If the pandemic has kept you up at night, you are most definitely not alone. More than one in three Americans has reported an increase in trouble sleeping since March 2020, according to a Kaiser Family Foundation poll. And with a large percentage of people now working at least part of the time remotely, work/home lines blur, schedules are turned upside-down, and bed and wake times—previously something so routine you hardly thought twice about it—are suddenly up for grabs. All of this upheaval and stress is no good for your sleep habits, which thrive on calmness and consistency. More and more people are now facing insomnia and other sleep disorders. “Since COVID started, we’ve noticed a high frequency of referrals, much more than ever before,” says neurologist and sleep specialist Alon Avidan, MD, the director of the UCLA Sleep Disorders Clinic in Los Angeles. “It’s hard to find anyone who doesn’t have one sleep issue or another right now.” Interestingly though, while current stressful times are contributing to a temporary spike in insomnia cases, the sleep disorder may actually be less situational than doctors previously thought. A specific event (you got divorced, you lost your job, there’s a global pandemic) does raise the risk for sleepless nights, but a new report in JAMA Psychiatrysuggests that insomnia is more likely to be a chronic condition rather than an event-driven one. In the study, researchers monitored more than 3,000 people over the course of five years. They found that of those who had insomnia initially, nearly 40 percent still battled it five years later. And that’s the tricky thing: Insomnia can be a heck of a health issue to beat. “One in 10 Americans has insomnia,” says Dr. Avidan. “Of those, three or four have chronic insomnia, where you see sleep disruption over at least several months for a couple nights each week, with an impairment in daytime functioning.” You might be thinking, OK, so what? I have trouble sleeping, but it’s not the end of the world. Right? Not exactly. Sleep deprivation is responsible for a whole host of unwanted effects on your body, from cognitive impairment (that’s code for making mistakes at work or while driving) to weight gain to increasing the odds of Alzheimer’s disease, according to 2018 National Institutes of Health study. Other research links poor sleep to type 2 diabetes, certain cancers and low immune function (a.k.a. getting sick easily). Bottom line: Your body needs sleep to operate—and sleep disorders rarely solve themselves. Finding a remedy if you suffer from chronic insomnia takes time, but it can be done. First, you need to start with a solid understanding of what insomnia is and what causes it to occur. Here’s everything you need to know.
So, what is insomnia?
Let’s start with what insomnia is not: It’s not staying up too late watching Seinfeld reruns. It’s not downing a liter of cola 30 minutes before bed and wondering why you can’t doze off. And it’s not vacationing in Maui and struggling to get your body’s clock adjusted to the multi-hour time difference. Insomnia, in the clinical sense, is an inability to sleep soundly despite the best efforts to create a sleep-friendly space. It can be either acute (short-term, lasting a night to a few weeks) or chronic and long-lasting. “Everyone has the occasional night of poor sleep, but in order for sleep difficulties to meet criteria for chronic insomnia disorder, the individual needs to experience sleep disturbance at least three nights a week, for three months or longer, as well as daytime symptoms resulting from sleep difficulties,” says Michelle Drerup, Psy.D., the director of behavioral sleep medicine at the Cleveland Clinic in Ohio. In a nutshell, says Drerup, “chronic insomnia is characterized by difficulty falling asleep, difficulty staying asleep throughout the night, and/or waking up earlier than desired in the morning.” If this is sounding familiar, clinicians have identified several other telltale signs you could have insomnia, including:
Daytime tirednessAnxiety, irritability or depressionDifficulty focusing or concentratingAn increase in mental mistakes or physical accidentsGrowing concern over not being able to fall asleep
Adding a layer of complexity to its diagnosis, insomnia is both a disorder in itself (known as primary insomnia) and a symptom of other health conditions, ranging from depression to cancer to sleep apnea. This is known as secondary insomnia. It can be hard, in some cases, to distinguish between the two—lack of sleep can make you feel depressed, for example, and depression can lead to lack of sleep. Talking with your doctor can help you get a better handle on the type of insomnia you have.
