The Mystery Of Sleep: Why Can't I Rest?

Sleep is an essential part of a healthy life, but many people struggle with falling asleep or staying asleep. This condition is called insomnia, and it can have a wide range of causes, from lifestyle habits and medications to physical or mental health conditions. Emotional issues such as stress, anxiety, and depression are among the most common causes of insomnia, but your daytime habits, sleep routine, and physical health may also play a role. Certain types of medications, including antidepressants, stimulants for ADHD, and high blood pressure medications, can also interfere with sleep. Furthermore, medical conditions such as asthma, allergies, and acid reflux can contribute to insomnia. To improve sleep quality, it is recommended to establish a relaxing bedtime routine, maintain a comfortable sleep environment, and address any underlying physical or mental health issues.

Caffeine, alcohol, and heavy meals before bed

Caffeine, alcohol, and heavy meals can all have a detrimental impact on your sleep. Consuming caffeine can provide an energy boost and help you feel more awake, but you can feel the effects for up to six hours. If you have a caffeinated beverage within six hours of your typical bedtime, the caffeine can keep you from feeling sleepy and falling asleep.

The American Academy of Sleep Medicine recommends that you stop drinking caffeinated beverages at least six hours before bedtime. People who are sensitive to caffeine may need to stop even earlier.

While alcohol can make you feel sleepy at first, it can make it challenging to get a good night's sleep later. Drinking alcohol affects how long you spend in the rapid-eye movement (REM) stage of sleep, which is essential for processing emotional memories. Alcohol can also cause or worsen sleep apnea, as it can irritate the airway, making it collapse and contribute to snoring.

Heavy meals consumed within two hours of bedtime can also disrupt your sleep. They can leave you feeling uncomfortably full and, over time, can contribute to obesity—a well-known risk factor for sleep apnea.

Chronic pain

In addition to shorter overall sleep time, chronic pain can also cause frequent nighttime wakings. In fact, this appears to be the most common sleep complaint in people with chronic pain.

As we sleep, we cycle through light sleep, slow-wave sleep, and rapid eye movement (REM) sleep. In order to feel well-rested, we need a balance of all these sleep stages, especially slow-wave sleep and REM sleep. Disrupting this cycle interferes with the progression of the sleep stages, and leads to less restful sleep and next-day tiredness.

Apart from the pain itself, some people with chronic pain also experience one or more sleep disorders, such as obstructive sleep apnea or restless legs syndrome. Medication for pain or for a chronic illness may carry side effects that interfere with sleep. Pain can also be accompanied by anxiety, stress, or depression. These conditions can cause sleep problems in their own right, and should be treated as part of an overall health plan.

When learning how to sleep with pain, the type of pain may dictate your sleeping position. Those with hip, knee, or shoulder pain — as in the case of rheumatoid arthritis — may need to avoid sleeping on their side.

By contrast, people who are sensitive to pressure build-up in the lower back may need to be careful when sleeping on the back or stomach. A mattress and pillow designed to cushion pressure points and support the natural curvature of the spine may help alleviate some of the pain.

Other conditions cause diffuse pain, such as multiple sclerosis. These conditions attack the nerves, which means people may need to switch sleeping positions more frequently to avoid numbness and tingling. These sleepers may need a more responsive mattress that facilitates movement on top of the bed. Reach out to a caregiver or sleeping partner for help if you have trouble adjusting positions on your own.

There is an unquestionable link between sleep and pain, but emerging evidence suggests that the effect of sleep on pain may be even stronger than the effect of pain on sleep.

Researchers have found that short sleep times, fragmented sleep, and poor sleep quality often cause heightened sensitivity to pain the following day in chronic conditions like rheumatoid arthritis. People with sleep problems also appear to be at a higher risk of eventually developing conditions like fibromyalgia and migraines. Encouragingly, many studies have also found that in the long term, quality sleep may improve chronic pain.

Sleep and pain appear to share similar pathways and neurotransmitters. For example, melatonin is best known for its role in regulating our circadian rhythm, and new research is starting to uncover melatonin’s role in our perception of pain. Sleep loss also causes inflammation in the immune system, with corresponding effects on our body’s resilience. Vitamin D and dopamine also appear to play a role in both sleep and pain.

