Not being able to sleep can feel like torture.
It makes night time a misery, and everyday life feel like a constant battle.
More worrying still is that a lack of sleep has been implicated as a cause of chronic illnesses ranging from heart disease to depression and even obesity.
Scary stuff, right?
Although an inability to fall or remain asleep, or waking up to earlier than one likes, is generally referred to as insomnia, the problem can have a number of different causes.
Therefore an effective treatment will vary from person to person.
With this in mind, here is everything you ever wanted to know about why you cannot get to sleep, and the best ways of restoring an ideal sleep pattern no matter what the underlying cause of your insomnia is.
This will include how to identify and change habits that hamper sleep, how to combat night-time anxiety, and six easy to implement tips to help you sleep better tonight.
What is insomnia?
When most people think of insomnia they think of agonizing over an alarm clock until 5am.
However, the problem can actually take a number of different forms.
Insomnia can refer to having difficulties in falling asleep and/or staying asleep for as long as needed.
Such difficulties may manifest itself differently in different people, especially given the fact that different people need different amounts of sleep to function properly.
Rather than the amount of sleep you get, a key symptom of insomnia is regularly not being able to get enough sleep to function at our best.
Although everyone goes through periods where they struggle to get enough sleep, if your sleeping difficulties last for more than one month and happen three or more times a week, then it is likely that you have insomnia.
What causes insomnia?
Insomnia can have a multitude of causes, often working in combination with each other.
These causes broadly fall into three categories: behavioural, psychological and physiological.
Let’s explore these further:
Behavioural causes of insomnia
This refers to the things that you do which (knowingly or otherwise) hamper your ability to sleep at night.
This can include actions you take during the day, as well as your pre-bedtime ritual, and how you keep your sleeping environment itself.
These behavioural factors make up the often talked about concept of sleep hygiene.
Below is a checklist of all the most common behavioural causes of insomnia. They are all habits that you should be avoiding to ensure good sleep hygiene.
How many apply to you:
- Do you drink caffeinated drinks (tea, coffee, energy drinks etc) after midday?
- Do you regularly drink alcohol in the evening?
- Do you eat within two hours of going to bed?
- Do you go to bed at irregular times (outside of a one hour timeframe, including weekends)?
- Do you exercise within 3 hours of going to bed?
- Do you smoke within 2 hours of going to bed?
- Do you spend a lot of time in bed or in your bedroom outside of bedtime hours?
- Do you have the time visible when you sleep?
- Do you use a screen (phone, tv or computer) in bed?
- Do you use a screen within an hour of going to sleep?
- Do you sleep with a pet, or with objects on your bed?
- Do you change your bed sheets less often than once a week?
- Is your bed too hard or too soft?
- Do you do any work related activities within 2 hours of going to bed?
- Do you take naps over 30 minutes in length during the day?
- Is there any light coming into your bedroom at night?
- Could your bedroom be quieter at night
- Is your bedroom too warm at night?
In short, you should aim to have a regular sleeping pattern, have your bedroom optimized for sleep, and avoid stressful or stimulating activities several hours before you go to sleep.
The more you identify and eliminate the above bad sleeping habits, the less likely you are to experience insomnia.
Psychological causes of insomnia
Psychological causes of insomnia refer to the thoughts and worries that prevent you from being calm enough to fall asleep.
In the past, there were evolutionary benefits of not being able to sleep when under stress.
During our hunter-gatherer days, we would usually experience stress when we perceived a threat to our safety.
During such periods we would need to be awake in order to eliminate these threats.
Otherwise we would not survive.
For better or for worse, we now live in a world where our most of our stressors are not immediate threats to our safety.
Therefore, rather than staying awake, we are best equipped to eliminate the causes of our stress if we have a good nights sleep and are at our best the following day.
Unfortunately our brains have not adapted to this phenomenon. This is why rates of insomnia are increasing decade on decade
It’s a scary fact, but there are things we can do about it:
In the vast majority of instances, insomnia is the result of certain behavioural and psychological causes that reinforce each other.
The vicious cycle that characterises some of the psychological causes of insomnia
An example of this would be an individual who cannot fall asleep due to stress from work (psychological cause), this leads him to drink in the evening, which further disrupts his sleep (behavioural cause).
As he becomes more sleep deprived, our individual becomes more anxious about work, making it even harder to fall asleep (psychological cause).
The cycle can be a vicious one.
Fortunately, as the behavioural and psychological causes of insomnia are so interlinked, eliminating the behavioural causes of insomnia should fight the psychological causes, and vice versa.
That being said, the psychological causes of insomnia are usually the toughest to overcome.
