It Might Not Be Insomnia After All

People come here looking for solutions to sleep problems. Some read about sleep restriction, a drug-free insomnia treatment, and decide to try it on their own. It’s not rocket science: insomnia sufferers who follow the guidelines often improve their sleep. It’s empowering to succeed.

But self-treatment is not the right approach for everyone. Sometimes insomnia is complicated by another disorder, or what looks like insomnia is actually something else. In both cases, the best thing to do is to have yourself evaluated by a sleep specialist ASAP.

Self-help treatments for insomnia will not work for other sleep disordersI’m a take-charge person when it comes to managing chronic health problems, especially when solutions proposed by doctors are unsatisfactory. I hunt for solutions myself, reading a lot and sometimes coming up with a fix.

People come to my blog looking for solutions to their sleep problems. Some read about sleep restriction, a drug-free insomnia treatment, and decide to try it on their own. It’s not rocket science: insomnia sufferers who follow the guidelines often improve their sleep. It’s empowering to succeed.

But self-treatment is not the right approach for everyone. Sometimes insomnia is complicated by another disorder, or what looks like insomnia is actually something else. In both cases, the best thing to do is to have yourself evaluated by a sleep specialist ASAP.

Up Late at Night

Chris wrote in with questions about sleep restriction several months ago:

I recently started sleep restriction therapy about 3 days ago, and I’m not too tired during the day even though I barely slept the last two nights. Is this normal? I set my bed time at 3:30 a.m. and force myself to get up at 9:30 a.m. even if I haven’t slept too well. Should I restrict my time even more if I’m not too tired? Additionally, I find that I have anxiety when I am in bed sometimes. Do you think I should get out of bed if I am anxious?

Chris knows he experiences insomnia, but the symptoms he reports aren’t the classic symptoms of people with insomnia disorder.

  • He’s “not too tired during the day” even though he “barely slept the last two nights”; many insomniacs during the first week of sleep restriction report feeling tired and out of sorts.
  • He’s set his sleep window at 3:30 to 9:30; a more normal sleep window would be from 12 to 6. Maybe Chris works the evening shift and can’t get to bed until 3:30. But if this is his sleep window of choice, then maybe he has a circadian rhythm disorder—in which case sleep restriction would not be an appropriate treatment.
  • He’s anxious when he’s awake in bed; many insomniacs are, too. But Chris’s anxiety could also be an indication of something else.

Chris’s situation sounds complicated and as though in starting sleep restriction he may be on the wrong track. My response to Chris and others like him is to suggest seeing a sleep specialist for an accurate diagnosis and guidance in managing the problem.

Sleepy in the Afternoon

Shelley contacted me via Ask The Savvy Insomniac. “Could sleep restriction help me?” was the subject line of her email.

I’ve had insomnia for 5 years now. Getting to sleep is no problem. But I wake up several times at night. It’s a drag. The alarm rings in the morning and it never feels like the night was long enough. I manage OK in the morning but after lunch I’m like the walking dead. Coffee doesn’t help. I fall asleep during meetings all the time and people notice. It’s embarrassing.

Nighttime wake-ups are a common symptom of chronic insomnia. But Shelley’s inability to stay awake during afternoon meetings gives pause.

It might seem logical that a person with insomnia would feel sleepy during the daytime, and some insomniacs report that they do. Other words that describe the feeling are tired, fatigued, and exhausted.

But the actual inclination to nod off involuntarily during the daytime is not as common in people with insomnia as it is in people with other sleep problems: sleep apnea, for example, and narcolepsy. It might sound counterintuitive, but a majority of insomniacs given opportunities to sleep during the day are no more likely to do so, say sleep experts, than people who sleep well at night. In fact, some studies show it takes insomniacs longer than normal sleepers to fall asleep during the daytime.

If Shelley has sleep apnea or narcolepsy, sleep restriction will do more harm than good. She needs to consult a sleep specialist and get a diagnosis before starting any type of treatment.

The Take-Away

What looks like insomnia may not actually be insomnia disorder. Before you plunge into sleep restriction or any other insomnia treatment, see a doctor for a diagnosis or do lots of reading to make sure that what you’ve got is insomnia and not something else.

Insomnia: Let’s Stop Blaming the Victim

It’s cruel to blame people for health problems they have little if anything to do with creating. Yet the urge to do so is powerful when the true causes of an affliction remain unknown. In the 20th century many illnesses were seen as psychological or behavioral problems, and insomnia was one.

We’re in the 21st century now, and biology and neuroscience are teaching us that the causes of many chronic disorders and serious diseases are complex. But some people still regard insomnia as stemming from “bad” behavior or as “all in the head.” Here’s my take.

BlamingIt’s cruel to blame people for health problems they have little if anything to do with creating. Yet the urge to do so is powerful when the true causes of an affliction remain unknown. In the 20th century many illnesses were seen as psychological or behavioral problems.

