In the depths of her insomnia, Helena Morland tried it all — meditation, herbal supplements, a change in diet, medication and psychology.
The mum-of-two was desperate to find a solution to the seemingly never-ending spiral of disrupted sleep followed by days of exhaustion.
“I’d be in tears in the middle of the night out of pure frustration because I couldn’t understand what was going on,” she said.
“It’s absolute misery. And if you haven’t been through it, you don’t understand it.
“Imagine having a newborn baby that wakes you all the time. Except there’s no one waking me up – it’s just me.”
For three months, Ms Morland battled through worsening sleeplessness while juggling a university course and raising her family.
“I was unable to cope,” she said. “I didn’t want to see anyone when I was really bad and hadn’t had an opportunity to catch up on sleep.
“I had a lot of unproductive days where I just had to stay at home, and basically do nothing or try and catch up on sleep, because I didn’t have the mental capacity to do anything apart from very basic things.”
For decades, Melbourne health psychologist and Sleep Health Foundation board member Moira Junge has seen patients at this “pointy” end of insomnia, when the act of sleep itself – far from being a relaxing and reinvigorating experience – is wracked with performance anxiety.
“Sleep itself becomes the performance,” Dr Junge said. “It’s like a job interview. And when you go into bed you think, ‘I’ve got to do this well, I’ve got to sleep’.
“But sometimes if you’re really worried about it, or have a lot riding on it, then you don’t.”
Late at night, online insomnia forums are populated with the desperately sleepless. Sometimes they post medication questions or treatment recommendations, but mostly they’re just looking for someone who understands the lonely despair of what feels like endless consciousness.
“Second day on no sleep, who else?” asks one poster.
“Anyone else have a partner who sleeps like a baby every night? So infuriating!” comments another.
“I know this may sound ridiculous, but will I die from insomnia?” another post reads. “I am so scared my brain is broken and that it will never let me sleep again … I’m not over-exaggerating, I truly feel this way.”
Insomnia disorder is defined by a failure to fall or stay asleep for three or more nights a week for three months or longer. A 2019 Sleep Health Foundation study found nearly 15 per cent of Australians have symptoms which could meet the diagnostic criteria, whether they realise it or not.
While many people experience disruptions to sleep during times of upheaval or anxiety, the difference in patients with insomnia is the sleep problem will persist even after the initial stress trigger is resolved, says Sean Drummond, a professor of clinical neuroscience at Monash University.
“For 85 per cent of the people out there, when that initial stressor is gone, sleep goes back to normal, and everything’s fine,” he said. “But for roughly 15 per cent of people, even once the stressor is gone, they continue to sleep poorly.
“Those are the people who then we say go on to develop chronic insomnia.”
People might try to cope by going to bed early, napping during the day, drinking extra caffeine, spending more time in bed looking at a phone, or being overly sedentary.
While these behaviours are understandable among people who are feeling tired, Professor Drummond said they often became “perpetuating factors” that could ultimately make the situation worse.
“It’s essentially a series of behaviours and thoughts that utterly conspire to make this insomnia worse and keep it going over time,” he said. “And that’s when it really develops a life of its own.”
In their desperation, many insomniacs begin designing their lives around improving their sleep, Dr Junge said.
“What happens is you get anxious about not sleeping, and then worry about it and put all these sort of maladaptive habits in, like trying too hard,” she said.
“You have less tolerance for tiredness, and everything gets blamed on the tiredness. A lot of people develop a misattribution that everything is to do with sleep – like, ‘If only I slept better, I’d be the Prime Minister’.”
Professor Drummond said trying too hard to sleep is unhelpful. “People develop what’s called an attention bias towards sleep,” he said. “Everything they’re thinking about is related to sleep.
“It leads to almost an obsession. Sleep is one of these funny things that the harder you try to do it, the less likely it is to actually happen.”
As a person becomes more fixated on sleep, and anxious at the prospect of another sleepless night, the body responds to bedtime counterintuitively, by generating stress hormones – rendering the person almost physically incapable of sleep and developing an association with bed as a place of stress, not rest.
“The person develops what we call conditioned arousal,” Professor Drummond said.
“As soon as they go into the bedroom and lie down in bed, that conditioned arousal kicks in and bang, their eyes open and their brain starts to go and they can’t turn it off, and all of a sudden they can’t fall asleep.
“It’s all because the bed now has become a symbol to the brain that, ‘Hey, you’re supposed to be awake and anxious and stressed out’ rather than, ‘You’re supposed to be relaxed and sleepy’.”
