Sleep is something that we spend around a third of our lives on. It is one of our basic needs and is important for both our physical and mental wellness. However, not everyone is able to sleep well at night. Insomnia is often attributed to worrying and anxiety, as many of us worry and brood late at night. Conversely, the lack of sleep leaves us feeling exhausted, anxious, and irritable, which can make our worries in the day worse. Psychologist Dr. Jaswyn sheds more light on the link between the two.
What is insomnia?
Insomnia is one of the most prevalent sleep disorders. It refers to the predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
1. Difficulty initiating sleep
2. Difficulty in maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings.
3. Early-morning awakening with inability to return to sleep.
It is commonly diagnosed according to the Diagnostical and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), which specify that symptoms must cause clinically significant functional distress or impairment, be present for at least 3 nights a week for at least 3 months, and not be linked to other sleep, medical or mental disorders.
According to various studies worldwide, insomnia affects about 10-30% of the population, in some countries some as high as 50-60%. It is more common in older adults, females, and individuals with medical or mental health problems.
Insomnia can lead to impairment in daily functioning in terms of poorer work performance and quality of life as well as increased risk of traffic accidents.
Sleep-Initiating Insomnia VS Sleep-Maintenance Insomnia
Sleep-initiating or sleep-onset insomnia refers to the condition where one is unable to fall asleep. There are many factors that can trigger sleep-onset insomnia, such as:
- Physical discomfort (e.g. Pain issues)
- Worrying or over-thinking
- Changes in sleep routine (e.g. jet lag, shift work)
- Poor sleep hygiene habits (e.g. showering just before bedtime, high consumption of caffeinated drinks in the day time)
- Lack of conducive sleep environment (e.g. noise, room temperature, distractions)
- Inadequate exercise or physical activity in the day time
Sleep onset insomnia can lead to poorer focusing and concentration, fatigue or excessive sleepiness during the day and irritability.
Sleep maintenance insomnia refers to the inability to stay asleep for longer during the night. This means that the person cannot sustain sleep for a long time, may wake up multiple times during the night, and take a long time to fall asleep again.
This leads to fragmented sleep and affects both quality and quantity of sleep. The person may have trouble waking up early in the morning, feel very tired and irritated, as well as experience headaches. Some of the reasons that can lead to sleep maintenance insomnia include:
- Hypervigilance (where the body is constantly in “flight or fight” mode and does not allow for any kind of relaxation)
- Medication conditions such as sleep apnea, restless leg syndrome, periodic limb movement disorder, night time urination and Gastroesophageal reflux disease (GERD
Ironically, worrying about not getting enough sleep or good quality sleep is one of the most commonly reported complaints for people with insomnia. Generally, when night falls, people with insomnia might start to worry, get anxious, or dread going to bed.
The truth is, the more they worry about not being able to sleep, the less sleep they are likely going to get. This is because worrying triggers the body’s “fight-flight” responses to perceived danger or stressors and hence, they are kept awake.
Besides sleep, we also worry about many other things- such as the well-being of our loved ones, having to attend a job interview the next day, or going on a first date. These worries typically surround our “what ifs” and “worst case scenarios”, and when these worries become persistent and uncontrollable, there is a need to better manage them.
1. Distinguishing between helpful versus unhelpful worries
Not all worries are bad. Helpful worries are worries about problems that are within our ability to control or change. Such worries are focused on problem-solving. Once solutions are derived, we may then proceed with an action plan to resolve the problems. Once the problem is resolved, we may stop worrying and any anxiety can be relieved.
An example of a helpful worry could be “How do I keep myself safe in the midst of the pandemic?”. The possible solutions that we can act upon would include taking the vaccine, wearing masks, maintaining social distancing and practising good hygiene.
However, if we worry about “Will I get Covid-19? When will I get Covid-19?”, this becomes an unhelpful worry. Unhelpful worries are worries about problems which are not within our ability to control or change. We are unable to derive any solutions or a useful action plan. As a result, these worries become rumination, and we find ourselves going around in circles feeling perpetually anxious.
Therefore, there is the need to examine your worries. Focus your worries on the helpful ones instead of the unhelpful ones.
