“How do people fall asleep? I’m afraid I’ve lost the habit, ”reflects the unnamed protagonist of Dorothy Parker’s short hours , published by The New Yorker in 1933.“ Go to bed early, and you wish you were dead. In bed before eleven, crazy before seven ”.
If you have also had difficulty sleeping, you will almost certainly recognize yourself in this frustration. The more we try to create suitable conditions for sleep, the more that seems to escape us; the very desire to fall asleep makes it impossible. Parker’s character experiences such anguish over unwanted wakefulness that he considers putting the lamp on his head.
The feeling is likely to be familiar to many: insomnia is a common complaint. It also has a great economic and health impact. Yet for decades, scientists have tried in vain to find a viable solution. In recent times, however, sleep research has exploded and helped identify the neurological and mental processes underlying insomnia. The deeper understanding of how the brain can cause this debilitating malaise means that a tipping point has been reached to cure it.
Basically, we now have more elements to understand why a person has difficulty sleeping and what is the best way to help them rest as desperately as they would like. “Insomnia is a solvable problem,” confirms Colin Espie of the University of Oxford.
Words that are sweet music to the ears of many. With insomnia spreading, it is likely that you (or someone close to you) can benefit directly from these new discoveries. According to various researches, one third of people regularly struggle to fall asleep and stay asleep.
To be considered insomnia, nocturnal restlessness must occur at least three times a week for a period of more than three months and, above all, the loss of sleep must not be linked to external factors, such as a baby’s crying or too many parties. . It must also compromise the performance of daytime activities, due to tiredness, irritability or difficulty in concentrating. About 10 percent of the world’s population meets these strict criteria, even though there are significant differences between men and women.
In an ideal world, one could fight insomnia with sleeping pills that are effective for everyone and free of side effects. But at the moment they don’t exist
Insomnia has repercussions on health: sufferers run a higher risk of developing depression, diabetes, cardiovascular disease and Alzheimer’s. But the financial implications are no less. In the UK, lost productivity due to insomnia is equivalent to 1.7 million working hours per year, with an economic impact of nearly $ 50 billion. In the United States, 9.9 million hours of work are wasted every year, for an economic damage of 411 billion dollars. Lack of sleep costs these countries around 2 percent of their gross domestic product. So how can we intervene?
In an ideal world, one could fight insomnia with sleeping pills that are effective for everyone and free of side effects. Unfortunately, these medicines do not yet exist. In early 2022, Andrea Cipriani and his colleagues at Oxford University reviewed published results on thirty sleeping pills, with a comprehensive meta-analysis of over 150 clinical studies.
The team of researchers determined that a drug candidate can be considered effective if it acts relatively quickly (within one month) and provides relief for at least three months, as well as being well tolerated.
The results were disappointing. In total, only two out of thirty drugs have been shown to bring both short- and long-term relief. One of these – eszopiclone – enhances the action of an amino acid called Gaba, which inhibits electrical signaling in neurons. Another – lemborexant – blocks the action of the neuropeptide orexin, which makes neurons extremely excitable. Both drugs have been approved in the US, but not yet in the UK.
It is significant that Cipriani’s team discovered that some of the most frequently prescribed drugs for the treatment of insomnia – including benzodiazepines, which also work through Gaba – do not appear to provide any long-term relief, while their unwanted side effects include daytime fatigue, dizziness, cognitive fog, and risk of addiction.
There are also pills that modulate the levels of the hormone melatonin or mimic its action in the brain: in people without insomnia, melatonin accumulates naturally as the day fades into night and decreases in the morning, thus regulating the sleep cycle. wakefulness. But Cipriani’s team has gathered very weak evidence about any significant even short-term benefits associated with these pills. “There is no point in prescribing them as a first-line treatment (ie administering them to patients who have never been treated with this therapy before),” concludes Cipriani.
