Sleep in the 21st Century
By Y. Brody at Oct 26, 2008
Sleep is like food and water—sufficient amounts are necessary for physical and mental well-being and deprivation can eventually lead to death of the organism. More often, whether it’s due to sleep deprivation or insomnia, insufficient sleep can cause biological, psychological and social problems in humans. The health and performance consequences of both sleep deprivation—i.e., not putting aside enough time for sleep—and insomnia—i.e., having difficulties initiating and maintaining sleep—need to be taken seriously.
There are many individual and social factors that are related to the amount people sleep, including age, circadian and homeostatic factors, anxiety and depression, medical conditions, alcohol and drugs, as well as lifestyle and environmental factors including work, family, and social obligations. In a rapidly evolving American society, people are sleeping less and less. Yet, partly due to the strength of the pharmaceutical industry, they are often not receiving proper treatment, and the larger cultural forces at work are too rarely considered as a causal factor.
While sleep deprivation and insomnia are both related to insufficient sleep, they are actually two very different phenomena.
Increased sleep deprivation, or sleep deficit, has sometimes been described as a symptom of the recent decrease in leisure time, at least in American society (see for example the NY Times bestseller The Overworked American). Working hours increased in the second-half of the 20th century along with the sharp growth of American productivity and prosperity. This doubling of productivity could have translated into both higher incomes and decreased working hours, yet employees rarely have a choice between getting paid in time or money. Instead, Americans are, relative to the past, working more, earning more, and spending more. This focus on work and consumption over leisure time has brought about an increased “time squeeze." While this is especially true for the average American woman, the time squeeze cuts across gender, social class, and marital status. Moreover, the recent growth of digital media, very often mobile and permanent extensions of self (e.g., Blackberrys, IPhones), has dramatically raised productivity expectations and blurred the line between work and personal life. This decrease in free time and increased pace of life and stress has brought with it reduced sleep, with real consequences for physical and mental health, performance at work, and quality of life. For example, in the 1960s, the average amount of time Americans spent sleeping was between 7 and 8.5 hours a night while today 50% of the population averages under 7 hours, and, according to a 2008 survey, 1 out of 3 Americans say they get a good night’s sleep only a few nights a month or less.
Research shows that negative consequences of (non-military) sleep deprivation include excessive daytime sleepiness; micro-sleep episodes (often outside of awareness) during waking hours; lapses in concentration, attention, memory, and judgment; reduced creativity and mental flexibility; increased irritability; decreased motivation, interest, and initiative; and increased risk of physical problems such as diabetes, infection, and cardiovascular disease. Additionally, skills related to driving a car suffer, and several major accidents (e.g., Exxon Valdez, Chernobyl) have been linked to sleep deprivation, underlining the seriousness of the issue as a public safety hazard.
Insomnia, as opposed to sleep deprivation in general, is defined by the World Health Organization as a problem in initiating and/or maintaining sleep, or the complaint of nonrestorative sleep, that occurs on at least three nights a week and is associated with daytime distress or impairment. Severity is usually determined by the amount of time it takes to fall asleep and the duration of awakenings, as well as frequency and duration of sleep difficulties. Most people, at some point or another, experience acute insomnia in life; this is normal and must be distinguished from persistent insomnia lasting more than one month. Hyperarousal and hypervigilance around sleep are important factors in persistent insomnia.
Several psychological and quality of life symptoms appear to be caused by insomnia. These include daytime fatigue (as opposed to daytime sleepiness, which is associated with reduced arousal) and emotional disturbances such as irritability, anxiety, depressed mood, and helplessness. Longitudinal studies suggest that persistent insomnia may be a risk factor for developing clinical depression (and having depression is also a risk factor for insomnia). Somatic complaints such as gastrointestinal and respiratory problems, headaches, and non-specific aches and pains are also linked with insomnia. Interestingly, cognitive impairments resulting from insomnia, such as those in attention, concentration, and memory, appear to be more limited than those for sleep deprivation.
