Understanding Insomnia
1. What is insomnia and what are the primary types of insomnia? How do their causes and symptoms differ?
Insomnia is the experience of having difficulty entering and/or maintaining sleep regularly despite having a sleep-friendly environment and ample opportunity for sleep. You wake up feeling dissatisfied with your sleep, and start to notice how your mood, attention, productivity, even relationships, have taken a toll after consecutive nights of poor sleep. It almost seems as if your body and brain are not cooperating with your intention to sleep, and the once-peaceful embrace of sleep morphs into a frustrating and anxiety-provoking struggle.
There are two main types of insomnia. Acute insomnia occurs when you experience insomnia symptoms for less than three months. There is usually a recent trigger that you can ascribe the insomnia to, such as a stressful life event, medical illness, or travelling across multiple time zones. This typically eases as the stress fades away and your body and mind realign to its natural sleep-wake cycle. Chronic insomnia is diagnosed when insomnia symptoms persist beyond three months. Often, the stressors that caused the initial bout of insomnia have been resolved, yet unsatisfying sleep persists. For some, this may last for years or decades.
2. How does insomnia affect a person's daytime functioning, mood, and overall quality of life?
Restorative sleep is our body’s natural way to rest and recharge. When we can’t get enough good quality sleep over a prolonged period, our body and brain tend to enter power-saving mode, and everything feels a little off. We may feel mentally foggy, where it's hard to pay attention, concentrate, make decisions, and remember things. Our emotional reserves are low, so we may experience more agitation, anxiety, sadness or stress when things don’t go our way.
With the physical and emotional fatigue weighing on us, our attention shifts towards how we can get more rest. We think a lot about sleep, and life revolves around getting more sleep. We may to start to withdraw from social engagements, or activities and hobbies that we once participated enthusiastically in. We feel compelled to buy and use products or engage in activities that promote sleep, but somehow, prolonged restorative sleep continues to evade us – as if we are chasing a shadow.
3. What are some common misconceptions people have about insomnia, and how do you address them with your patients?
One misconception I hear is, “I’m trying so hard to fall asleep.” The thing is that sleep isn’t an engineering problem that requires you to work diligently to solve. If you ask good sleepers what they do to sleep, they often reply that they don't really think or do much for sleep to happen. Sleep is more like a dove: the harder you chase it, the further it flies away. In therapy, I help my clients to understand and practice letting go of that struggle of being awake at night, so that their mind and body are calm enough for the dove of sleep to land ever so gently on them.
Another misconception is thinking that insomnia is just a nighttime issue. In truth, insomnia is a 24-hour condition. The way we think about sleep, how we manage stress, and even our daily routines all influence how sleepy or alert we are at bedtime. I help my clients look at the full picture with a thorough clinical assessment. Sometimes, the problem lies in the day, and working on that helps to alleviate their insomnia.
Some also believe that supplements or medication are their only option, although they have tried everything on the shelves. I gently explain that insomnia is a learned condition, and with the right guidance, it can be unlearned. Cognitive Behavioural Therapy for Insomnia (CBT-I) offers the knowledge and tools to retrain the mind and body for sleep and this is the gold-standard therapy recommended by medical professionals for insomnia treatment.
4. What are the long-term consequences of untreated insomnia?
Chronic poor sleep has been linked to increased risk of heart disease, high blood pressure, diabetes, obesity, and weakened immune function. Unhelpful behaviours that often accompany chronic insomnia, such as unhealthy late-night snacking and reduction in physical activities, further contribute to these health risks. Furthermore, the long-term impairment of attentional and decision-making processes may lead to bad life choices or increased risk of physical accidents.
Insomnia sufferers may feel more reactive, overwhelmed, or defeated, and these internal states affect the way they manage their relationships, work, and sense of self. That is why insomnia is associated with increased risk of onset or relapse of psychological disorders like anxiety and depression. It can also make it harder to manage existing conditions, like ADHD or chronic pain.
The Sleep Environment
5. How critical is the sleep environment in treating insomnia? What are the key elements of an ideal sleep environment?
You wouldn’t be able to sleep while you are tempest-tossed at sea, or in the middle of a live Taylor Swift concert. Hence, the basics of insomnia management involve creating and maintaining a good-enough sleep environment. Keeping the bedroom reasonably cool, dark, quiet and comfortable is a good first step to setting the physical stage right. Then comes the human environment, where you may have to communicate and negotiate with family members (or pets) who may be engaging in nighttime behaviours that disrupt your sleep.
Another important setting that is often neglected is your mental sleep environment. Good sleepers tend to have a strong mental association between their beds and restful sleep; hence their minds wind down quickly and they drift into sleep shortly. On the contrary, insomnia sufferers have unwittingly learned to associate their beds with wakefulness, frustration, and anxiety, rendering it difficult for them to turn down the buzz of mental activity and alertness in the dark. This is often one of the core treatment targets in psychological therapy for insomnia that I find to be effective.
