Insomnia

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This text is part of: "Science of sleep" by Piotr Wozniak (2017)

Problem of insomnia

Insomnia is a difficulty in falling asleep or in staying asleep. Psychophysiological insomnia can often persist for years, and result in untold damage to a person's life. Those who are desperate enough to visit a doctor are often prescribed slipping pills that are usually not much better than insomnia itself! The good news is that in most cases insomnia can be remedied easily with a sleep phase adjustment as described below. Bad news is that such an adjustment may be incompatible with one's desired work or school schedule.

Half of the population in the industrialized nations has problems with falling asleep! This is called a sleep onset insomnia. Except for various underlying organic reasons, the overwhelming majority of cases of sleep onset insomnia result from the inability to entrain one's sleep hours to match the desired waking time.

In other words, most of otherwise healthy people who cannot fall asleep in the evening suffer from the combination of two chief factors:

  • going to sleep too early in reference to their natural circadian cycle
  • suffering from the associated stress: if I do not fall asleep immediately, I will be totally wasted in the morning

If the same people were allowed to sleep as much as they wanted and go to sleep only then when they are really tired (perhaps 2-5 hours later), in a vast majority of cases, the problem would not exist! Some scientists speak of insomnia as the inhibition of de-arousal processes. In sleep phase problems, the problem of de-arousal does not exist! De-arousal proceeds correctly. It simply proceeds at a later phase.

For the young studying population, the sleep phase problem is the most frequent cause of insomnia. For students who need to get up for school early, their sleep phase is often positioned too late in reference to the desired waking hour. In other words, the optimum sleep time comes too late. Sleepiness arrives too late, and natural waking comes later by the same degree. Such a student will always battle with sleep deprivation when going to sleep late, or a degree of insomnia when going to sleep early. In that sense, there is a physical/biological underlying cause. However, as sleep deprivation is pretty unpleasant, a student may try to go to sleep early (to ensure the night is long enough), but be unable to fall asleep due to the early circadian hour. If this occurs again and again, a psychological component may compound the original problem of insomnia. The recurring sleep deprivation will produce a fear of not falling asleep in time and making things even worse. In other words, in a vast majority of cases the problem is both biological and psychological. The only true remedy is to go to sleep later and wake up later thus being late for school (almost certainly a lesser evil given some understanding on the part of the educators). The only natural half-remedy is to measure as precisely as possible the optimum time of going to sleep, and sticking to that time religiously every day. That optimum time is the earliest time that roughly provides 95% or more certainty that sleep latency will be less than 10-15 min. (i.e. no more than a quarter of an hour of tossing and turning). Very often, this optimum time will provide for a mere 4-6 hours of sleep. However, this sleep is most likely to be the best quality sleep achievable in such conditions. Naturally, affected individuals will suffer a degree of sleep deprivation on a daily basis. This is still better than futile tossing and turning, waste of time, and fitful sleep associated with insomnia. If you suffer from sleep onset insomnia, and you suspect it could be caused by DSPS, you could research additional remedies such as morning sports, strong morning lights, evening melatonin, and radical solutions such as ... giving up electricity after 19:00.

Another type of insomnia, nocturnal awakening, is also often related to going to sleep at a wrong time. People who need to get up earlier than indicated by their body clock, often try to compensate for the short night by going to sleep early. If they succeed in falling asleep, they will often experience premature awakening that is nearly always accompanied by a difficulty of re-initiating sleep. If the same people were allowed to go to sleep only then when they were really tired (perhaps 2-5 hours later), the problem would likely not exist!

If you wake up often during the night, you should identify and eliminate possible reasons, esp. if you appear to wake up tired. The reasons and the way to diagnose them are too many to describe. However, you should always start from the simplest one: problem with the circadian phase. In simple words, the timing of your sleep may be wrong. Partitioning of sleep is a typical symptom of going to sleep too early. If you are healthy, in free running sleep, you will rarely wake up during the night, and if you do, you will fall back asleep fast, and if you won't be able to, the reasons will be quite obvious such as: stress, noise, thirst, cold, full bladder, etc. However, if you attempt to regulate the timing of your sleep, the partitioning of sleep (i.e. interrupted sleep) will be a frequent result. It is possible to push your sleep slightly ahead or back (e.g. 15-25 minutes per day) without this negative outcome. However, once you try to push too hard (e.g. more than an hour per day), partitioning is almost inevitable. If you push backwards (i.e. going to sleep earlier and earlier), you will likely wake up early in the night, i.e. before your circadian low ensures deep sleep. On the other hand, if you push forward (i.e. going to sleep later and later), your circadian low will end before you complete your sleep cycle. As a result, you will often wake up earlier than expected. If this waking up happens very early (when you push ahead very hard), you will be tired enough to fall asleep again. In other words, whichever way you push your sleep, it will not be properly aligned with your circadian rhythm. You will then wake up early or late in the sleep cycle depending on at which end the misalignment occurs. In a vast majority of cases, waking up problem can be resolved by going to sleep at the time when your body calls for it.

