It is habitual to sleep to rest; and this comes naturally. However, we learn from psychologist Ms. Velda Chen that sleep does not always come easily. In conjunction with World Sleep Day, which falls on March 17 every year, we find out more about insomnia and how cognitive behavioral therapy (CBT) can help.
While sleep is a natural state of rest for the body and mind, our internal body clock regulates much of when and how much we sleep.
An important sleep regulatory process is the circadian rhythm, the internal 24-hour biological clock which regulates when we feel awake and sleepy. It is affected by cues such as light and darkness.
Hence, when our body is synchronized with the external environment, we are more likely to feel more alert when awake.
Another key sleep regulatory process involves the homeostatic sleep drive which refers to our need for sleep. The longer we stay awake, the more we will need to sleep. This sleep drive is influenced by particular brain chemicals; including melatonin, which promotes sleepiness.
Other sleep arousal factors include noise, temperature, and lifestyle factors such as work schedules, social influences, and diet.
These sleep regulatory processes work together to help our body get the sleep we need to stay healthy and alert. As we drift off into slumber, our body is given the chance to rest and rejuvenate, repairing tissues and boosting our immune system.
In addition, our mind is freed from the worries and stresses of the day. While that sounds tranquil and restful for many, falling asleep can be a struggle for some.
According to Ms. Chen, sleep problems are commonly experienced.1
“Sleep problems could arise from poor sleep hygiene, lifestyle factors, poor coping with ongoing worries, and life stressors,” she says based on the common reasons cited by her patients for being kept awake. “Underlying and pre-existing mental health difficulties such as depression and anxiety also cause sleeplessness.”
To assess sleep hygiene, one would have to evaluate the bedroom environment and for the presence of regular daily routines and healthy habits which promote consistent and uninterrupted sleep.
The lack of or poor quality execution of these factors may result in poor sleep hygiene.
A population-wide study done before the Covid-19 pandemic reported that 27.2% of Singaporeans aged 18 and above experienced poor sleep.2 The uncertainties of the pandemic compounded the problem.
“The pandemic worsened sleep for many of my patients due to a combination of factors including the behavioral changes due to home confinement for work. Such an arrangement for work affects sleep hygiene and stimulus control, causing disruption to circadian rhythms with the disruption to routine life and structure," Ms. Chen explains.
In addition to the colossal adjustments to daily routines, exposure to the constant worrying news feed about Covid infection, financial consequences, and loneliness made sleeping harder. Social distancing to slow the spread of the coronavirus cut many people from their emotional and social support systems. Isolation led to loneliness which might have induced increased feelings of vulnerability, hence sleep arousal, disturbing sleep.3
Now that work and daily routines are normalized, quality sleep may not necessarily return. “Improvement in sleep condition varies, depending on individuals’ stress tolerance to changes, adjustment back to lifestyle habits, or behavioral changes and life circumstances,” she explains.
For instance, those returning to the office may experience better improvements compared to those with a partial return. In addition, those who have resumed physical exercise may have improved sleep and those who cope and manage worries better have improved sleep.
Insomnia is a sleep disorder which affects millions of people worldwide. It is characterized by difficulty in falling or staying asleep and it can significantly impact your daily life and overall health.
"Based on the latest Diagnostic and Statistical Manual of Mental Disorders4 diagnostic criteria for insomnia, the symptoms have to be present for at least three months and occur at least three days per week despite adequate opportunity for sleep," Ms. Chen explains.
The symptoms of insomnia are difficulty in falling asleep or staying asleep, or waking up too early in the morning with the inability to return to sleep.
Another positive diagnostic symptom is when the sleep disturbance causes significant distress or impairment in social or occupational functioning, or other similarly important areas.
Finally, the sleep disturbance must not be due to another sleep disorder (such as sleep apnea), mental disorder, neurological condition, medication, or substance use.
As a general guide, adults require 6-8 hours of sleep; any period less than 6 hours is not ideal. However, there is some level of individual variation to be considered, as some may need fewer hours of sleep than others. But that does not mean that they are insomniacs.
“There are no clear criteria of how many hours of sleep an individual enjoys to be considered as insomniac as individuals have varying sleep needs. One is only diagnosed with insomnia if the individual is clinically distressed or exhibits impairment due to difficulties with sleep,” she adds.
Insomnia can affect anyone but certain risk factors may increase a person's likelihood of developing insomnia. According to a study in 2009 which estimated the incidence, the risk is higher for those with a previous episode or family history of insomnia.5 Other risk factors include:
“These factors could increase the likelihood of experiencing sleep difficulties and affect daily functioning. Insomnia can have negative daytime consequences such as excessive drowsiness which can affect one’s ability to drive or work safely. Chronic insomnia can lead to long-term health consequences such as increased risk for developing cardiovascular diseases and depression,” Ms. Chen says.
