Insomnia

 

So to begin with, my love hate relationship with sleep.

I was a chronically poor sleeper for as long as I can remember.  I recall my mom telling stories about when I’d fall asleep in the middle of a restaurant, but somewhere along the line that turned into taking hours to fall asleep at night with multiple wake ups and lingering fatigue throughout the day.  By the time I was a teen, I probably got only 6 hours of sleep a night.  Unless I had a migraine, at which point I slept throughout the day to avoid the pain.  But that’s another story… When the depression would get worse, I would still have difficulty falling asleep and staying asleep, but I found myself napping at any possible time as well.  And then there were the periods of insomnia, where I would be lucky to get 3-4 hours of sleep a night.  Those periods would last a few months at which point I almost prayed for the depression to get worse so that I could at least nap on occasion.  And then I had kids.  Specifically, kids who slept as poorly as I did.  Now my 3-4 hours a night was broken into 45 minute naps.  I about went crazy.  I tried sleep meds, went crazy on Ambien, had nightmares on trazadone, loved amytryptaline until I ended up at the ER with an allergic reaction.  Nothing helped for more than a night or two.

And then I learned about Cognitive Behavioral Therapy for Insomnia (CBT-I).  As part of my graduate training in clinical psychology I did a rotation working in a health psychology outpatient clinic.  One of the conditions we treated was insomnia.  It was like I’d found the gold at the end of the rainbow.  It sounded too good to be true.  Fix my insomnia in a few weeks?  For good?  I had to give it a try.  I had to modify the training a bit in order to stick to it, but sure enough, within a month I was getting about 5-6 hours of sleep.  Six years later, I am consistently getting 6-7 hours of sleep, feel rested during the day, and when I have a couple nights of poor sleep, I’m able to fix it right away rather than having it turn into a months’ long episode of insomnia.  All without medication.  Now true, I still think I’m a sensitive sleeper, and I’ve found there are triggers that will affect the quality of my sleep.  But now that I know what they are I can be proactive and do something about it.  The most exciting thing of all has been the confidence that I have control over my sleep and I’m not at the whim of the monster of insomnia.

Sleep cycle

The brain is active and engaged in different brain patterns when we sleep.  Sleep is made up of slow wave sleep (SWS) and Rapid Eye Movement (REM) sleep, referring to different types of brain wave patterns.  Your brain is engaged in different functions during these types of sleep.  Slow wave sleep is broken down into 4 stages. 

The first stage is your shallow type of sleep, where you may actually still be aware of your surroundings.  Stage 1 is light sleep where you drift in and out of sleep and can be awakened easily. In this stage, the eyes move slowly and muscle activity slows. During this stage, many people experience sudden muscle contractions preceded by a sensation of falling. Think that little nod off in a boring class.  Practiced meditators will often show brain waves that are in stage 1 sleep.

There is a major transition in the brain waves as it moves from the 3rd to 4th stage of SWS.  This stage is often referred to as deep sleep.  During deep sleep blood supply increases to your muscles, tissue growth and repair occurs, and your immune system is bolstered.  This happens because your body releases a number of different hormones.  Some are to repair your body, like growth hormone, and others manage your blood sugar levels and appetite like ghrelin and leptin.  When you are deprived of this deep sleep you are more at risk for chronic pain and obesity.

Now REM sleep is what we usually think of as dreaming sleep.  If a person is awakened during REM sleep they can usually remember the dreams.  During REM, the breathing becomes more rapid, eyes jerk rapidly, blood pressure rises and heart rate increases, and limb muscles are temporarily paralyzed.  This is also a time where the brain engages in memory consolidation.  Whereas deep sleep is repairing your body, REM sleep is repairing your mind.  Having the right amount of REM sleep is important for concentration, managing stress and can even affect depression.

The most important part to remember here is that you want quality sleep not quantity.  For a healthy person, the total amount of deep sleep and REM is less than 4 hours.  In theory, you could get 4 hours of sleep a night and do quite well, if it was quality sleep.

