Sleep Awareness, Normal Range, and Insomnia

Source: Photo by Elijah O'Donnell on Unsplash

Welcome back! I realize that this post’s topic is not the one promised, but I also realize that it may be puzzling why the allocation of behavioral and mental resources towards getting better sleep was identified as problematic in the last post. Just about all sleep-related talks and publications urge us to make sleep a priority, to be more aware of the need for healthy sleep and the negative consequences of inadequate sleep. How can taking this urge seriously cause or “perpetuate” insomnia? Please let us have a clear answer before we delve into individual perpetuating factors: it’s not taking the urge to increase sleep awareness seriously, it’s taking it out of the context that perpetuates insomnia.

Indeed, insufficient sleep is found in over a third of the population, and reaches about 60-70% prevalence in some groups (e.g., adolescents/young adults and shift workers, 2017a, 2017b, 2014). Indeed, there are multiple individual and social problems of various degrees of gravity that are associated with insufficient sleep. However, insomnia as a disorder is estimated to affect about 5-15% of adults (2015). A rough approximation tells us that about twice as many people don’t get enough sleep not because sleep doesn’t come to them, but because they don’t or can’t take time to sleep. Think of how often you hear variants of “who needs sleep if there is caffeine?” posited jovially and self-assuredly. And think of how often you hear someone say, “I told my boss I couldn’t meet the deadline because I have to make sure I get enough sleep.”

Sleep may be viewed as something secondary even by healthcare professionals. A friend of mine was recently told by a provider not to interfere with his adolescent child using a laptop in bed past midnight, because the provider was in the habit of doing the same thing, with no apparent ill effects. While allowing an adolescent autonomy is an important family goal, I doubt any provider would have told a father not to interfere with his child smoking on the pretext that the provider is also a smoker. The difference is simple: within the last half a century, deleterious effects of smoking have been well recognized medically, legally and socially, while a comparable recognition of deleterious effects of insufficient sleep is still underway—in the society at large. But for an individual grappling with insomnia, this recognition is often heightened to an unhelpful degree.

To consider another example, the notion of healthy eating is applicable to everyone, but nobody would think to talk about dangers of obesity to a group of people battling with anorexia. This observation brings us to the idea of a normal range, the extreme “tails” that lie outside of the normal range, and different approaches that people falling into the opposite extremes may require to reach the healthy middle. We previously discussed how behaviorally induced insufficient sleep and insomnia can be viewed as two opposite extremes.

The concept of a biological function as a range allows us to appreciate differences between individuals and variations in one individual over time. Compare sleep requirements with requirements for caloric intake and exercise. No one consumes 2,000 calories per day every day. The recommended amount of exercise would differ greatly between a young athlete preparing for a competition and a middle-aged person who recently sustained a leg fracture. Sleep, as a biological function, is similar. When asking how much sleep is necessary, people often expect to hear a single numeric requirement that must be met on every single night. However, it may be better to think of the recommended amount of sleep as a range of values that may vary depending on the individual and the situation.

This “range-based” approach also helps recognize that the desired goal is achievable via steady progress rather than through a sudden change. Although the benefits of physical exercise are regularly extolled by healthcare providers, a person with a fractured leg would be advised not to exercise to avoid further injury. The healing process would commence with wearing a cast, proceed with physical therapy, and only then graduate to slowly reinstating the exercise routine.

Similarly, after an acute bout of difficulty sleeping that occurs commonly (43%-50% of adults report at least one symptom of insomnia, 2011, 2008), a person would be advised not to try too hard to sleep in order to avoid long-term insomnia. “Trying too hard” in this case would mean, among other things, going to bed earlier, staying in bed later, and reclining in the middle of the day in attempt to compensate for previously unattained sleep as soon as possible. “Just the right amount” of effort would entail, among other methods, keeping a consistent and relatively short bedtime schedule with the goal of gradually returning to the healthy middle section of the sleep range. In the next post, we will focus on how the intuitive desire to stay in bed and wait for sleep longer actually perpetuates insomnia, and how the counter-intuitive recommendation to stay out of bed when awake helps treat it.