“I haven’t slept in over a week”
You’ll sometimes hear of instances in people with chronic insomnia saying that they haven’t slept a wink in days or even weeks on end. That’s a terrifying feeling when you are worried about the effects of not sleeping on your functioning and overall health.
To be honest, as a clinician who has provided behavioural therapies for insomnia, I’m typically quite sceptical when I hear somebody say that they haven’t slept in several nights. Not necessarily from a subjective perspective – it’s very possible that may be how somebody experienced the last few days. However, from a sleep science perspective, it’s likely that people are getting a bit more sleep than they think.
I write this post not to invalidate others’ experiences or deny that they really have not been sleeping for days. My intention is to shed some light on this phenomenon to 1) provide a sleep science perspective on why we feel like we haven’t gotten a drop of sleep and 2) hopefully reduce some anxiety about sleep (or in this case, not sleeping).
1. Low build-up of sleep drive in insomnia
Sleep drive (or sleep pressure) is the propensity to fall asleep at any given moment. Sleep drive is spent during the night when we are asleep and built-up during the day once we wake up and our feet hit the flow.
Throughout the day, sleep pressure increases with the activities we engage in and the amount of time we spend awake. A higher build-up of sleep pressure is what provides us with the deep, restorative sleep that we need to feel good during the day.
In people with insomnia, they engage in behaviours that are counterproductive to building up sleep drive because they are so exhausted and worried about not getting enough sleep. They may sleep-in, cancel activities, nap if possible, and go to bed early to increase the opportunity for sleep. These behaviours reduce sleep pressure, leading to lighter and more broken sleep.
This piece of the puzzle will be important to note as we discussed move onto the next section.
2. Hyperarousal and the flight-or-flight response
People with insomnia are often very concerned about their sleep and worry excessively about the consequences of not getting enough of sleep (or not being able to sleep at all). Consequently, their body is in a constant physiological state of arousal – a fight-or-flight response of anxiety, especially during the night time. They may notice that their heart is racing, they are sweating, their breathing is harder, among a bunch of other anxiety symptoms.
Unsurprisingly, nighttime anxiety is the natural enemy of sleep, making it harder for sleep to come by. In combination with behaviours that impact sleep drive, this leads to a night of very unrefreshing, tossing-and-turning sleep. Over time, this feeling of distress in bed can lead to conditioned arousal.
Okay that’s interesting. But how does this relate to me feeling like I didn’t sleep at all?
When you combine low sleep pressure (which leads to more nighttime awakenings) and high anxiety (which further increases arousal), it leads to something called ‘sleep-state misperception’.
With the higher arousal from anxiety, our brain is much more consciously aware of times in the middle of the night that we are awake. Unlike people with low arousal levels, these awakenings are much more likely to be encoded into memory as being awake.
Let’s say you were awake at Point A, fell asleep for 30 minutes, and then woke up at Point B. Because of the high arousal levels, our brain very clearly remembers being awake at both points. However, because our brain didn’t register the time we fell asleep for 30 minutes (given that it was lighter sleep), our brain fills in the blank and thinks we were awake the entire time.
In insomnia, this can happen at a larger scale, where some people feel like they were awake the entire night. They may also report feeling like they were in a twilight zone of sleepiness and wakefulness, where they weren’t sure if they were awake or asleep.
Sleep-state misperception is the reason why people sometimes feel like they were awake in bed for the entire time they were in bed. Research also suggests that people with insomnia tend to underestimate how much sleep they got, and overestimate how long they are awake (Harvey & Tang, 2012).
Photo by Volodymyr Hryshchenko on Unsplash
Being a sleep detective!
I would encourage you the next time you are having a tough night to notice times during the middle of the night where you feel like time seems to have suddenly passed by. I’m sure people have been on an 8 hour flight before – it was probably a pretty tough experience. If you notice that several hours have gone by with you tossing and turning, there’s a reasonable chance that at least some of it was sleep – albeit probably unrefreshing sleep.
Besides sleep in the middle of the night, people with insomnia may also not take notice of certain times where they did receive some sleep. For example, some people may accidentally doze in the evening when they’re watching TV, or close their eyes on the couch and fall asleep for a little while.
It’s important to be a sleep detective in these situations to see where we might be catching more sleep than we think. This is important in reducing the fear that “I haven’t gotten any asleep at all” and it also gives us areas where we may be thwarting our sleep drive. Consider times in the evening where you are resting or times in the morning when you lie on your bed. Those may be good times to put on your sleep detective hat.
How to get back to being a good sleeper
Cognitive behavioural therapy for insomnia and medication are two effective treatments of insomnia. They both have their pros and cons, which you can read more about in the linked article.
CBT-I is effective and durable because it targets the causes of insomnia. As we talked about, low sleep drive and hyperarousal are two factors associated with insomnia being maintained over time. Therefore, the recommendations of CBT-I seeks to break these maintaining factors. If you’re interested, I would take a look at providers near you to see if any of them are qualified to provide CBT-I. There are also self-help books on CBT-I.
Final thoughts
Overall, I hope this post was helpful in clarifying fears of not sleeping for several days. The information shared in this post does not mean that you don’t have insomnia, or that you aren’t sleep deprived. Hyperarousal (the fight-or-flight anxiety response) can absolutely limit our sleep and lead to feeling unrefreshed, so please check with with your medical provider to get the help you need.
Best wishes,
P
Simply Mental Health 