When faced with a problem, many of us frame it as something we need to “beat” or “tackle” or “conquer.” But true insomnia (what we doctors call psychophysiologic insomnia, which means insomnia not due to another medical condition like sleep apnea or a thyroid issue, etc) is one of those problems that doesn’t respond to that approach. The more you focus on overcoming insomnia by telling yourself “I’m going to get in bed early and have a good night’s sleep tonight,” the more the insomnia can stubbornly persist. This can even make the insomnia worse as you develop a performance anxiety in which you actually dread having to go to bed as nighttime approaches. How do you stop this cycle?
I like to describe my approach to improving insomnia as a pyramid with three levels. Each level builds upon the one below it and you can’t build a higher level if there’s no lower level to support it. The first level of that pyramid is learning to tell yourself two words: It’s okay. By that I mean learn to accept that it’s okay to have a bad night of sleep. Tell yourself you’ve gotten through it before, and you will get through it again. And that really is the truth. Insomnia is a very challenging and lonely illness to cope with that I would not wish on my enemy, but at the very least most people know they have gotten through many bad nights in the past. Therefore, there’s no reason to think the next bad night won’t have the same outcome. You may be thinking that’s easier said than done when you’re wide awake at 3a.m. and have a full day of work ahead of you.
It is true that learning to really internalize the concept that it’s okay to have a bad night of sleep is difficult; however, it can be done. It requires those 3 Ps: patience, persistence and perseverance. I’ve met many patients who dealt with insomnia for decades and they have told (and asked) me, “Yes, I actually have already gotten to that place with my insomnia. What’s the next step?” And I could tell from their expression that they really were, in a sense, at peace with it.
Think of your insomnia as a child having a temper tantrum. If you sternly tell this child during a full-blown meltdown to stop crying right now and calm down, does that stop the tantrum? Usually not and you might just get some higher decibel screams in response. The conventional wisdom is to get the child to a quiet space and let the tantrum run its course. To phrase it another way, the first step to stopping a tantrum is to stop fighting it and just accept that this is the reality at this moment. Does accepting the tantrum magically make the tantrum stop? No. But it is the first step in a process to changing this behavior. And the knowledge that you don’t have to fight a tantrum can be comforting as well because it no longer drains so much of your mental energy. The anxieties and frustrations about the tantrums go away, which improves your quality of life, even if the tantrums still occur.
The same concept applies to insomnia. When you accept that it’s okay to have a bad night of sleep, insomnia does not magically go away. But what does go away is the frustration and anxiety about not sleeping. Sometimes that alone can be enough to help insomnia improve, but oftentimes there is more work to do.
This concept of “it’s okay” is essentially an application of the idea of mindfulness, which is becoming a more widely accepted strategy for reducing stress and improving health. Mindfulness is a way of training your brain to stop judging and pushing against your experiences, and learning to accept them as they are, even if that present moment is unpleasant. It has been studied with promising results for helping depression, anxiety and chronic pain. Although the evidence supporting mindfulness as a strategy for improving insomnia is not yet definitive, I do believe that it can help when framed in the right way.
There are of course many other aspects to insomnia diagnosis and treatment. Getting to the bottom of it often takes sitting down with a well-trained healthcare provider with experience treating sleep disorders beyond just prescribing sleeping pills. However, building that first level of the sleep pyramid is the necessary initial step.
Bonus question: If there were a sleeping pill that could put you to sleep within minutes and there was no risk of a side effect or abuse or dependency, should someone without insomnia take it? Email me your answer and your reason for it.
What sleep topic should I write about next? Send suggestions to [email protected]
David Rosen, MD is a board-certified sleep medicine physician who is the co-founder and CEO of a digital health platform for simplified sleep apnea care called Renuma (www.renumasleep.com).
