Sleeping better

Rachel Manber, PhD, is a professor of psychiatry and behavioral sciences at the Stanford University Medical Center. With a clinical and research focus upon non-pharmacological treatments of insomnia, Rachel has keen insights into that all too common problem facing many of us: an unsatisfactory sleep pattern. 

How is insomnia defined?

People use the word insomnia to describe difficulties sleeping, such as taking a long time to fall asleep, having difficulties with waking up multiple times a night or being awake for a long time in the middle of the night. 

Sleep specialists use the term to refer to Insomnia Disorder, which means that in addition to having difficulty sleeping, the problem with falling or staying asleep has negative day time consequences — such as poor concentration, low energy, or irritability. These daytime consequences sometimes impact work performance and relationships. 

What factors contribute to insomnia?

Sleep difficulties are common when there is an increase in stress levels. Sometimes the problem sleeping may be caused by certain medications or medical illnesses, particularly those associated with pain. Most often when a stressful life circumstance changes for the better or the person adjusts to it, the sleep problem naturally resolves.

However, if the stress and the sleep problem which results occur for a long time, or if the person reacts with great alarm to the sleep problem, the insomnia can persist long after the original stressor is no longer in the picture. 

Sleep can be impacted by other factors. Here are a few:

  • Most people are aware of the negative impact of caffeine on sleep. Fewer know that alcohol, which is initially relaxing and therefore is sometimes used to take the edge off and help with falling asleep, often causes sleep disruptions later in the night.
  • Genetic factors relating to regulation of sleep and wakefulness might play an important role. So-called “night people” may possess an internal clock which is delayed relative to the earth’s clock — which makes it difficult for them to sleep when other people sleep. They have difficulty falling asleep at a typical bedtime and find it extremely difficult to wake up and get going in the morning. 

Does sleep change across the life span?

Like many other physiologic functions, sleep changes across the life span as well as the ebb and flow of our physical and psychological well-being. As we get older, sleep becomes more fragmented. Brief awakenings in the middle of the night are the norm, rather than the exception. Healthy older people do not necessarily sleep less, but they spend less time in the deepest stage of sleep and more time in the lightest sleep stage.

Although one-quarter to one-third of adults age 65 years or older complain about their sleep, a large European study of sleep complaints across the life span (conducted by Stanford University researcher, Maurice Ohayon, MD, PhD) concluded that age is not in itself a risk for poor sleep. Instead, factors such as low activity level, poor physical or mental health, and low satisfaction with social life are better predictors of sleep difficulties in older age. 

However, some sleep disorders, such as sleep apnea, do increase in prevalence as we get older, regardless of these other factors. Sleep apnea is a sleep disorder associated with partial or full obstruction of the airways during sleep, and it is often associated with loud snoring and daytime sleepiness. Untreated sleep apnea is associated with low energy and sleepiness during the day and increases the risk of cardiovascular diseases. However, sleep apnea is a treatable condition.  

Do women and men experience different sleep issues?

Women are twice as likely as men to have insomnia. Reasons for the difference are not well understood but may include hormonal, environmental and social factors. 

Some life experiences that are unique to women, such as pregnancy and menopausal transition, can have a profound impact on sleep. For example, during pregnancy, insomnia symptoms are more prevalent, with more frequent middle-of-the-night awakenings.

My research lab is conducting a federally funded study to test non-medication approaches to insomnia during pregnancy. (If you think you fit this profile, and are interested in participating in the clinical research study, call 650-723-2641.) This research also addresses some of the sleep challenges women face during the postpartum period by discussing strategies to promote the development of healthy infant sleep.

Another sleep disorder that may emerge or worsen during pregnancy is restless legs syndrome. The hallmark of this disorder is a deep uncomfortable sensation in the leg, usually the calf, that occurs mostly at night when at rest; the symptoms are relieved by movement. After delivery of the baby, these symptoms commonly decrease or abate.

Peri-menopause is also associated with increased prevalence of insomnia symptoms, which in many cases is related to nocturnal hot flashes. Additionally, although the prevalence of sleep apnea is greater in men than women, the difference in prevalence is smaller when comparing postmenopausal women to men of similar age. It is believed that the reduction in female sex hormones explains the increase in prevalence of sleep apnea post-menopause.

Are sleep and emotional health linked?

Yes. Emotional pain, just like physical pain, can interfere with sleep. When we are anxious or unhappy we tend to not sleep well. Our ability to cope with life’s daily challenges also suffers after sleeping poorly. The problem is even worse after several nights of poor or insufficient sleep.

The converse is also true: when we do not sleep enough for days in a row, our emotional health may suffer. Poor sleep is also a common symptom of some psychiatric disorders, such as depressive and anxiety disorders. The sleep of some people that have post-traumatic stress disorder, such as combat veterans and abuse victims, may be light because they continue to be on guard even when they sleep. Some also experience nightmares.

My research lab has just completed a study of the treatment of insomnia in people who are also depressed. The study provided antidepressant medications to treat the depression as well non-pharmacological treatments of insomnia. The study found that insomnia can be treated effectively even when depression is also present and is being medically treated. The study also found that greater improvement in insomnia severity after 6 weeks of treatment was associated with greater reduction of depressive symptoms over the full 16 weeks of the treatment period.  

Are there non-pharmacological options/treatments you recommend?

For people who have insomnia, there is an effective and relatively brief psychotherapy that specifically targets insomnia. This therapy has been shown to have equivalent efficacy to sleep medications and also to have more lasting effects after treatment is discontinued. People do not need to be off sleep medication to benefit from this treatment. Therapists who are specifically trained to deliver this sleep-focused therapy can effectively treat insomnia. A list of therapists that have been certified by the American Board of Sleep Medicine can be found at the following website:

Three Stanford University faculty members from the department of Psychiatry and Behavioral Sciences are among those certified and offer insomnia therapy. The three faculty members are Rachel Manber, Allison Siebern and Norah Simpson.  

Sleep webinars:

Sleep and Why It Is Sometimes Elusive - Rachel Manber, PhD
Free, pre-recorded webinar

Interview conducted by Julie Croteau and edited by Lane McKenna.

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