Three Causes of Chronic Insomnia That Must Not Be Overlooked

Behavior, thought and emotion that turn sleep difficulty into a chronic problem.

Posted Feb 07, 2019

Photo by Daniel Höhe on Unsplash
Source: Photo by Daniel Höhe on Unsplash

In making sense of the multitudinous causes of insomnia, we previously employed Dr. Spielman’s “3P” model (1987). It provides a guiding principle for clinical practice (2018) by organizing all potential sources of poor sleep into 3 groups of factors on the basis of timing. The first group is comprised of predisposing constitutional factors that make one’s sleep vulnerable, such as greater sensitivity to stressors or a circadian propensity towards early rising, among others. These factors alone do not necessitate poor sleep and may even be beneficial for certain daytime functions. As these factors are tied to the personality and neurological make-up, they remain relatively stable over time and are hard to change. The second group, precipitating factors, consists of all major and minor events and conditions that acutely and directly hurt sleep, such as life stressors, physical ailments and emotional perturbations. Typically, these events and conditions have relatively well-defined timing. They are approached by both the person and the healthcare provider as something to be isolated, coped with, controlled and, ultimately, eliminated. In the majority of people who seek help for chronic insomnia, such precipitating events or conditions have been identified and adequately addressed a long time prior to the initial visit with the insomnia specialist. A stressful debt has been paid off, a hospital stay recovered from, an outbreak of anxiety successfully managed, but the unpredictability of sleep remains frustrating and debilitating. To understand why, we must turn to the factors perpetuating chronic insomnia.

Broaching the subject of perpetuating factors in clinical practice is always associated with the risk of irritating the client, imbuing her or him with a sense that the practitioner is trying to blame the victim. At a glance, perpetuating factors encompass numerous methods and convictions that the person has developed over an extended period of time exactly with the intention to combat insomnia, and has even achieved a degree of success on occasion. And suddenly, someone you’ve just met is telling you that you’ve been doing it all wrong. Besides, most of the therapeutic techniques that are offered instead you’ve already heard about multiple times and perhaps even tried to a miserable result. Yet, these are the very techniques that comprise the oh-so-recommended CBT-I. Why would it make any sense that the medical field promotes these techniques so much? To address this question, I invite you to take a closer look at the three most common perpetuating factors, how they make insomnia chronic, and how CBT-I helps eliminate their negative effects on sleep. In this post, we will briefly identify them, and in the three subsequent posts, will carefully review the evidence for each of them individually.

Since there is no way to introduce them genially within the confines of a short post, here they are: spending a lot of time trying to sleep, spending a lot of time thinking about sleep, and spending a lot of time fearing not being able to sleep. Before you drop this as something nonsensical, please let us recall that CBT-I, the most evidence-supported insomnia treatment to date (2018, 2016), relies on interventions that can be broadly described in two terms: 1) strict regulation and standardization of the time allotted for sleep attempts, and 2) replacement of a continuing concentration on various isolated aspects of sleep and negative effects of its absence with a systematic understanding of sleep as an integral part of physical and mental functioning in general.

Perhaps the most frequent argument that clients with insomnia make against the regularization of sleep attempts can be phrased as this: “I am trying to get more sleep, and you are telling me to forfeit most of the opportunity to sleep. How am I to get any sleep at all?” Indeed, a person struggling with insomnia usually aims to maximize the opportunity for sleep by allocating quite a bit of time to reclining, often in bed, but also on a couch or an armchair, sometimes on an office sofa, maybe on a bus or car seat, or even on a balcony. As the majority of these attempts do not result in any discernible sleep, two things begin to happen. First, the person works harder to increase the frequency and duration of the attempts, viewing them as the main, perhaps the only way of attaining sleep. Second, the person employs various means of distraction, often electronic media, to divert the attention away from the labor and irritation of fruitlessly trying to sleep. And the whole process solidifies into a habit. In the next post, we will analyze in detail how this habit alone can maintain insomnia for years and why breaking out of it helps reinstate healthy sleep.

While not every person who develops chronic insomnia can or does increase the reclining time beyond the 7-8-hour period typically recommended for good sleepers, just about everyone with sleep difficulty takes a great deal of time to think about sleep. In other words, the amount of time that is much greater than any good sleeper spends thinking about sleep. And that makes perfect sense: if a problem–any problem!–comes up, we solve it by thinking about it, paying close attention to its different facets, generating a solution, then trying the solution, monitoring the outcome and either sticking with it if it works, or discarding it if it doesn’t and generating a new one. Unfortunately, when this process, which serves us so well during wakefulness, is applied to our own sleep difficulty, sleep as a physiological process comes to a halt. Unlike nearly all waking activities, sleep is inhibited by close attention and conscious scrutiny, cognitive functions that make us more alert. A well-developed and highly influential model of chronic insomnia places the inopportune deployment of cognitive functions front and center in the theory and practice of insomnia and its treatment. We will dedicate an entire post to this cognitive model of insomnia and therapeutic techniques associated with it.

Similarly, the fear of sleeplessness and its negative consequences is another very common factor that maintains insomnia. OK, “fear” may be too strong a word. Annoyance, worry or concern may be more appropriate descriptors of the negative emotional state that comes with the inability to sleep when intended. Experiencing displeasure when something goes awry is quite natural; after all, it’s what motivates us to work on improving the situation. More specific to insomnia, the public awareness of ill effects of inadequate sleep has been increasing, providing justification for the worry. However, emotional negativity and the desire to do something to alleviate the problem as soon as possible promote mental and physical activation, not sleep! If getting ready for bed feels like getting ready to “fight or flight” for your life, sleep becomes–quite literally–physiologically  impossible. It deserves a separate post to discuss the role of emotional disquiet and apprehensive expectations at bedtime in perpetuating insomnia night in and night out, and what can be done to help quell this negativity and give way to sleep.

To be certain, there are numerous other perpetuating factors, and not all of them are present in every person who struggles with sleep. But these three–trying too much to sleep, thinking too much about sleep, and worrying too much about sleep–are most pervasive ones, and are most targeted by CBT-I. Having identified these “usual suspects,” we will next take an aim at them one by one, with the intention of defining how much trying, thinking and worrying is “too much,” and how much is just right. See you in a week!

References

Spielman, A. J., Caruso, L. S., & Glovinsky, P. B. (1987). A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America, 10, 541-553.

Anderson, K. N., (2018). Insomnia and cognitive behavioural therapy–how to assess your patient and why it should be a standard part of care. Journal of Thoracic Disease, 10 (Suppl 1), S94-S102. doi: 10.21037/jtd.2018.01.35.

Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165, 125-33. doi: 10.7326/M15-2175.