Any useful attempts to do so will generally involve either controlling the physiological manifestations of stress, diffusing uncomfortable thoughts and feelings, or learning to associate your bedroom with sleep only.
Controlling the physical manifestations of stress
Stress and worry, like all emotions, are a combination of physiological (in your body) and psychological (in your mind) factors.
The physical manifestations of stress include:
1) Increased heart rate 2) Increased sweating 3) Dry mouth 4) Needing to use the toilet more often than usual 5) Tight stomach 6) Faster breathing
Such visceral stimulation takes your body further away from the state that it needs to be in to get to sleep.
Certain techniques can be employed to lessen these physiological manifestations of stress and therefore calm your body towards a restful sleep.
These are:
1) Concentrating on taking deep, regular breaths can slow heart rate and breathing.
Heart rate and breathing are closely connected. Breathing deeper will slower your heart rate. Additionally, concentrating on your breath may help put anxiety-provoking thoughts out of your mind. This is a technique used in mindfulness
2) Stay hydrated to mitigate the effects of sweating and dry mouth.
Sweating can dehydrate you, which can lead to night time awakenings, increase the risk of sleep-apnoea, and cause headaches when you wake in the morning. Similarly the discomfort of a dry mouth can stop you from getting to sleep. Always have a large glass water beside your bed to avoid having to get up. You should also try to drink at least 300 millilitres of water soon after you wake up.
3) Sleep in a cool room
Increased heart rate can increase your body temperature. This can hamper your ability to sleep. The ideal temperature for sleeping is between 16 and 18°C (60-65°F).
Keeping your bedroom cool may improve your sleep
Letting go of the stressful thoughts that cause insomnia
Controlling your thoughts is difficult.
If it were easy, then no one would suffer from stress and anxiety.
As our scientific understanding of psychology grows, we are getting a better understanding of how to manage our thoughts in order to not feel overwhelmed or negatively affected by them.
Many insomniacs report that an inability to sleep stems from a feeling of helplessness.
This often starts with a problem from work, school, or one’s personal life.
Naturally, you want to solve such problems as soon as possible, and they swirl around your head until a solution is found.
As these racing thoughts prevent you from getting to sleep, a new helplessness creeps in as you start to feel hostage to your anxieties, unable to get the rest you need to effectively solve them the following day.
The feeling of helplessness builds and builds, leading to frustration with yourself and taking you even further away from the calm state necessary to get to sleep.
Sound familiar?
This describes so many people’s night-time struggles because ultimately no-one has complete control over their thoughts.
This means that our ability to overcome the anxiety that keeps us awake necessitates that we accept that our stressful thoughts exist and to try and understand them for what they are- just thoughts.
Understanding what your thoughts are (i.e. often your most negative interpretation of a situation), why you have them, and what they are not (an objective reality) can help take the sting out of your sleep inhibiting thinking patterns.
Coming to such insights may require help from a professionally trained therapist.
Acting on what you can control, and letting go of what you cannot
When asking insomnia sufferers what worries keep them up at night, the most common answers you hear are:
1) Work and financial problems 2) Health concerns 3) Worries about children and family 4) Frustration at their inability to sleep
The common theme across all these matters is that they all are largely made up of elements that are beyond our control.
Take a common work problem, namely: having competing deadlines and not feeling like we have enough time to meet them.
Although some stress over this problem is necessary to motivate yourself to alleviate the stress by completing the tasks, the majority of our time spent worrying about this particular problem is probably spent stewing over matters that we cannot control.
This can include negative thoughts such as:
1) “I wish my boss hadn’t set such unrealistic deadlines” 2) “How did I find myself in a job which is this stressful” 3) “I’m not intelligent enough to do my job properly” 4) “If I do not complete these tasks then I will miss out on promotion” 4) “If I do not get eight hours sleep, then I cannot do my work tomorrow” 5) “I could have done more at work today”
All of these are worries about things that they cannot control.
They therefore do not have any motivational value, as the worry cannot be alleviated through our personal action.
Rather, we must focus on what we can control, act in away that makes these factors as pleasant as possible, and try to let go of everything else.
