Alcohol withdrawal syndrome (AWS) is a set of physical and psychological symptoms that occur when an individual with an alcohol use disorder (AUD) quits or reduces alcohol use abruptly. The symptoms of alcohol withdrawal can range from mild to severe and often include insomnia and other sleep disruptions. Persistent sleep disturbances raise the risk of relapse during the first few months of treatment. According to the National Center for Biotechnology Information (NCBI), as many as one-third of alcohol-dependent patients suffer persistent insomnia symptoms throughout the year.
Alcohol Withdrawal Insomnia
Insomnia refers to the experience of having trouble falling asleep, waking up frequently (sleep fragmentation), staying up for lengthy periods, or sleep that is generally unrefreshing despite getting enough sleep time. Insomnia in alcohol-dependent patients in recovery is characterized using polysomnography (PSG) as increased sleep-onset latency, rapid eye movement (REM) sleep percentage, sleep fragmentation, reduced sleep efficiency, slow-wave sleep (SWS) percentage, and REM latency.
It’s a common symptom during the acute withdrawal phase (one to two weeks in the alcohol withdrawal timeline) and early recovery (two to eight weeks after detoxification). However, some individuals may experience prolonged insomnia during their sustained recovery phase (three or more months after detoxification). Withdrawal symptoms during the sustained recovery phase are referred to as post-acute withdrawal syndrome (PAWS). Sleep disturbances during this period can last for years.
Why Does Alcohol Withdrawal Cause Insomnia?
To understand why withdrawal from alcohol causes insomnia, it helps to know the effects of alcohol on your brain and body and the different stages of the human sleep cycle.
According to the Sleep Foundation, a normal sleep cycle consists of three non-rapid eye movement (NREM) stages and one rapid eye movement (REM) stage. Throughout the night, these four stages recur in a cyclical pattern. One of the most detrimental impacts of alcohol on sleep is its tendency to diminish the amount of REM or deep sleep and increase NREM sleep. A sufficient amount of REM sleep is crucial for our well‐being and sleep quality. Without it, people are more susceptible to mental and physical health issues.
Alcohol has several effects related to the neurotransmitters involved in the control of normal sleep, including an increase in mesolimbic dopaminergic activity, the facilitation of gamma-aminobutyric acid (GABA) inhibition, alteration of serotonin receptor function, the inhibition of glutamate excitation, an increase in endogenous opioid synthesis and release and the promotion of adenosine signaling. With chronic alcohol consumption, these effects become more exaggerated, affecting the control and quality of sleep and wake cycle.
Recovering alcohol-dependent patients may experience difficulty falling asleep and remaining asleep during the night and daytime sleepiness. A major risk factor for relapse is non-restorative sleep, which is also one of the last sleep cycles to return to normal for patients with alcohol use disorder.
Alcohol Withdrawal Insomnia vs. Insomnia Disorder
Controversy exists regarding whether insomnia in patients with alcohol use disorder differs from insomnia disorder. The Diagnostic and Statistical Manual of Mental Disorders ((DSM-V) separates substance or medication-induced sleep disorder from insomnia disorder, with the former being defined as a severe disturbance in sleep causing clinically significant psychological distress or impairment that developed during or soon after the substance use or after withdrawal from use.
In contrast, the International Classification of Sleep Disorders (ICSD-3) no longer promotes that insomnia occurs as a secondary sleep disturbance related to an underlying primary disorder, such as a substance use disorder. Instead, it provides a single diagnosis of chronic insomnia disorder for all patients with frequent, persistent insomnia.
Different factors should be considered for patients experiencing alcohol withdrawal insomnia compared to those experiencing general insomnia when evaluating treatment choices. Insomnia treatment for AWS should be determined based on its ability to reduce the risk of relapse in patients.
How Do Sleep Problems Threaten Recovery?
Prolonged deprivation of quality sleep can have harmful impacts on health. It can severely weaken the immune system, impair cognitive and motor function, and raise the risk of cardiovascular disease, heart attack, stroke, diabetes, and other conditions. Insomnia also contributes to irritability, anxiety, and depression, all of which can have severe consequences for those in recovery.
Symptoms of alcohol withdrawal, including insomnia, can make the recovery process extremely challenging. This is why it is advised to seek the guidance of an addiction professional to overcome the alcohol detoxification phase safely and successfully. Our specialists and experts at Futures Recovery Healthcare integrate evidence-based therapies and modalities to help you overcome alcohol withdrawal symptoms and lead a healthier, more rewarding life.
