Insomnia 101


What is insomnia?

Insomnia is a 24-hour sleep-wake disorder. Those who suffer insomnia often struggle to fall asleep, stay asleep, or feel refreshed after sleeping. They also experience daytime difficulties like fatigue, fogginess, difficulty thinking, anxiety, pain, and a range of other symptoms. Insomnia is not the same thing as sleep deprivation. Sleep deprivation is when someone does not have adequate opportunity to sleep due to outside constraints (e.g., having multiple jobs and too few hours to rest, care-giving duties that keep you out of bed). Insomnia, on the other hand, is when you have adequate opportunity to sleep but still have difficulty sleeping well.


Why/how do people develop insomnia?

Usually, insomnia starts because people experience a stressful period or biological change, whether it’s moving, exams, injury, divorce, illness, interpersonal conflict, pregnancy, menopause…there are as many different “sparks” that light the fire for insomnia as there are insomnia sufferers. But short-term insomnia, which usually resolves on its own, can turn into chronic insomnia (i.e., lasting more than a month or two) when perpetuating factors enter the picture. These factors are usually behaviors, sometimes the very behaviors people intuitively use to cope with sleep problems, that disrupt the body’s natural ability to sleep well.


How is insomnia treated?

Treating insomnia requires pinpointing these perpetuating factors—the logs that keep the fire going—and addressing them. The first-line treatment for chronic insomnia is called Cognitive Behavioral Therapy for Insomnia (CBT-I). This treatment uses non-medication approaches to address the behaviors, attitudes, and physiological processes that have become entrenched because of insomnia. It works by removing these perpetuating factors and restoring the body (and mind) to its natural relationship with sleep.


What does CBT-I look like in practice?

CBT-I is a hands-on, solutions-focused behavioral treatment. It is not like “talk therapy” that you see in movies, which mainly consists of free-form exploration, often focusing on the past. CBT-I focuses on the here and now. It’s like physical therapy—you meet with your therapist once per week (or two weeks) to identify problems and learn new skills/exercises, you practice those at home while monitoring your progress, and re-convene with your therapist to tweak the program as needed. Usually, patients see improvements after 3-4 sessions, and a full course of treatment lasts 4-6 sessions. A longer course of treatment may be needed if you are also working on other sleep/behavioral disorders at the same time, or if you continue with “booster sessions” to help taper off of sleep medications.


What about sleep medications?

Sleep medications can be helpful for managing short-term sleep disruption, and you should speak to your physician about the pros and cons. In the long term, someone with chronic insomnia tends to develop tolerance to sleep medications (i.e., it stops being effective). Sometimes, physicians will also be reluctant to continue prescribing sleep medications, especially if you are a senior or if you are taking other types of medications that do not interact well with sleep aids. In any case, sleep medications do not address the factors that maintain chronic insomnia, and sufferers are unlikely to spontaneously get better if they continue to rely on medications for sleep.

If you are interested in cutting down or tapering off of your sleep medications, speak to your physician about this. Know that you can do CBT-I while continuing to take your sleep medications, and that a behavioral sleep medicine specialist can help you to taper off of your sleep med after CBT-I.


How do I find a CBT-I therapist?

Unfortunately, there are not many of us. Ask your doctor or therapist for a referral. You can also find a listing of behavioral sleep medicine specialists by state here. Be aware that therapists will often list “sleep” or “insomnia” as one of the issues they treat, but they may not have specialized training in this area. Treating insomnia and other sleep problems requires specialized knowledge (it’s not intuitive!) and general training in psychotherapy is not sufficient. Ideally, you want to work with someone who is a specialist and has extensive training in CBT-I.


My sleep problems don’t seem to match what you’re describing. What else could be going on?

There are other ways your sleep may be disrupted. For example, a common sleep-related breathing disorder is called obstructive sleep apnea (OSA), which is very different from insomnia. Red flags for OSA include loud snoring (or gasping for air, snorting, stopping breathing during sleep), falling asleep during the day, and unexplained high blood pressure. You are at particularly high risk if you are male and middle-aged or older, are overweight/obese, or have a larger neck. However, young, slim women can be affected too! Ask your doctor about screening for OSA if you suspect that you may have it, as it is a serious disease that significantly affects your heart, brain, and overall health. A behavioral medicine specialist can help you to adapt and adhere to OSA treatment (e.g., continuous positive airway pressure—CPAP), which many find difficult.

Another common sleep-wake problem is having trouble falling asleep or being awake at the appropriate times. For example, you may be a night owl who feels most energetic at night, and have a tough time waking up at 7am for work/school. This is a serious problem for not only your quality of life, but also your mental and physical health. This is another area that a behavioral sleep medicine specialist can help, by teaching you strategies for adjusting your body clock.