David Mann started struggling with sleep in 2000. He had moved into an apartment near the front door of the building, and he attributed his frequent awakenings to hearing people coming and going at all hours. When he later moved into a house and the problems continued, he blamed his bedroom’s lack of darkening curtains. Then it was the nighttime disturbances of a new baby.
“One thing replaced the last thing as the explanation, and it kept going on and on,” he recalls.
Now, 20 years later, he still struggles to get an uninterrupted seven or eight hours of sleep most nights, despite taking a variety of over-the-counter sleep aids, participating in a sleep study, and seeing several sleep specialists.
Mann is far from alone. According to the Sleep Foundation, up to 30 percent of American adults suffer from chronic insomnia. That clinical diagnosis is based on specific symptoms: frequent difficulty falling or staying asleep, resulting in daytime impairment or distress.
“Insomnia comes from the three Ps,” explains Phyllis Zee, PhD, a Northwestern University circadian-health researcher and insomnia specialist. “A biological predisposition; a precipitating factor, such as a traumatic event or shift work, which causes short-term insomnia; and a perpetuating factor — attitudes and behaviors that make the insomnia chronic.”
Insomnia is often conflated with sleep deprivation, but there are important distinctions between them. Insomnia is chronic (at least three nights of impaired sleep per week for three months or longer) and occurs despite ample sleep opportunity.
It’s a daunting diagnosis, but identifying and addressing its root causes can help you start to put the issue to bed.
Sleep Quantity vs. Quality
We all know how important it is to get enough sleep, but equally critical is sleep quality. Sleep-medicine specialist W. Chris Winter, MD, author of The Sleep Solution, explains that slumber has three main phases: light, deep, and dream (or REM) sleep. If transitions to deep and REM sleep are disrupted, we may spend more time in light sleep, which is not as restorative.
“Sleep is like food — you can eat a lot and not feel healthy,” notes Winter. “You also need the right kind of food.” Some insomniacs may get “enough” sleep, but because the quality is poor, they wake up feeling as if they hadn’t dozed at all.
“Some people have a condition called heightened arousal,” explains Zee, “so even during sleep their brain doesn’t shut down. It’s a lighter sleep and they wake up more frequently, so they feel like they’re not sleeping soundly.”
Since sleep is critical to overall health, we may be motivated to do whatever we can to get those precious z’s, including turning to prescription medication. A July 2018 Consumer Reports survey found that nearly a third of people who complained of sleep problems had used a sleep drug in the past year. Of those using over-the-counter or prescription sleep aids, 60 percent reported side effects, such as drowsiness, confusion, or forgetfulness the next day.
“It is possible that medication-induced sleep does not provide the same restorative immune benefits as natural sleep,” writes sleep researcher Matthew Walker, PhD, in his book Why We Sleep.
What’s more, over-the-counter sleep drugs frequently contain sedating antihistamines that trigger dry mouth and constipation.
Prescription sleep aids have also been associated with health issues of their own, including impaired memory, headaches, and gastrointestinal issues.
Studies in mice suggest that benzodiazepines (used to treat insomnia as well as anxiety and alcohol withdrawal) may even increase susceptibility to infection by interfering with the signaling of the soothing neurotransmitter GABA (gamma-aminobutyric acid). Walker finds the correlation between sleep medication and infection risk particularly concerning for older adults, who use these prescriptions more than any other segment of the population.
Changing Sleep Rhythms
Our sleep patterns evolve as we age. While young children might need nine or 10 hours of sleep each day, older adults may require closer to seven.
“From the time we’re born until we die, there’s a slow loss of sleep need,” says Winter. “And there are periods when that reduction is accelerated, like between infancy and age 2, or during menopause.”
When older adults have trouble sleeping through the night, it may be due to shifts in circadian timing. As we age, our internal clocks release the sleep-signaling neurotransmitter melatonin earlier in the evening, which can lead to more frequent dozing off in front of the TV.
Our drive to sleep typically increases slowly through the day, building what’s known as “sleep pressure,” explains Walker. When that pressure is reduced by an early-evening catnap, it can be more difficult to fall asleep at bedtime or stay asleep during the night. And that regressed circadian clock also sounds the internal alarm earlier in the morning. “Add these things up, and a self-perpetuating cycle ensues,” he says.
One way to address this circadian shift is to get plenty of bright-light exposure in the late afternoon, delaying the evening release of melatonin. A 2007 study also found that taking melatonin helped older adult subjects (those over age 55) fall asleep more quickly and improved self-reported sleep quality and morning alertness.
Caffeine is a powerful stimulant, which means it can be tempting to reach for it in the morning after tossing and turning all night. But its stimulating properties make it a double-edged sword for insomniacs.
“We think that caffeine makes us more alert,” says Orfeu Buxton, PhD, a Penn State University professor of biobehavioral health. “It actually makes us more anxious and a little more alert, and the anxiety lasts longer than the alertness.”
Caffeine is also habit-forming and tolerance-inducing — meaning you’re likely to need increasing amounts to achieve the same buzz.