Treatment for Insomnia During Detoxification
As untreated sleep disturbances can increase the risk of alcohol relapse, it is crucial to address them duly to improve treatment outcomes for alcoholic patients in recovery. According to the National Center for Biotechnology Information (NCBI), cognitive-behavioral therapy for insomnia (CBT-I) is a multi-component treatment that includes behavioral and cognitive strategies to reinforce nighttime sleep and improve sleep quality and daytime functioning. CBT-I is conducted individually and in groups and usually involves six to eight treatment sessions, although a shorter duration of the therapy has also shown promising results.
The primary components of CBT-I include:
- Sleep Restriction- Patients with insomnia frequently spend many hours in bed, trying to fall asleep but unable to do so. These patients are advised to reduce their sleep time or time spent in their beds. Insomnia can be alleviated by limiting sleep, but doing so may make you feel more tired during the day. Once it has been determined that the majority of time spent in bed is truly spent sleeping, the amount of time spent in bed can be gradually increased.
- Stimulus Control – Pre-sleep stimulation can have detrimental effects on sleep quality. Chronic insomnia can be caused by nighttime activities such as reading, watching television, using your phone, or worrying about the inability to sleep. As a result, one of the key goals of stimuli control therapy is to modify these associations and reclaim the bedroom as a sanctuary for uninterrupted sleep.
- Sleep Hygiene Education – Practicing good sleep hygiene entails making adjustments to your daily routine and environment that enhance your chances of having a restful night’s sleep every night. This teaches patients about behavioral practices that can help or interfere with nighttime sleep. The goal is to increase patients’ understanding and encourage changes in daily activities and environmental factors contributing to poor sleep.
- Relaxation Therapy (RT) – This can be helpful for individuals who demonstrate increased physiological or cognitive arousal at night or during the daytime. There are several types of RT techniques. Some focus on reducing physiological arousal (for example, progressive muscle relaxation (PMR) and biofeedback), while others attempt to reduce cognitive arousal (for example, visualization and thought stopping). RT usually requires professional guidance and dedicated practice over several weeks.
- Cognitive Therapy – This practice seeks to change dysfunctional beliefs about sleep that contribute to persistent sleep problems and helps patients develop more realistic sleep expectations. Dysfunctional beliefs in insomnia patients can be addressed using psychoeducational therapies or a more traditional cognitive therapy model. Recent findings reveal a positive relationship between a reduction in sleep-related dysfunctional beliefs and attitudes and treatment outcomes.
- Sleep Medications – In some circumstances, sleep aid medications may be prescribed to treat alcohol withdrawal insomnia. While pharmacological agents can aid with sleep regulation in some patients, they are not designed for long-term use.
Tips for Managing Insomnia During Alcohol Detoxification
In addition to seeking professional help, you can also follow the below sleep habits to manage insomnia during acute alcohol withdrawal and reduce the risk of relapse:
- Commit to a regular sleep schedule – Committing to a structured schedule by going to bed and waking up at the same time each day can profoundly impact your sleep. A regular sleep schedule is crucial to set your body’s internal clock, called circadian rhythms. The more consistent your sleep is, the better the quality of sleep you will achieve.
- Establish a relaxing bedtime routine – Be it listening to calming music or taking a warm bath, establishing a relaxing evening routine will help improve your sleep. Avoid watching TV or using any other electronic devices before winding down, as these can stimulate your brain to stay awake longer, resulting in sleep disturbances.
- Be mindful of what you eat and drink – Studies suggest avoiding stimulants such as nicotine and caffeine at least four to six hours before going to sleep, as they tend to make it more difficult to fall or stay asleep. It is also advised to not go to bed hungry and to limit liquid intake before bedtime to prevent having to wake up often during the middle of the night to eat or use the washroom.
- Keep naps short – Research recommends keeping naps limited to 15 to 20 minutes to feel refreshed and energized upon awakening. Napping for longer than 30 minutes during the day can affect your body’s internal clock, making it difficult to fall asleep at your usual bedtime. This can further cause increased daytime sleepiness.
- Get regular exercise – An instrumental amount of scientific evidence associates exercise with better sleep. Following a regular exercise routine can help you fall asleep faster, have a more restful sleep, and wake up with increased energy. Physical exercise also helps you achieve deep sleep, which can help boost your immune system, improve cardiac health, and decrease anxiety and stress.