How to Get Bad Sleep Back on Track

If you’ve ever lain in bed staring at the ceiling for what feels like forever, you know the pain of insomnia. The missed opportunity for sleep is bad enough, not to mention the worry about what it will mean for your performance the next day.

I’ve written elsewhere about the best way to treat chronic insomnia, which involves cognitive behavioral therapy for insomnia (CBT-I). If you’ve battled insomnia for years and have tried everything else, give CBT-I a try; if you’ve never tried treatment for your insomnia, CBT-I is a great place to start.

But how can we prevent chronic insomnia in the first place? To answer this question I spoke with Dr. Michael Perlis, a psychologist and sleep specialist at the University of Pennsylvania. Dr. Perlis works at the frontier of sleep medicine, and has played a key role in developing CBT-I; he’s the first author on a therapist guide for CBT-I entitled Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide.

Let’s start by distinguishing between two different types of insomnia.

What Is Acute Insomnia?
Insomnia means trouble sleeping, whether it happens at the beginning, middle, or end of the night. As Dr. Perlis explains, “Insomnia includes not being able to fall asleep or stay asleep, or waking up too early in the morning.” Those difficulties can last a short time (acute) or a long time (chronic), and the distinction matters. So what is acute insomnia?

Michael L. Perlis: Somewhere between a few days and two weeks of three or more days per week is often considered the threshold of acute insomnia. Some people go as much as a few days to three months before they call it “chronic,” so everything before three months is considered acute insomnia.

Acute Insomnia Is Very Common—and Most People Recover
Most of us have experienced acute episodes of insomnia, as you’ve probably heard the people you know describe from time to time. New research is confirming just how common acute insomnia is, and how likely it is that people recover before it becomes chronic.

MLP: We just finished a study of a national sample of about 1500 people who started as good sleepers. They completed questionnaires for us quite frequently: daily sleep diaries, weekly measures of insomnia. And we just watched. And it was astounding—in confirmed good sleepers, around thirty percent had acute insomnia in one year. In England the same study was done with a colleague of mine and he found fifty percent. That’s a lot of people. The interesting thing is, ninety percent of people who have acute insomnia recover.

Unlike Chronic Insomnia, Acute Insomnia Is Unrelated to Age
Acute insomnia is relatively “equal opportunity,” meaning it doesn’t discriminate by age—which raises important questions about its function.

MLP: There is a belief—and it’s true—that as we get older decade by decade, the rate of chronic insomnia goes up. One of the things I’m working on in the data set is to see if this humongous incidence of acute insomnia varies by age, but so far it doesn’t—which is really telling you something. If a humongous percentage of the population has acute insomnia now and again, like once every three or four years, and it doesn’t differ by age the way chronic insomnia does, which gets more and more prevalent with each passing decade—how “abnormal” is that? Popularity is not a great way to define normal, but it is a way, and if something is highly prevalent and doesn’t vary the way the chronic form of it does, you start to wonder if this is normal. And then you start to wonder, How could that be?

Acute Insomnia Is Usually Linked to Stress
So what causes acute insomnia? Many factors can be involved, and most of them involve stress. The stress may be related to physical pain, illness, worry, or that argument you had with your sibling earlier in the day. As Dr. Perlis points out, it makes sense that our bodies at times make sleep a lower priority. As the late Dr. Art Spielman, another major figure in the insomnia treatment, said, “Sleep is adaptively deferred when the lion is at the mouth of the cave.”

MLP: There has to be an override when there is perceived or real threat, to disable the normal governance of sleep, so that you can stay awake and run or fight. So acute insomnia is part of the fight-or-flight response, such that if you are under siege and at mortal threat, don’t sleep. And that’s a good thing.

But why would our brains override the sleep drive when stress is more psychological, like having big deadlines at work? Is that just a function of our stress response, which doesn’t distinguish between physical danger and psychological distress?

MLP: You can argue, “Maybe for the caveman living on the savannah, evolutionarily speaking, that was important….But now it’s not adaptive at all, it’s just bad. We’re responding with inappropriate levels of fight/flight response, of being adrenalized, because I’m worried about work? Because I’ve got some financial problems? Those are not life threatening. I shouldn’t lose sleep over that.” And I hear that, and maybe this is vestigial, or maybe it’s not. Maybe insomnia is what you’re begging for when you’re under stress. What is insomnia but the gift of more time? It’s what you’re begging God for—”If only I had a 40-hour day, I could get all this stuff done!” You asked, you got it. So maybe it’s still adaptive in its acute form