Studies have found differing results for the effects of sleep deprivation on our pain threshold and the brain’s capacity for pain inhibition. It may be that sleep alters pain through different pathways depending on the condition and the type of sleep deprivation.

The ability to deal with sleep disturbance and pain may have a sociodemographic aspect as well. Many studies show when it comes to increased pain due to insomnia, women are more sensitive than men, and young people are more resilient than older people.

People with chronic pain may feel fatigued during the day. Depending on their level of disability, they may be less likely to exercise or follow a healthy diet, both of which are important for getting a good night’s sleep. Unsettled sleep due to chronic pain can also disturb a spouse who shares the bed, with corresponding consequences for their sleep quality and health.

Both adults and children with chronic pain report poor sleep quality, and those who sleep poorly also have more intense pain and greater levels of disability. Though sleep undoubtedly plays its own independent role, researchers believe this relationship is due in part to psychological factors.

People with chronic pain may suffer from a self-perpetuating cycle of pain, insomnia, and depression or anxiety. For example, someone who is in pain may become anxious when they cannot sleep. They may sleep poorly and wake up feeling depressed, which increases their sensitivity to pain. The next night, they are in pain again, so they cannot sleep well, and the cycle continues. Over time, this negative cocktail may worsen existing conditions and even have an influence on a person’s level of disability.

One of the more important psychological factors seems to be the tendency to catastrophize. A study on osteoarthritis patients found a link between catastrophizing, poor sleep quality, and a more active central nervous system, suggesting that catastrophizing amplifies felt pain.

It’s estimated that one-third of people with chronic pain also meet the requirements for clinical depression. On the whole, it appears that chronic pain patients with depression have higher pain levels, poorer sleep hygiene, and find it harder to switch off their brains at night.

Cognitive behavioral therapy for insomnia (CBT-I) and, to a lesser extent, cognitive behavioral therapy for pain (CBT-P), have been shown to help treat insomnia in patients with chronic pain. There is limited evidence for the effectiveness of CBT-I in people who have both chronic pain and a coexisting condition such as anxiety or depression. However, close attention to both sleep quality and catastrophizing appears to lower the chances of developing chronic pain in patients recovering from trauma.

The sensation of pain varies widely from person to person. Psychological factors are among several factors that affect the severity of the pain we feel. This does not mean the pain is not real, but it means that treating pain may require a multifaceted approach that accounts for these various and complex psychological factors.

Jet lag and shift work

Jet Lag

Jet lag is a circadian rhythm sleep-wake disorder that occurs when your 24-hour internal clock does not match the local day-night cycle. It can cause fatigue, insomnia, irritability, and digestive problems. Jet lag can last anywhere from a few days to a few weeks.

To prevent or reduce jet lag, it is important to realign your circadian rhythm with the time zone of your destination. This can be done by managing your exposure to light and darkness, as light is the most powerful influence on the circadian rhythm. When travelling shorter distances, it may be possible to maintain your regular home schedule. For longer distances, it is recommended to gradually switch before the trip by incrementally adjusting mealtimes and bedtime to match the schedule of your destination. During the flight, it is important to stay hydrated and avoid caffeine and alcohol, which can worsen jet lag symptoms. Upon arrival, switch your bedtime as soon as possible to match the new time zone. If you need to wake up earlier, get early morning sun; if you need to wake up later, get exposure to late afternoon sunlight.

Shift Work

Shift work sleep disorder (SWSD) is a circadian rhythm sleep disorder that affects people who work non-traditional hours. It causes issues with falling asleep, staying asleep, and sleepiness at unwanted times. SWSD can lead to poor work performance, higher accident risk, mood issues, and an increased likelihood of alcohol and substance use.

