Article Summary: Disturbed Sleep contributes to significantly diminished mental health and is a gateway to increased risk of serious mental health problems.
Depression and insomnia
Insomnia was in the past seen as a symptom of ‘something else’ or, if associated with depression, the general consensus was that the insomnia would just ‘go away’ when the depression was treated. This concept was first challenged with the finding that if individuals had previously experienced depression, sleep disturbance in the form of insomnia was found to be a symptom that preceded a recurring bout of depression (Breslau, Roth, Rosenthal, & Andreski., 1996). More direct relationships between untreated insomnia and depression have since been established (Riemann & Voderholzer, 2003; Cole & Dendukuri, 2003)
Cognitive model of insomnia
The ‘wired and tired’ or hyperarousal state is a common distressing feature of insomnia. Excessive negative cognitive activity leads to increased physiological hyperarousal and selective attention (Harvey, 2002). Chronic insomnia is maintained by worry, unhelpful beliefs about sleep, use of safety behaviours, monitoring of the sleep-related threats, and inaccurate perceptions of sleep and the consequences of sleep loss.
The challenge faced by the client/patient is not in the learning of the relaxation exercises and cognitive exercises, but in mustering the discipline to stick to a practice schedule and taking action to use the exercises on an as need basis.
Worry precipitates and/or perpetuates insomnia. Worry about the daytime consequences of not obtaining enough sleep (associated with increased absenteeism and performance anxiety) triggers the flight or fight response (Bonnet & Arand, 1997), resulting in more emotional distress and worsening sleep. Unhelpful or dysfunctional beliefs about sleep include statements such as “I need 8 hours of sleep every night to feel refreshed” and “If I don’t sleep well at night I know I cannot possibly function well the following day”, which exemplify the unrealistic beliefs maintained by worry.
As a consequence, less sleep leads to less energy and more frustration. This double whammy (negative thinking and decreased physical energy with an increase of physical health problems) affects brain chemistry and contributes to the return of clinical depression.
Safety behaviour is a paradox as the individual engages in behaviour that is more likely to make their sleep worse (e.g., napping, sleeping late, consuming large amounts of caffeine/alcohol, erratic use of medications). Monitoring of sleep-related threats further perpetuates the worry, and this attentional bias results in continual internal checking for a reason why the individual is not sleeping (e.g., too hot, too cold, stiff shoulder, breathing partner) or for an external cause for sleeplessness (e.g., dog barking, tap dripping).
An additional challenge faced by the client/patient is the temptation to self soothe with mood altering substances (clinically referred to as self-medicating). As social work clinicians and mental health experts, we remind our clients about common sense information such as how alcohol, caffeine, sugar, tobacco, etcetera throw the proverbial wrench in the in the fine balance of the complex mix of brain chemistry and prescription medications). Striving for a holistic life by eliminating negative habits and adding good habits during times of personal crisis is like bettering the Greek myth of Sisyphus. This is why we have a Wellness Program at Lidkea Stob & Associates.
All of these perceptions have a negative effect on daytime mood and performance. An inaccurate perception of sleep is common. Good sleepers tend to overestimate their sleep and individuals with insomnia underestimate their sleep. Interestingly, a difference of only 35 minutes of objectively measured sleep was found between good sleepers and those with insomnia (Chambers & Keller, 1993).
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