Everyone has trouble sleeping from time to time, especially when things are stressful. But some people lie awake night after night, silently suffering from chronic insomnia. Losing so much sleep can be debilitating and devastating to one’s health, and yet it can be exceptionally difficult to procure treatment outside of sleeping pill prescriptions. What causes this issue, and why are sustainable solutions so elusive? Let’s dive in.

What is insomnia?

Insomnia occurs when someone has difficulty falling or staying asleep, or when they awaken much earlier than they’d like, at least three nights per week, says Shelby Harris, PsyD, a behavioral sleep medicine specialist and author of The Women’s Guide to Overcoming Insomnia. For it to be considered chronic, the individual must experience such insomnia for a period of at least three months.

Insomnia is more common than you may think. According to research, 25 percent of Americans experience acute insomnia (e.g., an occasional restless night or a couple of bad nights in a row) each year. Twenty-five percent of those people then develop chronic insomnia, which ultimately affects around 10 percent of the population. It tends to afflict more women than men, says Dr. Harris, at a rate of 3:2, and more people over 65 than under. One-third of those in the 64-80 age demographic utilize some kind of sleep aid, in fact.

What are the causes of insomnia?

Insomnia can have physical and psychological causes. “I always think of it as biopsychosocial,” says Dr. Harris. “Biologically, it could be triggered by hormonal issues [e.g. shifts experienced in perimenopause and menopause], cancer and sometimes cancer treatments, fibromyalgia, chronic pain, diabetes—there are a bunch of medical things that can cause insomnia.”  There may be a genetic component, too, she adds.

Psychological causes, on the other hand, can include things like anxiety and depression. Possessing certain traits can be a risk factor, too. “There’s a predisposed personality that experiences insomnia,” says health and sleep coach Devin Burke, founder of Sleep Science Academy and author of The Sleep Advantage: Optimize Your Night to Win Your Day. “Usually they’re highly intellectual and driven perfectionists.”

Often times, unique stressors—job loss, the death of a loved one, the pandemic—can launch a bout of acute insomnia. “It can be good stressors, too,” says Dr. Harris. “If someone’s excited about getting married or having a new job, it can still lead to insomnia.”

Once an acute bout of insomnia has begun, people tend to engage in behaviors that maintain the insomnia. “People understandably start worrying about their sleep,” Dr. Harris explains. That can lead people to make what are essentially poor decisions: going to bed earlier or sleeping in, napping, drinking caffeine, and so forth. “For many people, that’s actually the stuff that maintains the insomnia when it becomes chronic,” Dr. Harris says. “So even though something [else] might have started it, the stuff you’re doing to try and compensate is actually what’s maintaining it.”

Burke says that the more people try to control their sleep, the more elusive sleep becomes. “I call that ‘the insomniac’s paradox,’ where the harder you try to fix it, the worse it gets,” he says. “When you don’t sleep, your body’s in a stress state, and when your body’s in a stress state, you’re not going to sleep.”

And once insomniacs get into bed for the night, says Burke, they often experience anticipatory anxiety—a fear of not sleeping—which further sabotages their ability to catch zzz’s. “If your stress switch is stuck in the ‘on’ position, you’re not going to turn off,” he says.

Health consequences of insomnia

While it may not seem like that big of a deal from the outside—who really sleeps these days, anyway?—insomnia can have severe consequences. In the short term, Dr. Harris and Burke says people can suffer from absenteeism at work and even become unable to maintain employment, they can find their relationships straining or breaking, and they can be more prone to potentially devastating accidents.

Longer-term consequences include memory loss, an increased risk for dementia and Alzheimer’s disease, mood issues, and increased risk of cardiovascular events and of developing type 2 diabetes. “It really does affect every single aspect of your life—your relationships, your career, your health,” says Burke.

Initially, Burke says most people try supplements such as melatonin and magnesium, but when those fail to fix the problem, they usually resort to pills—because that’s what their physicians prescribe. “Then they start to rely on this pill, which is really meant for temporary relief,” Burke says. “It’s not solving the problem, addressing the root of why you’re experiencing what you’re experiencing.”

