What’s Behind your Sleep Struggles

Please read this section in its entirety.

Before we explore ways to improve sleep, it is important to understand how sleep problems can arise. Each person's mind, body, behavior, and thoughts are unique and complex. Though this makes it hard to describe why all people struggle with sleep, we’ll do our best to describe the main things that generally drive sleep issues. Sleep struggles typically fall into one or more of the following six categories: insufficient sleep, poor sleep hygiene, conditioned arousal, poor sleep thoughts/beliefs, pre-sleep mental status, and sleep disorders. By the end of this section, you should have a clear understanding of what might be causing your sleep issues, unless you have an undiagnosed sleep disorder. We explain sleep disorders in the following section.

Insufficient Sleep

As singer/songwriter Ryan Hurd once said, “Sleep deprivation is an illegal torture method outlawed by the Geneva Convention and international courts, but most of us do it to ourselves.” Getting insufficient sleep is what most commonly prevents people from enjoying the numerous physical, mental, social, and cognitive benefits of having healthy sleep. After all, trying to improve sleep will likely have little to no effect unless you start by allowing yourself the opportunity to get the correct amount of sleep. Different age groups need different amounts of sleep due to the demands of each stage of brain development. Although the exact need may vary from person to person, the vast majority typically fall in the following ranges as determined by age: Adults typically need 7-9 hours per night, adolescents ages 13-18 need 8-10 hours, and children ages 6-12 need 9-12 (Paruthi et al., 2016; Click here for more info on the sleep needs of different age groups). Those who struggle with premature awakenings find that this problem goes away as they address their other sleep struggles. Everyone else who is able to get the sleep they need should start by giving themselves the opportunity to get it.

Sleep Hygiene

Sleep is a lot like food, water, and oxygen: it is necessary for survival. As such, your body is equipped with its homeostatic sleep drive, which is a series of mechanisms in the brain and body that facilitate sleeping and waking. The strength and timing of everyone’s sleep drive is different (Rusterholz et al., 2010), making it harder or easier for some to fall asleep. However, since you need sleep to survive, the sleep drive that you do have is likely sufficient as long as you don’t get in the way. In order to let your body’s sleep drive work its magic, it is necessary to practice good sleep hygiene.

By sleep hygiene, we don’t mean flossing and brushing your teeth before bed (although we strongly recommend that too!). Rather, sleep hygiene refers to habits and behaviors that, when practiced consistently, lead to healthy, restorative, and satisfying sleep. These habits do an excellent job of improving sleep in two key ways: 

• Adding behaviors that help facilitate your body’s innate ability to get the sleep it needs

• Removing behaviors that interfere with your body’s innate ability to get the sleep it needs

When these habits aren’t maintained, your sleep drive may be weakened in a way that makes it harder to fall asleep, stay asleep, and feel rested throughout the day. We’ve listed the most proven, research-based sleep hygiene practices below:

1st Priority Practices

• Consistent Sleep Schedule: Go to bed and wake up at the same time every day, within a 30-minute window.

• Only Use Bed for Sleep: Stay out of bed during the day and get out of bed at night if you can’t sleep or if you wake up for 30 minutes or more. 

• Avoid Naps Close to Bedtime: Do not sleep within 8-9 hours of going to bed at night. 

• Avoid Caffeine Before Bed: Refrain from caffeinated beverages like coffee, energy drinks, or caffeinated soda 8 hours before bed. It may be wise to avoid it 6-11 hours before bed, depending on your sensitivity to caffeine and the amount you’re consuming. Generally, 8 hours is a safe rule.

• Sleep Routine: Maintain a calming and consistent routine that makes sleep predictable using internal and external sleep cues.

• Light Exposure: Try and be exposed to bright, natural light shortly after waking up while avoiding bright lights for an hour before bed. 

2nd Priority Practices

• Physical Exercise: Engage in 30 minutes of mild, moderate, or strenuous daily exercise no later than an hour before sleep. 

• Avoid Eating Before Bedtime: Refrain from eating food, especially heavy meals, an hour before bedtime, and avoid going to bed thirsty. 

• Bedroom Environment: Manage where you sleep by making your bedroom dark, clean, quiet, cool, and safe from outside threats. If you find yourself constantly checking the time, remove all clocks from the room. 

Sleep Hygiene: Necessary but Not Always Sufficient

Before you take a screenshot of these tips and leave this module, never to return, it is important to note that these sleep-enhancing habits are NOT a cure-all for each and every sleep malady. For many people, sleep hygiene is only the first half of the equation (Chung et al., 2018). 

In the field of sleep medicine, the role of sleep hygiene is often illustrated using the metaphor of a foundation and a house. When rains come, it is not enough to have a strong foundation without a house on top of it. On the other hand, a good house with no foundation will flood and deteriorate when it rains. Here, sleep hygiene is like the foundation for the house: it is necessary for good sleep, but alone it is not sufficient. Healthy sleep psychology is needed in addition to the foundation provided by sleep hygiene. While some who read this module already have healthy sleep psychology and may only be missing good sleep hygiene, most will need to adjust their psychological relationship with sleep. Healthy sleep psychology involves addressing conditioned arousal, harmful sleep thoughts/beliefs, pre-sleep arousal, and possible sleep disorders. Those four things comprise our remaining categories of sleep struggles. Let’s explore them below.

