A number of my military patients – and likely your patients, too, judging by the consultation requests we see – seem to have gotten so used to the effects of getting insufficient sleep they wonder if they don’t really need much sleep. Maybe they’re just short sleepers, they wonder; maybe there’s no need to change their sleep habits.
You might ask what the differences are between short sleepers and those who are sleep deprived. That seems straightforward enough. With short sleepers, they may not sleep more than 5-6 hours, but they awaken with minimal sleep inertia and feel refreshed, with plenty of daytime energy and no functional impairments. In sleep deprivation, with 5-6 hours of sleep we would expect to see significant fatigue and daytime consequences, such as cognitive and emotional deficits and impaired physiological health. Unfortunately, with chronic sleep deprivation patients lose insight into the severity of these deficits, almost becoming habituated to functioning at an impaired level. At the same time, they may load up on caffeine and other substances to stave off fatigue and create a kind of pseudo-energy. In practice, this can sometimes make it difficult to tell what’s going on, even with a sleep log clearly showing a short sleep time (despite no symptoms of insomnia).
Studies in the last decade have begun to shed light on natural short sleepers, found to have a lifelong sleep need of only 4-6 hours (He et al, 2009). So far several genes have been implicated, including several mutations of DEC2, which is related to orexin, a hormone that promotes wakefulness and is deficient among those with narcolepsy. Now, ADRB1, which is the β1-adrenergic receptor gene, is also implicated (Shi et al, 2019). This is pretty interesting when you consider that medications that are β -blockers often have a side effect of impaired sleep ability. Aside from genetic differences, there are phenotypic differences – meaning different physical traits – too. Short sleepers release melatonin for a shorter period of the night and tend to spend the same amount of time in deep sleep, but less time in a lighter stage (Ashbrook et al, 2020).
However, these genes associated with a naturally lower need for sleep and no functional impact are pretty rare, if not really rare. While epidemiologic studies are lacking, the lead author of this line of research, Dr. Ying-hui Fu, has estimated prevalence of between 1% to at most 3% of the population (various sources, see below).
So, even if your patient reports that they can get by on 6 or fewer hours of sleep, it’s highly unlikely that he or she is a short sleeper. It’s more likely the case of sleep deprivation. Tell-tale signs include use of caffeine or stimulants, “catching up” on weekends or with naps, and objective observations of deficits (this could include cognitive, behavioral, or emotional impacts such as irritability, whether in your office or patient report of others’ comments). These deficits unfortunately have likely had a significant negative impact on the patient’s life, including reduced alertness and reaction time, poor attention and memory, difficulty learning new information, decreased mood, and even impaired health including insulin resistance, increased blood pressure, and hormone dysfunction.
The good news is that sleep deprivation is definitely something you as a behavioral health provider can address. The first step would be to get a baseline sleep log of one to two weeks. Tip: You can rule out insomnia by comparing the baseline average time in bed with average total sleep time; if these numbers are close, that suggests there is no insomnia element. If there is a large discrepancy between the two, that is consistent with insomnia and warrants Cognitive Behavioral Therapy for Insomnia instead. Next, assist the patient with a plan to prioritize their sleep schedule: Do they need a wind-down routine? To adjust their social or work schedule to accommodate time in bed, for example shifting morning exercise to afternoon? Should they scale back on volunteer commitments? Are there environmental factors, such as children waking the patient up? Once you feel that the patient has an adequate plan in place, then guide the patient in setting up a gradual expansion of time in bed. If they are sleepy before bedtime, you could begin at bedtime. If they are having to wake early due to activities that are movable and struggle to arise, you could begin at waketime. I would recommend going gradually, since if the patient expands time in bed too fast “holes” could develop in his or her sleep. Instead, the patient can add 15 minutes every 3-4 days as long as sleep remains consolidated. The patient should stop expanding when either time to fall asleep or time awake in the middle of the night becomes problematic, or the patient feels refreshed on awakening, or both. Keep in mind we all have a little sleep inertia when we first wake up, so describing sleep as refreshing should take into account that the first 20 minutes or so of being awake we are still transitioning from sleep and may feel a bit icky, which is normal.
We can look at sleep deprivation as a sort of self-imposed poor sleep opportunity. Even if not intentional, our patients may sometimes have developed a schedule that is a barrier to healthy sleep. For military-connected patients, they may have little or no leeway in their schedule; their sleep deprivation may result instead from mandated long shifts or operational requirements. In these cases, problem-solve as much as possible and encourage them to prioritize their sleep schedule when they can. Ultimately, the goal is not to aim for a predetermined amount of sleep, say 8 hours, but rather the maximum amount of uninterrupted sleep the patient can sustain consistently. When it comes to sleep, more is more!
Note: Please see the DoD's recent 'Study on Effects of Sleep Deprivation on Readiness of Members of the Armed Forces' for more findings on the detrimental impact of sleep deprivation in the military and the role of military culture. https://health.mil/Reference-Center/Congressional-Testimonies/2021/02/26/Study-on-Effects-of-Sleep-Deprivation-on-Readiness-of-Members-of-the-Armed-Forces-Final-Report
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Diana Dolan, Ph.D., CBSM, DBSM, is a clinical psychologist serving as a Senior Military Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and presents trainings on a variety of EBPs and deployment-related topics, and provides consultation services.
Ashbrook, L.H. Krystal, A.D., Fu, YH., Ptacek, L.J. (2020) Genetics of the human circadian clock and sleep homeostat. Neuropsychopharmacology 45: 45-54.
He, Y., Jones, C.R., Fujiki, N., Xu, Y., Guo, B., Holder, J.L., Rossner, M.J., Nishino, S., & Fu, Y.H. (2009). The transcriptional repressor DEC2 regulates sleep length in mammals. Science 325 (5942), 866–870.
Shi, G., Xing, L., Wu, D., Bhattacharyya, B.J., Jones, C.R., McMahon, T., Chong, S.Y.C., Chen, J.A., Coppola, G., Geschwind, D., Krystal, A., Ptacek, L.J., & Fu, YH (2019). A rare mutation of β1-adrenergic receptor affects sleep/wake behaviors. Neuron 103(6): 1044-1055.