Curbing Insomnia
6. What are the ways to curb insomnia?
Sleep medications prescribed by medical professionals can be helpful to alleviate brief episodes of insomnia. For example, if your sleep is disturbed during a period of mourning over the loss of a loved one, or if you have an important business trip on the other side of the world and your body clock has difficulty catching up to the local time zone. However, other treatment options should be considered if the insomnia persists beyond that.
As I have mentioned, Cognitive Behavioural Therapy for Insomnia (CBT-I) is one of the most well-researched, evidence-based approach to alleviate both acute and chronic insomnia. It is recommended over and above pharmacological treatments as it identifies and addresses the underlying psychological and behavioural factors that fuel the fire of insomnia.
CBT-I is a comprehensive treatment protocol that empowers you with essential knowledge about why and how you sleep, behavioural strategies that help you work with and not against your sleep biology, cognitive strategies to tackle the anxious and racing thoughts keeping you up, as well as relaxation strategies to manage your physical tension and arousal.
7. What role does sleep education play in preventing insomnia and promoting better sleep health in the general population?
If I had a say, I would include sleep education in every school curriculum or employee welfare handbook. Sleep is a fundamental physiological need, yet most of us have not been taught how sleep really works!
In my experience, many cases of insomnia begin with good intentions gone wrong. They can’t sleep, so they start napping, lying in bed awake, sleeping in, or worrying constantly about sleep. These well-meaning habits make things worse. With education, people learn how to avoid these pitfalls before they become chronic problems.
Sleep education also reduces stigma and promotes self-efficacy, which is your belief in your confidence and ability to manage sleep challenges. It helps people see that sleep difficulties are common, reversible, and not a personal failure or an ailment they have to live with. It empowers them to take action, whether by making and persisting in adjustment or changes that facilitates sleep or seeking professional support.
When shared in schools, workplaces, and communities, sleep education becomes a powerful public health tool. Just like how we advocate the role of nutrition and exercise, sleep also deserves a seat at the table. After all, it's one of the pillars of health and, sadly, the one still often overlooked.
8. What advice do you give to people who work shifts?
Shift work can really challenge your body’s natural sleep-wake rhythm as you must go against the natural environmental cues as well as the social cues of society and family. Here are some things you can implement if you are a night or early morning shift worker.
Firstly, take a strategic nap in the late afternoon or evening before your shift. It can give your alertness a helpful boost. Avoid taking naps in the early morning or before your shift ends as much as possible, to consolidate all that sleepiness for your shuteye at home.Secondly, use light and darkness to your advantage. Bright light can help you stay alert during work, so try to work in a brightly lit environment over most of your shift. As your shift ends, you want to reduce the amount of light that your eyes receive, such as wearing a cap or sunglasses on your way home.
Thirdly, keep your bedroom environment dark with blackout curtains or use an eye-mask. Keep it quiet, cool and comfortable. If necessary, discuss with your family or neighbours and work together on a reasonable solution to foster a restful sleep environment for you in the day.
Lastly, if you continue to struggle with insomnia, excessive daytime sleepiness, and other physical and mental health consequences from working shifts, please reach out to a medical or mental health professional as we can provide you with further support.
9. What are some of the latest advancements or emerging trends in the treatment of insomnia?
One trend we see is the advancement and increasing use of consumer health tracking devices (like Apple Watch and Oura Ring). While not perfect, these tools can give helpful insights into sleep patterns that can aid the management of insomnia. For example, paradoxical insomnia is a type of insomnia where an individual feels that they have not slept at all for consecutive days, weeks or even months. In my practice, I may invite them to monitor their sleep with a sleep tracker to measure the objective variables of their sleep. The sleep report often paints a different picture from their subjective experience, and this paves a way to educate them on what causes sleep state misperception and how we can work together on a treatment plan to improve their insomnia symptoms.
Nonetheless, consumer sleep tracking has become a double-edged sword. Orthosomnia is a term increasingly used to describe individuals with an excessive preoccupation on attaining “perfect sleep”, as arbitrarily defined by their sleep score on their sleep tracking apps. This obsessive focus can paradoxically lead to increased anxiety over one’s sleep and poorer quality sleep!So, please remember that sleep is not an engineering problem, or something which needs to be hacked or perfected. Sleep is like breathing – it just happens. You may cough, or choke, or hyperventilate at times, but your breathing naturally restores itself. So will sleep.
BIO
Dr. Julian Lim is the Co-Founder and Lead Sleep Psychologist at Somnus Sleep Wellness. He graduated with a PhD in Psychology with Clinical training from the University of Pennsylvania in 2010 and has conducted psychological research for over 20 years. From 2015-2022, he was Assistant Professor at Duke-NUS Medical School and subsequently at the Yong Loo Lin School of Medicine at the National University of Singapore.
Dr. Lim is regarded internationally as an expert in mindfulness and sleep, with over 40 peer-reviewed publications. He is currently an Adjunct Professor at the Centre for Sleep and Cognition at the National University of Singapore.