Along with the 24-hour circadian cycle that governs our internal clocks, internal sleep pressure helps regulate resting and wake times. Caffeine produces alertness by latching on to the brain’s adenosine receptors; adenosine is a sedating chemical that accumulates over the course of the day and builds sleep pressure.
When we block adenosine with caffeine, it mutes one of the body’s primary cues to ready itself for sleep. This is great when we want to be awake, but it often backfires.
Once the body has metabolized caffeine, backed-up adenosine rushes in, which can lead to the all too familiar caffeine crash. When we hit that wall, we often reach for more caffeine to power through the day.
But caffeine’s half-life can be five hours or more, so if we have coffee or tea at 4 p.m., as much as 50 percent of its caffeine may still be circulating in our brain tissue and blocking adenosine receptors at 9 p.m. This sets the stage for another sleepless night.
It’s a cycle of dependency familiar to many insomnia sufferers. “Caffeine, like sleeping pills, is an example of a temporary countermeasure to insomnia that might be OK in the short term but tends to point you in the wrong direction over time,” says Buxton. (For more on caffeine’s effects, see “The Pros and Cons of Caffeine”.)
Winding down in the evening with a nightcap has timeless appeal, but for those who suffer from insomnia, alcohol is likely to have the opposite effect. It works more like a prescription sedative, shutting down brain activity but not helping the body transition into restorative deep sleep.
“Alcohol doesn’t make a person fall asleep or stay asleep better,” says Winter. “It makes a person unconscious.”
What’s more, if you have a taste for sweet mixed drinks or sweet wine, the high sugar content can cause a quick boost in blood sugar that is usually followed by a crash. When your blood sugar plummets during sleep, it can trigger a surge of the stimulating neurotransmitter norepinephrine — which wakes you up. For those who were already nursing worries about whether or not they would sleep that night, the norepinephrine can aggravate that anxiety.
Michael Ruscio, DNM, DC, picked up a gut parasite when he was in college. The microbiome researcher and author of Healthy Gut, Healthy You was tipped off to the microbe’s presence not by digestive symptoms (he had none), but by his debilitating fatigue and insomnia.
“The gut–sleep connection is one of the most overlooked aspects of gut health,” says Ruscio. “There’s solid data showing that those with irritable bowel syndrome and inflammatory bowel disease have poor sleep and increased prevalence of insomnia.”
Ruscio believes therapeutics that improve gut health, such as a well-rounded probiotic protocol, can improve sleep quality. “Because probiotics have an effect on helping depression and anxiety, it could be they’re also buffering the impact of stress on the microbiota,” he explains. And because depression and anxiety commonly affect sleep, probiotics’ beneficial effects can extend to it as well.
Research has shown that probiotics can also help protect against the harmful effects of stress on sleep. A Japanese study found that medical students taking Lactobacillus casei probiotics while preparing for an important exam maintained their sleep quality better than students given a placebo.
Food has an impact, too, says Ruscio. Anyone coping with GERD (gastroesophageal reflux disease) should be careful to avoid irritating foods, such as fried, processed, or spicy fare, especially near bedtime.
“Eat light after dark” is an old adage, and the National Sleep Foundation recommends fasting two to three hours before bedtime. Still, everyone is different, and some people sleep better if they have a small snack before bed or if they tend to wake up in the middle of the night.
“When people wake up two or three hours before their alarm goes off, it might be because their blood sugar is low,” Ruscio says. “An easy-to-digest snack like some protein powder mixed with fruit juice can get their blood sugar back up and help them fall back asleep.”
(For more on the connection between food and sleep, see “The Food-Sleep Connection”.)
Digital devices interfere with sleep in two ways. The first is the blue light they emit. “Even small amounts of light at night can be disruptive to sleep,” says Winter, who recommends darkening your bedroom as much as possible at night. This can be done by removing light-bearing electronics and adding light-blocking curtains.
The blue light from smartphones, computers, and tablets can be especially sleep-inhibiting. “Blue light suppresses melatonin production,” explains Buxton. “If you’re looking at a screen that’s not orange after 9 p.m., you’re hurting your sleep.”
The content of our screens can also impede slumber. “You might not have too much trouble if you’re looking at a TV showing a crackling fire or aquarium,” says Winter. “But most of what’s online is designed to elicit a dopaminergic response, and it can be distressing and anxiety-provoking.”
A 2014 study found that even participants using an e-reader to read a book needed an extra 10 minutes to fall asleep; they also experienced less REM sleep than people who read a printed book with indirect light.
“If you must use light at night, try either to filter out the blue and green from your device or consider wearing blue-blocking glasses,” advises Winter. He recommends powering down devices at least an hour before bed.
Stress and Anxiety
Anyone who’s ever had a big presentation, early flight, or important exam knows how sleep can suffer the night before. Stress can prompt the sympathetic nervous system to release adrenaline and cortisol, hormones that raise the heart rate and put the body in a revved-up, fight-or-flight state.