To cope with the challenges of shift work, it is important to prioritize sleep and create a conducive sleep environment. This may include making changes to your work and sleep routines, such as reducing exposure to sunlight after a night shift and taking naps before or during shifts. Maintaining a consistent shift work schedule and minimizing the number of consecutive challenging shifts can also help. Additionally, managing your exposure to light is crucial, as it plays a significant role in regulating your body's internal clock. Bright light therapy and melatonin supplements may also be beneficial in adjusting your sleep schedule.

Medication and mental health

Medication Affecting Sleep

Certain medications can cause insomnia, disturbed sleep, nightmares, and oversleeping. Psychiatric medications, for example, can cause insomnia, and stopping psychiatric drugs can also lead to sleep problems. Antidepressants, for instance, can sometimes cause fatigue, with one study showing that over 90% of people with major depressive disorder were very tired, despite over 80% of them taking antidepressants. Additionally, medications such as painkillers, antidepressants, and over-the-counter drugs can interfere with the effectiveness of sleep aids.

Mental Health Affecting Sleep

Mental health issues can also cause sleep problems. Research suggests that most people with mental health disorders like anxiety also experience some form of sleep disruption. Anxiety can cause racing or repetitive thoughts and worries that keep you awake, and you may also experience panic attacks while trying to sleep. Depression can make you sleep more, including staying in bed for longer, and it can also cause insomnia. Experiencing trauma can cause nightmares or night terrors, and you may feel unsafe or uncomfortable in bed or in the dark. Paranoia and psychosis may also make it difficult to sleep, as you may hear or see things that are frightening or disturbing.

Treatment Options

If you are experiencing sleep problems, it is important to seek help from a healthcare professional, who can recommend treatment options such as therapy or medication. Cognitive Behavioural Therapy for insomnia (CBT-I) is often recommended as a first-line treatment for insomnia. This therapy teaches patients how to break the association between their bed and worrying and being distressed, and instead, see the bed as a place for sleeping. CBT-I also includes relaxation strategies and mindfulness techniques, and it usually lasts around four to eight sessions.

Your healthcare provider may also recommend medication to treat anxiety or other mental health disorders, or sleep-related disorders such as restless leg syndrome or insomnia. These can include prescription drugs such as benzodiazepines, "Z-drugs" like eszopiclone (Lunesta), or melatonin in prescription strength. Over-the-counter options include antihistamine drugs like diphenhydramine (Benadryl) and doxylamine (Unisom), as well as the hormone melatonin. However, it is important to note that some medications may increase anxiety or make sleeping more difficult, and many sleep aids can be habit-forming, so it is crucial to consult a healthcare professional before starting any new medication.

Sleep environment and bedtime habits

Bedroom Environment

• Keep your bedroom quiet, dark, and cool. Noise, light, and temperature extremes can interfere with sleep.
• Use a sound machine or earplugs to block out noise.
• Install blackout curtains or use an eye mask to block out light.
• Adjust the temperature to a comfortable level.
• Experiment with different levels of mattress firmness, foam toppers, and pillows to find what works best for you.

Bedtime Routine

• Stick to a regular sleep schedule. Go to bed and wake up at the same time every day, even on weekends.
• Avoid stimulating activities before bed, such as watching TV, using your phone, or working on a computer.
• Turn off all screens at least one hour before bed. The blue light emitted by electronic screens disrupts your body's production of melatonin, a hormone that regulates sleep.
• Avoid naps during the day, especially in the evening. If you must nap, limit it to 30 minutes and try to nap before 3 pm.
• Avoid consuming too many liquids close to bedtime to reduce the need to wake up during the night to use the bathroom.
• Avoid alcohol, as it interferes with your sleep cycle and can cause sleep disturbances.
• Eat dinner earlier in the evening, and avoid heavy, spicy, or rich foods within two hours of bedtime to prevent stomach troubles and heartburn.
• Avoid caffeine within six hours of bedtime. Caffeine can keep you awake and interfere with your sleep.
• Engage in relaxing activities before bed, such as reading a book, listening to soft music, or taking a warm bath.
• Practice deep breathing or meditation to calm your mind and body.
• Write down your thoughts or a to-do list to clear your mind and help you feel more relaxed.

Frequently asked questions