This is the second instalment of a series that will explore the question: Am I Normal? (Read the first instalment.)
Are you tired but wired? A clock watcher or a dark riser? It's normal to think your sleeping is abnormal. But what does insomnia really look like?
As is often the case, abnormal has many subtypes.
The disordered sleep patterns I hear about take three forms. Most people describe either a hard time getting to sleep or not being able to get back to sleep (tired but wired), with either middle-of-the-night waking (clock watchers) or very early wakening (dark risers). Each of these subspecies can be exacerbated in our always-on world of e-mail, TV and Googling.
Length of insomnia is also important: the occasional bad night (transient insomnia), a few days to a few weeks (short-term insomnia) and lasting over a month (chronic insomnia).
The rates of insomnia are variable depending on the definition and population studied. A survey of primary-care patients found that 69 per cent had insomnia. The insomnia was reported as occasional by 50 per cent and chronic by 19 per cent.
A review of 50 studies had the rate of chronic insomnia, with related daytime consequences, closer to 10 per cent of individuals.
The factors – ranging from your sex, age, your family and employment situation – are varied and can seem contradictory.
If you are a woman and think that your male partner sleeps better than you, this is backed by data: The insomnia rates of women are about 50-per-cent higher. Many of the women I talk to in clinic would wonder how much this number is influenced by male snoring.
Parents with young children rarely report a blissful and sustained sleeping experience.
People who are unemployed or alone (divorced, widowed, separated) also have more insomnia.
If you think you are sleeping less well as you get older, then you are also normal. Studies show that for most of us our sleep efficiency decreases as we age. In one study of elderly individuals, 57 per cent had complaints consistent with insomnia and only 12 per cent reported normal sleep.
Most people think the global target is eight hours, when in fact it's closer to seven. The clinical reality is that people tend to know their own personal target number.
Another interesting factoid is that when we measure the amount people actually sleep, they usually think they slept less than they actually did.
What's more, it's normal to move in and out of insomnia.
A study published this year by University of Laval professor Dr. Charles Morin and colleagues took a representative sample of 100 patients. Every month for a year, they had a long telephone conversation with each about their sleep. Initially 42 were good sleepers, 34 had insomnia symptoms and 24 had an insomnia syndrome.
As the year went by, 66 per cent of participants changed their category, with the biggest movement in the middle category, where 90 per cent moved toward a good night's sleep. About half of the good sleepers developed symptoms at one point over the year, and 14.5 per cent developed a syndrome.
Interestingly, in the clinic I find patients don't often complain about their insufficient sleep as they think this is normal. However, if I make inquiries I get the full story – so I tend not to ask about sleep when I am behind, which is too bad. In medicine we focus too much on the silos of diseases and lab values and tend to skip over opportunities that cut across silos such as increasing activity, thinking better and increasing our sleep efficiency.
Our sleep is so intertwined with our moods, attitudes, food decisions and abilities to problem-solve. When we're not getting enough of it, it's normal for both you and me to seek the simple solution, a sleeping pill. But research on insomnia points to cognitive behaviour therapy (through which we reboot behaviours and thoughts at bedtime to improve your sleep) as the single best long-term treatment.
The bad news is that therapists who do this work are limited.
The good news is that Dr. Google is bringing Web-based versions that are proving effective and much more scaleable.
Chances are you need help.
Dr. Mike Evans is a staff physician at St. Michael's Hospital, an associate professor of family medicine and public health at the University of Toronto, and a scientist at the Li Ka Shing Knowledge Institute. Evans curates resources and information for a range of common conditions on docmikevans.com and runs a different kind of health lab that fuses filmmakers and illustrators with clinicians and best evidence. His video, 23 and ½ hours, has been seen by over four million people and his Medical School for the Public on YouTube has been viewed by over nine million. Follow him on Twitter @docmikeevans