And life delivers plenty of stress. Thirty-six percent of Americans note that coronavirus-related worry is interfering with their sleep. A recent paper in Sleep Health showed that teens who experienced intrusive police-stops, especially those involving frisking and harsh language, reported poorer sleep quality.
“We think of insomnia as activating hypervigilance in the brain, so if you’re under sustained stress or threat, you have sustained vigilance at night,” explains Buxton. “Stressors with an element of unpredictability, like domestic violence or the threat of eviction, can directly lead to insomnia. Dread makes it very hard to sleep.”
This includes worrying about how sleeplessness will affect our health. When worry starts to affect sleep, it can lead to a negative feedback loop in which anxiety about not sleeping makes it even harder to drift off.
“It’s like the difference between practicing free throws alone in the gym and shooting for the championship,” says Winter. “You’ve added this intense psychological element to it.”
The key, he says, is to not put so much pressure on yourself, or attach so much importance to any one sleepless night.
There are things you can do when you’re wide awake in bed, stressing out. “Get up,” says Buxton. “Lying in bed worrying about not sleeping means you’re associating the bed with not sleeping.”
Don’t turn on the TV or reach for a device; the blue light is likely to wake you up further. Instead, read a print book, or try coloring in a coloring book. “Often it doesn’t take that much reading to get back in the sleepy zone,” Buxton says.
Stress-reduction techniques such as mindfulness meditation can help reduce the impact of stress and improve both sleep quantity and quality. If your sleepless nights have become chronic, techniques like cognitive behavioral therapy for insomnia (CBT-I) and sleep restriction (limiting your time in bed to help reset entrenched attitudes and behaviors) can help you get back on track to a good night’s sleep.
It’s not just cortisol and adrenaline that play a role in sleep quality. Progesterone, for example, has a mildly sedative effect, so its fluctuations can affect women’s sleep. This hormone tends to drop right before menstruation each month, and according to the Sleep Foundation, women diagnosed with PMS are at least twice as likely to experience disrupted sleep before and during their period.
Zee says sleep changes and disturbances are common during pregnancy, perimenopause, and menopause. “Alterations between estrogen and progesterone ratios lead to higher prevalence of insomnia at these times,” she explains. About two-thirds of perimenopausal women experience hot flashes, which can be especially disruptive during the first hours of sleep.
Hormones can also affect the development of seemingly unrelated sleep disorders. “Estrogen is protective against sleep apnea and breathing disturbances in the night,” says Winter. “Men tend to have more sleep apnea, but after menopause the prevalence in men and women starts to even out.” (Note: Testosterone doesn’t affect sleep quantity or quality, but a lack of sleep or poor-quality sleep will lower testosterone levels, because the body produces the majority of this hormone during REM sleep.)
Thyroid hormones can affect sleep too, adds Zee. Hyperthyroidism — the overproduction of the hormone — can be particularly insidious, leading to anxiety, rapid heart rate, and insomnia.
Working with an integrative hormone specialist can help solve the issue before it becomes chronic. “It’s so much easier to address the precipitating factors early on,” says Zee.
After Mann had struggled with insomnia for 15 years, a specialist recommended he come in for a sleep study. He was hooked up to sensors in a special room and told to go through his normal bedtime routine. The results were revelatory: He was waking up, on average, 20 times every hour, choking on his tongue. Sleep apnea was sabotaging his slumber.
The disorder is characterized by breathing that repeatedly stops and starts. The cause can be mechanical, such as an obstruction of the throat (as in Mann’s case), neurological, or both. Telltale signs include loud snoring, gasping for air, waking up with a dry mouth, and insomnia.
Up to 9 percent of American adults suffer from sleep apnea, according to the Sleep Foundation, and many more may be undiagnosed.
Physicians routinely prescribe the nightly use of a CPAP (continuous positive airway pressure) machine to treat the condition. This pushes air into the airway through a mask during sleep.
Yet the machine alone may not guarantee a good night’s sleep. Mann tried a CPAP machine but still struggled with waking repeatedly, even though he was no longer choking.
“The physiologic stress of waking up gasping for breath [for years] can lead to comorbid insomnia,” explains Buxton. “The CPAP only treats the apnea. You may also need insomnia treatment to unlearn that behavior of lying awake in bed.”
Genes seem to play a role in multiple aspects of sleep, including how much we need and a predisposition to insomnia. Researchers have discovered genetic variations in pathways associated with sleep and circadian rhythm that appear linked to insomnia, and a family history of insomnia is considered a risk factor for developing the condition. (Many experts feel direct-to-consumer genetic tests are of limited value in assessing whether you have a gene for insomnia; it may be simplest to assume that you may have inherited the tendency if it runs in your family.)
Tellingly, researchers have found significant overlap in genes associated with insomnia and those linked to depression and anxiety. This might help explain why CBT-I, which focuses on a person’s thoughts and emotions in addition to their sleep habits, can be such an effective treatment approach for insomnia sufferers.
If you’ve tried addressing all of the factors on your own but still struggle to get proper rest, Zee advises seeking out a sleep specialist for help.