Types of Sleep Difficulties
Most adults need seven to nine hours of sleep each night (Hirshkowitz et al., 2015). If you are not getting this much sleep, you are definitely not alone. Millions of Americans suffer from sleep difficulties that are caused by a variety of factors including pain, asthma, depression, anxiety, alcohol, medication side effects, stress, trauma, genetics, an inconsistent work schedule, and older age. Given the many different biological, psychological, and social factors that impact sleep, it is not surprising that there are equally as many different types of sleep disorders.
Indeed, according to the Stanford Center for Sleep Sciences and Medicine there are over 100 different types of sleep disorders! Sleep disorders include from insomnia, sleep apnea, parasomnias, narcolepsy, and restless legs syndrome. Let’s quickly review some of the more common sleep disorders, specifically insomnia, sleep apnea, and parasomnias.
Insomnia is a sleep disorder that can affect a person’s ability to fall asleep, stay asleep, or cause someone to wake up early and not be able to go back to sleep. Most people experience short-term insomnia that lasts for a few days or weeks, typically due to stress or trauma. When the insomnia lasts for over a month, it is considered to be chronic. Either way, insomnia can negatively impact your energy levels, work performance, mood, and overall quality of life.
Another sleep disorder is sleep apnea. Sleep apnea is when your breathing becomes very shallow or stops while you are sleeping. The most common form of sleep apnea is called obstructive sleep apnea, which is when your airway collapses or becomes blocked during sleep. People with sleep apnea typically snore very loudly, but if you snore loudly it does not necessarily mean you have sleep apnea. Sleep apnea results in worse sleep quality, which leads to drowsier individuals. This can be a safety concern if the drowsy people are operating driving cars or operating dangerous machinery at work.
The last type of sleep disorders to be discussed is parasomnias. Parasomnias include nightmares, night terrors, and sleepwalking. Nightmares, which we have all experienced, are vivid dreams that cause fear and/or anxiety. Typically a person wakes up from a nightmare during REM sleep and can describe the details of the nightmare. Often it is hard for the person to fall back asleep after they wake up.
Night terrors are different from nightmares in that while the person wakes up, he or she is confused and not able to communicate with others. The night terror can last 15 minutes, after which time the person typically lays down and falls back asleep. Typically the person will have no recollection of the night terror the next morning.
[Not to make light of night terrors, was just too perfect a gif for a Game of Thrones fan]
Sleepwalking is when someone is up and moving around, although that person is still asleep and will have no memory of the event unless they are woken up. Sleepwalking tends to occur more frequently with children, but can happen with individuals of any age. Contrary to popular belief, it is not actually dangerous to wake up a person who is sleepwalking. While the person may be a bit disoriented and confused at first, they will most likely thank you for stopping them from doing something that could hurt themselves by accident!
As you can see from just this brief overview of a few different sleeping disorders, sleep problems can look very different from each other. Next, let’s explore why it is important to study these sleep disorders and create treatments for sleep problems.
Why is Sleep Important?
Sleep is instrumental for good mental health and physical health. It is tied to a ton of positive outcomes, including helping us learn and remember new information, pay attention, be creative, make good decisions, and stay emotionally balanced.
Lack of sleep is associated with negative physical effects such as increasing risk for heart disease, stroke, high blood pressure, and obesity. This happens in part because sleep impacts hormones created in your body related to feeling hungry and also impacts insulin, which controls blood sugar levels. Sleep is required for normal growth with children and adolescents, having a healthy immune system, and helping your body heal from injuries.
Here are two studies that highlight some of the negative consequences of sleep problems:
According to a massive study of almost 80,000 Americans, approximately one-quarter of adults experienced frequent problems with sleep (Strine & Chapman, 2005). Problems with sleep was associated with a bunch of different problems including worse general health, frequent physical problems, frequent mental health problems, more limitations for activities, and more depressive symptoms, anxiety, and pain.
In a large study of nearly 48,000 Norwegian adults, 13.5% of the population experienced insomnia (Sivertsen et al., 2009). Women, older adults, and those with less education were more likely to have insomnia. This study found that adults with insomnia often had co-occurring problems including: anxiety, depression, fibromyalgia, headaches, and chronic pain [LINK] conditions such as migraines.
Sleep disorders clearly negatively impact physical and mental health. The question then becomes what is the best way to treat a sleep disorder? Medications can be very effective for certain people and for certain sleep disorders. However, there are also some disorders, such as insomnia that can be treated without the use of medication.
Read the next section to learn about how psychological treatment improves sleep without the use of medications by focusing on thoughts and behaviors that are interfering with sleep.
What to Do About Sleep Difficulties
Cognitive-behavioral therapy (CBT) is one recommended treatment for insomnia (Edinger & Means, 2005) and will be briefly outlined here. While this section will focus on CBT for insomnia (CBT-I), some of these techniques used in CBT-I can also be helpful for other types of sleep problems.
CBT-I focuses on both cognitions (thoughts) and behaviors that interfere with quality sleep. Cognitive factors that are related to insomnia include distortions about the causes of insomnia, incorrect beliefs about sleep more generally, and catastrophizing about consequences of sleep deprivation. Indeed, research suggests that reducing incorrect beliefs about sleep is key to understanding why CBT-I leads to better sleep.
In addition to the cognitive factors related to insomnia, a significant amount of attention has been placed on behavioral factors related to insomnia. Edinger and Means (2005) outline four behavioral treatments for insomnia: relaxation therapy, stimulus control therapy, sleep restriction therapy, and sleep hygiene. There is some overlap between these treatments, but major parts of each treatment will be reviewed.
Relaxation therapy refers to using relaxation techniques to help with cognitive factors such as racing thoughts in addition to physiological factors such as having tense muscles or feeling agitated. Types of relaxation strategies that I teach in treatment frequently include progressive muscle relaxation, deep breathing, mindfulness exercises, and positive imagery. Other strategies such as biofeedback can also be used.
