Sleep and money

Don’t you wish you could make money by sleeping? I suppose we all do. Unfortunately, right now, many people are losing sleep over money issues. For anybody with a stock portfolio, or any body with a job that could be down-sized, you are probably worrying about money.

Of course sometimes we worry about money in the day. But we get so busy doing things that we kind of forget about it for awhile. By the end of the day we are so tired we go to bed, only to wake up thinking about how to pay for the kids college, or how to pay for the rent, or how to pay for the car insurance, or whether or not we’ll even have a job in another couple of months. Thoughts like these can cause real anxiety and even panic attacks, and can really ruin sleep.

Someone once said that everything seems more gloomy in the night because being afraid at night made our ancestors stay huddled in their caves—safe from harm. In other words, it is normal for things to seem worse in the night, and it might even be a good thing.

When you are stressed, it is extra important the you follow good sleep habits, such as we post on the Goal of the Can’t Sleep Café. Sometimes people do the opposite—when they are stressed out, they quit all the good habits, and maybe start drinking a little more alcohol before bed, or lying in bed calculating accounts rather than sitting up and reading. Or worse—they go to be extra early because they are stressed, and allow themselves to sleep in late in the morning, since maybe they are a little depressed also. These kind of behaviors are called mal-adaptive, because they actually make sleep worse, both in the short term and in the long term.

Tough times are the times to be sure that you don’t spend excessive amounts of time in bed; that you take care of your body and eat right and drink right; that you set aside extra time for exercise and other relaxing activities; that you double up your Church time, prayer time, or meditation time; that you don’t try to sleep when your mind won’t—get up and do something else—or get up and worry in the kitchen, not the bed. Don’t overuse sleeping pills. Review my main tips on how to sleep better.

Lastly, remember, the stock market goes up and down, but if you get into bad sleep habits now, you might never recover. Enjoy your sleep.

Sleep disorders

Sleep disorders is a field that can cover just about any human condition—imagine if there was a field a “wake disorders.”

Usually though, the bladder and sleep are used in the same sentence only in regards to older men with larg prostates.  That is, waking up to urinate 1 to 3 times per night is quite common in this age group because the prostate makes it difficult to fully empty the bladder, so it fills up again more quickly.  

A worse problem is NOT waking up to urinate.  I saw JC again today, a 14 year old boy who has wet the bed almost every night of his life since being out of diapers.  He has seen his pediatrician and worked with a urologist.  He has had tests on his bladder—it is normal in all ways—and taken several medications.  These medications are of various types to decrease bladder tension, increase tension in the bladder outlet, and to decrease the amount of urine made.  Nothing has helped.  The “bell and pad” method, wherein a mattress pad beeps as soon as it gets wet has not helped.  Have any of you parents had experience with treatments for bedwetting?  Have medications like imipramine, amiytriptyline, or DDAVP been successful?  

Although most kids outgrow enuresis—and JC probably will in the next year or so—it is unusual to persist into teen age years, and JC looks even older than 14.  It can be considered a sleep disorder because the urination occurs during the deepest stages of sleep—stages 3 and 4, also called slow wave sleep, or delta sleep.  It’s kind of like sleep walking—there is a disconnect between the physical activity and the state of mind.  The body just does it’s thing, even though the brain remains awake.  JC snores, and sometimes snoring produces brain (EEG) arousals that trigger activities like sleep walking.  We’ll see if treating snoring stops the bedwetting in this nice young man.  It would be very interesting to know if others have had success with enuresis by treating snoring in children. 

Sleeping pills in the night

A new study published in SLEEP reports the results of a new formulation of Zolpidem (Ambien) which is placed under the tongue for people who have middle of the night insomnia. This is a patented lozenge which is said to dissolve quickly and have acid-base buffers that enhance its rapid absorption into the blood stream.

People were recruited who complained of trouble getting back to sleep in the middle of the night, but those with sleep disorders or depression were not allowed into the study. They were allowed to sleep for 4 hours, awakened by the researchers, took the lozenge, sat up for 30 minutes, and then tried to sleep again for 4 more hours. Each subject did this on two separate nights, once with the drug and once with placebo. Those taking the zolpidem lozenge fell asleep more quickly and had more sleep in the coming four hours. They are said to have had no morning side effects such as sleepiness or trouble doing a math task.

