By Catherine Darley, ND

Insomnia, that inability to sleep that may have your mind racing or your body tossing and turning, can cause a profound disruption to people’s lives. About 10-30% of the population experience insomnia.¹ Sleep problems have gotten a lot more attention by the public in the last year due to the pandemic.  Insomnia is increased in survivors of COVID-19 infection.² People suffering insomnia often seek care in their primary provider’s office, making it a condition most of us will be called upon to treat.

What is insomnia? According to The International Classification of Sleep Disorders, the patient must have difficulty sleeping or resistance going to bed, and daytime consequences due to the nighttime sleep difficulty, which cannot be explained by insufficient time in bed or sleep disruption.³ For a diagnosis of chronic insomnia the sleep problem must be experienced at least three times a week for three months. For short-term insomnia all criteria are the same, except that there is no criteria for number of times per week, and the duration is less than three months. (For the full criteria see Table 1, below)

Insomnia can be found in people of all ages, with 36% of preschoolers, 20% percent of children, and 24% of teens experiencing insomnia.⁴ Women tend to report more insomnia, at 19% versus 13% of men,⁵ and 75% of seniors.⁶

Mechanisms/Causes

There are many possible causes of insomnia. As holistic providers, treating the cause is our aim; and for that, we must first identify it. Insomnia can originate from the physiological or psychological. In this paper we will focus on the psychological, though of course there is an interplay between the physical and psychological.

Hyperarousal is a key component of insomnia. Part of that is the idea of sleep reactivity, which is the extent to which sleep is disrupted by stress. People with normal sleep who have high sleep reactivity are at increased risk of future insomnia. Family history, genetics, and stress along with gender all increase sleep reactivity. Nighttime rumination and worry, both types of cognitive-emotional reactivity, contribute to insomnia as well.⁷ 

Other psycho-emotional states that contribute to insomnia include depression. Depression and insomnia have a bi-directional relationship, each contributing to the other, without a clear first cause. Newer research has indicated that insomnia may be a prodromal symptom of depression.⁸ With this thinking, it’s important to treat both simultaneously.

A little-known factor that contributes to insomnia, and may be particularly important in these times, is loneliness. It’s thought that we need to feel socially secure in order to sleep well, thereby setting aside vigilance. The relationship between sleep and loneliness appears bi-directional, suggesting that treating sleep problems may decrease loneliness.⁹

Treatments

The recommended first line treatment is cognitive behavioral therapy for Insomnia (CBT-I). First developed by Charles Morin and presented in his book Insomnia,¹⁰ there are four main components, which are implemented in a series of appointments over the course of weeks. At each appointment the clinician advances treatment in each of the four components that are relevant for that patient.

The first component of CBT-I is sleep restriction (this is a misnomer, it really is “time in bed restriction” which somehow doesn’t roll off the tongue as easily). In sleep restriction, you first identify how much sleep the person is getting on average. You then start the treatment process by giving a scheduled time in bed that allows only that amount of sleep. Then, at each appointment, you evaluate the patients’ sleep efficiency, which is total sleep time divided by time in bed. So long as their sleep efficiency is 85% or more, you increase their opportunity to sleep by 15-20 minutes each week. This strategy increases their sleep drive, making it easier to fall asleep and stay asleep through the night. Once they are getting the amount of sleep they need, an increase in time in bed will result in more wake time. At that point you can stop increasing their time in bed, or even take one step back to the total time in bed where they had high sleep efficiency. In my experience, it is best to take a slow steady approach increasing their total sleep time. The slow approach allows them to have success and reverse the negative sleep associations they have built up over the course of their insomnia experience. Including this component of CBT-I is essential. Sleep restriction is contraindicated in untreated sleep apnea, parasomnias, bipolar disorder, and seizure disorder.¹¹ In my clinic, I’m cautious about recommending less than six hours in bed and always advise people that more time out of bed should not mean more time on tasks.

This strategy may help insomniacs in terms of the “Sleep to remember, sleep to forget” theory. In REM sleep memories are consolidated and also pruned so that our synapses aren’t overwhelmed with information. In healthy sleepers this function is intact. In animal models of medical conditions known to have sleep disorders such as PTSD and autism, this forgetting function is impaired. By consolidating sleep and potentially restricting some REM sleep, the insomniac may be spared some time when unhelpful information is being re-enforced rather than pruned ¹² 

The next principle is called ‘stimulus control,’ which aims to re-associate the bed with sleep. The patient is instructed to avoid all wakeful activities in the bed and even in the bedroom. In the evening, or in the morning after waking, they need to do their restful activities elsewhere. Sometimes people lament the loss of that cozy experience – in bed, in their comfy clothes, supine with low lighting, pillows and blankets. In that case, I encourage folks to have that pleasant experience, simply move to another place in their home such as the sofa or a bean bag chair. This is especially important for those insomnia patients who find they are able to sleep well elsewhere, just not in their own bed. This principle also comes into play in the middle of the night, with patients being instructed to get out of bed if they have been awake for approximately 15 minutes. They should do something boring in low light. I’ve found that the ‘boring’ part is important, as you want to avoid re-enforcing those mid-night awakenings with a pleasant experience. C.S. Lewis said, “Many things – such as loving, going to sleep, or behaving unaffectedly – are done worst when we try hardest to do them.” Getting up when not sleeping gets your patient away from trying hard.

The third piece is cognitive reframing. This component is meant to raise to awareness of any dysfunctional beliefs and attitudes that are making sleep difficult. A good tool to start the process is the Dysfunctional Beliefs and Attitudes Scale (DBAS). There are both short and long versions with sleep statements the patient is asked to rate from strongly agree to disagree on a ten-point scale. One example is: “I am worried that I may lose control over my ability to sleep.” Often patients tell me that they start to have these thoughts after dinner, continuing until they get into bed hours later. Once those sleep-disrupting thoughts are identified, the work is to intentionally shift to sleep-promoting thoughts. With the patient, examine one of their dysfunctional thoughts, then discuss ways in which it may not be true. You’re simply trying to gently introduce other possibilities. It’s important to work with their specific thoughts, and the time of day these come up. For instance, people may have sleep-disrupting thoughts during the day, possibly attributing every difficulty to their sleep. Sometimes it’s useful to write down sleep-positive alternatives for people to read when their thoughts turn negative. The clinical key is that these sleep positive statements must have the power of truth for that individual patient; generic affirmations will not be as effective, if at all.

The last piece is sleep education or sleep hygiene, depending on the author. Here is where the patient receives sleep hygiene recommendations such as no caffeine after noon, no alcohol or meals three hours before bed, to observe whether exercise in the evening interferes with sleep, etc. Education on how sleep works can also be useful. For instance, patients may report a sensation of lighter sleep or more dreams close to wake time. Teaching them about REM sleep being close to wake time and the brainwaves being more similar to waking brainwaves can help them understand their experience is normal.

Cognitive behavioral therapy for insomnia has been proven helpful in some special populations, including depression, for breast cancer survivors, fibromyalgia patients, and children, among others.^13-16

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