CBT for insomnia (CBT-I)8 is recommended as a first-line treatment for chronic insomnia in adults with short-term medications recommended only if CBT-I is not available or ineffective. The cognitive therapy strategies typically target the over-attention on sleep and worries about not sleeping or the consequences of poor sleep which heightens the anxiety about sleep, thus perpetuating insomnia.
Multi-component CBT-I combines cognitive therapy strategies with education about sleep regulation, stimulus control (SCT), and at times sleep restriction therapy (SRT).
“The goal of SCT is to associate the bedroom environment as a primary stimulus for sleep and to reduce cues for arousal. It works by enforcing day (wake) and night (sleep) environments and developing a consistent sleep-wake cycle," Ms. Chen explains.
Essentially, it is training the mind and body that going to bed means going to sleep; following simple guidelines including getting out of bed if sleep does not happen in the space of 15-20 minutes and only returning to bed when drowsy. This is also known as the quarter-hour rule.
The bedroom is a place strictly for sleep, so no eating, watching TV, or using devices in bed. It also requires a fixed wake time regardless of when one goes to bed on both weekdays and weekends, no lying in bed when awake or in the daytime, and no daytime napping.
SRT is applied to restrict one’s time in bed to the average time slept in the past week (typically with a minimum of five hours). The central concept is that insomniacs spend more time in bed awake and less time asleep.
SRT is designed to correct this imbalance and increase sleep efficiency, calculated by dividing the time spent asleep by the total time spent in bed. Normal sleep efficiency is considered to be 85% or higher.
Relaxation strategies and counter-arousal methods are also included in CBT-I to address symptoms of worrying typically observed in patients with insomnia.
“Typically, treatment progress is monitored by using information gathered with sleep diaries completed by the patient throughout the course of the treatment,” she says.
Ms. Chen elaborates, “There is evidence from clinical trials to suggest that in-person CBT-I can be effective within 4-8 sessions during the acute treatment phase and is more effective than sedative-hypnotics in the long term; for example, more than three months after treatment.
“The effects of CBT-I can be maintained up to two years with follow-up.9 However, there is varying clinical response depending on the patient's motivation for change, medication use, and the presence of underlying medical or mental health conditions. All of which needs to be taken into clinical consideration.”
Insomnia is a medical condition and it should be treated as soon as it impacts your daily functions, reasoning, and moods. These effects are just scratching the surface, as leaving insomnia untreated can negatively impact overall physical and mental health and the quality of life.
Once the underlying cause of sleeplessness is identified, there are options that your healthcare provider can offer in developing a personalized treatment plan to help you improve your sleep quality and help restore your overall well-being.
2 Lee YY, Lau JH, Vaingankar JA, Sambasivam R, Shafie S, Chua BY, Chow WL, Abdin E, Subramaniam M. Sleep quality of Singapore residents: findings from the 2016 Singapore mental health study. Sleep Med X. 2022 January 28;4:100043. doi: 10.1016/j.sleepx.2022.100043. PMID: 35243325; PMCID: PMC8861160.
4 For more, please see https://www.psychiatry.org/psychiatrists/practice/dsm or https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t36/
5 LeBlanc M, Mérette C, Savard J, Ivers H, Baillargeon L, Morin CM. Incidence and risk factors of insomnia in a population-based sample. Sleep. 2009 Aug;32(8):1027-37. doi: 10.1093/sleep/32.8.1027. PMID: 19725254; PMCID: PMC2717193
6 Klink ME, Quan SF, Kaltenborn WT, Lebowitz MD. Risk factors associated with complaints of insomnia in a general adult population. Influence of previous complaints of insomnia. Arch Intern Med. 1992 Aug;152(8):1634-7. PMID: 1497397.
7 Morin CM, Jarrin DC. Epidemiology of Insomnia: Prevalence, Course, Risk Factors, and Public Health Burden. Sleep Med Clin. 2022 Jun;17(2):173-191. doi: 10.1016/j.jsmc.2022.03.003. Epub 2022 Apr 23. PMID: 35659072.
9 Muench A, Vargas I, Grandner MA, Ellis JG, Posner D, Bastien CH, Drummond SP, Perlis ML. We know CBT-I works, now what? Fac Rev. 2022 Feb 1;11:4. doi: 10.12703/r/11-4. PMID: 35156100; PMCID: PMC8808745.