Conditioned Arousal

Dr. Michael Grandner, a renowned insomnia researcher and clinical sleep psychologist, said, “There’s really only one cause of chronic insomnia... it’s what’s called conditioned arousal.” To illustrate conditioned arousal, let’s start with a classic example in psychology research. In the late 1890’s, Ivan Pavlov, one of psychology’s first researchers, demonstrated that dogs could be trained to salivate at the sound of a bell if a bell was rung every time they were given food. Pretty soon, the dogs would drool at the sound of the bell, even without food. As it turns out, you and I are somewhat similar in the way we learn certain associations, and these connections often play a significant role in sleep struggles.
Imagine someone waking up in the middle of the night, fully alert despite feeling sleepy moments earlier. Frustrated and unable to fall back asleep, they lie awake. If this cycle repeats itself night after night, the result is conditioned arousal—a learned association between wakefulness and trying to sleep. Just as Pavlov’s dogs learned to salivate at the sound of a bell, this person learns to involuntarily feel awake and alert when they want to be sound asleep. With enough time spent in this vicious cycle, even the bed itself can become a place of wakefulness rather than restfulness as it turns into a trigger for feelings of stress and anxiety.

There are many things that may cause you to develop conditioned arousal. It might be due to persistent racing thoughts before bedtime, excessive amounts of time spent in bed doing things other than sleeping, or consistently poor sleep drive management during the day. It might even be that you have simply struggled with sleep for long enough that falling asleep and staying asleep is a stressful nightly experience. Since conditioned arousal happens as a result of regularly spending time awake when you’re trying to sleep, the solution is--in overly simple terms--to use the bed only for sleep. This is known as stimulus control therapy. We introduce this intervention along with others that will work to address conditioned arousal in the next section.

Sleep thoughts/beliefs

Most people don’t realize that the thoughts and beliefs about sleep that they carry throughout the day can significantly impact the quality and duration of their sleep at night. Among sleep experts, insomnia and other sleep issues have become known as “24-hour disorders,” meaning that what you think and believe about sleep during the day is likely having an impact on your ability to sleep at night (American Academy of Sleep Medicine, 2005; Harvey, 2002; Morin & Espie, 2007). Developing helpful expectations and beliefs about sleep is a crucial step toward cultivating deep, satisfying, and restorative sleep. On the other hand, unrealistic, misinformed, or otherwise dysfunctional thoughts and beliefs about sleep that are spontaneous, unwanted, and worrisome may be setting you up for struggle and frustration when you try to sleep at night (Baker et al., 2015). Below are a few of the most common thinking errors that people encounter who struggle with sleep. We go over an exhaustive list of these thoughts and beliefs later in the module.

Addressing these thoughts and beliefs has been shown to reduce insomnia symptoms and positively impact other aspects of sleep health, such as sleep behavior (Nielson et al., 2023). We introduce interventions to address negative thoughts and beliefs about sleep in the next section.

Pre-sleep mental status

While sleep thoughts and beliefs refer to your general attitude toward sleep, your pre-sleep mental state refers explicitly to your mental state (specifically, your level of arousal) as you try to fall asleep. To illustrate the importance of your thought content just before sleep, we will borrow a metaphor from Dr. Michael Grandner, a renowned sleep researcher and clinician. Dr. Grandner compares falling asleep at night to stopping your car at a red light. When you see a red light, you can either gently apply the brakes from a distance and coast toward the light or you can wait until the last moment and slam on your brakes in order to stop. 

In this metaphor, your daily stresses and arousal are like the speed that you travel in your car. Although going fast during the day isn’t necessarily a bad thing, it matters what you do with your speed as you approach the red light, or in other words, as you approach bedtime. Do you gently apply the brakes, allowing yourself to relax and wind down, or do you wait until you’re lying in bed to attempt to slam on the brakes? If your mind is going at 100 miles per hour, and you don’t hit the brakes until you’re three inches away from the light, then perhaps it should come as no surprise that you end up in the middle of the intersection, wide awake in bed and frustrated that you can’t get to sleep.

If your mind is so filled with racing thoughts about problems to solve and things to do that you can’t fall asleep at the beginning of the night, it is likely not because you have something wrong with your brain or with your ability to slow down. You may simply be waiting too long to do so. Repeatedly trying to fall asleep this way may even cause you to develop conditioned arousal, which we discussed earlier. If you've developed a habit of going to bed in an aroused state causing the bed to become a place of wakefulness, then you may now benefit from slowing down and relaxing further ahead of time so that you can go to bed in a serene, calm, and relaxed state. We introduce ways to do this in the next section.

Sleep disorders

At the beginning of this section, we mentioned that sleep is vital for survival, and your body is naturally equipped to meet this need as long as you don’t interfere. Although this homeostatic sleep drive works well for most people, however, it doesn’t function perfectly for some. If there’s a dysregulation in your brain or body that makes it difficult or impossible to naturally regulate your sleep/wake drive, you may have a sleep disorder. Sleep disorders can make it difficult or impossible for you to get good sleep, even if you’re doing everything right. For an overview of the most common sleep disorders, refer to the next section of the module, titled “A Note on Clinical Sleep Disturbance.”

In this section, we presented six common categories of sleep struggles. Have you identified any underlying factors contributing to your sleep issues? Remember, sleep hygiene forms the foundation for healthy sleep, while addressing conditioned arousal, sleep thoughts and beliefs, pre-sleep mental status, sleep disorders, and sleep value/prioritization builds on that foundation. If you find that you only struggle with certain aspects of sleep hygiene, focus on those activities in the personal growth experiment. However, most will benefit from improving both the foundation and the house by implementing practices from various categories. Next, we go into greater depth concerning clinical sleep disorders.

Contributor: Bryce Klingonsmith