2. Challenging unhelpful thinking
Unhelpful thinking or cognitive distortions are mental filters or biases that contribute to our anxieties or low mood. Some types of unhelpful thinking include:
- “All or nothing” thinking
- Discounting positives
- Emotional reasoning
- Jumping to Conclusions
- “I-should” thinking
- Personalising and Self-Blame
Challenging unhelpful thoughts could involve:
- Looking for evidence that supports and does not support the validity of our thoughts
- Focusing on probability, instead of the possibility that something bad might happen
- Asking ourselves whether continuing to ruminate over the worry is helpful for us and whether we can spend the time could be spend more effectively on other matters
- Giving self-assurances as how we would give assurances to a friend who might be worrying about something.
Cognitive-behavioural therapy (CBT) is a form of therapeutic approach that focuses on helping clients identify and overcome cognitive distortions that are contributing to their emotional distress.
3. Using Distraction Strategies
Distraction acts as a form of interruption to your worries. When we are engaged in activities, these activities take our mind off our worries. Some of the activities that could be helpful include
- Doing meditation or Yoga
- Practising deep breathing exercises
- Engaging in a hobby (e.g. baking) or pleasurable activity (e.g. going for a facial)
4. Seeking Help
Suppressing our emotions or keeping problems to ourselves will only lead to further worsening of our emotional distress.
Confiding in a trusted friend or family, one who is understanding and would not judge you negatively, is one of the more effective ways of managing your worries. For example, you may feel less alone if you know that others are struggling with similar problems.
When others give you assurances, your worries might seem less overwhelming and perhaps, irrational. Having a strong supportive network is actually very important to our mental well-being.
In situations where you prefer not to confide in a family or friend so as not to cause them unnecessary worry or burden, you may also choose to seek professional help. It is always advisable to see a psychologist for therapy if you have difficulties managing your negative emotions on your own. A psychologist will listen to you without judgement and work collaboratively with you on overcoming the challenges that you are facing and improve your mental well-being.
Understanding the Sleep Cycle
While sleeping, our brains repeat cycles of two different types of sleep: REM (rapid eye movement) sleep and non-REM sleep. There are four sleep stages as defined by the American Academy of Sleep Medicine (AASM). These stages are determined based on brain activity during sleep.
Stage 1: Non-REM Sleep
Stage 1 sleep normally lasts between one to five minutes. It is the period of transition between wakefulness and sleep, the point where we are “dozing off” to sleep. It is easy to wake up someone up during this time. In the absence of disturbances, we may quickly enter stage 2 sleep.
Stage 2: Non-REM Sleep
Stage 2 is light sleep. During this stage, our heart rate and body temperature start to drop, our breathing slows and muscles become more relaxed. Although our brain activity also starts to slow, there may be short bursts of activity that can actually help resist being woken up by external triggers. Stage 2 sleep lasts about 20 minutes.
Stage 3: Non-REM Sleep
Stage 3 sleep is deep sleep where our heart rates and breathing rates further drops and muscles become even more relaxed. Experts believe that this stage is critical to restorative sleep, allowing for bodily recovery and growth. Restorative sleep is important for strengthening immune system and other key bodily processes. Stage 3 sleeps usually last for 20-40 minutes.
Stage 4: REM Sleep
Stage 4 is REM sleep, where our eyes move rapidly, brain activity near levels seen when we are wake, and dreaming occurs. At the same time, the body experiences atonia, which is a temporary paralysis of the muscles. We enter REM sleep after having been asleep for about 90 minutes. Experts believe that REM sleep to be essential to “restoring the mind”. In early studies, participants tested to measure how well they had learned a new task improved their scores after a night’s sleep. Therefore, REM sleep is important in maintaining our cognitive functioning.
On a typical night, our sleep cycle repeats itself about 4-5 times. With each cycle, we spend less time in the deeper stages three and four of sleep, and more time in REM sleep.
Why are Sleep Stages Important?
Sleep stages are important because they allow both the brain and body to restore and develop. Insufficient REM can affect cognitive functioning (e.g. memory) while non-REM sleep can negatively impact on our physical health functioning (e.g. immune system). Inadequate or poor quality sleep can lead to fatigue, decreased energy, irritability, poorer concentration and chronic health problems (e.g. cardiac diseases and diabetes). Additionally, sleep problems often coexist with depression and anxiety.