This study is important because people who only have insomnia in the last half of the night have few options for medication treatment. All of the older benzodiazepine medications take too long to take effect and also take too long to be eliminated by morning. The only real option is Sonata (zaleplon), which can take effect in as little as 30 minutes and be pretty much eliminated in 2 or 3 hours. It is approved by the FDA to take with four or more hours of planned sleep, but it suffers from eratic absorption (food and fat delay it), and it has not been tested extensively in the middle of the night. Similarly, taking regular zolpidem (Ambien) in the night is a problem due to the time of absorption and the longer elimination period. About 7 hours of planned sleep is suggested for oral Ambien.

I know of patients and colleagues who use a sublingual (under the tongue) method for regular zolpidem and zaleplon. For zaleplon, you have to open the capsule, and dump the powder out and for zolpidem you have to crush the pill or wait for it to dissolve. The current study used a low dose of zolpidem (about 3 to 4 mg), and the best dose to be recommended remains to be determined. These problems will be much less when further studies of the lozenge are released.

In general, I favor the shortest acting sleeping pills so that there is less chance of residual effect and less total time of the drug in the body. The sublingual form allows for very rapid absorption, so the drug can get straight to work, and the liver and kidney can immediately metabolize it. Someone should have thought of this before !

Can’t sleep? What to do

One of the activities that we recommend in the Can’t Sleep Café is to get up from bed if you cannot sleep. This is to avoid the frustration of lying in bed, tossing and turning, worrying about tomorrow, and just being upset by the fact that you are awake at night--again.

But what to do? Well, even if you are going to be frustrated by being awake, and even if you will be worrying about performing tomorrow, and even if you are angry about being awake again, it is better to have these feelings while sitting up than while lying in your comfortable bed. This is to prevent the negative associations that can develop between “trying to fall asleep” and “the bed.” It is vitally important, and a long term issue, that your bed be a place of pleasantness, if not happiness and calmness. Being tortured in bed by insomnia just sets up your brain to be in that habit--not good for falling asleep.

The usual advice is to get up, go sit in a comfortable place in another room, and doing something relaxing. For example, I advise against vacuuming or paying the bills. Reading and having a hot tea is good, or just sitting and having a hot tea. This is a good time to meditate or to pray so that your mind is focused on something besides your sleep problem. Also, such an internal activity makes you independent—you don’t need that book, CD, or TV to distract you—you can do it yourself. Remember, however, that meditation, prayer, or a relaxation technique are not methods to actually put you to sleep; rather, they are general stress reducers that allow you to occupy your brain when you are forced to be awake.

They help sleep indirectly in several ways. Other good activities would probably include listening to relaxing music, but not dancing to it. Maybe TV, although the brighness and commercials are generally stimulating, so I don’t recommend it. A computer is fine, especially if you are reading boring political analysis for example, not surfing websites that are stimulating. A lot of people ask me if sex helps sleep. I’m not sure, but this is usually a short-lived activity that gets your mind off your problems, after which sleep might come easier; so give it a try too.

If you are going to worry, it is still better to do this in another room than your bed, if possible. If not possible, at least sit up, turn on a DIM light, and then worry. Make a list of things you are troubled by or need to get done this week. Many times, life seems worse in the night, and better in the morning. Although it is not technically true, in some ways, “the darkest hour is just before the dawn.”

I found a web site with some good suggestions for things to do in the night, and I have added it to my blog roll, isleepless.com.

This site is for people with insomnia, and it appears to be run by a person with insomnia. There are several good reads on this site, including a long list of things to do in the night, although I have not been to all of the site. Take a look some night when you can’t sleep; it will be one way to help yourself and your sleep.

Insomnia blog

Hello from insomnia land. A google alert flashed across my computer screen today, and I went to sleepstarved.org. This is a site started by a woman with insomnia by and for people with insomnia. It reminded me a lot of our own Can’t Sleep Café. Clearly, there are people with insomnia who want to talk about the problem, support other people with the problem, and be supported by others. This is really important for a condition that is often long-term, poorly understood, has limited treatment, and affects our sense of well-being so much.

But a lot of people with insomnia ignore it. They think that it is just part of life, part of the result of stress. Most people with insomnia never go to the doctor, although the direct-to-consumer advertising from the sleeping pill manufactures might have changed that. In fact, I almost think that people with insomnia don’t want to talk about it. So I am pleased to call your attention today to the Can’t Sleep Café and the insomnia site.