While use of sleep medication has increased recently, less well known is that the most effective long-term treatment for insomnia is short-term cognitive-behavioral therapy. Expensive marketing campaigns waged by pharmaceutical makers are misinforming the public. Prescription sleep drugs are reportedly the most popular drug ads on TV and industry expeditures rose four-fold between 2004 and 2005, to $300 million. However, despite the PR onslaught aimed at consumers, top sleep professionals are convinced that cognitive-behavioral therapy is as effective as sleep medication in the short-term and is more effective than sleeping pills in the long-term.
Cognitive-behavioral treatments for insomnia are usually time-limited and can focus on several different components including stimulus control therapy (limiting the amount of time spent in the bed/bedroom while awake, and restricting the kinds of behaviors one engages in in the bed/bedroom), sleep restriction therapy/sleep scheduling (requiring patients to limit the amount of time they spend in bed, whether asleep or not, in order to increase sleep efficiency), cognitive restructuring (changing false beliefs that restrict ability to sleep), relaxation training, phototherapy, sleep compression, and neurofeedback.
Many people with difficulty sleeping have what sleep professionals call poor “sleep hygiene.” There are several simple ways experts recommend that you can improve your sleep hygiene and increase the likelihood of a good night’s rest. Here are some general tips for overcoming insomnia:
1. Restrict time spent in bed in order to consolidate and deepen sleep. Use bed only for sleeping (and sex). Reading, using the computer, or doing other things in bed only conditions your body and mind that bed is a place to remain alert. Similarly, if you can’t get to sleep after 20-30min, get out of bed and do something else. Only return when you feel relaxed and ready for sleep to engulf you. Also, do not try to fall asleep, this only makes the problem worse. Avoid daytime napping.
2. Get out of bed at the same time each day, even on weekends. This helps set your biological clock.
3. Avoid alcohol, tobacco, and caffeine in the 4 hours before bedtime. Alcohol has an initial depressant effect, but later in the night becomes a obstacle to restful sleep.
4. In general, lowered body temperature and sleep go together; increased body temperature can be a detriment to sleep. Avoid hot baths right before bed, and think about letting in some fresh air at night.
5. Extreme environmental temperatures deter sleep. Avoid making your bedroom too hot or too cold.
6. Make sure the bedroom environment is free from light and noise.
7. Do not go to bed hungry. However, avoid heavy meals just before bed.
8. Regular exercise helps initiate and deepen sleep. However, avoid vigorous exercise in the 3 hours before bedtime—such an increase in arousal before bed can have the opposite effect.
9. Put the clock under the bed or turn it so that you can’t see it—clock watching can provoke anxiety or anger which interfere with sleep.
Two further points: “Sleep debt” is cumulative over the long-term, which means that if you don’t ever make up lost sleep you are increasing your risk of developing future health problems. Also, people have individual differences in sleep needs but most people need between 7 and 8.5 hours to feel rested and alert throughout the day.
If you find yourself chronically sleep-deprived, your social and cultural environment is likely to blame for putting you at risk for future health problems. Think seriously about making minor or major lifestyle changes in order to improve your overall health and work performance. And if you’re one of the estimated 10-14% of people experiencing persistent insomnia, look for a therapist who specializes in cognitive-behavioral sleep therapy. Sleep medication, whether alone or in conjunction with therapy, is recommended and effective only for acute problems sleeping. A large body of empirical evidence shows that cognitive-behavioral therapy is more efffective for persistent insomnia.
Finally, in addition to individual treatment, societal and cultural factors need to be considered if the alarming trend towards less and less sleep in America, along with the increased health problems associated with insufficient sleep, is ever going to be reversed.
Find a sleep center near you (US only):
Further reading on insomnia treatment:
Further reading on recent social-economic changes in the US related to sleep deprivation:
Perlin, M. L., Jungquist, C., Smith, M.T., & Posner D. (2005) Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. New York: Springer.
Morin, C.M. and Espie, C.A. (2004) Insomnia: A Clinical Guide to Assessment and Treatment. New York: Springer.
Schor, Juliet B. (1992) The Overworked American. New York: Basic.