Using relaxation strategies to help with insomnia is great because the strategies are easily learned. In addition, a major benefit is that clients can use these relaxation strategies not only to help with insomnia, but also more generally to manage stress in their lives (which undoubtedly also helps with insomnia).
Really the hardest part about relaxation strategies is setting the time aside in your day to practice the strategies and remembering to use them when needed. Relaxation techniques do not need to take a lot of time to complete and can be accomplished in a few minutes if that is all the time you have.
It is recommended to initially practice the relaxation strategies when you are not feeling very stressed out, tense, etc., to get a hang of how to use relaxation strategies effectively. Ideally, individuals incorporate the relaxation strategies into a daily routine that gets used, but you will have to figure out what works for you.
Ideally, a bed is positively associated with relaxation, comfort, and most importantly, sleep. However, when someone has chronic difficulty with sleep, that person’s bed can be associated with frustration, stress, and being awake. Stimulus control therapy attempts to change negative associations of the bedroom and the bed to more positive associations.
How stimulus control therapy works is by
limiting the time spent in bed to only what is necessary for sleep. This means that you should not be eating in bed, watching TV in bed, reading in bed, etc., with the only exception being made for sex. According to stimulus control therapy, someone should ideally only go to bed when sleepy, wake up at the same time every day, and get out of bed whenever s/he is not able to fall asleep. Lastly, daytime napping should be avoided to help keep the association between nighttime and sleep (assuming of course the person is not working nights).
Sleep restriction therapy works by restricting time in bed to only the time believed necessary for someone to achieve a full night’s rest. As mentioned previously, there are individual differences in terms of how much sleep a person needs, so this will have to be determined on an individual basis.
What sleep restriction therapy then does is take the amount of time an individual needs for sleep and add about 30 minutes to it to account for the time it takes to fall asleep. So if a person needs 7 hours of sleep each night, that person should spend 7.5 hours in bed.
Once this schedule is set, it needs to be strictly followed and it is helpful to maintain a sleep diary to track how well rested an individual is over time. Based on whether the initial amount of time in bed is too much or not enough, changes are made to the total amount of time in bed by 15 minute increments. The idea is to slowly determine what the ideal amount of time in bed is for an individual.
Lastly, sleep hygiene involves educating clients about healthy sleep habits. Topics related to sleep hygiene include discussing the benefits of exercise with regard to sleep, discussing the importance of making sure the bedroom is quiet, cool, dark, and comfortable to promote sleep, and avoiding substances such as caffeine, nicotine, and alcohol that can negatively impact sleep. Other topics related to sleep hygiene that have already been mentioned include not watching TV or reading in bed, getting out of bed if you cannot fall asleep immediately, keeping a regular sleep schedule, and avoiding naps.
Some Final Comments on CBT for Insomnia
As previously mentioned there is overlap between these behavioral interventions, but they do get at some really important ways to help improve sleep. CBT-I works by combining these behavioral interventions with cognitive restructuring that targets unhelpful and incorrect beliefs about sleep.
Unfortunately there is no magic pill that will cure sleep problems. Indeed, if you decide to try CBT-I, your sleep is likely not going to be perfect. There will still be incredibly frustrating nights that you do not get much sleep so it is important to have realistic expectations. However, research suggests that CBT-I can help improve your sleep and that these positive changes can last over time (Morgenthaler et al., 2006).
Having worked with a variety of clients, I do think that sleeping medication can be very helpful when used as instructed by trained medical personnel. However, I am also a firm believer that taking medication does not teach new skills and as such the benefits of medication typically disappear after the person stops taking the medication. Unlike using medication, CBT-I helps teach you strategies to empower yourself to have better sleep that continues long after treatment ends.
To improve your sleep, you have to be dedicated and consistent. Understandably, it is often hard to motivate oneself to stick to a strict sleeping schedule. After a few nights of restless sleep, it feels all too easy to take a long nap during the day or sleep in when you can. Ultimately, you are going to have to figure out a system that works best for you.
Sleep problems are incredibly common and there are many different ways to improve one’s sleep. Hopefully you learned something new about sleep problems and about how CBT-I, a frontline treatment for sleep problems, works to address sleep-interfering thoughts and behaviors. Wishing you all sweet dreams!
The Clinically Relevant Insights Blog, part of ShawnWilsonPhD.com, shares news and research related to psychology and wellness.
Edinger, J. D., & Means, M. K. (2005). Cognitive–behavioral therapy for primary insomnia. Clinical Psychology Review, 25(5), 539-558. doi:10.1016/j.cpr.2005.04.003
Hirshkowitz, M., Whiton, K., Albert, S. M., Alessi, C., Bruni, O., Doncarlos, L., . . . Hillard, P. J. (2015). National Sleep Foundation’s sleep time duration recommendations: Methodology and results summary. Sleep Health,1(1), 40-43. doi:10.1016/j.sleh.2014.12.010
Morgenthaler, T., Kramer, M., & Alessi, C. (2006). Practice parameters for the psychological and behavioral treatment of insomnia: An update. An American Academy of Sleep Medicine report. SLEEP, 29(11), 1415-1419.
Sivertsen, B., Krokstad, S., Øverland, S., & Mykletun, A. (2009). The epidemiology of insomnia: Associations with physical and mental health. Journal of Psychosomatic Research, 67(2), 109-116. doi:10.1016/j.jpsychores.2009.05.001
Strine, T. W., & Chapman, D. P. (2005). Associations of frequent sleep insufficiency with health-related quality of life and health behaviors. Sleep Medicine, 6(1), 23-27. doi:10.1016/j.sleep.2004.06.003