While pills aren’t necessarily an answer for insomnia sufferers, neither are overly simplistic behavioral interventions. From the seventies until fairly recent times, the main option on this front was education in “sleep hygiene”, which involves the purchase of a comfortable mattress and good curtains, in order to make the bedroom as restful as possible, and advise against drinking coffee in the afternoon or watching TV in bed, to avoid feeling too awake when it’s time to turn off the light. They all seem like common sense choices, but they may not be particularly effective.
This is the result of a review published in 2021 of the results of 89 studies related to the treatment of insomnia, according to which sleep hygiene education as the only intervention produces barely an improvement in symptoms.
But there is a way to make a real difference. Psychologists today know that they need to pay much more attention to the mental processes that lead to insomnia. This aspect has been at the center of research since the 1990s and efforts are beginning to bear fruit.
Much of the study has focused on the idea that people with insomnia experience over-arousal fueled by ruminative thoughts that cause them anxiety and nervousness, making it more difficult to fall asleep when it’s time for bed, and can prevent them from getting into one. deep sleep, more likely to wake up during the night.
Today this theory is supported by various tests, related, among other things, to measurements of the structure and functions of the brain. In 2019, for example, Kira Vibe Jespersen and her colleagues at Aarhus University in Denmark showed that people with insomnia tend to have reduced connectivity between the frontal lobe, the part of the brain associated with self-control, and regions such as the insula , which are involved in the processing of emotions. “A consequence of this reduced connectivity could be greater difficulty regulating emotional states and stress responses,” says Jespersen.
The image of a ruminant brain getting high also matches the work published in 2021 by Yishul Wei and his colleagues at the Netherlands institute for neuroscience in Amsterdam. Researchers found that the brain activity of a person with insomnia is generally more immobile, therefore less able to vary. This “inertia,” the researchers concluded, could help explain the tendency of people with insomnia to get stuck in fixed patterns of negative and repetitive thoughts.
Worrying excessively about sleep loss and its consequences appears to worsen daytime symptoms of insomnia
As might be expected, rumination is likely to be particularly harmful if thoughts are focused on waiting for sleep, causing a state of intense arousal just when the subject would need to relax. It has also been shown that people with insomnia show increased activity of the amygdala (another area of the brain responsible for processing emotions) if something reminds them of sleep.
More importantly, worrying excessively about sleep loss and its consequences appears to worsen daytime symptoms of insomnia – which include fatigue and trouble concentrating – through a process known as the nocebo effect. Similar to its more benevolent twin, the placebo effect, the nocebo effect is a kind of self-fulfilling prophecy. When it comes into action, negative predictions lead to even more dire consequences than would otherwise occur.
Negative expectations Several observational studies provide evidence in line with this idea. The more those involved worry about lack of sleep, the more their symptoms get worse, regardless of whether they actually sleep well. Perhaps most significant is that the researchers have even managed to identify a group of “good dorms who complain”, that is, individuals who do not seem to suffer from any objective sleep deprivation, but who experience all the problems of tiredness and concentration of people. with insomnia as a result of their negative expectations. The worst situation, of course, is that of those who sleep little and worry excessively about the consequences, the “bad dorms complaining”.
The good news is that as we come to understand more clearly the causes of insomnia and the thoughts that cross the mind of those who suffer from it, effective psychological therapies are now available.
A proven solution is cognitive-behavioral therapy for insomnia (Cbt-i). If done face-to-face, it typically takes place over four to six sessions, during which the therapist discusses strategies for freeing oneself from rumination when it occurs. Rather than straining to sleep, for example, the patient may be advised to focus their thoughts on trying to stay awake.
This counterintuitive technique, called paradoxical intention, can reduce “performance anxiety,” leading to a faster fall asleep. The therapist will also help the patient to counteract negative beliefs about sleep deprivation when, for example, it begins to catastrophize the effects of even minimal disturbances. To be on the safe side, CBT-i also includes education in concepts such as sleep hygiene, which can be useful when combined with cognitive strategies. Overall, according to a recent review of studies, more than 70 percent of people show improvement in sleep after CBT-i, and 40 percent experience remission of insomnia.