Below is a table of how we can do this with the above examples:
| Useless worries: | Distinguishing between what we can and cannot control: | Acting on what we can control: |
|---|---|---|
| “I wish my boss hadn’t set such unrealistic deadlines” | “I cannot control what my boss does, but I can give him feedback on how he manages me.” | Speak to your boss about why you are finding these deadlines tough and how you can be supported |
| “How did I find myself in a job which is this stressful” | “I cannot change my job overnight but I can find ways of managing my workload and stress” | Try to find stress reducing activities and practices to do outside of work. Talk to you boss and/or colleagues about your stresses |
| “I’m not intelligent enough to do my job properly” | “I realise that I am finding work very overwhelming and am having self-doubts, but I need to continue giving my all” | Continue putting in full effort at work and ask for help with things you are finding hard. |
| “If I do not complete these tasks then I will miss out on promotion” | “I cannot control if I get promoted or not, I just need to put everything into my work and let the relevant people know if deadlines are missed” | Tell your boss if you are struggling to hit deadlines and make a contingency plan |
| “If I do not get eight hours sleep, then I cannot do my work tomorrow” | “I cannot control exactly how much sleep I have but I will be more likely to sleep if I relax” | Focus on your breath and on relaxing rather than watching the clock. |
| “I could have done more at work today” | “I cannot change what happened today, only what I do tomorrow” | Reflect on what went wrong today and make sure it doesn’t happen tomorrow |
Focussing on what you can control rather than what you cannot has the double effect of reducing unnecessary worries and focussing your mind on the most important goals, which should in turn give you less to worry about.
Clearly, changing the way you think isn’t easy.
Fortunately, there are trained professionals who can help you develop techniques to do this effectively.
The role of a sleep therapist
A sleep therapist will help you identify what behaviours are contributing to your sleep problem.
Together you will also explore what thoughts and emotions show up around not sleeping (at night and perhaps during the day).
The sleep therapist will then teach you skills and tools how to deal with your thoughts and emotions more effectively.
Together, you will develop an action plan and set goals for implementing your new strategies into your daily life.
This will encompass psychological therapies, as well as developing routines and behaviour that promote regular sleep.
Learning to associate your bedroom with sleep
One way that the mind functions is by forming associations between one’s environment, and the way that one ought to behave.
For example, when in an office environment, you are more likely to act in a formal, professional manner than if you are down the pub.
Your bedroom environment will also carry some sort of association for you.
This association will be based on past experiences that you have in these surroundings.
Therefore, in order to associate your bedroom with sleeping, and feelings of relaxation and sleepiness, you need to use your bedroom for as little as possible other than sleeping.
This means that you should try to keep activities such as watching TV, using the computer, working, and other leisure activities outside of the bedroom as far as possible.
Keep your TV out your bedroom
Doing this should, over time, form an association in your mind between your bedroom and sleep, therefore automatically priming your body to get ready for sleep as soon as you enter your bedroom.
Doing as little as possible other than sleeping in your bedroom is just one aspect of maintaining good sleep hygiene, a series of habits that correlate highly with good sleep.
Click here to find out more about sleep hygiene.
Physiological causes of insomnia
Difficulty sleeping and daytime sleepiness can be a side effect of a large number of physical and medical problems.
Additionally, problems with sleep may also occur as side effects of common over the counter and prescription medications.
The most common health problems that can cause disrupted sleep and daytime sleepiness are:
- Diabetes: Diabetes can cause you to feel very hot or tingly at night, due to nerve damage. It can also cause night sweats and excessive urination, which can disrupt sleep.
- Heartburn and acid reflux: Pain from heartburn can become worse as you lie down. Acid reflux can also wake you up if it occurs when you are asleep. You can minimize these problems by avoiding eating within 3 hours of going to sleep, or by elevating your head when you sleep.
- Asthma: Coughing, weezing, and shortness of breath can make it hard to sleep, and can wake you up at night.
- Chronic pain: Chronic pain has the double effect of making sleep difficult, and making everyday tasks more energy consuming. Sufferers of chronic pain therefore are often fatigued. Additionally, recent research indicates that conditions associated with common pain such as fibromyalgia have difficulties achieving the deepest stages of the sleep cycle, which worsens the quality of their sleep.
- Sleep apnoea: Sleep apnoea is characterised by airways closing during sleep. This makes it difficult to breath during sleep, causing rapid awakenings that, although too fast to remember, disrupt the sleep cycle. This worsens one’s quality of sleep leading to excessive daytime sleepiness. Fortunately, most cases of sleep apnoea can be treated by wearing a specialised sleeping device that can be made by a dentist.
Dental Appliance for sleep apnoea
6) Thyroid disease: An overactive thyroid stimulates the mind and body, making sleep difficult. An inability to relax and lie still, as well as overheating and night and night sweats can be indicative of an overactive thyroid. Sufferers of an underactive thyroid can experience excessive daytime sleepiness, even if they sleep well at night.
7) Heart disease: Heart disease can cause a sufferer to wake up in the middle of the night short of breath, therefore worsening the quality of their sleep. Sleep apnoea is also more common in people with heart disease.