Sleep aids come with their own risks, too. For starters, common prescription insomnia medications are “sedative hypnotics.” These sedate you, which isn’t the same as putting you to sleep, and this means you’re not reaping the restorative benefits of an actual night of shuteye. Alarmingly, one study showed that patients taking a sleep aid two to three times per week had a 35 percent increased risk of developing cancer and a five-fold increase in risk of death. The use of over-the-counter medications such as Benadryl and Tylenol PM can lead to side effects such as confusion and constipation, and they’ve been linked to an increased risk of dementia, too.

So if sleeping pills aren’t the answer, what is—and why is that solution rarely recommended to people who seek help from their doctors?

Insomnia treatment

One of the main reasons people have difficulty accessing insomnia treatments outside of sleeping pills, says Burke, is that psychiatrists and physicians tend to lack sleep-specific training. And, Burke notes, there is a lack of specialists—qualified cognitive behavioral therapists who are trained in treating insomnia. He also points out that sleeping pills are a big business, which probably helps to account for their prominence as a treatment. Using them is quicker and easier than engaging in behavioral therapy, too.

Behavioral therapy is, however, the most effective form of treatment for insomnia. Cognitive Behavioral Therapy for Insomnia (CBT-I), which Dr. Harris practices and which Burke incorporates into his program at Sleep Science Academy, seeks to address the unhelpful behaviors that contribute to insomnia.

But while it’s highly effective, CBT-I can be difficult to obtain. Providers, as noted, are scarce, and insurance rarely covers what typically amounts to two months’ worth of sessions (which can total thousands of dollars).

There are, however, ways to access the concepts behind CBT-I without forking over such large sums of cash. “There are a lot of great apps out there that do CBT for insomnia, and they’re really going to quickly correct some of the behavioral and the cognitive issues that might be going on,” says Dr. Harris.

If you suffer from chronic sleeplessness and aren’t sure where to start in your quest for a good night’s rest, these two sleep pros offer three pieces of insomnia-busting advice below.

3 insomnia tips that are *actually* helpful

1. Spend less time in bed

One of the main techniques employed in CBT-I is sleep restriction, which involves limiting the amount of time you spend in bed. “Stop trying to compensate by sleeping in in the morning and going to bed earlier,” Dr. Harris says. “If you don’t get up at the same time every day, you’re not going to build up hunger for sleep the next night.”

You also want to avoid laying in bed while trying to fall asleep. “You’re anchoring your bed with arousal, anxiety, and wakefulness. That’s not what you want to do,” says Burke. Instead, you should get up and move to, say, the couch to engage in an (ideally screen-free) activity such as reading.  “A lot of people think that getting up is meant to make you sleepy, and they’re like, ‘Oh, I went out on the couch, I sat there and read and I didn’t get sleepy, so it didn’t work’,” Dr. Harris says. “But that’s not the point. The point is that you’re not laying in bed teaching your body that it’s a place to force sleep and be annoyed. Sleep will come when it comes. It might not come when you’re sitting on the couch reading, but at least you’re not trying to force yourself to get sleepy sitting in the bed.”

And even though it can be difficult to refrain after a sleepless night, napping is a no-no, too. Ultimately, you want to stay up as long as possible the day after an insomnia bout in order to best break the cycle, despite extreme exhaustion.

2. Practice acceptance

A lot of the work done with clients at Sleep Science Academy is actually “spiritual” in nature, says Burke. He notes that his coaches spend a lot of time working with clients on the concept of acceptance. This can go pretty deep, but at its simplest level Burke says it’s about practicing acceptance with respect to a night’s sleep. “‘Accepting what is’ would be like accepting that maybe tonight you’re going to have a bad night’s sleep, and truly accepting that and being okay with it,” Burke says. This practice alone can help to alleviate some of the anxiety that perpetuates sleeplessness.

3. Have hope

If you’ve ever suffered from insomnia, especially chronic insomnia, you’re probably aware that it can feel like a hopeless affliction—especially given how difficult it is to access treatment and/or eschew pills for potentially sleepless nights when the world doesn’t stop its demands just because you’re sleep-deprived.

Often times, insomniacs can feel stuck, like they will forever struggle with their sleep. But Burke says this isn’t the case. “It is solvable—I’m helping people solve it every single day, and these are people who’ve had insomnia for decades, who were on sleeping pills for decades,” he says. “Your body has innate wisdom, and sleep is a natural biological process that happens when you remove the barriers to it happening.”

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