Getting to Sleep

There are 2 components to falling asleep: homeostatic sleep/wake drive and the circadian rhythm.  The homeostatic sleep drive simply means that the longer you are awake, the more your body wants to fall asleep. 

The circadian rhythm is your body’s built in clock.  The circadian rhythm dips and rises at different times of the day.  Sleep drive decreased in the morning, rises in the middle of the afternoon, decreases around dinner, and then increases again in the late evening.  Cultures that embrace a rest period after midday are more in tune with our natural functioning than our go at all hours culture.  Many people who feel an overall lag in energy in the afternoon will perk up around 5 or 6, again due to the circadian rhythm.  One of the things the circadian rhythm controls is core body temperature.  The body temperature drops when it is time for your body to sleep.  This is why many people will feel cold when they get tired.  

One key feature of the sleep cycle is that it is an inhibitory process.  In other words, you can’t make yourself fall asleep.  The harder you try, the less likely it will happen.  This is due to the effects of the autonomic nervous system (ANS).  There are two parts to the ANS: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). 

The SNS is your fight or flight response, or your stress response.  It’s like the gas pedal of your car.  When the SNS is activated your heart rate increases, blood pressure increases, breathing becomes shallow and more rapid, your blood vessels constrict in your hands and feet, and key point, your core body temperature increases.  Hint, this will prevent you from falling asleep.  Interesting fact, people with chronically activated SNS usually have cold hands.

The parasympathetic nervous system (PNS) is your relaxation response, or like the brake pedal on your car.  When the PNS is activated your heart rate decreases, blood pressure goes down, breathing becomes deeper.  As your PNS is activated your core body temperature drops, and your hands and feet get warmer.

Getting frustrated about not being able to sleep, tossing and turning for hours at end, staring at the clock, worrying about being exhausted the next day, all of that keeps the SNS activated and keeps your core body temperature from dropping and allowing your body to fall asleep.  One of the key components of CBT-I is learning how to turn off the SNS or stress response, and turn on the PNS or relaxation response, when you want it.  

Stimulus Control

The first part of the treatment is learning how to get back in sync with your body and letting it work with you instead of against you.  You want to do things that help your body lower its SNS or stress activation, and work with your circadian rhythm.  

First the list of things to avoid:

  1. No napping.  Remember that homeostatic sleep/wake drive?  If you nap during the day, you reduce your body’s drive to sleep at night.  Once your insomnia has gone away you can decide whether naps are helpful for you or not, but right now as you work on resetting your sleep cycle, no napping.  Period.
  2. No stimulants before bed, including caffeine and nicotine.  It usually takes 7-8 hours for a stimulant to be cleared from your body, even if you don’t feel like you’re experiencing the effect, it’s there working on that SNS, keeping you from falling asleep.  For me personally, I’ve found if I have caffeine 8-9 hours before I want to sleep I will have trouble falling asleep.  Start to experiment for yourself and notice what your particular pattern may be.
  3. No alcohol in the evening while you are trying to reduce your insomnia.  Even though alcohol is not a stimulant, after about 6-7 hours your body metabolizes it into a stimulant and you can have a nasty awakening in the middle of the night due to drinking alcohol.  Now I’m not a teetotaler by any means and enjoy a glass or two with dinner.  But when I have a few rough nights and it’s time to get my sleep cycle back on track I lay off the alcohol for a few days until I’m sleeping like a baby again.
  4. No exercising right before bed.  Exercise is good for you and people who exercise do sleep better.  however, some people find that exercising right before bed is stimulating and makes it difficult to sleep.  Try to allow at least an hour or two between exercising and when you want to go to bed.

