COVID Q&A: Insomnia
We asked Ethan Gorenstein, PhD, Associate Professor of Behavioral Medicine (in Psychiatry) at Columbia University Irving Medical Center, for some practical advice for those suffering from insomna during the COVID-19 pandemic.
ColumbiaPsychiatry: Anxiety about the coronavirus, job loss and financial insecurity must be causing sleepless nights for many lately. Have you seen an increase in patients with insomnia during the COVID-19 pandemic?
Dr. Gorenstein: Anxiety is a prime contributor to sleep difficulty. So, as anxiety rises due to the corona virus, sleep difficulty (insomnia) also rises. When people are anxious, their nervous systems are more activated, and an activated nervous system does not readily succumb to sleep. When anxious, people can find they take longer to fall asleep, or awaken frequently in the middle of the night, or experience more restless sleep.
One form of sleep difficulty arising in the current situation may be more a matter of perception than reality, however. As people no longer leave for work in the morning - either because they are working from home or they have been furloughed or laid off - their wake-up times tend to drift later. What some people don't realize is that, as their wake-up time drifts later, the time that they can expect to fall asleep at night will also drift later. So, if you used to sleep from 11:00 pm to 6:00 am, but you are now awakening at 8:00 am, you will find you are no longer able to sleep readily at 11:00 pm. Indeed, you may find yourself lying awake for a couple of hours before falling asleep. This is really pseudo-insomnia. The person just went to bed too early.
Columbia Psychiatry: What is insomnia?
Dr. Gorenstein: Insomnia is a “sleep disorder” characterized by insufficient sleep quantity or quality. Insomnia can involve difficulty in falling asleep or in maintaining sleep once it is initiated. The consequences of insomnia can include fatigue, impaired concentration, and depressed or anxious mood.
Columbia Psychiatry: How can someone determine if they have insomnia or are just experiencing a few rough nights?
Dr. Gorenstein: There is no absolute dividing line between sleep difficulty and a sleep disorder (insomnia). Clinicians define an "insomnia disorder" as a sleep difficulty that occurs at least three nights per week for at least three months. However, short-term sleep difficulty can also cause distress and functional impairment, and can become a gateway to persistent insomnia if an individual lacks the means of reversing the pattern.
Columbia Psychiatry: I understand Cognitive Behavioral Therapy (CBT) is often used to treat insomnia – what is it and how does it work?
Dr. Gorenstein: Cognitive-behavioral therapy for insomnia (CBT-I) is an effective psychotherapy for insomnia when the insomnia is uncomplicated by other disorders. CBT-I involves changing both behavioral and thinking patterns that can interfere with sleep. Behavioral strategies focus on changing the bed schedule to condition new sleep patterns. The therapist works with patients to minimize the amount of time that patients spend in bed struggling to sleep and not succeeding (as sleepless time in bed can promote wakeful associations to being in bed). Thinking (cognitive) strategies focus on attitudes about sleep and related matters. As people experience sleep difficulties, their thoughts can become excessively concentrated on sleep matters. This concentration can, in turn, make it harder to sleep. So, cognitive strategies help patients alter these thought patterns. CBT-I can also include various forms of relaxation training. When insomnia is accompanied by other psychiatric disorders, such as anxiety or depression, psychotherapy can be expanded to address those conditions as well.
Columbia Psychiatry: What other treatments are available for insomnia?
Dr. Gorenstein: Psychiatric medications can be helpful in alleviating psychiatric disorders that may entail insomnia, allowing insomnia to be brought under better control. In addition, short-term use of sleep medications can be helpful in providing temporary relief of insomnia.
Columbia Psychiatry: What are some tips for those who suffer from insomnia or the occasional rough night?
Dr. Gorenstein: Probably the most important bit of advice is: "don't panic." Most sleep difficulties will be short-lived if you take them in stride and don't become excessively focused on making yourself sleep. Above all, try to maintain a consistent morning wake-up time, even if you didn't sleep so well the night before. The sleep deprivation can eventually work in your favor, making it more possible to sleep eventually. Conversely, if you sleep later in the morning (or nap) to compensate for a poor night's sleep, you may find it even more difficult to fall asleep the following night. Also, avoid getting into the bed at night if you don't feel ready to fall asleep. Rather, wait until you feel distinctly sleepy. If you have to err, err on the side of going to bed too late rather than too early. Also, if you are in bed and find you are not able to sleep, after about 20 minutes of trying and not succeeding, get out of bed, do other things, and don't return to bed until you feel sleepier.
Columbia Psychiatry: Do sleep apps work?
Dr. Gorenstein: Relaxation prior to bedtime can be helpful in "quieting the mind." A quieter mind makes it easier to fall asleep. Many apps are available to assist with this, but what one person finds helpful may not be helpful to another person. Some people benefit from physical relaxation exercises (such as muscle relaxation or paced breathing). Others benefit from meditation or "mindfulness" exercises. A third option is soothing bedtime stories (typically available on Youtube). A person may need to experiment to figure out what meets their needs the best.
Columbia Psychiatry: Is there anything people can do to deal with sleeping problems they might be having during this pandemic?
Dr. Gorenstein: Stress is a prime contributor to insomnia and the COVID-19 pandemic creates a unique combination of stressors: stress due to threat of contagion, economic challenges and lifestyle changes imposed by shutdown orders. In general, when we have stress due to factors outside our control, the means of reducing stress is to narrow the focus to the matters that are within our control. Under current circumstances, what is mainly within our control is our adaptation to the lifestyle changes imposed by the COVID-19 pandemic (as opposed to the reasons for those lifestyle changes, namely, the health and economic threats). It is important to establish a personal routine for managing the day, and to keep the focus on getting the most out of that routine. Above all, it is important to wake-up at the same time every morning (even if you don’t have to), to get up and get dressed, and follow an agenda of activities (planned at least the night before), so you are not drifting through the day or trying to make it up as you go along. This keeps the focus narrowed to what you control, and can have a calming effect when the matters outside your control are chaotic and threatening. Also, for many people, this may mean limiting access to the relentless news cycle of pandemic reporting. If you can maintain a calm and positive routine this will help ward off some of the stress that might otherwise intrude and get in the way of sleep.