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  Challenges

Insomnia

Sherry-Lee Smith

Registered Psychologist
Perth, Western Australia

What is insomnia?

Insomnia is a prevalent public health concern and one of the most common psychological health complaints worldwide. Insomnia refers to difficulties initiating sleep, maintaining sleep, or waking early and not being able to get back to sleep. People can also have complaints of consistently feeling dissatisfied with their sleep quality and not feeling refreshed after a night sleep. Difficulty sleeping may be accompanied by feelings of tiredness during the day, problems concentrating, difficulties with memory, upset stomachs, irritability and lack of motivation.

Most people have some difficulty with insomnia, with one third of people experiencing these symptoms from time to time. This is known as transient insomnia, which is often associated with stressful life events, such as work stress or job loss, relationship difficulties, financial problems, jet lag, medical illness, and psychological difficulties. In these instances insomnia is usually resolved when the situational stress has subsided. Sometimes insomnia becomes habitual after stressful life events have abated. When this occurs it is known as chronic insomnia.

Chronic insomnia is present when difficulty sleeping lasts longer than one month. A sustained pattern of insomnia is associated with poor health and can significantly impair a person's life if left untreated. Studies have shown between 6-16% of the population suffers from chronic or persistent insomnia.

Insomnia and other physical and mental health issues

Insomnia often co-occurs with other medical or mental health concerns. When insomnia is present with another illness, diagnosis and treatment become more complicated. Often insomnia is thought of as just a symptom of another problem, but frequently it is an issue demanding treatment alongside the other condition. Physical concerns such as obesity, chronic pain, memory impairment and heart disease often co-occur with insomnia. Asthma, fibromyalgia and chronic fatigue syndrome are health concerns that may affect a person's sleeping pattern and play a role in insomnia. If you are suffering any of these health concerns it is important to seek treatment from your doctor.

Insomnia may be related to mental health issues. Anxiety disorders, depression, substance use, suicidal ideation, post-traumatic stress disorder, bipolar disorder and psychosis are commonly associated with insomnia. Chronic insomnia can increase a person's risk of developing these disorders and is also a factor in relapse of these concerns.

Anxiety and insomnia are closely connected as insomnia is intensified by anxiety. However, most frequently, anxiety disorders are present before insomnia develops. People who suffer from insomnia are almost twice as likely to have anxiety as those without insomnia. The presence of insomnia has also been found to predict the onset of anxiety disorders.

Depression and insomnia have a complex relationship. Insomnia is one of the symptoms of depression and sleep disruptions are present in almost 80% of people with Major Depression. Disturbed sleep and tiredness are the most commonly reported enduring symptoms after remission from a depressive episode. Moreover, insomnia is a risk factor for depression and has been shown to be predictive of depressive symptoms over time. There is consensus between sleep clinicians that if insomnia is present it should be diagnosed alongside depression rather than considered just a secondary symptom. Psychological treatment in these cases should address both depression and insomnia.

Effects of lack of sleep and insomnia

Insomnia is a common psychological problem with debilitating effects socially, occupationally, psychologically and physically. It can cause irritability and difficulty fulfilling social roles. Insomnia can create problems with work or educational functioning and performance. Psychologically, it may produce memory difficulties, concentration problems, reduced motivation and mood disturbances. Furthermore, it may produce gastrointestinal problems, fatigue and lack of energy.

Factors that contribute to insomnia

There are many factors that cause or contribute to insomnia. Some sleep clinicians have proposed what is called the '3P model' of insomnia to explain how and why it develops (Ebben & Spielman, 2009). The first P involves 'predisposing' characteristics that make a person more vulnerable to developing insomnia. For example the personality trait of hyperarousal. People with hyperarousal generally experience more emotional, psychological and physiological tension than others, which can lead to difficulties initiating or maintaining sleep.

