Struggling to get a restful night’s sleep? You’re not alone. Insomnia is a very prevalent sleep disorder that is estimated to affect up to 10% of the world’s population, with an additional 20% suffering from occasional insomnia symptoms. Despite being so common, it can be extremely debilitating, sapping us of our productivity and raising our risk of serious illnesses such as diabetes, heart disease, and depression.
But there’s no need to suffer through sleepless nights forever – evidence-based interventions can help. We’ve taken a look at what causes insomnia, its impact, and how choosing science-backed strategies over quick fixes can help break the cycle.
If you already feel that you understand insomnia and are just interested in how to improve it, jump to the section “So, what can you do about insomnia?" Otherwise, read on.
What is insomnia?
Insomnia is generally defined as problems with falling or staying asleep. This means that not all sleep problems are considered insomnia (such as narcolepsy). There are specific criteria needed for a clinical diagnosis of chronic insomnia, as laid out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). These include sleep difficulties that occur at least three nights per week for three months and significantly impede your everyday functioning. However, sleeping problems also significantly impact many people who do not meet this definition. This article should be relevant for almost anyone whose trouble sleeping is impacting their quality of life!
What causes insomnia?
Researchers have often defined insomnia as a disorder of hyperarousal, a state of elevated activity in your nervous system – or difficulty ‘switching off.’ Some studies have suggested that sufferers of insomnia may experience hyperarousal throughout the day, not just at night. This could manifest both psychologically (racing thoughts or increased alertness) and physiologically (increased heart rate or stress hormone levels). Physiological and psychological symptoms can often mutually reinforce each other. For example, anxiety can trigger stress hormones, while the resulting physical arousal can further fuel anxious thoughts.
What triggers this hyperarousal? There are many reasons why you might experience a state of hyper-alertness that can interfere with sleep, which generally fall into three categories:
Behavioral causes of insomnia
Insomnia can be perpetuated (or even primarily caused!) by behavioral factors such as drinking alcohol right before bed, taking stimulants, sleeping irregular hours, or a sleep environment that is not conducive to rest (such as a room that is too loud, or too hot or too cold).
One behavioral theory of insomnia is the cognitive model. At first, you start to experience sleep difficulties because of some other cause, such as anxiety or a poor sleep environment. Once these sleep problems start, you begin ruminating about your inability to sleep and its potential consequences, which can create a state of hyperarousal. Ironically, this cycle may get set in motion due to overestimating the severity of your sleep problems and how much they’re impacting you during the day. This can lead to a hyper-focus on trying to improve your sleep. You might try counterproductive strategies to counter insomnia – such as reducing daytime activities to ‘save energy’, taking naps to make up for lost sleep, trying hard to fall asleep when in bed, or relying on caffeine or stimulants to stay alert during the day. Each of these can make insomnia worse, leading to a self-perpetuating cycle that worsens your symptoms!
Mental health causes of insomnia
Insomnia and mental health are closely tied. According to the American Psychiatric Association, approximately 40% to 50% of people with insomnia have another mental disorder as well.
The causal link between insomnia and mental health issues is complicated. Poor mental health can be both a cause and a consequence of sleep difficulties. Insomnia may also exacerbate mental illnesses and make them harder to treat. Many psychiatric medications list insomnia as a side effect.
The association between insomnia and depression is particularly strong. One sample of over 8,500 people found that more than 80% of subjects with depression had symptoms of insomnia. In fact, insomnia is so common in depressed patients, and is so often the symptom that prompts them to seek medical help, that some clinicians have advocated for caution in diagnosing depression without a co-existing complaint of poor sleep. In our PersonalityMap system, which provides access to over a million correlations, we find quite a high correlation of r=0.57 between depression (as measured by the PHQ-9 scale) and strength of answer to the question "On a typical night, how much difficulty do you have falling asleep?"
Around 50% of anxiety sufferers are estimated to also experience insomnia. Nighttime, when we have few distractions, can provide ample opportunity to hyperfocus on racing thoughts and worries. Anxiety can increase levels of stress hormones like cortisol and adrenaline, contributing to hyperarousal and disrupting sleep. On PersonalityMap, we find nearly as high a correlation between anxiety (as measured by the GAD-7 scale) and trouble falling asleep as we did with depression: r=0.48.
Medical causes of insomnia
Physical health issues can also cause insomnia. Medical conditions such as restless leg syndrome or an overactive thyroid are common contributors to sleep problems. Sleep apnea is also often comorbid with insomnia – it causes periods of interrupted breathing during the night, which can lead to fragmented sleep.
As with behavioral causes, physical health conditions and insomnia often mutually reinforce each other. When you’re in a state of hyperarousal, you may be more sensitive to the sleep interruptions caused by an underlying physical health issue, making it even harder to fall or stay asleep. And it goes the other way, too: chronic sleep deprivation can exacerbate symptoms of many physical health issues. This cycle can make it difficult to determine whether your insomnia is primarily caused by the physical condition or if poor sleep is aggravating the condition itself.
What are the consequences of insomnia?
Lack of sleep can have a wide-reaching impact. Insomnia has been linked with a higher risk of heart disease and diabetes. It may make you more likely to experience cognitive decline such as memory, executive function, and attention impairments, or increase your risk of dementia. It can also weaken your immune system.
