If you’ve participated in therapy, you’ll know that one of the questions your therapist asks in the first session is “How are you sleeping?”. On the surface, it’s a simple question. But your answer provides your therapist with insight into your emotional functioning and directions for therapeutic treatment. In fact, it is likely that your therapist has asked about your sleep patterns at multiple points throughout your treatment.
So, why focus on the quality of your sleep?
Approximately one-third of adults living in the U.S. are sleeping less than the amount recommended by healthcare professionals. Of these adults, about 20% of them are also living with mental illness (Blackwelder, 2021). But, difficulty initiating and maintaining sleep does not automatically constitute insomnia. Specifically, we all experience difficulties with sleep from time to time. However, insomnia is characterized by persistent and pervasive difficulties initiating and maintaining quality sleep.
How is insomnia defined?
Per the DSM-5 (American Psychiatric Association, 2013), the following criteria is required for a diagnosis of Insomnia:
Dissatisfaction with sleep quality or quantity in at least one area:
Difficulty initiating sleep
Difficulty maintaining sleep (i.e. frequent awakenings and/or problems returning sleep after awakening)
Early-morning awakening with an inability to return to sleep
Symptoms occur for at least 3 nights per week for 3 months
The sleep difficulty occurs despite adequate opportunity for sleep
The sleep disturbance causes significant distress and/or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning
Meadows and Dimitriu (2023) also note that individuals experiencing insomnia often experience fatigue, poor memory, poor concentration/attention, irritability, hyperactivity/impulsivity, lack of motivation, low energy, and increased mood swings. Diagnosis of insomnia usually involves a medical exam and questionnaire. Additionally, providers may recommend a sleep study to rule out more serious sleep disorders including apnea (Meadows & Dimitriu, 2023).
What are the effects of insomnia on mental health?
Unfortunately, the effects of insomnia can be pervasive and numerous in nature. Blackwelder et al. (2021) found in their study found that individuals who averaged less than 6 hours of sleep per night were approximately 2.5 times more likely to experience frequent mental distress. Similarly, Suni and Dimitriu (2023) note that poor sleep quality can be contributed to worsening mental health problems. Specifically, they state that approximately 75% of individuals experiencing depression also endorse experiencing symptoms of insomnia. Furthermore, they note poor sleep has the potential to activate anxiety-based symptoms and may contribute to the development of anxiety disorders (Suni & Dimitriu, 20223).
In contrast, Scott et al. (2021) found that improving sleep is related to improvements in physical health, including fatigue and chronic pain. Authors also highlighted a causal relationship between sleep quality and mental health functioning, noting that improvements in sleep positively impacted mental health (Scott et al., 2021). Interestingly, improvements in sleep quality were associated with improved mental health functioning regardless of the severity of the mental health difficulty (Scott et al., 2021). Suni and Dimitriu (2023) also state that REM sleep assists in the processing and consolidation of emotion, especially positive emotion.
How can my therapist help me with insomnia?
At this time, Cognitive Behavior Therapy for Insomnia (CBT-I) is one of the most widely recommended therapeutic options to treat insomnia. Similar to traditional CBT, CBT-I is designed to be a time-limited therapeutic approach, with most treatment courses requiring 6-8 sessions (Newsom & Dimitriu, 2023). CBT-I focuses on psychoeducation, cognitive interventions to address maladaptive thoughts associated with sleep, and behavioral interventions (Newsom & Dimitriu, 2023). In fact, Rossman (2019) notes that CBT-I is the most effective, non-pharmacological, treatment to improve the quality and quantity of sleep. Additionally, Rossman (2019) finds that CBT-I results in decreased regression in sleep and that the positive benefits tend to be long-term in nature. Furthermore, Newsom and Dimitriu (2023) note that CBT-I may be more effective than medication management of sleep.
Independently, there is quite a bit that you can do to improve your sleep as well. When reviewing sleep patterns and sleep hygiene with my own patients, I encourage them to create a consistent bedtime routine and sleep schedule. Additionally, it is often helpful to create a sleep space that is free of chaos and stimulating items (i.e. televisions, computers, cell phones, etc.). Individuals should also consider limiting their alcohol intake, increasing engagement in physical activity, and limiting screen time to assist in improving sleep patterns.
Additionally, The National Sleep Foundation recommends that individuals limit the time they spend in bed lying awake (Newsom & Dimitriu, 2023). If you are having difficulty falling asleep, it is often more helpful to get out of bed and engage in a low-stimulating activity (I often tell my patients to fold their laundry or wash their dishes) and try to initiate again sleep after 20-30 minutes. It is also beneficial to avoid daytime napping as much as possible as it will interfere with the quality and quantity of sleep.
The experience of insomnia is frustrating and has far-reaching impacts on your emotional, physical, professional, and relational functioning. Research has found clear links between mental health concerns and the quality of sleep. As such, it is vitally important to learn strategies to ensure a good night’s sleep as much as possible. If you are experiencing difficulties managing your sleep independently, reach out to your therapist to learn strategies to help!
About the Author
Dr. Montes is a licensed clinical psychologist and co-owner of Cognitive Behavior Therapy Center in Chesapeake, VA.
References
American Psychiatric Association. (2013). Diagnostic and statistic manual of mental disorders (5th ed.). American Psychiatric Publishing.
Blackwelder, A., Hoskins, M., & Huber, L. (2021, June 17). Effect of inadequate sleep on frequent mental distress. Centers for Disease Control and Prevention. Retrieved March 28, 2023, from http://www.cdc.gov/pcd/issues/2021/20_0573.htm
Freeman, D., Sheaves, B., Goodwin, G., Yu, L.-M., Nickless, A., Harrison, P., Emsley, R., Luik, A., Foster, R., Wadekar, V., Hinds, C., Gumley, A., Jones, R., Lightman, S., Jones, S., Bentall, R., Kinderman, P., Rowse, G., Brugha, T., … Espie, C. (2017, September 6). The effects of improving sleep on Mental Health (OASIS): A randomised controlled trial with mediation analysis. The lancet. Psychiatry. Retrieved March 28, 2023, from https://pubmed.ncbi.nlm.nih.gov/28888927/
Meadows, A., & Dimitriu, A. (2023, March 3). Treatments for insomnia. Sleep Foundation. Retrieved March 28, 2023, from http://www.sleepfoundation.org/insomnia/treatment
Newsom, R., & Dimitriu, A. (2023, March 3). Cognitive behavioral therapy for insomnia (CBT-I). Sleep Foundation. Retrieved March 28, 2023, from http://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia
Rossman, J. (2019). Cognitive-behavioral therapy for insomnia: An effective and underutilized treatment for insomnia. American Journal of Lifestyle Medicine, 13(6), 544–547. https://doi.org/10.1177/1559827619867677
Scott, A. J., Webb, T. L., Martyn-St James, M., Rowse, G., & Weich, S. (2021). Improving sleep quality leads to better mental health: A meta-analysis of randomised controlled trials. Sleep Medicine Reviews, 60, 101556. https://doi.org/10.1016/j.smrv.2021.101556
Suni, E., & Dimitriu, A. (2023, March 17). Mental health and sleep. Sleep Foundation. Retrieved March 28, 2023, from http://www.sleepfoundation.org/mental-health
Treatments for insomnia. Stanford Health Care (SHC) - Stanford Medical Center. (2019, July 1). Retrieved March 28, 2023, from https://stanfordhealthcare.org/medical-conditions/sleep/insomnia/treatments.html