Insomnia and the Vicious Psychological Cycle

I very recently spoke with Dr. Allison Harvey (University of California — Berkeley) and will soon be posting on that conversation. As ever, in advance of that conversation I endeavored to complete a deep dive on her background, and, in this case, that included many articles relating to her major scholarly topic: sleep disorders. At the risk of being obvious, I’ll start by highlighting that sleep dominates years of our existence and typically takes up about a third of one’s day. Sleep is at once mundane and, yet,  profound in its importance to our lives. And, for those who suffer real and persistent sleep disorders, disturbed sleep can quickly overshadow every aspect of their lives. From the part of my journey into the research of Dr. Harvey and the nuance of sleep research, there is much to share.

Our bodies are rhythmic.  We cycle rapidly through patterns of neural oscillations as our brains react to patterns of stimulation;  we have a rhythmic lub-dub from the rumba of our heart beating each minute; and we experience a cycling rhythm with the pendular swinging of our limbs while we walk, run, and move about the world. Our bodily rhythms cycle more gradually through ever changing levels of arousal during our daily lives: from moments of high alert to drowsiness. We cycle through waking and sleeping in circadian rhythms that partially mirror the rotation of our planet, through seasonal cycles that reflect our orbit around the sun, and through even more gradual changes in our body during our lifespan. The rhythms of our lives combine the celestial with our individuality to produce the reality of our lives.

In our first years, the rhythmic cycles of our bodies dominate everything. I have no memory of my own infancy. If you believe that you do, well, candidly, I don’t believe it. What can I say? Dan Schacter convinced me that memory is not designed for that kind of preservation (but rather for future planning). Also, you were asleep for much of that time, anyway!

I may not remember my first years, but I am distinctly aware of the infancy of my son. As parents we needed to plan every activity around his sleeping, eating, and alertness cycles. When to rest and when to wake, when to work and when to eat, when to cook, to exercise, to read, to sleep: the rhythm of our lives as parents were dictated by the constraints of our child’s biological rhythm. Violate that rhythm of the infant child at your own risk. And what are those risks? Even less sleep for the parents. Oh, how a few precious hours of sleep become so ethereal, so elusive during new parenthood! Minutes or maybe hours during the day of supporting your child through the discomfort from their lack of sleep. The cries of an infant seem to be targeted exactly at those peak frequencies of sensitivity in our auditory sensory system. Thank you evolution for developing our hearing to be so acutely in tune to our children! That loudly expressed pain of the out-of-rhythm infant will put one’s parental empathy into overdrive, creating a maddening cycle of anxiety and distress embedded within the many other rhythms in the lives of new infants and parents.

Oof.

One needs to be respectful of those life rhythms or there is hell to pay for the infant child and his parents.

As we develop into our teenage years there are new social and biological contexts that make the circadian cycles relating to sleep seem more plastic. I remember hearing tales from older siblings of my friends who bragged of “pulling an all-nighter” to prepare for what, now, seems like almost trivial scholarly pursuits. A math test. A geography test. Were the pressures in middle school and high school really so definitive that they warranted an all-nighter of devoted study? At the time, at least to some people, that seemed to be the case. School matters. Professional academic and instructor that I am, I  have no dispute with the ethos that succeeding in school matters. But I do wonder at the appropriate level of sacrifice.

How much sleep vs. how many waking restfulness vs. how many hours each day of devoted study are necessary? Do those devoted hours appropriately integrate with the biological rhythms of a typical student? Multiple studies suggest that there is a profound cost to learning when schools start too early in the day and when students have too many scheduled hours of activity during the day — something we impose on our tweens and teens regularly (e.g., this meta-analysis consisting of more than a dozen studies and nearly 15,000 students from Dewald et al., 2010 elegantly makes this point).

The thing is that when we overextend alertness in our infant children the costs are obvious. Young children will be emotionally disturbed and unstable. They will be irritable, overtired, and in need of real and extended periods of rest before regaining homeostasis.  In tweens, teens, and adults we don’t tend to scream and fight to regain our bodies’ homeostasis. We don’t typically sob uncontrollably and inconsolably. Nonetheless, our moods are affected. Our ability to perform cognitively and socially is affected. There are real costs even after we reach a stage of maturity in which we can partially ignore those costs. We will not make up that lack of sleep when we’re dead. We can’t totally substitute coffee or Red Bull for an appropriate sleep schedule. We will be better able to perform if we allow ourselves the time for real and fulfilling sleep.

For some, the issues with sleep are possessing and constant. Insomnia (not sleeping enough). Hypersomnia (sleeping too much). Disturbed and shallow sleep that  does not produce a feeling of restfulness. These are real and (as Dr. Harvey argues) primary psychological disturbances that merit direct and effective treatments.

The costs from those sleep disorders will be to one’s cognitive abilities in the form of a loss of concentration and focus. There will be difficulty memorizing things and thinking clearly about things. There is a cost to one’s sense of alertness and restfulness. There is a pall of constantly feeling a little tired,  never fully rested, and always struggling to keep up. And consequently, there may be a feeling that one always needs to find more time to sleep but simply can’t get enough. There will be a cost to one’s mood. The changes in mood may reduce the control of frustration and irritability, decrease impulse control, and increase feelings of withdrawal and depression. There is a cost to one’s health. Lack of sleep makes one more susceptible to illness. It makes it harder to fight off infection, harder to heal after injury, and harder to fully regain health. There may be pains that linger and colds that seem to never totally go away.

In Dr. Harvey’s research people with insomnia define a good night’s sleep with a feeling of restfulness and a lack of fatigue. Those without insomnia define their good night’s sleep with a feeling of alertness during the day. Kind of a big difference, right?