Unsurprisingly, sleep deprivation can make you more likely to injure yourself. For example, one survey of over 8,000 community respondents reported that 8% of insomniacs vs 1% of non-insomniacs had suffered an accident at work within the past 12 months. A Norwegian study that followed more than 54,000 participants over 14 years found that experiencing symptoms of insomnia is linked to an elevated risk of being in a car accident.
Insomnia and mental health are closely tied. Mental health issues like anxiety and depression can be a cause of insomnia, but they can also be a consequence. The overlap between insomnia and mental health problems is estimated by the American Psychiatric Association to be around 50%. Insomnia can also worsen the symptoms of existing mental illnesses and make them harder to treat.
So, what can you do about insomnia?
As we discussed earlier, many of the ways in which people try to combat insomnia can end up making it worse. There are quick fixes for insomnia which may provide some short-lived relief, but exacerbate your symptoms in the long run. For example, regular use of sleeping pills can lead to dependence which makes it difficult to sleep without them (of course, sleep medication can be an appropriate treatment for some specific sleep disorders, but they are usually only recommended for short-term use). Drinking alcohol may help you drift off, but studies suggest that it may also reduce the duration of REM sleep. Trying to ‘make up’ for lost sleep by napping or sleeping in can disrupt your natural sleep schedule.
Tempting as these solutions may seem, taking a longer view can help you avoid these self-perpetuating cycles. Here are some scientifically-backed interventions that have a better chance of helping you banish insomnia for good:
1) Cognitive Behavioural Therapy (CBT)
CBT is often the first treatment recommended to patients with clinically diagnosed insomnia and can help reduce symptoms in many people experiencing sleep difficulties. An analysis of 20 studies on the effectiveness of CBT for insomnia found that it meaningfully reduced the amount of time it took subjects to fall asleep, and increased their total time asleep and sleep efficiency (the percentage of time in bed spent asleep).
The type of CBT usually used for insomnia is known as CBT-I. As the name ‘Cognitive Behavioral Therapy’ suggests, it targets both the cognitive and the behavioral causes of insomnia. The cognitive aspect of CBT-I focuses on countering erroneous and unhelpful beliefs around sleep such as “I’ll never be able to sleep tonight” or “If I can’t get to sleep in the next hour, tomorrow will be ruined”. Your therapist will help you identify and overcome these types of self-fulfilling prophecies.
The behavioral aspects, on the other hand, involve reducing stimuli around bedtime by, for example, refraining from using your bed for activities such as reading or watching TV, and ensuring your sleep schedule is regular, including refraining from “making up” for lost sleep. This also involves, counterintuitively, restricting time spent in bed – but this doesn’t mean restricting sleep! The restriction part of CBT-I is designed to reinforce the association between bed and sleep. For example, if someone typically goes to bed at 11pm and gets up at 8am, but is only actually asleep for six of those nine hours, then they might restrict time spent in bed to between the hours of midnight and 6am. This is gradually increased over time, and should produce an incremental increase in sleep time. Another important component to re-establishing the sleep-bed association is not using your bed for other activities such as working or reading.
Since we believe that CBT-I is an effective method that can help many people, we're excited to partner with the Insomnia Therapy Programme, which offers a six-week CBT-I program with a highly trained coach, for just $420. You’ll get your first session free, and your money back if your sleep doesn’t improve after six weeks according to a diagnostic assessment. If you're interested, you can take your first step towards better sleep by booking a free consultation today! Click here to get started. [link to landing page]
2) Regular exercise
Exercising regularly has long been linked to better sleep. It can improve sleep duration and quality in many ways such as promoting the production of melatonin (a hormone that regulates sleep-wake cycles) reducing stress, elevating mood, and even regulating body temperature (exercise initially raises your body temperature, but the subsequent drop that occurs 30-90 minutes later may facilitate sleepiness).
3) Mindfulness and meditation
Mindfulness-based interventions, such as Mindfulness-Based Stress Reduction (MBSR) can help reduce insomnia symptoms. MBSR is a practice involving observing thoughts and sensations without judgment, which may reduce nighttime hyperfixation and anxiety that can exacerbate insomnia. MBSR usually takes the form of structured sessions with a specialised trainer involving group sessions over several weeks. You might complete exercises such as guided audio meditations or keeping a sleep diary.
4) Improving your ‘sleep hygiene’
Another approach for reducing insomnia is improving your ‘sleep hygiene’, or making the environment you sleep in, and your behavior before bed, more conducive to rest. This means ensuring that your bedroom is cool, quiet, and dark and that you avoid screen time and stimulants for a period before sleep. The scientific consensus is that most people sleep best in 60°F-67°F (15.5°C–19.5°C) temperature rooms, though some people may be exceptions and require a higher temperature.
Need help to get rid of insomnia? Consider signing up to Overcome's Insomnia Therapy Programme today
Insomnia can seriously diminish your quality of life, but there is a way out. Resisting the temptation to choose quick fixes over long-term, evidence-backed solutions will greatly improve your odds of banishing bad sleep! If you are interested in giving evidence based methods a try, we suggest you give our partner Insomnia Therapy Programme a try. In a recent study, their program was found to significantly improve sleep in 80% of cases.Sign up today, and receive a full refund if you see no improvement. We've teamed up with them in a paid partnership because we believe in their work and are confident it could benefit many of our users.