When 7-Hour Nights Aren’t Good Enough

To many insomnia sufferers, the prospect of sleeping 7 hours a night sounds great. Insomniacs who write to me with news that they’ve achieved this feat after undergoing some type of insomnia treatment are thrilled.

Other people are not so thrilled about 7-hour nights. No matter how long they sleep, they wake up feeling unrested. Insufficiently refreshing sleep is the main symptom of people diagnosed with nonrestorative sleep.

Nonrestorative sleep may or may not be a form of insomniaTo many insomnia sufferers, the prospect of sleeping 7 hours a night sounds great. Insomniacs who write to me with news that they’ve achieved this feat after undergoing some type of insomnia treatment are thrilled.

Other people are not so thrilled about 7-hour nights. No matter how long they sleep, they wake up feeling unrested. Insufficiently refreshing sleep is the main symptom of people diagnosed with nonrestorative sleep.

A Closer Look at What Nonrestorative Sleep (NRS) Feels Like

Jeremy wrote to me recently complaining of insomnia. But the way he described his problem was different from the insomnia stories I usually hear:

I do not struggle with sleep onset at all or awakening from sleep. But the ‘sleep’ I do receive is of such low quality it feels like I did not sleep at all. . . . I am often unconscious for 6 to 7 hours. But it feels like I receive practically nothing (the most similar feeling I have ever experienced is being extremely hung over from excessive alcohol consumption).

To “receive practically nothing” after a full night’s sleep makes Jeremy’s situation sound rather desperate. Normal sleep affords many benefits: it allows for the conservation of energy, enables the growth and repair of body tissue, shores up important memories and prunes the unimportant ones, enables the processing of emotion, improves our ability to perform tasks and procedures. Importantly, a night of sound sleep primes us to meet the demands of the day ahead. If Jeremy’s waking up feeling unrested, then even though he’s sleeping, he’s really missing out.

A Subjective Diagnosis

The causes of NRS are still unknown and no objective tests for it exist. Identifying its biological markers is a project only just begun. So the diagnosis of NRS is subjective, based on symptoms alone.

In 2013 Canadian investigators published an NRS questionnaire after identifying 4 key features of the disorder. Compared with healthy sleepers, people with NRS tend to:

  1. Experience poor quality sleep and wake up feeling unrested
  2. Have more aches, pains, and medical problems, including symptoms of panic
  3. Experience impaired daytime functioning (e.g., experience low energy and alertness, and have trouble with memory and concentration)
  4. More often feel depressed and/or irritable during the day

Is It Insomnia or Not?

Sleep experts have tossed this question around for years. The daytime symptoms of NRS are similar to those associated with insomnia (although the impairment caused by NRS may actually be more severe). Also, overnight sleep studies of people with NRS often look the same as those of normal sleepers, suggesting that NRS might have something in common with paradoxical insomnia, a diagnosis often given to people whose sleep studies look normal but who feel like they’re only getting an hour or two of sleep a night.

But the differences between NRS and insomnia may prove to be more important and argue for NRS to be considered a separate sleep disorder. Unlike people with insomnia, who report trouble falling asleep or staying asleep, many people with NRS experience neither of these nighttime problems.

Funded by a grant from the National Institute of Mental Health, a team of researchers looked for differences between the symptoms of insomniacs and people with NRS in large sample of the general population. They noted the following:

  • The prevalence of insomnia increased with age; the prevalence of NRS decreased with age.
  • Insomnia was significantly associated with cardiovascular disease; NRS was not associated with CVD but was significantly associated with different medical problems, including emphysema, chronic bronchitis, habitual snoring, sleep apnea, and restless legs syndrome.
  • After adjusting for confounding factors, levels of C-reactive protein, a marker of inflammation, were significantly high in people with NRS only but not in people with insomnia only.

The elevated levels of C-reactive protein might be clue about the causes of NRS. “Indeed,” the authors write, “NRS is a core symptom of chronic fatigue syndrome and some forms of major depression, both of which have been shown to be associated with increased . . . inflammatory markers.” For anything more definitive, we’ll have to wait and see.

How Is NRS Treated?

The medical literature is sadly lacking here. If you think you might have NRS, consult a sleep specialist and see what he or she recommends. NRS often occurs in conjunction with another medical problem, such as fibromyalgia or sleep apnea, or a psychiatric problem such as depression. Treatment of that problem may improve sleep quality and help to resolve the issue with NRS.

Some research has also shown that the sleep of people with NRS is characterized by increased alpha wave activity, a phenomenon associated with hypervigilance. If this is true, then vigorous daily exercise may help.

Q & A: Is What I’ve Got Insomnia?

Recently I was telling a new acquaintance about my book.

“Insomnia?” she said. “How do you define that? My problem is that I wake up several times every night. Does that qualify as insomnia?”

dont-knowRecently I was telling a new acquaintance about my book.

“Insomnia?” she said. “How do you define that? My problem is that I wake up several times every night. Does that qualify as insomnia?”

“That depends,” I replied, and then I rattled off the medical definition of insomnia: trouble getting to sleep or staying asleep, awakening too early, or nonrestorative sleep; and distress or impairment in key areas of functioning during the day. “Do you feel impaired during the daytime?”

“I have a lousy memory,” she said. Then she launched into a litany of lost remembrances: trips taken, family gatherings, books read. The relationship of sleep and memory is a hot topic these days and she was curious: did her longstanding memory problems and frequent wake-ups mean she was suffering from insomnia? (And if she could get rid of the wake-ups, would her memory improve?)

First Impressions

A good diagnostician or sleep specialist would interview her further before reaching a conclusion; I am neither of these things and don’t pretend to be.

Yet my impression was that—whether or not her symptoms would meet the medical definition of insomnia—she didn’t have a lot to worry about. This woman owns a successful business with stable roots in the community where she lives, and she’s endowed with a vibrant personality, fabulous communication skills, and energy to burn.

Most insomniacs I know present a different picture and tell a different story. Asked about their daytime symptoms, and they talk about everything from fatigue and exhaustion to moodiness and brains that limp along in second gear. Memory impairment, too, is a common complaint, and it’s certainly one of mine.

More Information

Appearances can be deceiving, yet my sense was that if this woman would be given a diagnosis of insomnia, she had a rather mild case. She confirmed this a minute later when she told me what she does when she wakes up at night. “I roll over,” she said, “and I fall right back to sleep.”

I felt a sharp stab of envy: what wouldn’t any red-blooded insomniac give, when we wake up at 2 or 3 a.m., to be able to roll over and fall right back to sleep?

I kept the thought to myself, though, and made a suggestion about how she might improve her sleep. And about this, I’m a believer: no matter the shape and size of a sleep problem, there are probably ways to make it better.

But the memory issue? There’s a question scientists may be working to answer for a long, long time.

What kind of insomnia do you have, and do you experience any negative effects during the day?