Insomnia and the rise of sleep disorders

It seems like sleep complaints are cropping up more in conversations. I’ve certainly heard friends and family (of varying ages) express growing concerns for their poor sleep experiences. While stress, demanding work schedules and other external factors contribute to poor quality sleep, are insomnia cases on the rise? If so, what are the best ways to treat the disorder?

The rise in cases of sleep disorders has been declared a public health epidemic by the Centers for Disease Control (CDC), with insomnia being the most common sleep disorder. Statistics from multiple countries found that around one-third of adults experience insomnia symptoms and 10% suffer from chronic insomnia (American Psychiatric Association, 2020; DSM-5-TR, 2022). 

In the Middle East and North Africa (MENA) region, sleep quality and sleep duration were severely impacted as the prevalence of sleep disorders significantly increased after the COVID-19 pandemic (Al-Ajlouni et al., 2022). In fact, the COVID virus itself has led to short-term and long-term insomnia which is now known as “coronasomnia”. 31% of people with long COVID report experiencing disrupted sleep as a symptom of COVID (Sleep Foundation, 2023).

We’ve all had trouble sleeping at some point in our life, so how do we know when it’s insomnia? 

Insomnia involves the persistent inability to sleep and/or stay asleep long enough for optimal functioning the next day, even when presented with the ideal opportunity to sleep (Riemann et al., 2010). Insomnia has been categorized in several ways but the main three types are: 

1. Chronic insomnia: occurs 3 days per week and lasts more than 3 months
2. Short-term insomnia: lasts less than 3 months
3. Other insomnia disorder: entails significant sleep problems but does not fit the above two categories (American Academy of Sleep Medicine, 2014; Suni, 2022).

It is important to mention that having insomnia is a 24-hour disorder that interferes with one’s ability to function in many areas of life such as work or school (Stanford Medicine, 2011). This means people experience difficulties and symptoms both at night and during the day due to a persistent inability to sleep. Not everyone who encounters sleep issues is distressed and unable to function the next day. The daytime symptoms of insomnia manifest in several ways such as irritability and not feeling well-rested. Sleep deprivation can impact cognitive performance including, attention, memory and decision-making. (American Psychiatric Association, 2020). 

Causes & Risk Factors of Insomnia

To be diagnosed with insomnia, your physician would first have to make sure it is not due to (1) other sleep disorders, (2) a side effect of a medication or (3) misuse of a substance such as caffeine or alcohol. 

And since insomnia may occur independently or alongside other illnesses, your physician would also have to check if it’s a symptom of a physical illness such as cancer or heartburn or a symptom of mental illnesses such as depression, anxiety, schizophrenia and/or PTSD. (American Psychiatric Association, 2020). Some cases of short-term insomnia may be triggered by stress and anxiety due to adverse circumstances such as the loss of a loved one or the loss of a job. 

Insomnia may also be described as a “24-hour hyperarousal disorder”. This can be explained as experiencing heightened levels of alertness and anxiety during the day (for whatever reason) that are carried into the night and are preventing you from sleeping even though you are tired and want to sleep. In other words, when you’re constantly “wired but tired” (Pillai et al., 2016; Stanford Medicine, 2011). For a more scientific explanation see Rosenberg et al. (2021).

Other reasons one may develop short-term or chronic insomnia include genetic predispositions and/or environmental problems such as extreme temperatures, an uncomfortable bed/pillow or too much light. Being above the age of 56 is another risk factor (Gavidia, 2020). It is not agreed upon whether the elderly simply need less sleep or if they have lost the ability to sleep for as long as they used to but 50% of older adults report insomnia symptoms even though sleeping less is not a part of aging (Stanford Medicine, 2011; Brewster et al., 2018). 

Bad ‘sleep hygiene’ may also exacerbate insomnia symptoms. This includes:

• Not sticking to a consistent sleep schedule (where you sleep at the same hour and wake up at the same hour each day
• Not allowing your mind and senses to calm down before bed. Instead you might do the opposite by using electronics. Blue light in screens increases the risk of insomnia and bad quality sleep (Fleming, 2018). (If this is a hard habit to break, start by at least setting a timer to remind you when to stop and also change your display settings to night mode/enable night light) 
• Napping during the day
• Not getting enough sunlight, especially after lunch
• Consuming alcohol, caffeine and/or heavy meals at night (APA, 2020).

Note: Avoiding (one or all of) these behaviours may not be enough to effectively treat chronic insomnia. Don’t beat yourself up if you do not develop a regular sleep schedule right away. Treating insomnia takes time and patience. In fact, trying and sometimes failing to abide by all these rules might just make your chronic insomnia worse. Insomnia worsens when you start to associate sleep with anxious thoughts instead of a time for relaxation. Practicing good sleep hygiene for chronic insomnia should be done in combination with a treatment such as CBT-I.

The Problem with Sleep Medication

Inevitably, the use of sleep medication has become a norm for a large number of people. In 2020, 8.4% of American adults (aged 18 and above) reported using sleeping pills in the past 30 days, almost every day (CDC, 2023). 

Sleep medication is often prescribed by doctors for short-term use for those suffering from chronic insomnia. There are several types of sleep medication but many come with side effects or may increase risk of addiction. 

