Why can’t I fall asleep at night?

If you are one of the 71% of the UK population that is affected by poor sleep, falling asleep could be a real pain for you. It feels incredibly frustrating to be having regular problems with falling asleep and then staying asleep every night, after night, after night.

So here’s on the potential mistakes you are making trying to help yourself to fall asleep and also the things you might not be aware of which interfere with your body’s natural way of letting you into peaceful sleep.

Sleep scientists still can’t answer this question fully: how do humans sleep? Matthew Walker, Professor of Neuroscience and Psychology at the University of California, Director of the Centre for Human Sleep Science, says about our sleep, "We still do not fully understand exactly how sleep happens, … but we know that it is nonnegotiable from a biological standpoint.”

From sleep experiments over the past 30 years we know that human sleep is governed by two systems: the homeostatic system (or the sleep drive) and the circadian rhythm system (our biological clock). Interestingly, these two systems are not running in sync with each other, but are rather superimposed on one another, working together to facilitate sleep.
You need sufficient sleep drive in order to be physically tired to produce sleep, and you also need to align with your biological clock (the circadian system) in order to fall asleep and sleep through. When one of them is working well, you may fall sleep easily but sleep fitfully, get mis-aligned with your circadian clock, and you may wake up at 3 or 4 am wondering what to do with yourself for the rest of the night.

Before you start wondering which of the systems is overplaying in your case of bad sleep, let’s see what insomnia is. In my practice, many people think they have insomnia, but they have other sleep disorders, not insomnia. Insomnia is defined as “a persistent difficulty with getting to sleep, maintaining sleep, or quality of sleep, which occurs despite adequate opportunity and circumstances for sleep”. But this is not all. There are a few important components to insomnia. insomnia is always accompanied by daytime difficulty of functioning - symptoms of depressed or low mood, irritability, sometimes malaise and headaches, cognitive impairments like lack of focus and attention, fatigue. However, people with insomnia do not feel sleepy during the day. They feel quite the opposite of that: they feel tired but wired. Hence, given a chance to sleep in the day, they find it difficult to fall asleep.

Insomnia is inherently subjective. The assessment for insomnia is done by a sleep practitioner interviewing the person with sleep problems. Insomnia is rarely diagnosed in a lab and never via the actigraphy (the use of a Fitbit, or any other wrist wearable, or by an external source such as an online assessment. By assessing one’s sleep diary, together with asking them questions on their sleepiness score, a sleep expert can diagnose insomnia. If you think you may have insomnia, the Epworth Sleepiness scale is a good place for you to start. A score of less than 10 is not insomnia, but some other sleep disorder that is going on.

In people with chronic insomnia there is also a third system that plays a big role. It is the arousal system. This is a cognitive part, which means you are having persistent thoughts that interfere with your sleep. Your thoughts might be centred around your inability to have good sleep, you may wonder if you are one of those people whose sleep is ‘broken’, or your body simply cannot generate sleep. These cognitive habits interfere with your natural ability to sleep by a large degree. In fact, the arousal system is present in good sleepers too, they also can get interrupted nights, waking up from racing thoughts. But the difference in good sleepers is that these moments are temporary, typically occurring in periods of high stress. Once the stressful event is over, good sleepers know that they will be able to sleep well again. In insomniacs, the belief about ‘broken sleep’ is permanent.
Thus, CBTi, which is first-line insomnia treatment therapy includes the cognitive component (the ‘C’ in the CBTi title) - where the practitioner works with one’s system of beliefs about their sleep.

In CBTi we generally apply a rule of 10 minutes. If you lie in bed for more than 10 minutes and you notice that instead of getting more relaxed and sleepier, you become more and more awake and frustrated by your efforts, get up. Leave the bed. You need to have a comfortable alternative place for these moments when you can’t sleep. If you continue lying in bed getting helpless and frustrated at your body’s lack of cooperation, your physiological body may start associating bed with frustration, anger, feeling helpless. None of these emotions are conducive to good sleep. Thus, find a solution where you’re going to be in your house in moments of wakefulness. It needs to be a cosy place (an armchair in your sitting room, for example) with rather dim lights. You can read, listen to calming music, do a crossword, but preferably not use digital devices or TV. Go back to bed when you feel sleepy again.

If you are generally a good sleeper, and recently you have been waking up in the middle of the night unable to sleep, most likely you have an issue with your stress response. Stress response is the firing of your sympathetic nervous system where the hormones of stress, such as cortisol and adrenaline, are constantly elevated. When you are in stress response, your heart beat is increased, blood pressure is elevated, and these two are enough to prevent you from falling asleep or staying asleep. To help you deal with high levels of stress, make sure you give yourself a full hour of unwinding time before bed - refrain from all digital devices, and instead do some stretching, yoga, journalling, take a bath, listen to relaxing music, go for a walk or simply sit in the room without lights, allowing your eyes get used to diminishing daylight. The evening light around 8:30pm right now, in spring time, is absolutely wonderful for relaxing.

This is perhaps the most common question I get on sleep whenever I work with a patient or during company presentations on sleep. Majority of us think that our times of going to bed and waking up are rather individual and unique. It is as if by some divine power out there, each one of us had been created with our specific programmed times set for falling asleep and waking up. So I have heard some rather wacky suggestions: people breaking the night into two chunks (“getting two sleeps”); people going to bed at 8:30pm and waking up at 3:30am (to train for a marathon, for example); or people going to bed at 4am and waking up at 12pm (to complete a Netflix series) - these were not due to shift work.

