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The Most Important Thing Most Americans Misunderstand About Insomnia

Derek and Dr. Jade Wu discuss Americans’ anxiety about sleep and the connection between sleep and health

Sick Woman Photo Illustration by Ute Grabowsky/Photothek via Getty Images

I am fascinated by sleep and also—perhaps, relatedly—not very good at it. Like tens of millions of Americans, I’ve had trouble falling asleep and staying asleep for most of my life. I also know that sleep is the glue that holds together health—a fact that sometimes haunts me as I toss and turn at night. Behind the fitness and health fads, what’s the truth about insomnia? How dangerous is it? When do we know when we have a problem? How is it different from sleep deprivation? What have we learned about sleep in the last few decades that’s most important for average people to remember? Dr. Jade Wu, a behavioral sleep medicine specialist and researcher at Duke University School of Medicine and the author of Hello Sleep: The Science and Art of Overcoming Insomnia Without Medications, explains how the modern panic about sleep and insomnia misunderstands some fundamental facts.

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In the following excerpt, Derek and Dr. Jade Wu discuss the difference between sleep deprivation and insomnia, and why clinicians need answers for both.

Derek Thompson: First off, tell me who you are, what you do, and how, as both a researcher and a clinician, you came to sleep as your specialty.

Dr. Jade Wu: OK. So I’m Dr. Jade Wu, and I’m a behavioral sleep medicine specialist. So that means I help people to overcome their sleep problems, to improve the quality of their sleep, without using medications. And so I actually came to sleep because of a personal love for sleep. So I started college as a double major, math econ, but then there was a prerequisite for an econ class that started at 8 a.m. And I am not a morning person, never have been, especially in college. And I was like, no, no, no, no. I need to get enough sleep. So then what other major can I do that allows me to get up at 8 and go to class at 9:30? And turns out that was Psychology 101, and it just so happens that the professor teaching that class was a sleep researcher, and I just fell in love from there.

Thompson: My dad’s favorite comedian was Lewis Black. And Lewis Black had a line about literally, I think it was economics classes starting at 8 a.m. in the morning on a Friday. And his joke was, are they trying to keep this shit a secret? Because that is the only reason why they would possibly start this class at this time on this day.

Wu: It’s a conspiracy.

Thompson: It is a conspiracy. All of economics is basically a conspiracy. I do want to get into the nitty-gritty on the science of sleep and wakefulness, but before we get into the science, there’s a big-picture question that I want to clear up. I think there’s a very fascinating tension, almost a paradox in America today, at the heart of how we talk about sleep in this country. On the one hand, sleep, we are told, is at the heart of everything. It is one of the most important things in the world. It is the best mood stabilizer. It is the best stress reliever. It is the best immune booster. High-quality sleep is treated like a miracle drug, and without it, it’s like we’re screwed.

On the other hand, if you take all of that too seriously, the ordinary person may very well develop an anxiety disorder around sleep that will increase their odds of insomnia. And many people, I think, feel that tension writ small when they’re lying awake in their beds. It is precisely their urgent anxiety to fall asleep that is keeping them awake. So here’s the central tension for an insomniac country, as I see it. We are told, if you can’t sleep, just calm down. But if you don’t fall asleep, you’re going to die. So what wisdom can you offer us to help resolve that tension?

Wu: Well, you’ve asked the most insightful question because there is such a tension, and I see it with my patients all the time. They’re coming in saying, “I’m afraid that I’m going to die early because I’m not sleeping well. And the fact that I’m worrying about having hypertension or dementia or whatever is the thing that’s keeping me up.” So that is definitely a common phenomenon. Now, at the heart of this is a common misconception that I think we all have, and that’s that sleep deprivation and insomnia are used interchangeably as if they’re the same thing. But actually they’re very different things. In fact, in some ways they’re opposite things.

So sleep deprivation is when you don’t have enough opportunity to sleep. So this is the college student pulling the all-nighter to study or party. This is like someone who’s working three part-time jobs and they do shift work and they just don’t have enough time in bed. So that would be sleep deprivation. And also there are some medical conditions like sleep apnea, where your own breathing problems are interrupting your sleep throughout the night. That’s also sleep deprivation.

On the other hand, with insomnia, you have enough opportunity to sleep. In fact, people with insomnia are usually working really hard to perfect their sleep hygiene and sleep environment, and they have all the right setups and all the time in the world, but then something internal is keeping them up. So these two are very different concepts. And the easiest way to think about how they’re different is if you are sleep deprived, you are going to be really sleepy, like, falling asleep standing up. And if you’re that sleepy, you are not going to have insomnia. You’re not going to have trouble falling or staying asleep. So in this way, these are actually opposite things.

Thompson: I don’t think anyone has actually explained it to me like that, that sleep deprivation tends to be high sleepiness, but not enough bedtime, and insomnia tends to be low sleepiness and often too much bedtime.

Wu: Precisely.

Thompson: It sounds to me like the way we’re panicking about sleep in this country is totally wrong. If it is sleep deprivation that has the higher risk of these lifetime negative consequences, sleep deprivation seems to be the greater health risk, if I’m hearing you right, while insomnia is the more common anxiety.

Wu: Exactly. And the irony is, people who are sleep deprived, either they cannot change their schedules and sleep more or get more time in bed, or they just don’t care. They’re, like, 19 and partying. And then the people who have insomnia, who really need to calm down more about sleep and be less anxious, they’re the ones working really hard to perfect their sleep hygiene. So in a way, the difficulty, the challenge for us sleep scientists and clinicians is how do we put a public health message out there that doesn’t freak people out too much about sleep, but also tells them how important it is? We’re trying to really target the right audience with the right message, and it’s really hard to do.

This excerpt was edited for clarity. Listen to the rest of the episode here and follow the Plain English feed on Spotify.

Host: Derek Thompson
Guest: Dr. Jade Wu
Producer: Devon Manze