Sleep Strategies Behavioral therapy for mindfulness -based insomnia (Mbti, awareness) is another rising star. As the name suggests, Mbti is based on the Buddhist principles of non-judgmental awareness and acceptance, and participants are trained to notice the thoughts and feelings they may experience as they approach falling asleep without necessarily trying to change them. “The way you relate to that thought is more important than the thought itself,” says Jason Ong, a former professor at Northwestern University of Illinois in the United States, pioneer of the technique and now responsible for behavioral sleep medicine. for the US company Nox health.
The passive observation of thoughts and the recognition of their fleeting nature aim to defuse some of the frustrations of those suffering from insomnia, preventing the person from being drawn into the rumination and worry that aggravate his discomfort. Clinical studies confirm this. A 2018 research showed that MBTI can significantly reduce the symptoms of insomnia, while a 2020 study confirmed that these benefits last even after the end of therapy.
Most researchers agree that each person’s insomnia differs in the details of causes and consequences. Over time, however, it may be possible to identify the specifics of each and predict which therapies will prove most useful.
Tessa Blanken of the University of Amsterdam has already taken some important steps in this direction. By analyzing a wealth of data on insomnia and its potential causes, she identified five distinct subtypes of the disorder, each with unique patterns of sleep arousal and daytime distress.
Earlier this year, Blanken showed that those with some of these subtypes are more likely to develop depression as a result of sleep deprivation and that their mental health can benefit particularly from CBT-i. In the future, she hopes these findings can help personalize care. “We could find out when specific factors are important to certain people and through what mechanisms a cure is effective,” says Blanken. “We would then be able to give precedence to who could get the most benefits from a given therapy.”
But it is unlikely that we will be able to hit the target anytime soon, especially due to the lack of available therapists. “For every professional trained in CBT-i there are thousands of patients,” confirms Daniel Gartenberg of Pennsylvania state university. This means that most people with insomnia continue to receive medication prescriptions, despite the evidence for psychological therapies. “It is not fair that there is such a widespread disorder and that a cure that has been proven effective is not available to everyone,” says Espie.
The discouragement of this situation has led more and more sleep scholars, including Espie and Gartenberg, to investigate whether our smartphones can hold the answer, thanks to sophisticated applications they provide (usually for a small fee) the kind of knowledge and advice that is usually offered by a therapist.
Sleep App Online therapy has some obvious limitations compared to the sessions in the presence. “The human relationship is very important,” says Cipriani. But the results of some recent trials show that these technological approaches are worth pursuing. Let’s take Espie’s Sleepio application for example.
The program includes a six-week course focused on CBT-i, with an artificial intelligence algorithm that helps to customize the application according to the patient’s behavior, recorded through an online sleep diary or via wearable devices. In May, the National Institute for Health and Care Excellence, which is part of the UK Department of Health and provides guidance to doctors on usable therapies, recommended that Sleepio be made available free of charge by the National Health Service, based on data from twelve studies. carried out in recent years.
In one such research, Espie says, the remission rate was over 70 percent. “Throughout my career we have always prescribed medicines to patients, so this is a real turning point.”
Gartenberg is testing a similar project with its SleepSpace app which, like Sleepio, tracks data from a patient’s phone or smartwatch to come up with a custom form of Cbt-i. In addition, during the night, through the speakers of the smartphone SleepSpace provides short, restful sound pulses, designed to induce the correct frequencies of slow brain waves associated with sleep, and can be connected to “smart lights” that change color to adapt to the phases of the sleep. circadian rhythm. According to Gartenberg, SleepSpace could be used in conjunction with qualified therapists or as a stand-alone treatment, as long as the ongoing trial yields positive results.
We may not have found a quick and easy solution to get rid of sleepless nights yet, but most people with insomnia should have access to good, evidence-based therapies early, without resorting to addictive pills. Dorothy Parker, if you wrote today, you could have the protagonist of her story put the lamp aside. There are currently better solutions than putting the bedside lamp on your head.