Understanding insomnia causes
Raise your hand if you’ve laid in bed at 2 a.m., wide awake and filled with frustration, wondering why you can’t just shut it down and go to sleep already. “People with insomnia have a group of neurons in the brain that simply don’t turn off,” explains Dr. Avidan. “Those neurons promote wakefulness and are widely distributed in the brain, making the signal to stay awake abnormally high.” This hyperarousal, by the way, served a real purpose back in the day. Your caveman ancestors, like other members of the animal kingdom, were reluctant to fall asleep at night, as this left them vulnerable to enemy attack (see: becoming a lion’s dinner). The ability to prevent oneself from sleeping was a real advantage—and although little inventions like houses with doors have made such vigilance no longer necessary, the neural coding for it remains. “The body has developed a fairly large range of systems to keep itself awake or asleep,” says Dr. Avidan. “In people with insomnia, there is an ongoing battle between sleep-promoting and wake-promoting neurons.” Lion attacks may no longer be relevant in modern life, but these other factors can cause a similar insomniac reaction:
Stress: When your body senses tension in the air, it releases a string of chemicals like adrenalin that rev your system up for a fight, posing a serious challenge to dozing off.Environmental factors: The conditions you sleep in matter big time when it comes to how comfortable you feel, which in turn affects how quickly you drift off. Things like your bedroom lighting, room temperature and noise level all play a role in determining your sleep quality.Mental health issues: Depression and anxiety are the big ones when it comes to psychological disorders that contribute to insomnia.Other illness: Any health issue that causes you pain, like cancer or arthritis, can disrupt your sleep, causing you to wake during the night.Hormone fluctuations: “Hormonal changes, such as those related to menstruation, pregnancy, menopause or thyroid disease, can cause insomnia,” says Drerup.Medications: Many OTC and prescription drugs can mess with your sleep, including blood pressure meds (beta blockers and clonidine), heart medication (procainamide, quinidine, and disopyramide), corticosteroids used for asthma, flu and pain meds containing alcohol and caffeine, nicotine products and more.
Is insomnia genetic?
There is an exceptionally rare, obscure type of insomnia called fatal familial insomnia, which—as the name implies—is deadly. It typically shows up between the ages of 40 and 60 and is directly correlated with mutations in the PRNP gene. The disease typically kills people in six to 36 months, but there’s little reason to worry: Only 70 families with this condition have ever been reported in scientific literature, according to the National Institutes of Health Genetic and Rare Diseases Center. When it comes to more mainstream types of insomnia, “no one has discovered a certain gene where doctors can say, OK, if you have this gene then insomnia is present or if you can alter this gene, you’re cured,” says Dr. Avidan. “There is no real test you can do and say, well, the patient has a risk for insomnia.” Still, scientists are getting closer to pinpointing genetic contributions to the sleep disorder. In one study, researchers at Harvard Medical School identified 57 gene regions associated with insomnia—albeit not specific genes themselves. “Recent research has also identified genes that may trigger the development of sleep issues and has also demonstrated a genetic link between insomnia and psychiatric disorders such as depression, as well as physical conditions such as type 2 diabetes,” says Drerup. Even without a specific gene that can be identified as triggering insomnia, scientists agree there is an increased chance that you will develop the condition if someone in your family has it as well. A study of identical and non-identical twins at Virginia Commonwealth University found a heritability factor of around 59 percent for women and 38 percent for men. For now, though, diagnosis of this disorder relies on patients describing their symptoms to their doctor, combined with things like sleep diaries, where you keep track of how much sleep you got and the quality of that sleep, over the course of several weeks. “Right now, insomnia is diagnosed clinically,” confirms Dr. Avidan. “There is no one genetic test.”
Treatments for insomnia
If you’re thinking the best thing to do when you can’t fall asleep is to pop an Ambien, you’d be wrong. “For chronic insomnia, the first line treatment is cognitive behavioral therapy,” says Drerup. “This brief, structured intervention helps you identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep.” Unlike sleeping pills, she points out, cognitive behavioral therapy addresses—and therefore helps you overcome—the underlying causes of your sleep problems. Science backs her up: A recent study in the British Journal of General Practicefound that just four sessions of cognitive behavioral therapy for insomnia helped people fall asleep as much as 30 minutes faster and spend less time awake in the middle of the night. And happily, for those who are reluctant to make the schlep to see a therapist right now, other research verifies that digital cognitive behavioral therapy (online therapy through Zoom chats and iPhone apps you can download) are equally effective in treating insomnia. In addition to a therapy-based approach, modifications to your sleeping space can also go a long way to helping you sleep better. Start with these strategies:
Dim the lights: Bright lights are your body’s cue that it’s time to rise and shine—definitely not what you want when you’re struggling to sleep. If your bedroom window looks out on a streetlight or you work nights and sleep during the day, get yourself blackout shades for the windows.Put away devices: An hour before you hit the sack, it’s time to turn off your phone, tablet, laptop and TV. The blue light emitted from these devices messes with your melatonin levels—the chemical that tells your body it’s time for sleep.Turn down the thermostat: “Cooler temperatures help you feel sleepy,” says Dr. Avidan. Aim for 65 degrees in the bedroom.Limit noise: The sound of traffic or noisy neighbors is enough to keep even a good sleeper awake. White noise machines, wireless headphones, and apps that play soothing sounds like ocean waves can all help you meditate your way to deep sleep.
