I have spent the last 30-plus years trying to understand and find the best solution for the phenomenon of insomnia. Having spoken to countless thousands of patients and research participants, I know that being unable to sleep when you need to, and when you want to, is one of the most frustrating of human experiences.
So, three key questions. What exactly is insomnia? How does it come about? Can it be treated? Whether or not you use the term insomnia, I expect you know what I mean. Insomnia is a difficulty getting to sleep and/or staying asleep, occurring three or more nights per week, for at least three months. In fact, in my clinics the average duration of insomnia is more like five to 10 years.
Not only is insomnia a night-time problem, it also causes significant daytime deficits. It is part of the definition of insomnia disorder that poor sleep results in depleted energy, impaired mood, or poor concentration during the day. Everything seems harder … and our friends and family members, maybe also our work colleagues, can often see these effects too. It’s those consequences of insomnia that drive people to look for help because waking up after a bad night is often followed by a bad day.
Indeed, my patients feel that the edge has been taken off their lives. They often feel that their problem is not well understood, or even that it is doubted, including by those in the medical profession. So, they just have to learn to live with it. Historically, it is as if it has not been regarded as a proper illness.
Well, nothing could be further from the truth, and I’m glad to say that the tide is turning. Science has discovered that people with insomnia are twice as likely as good sleepers to develop depression, and that they have an increased vulnerability to type 2 diabetes and to hypertension. Persistent insomnia is no trivial matter.
Sleeplessness is not just a consequence of “something else”; it is also a causal factor of illness. As far as I am aware there are only four things that are required to sustain life – air, water, food and sleep. This is true for almost all species. Can you imagine having an insufficient or poor-quality oxygen, water or food supply? Would that not cause major health problems?
We must not trivialise sleep as if it were just a lifestyle choice, or something to do if we have time in our busy schedules. Sleep is a life-sustaining force; and a lack of sleep, whether through our neglect to give sleep enough space in our lives, or through having a sleep disorder, is hugely important.
How does insomnia come about?
This is a complex issue, and there is a great deal of research going on in this area. Let me illustrate some of the things that we have found out.
Having a poor night of sleep is not uncommon. Indeed, it is a pretty universal experience; especially at a time of stress. But sleep is also a healer. Sleep helps us regulate our emotions, consolidate our learning, develop our immune responses and recover physically. So, for most people short-term insomnia is just that; temporary. Of course, it can be a struggle – having a new baby at home, dealing with health issues, bereavement, or a change in personal, financial or occupational circumstances. But sleep is there to help us cope, as well as at times being a casualty to the pressures. How often have people said to me: “If only I could get my sleep, I think I could manage.”
Insomnia disorder may grow out of short-term insomnia. A stressor may be a starting point, but people generally resume normal sleep after a period. Stress is not the cause of chronic insomnia. Rather, a vicious cycle develops where sleep itself becomes the focal point of attention. We go to bed wondering if we will sleep; fearing that we might not. We lie awake thinking about being awake and striving to get to sleep. We calculate the hours and minutes that we have left if we don’t sleep soon. We worry about the consequences of not sleeping … and it all becomes a self-fulfilling prophecy. Sound familiar?
Importantly, good sleepers have no idea how they do it. They’ve never had to learn. They sleep just like they breathe – without ever really thinking about it. They simply follow their biology – getting into a pattern of falling asleep and staying asleep when they are sleepy. This is important. People who have developed a chronic insomnia have become like tightrope walkers. Trying to navigate the challenges of sleep and wakefulness; constantly vulnerable to an imminent wobble.
People with insomnia become hyper-aroused in their bed and bedrooms because they are trying to walk a line. For good sleepers there’s nothing further from their minds. They are not doing anything. They are allowing sleep to be king.
Once insomnia becomes chronic, the only effective treatment is cognitive behavioural therapy (CBT) .
All international authorities and clinical guidelines agree on this. Sleeping pills are not recommended for more than a few nights’ use, and do not have an evidence base for long-term use. Although some people make sensible use of these pills (called hypnotics) for extended periods, the very fact they do so illustrates that they seldom solve insomnia. Besides, doctors are actively discouraged from giving more than one prescription because guidelines say this would not help and may cause some harms, like side-effects or dependency.
So, what is CBT? The best way to explain this is to say that CBT is the antidote to the problem that I described earlier. CBT helps to establish a biological sleep rhythm – the right amount of sleep for you and at the right time. The behavioural elements of CBT help you to build a healthy new sleep pattern; help you to discover how much sleep you need; and to rely on sleep occurring even when you try to remain awake. Pretty much like the good sleeper, in fact. Bed becomes re-connected to successful sleep.
The C in CBT refers to cognitive; that is the mindset. These parts of CBT help you dispose of the racing mind that is the enemy of sleep; help you to stop trying to sleep as if it is a performance; help you to put the day to rest long before you even go to bed; and help you to use relaxation and imagery to distract from an unhealthy focus on sleep itself.
As you can see, CBT is not a single therapy but a collection of therapies; and finding the right elements of CBT that work best for you is part of the therapy. Importantly, I want to stress that CBT is not just a set of “sleep tips”. If someone had a depressive condition, we wouldn’t say, here are a few tips to help you be more positive. We would take the depression seriously and provide an evidence-based treatment. People with insomnia deserve no less.
• Colin Espie is professor of sleep medicine at the University of Oxford. He is one of the world’s leading experts on insomnia and chief medical officer of Big Health, the company that created the digital (web/ mobile) CBT programme sleepio.com/nhs
Snooze button: NHS-approved digital CBT
Sleepio.com/nhs This is an online tool designed to help improve adults’ sleep through a cognitive behavioural therapy approach. It has been evaluated by the National Institute for Health and Care Excellence and approved by the NHS. Users take a simple test, and Sleepio then suggests techniques that can help. A full CBT-based programme is available for the poorest sleepers, tailored to each individual’s needs.