A lot of the information about poor sleep comes from sources who have a particular interest in the condition. Obviously, for example, those who make and sell sleeping pills want you to be concerned about insomnia and to ask your doctor about it. Others might be biased toward doing sleep tests on everyone with insomnia, or perhaps being opposed to the use of sleeping pills believing that they are harmful. Others might be particularly enamored with certain remedies like herbal supplements.

I can tell you that everyone with insomnia is different, and that some people benefit from each and every treatment out there, including sleeping pills. The most important aspects of understanding insomnia are to try and understand the cause, not to become anxious about the insomnia itself, and to use behavioral and relaxation techniques in combination with medications. I think that another aspect of treating insomnia is to talk to other people who have dealt with it, coped with it, and found their own way to improve it or to accept it.

You can start your own discussion of insomnia here, and then you might even better enjoy your sleep.

Sleep, marriage, and arguments

Mira Kirshenbaum has a great blog about getting along with your life partner, called Healthy Relationships. Recently she talked about the problem of getting sleep when you are having a rough spot in your relationship, or after a big fight. All of her advice is excellent. I want to talk a little bit about her first of five rules for getting good sleep while under this kind of stress: "You CAN go to bed angry." Well, yes and no.

Mira's point is that you can't keep arguing all night—you need some sleep in order to function the next day. This is true and important. However, NEVER actually go to bed angry. You might not be able to finish or resolve the problem, but don't be angry while you are lying in bed trying to sleep. Those of you who are familiar with my blog and the concept behind learned insomnia know that being angry, frustrated, anxious, or stressed out while lying in bed is one of the main reasons that people develop long-term insomnia.

At some point you need to quit arguing or otherwise let your anger pass. If you have stopped fighting and are still keyed up, I would recommend sitting in the dark or making a hot tea. Don't try to sleep when you know that you cannot. After a while, you might feel sleepy and then you can get into bed and try to sleep. Until then, lying in bed angry or stressed sets the stage for future sleep problems. You'll just have to get by the next day on less sleep—you have to anyway—so sit up if you cannot sleep.

"Don't' go to bed angry" does not mean that you have to keep fighting all night. During periods of stress you will sleep less. This is normal. Keep healthy sleep habits even during these times. Don't booze it up, sleep with the TV on, or be angry in bed. Also, sleeping pills are perfect for this situation—short-term stresses.

Sometimes it is the only way to get some sleep. Use them and follow the advice on sleep habits as well, and use them only for a week or two. And remember, no matter what, enjoy your sleep.

Patterns of insomnia

One of our Can't Sleep Cafe group members says that she is sleeping a lot better after starting CPAP therapy for sleep apnea.

We don't usually think about insomnia and sleep apnea in the same person, so I wanted to tell all what the pattern of your insomnia might suggest is the cause of your insomnia. These are general rules, not absolutely true all the time.

The first pattern is called sleep-onset insomnia. This is difficulty falling asleep in the beginning of the night, but sleeping pretty well through the night. This pattern of insomnia can be typical of anxiety, restless legs syndrome, or delayed sleep phase syndrome (typical in teenagers). In addition, so called "primary insomnia," which is sometimes called conditioned insomnia, learned insomnia, or psychophysiologic insomnia, usually causes difficulty falling asleep at the beginning of the night.

A second pattern of insomnia is sleep-offset insomnia, also called "end of night awakening," or terminal insomnia. This is the problem of falling asleep easily at the start of the night, but waking up too early and being unable to fall back to sleep, say at 3 am. This pattern of insomnia is famous as a symptom of depression, but can be caused by any type of stress as well, and our sleep is lighter in the last half of the night so thoughts can more easily intrude. It is also typical of advanced sleep phase syndrome, in which the body clock is running early, so the person gets sleepy in the evening but then is awake too early. This pattern of insomnia is more common in older people. A similar pattern is to wake up for a few hours in the night and then fall back to sleep just in time for the alarm—stress or alcohol intake are typical causes.

Lastly, sleep-maintenance insomnia is when you keep waking up in the night but falling back to sleep. Needing to get up to urinate 4 times in an older man is an example. However, for others, frequent awakenings are a sign that something physical is happening in the night that awakens you. Breathing disturbances, pain, or leg jerks are perhaps the most common. It is this pattern of insomnia that is more likely to cause daytime sleepiness, and it is this pattern of insomnia that should definitely make you see a doctor and get a sleep study.

