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Sleep-Related Issues

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Insomnia

What is it?

Insomnia disorder is categorised as a sleep-wake disorder, where the individual struggles to fall asleep, stay asleep and/or wakes early. Although all people may struggle with sleep occasionally, insomnia disorder requires that the disturbance in sleep causes significant distress or impairment in functioning, including occupational, emotional and social functioning. This is commonly the case because lack of sleep can impact a person’s ability to perform complex tasks and may impact cognitive performance (e.g. attention, focus, memory). In addition, the irritability experienced from lack of sleep can impact social relationships and home life.

Individuals who have insomnia disorder experience issues with sleep at least three times a week and the problem persists for at least three months. The sleep issues are also present despite enough opportunity to sleep (i.e. the sleep deprivation does not occur as a result of being too busy, or not having enough time to sleep).  

Symptoms

Symptoms of insomnia disorder include the following:

  • Trouble falling asleep at night
  • Lying awake for long periods of time
  • Inability to fall asleep is not necessarily related to stressful thinking
  • Waking several times during the night
  • Waking up early and being unable to get back to sleep
  • Not feeling refreshed or energised after sleep
  • Experiencing fatigue during the day
  • Attentional difficulties and struggling to focus on tasks
  • Irritability
  • Having a sense of slowed processing
  • Feelings of being on edge
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Causes and Risk Factors

Insomnia Disorder does not have one specific cause; however, there are numerous factors that are likely to contribute to it. These include:

  • stress and anxiety: both of them issues can impact physiological symptoms that make it difficult to fall asleep, as well as cognitive symptoms (i.e. over-thinking, over-analysing, being unable to shut off thinking, etc.).
  • Depression: although people often associate depression with too much sleep, depression also commonly impacts a person’s ability to fall asleep.
  • Health conditions: a number of medical problems such as chronic pain, tinnitus, arthritis, or reflux can all interrupt sleep in various ways and may trigger the onset of insomnia disorder.
  • Medication and substances: some medicines, drugs, or alcohol can lead to insomnia for various reasons – by impacting blood pressure, sleeping patterns, circadian rhythm, etc. 
  • Other sleep disorders: people who suffer from issues such as restless legs syndrome, period limb movement disorder, or sleep apnoea can affect a person’s ability to stay asleep due to the symptoms of each of these conditions. 

Other Sleep Conditions

 

Other sleep conditions share certain symptoms of Insomnia Disorder, which can at times make diagnosis more complicated. The most common sleep disorders that may be considered amongst Insomnia Disorder include:

  • Narcolepsy: although there are some similarities, the obvious differences between the two are that narcolepsy includes symptoms that not occur in Insomnia Disorder, such as sleep paralysis and sleep-related hallucinations.
  • Breathing-Related Sleep Disorders: these disorders include conditions such as sleep apnoea, which may contribute to Insomnia Disorder.
  • Parasomnias: this group of sleep disorders involve unusual and undesirable physical events or experiences that disrupt your sleep, which are behaviour-related. Examples include, sleep terrors, sleepwalking, nightmare disorder, sleep-related eating disorder and sleep paralysis.
  • Normal variations to sleep: Most people may experience certain symptoms of Insomnia Disorder from time-to-time; however, other symptoms are not experienced (e.g. daytime sleepiness). In addition, the sleep issues may be a direct cause of lacking opportunity to sleep enough. 

Treatment

CBT- I

(Cognitive-Behavioural Therapy - Insomnia)

Although Insomnia Disorder may start for various reasons as discussed, the disorder can impact a person’s thoughts, feelings, beliefs and behaviours related to sleep. These, in turn, can maintain and worsen insomnia. Cognitive-Behavioural Therapy-Insomnia (a particular type of CBT treatment specifically developed for insomnia) aims to challenge and shift beliefs and behaviours.

There are specific components included in CBT-I including:

  • relaxation: Physiological arousal is commonly associated with insomnia disorder, making falling asleep much harder as the body is sending signals to stay alert. Part of treatment may therefore involve relaxation strategies to calm or even deactivate the arousal system.
  • stimulus control: this part of treatment focuses on altering unhelpful associations and creating new associations between bed, bedtime and sleep, as well as, developing a healthy sleep/wake cycle. 
  • sleep restriction: this approach aims to limit the amount of time spent in bed in order to induce mild sleep deprivation, which should, in turn, cause the individual to fall asleep quicker and experience efficient sleep.
  • paradoxical intention: this approach aims to help the individual purposely stay awake for as long as possible, in an attempt to cause a forced sleep. This particular technique is used for individuals who struggle to fall asleep, but not those who struggle to stay asleep. 

Importantly, the individual issues faced by the person suffering from Insomnia Disorder will guide which approach is going to be useful. Psychological treatment, therefore, needs to be tailored specifically to the individual. 

ACT

(Acceptance and Commitment Therapy)

As described earlier, Insomnia Disorder can be influenced by stress and anxiety amongst other things. Once anxiety is associated with sleep, the individual might start having anxiety about not being able to sleep – this creates a vicious cycle. At such times, ACT may be a useful approach as it helps the person accept that sleep may not be perfect (rather than feeling anxious about). ACT looks at the issue from the perspective that fighting against the problem and working tirelessly to “fix” an issue may actually perpetuate the issue further. It also aims to help the person distance themselves from their anxious thoughts (rather than focusing on changing them), allowing natural fatigue to take over and help induce sleep. 

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Sleep Hygiene

Sleep hygiene is an approach that focuses on the routines, habits, and practices that can help with good sleep. People often engage in habits and practices that may promote arousal and brain activity rather than sending signals to sleep. Factors that are commonly explored include: diet, exercise, activities leading up to bedtime, when food and drink are consumed, involvement of caffeine, involvement of light sources prior to and in bed (as well as the type of light being used).