If your insomnia has gotten so bad that the stress of not being able to sleep is preventing you from doing just that, your doc may prescribe you sleep aids for temporary relief and to break the stress-feedback cycle. The trouble, though, is that these pills don’t just make you sleep, they sedate you, says Dr. Avidan. “Drugs like benzodiazepines (Xanax) or zolpidem (Ambien) make you feel groggy,” he explains. “Whenever you use a medication to promote sleep or diminish wakefulness, you don’t get normal sleep, you get sedation, and that’s not necessarily healthy.” These are a few meds your doctor may talk with you about for short-term help with your insomnia (always ask about side effects before taking):
doxepin (Silenor)estazolam (Prosom)eszopiclone (Lunesta)ramelteon (Rozerem)suvorexant (Belsomra)trazodone (Desyrel)zaleplon (Sonata)zolpidem (Ambien)
How to treat anxiety-induced insomnia
Insomnia—regardless of its cause—is usually treated the same way: Cognitive behavioral therapy, lifestyle modifications and if all else fails, medication. It’s possible that anti-anxiety meds themselves may help, if your anxiety is the root cause for the sleep troubles, but it can sometimes be hard to separate cause and effect, notes Dr. Avidan. “There is a huge placebo effect in sleep medicine—if you believe something works, it usually does,” he says. There also appears to be a growing trend, he says, of people seeking insomnia help without medication. About 70-80 percent of patients at the UCLA Sleep Disorders Center say they would prefer to fall asleep naturally—a marked change from several years ago, he says. Where prescription drugs are falling out of vogue, cannabis-everything is the newest in-demand sleep aid. CBD gummies, oils, drops, and more (cocktails, anyone?) are being touted by cannabis companies as “natural cures” for insomnia—although there is limited evidence suggesting they work. Weighted blankets are another natural sleep remedy, relying on the gentle pressure from the heavy blanket to provide a sense of calm and security. There is little downside to giving it a try: Look for a blanket weighted to about 10-15 percent of your body weight, and if you’re in naturally warmer climes, seek options that are breathable as well. In addition, activities like walking and yoga have been shown to lower stress and anxiety levels, so incorporating movement and stretching into your day may ease some of your insomnia symptoms. Exercise has the extra benefit of getting you outdoors and into the sunlight. This triggers your body’s internal wake/sleep clock, which may reset itself and be more likely to encourage sleep when night falls. “I tell patients to try and promote wakefulness during the day,” says Dr. Avidan. “Wake up, go for a walk, get light exposure. Walk the dog. Especially right now with so many people staying indoors, you don’t get the circadian signal when it’s time to be awake or go to bed.”
How do you know if you have insomnia?
Symptoms of insomnia occur in approximately one-third to half of adults in the U.S., says Drerup, but the full-on disorder is estimated to affect 10-15 percent of the population. An even smaller subset of those go on to be officially diagnosed with chronic insomnia. Because there is no single test for chronic insomnia, many doctors go by the textbook definition of needing three or more nights of sleeplessness for three or more months in a row. In reality though, you and your doctor need to use your common sense and good judgment in determining whether or not you have insomnia, says Dr. Avidan: “If I see a patient who has been having terrible sleep issues twice a week for a month, am I going to say, ‘Sorry, can’t help you, you don’t have insomnia.’? Of course not!” The ultimate decision on whether to call it a disorder or not depends on the degree to which a person’s sleep challenges interfere with their quality of life, he adds—regardless of whether it’s twice a week or every night. “If a patient tells you they are suffering, their quality of life is impaired, or daytime fatigue is so bad they’re having difficulty holding a job,” he says, “it’s a sleep disorder and it needs treatment.” For more help falling—and staying—asleep, check out these sleep-friendly podcasts.
Sources:
Alon Avidan, MD, neurologist and sleep specialist, Director of UCLA Sleep Disorders Clinic in Los AngelesMichelle Drerup, Psy.D., Director of Behavioral Sleep Medicine, Cleveland ClinicKaiser Family Foundation: “KFF Health Tracking Poll – July 2020”JAMA Psychiatry: “Incidence, Persistence, and Remission Rates of Insomnia Over Five Years”Procedures of the National Academy of Sciences: “β-Amyloid Accumulation in the Human Brain After One Night of Sleep Deprivation”Johns Hopkins Medicine: “The Effects of Sleep Deprivation”Harvard Health: “Medications That Can Affect Sleep”Molecular Psychiatry: “Genome-Wide Analysis of Insomnia Disorder”National Institutes of Health Genetic and Rare Diseases Information Center: “Fatal Familial Insomnia”Sleep: “A Longitudinal Twin Study of Insomnia Symptoms in Adults”Nature Genetics: “Biological and Clinical Insights from Genetics of Insomnia Symptoms”British Journal of General Practice: “Cognitive Behavioural Treatment for Insomnia in Primary Care: A Systematic Review of Sleep Outcomes”JAMA Psychiatry: “Effect of Digital Cognitive Behavioral Therapy for Insomnia on Health, Psychological Well-being, and Sleep-Related Quality of Life: A Randomized Clinical Trial”Mayo Clinic: “Sleeping Pills”