Dr. Harvey found that people with insomnia in sleep studies often miscategorize their own stages of sleep. During the lighter, earlier stages of sleep a researcher with a participant sleeping under observation (in the lab) can detect the neural patterns, heart rate, and respiration patterns to indicate sleep. If you wake up a person who does not have disturbed sleep they’ll have a fairly good recollection about when they fell asleep and be cognizant (possibly irritated) that you woke them up. An insomniac has a very different experience. They often inaccurately underestimate when they fell asleep (experiencing it as occurring later than it actually did) and if awoken during the early stages of sleep they will believe themselves to not yet have fallen asleep. To an insomniac, it feels like they were awake during those early stages. Another big difference,  right?

The other common experience of insomniacs, and one that is well explicated in Dr. Harvey’s research, is anxiety-related thinking. A plague of recurring, increasingly catastrophic thoughts that combat the capacity of one’s brain to slow down and fall into sleep for a night of rest. That lack of rest may trigger the particularly painful challenge of concerns about a lack of sleep to one’s health. There’s a horrible irony: concern for lack of sleep producing anxiety that causes lack of sleep. Repeat.

Sleep is such a huge part of a person’s life. We will spend more time in our lives sleeping than almost any other single activity: more than eating, more than having sex, more than paying bills, etc. It is worth highlighting that importance because, in another unfortunate twist in the saga of understanding sleep, the most commonly accepted psychological and psychiatric treatments (using Cognitive-Behavioral Therapy and using pharmaceuticals, respectively) are more effective in reducing the symptoms of most other psychological disorders than in treating insomnia — another finding from Dr. Harvey’s research.

Sleep is mundane and yet it is profound in its importance.

As a field we know and recognize a number of strategies that have been found to improve an individual’s ability to overcome insomnia:

Make your bed a place for sleep, and not a place where you work, watch youtube/TV/movies, spend time chatting on the phone, playing apps, etc

Remove technology and screen time in the hour before you intend to go to sleep

Stop drinking caffeinated beverages and ingesting other stimulants about 8-10 hours before you go to sleep at night

Those recommendations and others have been well-popularized. Here are some of the more recently emerged strategies for reducing insomnia and aiding the effectiveness of the strategies above:

Change your cognitions before sleep by reciting gratitudes, accomplishments (e.g., savoring), and virtues before going to sleep

Think about this. If you have racing and increasingly catastrophic thoughts before sleep then one thing is certain: those thoughts will not turn off just because you know you need sleep. Recent advances with mindfulness therapy, and from the positive psychology movement, have promoted this idea to actively change your cognitive state.  Mentally recounting three things from your day for which you are grateful (maybe little things, maybe big things), then recounting three things that you accomplished that day, and finally recounting three things that you value in yourself, is a strategy to calm your mind. It is also a strategy to self-affirm. Importantly it is a strategy to cease and replace a tendency towards anxiety-provoking, self-talk with ideas that will affirm and promote a sense of calm and control. The positive thoughts are designed to supplant those negative, recurring catastrophic thoughts (a bit like counting sheep). The new thoughts can replace those negative cognitions and calm your mind. And to substantiate and emphasize the things you value, thus promoting the enjoyment of your life. Insomnia threatens to sap the feelings of fulfillment and joy from your life; this is a recently-developed cognitive strategy to directly combat this issue.

Exercise, but not right before bedtime (same goes for naps)

Exercise, especially aerobic exercise is well-established as highly beneficial to health and longevity. It can also promote a healthy cycling of arousal levels so that one is tired at the end of a day. Exercising too close to one’s bedtime screws that up — leaving a person at high arousal with a raised heart rate in the hour or two following the exercise, and unable to calm down for sleep.

Napping can be beneficial but if a nap is too long (more than about an hour) or too close to bedtime (within about 5 hours of going to sleep),  it will alter one’s arousal cycle and make going to sleep at bedtime more difficult. If one has insomnia, then it is really critical to be aware of what might upset getting a full and fulfilling night’s sleep: so careful with the timing of exercise and naps.

Attention to social cues for arousal vs. calm

Most people are aware of the cues in their environment from light and noise that can increase arousal. Too much of either light or noise is a cue to be awake and alert. But what about conversations before bed? Being on the phone just before sleep? Social cues, when one eats meals, interactions with people are all factors that can influence biological rhythms. Knowing that you need a certain amount of time to digest and/or that talking on the phone gets you alert and aroused is important and can upset the circadian cycles of sleep.

Stick to the same bedtime everyday

Circadian  rhythms, arousal cycles: these cycles can easily be upset. Staying up way too late once or twice a week, or getting up at a different time each day are easy ways to upset those cycles. Your body adjusts to a pattern and a major deviation from that pattern will make it harder to set a time to sleep and wake-up. For those with insomnia, keeping the same pattern every day is a better strategy.

Avoid alcohol — especially in higher quantities

Alcohol causes a lot of people to be drowsy and fall asleep. But the recommendation is very clear: use of alcohol promotes lighter sleep, less restful sleep, and waking up during the night. If you are trying to avoid insomnia alcohol tends to hinder sleeping deeply and the likelihood of sleeping through the night.

 

Sleep is such a profound issue. I have to say that complaints about sleep disturbances are by far the most commonly cited psychological concern that I hear about from my students. Those sleep issues are deeply affecting and they get expressed to us instructors with everything from grave concern and panic to a kind of badge-of-honor to be getting through a semester despite an insomnia handicap.

At the least, one can note that the interventions for insomnia have improved. The critical thing seems to be an awareness of the context and activities that produce arousal during the day and the reduce and/or replace the occurrence of those contextual cues in the time leading up to sleep.

Nighty-night!

(Image from the road in Wyoming, somewhere along this journey. Credit to Alexis Yael, http://www.alexis-yael.com)