Additionally, the anxiety caused by having such health conditions can cause insomnia.
Due to the many causes of insomnia, difficulty sleeping, and excessive daytime sleepiness alone should not be enough to warrant fears of having any of the above health conditions.
Medications that can disrupt sleep
Below is a table of medications which are known to make sleep difficult or cause excessive daytime sleepiness.
If you believe that your medication may be causing sleep problems, please talk to your doctor about possible alternative medications.
Can I use sleeping pills to treat insomnia?
While sleeping pills can offer relief when you’re staring at the ceiling at 3a.m. with nothing but an impending sense of doom for company, they should not be seen as a long-term solution to treat insomnia.
Both over the counter and prescription pills can be used occasionally when sleep is completely impossible, such as when you are jetlagged or after several nights without sleep.
In the UK, there are three main categories of sleeping pills available.
These are: over the counter medication that cause drowsiness, prescription sleeping pills and natural sleeping aids.
Each work in a slightly different way, and have their own set of side effects.
Over the counter sleep medication
Certain medications that can be purchased at pharmacies without a prescription cause drowsiness as a side effect.
Because of this, they can offer a short-term solution to insomnia.
In the UK, the most commonly available medications of this kind are anti-histamines diphenhydramine (Nytol) and promethazine (Phenergan, Sominex).
These are primarily used to treat allergies such as hay-fever, but also can induce sleepiness in users.
If you are using anti-histamines to combat insomnia, please be aware that not all of them have drowsiness as a side-effect. Please check the back of the label if you are unsure of this.
Anti-histamines should not be used as a long-term solution to insomnia for several reasons.
Firstly, the drowsiness that it causes lasts for a long time, leading to excessive daytime sleepiness, difficulties concentrating, and blurred vision the following day.
As this is what insomnia ultimately causes, using anti-histamines as a long-term solution to it is ultimately futile.
Furthermore, chronic anti-histamine use can cause damage to your liver and kidneys.
Anti-histamines should also be avoided if you have a number of conditions including epilepsy, an enlarged prostate, or glaucoma.
Please consult your pharmacist before using anti-histamines to treat insomnia.
Prescription sleeping pills
Sleeping pills are prescribed in the UK to treat acute insomnia.
They are seen as a short-term “easy fix” to sleeping problems.
They should not, however, be seen as a better alternative to psychological and behavioural interventions.
This is because these psychological therapies have much better long-term outcomes for insomnia than masking the problem with sleeping pills.
In the UK, there are two main types of prescription medications used to treat insomnia.
These are:
Benzodiazepines: These include diazepam, clonazepam and lorazepam, among others.
Z drugs: These include zaleplon, zolpidem and zopiclone.
Both drugs act in a very similar way and have similar problems associated with them.
These include:
Addiction potential: Both Z drugs and (to an even greater extent) benzodiazepines can be physically and psychologically addictive. Withdrawal symptoms including anxiety, tactile hypersensitivity, and heart palpitations.
Decreasing quality of sleep: These kinds of sleeping pills promote drowsiness at the cost of suppressing our ability to achieve the deepest stages of our sleep cycle. This includes the REM sleep that is vital to sleep’s restorative affect on us.
Causing drowsiness the day after use: Many of these prescription sleeping pills have a long half-life, meaning their effects are felt the day after they are taken. Drowsiness and an inability to concentrate are often reported the following day after use. This is further compounded by their negative affects on the quality of our sleep.
Tolerance following long-term use: People who use these drugs on a long-term basis build up a tolerance to it, meaning that they need to take more of it to achieve the desired affect. This can lead to overdosing on these drugs, which can (in the worst possible cases) cause respiratory depression and even death, especially when used in conjunction with alcohol.
Blackouts: Both benzodiazepines and Z Drugs can cause “blackouts” where you behave in a disinhibited way, and often cannot remember what you have done afterwards. While in this state you cannot take responsibility for your actions, and can behave in bizarre and dangerous ways. This can include violent and destructive behaviour, excessive eating or drinking, driving while intoxicated, and being verbally abusive to others.
If you believe that you have suffered a “blackout”, please contact your GP immediately.
In addition to all these possible side affects, sleeping pills merely mask the problem of insomnia, rather than solving its root cause.
Because of this, it cannot be seen as a long-term solution to insomnia.
Natural sleeping aids
These refer to substances that boost the production of chemicals naturally created in the body to promote sleep.
The thought behind them is that boosting one’s levels of particular chemicals will further promote sleep, without the side effects that come with putting unnatural chemicals into your body.
