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the problem with sleep

Let me tell you something about sleep

One of the most common complaints I get is “difficulty sleeping”. Insomnia is one of the most common presenting symptoms in psychiatry, and is present in almost all mental disorders. Not only that, stress and excitement with ordinary life events can also rob us of a few Z’s.

Losing sleep or lacking sleep can be very stressful and anxiety-provoking for some people. They put all their efforts into trying to go to sleep, only to remain awake throughout the night and into the next day. This cycle can repeat itself until the effects of sleep deprivation take its toll on them, and they eventually decide to seek medical consultation.

For some, sedatives (or “sleep meds”) are effective. They take a pill for a night or two, get a good night’s rest, and are able to carry on with their usual activities. They’d then just take meds as needed, for difficulty in sleeping.

For others, it can be more complicated. “The meds don’t work“, “I need something stronger“, “I’ve tried everything” are common complaints. Depending on the treating physician, the next step could be anywhere between adjusting their meds, or referral to a sleep specialist.

But what happens to a person who has been to a primary care physician, a neurologist, and a sleep specialist, yet still can’t find anything that works? Some of them get referred to a psychiatrist.

Personally, I’ve received a handful of referrals, especially the “I’ve tried everything” type. I’ve tried adjusting their meds, referring back to their sleep specialist, referring back to their neurologist, or teaching them sleep hygiene techniques.. Nothing seemed to work.

Fortunately, I was able to attend the workshop on CBT for Insomnia from the Beck Institute for Cognitive Behavioral Therapy last September. I learned that majority of the causes of insomnia are psychiatric and psychophysiologic (which is why we end up getting these referrals). What’s striking is that 9% of these are due to misperceptions about sleep.

Causes of Insomnia
(c) 2020 Beck Institute for Cognitive Behavioral Therapy

What are these misperceptions about sleep?

First, let me ask you, which is more important: the length of sleep in hours, or the quality of sleep? If you answered the former, you might be misinformed about what constitutes a good night’s sleep.

Sleep 101

Before diving into the factors affecting our sleep, let’s first review the sleep-wake cycle, so we can get an idea of what ‘normal sleep’ looks like.

The sleep-wake cycle is regulated by the homeostatic sleep drive, and the circadian wake drive.

These 2 are related in that a decreasing homeostatic sleep drive, and an increasing circadian wake drive cause arousal. Conversely, an increasing sleep drive and a decreasing wake drive put us to sleep. These 2 factors cycle within 24 hours, such that we naturally fall asleep and awaken at certain times throughout the day.

Take a look at how the 2 interact in the graph below.

Sleep Wake Cycle
(c) 2020 Beck Institute for Cognitive Behavioral Therapy

Sleep begins as the wake drive decreases, and the sleep drive increases. Wakefulness starts as the wake drive increases, and the sleep drive decreases.

Stages of Sleep

Sleep is dynamic, and we transition through sleep stages at 3-4 cycles per night, spending 90 minutes in each cycle.

Stages of sleep

Stages 3 and 4 are more prominent in the first half of the night, and decrease as the night progresses, while REM sleep increases over the course of sleep.

This is what a typical cycle looks like. Notice that Stage 4 occurs within the first 3 hours of sleep. Stage 4 is when restorative sleep happens. It’s when our body repairs any muscle or tissue damage.

Sleep stages
(c) 2020 Beck Institute for Cognitive Behavioral Therapy

So. How many hours do we need to get a good night’s sleep?


Sleep varies with age. In each age group, the number of hours vary as well. Infants sleep 2/3 of the day, while young adults sleep 1/3 of the day. Older adults sleep less. They even have less stage 3, 4 and REM sleep.

Here’s how the need for REM sleep changes with age.

REM need sleep changes with age
(c) 2020 Beck Institute for Cognitive Behavioral Therapy

More REM sleep is required for better learning. That’s seen in infancy up to early childhood.

Notice how the number of total daily hours of sleep declines as we age. At 70 or 80 years old, sleep will never be the same as it was when one was 30. This is normal. This is an age-related decline in the number of sleep hours. It’s handy to keep in mind that older people can sleep for up to 4-6 hours only.

If you have an elderly companion at home, who’s worried that he or she is “not getting enough hours of sleep”, it maybe helpful for them to know that it’s normal to sleep less compared to younger persons. This tip might reduce their anxiety and “sleep worry”.

Sleep worry” is when we worry about getting good sleep, going to sleep at the exact time, having the exact number of hours of sleep, or practically anything related to sleep. This often happens in people with insomnia, and may stem from their beliefs and attitudes about sleep.

Insomnia as a symptom is the complaint of poor sleep quantity or quality, associated with problems falling asleep, staying asleep or early morning awakenings. It is the most common health complaint after ‘pain’. It may occur as a symptom of a medical disorder, a mental disorder, or as a disorder of its own.

Insomnia Disorder, according to DSM-5, is when the sleep problem causes significant distress and dysfunction in areas of work, social relationships, etc. The sleep problem should occur at least 3 nights per week, persists for at least 3 months, and occurs despite adequate opportunities for sleep. It should not be better explained by another psychiatric disorder, a medical disorder, a physiologic effect of a substance, or another sleep disorder (there is a range of Sleep-Wake Disorders listed in the DSM-5). The diagnosis is given when coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

Sleep worry is a factor that perpetuates insomnia. Other perpetuating factors include dysfunctional beliefs and attitudes about sleep, such as unrealistic sleep expectations, misconceptions about sleep and sleep anticipatory anxiety.

Here are some common misconceptions about sleep:

If you want to evaluate your own beliefs about sleep, click HERE to answer the questionnaire on Dysfunctional Beliefs and Attitudes about Sleep (DBAS 16 Items).

Take note that these are beliefs and attitudes about sleep. They are variable, and are likely to change over time or under influence (a good one, I hope). Solely believing in them, or feeling strongly towards them does not constitute an insomnia disorder, or a mental disorder. If you are having problems with sleep that are interfering with your day-to-day functioning, please consult with a medical professional.

For some, sleep pattern can be regulated through behavioral techniques collectively called ‘sleep hygiene‘.

Sleep hygiene involves putting yourself in the best position to sleep well at night. It is not intended to induce sleep. I repeat, it is NOT intended to INDUCE sleep. Sleep hygiene does not involve sedating measures. Rather, it sets up our environment to be more conducive to sleep (i.e. more relaxing, more comfortable).

It is part of the treatment plan for insomnia disorder, but rarely works alone. It is usually used in conjunction with pharmacotherapy, psychotherapy, or both.

For those with minor sleep problems that do not constitute an insomnia disorder, sleep hygiene might help put you to sleep a little easier. Again, if you suspect that you have an insomnia disorder, please consult with a medical professional.

Here are a few sleep hygiene tips:

Before you get too sleepy reading this lengthy blog post (or maybe that’s a good thing?), please do share this information to a friend, a relative, a co-worker, or an elderly companion in need.

Being aware of the sleep-wake cycle and setting realistic expectations about sleep can go a long way in reducing sleep worry, and anticipatory anxiety about sleep. Which, in turn, may help a person suffering from insomnia. Even just a little bit.

Lastly, here are the PDFs available to download so that you can share these nuggets of information, spreading psycho-education to everyone around.

Let’s continue to spread mental health awareness for #WorldMentalHealthMonth2020


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