co-occur with sleep deprivation (i.e., inadequate sleep by choice) and other sleep conditions.

Sleep paralysis: If you’ve ever felt that you were unable to move your body, you may have experienced sleep paralysis. Some describe it as a weight being placed on the body, and occurs between falling asleep and waking up.
Sleepwalking: In sleepwalking, or somnambulism, people can sit up in bed, or even walk around and do tasks, such as driving a car!³⁵ Individuals tend to report they have no memory of sleepwalking. It’s not dangerous to wake someone who is sleepwalking, though a misconception about this exists. In fact, the National Sleep Foundation states that it’s more dangerous to not wake a sleepwalker,³⁶ as people sometimes injure themselves while sleepwalking (or sleep-driving, heaven forbid!).
Sleeptalking: Occurs when people talk, mumble, or shout during sleep. Sleeptalking probably does not have direct negative effects, but can annoy bed partners, and one or both may experience insomnia as a result. Also, the individual may be afraid to sleep away from home and therefore experience insomnia in unfamiliar settings.³⁷
Nightmares: Nightmares are dreams with disturbing content, and can occur in both children and adults. As with most other dreaming, nightmares occur during REM sleep.³⁸
Night terrors: Also called Sleep terrors, night terrors share some characteristics of nightmares, but do not occur during REM sleep. Night terrors can have more physiological arousal than nightmares, including dilated pupils, sweating, and increased blood pressure. Also, the individual may yell out, and the condition sometimes occurs with sleepwalking.³⁹
REM sleep behavior disorder: Also called RBD, this occurs when individuals act out their dreams. This condition overlaps with somnambulism and sleeptalking.⁴⁰

Causes of Sleep Problems

There’s a lot that goes into getting a good night’s sleep, and sleep has been studied since at least as early as 450 B.C.⁵

Many factors contribute to poor sleep patterns and poor sleep hygiene. Many people’s lives are busy – sometimes by choice, sometimes beyond their control. For example, some people must work two jobs to support their family. For other individuals, a type of addiction often overlooked or even encouraged in our US culture is an addiction to work itself – which can occur at the expense of getting adequate sleep.

With that said, most causes of inadequate sleep fall into the following categories. (For a more detailed overview of causes, see Sleep Foundation – What Causes Insomnia? http://sleepfoundation.org/insomnia/content/what-causes-insomnia]

Medical – things like chronic pain[http://sleepfoundation.org/media-center/press-release/2015-sleep-america-poll], illnesses that affect breathing, and thyroid problems are a few examples of medical conditions that can cause insomnia. Side effects of medication can also contribute to insomnia.

Stress – concerns about family, work and school can make it difficult to fall or stay asleep.¹⁴

Psychological – sleeping problems are often a core feature of psychological struggles like anxiety and depression.

Lifestyle – changes in your schedule, working the night shift¹⁶, choosing to stay up late and substances¹⁵ (e.g., alcohol, caffeine) can all contribute to inadequate sleep.

Cross Cultural Reflections on Sleep

Sleep habits are also in large part a product of one’s community or culture. One study found that people sleep the least in Japan, at a scant 6 hours 15 minutes on average per night, according to one source¹⁷.

And what about the Spaniards who often eat dinner around 10pm, go to bed around 1am and have a long siesta every day? Is this cultural, or a “bad habit?”¹⁸Interestingly, the New York Times reports a current movement to literally change the time zone in order to increase Spain’s work productivity. The intent would be to decrease the lengthy afternoon break (siesta) that’s been part of the culture for decades, in hopes of spurring on an economy that has been struggling.

Across the Atlantic, in the US and Canada, people sleep an average of 7 hours during the week, and 7.5 hours during the weekend.¹⁹ But this is still not the recommended amount of sleep, and the Center for Disease Control and Prevention has gone so far as to call insufficient sleep an “epidemic” in this country.²⁰ What might account for this? Oftentimes, other seemingly more important activities such as work and school are routinely prioritized over sleep in many cultures.

How about for you? What is the culture of sleep in your country, community, or household? And, for you personally, do you tend to stay up late finishing that report or school project at the expense of your own need for sleep?