Veronica Bosworth has dealt with intermittent periods of insomnia since she was a child and has experienced this feeling of being “tired but wired”.
“When my insomnia was at its worst, I would get anxious before going to bed – the whole opposite of what you need to be,” she said.
“I reached a stage where I was in a fugue state. I felt like I was existing. I was just pushing my body through the processes of the day as best I could, but I didn’t feel like I was living at all.”
If she woke up in the night, Ms Bosworth would frantically begin calculating the amount of time she had left to sleep.
“One thing that I used to do when I would wake up in the middle of the night is look at the time and then freak out at how little sleep I could get in before my alarm would go off,” she said.
“Although this was probably one of the most difficult things to do, I taught myself to never look at the time. The reason being that it made no difference. All it did was make me anxious.”
Many clients with insomnia also develop anxiety around the negative health effects of prolonged sleeplessness, Dr Junge said.
“I get so worried when I hear headlines around: ‘Less than eight hours sleep will cause dementia’ and the like,” she said.
“This is fantastic, great quality research… but when you’ve got insomnia, the last thing you need to hear when you’re driving to work is that your lack of sleep is going to harm you.”
While researchers are still investigating genetic risks for insomnia, both Dr Junge and Professor Drummond agreed there was a typical personality profile prone to the condition.
“Somebody who generally runs a little on the anxious side, somebody who we used to call the ‘Type A personality’ that’s really driven, always switched on, a go-go-go kind of person, somebody who ruminates a lot and has a hard time turning their thoughts off, is like more likely to develop insomnia,” Professor Drummond said.
Dr Junge said her patients were generally “very high achieving, very conscientious but also self-confessed worriers [with] high empathy.”
In the Sleep Health Foundation survey, significantly more female respondents than male respondents reported they “often or always” worried about getting a good night’s sleep (31 per cent vs 21 per cent) and were overwhelmed by thoughts when trying to sleep (35 per cent vs 25 per cent).
People with insomnia were likely to be fastidious in their attempts to improve their sleep, which might include following a regimented “sleep hygiene” program of avoiding caffeine after lunch, exercising vigorously but not too close to bedtime, and less screen time at night.
While this advice often works well for the general population, Dr Junge said following a sleep hygiene program too religiously could be problematic for those with an insomnia disorder as it could instil the belief sleep is impossible without following an elaborate list of rules, and even feed anxiety.
“Once you’ve got insomnia, those lists of dos and don’ts become quite rigid and ritualised and … really counterproductive,” she said.
Professor Drummond said the solution to insomnia was not sleeping pills or other medication but “unequivocally” a course of cognitive behavioural therapy (CBT).
Cognitive therapies are usually psychologist-administered and involve identifying and challenging a patient’s unhelpful thoughts and beliefs around sleep, as well as encouraging them to adopt behaviours more conducive to sleep.
Behavioural therapies include re-establishing the association of bed and sleepiness by asking the patient to get out of bed if they don’t fall asleep after 10-15 minutes and only returning when they feel tired again.
Another intervention is what Professor Drummond calls “sleep efficiency therapy”, a mild form of sleep deprivation where the patient limits their time in bed in order to increase their sleep drive and maximise the amount of time they are asleep.
While effective insomnia treatment involves intervention by healthcare professionals, studies show awareness around identification and treatment of insomnia disorder within the healthcare profession may be lacking.
A study spanning 15 years to 2015 found 90 per cent of people who discussed sleep problems with their GP were prescribed medication, with only one per cent referred onward to a psychologist or sleep specialist.
And a October 2020 narrative review found while deficient sleep had been recognised as a current health crisis, all Australian healthcare disciplines received limited training in addressing the condition, with one international study that included Australia and New Zealand finding medical students only received an average of 2.5 hours of sleep education.
“Despite the expansion of academic sleep programs over the past 30 years, basic sleep education has not filtered down into training programs for primary healthcare providers who service the majority of people affected by deficient sleep,” the study found.
Over the years, both Helena and Veronica have developed methods to manage and live with their insomnia.
Veronica follows a strict pre-bed routine involving meditation, relaxing music and affirmation recordings.
Helena has a flexible schedule at work and home in order to fit in with her disrupted sleep pattern, and says it’s been working for her.
“While I’m still working on my own sleep, it has definitely improved from when my insomnia began,” she said. “I do have days where I feel refreshed, and it’s like, ‘Oh, this is what it’s like to be a normal person and have a productive day’.
“I don’t want my story to be a message of hopelessness, but one of being a journey to find the right solution for me.”