Cancer? A disease of people who repressed their emotions. All that pent-up emotion and hostility just had to find expression some way, and it did so by causing cells to run amok.

AIDS? Brought on by sexual promiscuity.

Narcolepsy? Before the recent discovery of orexins–neurotransmitters that help keep us awake and which are lacking in narcoleptics, making them prone to daytime sleep attacks—narcolepsy was explained as a psychological problem of people who lacked motivation.

Insomnia? It, too, was self-created. “You! Are really the major cause of your own insomnia,” declared self-help author Valerie Moolman in 1968, at a time when sleeplessness was blamed on everything from internalized emotion and a desire for attention to bad habits like worrying and staying out late.

We’ve Come a Long Way, Baby . . . or Have We?

We’re in the 21st century now–century of the brain. Biology and neuroscience are teaching us that the causes of many chronic disorders and serious diseases are complex.

But wait. Near the end of journalist David K. Randall’s new book, Dreamland, Randall states this: “And yet insomnia is a unique and difficult condition to treat because it is self-inflicted.” Self-inflicted? Aren’t we beyond holding people responsible for a sleep disorder most sleep researchers say is based in part upon vulnerabilities predisposed at birth?

I don’t think we’ve come that far yet. “I have been made to feel like I must be doing something wrong,” wrote Carol, an insomnia sufferer who reviewed my book, The Savvy Insomniac, just last month, “drinking too much coffee (1 cup in the morning) or not really trying to get to sleep.”

“Bad” Behavior

There are some things we can do that will probably interfere with sleep:

  • Drinking coffee later in the afternoon or in the evening
  • Drinking alcohol right before bed
  • Sleeping late in the morning or taking long naps.

Avoiding these behaviors will likely improve sleep. But many of us already know these things and take them to heart. We hew pretty close to the straight and narrow . . . and still we have trouble sleeping.

Do We Create Insomnia in Our Heads?

Believing we can’t sleep will make sleep more difficult. Fearing insomnia will, too. Yet we don’t develop such beliefs and fears of our own volition. We learn them unconsciously. (See my blog on fear of insomnia.) And once in place, they’re hard to dislodge. (But not impossible. See my blog on laying fear of sleeplessness to rest.)

Even researchers who theorize that chronic insomnia develops in people who think too much about sleep or try too hard to do it are retreating from this claim as more evidence comes in suggesting the underlying cause of insomnia to be excessive arousal of the central nervous system.

Changing habits and mindsets can go a long way toward helping insomniacs sleep. But it’s time we stopped pointing fingers at the sleepless and started looking at insomnia as the multifactorial sleep disorder it truly is.

Insomnia and the Sleep Switch

So what exactly is the “sleep switch,” and how might it figure in insomnia?

This sleep-regulating center in the brain was actually discovered almost 100 years ago.

sleep-attackSo what exactly is the “sleep switch,” and how might it figure in insomnia?

The findings of Dr. Constantin Von Economo, who autopsied victims of sleeping sickness in the 1920s, were prescient. Researchers who went on to study the brains of rats and other lab animals confirmed his theory of a “sleep regulating center” in the brain. While damage to the rear of the hypothalamus sent the animals into a coma, damage to the front gave them a terrific case of insomnia.

Clearly some very important processes took place in the front and rear areas of the hypothalamus, a grape-sized structure deep in the brain.

Sleep Switch at the Front

The front part of the hypothalamus is now known to contain a small cluster of neurons called the VLPO, and they produce GABA and galanin, neurochemicals highly conducive to sleep.

These neurons are mostly off-duty during the daytime. But at night they come alive. When sleep pressure builds up high enough, the VLPO neurons start firing away like mad. Current theory holds that they’re powerful enough to shut the rest of the brain down, in essence functioning like a “sleep switch.”

Alerting Force in the Rear

At the rear of the hypothalamus is an important set of neurons that have the opposite effect: when they’re firing, they help keep you awake. They produce a substance called orexin, and they function “like a ‘finger’ on the (sleep) switch that might prevent unwanted transitions to sleep,” sleep scientist Clifford Saper has said.

The sleep-friendly neurons in the VLPO work to “tranquilize” the orexin neurons at night. But people with a substantial loss of orexin neurons experience narcolepsy. Narcoleptics have irresistible sleep attacks during the day and they also have trouble staying asleep at night. The trusty “finger” on the sleep switch, which helps to maintain a stable waking state, just isn’t there.

How This Relates to Insomnia

A deterioration of orexin neurons may also be a factor in the insomnia of older adults, Saper has hypothesized. Like narcoleptics, older adults tend to nap a lot during the daytime and have frequent wake-ups at night.

A causal factor of insomnia in younger adults, on the other hand, could be a reduced number of GABA neurons in the brain, or an overabundance of orexin neurons. Either condition could interfere with the sleep switch enabling quick, easy transitions to sleep.

These theories aren’t of practical value yet. But stay tuned. The FDA is reviewing a completely new insomnia medication – the first ever “orexin receptor antagonist” – right now.