The solution for most of cases of sleep onset insomnia and nocturnal awakening is: Go to sleep only when you are truly sleepy! Amazingly, most people do not care to listen to their body. Many struggle with sleepiness to get more life in the evening. Others force themselves to bed long before their optimum bedtime and then toss and turn for hours. This premature landing in bed is at the root of the epidemic of insomnia (even though the official figures put circadian disorders at only 10% amongst the causes of insomnia). The only sensible and healthy time to go to sleep is when you feel you start getting sleepy. If this natural time is outrageously late, see Curing DSPS and insomnia.

Early waking is also a problem for a large number of people. Those people may suffer from the ASPS syndrome. In their case, going to sleep earlier will often be a sufficient remedy. If you happen to wake up early in the morning, your further sleep decision should probably be made on the basis of how fast you believe you would be able to fall asleep. If you do not think the sleep is coming soon, it is definitely better to get up and do some work. This way you will gain in three ways:

  1. get tired and sleepy faster (work is more likely to make you tired again)
  2. you will not get anxious about falling back to sleep as soon as possible
  3. you will not waste time on futile tossing and turning

Insomnia vs. electricity

Insomnia has reached epidemic proportions since the advent of electric lighting. See how lifetime costs of insomnia match the degree of industrialization.

Disability-adjusted life year for insomnia per 100,000 inhabitants in 2002.
  no data
  less than 25
  25–30.25
  30.25–36
  36–41.5
  41.5–47
  47–52.5
  52.5–58
  58–63.5
  63.5–69
  69–74.5
  74.5–80
  more than 80

Disability-adjusted life year for insomnia per 100,000 inhabitants in 2002

How to fall asleep faster?

There are tons of lengthy books written about sleep onset insomnia and there are a zillion tricks that people use to be sure they fall asleep "in time". The sad truth is that all those tricks only fight the inevitable: the natural sleep mechanism. They are based on slowing down the brain at the time when the brain simply does not want to slow down. Yet these tricks rather tend to blow the problem of insomnia out of proportion by adding to the sleeper's stress: so much effort, so many tricks in use, and it still does not work... I will probably just have to live with this scourge for ever!

If you follow a conventional insomnia advice (see an example), you will quickly realize that most measures work great at the beginning, and then, when the placebo effect wears off, you are back to square one. Some hotels offer $1000 per night services in curing insomnia in jetlaggers. All those services are a big waste of time and money. Without a phase adjustment, insomnia will persist. It can only be masked for a while.

Here is some typical unworkable advice that you may get from your sleep "expert" or from your grandma:

  • Ineffective! Count sheep - this is nothing else than trying to slow neural firing in the brain. This will often work but there is an increased risk of waking up after 20-60 minutes of sleep. As a result, the chances for early slumber may be gone for good. The slowdown in firing can come naturally. However, it can only come at the right circadian time which may be 2-5 hours later than you would want
  • Ineffective! Thought dispersion - by trying to "think about nothing" you can indeed increase the chances of falling asleep; however, this may be of value only in a short period that precedes the ascending circadian sleep propensity slope. If you try it early, you will likely hover in a superficial sleep with substantial chances of awakening spontaneously. It is the circadian sleepiness that stands for your ability to maintain sleep
  • Ineffective! Cut down on sleep - this has some power to reset the circadian cycle, however, you will feel more tired, your cognitive powers will drop, your insomniac's stress factor will triple, and most of all... your creative brain will not benefit from the last REM-rich hours of sleep! Cutting down on sleep may be an unavoidable solution among those who experience DSPS and cannot free run their sleep
  • Harmful! Sleeping pills (esp. benzodiazepines) - pills change the sleep physiology and may affect the quality of sleep. As they often have little impact on modifying the actual circadian cycle, they can quickly become a serious addiction. Additionally, they affect short-term memory and the reaction time. Sleeping pills are a major enemy of a creative individual!
  • Ineffective! Warm bath, quiet room, rituals, cup of cocoa, etc. - all these work to reduce the stress factor and slow down the brain. However, again that won't work well if you try it too early in reference to the circadian cycle
  • Ineffective! Drink milk or eat turkey (tryptophan is used in the synthesis of melatonin) - this is again a method for a mild slow down with negligible effectiveness
  • Ineffective! Take vitamins - vitamins or minerals are a standard plug for whenever something goes wrong with health. For many people, the first question is "perhaps I do not get enough vitamins?" Doubling up on the recommended dose is what often follows. A healthy diet should rarely require supplementation!
  • Ineffective! Do not nap - well-timed short naps have little influence on the circadian cycle and not napping may only have a residual homeostatic influence at the cost of evening alertness. It may help slightly but will not solve the problem. Naps should be avoided only at times of major circadian misalignment when the body starts losing track of time and circadian variables start oscillating out of synchrony
  • Ineffective! Avoid caffeine - when taken in the morning in reasonable quantities, caffeine should have negligible effect on the quality of sleep. When you are really tired, it is really hard to prevent sleep with coffee. Naturally, giving up the addiction (gradually!) will help a bit and won't do any harm. However, it will never be a solution!
  • Ineffective! Herbs, meditation, yoga, aromatherapy, acupuncture, chamomile, relaxation, massage, magnesium, ... - ... the list is virtually endless!
Few things can produce as much wasted time in highly effective people as trying to fall asleep at a time when your body does not want to! Do not listen to sleep advice based solely on methods for slowing down in the evening or making you mentally or physically tired! Do not go to bed until your body slows down on its own! Go to bed only then when you are really sleepy!

