The prison of insomnia (and how to escape it)

INSOMNIA is a sign, a symptom and a terrible thing. You watch the clock click, minute by minute, hour by hour. Your anxiety rises. Worries crash over you like waves. Until the early morning light announces that you have once again failed to achieve something doctors say is critical for your health — a good night's sleep. 

I used to be able to sleep on demand. But a while ago my sleep patterns went haywire. And none of the “sleep hygiene" tips work. Lavender baths. Avoiding alcohol and coffee. A weighted blanket. No electronic gadgets in the room. A dark room. A cold room. White noise. Nada.

Sleep deprivation sucks your energy, slows you down,  makes you weepy, stupid and irrational. Borderline crazy. No wonder it is used as a torture technique. Marcel Proust, a famous insomniac, referred to it as “living in a sort of death punctuated by brief awakenings”.

And people are desperate for shuteye. The global sleep economy — products, services, medications and applications connected to sleeping — is expected to be worth almost $600 billion next year.

Trouble sleeping

Study after study has shown that getting sufficient sleep is essential for our physical and mental wellbeing. Most of us need between seven and nine hours a night, children and teens even more. 

Matthew Walker, a professor of neuroscience and psychology at the University of California, Berkeley and the writer of the critically acclaimed international bestseller Why We Sleep: The New Science of Sleep and Dreams, says: “Until very recently, doctors and scientists could not give you a consistent or complete answer as to why we sleep. Consider that we have known the functions of the three other basic drives in life — to eat, to drink and to reproduce — for many tens if not hundreds of years now. Yet the fourth main biological drive, common across the animal kingdom — the drive to sleep — has continued to elude science for millennia."

Walker says an explosion of discoveries in the past 20 years has underlined how critical sleep is to our physical and psychological health. It helps to restock our immune system, keeps our cardiovascular system healthy, helps to prevent infection, fine-tunes the balance of insulin and circulating glucose, regulates our appetites and helps our microbiome flourish. Sleep also affects our ability to learn, memorise, make logical decisions and choices and recalibrate our emotional brain circuits.

Underlying reasons

There are two kinds of insomnia. Acute insomnia symptoms are common and are brought about by stress at work, family pressures or a traumatic event. They can last for days or weeks. Then there is chronic insomnia, which affects one in 10 people. This is defined as having trouble sleeping three days a week for more than three months.  

“Trouble sleeping" comes in two broad categories: trouble falling asleep and difficulty staying asleep. Or a combination of both.

The two most common triggers of chronic insomnia are psychological worry and emotional distress. Walker says researchers have found that one of the critical biological causes underlying this emotional turmoil is an overactive sympathetic nervous system (the body’s fight-or-flight mechanism), which leads to “increased heart rate, blood flow, metabolic rate, the release of stress-negotiating chemicals such as cortisol, and increased brain activation, all of which are beneficial in the acute moment of true threat or danger".

Chronic activation of the fight-or-flight nervous system causes several health problems, one of which is insomnia. It also leads to higher levels of the alertness-promoting hormone cortisol and sister neurochemicals adrenaline and noradrenaline. These three chemicals further raise the heart rate and cause altered brain activity patterns.

“Think of when you closed the lid of a laptop to put it to sleep but came back later to find that the screen was still on, the cooling fans were still running and the computer was still active despite the closed lid," says Walker.

Insomnia is similar. “[Patients with insomnia] have a more fragmented REM sleep, peppered by brief awakenings that they are not always aware of [but which] still cause a degraded quality of dream sleep."

This means they are not rested when they wake up and often cannot function well during the day. Insomnia is a 24/7 disorder.

Pills are a blunt instrument

Walker says medication is a blunt instrument because it cannot address the complex underlying psychological reasons for imsomnia. 

“Sleeping pills, old and new, target the same system in the brain that alcohol does — the receptors that stop your brain cells from firing — and are thus part of the same general class of drugs: sedatives."

The electrical type of “sleep” these drugs produce lacks the largest, deepest brainwaves and puts people in a coma-like state instead of the immune-boosting restorative rest of natural sleep that is so critical to our health.