Bad advice

I found a blog today talking about sleep walking and Ambien. But instead of talking about the problem as a problem, the blog dismisses and belittles the problem. The writer, with considerable sarcasm, says that the scale of the problem is extremely small, that reports of sleep eating, sleep driving, and sleepwalking are overblown, that the FDA overreacted, and actually says "Personally, I'd blame the lawyers before I'd blame Ambien for sleep walking." Even worse for those who seek unbiased advice on health care and medications, this site suggests that they are there to help with sleep problems.  They are there to sell you Ambien on the Internet, at about 2.49 per pill, at sweetdreamsadvice.

First, the problem of doing things in your sleep after taking Ambien is NOT overblown. Most of us do not report our cases, so the WHO estimates are far to low. I would say that I see about one case every three months. The most recent lady was 50 years old and lived alone. She thought that she might be sleep eating because she would sometimes find food wrappers in her bedroom, and since starting Ambien about one year ago she had gained 20 pounds. Recently she went to a casino-hotel with some girlfriends for the weekend.

They had a great time sharing a room, especially taking picture of my patient. What was she doing? About one hour after going to sleep she got up, went over to the mini-bar area where there was a bowl of crackers. She took the bowl, sat down, and slouched over it shoveling crackers into her mouth. Then she went back to bed.

In the past I have told you about some of my other patients, including two who drove their car in the night, woke up in a parking lot, and did not remember it. And another who took Ambien on a plane and had to be arrested upon landing for acting out of line.

Second, Ambien is a fine drug. I have nothing against its proper use. It appears to be one of the safest sleeping pills ever, in terms of its low addictive potential, lack of morning hangover, and low interactions with other drugs. But it absolutely can cause things like sleep walking. And thus the decision to take it occasionally or regularly is a decision you should make with your doctor who can help you weigh the pro's and the con's.

When starting out, I do recommend that the person tell their bedpartner that they are taking a new medicine, just in case they do something weird. For those who live alone, I start with a super-low dose and slowly increase.

Third, don't buy your medicine on the internet unless you and your doctor agree to it. Enjoy your sleep.

How to sleep better

Recently I updated the most important 6 basic activities that everyone who has trouble sleeping should follow. They are in the Sleep Goal of the Can't Sleep Café. 

I'd like to briefly explain them here.

1.    Get 30 minutes of outdoor time each day. This is the easiest way for most people to get bright light. Getting some bright light helps to set your body clock and stimulates portions of the sleep-wake rhythm generators in the brain. Try to get the bright light at about the same time each day.

2.    Take only one serving of caffeine each day, only in the morning. Caffeine taken after lunch lingers in the system and can worsen sleep. Too much caffeine in the morning can cause a rebound of drowsiness later in the day.

3.    Practice a relaxation technique such as meditation for at least 20 minutes each day. This could also be exercise, prayer, or biofeedback. Prayer and meditation have the advantage that you can also do them when you might be awake in the night.

4.    Get up at the same time each day. This is the most important rule, and it is best to move the time a little earlier than you might naturally wake up. Somewhere near sunrise is also ideal if you can manage it.

5.    Plan your bedtime based on your wake-up time; for most people about 7 hours before the wake up time. The worst mistake for most people is to go to bed too early, hoping for 9 hours of sleep.

6.    Lastly, if you cannot sleep during the night, it is vitally important that you stop trying for a while. Get up, go sit in a recliner, and spend 20 to 30 minutes there before trying to sleep again. Then go into bed and try it again.

So there you have it—a little sunlight, only a little caffeine, a regular morning wake up time, some daily stress reduction, planning for 7 hours in bed, and if you still can't sleep, get up for a while and stop trying.

Women, sleep, and disease

A new research study has shown some interesting connections between sleep problems, psychologic stress, and risk factors in the blood for certain diseases. The researchers at Duke University studied over 200 normal people.

The subjects kept track of various aspects of their sleep for about one month. They also filled out various questionnaires about their psychologic state and stress levels. Blood samples were taken and tested for a number of markers of inflammation and heart disease. All of the subjects were non-smokers and the women were not on hormones of any type.

Previous studies have demonstrated connections between various measures of poor sleep and increased risk of coronary artery disease, type 2 diabetes, and high blood pressure. This study tried to assess the reason for this and also to understand the difference between men and women.

The results indicated that less more frequent sleep problems, less nightly total sleep time, and difficulty falling asleep were connected with increased psychologic distress and with increased blood markers including higher fasting insulin, fibrinogen and certain inflammatory biomarkers. It is likely that these markers in the blood are examples of HOW poor sleep seems to be linked with heart disease. It is not proven the extent to which these changes are due to the sleep problems itself or to the stress.