Assessing Sleep Disorders

A doctor or other trained sleep specialist is needed when sleep disorders are severe or long lasting. The professional treating the sleep problem may order a polysomnograph, in which your sleep is studied overnight by measuring any or all of the following: eye movement, muscle activity, heart rate, blood oxygen level, brain waves, and respiration (breathing). Many use pharmaceuticals to treat sleep problems. However, according to some experts, psychotherapy (e.g. cognitive behavioral therapy for insomnia, CBT-I) is the most effective treatment, that may be even better than medications.¹

It may be news to you that simply getting the recommended amount of sleep is not necessarily sufficient if you’re not getting quality sleep. Sleep hygiene is the practice of assessing and treating sleep problems, which may be more complex than you would have thought – (e.g. the blue light from electronic devices has been found to disrupt sleep when used just before bedtime²). Getting enough quality sleep is of the utmost importance and is actually considered a public health concern, as driving while sleepy can be just as dangerous as driving while intoxicated.³

Below are some additional assessment tools that you can try on your own to help identify factors contributing to your sleep difficulties.

“Sleep Self Assessment Quiz”

http://www.talkaboutsleep.com/sleep-self-assessment-quiz/

“The National Sleep Foundation Sleep Diary”

http://sleepfoundation.org/sleep-diary/SleepDiaryv6.pdf

Ways to Improve Sleep Problems

Sleep-related problems and their causes are numerous and it is difficult to address all of them here. It is important to talk to your doctor or sleep specialist to professionally assess and treat your sleep-related difficulty if you’re unable to find relief on your own. You may be asked to keep a sleep journal, or spend the night at a sleep study facility. The treatments for sleep-related problems vary widely, from talk therapy, to behavior change⁴¹(e.g. being overweight and eating heavy meals just before bed are associated with sleep problems), to buying more comfortable bedding materials, to medication.

Evaluate Your “Sleep Hygiene”
If you are having problems with your sleep, a good place to start is with a self-assessment of what’s known as “sleep hygiene” – your habits or routines related to sleep.

Good sleep hygiene includes things like having a regular bedtime, unwinding at night, avoiding caffeine and alcohol in the evening and ensuring that you are in a comfortable sleeping environment as far as temperature, light, bedding, etc. goes.

For more details regarding proper sleep hygiene, see this “Sleeping Tips & Tricks” from the National Sleep Foundation [http://sleepfoundation.org/sleep-tools-tips/healthy-sleep-tips].

For insomnia, behavioral therapy is the #1 proven technique, and can be used in addition to pharmaceutical interventions.⁴² Some solutions can be very simple, such as turning the clock away, if watching the time tick creates further anxiety about loss of sleep. For other tips and tools related to sleep, see the links below.

Blog Posts about Insomnia/Sleep Problems

Healthy Sleep Tips – The National Sleep Foundation

Interview with Sonia Ancoli-Israel, PhD, sleep expert – Healthmatters

“How much sleep do we really need?” – The National Sleep Foundation

“Benefits of a Good Night’s Sleep” – Healthypsych.com

“Cultural differences impact on sleep patterns” – Health Boosters

For ideas about coping with the night shift – The National Sleep Foundation

Insomnia and Sleep Problems Info from NIMH and CDC

Power Nap” Prevents Burnout; Morning Sleep Perfects a Skill (NIMH)

Evidence-Based Recommendations for the Assessment and Management of Sleep Disorders in Older Persons (NIMH)

A Night’s Sleep Gives Emotional Memories Their Staying Power (NIMH)

“Sleep and Sleep Disorders” (Centers for Disease Control and Prevention / CDC)

Improving sleep is not particularly glamorous or exciting, but is such an important, and often overlooked, physiological and psychological need. Please feel free to share your sleep experience by commenting in our Forum – sharing what has worked or not worked for you. Sleep well and sweet dreams!

Sources

1: Ancoli-Israel, S. (2014). Health Matters. Retrieved from https://www.youtube.com/watch?v=dg9kmZHqhUE

1.5: Institute of Medicine. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press; 2006.

2: http://www.washingtonpost.com/national/health-science/blue-light-from-electronics-disturbs-sleep-especially-for-teenagers/2014/08/29/3edd2726-27a7-11e4-958c-268a320a60ce_story.html

3: http://drowsydriving.org/about/

4, 26, 27: http://www.medscape.org/viewarticle/585753

5: http://www.howsleepworks.com/research.html

6, 7: http://www.ncbi.nlm.nih.gov/books/NBK19956/

8, 9: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769007/

10: http://www.ncbi.nlm.nih.gov/pubmed/12622846

11,: http://sleepfoundation.org/sleep-topics/sleep-drive-and-your-body-clock

12: http://sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need

13: Ancoli-Israel, S. (2014). Health Matters. Retrieved from https://www.youtube.com/watch?v=dg9kmZHqhUE

14: http://yas.sagepub.com/content/early/2013/10/24/0044118X13506720.abstract

15: http://www.nlm.nih.gov/medlineplus/magazine/issues/summer12/articles/summer12pg20.html