Sleep Deprivation Vs. Insomnia

Source: Braden Collum371610/Unsplash

Sleep deprivation is named by health care professionals and public media as a leading cause of various health problems, cognitive deficits, and accidents. The phrase “sleep deprivation” is also frequently used by people suffering from chronic insomnia to describe their condition. However, thinking of insomnia in terms of “deprivation” may become an obstacle in the course of insomnia therapy.

The term “deprivation” implies the lack of opportunity to satisfy an important physiological need. For example, famine can be called “food deprivation.” On the contrary, the definition of chronic insomnia, according to the International Classification of Sleep Disorders (2014), relies on “having adequate time and circumstances each night to obtain necessary sleep.” Therefore, it is not the lack of opportunity but rather the difficulty sleeping in spite of adequate opportunity that is a key feature of insomnia. If we extend the comparison with food consumption, we can liken insomnia to a food allergy or a gastrointestinal (GI) condition that prevents one from absorbing the nutrients appropriately or makes one ill while trying to eat. A solution for food allergy or a GI condition is to regiment one’s diet so as to avoid certain types of food. A solution for insomnia? To regiment when and for how long one is allowed to sleep!

If you, like many people, have struggled with tossing and turning in the middle of the night, I am quite certain you have heard the advice to get out of bed after about 20 minutes of wakefulness. This recommendation is actually an integral part of the Cognitive Behavioral Therapy for Insomnia (CBT-I), which has been identified by the American College of Physicians (2016) as the first line therapy for this condition based on the review of 11 years of randomized controlled trial data. If you have spent time and effort trying to figure out how to catch that elusive sleep, the recommendation to get out of bed and stop trying for a while probably makes you feel apprehensive. Indeed, if you think of your difficulty sleeping as “deprivation”, you are likely to feel increased anxiety at the notion of having to abandon the only way you know how to satisfy the need for sleep. Imagine how a starving person would feel seeing the food being taken away! The apprehension, triggered by the idea of deprivation, will get in the way of the well-supported therapeutic practice.

To eliminate this unhelpful apprehension, let us consider some evidence for the difference between insomnia and sleep deprivation. The latter has a technical name–Behaviorally Induced Insufficient Sleep Syndrome (BIISS). This is the category comprised of people who go to bed for just a few hours in a 24-hour period; multiple occupational and family demands, overbooked schedules, or simply sacrificing sleep for more desirable activities are typically the culprits. One study (2009) showed that people with BIISS, when tested during repeated naps in the laboratory, fell asleep significantly faster than normal good sleepers, edging towards the quickness seen in narcolepsy, which is consistent with the idea of recovery from externally imposed deprivation. By contrast, another study (2011) found that people with insomnia took significantly longer than good sleepers to fall asleep on the same type of nap test, showing intrinsic difficulty to utilize the available time in bed.

One might argue that not sleeping enough may have the same consequences for health and performance, regardless of whether causes are external or internal. Without directly challenging this argument, I invite you to note one more piece of evidence: When patients with chronic insomnia are externally kept awake and end up getting less sleep than their usual amount, their ability to sleep quickly improves. This result, first obtained 20 years ago (1998) and more recently confirmed under a procedurally different but conceptually similar protocol (2017), informs the clinical wisdom that different sleep issues have to be addressed with different techniques. People with BIISS have to be reminded to make sleep a priority and allocate more time to be in bed. The recommended approach to insomnia, on the other hand, involves such techniques as going to bed only when feeling ready to sleep, and getting out of bed when sleep does not occur promptly. If this is the advice your health care professional gives you, please do not dismiss it because of the concern about consequences of “sleep deprivation.” Such a concern only serves to escalate anxiety and sleeplessness. Instead, try thinking of the difference between the externally imposed sleep deprivation and insomnia, and remind yourself that a measured temporary curtailment of the opportunity to sleep actually improves insomnia in the long run. Keeping the long-term goals in mind is the best way to ensure the consistency of positive change and the success of CBT-I.