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Insomnia

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Mechanism

Physiological model of insomnia

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Cognitive and behavioural models of insomnia

Fig.1: Application of the cognitive model to the night and the day.

Fig.2: Two-level model of sleep-related arousal. Primary arousal refers to the cognitive content and activity that is directly related to the inability to sleep. Secondary arousal refers to the attention and emotional bias toward sleep-related thoughts, the degree of attachment one has in believing these thoughts, and the interpretive value of the sleep-related thoughts.

To find suitable treatments for insomnia it is important to fully understand the cognitive origin of this mental disorder. Over the past decades scientists came up with different approaches to interpret the cognitive processes of insomnia. It is assumed that sleep disruptions are induced through a number of factors. Such as emotional, cognitive, and physiological hyperarousal. Insominia can lead to performance anxiety or certain other behaviours such as, staying in bed longer to be able to sleep again which can lead to hyperarousal. Therefore patients diagnosed with insomnia are often treated with progressive muscle relaxation and biofeedback in order to lower the physiological arousal. Cognitive arousal is caused by sleep-related cognitions which keep the individual from falling asleep and combined with physiological arousal can create a vicious cycle of insomnia. People who suffer from insomnia tend to hold on to dysfunctional beliefs or common cognitive errors such as catastrophizing and probability over estimation. Those cognitive errors are addressed in cognitive-behaviour therapy for insomnia (CBTI).

Two components can lead to the inability to fall asleep or to dearouse. The first component is the loss of automaticity which means that sleep comes effortlessly and the second one is plasticity – sleep is flexible. The explicit intention to sleep and the belief that sleep must last a certain time creates tension which makes it more difficult to fall asleep consequently leads to a failure to dearouse. Individuals who suffer from insomnia tend to have these expectations of how sleep should look. Insomnia can lead to impaired daytime functioning and can cause hinderance when trying to sleep in the night. The false beliefs of their inability to function without enough sleep can also lead to performance anxiety.

In addition to these sleep-interfering processes it is assumed that also metacognitive processes play a role in the inability to dearouse. Metacognition can be understood as one’s awareness of the own thoughts. It can be imagined as “thinking about thinking”. Metacognition is the way the individual is thinking about the own thoughts like for example in the case of insomnia worries and negative emotions related to sleeplessness and the associated consequences.

Primary arousal is the cognitive activity directly related to the inability to sleep. Dysfunctional metacognition is a secondary cause for arousal which would also interfere with sleep. For example thinking that a certain amount of hours of sleep is needed to fully function the next day would cause primary arousal and additionally having strong attachments to the belief that not being able to sleep for this certain amount of hours will definitely have a negative impact on daytime functioning – this then leads to secondary arousal. Dysfunctional metacognition reinforces the attachment to negative cognition regarding the situation the individuals believes to experience. Primary and secondary arousal maintain the insomnia disorder.

Metacognitive processes are considered in mindfulness-based interventions.

Management

Non-medication based

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Mindfulness-based interventions

Mindfulness is the conscious awareness of the present moment including all present thoughts, emotions, and physical perceptions which can be captured by the five senses. Mindfulness has its roots in ancient meditation practices and helps people get educated on a mindset which is associated with the teachings in Buddhist philosophies. Mindfulness focusses less on the religious aspects an subtracts the cognitive means of the practices which positively influence the individual perception of certain thinking patterns and mental habits. The goal is to bring awareness to those thinking patterns and then to implement the ability to consciously shift the focus onto the present moment. An important role here plays the capacity to accept the present moment without the attempt to evaluate it as a positive or negative experience.

Mindfulness positively influences the well-being of people who engage in mindfulness-based interventions and who apply certain thought patterns to stressful situations such as not being able to fall asleep. The emotional, psychological and social well-being has an impact on sleep and morningness. Mindfulness positively predicts well-being which leads to an improved sleep and that is why mindfulness-based approaches can be a helpful treatment for individuals who experience insomnia.

Through mindfulness these individuals can raise their metacognitive awareness which aims at the cultivation of non-judging, present-focused awareness. This approach is also known as MCTI (metacognitive therapy for insomnia).

People with insomnia are often not aware of their negative thought patterns regarding their sleep disturbances. The focus usually lies on short or long-term negative-consequences of sleeplessness causing anxiety which can lead to a vicious cycle of insomnia. Mindfulness-based interventions teach an objective view on those negative thought patterns and help to redirect the focus towards a neutral perception of an experience, such as not being able to fall asleep. Meditation practice or activities which help to focus the attention to the present moment are part of mindfulness-based interventions. In MBSR (mindfulness-based stress reduction) and MBCT (mindfulness-based cognitive therapy) guided mindfulness meditations play a constant role in the interventions. This constant judgemental free redirection of the focus can be seen as a cognitive training. The more the participants engage in these trainings the easier it can become for them to take an objective point of view. Individuals with insomnia can learn through this objective point of view to detach the experience of not being able to sleep from the emotional attachment of seeking to sleep. The experience of not being able to fall asleep causes primary arousal and the emotional attachment to seeking sleep causes secondary arousal. Through a mindful approach to a situation with high arousal potential the individual learns to categorise the situation as neutral which prevents catastrophic thoughts about a possible negative consequence in the future. For example, one could have a shorter sleep than intended and only realises this fact without ruminating about the possible negative effect this could have on the day. To practice redirecting the focus back to the present moment helps to decrease hyperarousal caused by negative assumptions about the possible negative consequences.    

Mindfulness is supposed to help the individual bring awareness to their sleep related experiences and to re-establish a healthy sleep rhythm and a higher sleep quality.