But the connection only occurred in WOMEN, not in men. That is, men who had similar sleep complaints did not exhibit the blood changes or the psychologic distress as much as the women did. The reason for this is not clear, but it confirms that physical responses to sleep problems can differ between the genders and have implications for who is likely to get sick from sleep problems. We also know that insomnia is much more common in women than in men.

So is possible that this sleep-health connection will be particularly important for women as more research is done. The study is also reviewed here.J. Steven Poceta MD is a licensed practitioner of neurology and sleep disorders who has been engaged by Revolution Health. No information in this blog is intended to diagnose or treat any condition. The opinions expressed here are Dr. Poceta's own and do not necessarily reflect those of Revolution Health.

Only 4 hours of sleep

This week I heard a lecture by the remarkable Mr. S.N. Goenka.

Mr. Goenka has been teaching a type of meditation called Vipassana meditation for almost 40 years. This type of meditation is the closest in technique to that which the Buddha himself taught, and is based on awareness of bodily sensations as a tool to develop concentration of mind, equanimity, and happiness.
Mr. Goenka, in an off hand statement during the lecture, said that people who regularly practice Vipassana find that they need less sleep. He said that on average it might be one hour less of sleep each day. Interestingly, he said that sometimes only 3 or 4 hours of sleep is necessary in order to feel rested the next day.

The key to getting by with less sleep was practicing meditation during the night if one could not sleep. His technique is one in which the person focuses on bodily sensations but does not react to them. Practitioners keep a calm and focused mind, but accept the situation as it is, knowing that it will change sooner or later.
This reminded me of some of the advice we give patients with insomnia. In fact, a key aspect of cognitive behavioral therapy (CBT) for insomnia is to re-assess your beliefs and attitudes about sleep. For example, part of the therapy involves spending less time in bed when you are sleeping poorly, with the knowledge that such behavior will improve sleep in the long run. In addition, some type of mental or physical relaxation training is suggested in order to deal with stress and anxiety.

Do people who meditate really require less sleep? I don't know, but I do know that this type of mental activity is an important part of the treatment of insomnia. I have mentioned several places to learn more about relaxation techniques in previous blog posts.J. Steven Poceta MD is a licensed practitioner of neurology and sleep disorders who has been engaged by Revolution Health. No information in this blog is intended to diagnose or treat any condition. The opinions expressed here are Dr. Poceta's own and do not necessarily reflect those of Revolution Health.

-- Kill Your Insomnia and Sleep Well Tonight! --

Sleep, tigers, afraid in your cave

I came across the nightworrier blog today--obviously a blog written by someone with insomnia. Not just insomnia, but worry as well. In fact, worry in the night is the major feature of this person's insomnia.
Many times I have been awake at night and worried. Let me count the ways—my work the next day; the kids driving at night; paying for lessons, the house, college; whether to move; the argument from yesterday.

Somewhere along the line I had a realization that most of the things I was worrying about did not seem as bad the next day. I mean I would be just plain freaked out in the night and positive that something bad was going to happen and I had no idea how to deal with it. Then, when morning came, I was able to deal with it, forget it, and it didn't seem so bad. How could that be? I was the same person just a few hours later, but my perspective and reaction to the problem was very different. This happened enough times that the pattern was obvious. Kind of like "the darkest hour is just before the dawn" perhaps.

So one evening I'm giving a lecture on sleep in some fancy restaurant to a group of doctors. Doctors are a tough audience, but smart and usually interested in the topic or they wouldn't come. We're talking about insomnia and I mention to the audience that things look really bleak to me during the night, but then during the day the same problem seems manageable. "I wonder why that is."

A hand shoots up and the doctor says "It is good to be scared in the night—it keeps us hiding in our cave." This was brilliant, and the more I thought about it the more obvious it became. Clearly, for primitive humans, there would be an evolutionary advantage to staying quiet and still and hidden in the night. I mean, anybody who wanted to go whistling through the jungle at night probably didn't survive very long in the world of sabre tooth tigers and pythons. Those who did survive passed on the nighttime scardy-cat gene.

So think of this the next time that you are awake at night. You are hard wired to be anxious at night, and it helped your ancestors survive, and it might even still be good for you. Comfort yourself with the knowledge that this is normal, and that things will seem better come the dawn.