Even when taken correctly and as directed by your doctor, you might still have side effects. Around 80% of people who take sleeping pills experience these residual effects which include oversleeping, dizziness, balance problems and daytime drowsiness (Suni, 2023; Cleveland Clinic, 2021). Additionally, recent studies found that a big majority of people take sleeping pills in the middle of the night and so they do not allow the medication to run its 8 hour course before they have to wake up in the morning. Consequently, they do not wake up properly and might experience daytime drowsiness or worse, sleep driving (AASM, 2019).

Another problem is that you may run the risk of being met with an even more intense “rebound insomnia” when you try to stop taking medication. (Hoffman, 2022). It’s never too late to ask your physician to help break the cycle by gradually decreasing your dosage step by step.

Alternative Treatments:

For the above reasons, it’s encouraged to explore safer and more sustainable treatments for insomnia.

1. Cognitive Behavioral Therapy for Insomnia (CBT-I): CBT-I can only be provided by a specialist (usually a master’s degree holder) trained in CBT for insomnia specifically. Compared to more traditional types of psychological interventions, CBT is favoured by many because it doesn’t take as long, it focuses on the here-and-now instead of delving into your childhood and it is cost-effective. There is also a lot of research backing up its efficacy. These advantages are present with CBT for insomnia (CBT-I) as well. Studies comparing sleep medication and CBT-I found that both groups are able to sleep the same quality of sleep but the effects of CBT-I were much more durable than sleeping pills in the long run (Hellicar, 2022; Mitchell et al., 2012). From its name we can tell that CBT-I seeks to test how accurate your cognitions about sleep are and whether your sleep behaviors promote sleep. This is followed by educational reframing of your thoughts and behaviors in a way that will help you sleep. CBT-I usually only takes 6-8 sessions (Newsom, 2023). According to Sleep Foundation (2023), CBT-I combines a range of techniques including: 
   • Cognitive restructuring: replacing your dysfunctional, inaccurate beliefs about sleep with more rational ones because these thoughts may lead to behaviors that worsen insomnia (thus reinforcing your inaccurate beliefs). For example:
     • Dysfunctional belief: “I need X amount of hours of sleep to be able to function the next day and if I don’t sleep that exact amount of hours “something bad will happen.”
     • Behavior: This thought might then lead you to spend an excessive amount of time in bed trying to force yourself to sleep every night.
     • However, spending excessive amounts of time worrying in bed is counterproductive. Putting restrictive rules in place creates more anxiety around the act of going to sleep. CBT-I attempts to recondition these thoughts and replace them with more effective ones.
   • Stimulus control: Eventually, your bedroom can become a stimulus that immediately puts you in a state of unease when you enter it at night knowing you’re about to struggle to sleep. So stimulus control attempts to change these associations and “reclaim the bedroom as a place for restful sleep,” (Newsom, 2023). This is done by: (1) not allowing you to lie awake in bed for more than 10 minutes, (2) only getting in bed when you’re tired, (3) making you set an alarm to get out of bed at the same hour every morning and (4) discouraging daytime naps.
   • Sleep restriction: This is about limiting how much time you spend awake in bed in order to establish a regulated sleep schedule. The approach intends to make you more tired throughout the day, thus increasing your need for sleep at night. There are some exceptions to how this technique works when applied to the elderly or individuals with conditions such as bipolar disorder and seizures. 
2. Relaxation Training: Since insomnia might be due to hyperarousal, relaxation training can counter that. Mindfulness and meditation can quiet the mind and body to prepare you for sleep. Another relaxation technique called “progressive muscle relaxation” is where you contract and relax one muscle group after the other, especially muscles you don’t realize are tense such as the ones in your eyebrows/forehead or jaw. This is usually accompanied by breathing exercises (Newsom, 2023). This technique helps draw your focus away from your racing thoughts and to something you can control. It helps your body’s natural relaxation response kick-in (NCCIH, 2014).
3. Dietary Adjustments: Eating almonds, walnuts and kiwis before bed might support a healthier sleep cycle as they contain melatonin, serotonin and/or magnesium. These are important because melatonin regulates your body clock and tells you when to sleep and serotonin controls your sleep cycle. Magnesium promotes muscle relaxation and induces sleep. An insufficient amount of these chemicals and hormones will interfere with your ability to fall asleep. Furthermore, drinking chamomile tea may help as it contains an antioxidant which activates the brain mechanism that makes you sleepy. Other foods that promote sleep are turkey, fatty fish and white rice (Elliott, 2020). Caffeinated beverages, alcoholic drinks as well as fried foods, refined carbs and spicy food may exacerbate poor quality sleep (Kubala, 2021). Of course, simply eating certain foods and avoiding others won’t be enough to cure a serious case of insomnia. It’s also important to keep in mind that each individual digests and reacts to these foods differently, so these suggestions might not work for everyone (Zhao et al., 2020).
4. Hypnosis: Hypnotherapy is a relatively time- and cost-effective option. A hypnotherapist will help change negative thoughts and behaviors related to sleep. Hypnosis can be used alongside CBT-I (Suni, 2022). Chamine et al. (2018) reviewed 24 studies and found that 58% of them reported hypnosis to be beneficial, 29% reported no benefits and 12% reported mixed results. Hypnosis is a promising sleep technique that needs further study and investigation.
5. Breathing Exercises: Taking deep breaths is the simplest way to help encourage your body’s natural relaxation response. Refer to Sleep Foundation, 2022 for more information.

Disclaimer: The information provided should not be a substitute for professional medical advice.