The question posed in the present headline was intentionally provocative. You cannot fall asleep faster, but you can fall asleep fast. All you need to do is to wait for the right time. Instead of trying to fall asleep faster, go to sleep later, and fall asleep fast.

Phase-shift based insomnia

In most cases, the real culprit in insomnia is the relationship of your working hours vs. the circadian rhythm! This is magnified manifold by the associated stress factor. For many, insomnia produces an unsolvable vicious circle that just has to be lived with. However, everyone with a chance for a flex-time work system or telecommuting should realize that the greatest benefit of these may come from increased productivity as a result of better sleep that complies with natural body rhythms.

A very specific degree of morning misery is needed to reset the clock sufficiently in people with DSPS. In the equilibrium state in which misery is sufficient to keep a regular schedule, the whole night sleep is cut substantially. Daily sleep deficit and daily struggle with tiredness result. In such circumstances, it is best to go to sleep only shortly before the expected sleep hour! This way you can reduce stress, on one hand, and help your homeostatic component on the other (by making yourself tired for sleep).

Dr Kripke (see a critical chapter on short sleep) says: "The false belief that people generally need eight hours of sleep is one of the common causes of insomnia. Spending less time in bed is an important solution for many with insomnia". That statement is only partly true. Indeed, trying to get 8 hours of sleep by going to sleep earlier will backfire. It is better to get less sleep when it is initiated in the right phase than to force extra hours prematurely. However, the key is not in sleeping less, but in sleeping at the right time! If you sleep in the right phase and do not need to get up early in the morning, you might actually get your eight hours with zero risk of insomnia.

If you cannot free run your sleep make your morning misery as regular as possible to reach the equilibrium state. Once you know the equilibrium, stick to your standard bedtime hour. Morning misery solution should only be used as a last resort!

There remains the question of weekends. Many people catch up on lost sleep during weekends. This naturally unbalances the system and results in the Monday Morning Blues. Sleeping it out on weekends, you should weigh up your pros and cons:

  • on one hand, you entrain your sleeping cycle to later hours and make it harder to stick to your misery equilibrium
  • on the other, this is your only chance for quality sleep

There is no simple answer to the weekend dilemma! If you want to maximize the effects of sleep on learning, skills and experience, you would need to quantify how much you lose as a result on never actually getting enough sleep (the losses could be dramatic!) and how much you lose as a result of departing from the misery equilibrium on weekends thus tripling sleep disturbances early in the week.

For healthy people, the most effective solution for persistent insomnia or work-schedule-related sleep deprivation is free running sleep!

Free running sleep is simple to define, but a bit harder to execute for beginners. It will often conflict with one's expectations and needs as to the timing of sleep. You will know that free running sleep worked for you if you replace insomnia with no more than 3-5 min. in bed before you fall asleep (without medication).

In healthy people, the time to fall asleep should not be longer than 5 min!

If you succeed with free running sleep and discover that you can fall asleep in 5 min. as long as you go to sleep at your natural hour, you may discover a new problem. You might show a tendency to wake up later each day. If this is the case read: Curing DSPS and insomnia.