“Can’t I just treat my insomnia with a book?” My interlocutor was sure there was a book out there (including one of my mine) that “could get me to sleep just fine.”
Certainly many could do with a brief bout of Sleep School – understanding how sleep affects their health, performance, pleasure, pain, income and mortality – and how standard American sleep practice, from nighttime cellphone texting through to late night snacks and “exciting” TV news just before bed does not ensure regenerative rest. The causes and treatment of insomnia are complicated for innumerable reasons; here are a very few common ones:
Why People Can’t Sleep
Let’s start with:
1. Booze. Perhaps America’s favorite knock-out drop after sleeping pills, an ounce of “nightcap” frequently will, as Shakespeare’s knew, “provoke the desire but prevent the performance.” Generally booze will add 15-25 brief arousals from sleep per night. And though even very short arousals help ruin sleep effectiveness and quality most folks don’t remember them unless they last 6-8 minutes. Most don’t. My all time record – 1200 arousals during the night from a patient who said “I didn’t wake up once.”
2. Medications. Internists are generally not taught how much commonly prescribed drugs, like antihypertensives and antidepressants, affect sleep. In an era of rushed, programmed checklist medicine (BP “check”; lipids “check”’ glucose “check” – okay you’re fine,) they don’t want to find the time to find out.
3. Medical problems. Does anyone sincerely belief chronic obstructive lung disease does not affect sleep? Not to mention the steroid and stimulating beta-adrenergic agents used to treat it? In turns out most chronic medical ailments – from congestive heart failure to osteoarthritis – powerfully affect sleep, as do their standard treatments. Most clinicians are unaware that worldwide, pain is the most common cause of insomnia – and treatment of pain leaves a lot to be desired. To get good rest results quite complex clinical trade-offs must frequently be made – if the subject of sleep ever comes up.
4. Sleeping pills. Can the common treatment of insomnia cause it? The vigorous and vociferous response of those taken off of sleeping pills acts as angry proof. Most folks are unaware how little sleep – perhaps 10-15 minutes – at the beginning of treatment – are added to their nights by sleeping pills. Many are blissfully unaware that the memory wrecking effects of the drugs often obscure how often they aroused and awoke – making them feel subjectively “so much better.” They also know nothing about the increased mortality, which in Dan Kripke’s work on a very large population, represents a five fold increase with daily use.
5. Tobacco. About one sixth of the American adult population is still smoking. What even ecigarette users must face is that they will go into nicotine withdrawal arousing them from sleep – often many times every night.
6. Sleep disorders. Sleep apnea often causes insomnia – even after people get effective CPAP machines. And a huge portion of the country suffers from periodic leg kicks – short bursts of muscle activity during the night. Most are completely unaware they have it. Yet the majority of people over 65 kick more than 5 times an hour.
Why Insomnia Treatments Don’t Work
1. Physical treatments. It’s true that morning walks will improve mood, reset biological clocks, improve performance, increase survival and generally go a long way towards improving people’s sleep. But people have thousands of valid reasons why they can’t stroll – ranging from Minneapolis winters to unhappy cats to work and school schedules that provide “no time” in the morning. Something has to give, and precisely what is often a closely calibrated clinical negotiation. Even simple sleep rituals – the conscious patterning of behavior to rest the mind before sleep – quickly come undone by a preference for “favorite” television shows.
2. Mental Treatments. Cognitive behavioral techniques work. Stimulus control techniques – particularly when dealing with middle of the night insomnia – work. Getting people to consistently perform them is another matter. Despite its efficacy many will resist doing cognitive homework – even when there’s a simple app on their phone – and experience yet more have trouble following through month after month.
3. Social and work engagements – much of socializing and work is now 24/7. Students have no idea how few seconds it takes for bright cellphone surfaces to demolish melatonin production. Managers dealing with global supply chains tell me they simply cannot factor in how waking their underlings at 3 AM affects their performance the the next day – and the next. What, forgo the pleasure of the Internet with its bright lights and racy content just before sleep – what a terrible imposition, people tell me.
4. Body Clocks – professional football and baseball may be paying more attention, but most folks don’t know how much 24 hour clocks affect performance, health, waistlines, pleasure and survival. So what if shift workers live several years less than others? I’ve got my Instagram friends to keep up with.
The Simple and the False
As societal intercourse increases in complexity, so does the desire for simple solutions. Yet as Paul Valery wrote long ago, the simple is often false. When you meet people who come in with insomnia complaints often there are at the minimum five or six reasons they have unrestful sleep – ranging from drugs to dogs, body clock incomprehension to the powerful awakening propensities of aging prostates and dipping bladders. No wonder sleeping pills are so popular and so addicting, their many side effects so blithely disregarded.
Similarly, treatment for insomnia is often demanding and even intricate, demanding attention to the physical, mental, social and spiritual life of the many people who can’t rest. It’s not easy coming up with unerringly attractive prescriptions that engage how people move, how and when they work, how they socialize, when and what they eat.
Yet societal sleeplessness is a huge and growing problem. An age of anxiety increases the risk of insomnia. And sleep disorder clinics can rise to the occasion – if they put in the time and effort, and overcome the allure of limiting themselves to sleep apnea testing. Complexity is part of the substance of our lives. It’s better to embrace it than believe that self-help and self-treatment will always win the day.