Sleep, insomnia, and psychosis
Summary
What is sleep and why is it essential for mental health?
For a long time, sleep was thought to be a state of rest or a passive state in which the brain simply shut down. Today we know that sleep is a very important active process for health, during which neuronal activity is reorganized, multiple brain functions occur, and electrical changes are recorded.
Each sleep cycle lasts 90 minutes and essentially has two phases. The non-REM phase, during which important processes such as memory consolidation and the elimination of toxins (substances that can harm us) take place, and the REM phase, during which emotional processing and cognitive functions occur. The most intense dreams also take place during this phase. Therefore, sleeping well is essential for mental and emotional well-being.
What is insomnia and how often does it occur in the general population?
Insomnia is the most common sleep disorder. It is defined as dissatisfaction with the quantity or quality of sleep (whether it's difficulty falling asleep, staying asleep, or waking up too early) at least three nights a week for more than three months. It affects approximately 10 % of the world's adult population. In Spain, this figure rises to 14% of the general adult population, primarily due to specific sociocultural factors, such as those related to social customs and habits that often occur late at night.
Guidelines for combating insomnia
How are insomnia and psychosis related?
Insomnia and psychosis are closely related. People with a psychotic disorder are more vulnerable to insomnia, and this is linked to the fact that they experience a surge of dopamine at night.
We can say that insomnia precedes, maintains, and increases psychotic symptoms.
In many cases, insomnia is the first symptom and appears weeks or months before psychotic symptoms begin.
Furthermore, nearly 50 % of people with psychotic disorders continue to experience sleep problems after their first psychotic episode (Ferrarelli, F., 2021). In turn, insomnia can worsen psychotic experiences, especially paranoia and, to a lesser extent, hallucinations, which can make it harder to sleep (Reeve et al., 2015). In other words, a vicious cycle is created: poor sleep worsens psychotic symptoms, and psychotic symptoms make it harder to sleep.
How does insomnia change according to the clinical stage?
Insomnia appears in the very early stages. In young people, between 14 and 25 years old, who present with some mild or brief psychotic symptoms and who fall under the concept of High-Risk Mental State (HRMS), the prevalence of insomnia ranges from 30 to 50 %. The most frequent symptom is sleep quality disturbance. Insomnia at this stage can facilitate the transition to psychosis.
People experiencing a First Psychotic Episode (FPE) often have a higher prevalence of insomnia, up to 50 %. The most frequent disturbances are increased difficulty falling asleep and lighter sleep. If insomnia persists, psychotic symptoms may worsen.
In people diagnosed with schizophrenia, the prevalence ranges from 30 to 44 %. Insomnia at this stage is associated with greater depression, greater cognitive dysfunction, and a poorer quality of life (Bagautdinova et al, 2023).
Why is it worthwhile to treat insomnia in psychosis?
Treating insomnia is very important. We have already seen how insomnia is related to the dysregulation of circadian rhythms (our "internal clock"), changes in dopamine, and worsening of psychotic symptoms. This suggests that improving sleep can improve psychotic symptoms (Barton et al., 2018).
What can I do to improve my sleep quality? (A practical guide)
The recommended interventions for people with psychotic disorders are the same as for the general population. The first step is to work on sleep hygiene measures (Estivill, Sleep Clinic, n.d.).
- Maintain a regular schedule: go to bed and wake up at a similar time every day, even on weekends, to regulate your biological clock.
Although in people with psychosis the wake-up time may be later, the important thing is to keep it stable and, when it is established, be able to advance it every 15 minutes until a wake-up time more in line with social time.
It's important to integrate medication into your sleep routine; taking it at the same time each day helps regulate your biological clock. Some treatments can have a sedative effect, which can be helpful. However, excessive sedation can disrupt the sleep-wake cycle. It's advisable to consider the duration of the treatment's effects for each individual, so you can adjust your schedule to improve sleep. - Ensure a conducive environment: the bedroom should have an environment suitable for sleep in terms of reduced lighting, noise, and good ventilation.
- Avoid stimulants: It's important to avoid caffeine or nicotine before going to sleep. Activities like watching the news, having arguments, or using social media can also have a stimulating effect and should be avoided in the late hours of the day.
- Eat a light dinner: avoid heavy, spicy or sugary meals up to 4 hours before going to bed.
- Avoid exercising at night: intense exercise is not recommended 2 or 3 hours before bedtime. It's better to exercise in the morning or afternoon.
- Short naps: if taking naps, they should not exceed 30 minutes.
- Use your bed only for sleeping and sex: it's important that your brain associates your bed only with sleep and intimacy. Avoid working or doing leisure activities in bed.
In people with psychosis, where the room can be a place of safety, quiet activities can be allowed (listening to calming audios, reading). - How about a relaxing routine? Create a bedtime ritual (reading, warm bath, soft music) that promotes a state of relaxation.
- Limit screen time: turn off mobile devices at least an hour and a half before going to sleep.
- I can't sleep, what should I do?: If you've been awake for 20 minutes, get up and do something boring (read an instruction manual or some other very technical book) until you feel sleepy again. Don't fight insomnia. Forcing yourself to sleep increases anxiety and hyperarousal. If after several attempts it doesn't work, stay in the room with your eyes closed and slow breathing, perhaps listening to some calming audio (white noise). Resting also matters.
What treatments work when sleep hygiene is not enough?
When these measures are not sufficient , cognitive behavioral therapy for insomnia (CBT-i) can be recommended, with some adaptations to psychosis, prioritizing some modules such as sleep hygiene, relaxation and mindfulness (Furukawa et al., 2025).
In some cases, the psychiatrist may consider administering antipsychotics that promote sleep and have been associated with improved difficulty falling asleep and increased total sleep time, such as clozapine, olanzapine, and quetiapine. Melatonin has also been shown to improve sleep duration and quality, particularly in people with schizophrenia and older adults (Oliveira et al., 2019).
Questions about Psychosis