All the available sleeping medications can also cause “rebound insomnia". Walker says this is when patients stop taking the pills and experience worse sleep than before because the brain has developed a type of dependency. There can be a withdrawal process which involves a spike in insomnia severity.

Non-pharmacological therapies

The American Medical Association no longer recommends sleeping pills as the first-line treatment for insomnia. Nor do the American Academy of Sleep Medicine or the National Health Service (NHS) in the UK. 

Instead, they recommend cognitive behavioural therapy for insomnia (CBTi), an approach backed by hard scientific evidence.

CBTi aims to help people identify and change the underlying thoughts and actions that lead to sleep difficulties. The aim is to replace them with positive and beneficial thoughts and behaviours. 

The therapy can be in-person, with a trained therapist, but the NHS also recommends an app, Sleepio. The six-week programme uses an artificial intelligence algorithm to offer tailored, interactive online therapy sessions and practical help.

In the world’s first placebo-controlled trial for a digital therapeutic, Sleepio was shown to be significantly more effective than the placebo. After six weeks, the insomnia of 76% of Sleepio users improved clinically.

Stanford Medicine says: “Most patients respond to this treatment fairly quickly. Some experience significant changes after only two therapy sessions. Most improve after four to six sessions, but some might need more. Both group and individual treatments are effective."

How does it work?

The CBTi approach has a range of elements.

• Cognitive restructuring. A trained therapist assists you in identifying and changing unhelpful thoughts and feelings that may influence your ability to sleep.
• Stimulus control. This includes a sleep environment with no distractions and going to bed and getting up at the same time every day. It encourages you to get up when you can't sleep, rather than lying in bed tossing and turning.  
• Sleep restriction. The idea here is to initially restrict the time spent in bed then gradually increase it. You will also be encouraged to go to bed only when you are tired and to stick to a regular getting-up time, even at weekends. The overarching aim is to strengthen the link in your mind between sleep and bed, and it is recommended that you use your bed only for sleeping and sex. 
• Relaxation training. This uses techniques such as breathing exercises and meditation to calm your mind. A therapist will use cognitive therapy to help patients shift from trying to sleep to allowing sleep to come. One key element is to avoid clock-watching. For instance, you will turn your clock round so you cannot see the time but can still use the alarm.  
• Sleep hygiene. This encourages habits such as exercise, cutting out late-night eating, coffee and alcohol, and keeping your bedroom cool, dark and quiet. 
• Biological clock. Bedtime and when you get up should be aligned with your circadian rhythm (body clock). The therapist can use procedures to shift the circadian clock, such as adequately timed exposure to bright light. Exercising in the morning is advised because exposure to morning light regulates your body clock.

More tips

The last chapter in Walker's fascinating journey through the science of sleep has 12 helpful tips:

1. Stick to a sleep schedule. Go to bed and wake up at the same time each day.
2. Don't exercise before bedtime. Exercise is good, but not later than two to three hours before your bedtime.

3. Avoid caffeine and nicotine. They contain stimulants that can take up to eight hours to wear off.

4. Avoid alcohol before bed. It robs you of REM sleep. And it will wake you up when the effects of the alcohol wear off. (The dreaded liver clock).

5. Avoid large meals and beverages late at night. Taking in large amounts of fluid will also interfere with your sleep as you will wake to urinate.

6. If possible, avoid medicines at night. Some commonly prescribed heart, blood pressure or asthma medications and some over-the-counter and herbal remedies for coughs, colds or allergies can disrupt sleep patterns.

7. Don’t take naps after 3 pm.

8. Relax before bed.

9. Take a hot bath before bed.

10. Keep your bedroom dark, cool and gadget-free.

11. Get at least 30 minutes of natural sunlight a day. Daylight is vital for regulating daily sleep patterns.

12. Don’t lie in bed awake. If you are still awake after staying in bed for more than 20 minutes, anxious or worried, get up and do a relaxing activity until you feel sleepy. The anxiety of not being able to sleep can make it harder to fall asleep. (Watching TV or using an electronic device is not recommended because the blue light interferes with melatonin, the sleep hormone.)

* Why We Sleep: The New Science of Sleep and Dreams by Matthew Walker is published by Penguin. Get the Kindle version here or order the paper version from Loot.

♦ VWB ♦

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