There was a time when insomnia was considered a virtue. In medieval Europe, as the historian Eluned Summers-Bremner wrote in Insomnia: A Cultural History, “The Devil himself was seen as an insomniac, and required a corresponding vigilance” from all those who wanted to keep him away. Good Christians made their beds uncomfortable, Summers-Bremner wrote, so they wouldn’t too easily drift into deep sleep. (Fear of robbery, arson, and bedbugs kept people waking in the middle of the night, too.)
Today, insomnia is no longer considered a virtue, just a problem — one that affects an estimated 30 million Americans each year. The definition of insomnia is fairly straightforward: “A person with insomnia has trouble falling or staying asleep,” according to the American Psychiatry Association, and “when sleepless nights persist for longer than a month, the problem is considered chronic.” The definition of an insomniac, though, is more complicated — and potentially more harmful, too.
“Insomnia is a sleep disorder,” psychologist Kenneth Lichstein wrote in his recent paper in the Journal of Behaviour Research and Therapy, “but it may also be a cognitive appraisal disorder.” The paper, titled “Insomnia Identity,” underscores the division between the label and the condition: “There may be many people out there suffering because of their insomnia identity,” he wrote, “rather than an actual lack of sleep.”
Reviewing 20 studies that separately measured poor sleep and self-reports of poor sleep, Lichstein found that there is relatively little overlap between how well people sleep and how well they think they sleep. For example, one 1995 study of people aged 55 or older found most of the poor sleepers (defined in the study as taking more than half an hour to fall asleep, at least three nights per week, over a period of six months) didn’t think of themselves as experiencing insomnia. Remarkably, these people felt no more fatigue or anxiety the next day than people who slept significantly better. Another study found that while poor sleep is often associated with a 350 to 500 percent higher risk of high blood pressure, people who didn’t consider themselves to have insomnia didn’t show the expected increase.
On the other hand, there are also plenty of people who wrongly think of themselves as experiencing insomnia even though they get enough sleep.
In his analysis, Lichstein found that 37 percent of people who complained of insomnia actually weren’t insomniacs at all. Even though they slept for an adequate number of hours per night, these people tended to wake up with the same daily fatigue, depression, anxiety, and hypertension as people who really did have a “clinical deficit of sleep.”
It seems that thinking of yourself as an insomniac may be a self-fulfilling prophecy, explains Michael J. Sateia, an emeritus professor of psychiatry at Dartmouth’s Geisel School of Medicine. “The condition becomes a focus of attention and the sufferer may begin to arrange his/her life around this issue,” he says. “These negative expectations produce greater anxiety and arousal and, voilà, they don’t sleep well.”
But this vicious cycle still doesn’t explain why so many people who sleep well still think of themselves as — and feel like — insomniacs. Lichstein believes that the cycle begins with certain personality traits: Highly neurotic people, for example, may exaggerate small sleep issues, blowing them up into “untenable insomnia.” The same is likely true of people prone to hypochondria or “catastrophic thinking.”
What makes “insomnia identity” especially hard to shake is the fact that the diagnosis of insomnia is typically patient-driven: Someone will complain to their doctor about not being able to sleep, perhaps undergo a quick sleep assessment, and then get their confirmation that they are, in fact, struggling with insomnia. By the time the problem has become significant enough for someone to seek medical treatment, odds are good that they’ve already adopted the identity — I’m getting help because I’m an insomniac — and then the diagnosis is just reinforcement.
The nature of this initial exchange is likely too lax, Sateia says, and offers a definition of insomnia that’s overly broad. “For too long, patients and physicians have viewed this as more of a nuisance issue rather than seeing it for what it is,” he says, “a serious disturbance of a fundamental biological function.” To separate the condition and the sufferer, Sateia recommends identifying and treating the underlying causes of insomnia, notably depression.
The next step, he and Lichstein agree, is breaking down the worry over the loss of sleep with cognitive behavior therapy for insomnia (CBTi).
Over several sessions, a therapist focuses on the exaggerated nature of the patient’s worries and reactions, as a way of breaking down the identity that they’ve built around their insomnia.
Identities related to health aren’t constrained just to sleep. People with disabilities, for instance, often have “a series of identity struggles and considerations” over how to define themselves in relation to their condition, says Kayleigh Garthwaite, a social-policy and sociology fellow at the University of Birmingham in England. In a similar vein, some cancer patients will talk about “cancer identity” and the ways that a diagnosis has affected how they fundamentally see themselves. While insomnia may seem like a more trivial issue by comparison, the same mechanism is at work: Once an “insomnia identity” is implanted in a person’s mind — once they go from “experiencing insomnia” to “being an insomniac” — it can feel like a powerful shift.
And, for insomnia especially, adopting a health-related identity is a fascinating (and slightly disturbing) example of the amount of control our minds have over our bodies. Telling yourself you slept well even if you didn’t, as Lichstein’s analysis demonstrates, can go a long way toward preventing fatigue the next day; falsely believing you’ve slept terribly can move things the other way.
In other words: You can, for better or worse, temporarily trick your brain. Sleep may be a biological function, but it’s one that’s deeply tied up in the quirks of our psychology. “Worry about poor sleep is a stronger pathogen than poor sleep,” Lichstein says. “Perception creates reality.”