There are a large number of natural sleeping aids available.
The most commonly used ones include: chamomile and lemon balm. Both of these can be drunk in teas.
Melatonin is another natural sleeping aid with relatively sound evidence behind its ability to promote sleep.
However melatonin is currently only available on prescription in the UK, under the trade name Circadin.
Much like with other prescription sleeping aids, melatonin is only ever prescribed for short-term use.
Although none of the natural sleeping aids listed above are known to have dangerous side effects, believing that something being natural automatically implies that it is benign is simply a misnomer.
Nicotine grows naturally, but we all know that it is bad for your health, for example.
Furthermore, these natural sleep aids also do not solve the root problem of one’s inability to sleep.
Therefore they are not the best long-term solutions to the problem and pale in comparison to psychological and behavioural interventions.
What to do now? 6 actionable tips to help you sleep better
To finish, here are 6 steps you can easily take today to help improve your sleep.
The benefits of these should be felt within days of implementing.
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Here they are:
1) Optimize your bedroom for sleep
Your sleeping environment makes a huge difference to your quality of sleep. Studies have shown that we best sleep at temperatures between 16 and 18°C (60-65°F), with as little light and noise as possible.
Therefore, it may be well worth buying a (quiet) fan to cool your room down, as well as blocking out light with black out blinds or an eye masks.
You can also reduce the light in your room by turning electrical devices off, and by turning your digital alarm clock away from you. This should also make your sleeping environment quieter, as any background buzzing emitted by these devices will be stopped.
Finally, it is worth making an honest assessment of the comfort of your bed and making adjustments to the mattress, duvet and pillows if necessary.
If you want completely new bed, please visit the National Bed Federation for advice on how to find the perfect bed for your body.
2) Designate your room for sleep and sex only
You sleep better when you associate your bedroom with sleeping and nothing else.
In order to do this you must do as little in your bedroom other than sleeping as possible.
Move non-sleep related activities (other than sex) that you do in your bedroom to other parts of the house.
At the very least you should make sure that any stressful, work related activities should be kept out of the bedroom.
Working and sleeping in the same immediate space promotes rumination over work when trying to sleep.
If such anxieties regularly keep you awake at night, than making such changes should help you have a better nights sleep.
3) Move stimulating activities to earlier in the day
To get to sleep, we need to be in a calm physiological state, with slowed heart rate, slowed breathing, and slightly lowered body temperatures.
Many activities stimulate the body, taking it further away from the state needed to get to sleep. These activities include work, exercise, drinking caffeinated drinks, smoking and drinking alcohol.
Try to avoid coffee after midday
Importantly, the stimulating effects of these activities continue in the body long after the activity itself is done.
Therefore, you shouldn’t do anything that stimulates the body within 90 minutes of going to bed.
The effects of caffeine in particular are long lasting, so it should be avoided after midday. This includes English tea, which has almost as much caffeine in it as coffee.
Try to move such activities to earlier in the day, and do more relaxing activities such as reading or meditation before you go to bed.
4) Write down any anxieties you have, and keep them somewhere other than your bedroom
It is impossible to avoid anxiety. Sadly it is part of being human.
What we can do, however, is to try and let go of these anxieties when we go to bed.
One technique to do this is to physically lock these anxieties away outside of your sleeping environment.
To do this, write down whatever thoughts are making you anxious, and put these away in a room other than your bedroom.
As you do this, make a promise to yourself not to think about these worries until you come back and read them the next day.
Not only should this help you empty your mind of your worries before bed, but it should also help you prioritise your goals the next day to solve whatever problems are making you lose sleep.
5) Cut out blue light in the evening
Studies at the Universities of Harvard and Toronto suggest that exposure to blue-light emitted by the LED screens of TVs, computer monitors and phones suppress melatonin, a hormone that is produced by the body to promote sleep at light.
Although you should try to avoid using electronic devices within an hour of going to bed, it is well worth reducing your intake of blue-light throughout the day and (especially) in the evening.
There are some free apps which reduce the blue light emitted by your laptop screen. We would particularly recommend f.lux, which can be downloaded here.
Additionally both Iphones and Androids can have their blue light reduced in appearance settings.
6) Develop a bedtime routine
Routine is relaxing.
Uncertainty can produce stress and excitement, neither of which are conducive to getting to sleep.
If you develop a ritual which you follow every night before bed, you will automatically associate these series of actions with falling asleep, therefore allowing you to fall asleep more easily when this ritual is followed.
Additionally, if you go to sleep at a regular time every night (yes, even on weekends) your sleep cycle will be better regulated, leading to a more restful sleep.