Now, the things to do:

  1. Limit your bed to only sleep activities.  We are creatures of habit.  If you are used to working, reading, watching TV in your bed, as soon as you lie down your mind will perk up and get ready to absorb information, not sleep.
  2. Have a bedtime routine.  As you do the same things in the same order your body will begin prepping for sleep as well.  Our bodies really, really like routine.
  3. Get out of bed if you are not sleepy.  Again, you want to train your mind that your bed is for sleeping, not tossing and turning and watching the clock.  If you have been in bed for 20 minutes and have not fallen asleep, then get up. This is the one I hate the most.  Get out of my warm bed?  But I’m tired!  I need to sleep!  But this one technique has the biggest impact on reducing insomnia.  No tossing and turning in your bed.
  4. When you get out of bed, make sure you keep to dim light.  Bright light, including the TV, computers, and smartphones, will trigger your circadian rhythm that day is starting and it’s time to wake up.  So low light only.  Trying to find something very boring to read.  Our minds need something to do - we are always thinking.  If it has nothing to focus on it will grab some worries to polish up and review with you.  Having something boring will your mind occupied.  Don’t grab the latest thriller to read unless you want to crank on that SNS and really stay up all night.
  5. Get up at the same time every day.  What? No sleeping in on the weekends?  Are you crazy??? Alas, our circadian rhythm is set by morning light.  When you are consistent with your wake times, your circadian rhythm knows what to expect and can prep your body for sleep at the right time.  If you get up a few hours later on the weekend it’s as if you’ve given yourself jet lag.  It takes five days for a circadian rhythm to reset, so changing up your sleep on the weekend preps you for a very miserable Monday.  It’s actually more important to get up at the same time every day than it is to go to bed at the same time.

Cognitive Restructuring

Our minds our powerful things.  They do a lot of problem solving for us and at times can get caught in a pattern of worry and frustration.  This worry will keep your SNS or stress response activated and keep you from falling asleep.  One technique I like to use is calling “scheduled worry time,” or some people refer to this as “putting the day to bed.”  Have some dedicated time each evening to write out your worries, concerns, frustrations, plans, or to-do’s.  Set a timer, usually 20 minutes is a good length.  Write it all out, and then when the timer goes off, close your notebook.  I like to do this on my computer or smartphone or you can use good old fashioned paper and pencil.  Then, this is the critical part, when you are lying in bed and start to rehash your worries, you can tell yourself “I already wrote it down.  It’s taken care of for this evening.”  At the beginning, you may have to say this to yourself every minute for 20 minutes.  But once you get in the habit, it will get easier and easier.  Some people like to keep a notebook by their bed to write down things that they are afraid of forgetting.  My experience working with clients is that this is not helpful in the long run as it increases checking behavior to see if there is anything else that has been forgotten and again increases that SNS activation.  It tends to be the most useful to simply tell yourself “if it’s that important I”ll think of it again tomorrow."

If, then technique.

Worry, in a nutshell, is really about the fear of the unknown.  It’s the “what if.” One great way to reduce anxiety in general is to make the uncertain certain.  Unfortunately we can’t predict the future but we can make a plan as to how we’ll handle the scary “what if.”  So if such and such happens, then I will… Keep going down the line until you feel like you have a workable plan.

Because thinking about these worries may initially activate the SNS try to do this scheduled worry time at least an hour or two before bed.

Relaxation Training

We’ve talked a lot about shutting down the SNS or stress response.  Now it’s time to focus on increasing the PNS or relaxation response.  One thing I find over and over in working with clients is that our culture does not truly value or know how to relax.  Sure we all talk about vacations but even then we’re on our phones or doing, doing, doing.  It’s a new skill for most people to truly learn how to relax.  As with any skill, it takes time to really figure out how to make it come easily.  So practice these skills daily and not just when things get really out of control.

Autogenic Relaxation training:

  • Practice relaxation technique 2x a day for about 20 minutes, but not in bed
  • Can use this as needed when feeling stressed
  • Relaxation progression:
    • Explain this is deep relaxation, not hypnosis
    • Passively relax each place; use prompts such as heavy and limp, loose
    • Hand, arm and shoulder, face and forehead, back of head, back of neck, tops of shoulders, middle of back, shoulder blades, chest, stomach, lower back and rear, hip, thigh, calf and foot
    • Notice how relaxed, how easy to breathe, feeling calm and peaceful
    • In your mind’s eye, scan you body for any remaining tension.  If you find any passively relax those areas
    • Slowly count backward from 5 and become aware of your surroundings

For a recording of this relaxation exercise, click here.