Why Can’t I Sleep?

Research results regarding the physical and emotional costs of sleep deprivation are well known: lack of sleep can make you ill, both physically and mentally. Severe sleep deprivation can lead to death. While occasional, intermittent, and transient insomnia is extremely common, more serious sleeplessness is a primary reason people seek medical attention. A survey of suicide hotline workers indicated that chronic insomnia was a key symptom reported by callers. "I just wanted to go to sleep" is an all too common refrain heard in psychiatric emergency rooms, reported by frustrated and despondent insomnia sufferers who have taken overdoses of medication.

Insomnia is a symptom of many different psychiatric and physical diseases, and lack of sleep exacerbates many of these same conditions. This makes insomnia both a symptom and a cause of sorts, and places the sufferer in a frustrating vicious cycle of sleepless nights and worsening symptoms.

Insomnia comes in two "flavors" – trouble falling asleep and trouble staying asleep. Some people do suffer from both, although this is less common. Insomnia is diagnosed based not only on number of hours slept but on the quality of sleep and the subjective experience of sleep and waking. "Do you wake up feeling refreshed?" is a key diagnostic query in addition to gathering information about actual number of hours spent trying to fall asleep or trying to go back to sleep.

Physical Causes

  • Here are some possible physiological reasons why insomnia is wreaking havoc with your health:
  • Menopause or other hormonal changes, including pregnancy
  • Pain, especially chronic pain caused by arthritis or neck or back injuries
  • Asthma, either due to poorly controlled asthma symptoms and trouble breathing, or due to asthma medications (often stimulants are used to treat asthma)
  • Certain thyroid conditions may impact your ability to fall asleep and stay asleep.
  • Parkinson’s disease
  • Acid reflux or GERD may disrupt sleep
  • Medications. Some medications have a stimulant effect, or a stimulant rebound after they wear off. For example, some allergy medications typically make people drowsy, but in a few people have a reverse impact and cause sleeplessness and excitability/agitation.

If you are having trouble falling asleep, staying asleep, or getting quality sleep on a regular basis, start with a visit to your primary care physician to rule out any/all of these medical conditions.

Other Possible Causes

Before discussing depression and anxiety, the two most common psychiatric causes of insomnia, a brief word about substances and sleep is required. It is well known that caffeine and other over-the-counter and prescription stimulants ("no doze," diet pills, amphetamines, bronchodilators, etc.) will render sleep elusive, but what about Central Nervous System (CNS) depressants or sedatives? Won’t they do the opposite?

Alcohol is a CNS depressant, and most people will report that a few drinks make them feel sleepy, but these substances are not much help to insomnia sufferers. While depressants will depress (i.e. slow down) all body systems and their functioning, making things like heart rate and blood pressure slow down, depressants have a rebound effect. As the body processes the substance and it is leaving your system, once you have "bottomed out" in terms of the depressant action of the substance, a counterintuitive rebound starts, in which the opposite physical symptoms occur. Agitation, increased heart rate, increased body temperature, increased brain activity, etc., all occur several hours after you stop drinking, as the body slowly detoxifies and returns to its normal steady state. This is why some people report waking up at 3 a.m. after an evening of drinking – you fall into bed completely sleepy at midnight only to awaken and be unable to get back to sleep hours later. The fix for this type of insomnia would be to stop drinking earlier in the evening, and consume less alcohol in a single setting overall.

Both depression and anxiety impact sleep; insomnia is an extremely common symptom of depression. The classic media image of the depressed person as unable to get out of bed, exhausted, lethargic, and sleeping their life away hides the equally common reality that depression robs the sufferer of their ability to fall asleep and stay asleep, rendering them zombie-like all day. For some depression sufferers, insomnia is the single most severe symptom reported.

Anxiety is the most vicious of the vicious cycles associated with insomnia, as anxiety involves anticipatory worry about whether or not the insomnia will strike, thus essentially beckoning the sleeplessness in advance. An increase in overall anxiety symptoms and panic attacks most commonly occurs in the evening, as work, family life, and other distractions wind down. Once anxiety kicks in, it can be very difficult to self soothe and fall asleep.

Other psychiatric disorders can cause or worsen insomnia. For people with bipolar disorder, reporting any insomnia can be an extremely important part of maintaining control over the disease – often insomnia is an early warning sign that a manic phase is starting. Preventing a full blown manic episode can be achieved for some people by monitoring sleep and treating mild insomnia symptoms before they become more severe.

Managing Insomnia

While treating chronic insomnia is the scope of other articles, stressful times and transient episodes of insomnia can be managed. Along with good sleep hygiene, a positive attitude can be the key component that turns things around. Try to view the challenges and discomforts as an opportunity to grow and be philosophical about all you are going through. Lean on your faith and your family to get you through the tough times and try to stay open to learning, even when it is difficult. This too shall pass.