The second P denotes 'precipitating' factors. A precipitating factor is an event or circumstance that triggers transient insomnia. Common precipitating factors for insomnia include;

  • Medical problems
  • Psychological problems or emotional stress
  • Grief
  • Stressful work environments
  • Educational stress
  • Jet lag
  • Shift work
  • Lifestyle factors
  • Chronic pain
  • Natural aging
  • Pregnancy
  • Stressful life events (family separation, job loss etc.)
  • Other sleep disorders (sleep apnoea, narcolepsy, restless leg syndrome)
  • Traumatic memories
  • Side effects of medication

Transient insomnia may lead to chronic insomnia due to 'perpetuating' factors. In order to manage precipitating events or their impact a person may engage in behaviour that prolongs the insomnia, often after the precipitating factor/event has been resolved. Most commonly worry about lack of sleep and the impact it has perpetuates insomnia. This creates a vicious cycle of anxiety about sleep and daytime functioning, resulting in poor sleep which then leads to more anxiety over sleep. Other perpetuating factors include;

  • Self-medicating with caffeine or alcohol
  • Nicotine use
  • Day time napping
  • Developing an irregular sleep/wake cycle
  • 'Safety behaviours' such as going to bed early or staying in bed longer than needed
  • Engaging in activities in bed or the bedroom that aren't conducive to sleep such as eating, surfing the web, watching TV, or engaging with social media

How counselling/psychotherapy can help

Although insomnia is prevalent in the general population it often remains untreated. Most commonly individuals suffering from insomnia visit a medical practitioner and are prescribed medication to promote sleep. Medication may give a person temporary relief from insomnia however it does not address the cause or perpetuating factors than maintain insomnia and can have unwanted side effects. Generally when a person stops taking the medication the insomnia returns. Therefore psychological treatments are increasingly regarded as the treatment of choice for insomnia.

Psychological interventions can help reduce the impact of insomnia in the following ways;

  • Addressing or eliminating precipitating stressors
  • Identifying and exploring factors that contribute to insomnia
  • Developing an awareness of the relationship between behaviour and insomnia
  • Reducing or eliminating behaviour that interferes with sleep
  • Relaxation techniques
  • Meditation techniques
  • Treating co-occurring mental health issues such as anxiety, depression, stress etc.
  • Regulating sleep/wake cycles
  • Reassociating the bed and bedroom with sleep by breaking the association between the bedroom and sleeplessness
  • Creating a sleep conducive environment in the bedroom
  • Identifying and addressing the thoughts and beliefs that perpetuate insomnia

Tips to help you sleep better

The following are some helpful tips for improving your ability to initiate and maintain sleep;

  • Reduce or avoid alcohol, nicotine and caffeine consumption as these will impact your ability to sleep and reduce the quality of your sleep
  • Get up at the same time every morning, regardless of how tired you are or what you have planned for the day
  • Try going to bed only when you are tired
  • If it takes you longer than 20 minutes to fall asleep get out of bed and do something relaxing in another room (if you are not sure if it has been 20 minutes yet it's probably time to get out of bed)
  • Remove your clock from the bedroom or try not to watch the clock checking the time
  • Refrain from napping during the day, if you really need to have a nap do it before 3pm and limit it to one hour
  • People who exercise regularly are less likely to suffer from insomnia. Research shows a positive relationship between physical activity and sleep quality. However, avoid engaging in strenuous exercise late in the evening as this may impact on your ability to fall asleep
  • Develop a 'before sleep' routine that is the same each night, this will be a psychological signal for your body and mind that it is time to sleep
  • Try going to bed a little later than normal, going to bed too early when you aren't tired won't help your insomnia
  • Use the bed and bedroom only for sleeping and intimacy
  • Keep your bed to yourself (try to get your pets to sleep elsewhere)
  • Treat any medical problems that may be affecting your sleep
  • Avoid large meals before bed
  • Switch off your mobile phone or switch it to silent. If you want to receive emergency calls create a favourites list and switch you phone to do not disturb (allowing only your favourite numbers to call through)
  • Resist reading, watching TV or using electronic devices in bed
  • Enjoy morning sunlight
  • Try some yoga or tai chi - this may reduce your arousal and improve sleep quality
  • Manage stress and worry
  • Engage in relaxation or meditation
  • Avoid worrying about how long you have slept
  • Try having a hot shower or bath before bed

If you are experiencing any difficulties with insomnia or mental health issues and would like help with this please contact Sherry-Lee Smith on 042 135 1020 or smith.sherrylee@gmail.com.

Sherry-Lee Smith
Registered Psychologist

Mt Lawley Counselling Centre
13 Alvan St
Mt Lawley (Perth) WA 6050

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Ebben, M. R. & Spielman, A. J. (2009). Non-pharmacological treatments for insomnia. Journal of Behavioural Medicine, 32, 244-254.



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