The circadian clock system runs exactly the same in all adults, with an exception to teenagers. Our circadian clock is set by the SCN - suprachiasmatic nucleus - a bunch of neurons in the hypothalamus which regulate our sleep and wakefulness cycles. Thus, in every adult there is approximately a 24-hours-and-15 minutes clock every day, when our body repeats the cycle of waking up and falling asleep, renewing the cells, detoxifying our tissues and organs, restructuring cells, repairing tissue, etc. Every organ and every tissue in their own accord also have a biological clock for optimal working time and rest times - for repair and restructure.

The hormones cortisol and melatonin are the two main key players in the SCN regulation. They work in opposite direction to each other: when cortisol gets released early in the morning, melatonin is at its lowest point, hence, we get a signal that it’s been enough of sleep - get up and get energised. When cortisol levels begin to decline close to 9 in the evening, this is when melatonin starts getting released and we get sleepy and ready for deep slumber. Thus, if you have been disregarding the natural circadian clock of cortisol & melatonin cycles, and your sleep is fitful, not long enough, or you can’t understand what the real issue with your sleep is, you may have developed a circadian rhythm sleep disorder. Work with a professional who will help you re-set it.

Here is the hard truth: relaxation and bedtime routine is a must for everyone, but relaxation tools on their own are ineffective if you have sleep problems.

Relaxing before bedtime should be a necessary regular component of your bedtime routine. Human body is not a robotic piece of machinery - where we press a button and we sleep and we press another button and we are awake. In fact, if it takes you 5 minutes or less to fall asleep at night, you should know that you are chronically sleep-deprived. In a healthy, well-rested body sleep latency, the time it takes you to fall asleep, should be between 5 to 15 minutes. The American Academy of Sleep Medicine advises that up to 20 minutes is considered healthy.

If you use a mindfulness tool or app to get you relaxed, de-stress during your bedtime routine and your sleep is good, I applaud you, keep doing it. However, if you use an app for mindfulness practice, or a white noise app, or any other relaxation tool in order to fall asleep - this is rather bad news, I’m afraid, you are conditioning your body to only fall asleep to those tools. You condition your body (like a Pavlov’s dog) to rely on an external source to generate sleep. But sleep should occur naturally, without any external source.

Rubin Naiman, PhD, clinical psychologist specialising on sleep and dreaming, says this about our sleep, “The simplest yet the most difficult aspect of getting to sleep is the surrender of one’s volition. We cannot literally “go to sleep” as an act of will”.

If you have insomnia, reducing or getting rid of external sources that help you sleep could present a particularly tricky part in sleep recovery. This is where both behavioural and cognitive part in the CBTi therapy come into great help.

Here’s one of the most fascinating things about human sleep. If your arousal system is stronger than your sleep drive, you will wake up in the night and have difficulty falling back asleep. But if your sleep drive is stronger, then you will sleep through.

What is sleep drive? It is the first sleep system I spoke about at the beginning, the homestatic system. From the moment you wake up, your body starts building sleep drive, and it continues doing so until you feel sufficiently sleepy and ready to drop into restful sleep at night. Sleep drive is often called sleep pressure. The longer you are awake, the stronger your sleep pressure becomes. This pressure is dissipated during your sleep, especially during slow-wave sleep, and consequently, as soon as you wake up the following morning, you start building sleep pressure anew.

Interrupted sleep, racing thoughts, regular wakings are sleep issues that are acute for so many people. But yet, as I said before, if your sleep drive is strong enough, it overrides your arousal system. What should you do in order to build enough sleep drive?

1. Get into the habit of getting up within a few minutes of waking up. Staying longer in bed, in the hope that you may be able to sleep a bit longer decreases your sleep drive in the evening. Give yourself 5-10 minutes from the time you wake up and up you go. If you don’t have to get up for work or study, organise your schedule so that you have activities straight away in the morning.
2. The more active you are during the day, the more sleep drive you would have built. Your body needs to be physically tired in order to generate sleep. ‘Physically tired’ is the key word here. Mental tiredness does not count here. Any activity that makes you physically tired - walking, cycling, swimming, jogging, strength training, doing housework, painting, building, climbing trees with your kids in the park, you get the idea, will make you tired enough to generate good sleep drive.
3. Caffeine - in the words of Matthew Walker, “caffeine is most widely used and the most abused psychoactive stimulant in the world”. Caffeine blocks adenosine receptors in the brain. It is adenosine - the substance produced in the brain that is responsible for building your sleep drive. When caffeine occupies adenosine receptors, it blocks adenosine, and thus inhibits the sleepiness signal in you (for a time). The brain gets tricked into being energised, alert and awake. Caffeine has a half life of 5 to 8 hours, meaning that 5 to 8 hours are needed for your body to remove 50% of the caffeine concentration. Thus, if you drink a cup of coffee at 5pm, by 10pm your body would still be processing 50% of that caffeine circulating through your blood stream. Difficulty falling asleep could well be due to that.

Our sleep is a wonder, it is a sacred place we get into every night in order to let go of everything and get renewed and reenergised to start completely fresh the following morning.

There are many components to good restorative sleep, but if you let nature guide you without creating unnecessary bad habits, you will enjoy sleep in its simplicity without making any particular effort.

If you do struggle with sleep, reach out. I have been sorting sleep problems for the past 5 years. I am a CBTi (for insomnia) practitioner and work with circadian rhythm sleep disorders and other sleep conditions.

And now I am off to sleep, where I get to decide whether I want to stay in a dream or change it - aw… lucid dreaming, such a fascinating subject. Can you do it? Would you share your experience with it?

Stay healthy, be joyful!
Love,
Katya