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Less sleep is more sleep

No one really knows how much sleep the normal person "needs." Most people figure it out after a while, what with alarm clocks, coffee, dozing in meetings. For most people their body clock just does what it needs to do—get sleepy say at 10 pm and wake ups say at 530 am. But for people with insomnia, this is just not the case. They might get sleepy at 10 am but then wake up at 2 am and not be able to get back to sleep. This pattern of "early morning awakening" or sleep-offset insomnia is very common. It can be an indication of depression, but more commonly it is a pattern that occurs with any type of stress.

One of our major treatments for insomnia is to spend less time in bed. This can seem counter-intuitive, because many people mistakenly believe that if they are sleeping poorly they need to spend more time in bed. Unfortunately, spending long periods of time in bed if someone is awake just makes the insomnia worse in the long run. The brain "learns" to be awake in bed, and once a habit, it is difficult to change.

Our deepest sleep comes in the first 2 to 4 hours of the night, beginning about 16 or 17 hours after our morning wake up time. As soon as we fall asleep, our brain wave get slower and slower, and it is very hard to be awakened. This deep "slow wave" sleep continues for about an hour or so, then repeats itself in the first two cycles of the sleep stages. It is during this stage of sleep that growth hormone is released in children and most of the "bodily" restoration occurs. Later, in the last half of the night, sleep is lighter and most of our dreaming (REM) sleep occurs. The importance and function of this sleep is less clear. Some people have called the first half of sleep "core" sleep and the last portion "optional" sleep.

For these and many other reasons, it is necessary for someone with insomnia to take the perspective that they must get by with less sleep, even if they are tired the next day. For many, being in bed only 5 or 6 hours will get them just as much sleep as if they were in bed for 9 hours, and they will be training their brain to sleep better. Eventually, more sleep will come.

-- Use The Proven Insomnia Solution to End Your Misery Right Now! --

Tired? Got insomnia?

Sleep and wake are two sides of the same coin. Sleep affects daytime alertness and being awake in the day affects sleep at night. A basic concept of sleep-wake physiology is that there is a homeostatic mechanism at work, just like there is for hunger and eating. We get hungry so we eat, then get satiated and stop eating. If we don't eat we get hungry and want to eat. So too with sleep: We stay up all day and then get sleepy. We sleep and get less sleepy so we stop sleeping and are awake for a while.

This aspect of sleep is true, but it is not the whole story. Time-of-day (circadian) affects the likelihood of sleepiness or alertness for example. Also, the relationship breaks down in case of a disease or a sleep disorder. This is the topic for today: daytime sleepiness in people who have insomnia.

When we talk about insomnia, sometimes we might be talking about a symptom that happens once in a while, or we might be talking about a long-term condition itself, also called primary insomnia. This is the most common type of insomnia, the type that many people have even though they are not depressed and do not have another sleep disorder. Primary insomnia often begins with a stress of some kind, and over time becomes associated with anxiety and frustration in the night.

The interesting thing about people with primary insomnia is that even though they might only sleep 5 hours in the night, they usually cannot sleep during the day. This is a major difference from normal people, who if they have an occasional bad night are usually tired and sleepy the next day, and sleep more the next night. Again, for those people with primary insomnia, although they might be tired, exhausted, and can't function the next day, they usually cannot nap either. This is referred to as being "hyper-aroused." The usual homeostatic relationship between sleep and wake is altered, and there is less sleep in the night and less sleep in the day.

The lesson is this: If you have insomnia in the night lasting more than 3 months, AND if you are sleepy in the day, it is not likely that you have primary insomnia. It is more likely that you a sleep disorder causing the awakenings at night and you are trying to catch up in the day. This pattern of insomnia needs to be evaluated by a doctor and perhaps a sleep study to rule out sleep apnea or periodic limb movements. It should not be treated with sleeping pills until that time. Excessive daytime sleepiness, such as falling asleep when sedentary, is a symptom that needs evaluated no matter what.

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Getting off sleeping pills

A lot of people say, "I can't sleep without sleeping pills." I hear it as the main complaint from patients, and it is all over our insomnia forums and the "Can't sleep café." Today, I want to tell you how to get off sleeping pills.
Here is the short answer: You need to develop and practice techniques that help you sleep naturally. You need methods to help you cope when you don't get sleep. If you are sick or have depression or anxiety, they need to be treated. You need to get off the pills slowly, and lastly, your goals need to be realistic.

Let's start with realistic goals. There are some people who need sleeping pills, benefit from sleeping pills, and probably suffer no harm from sleeping pills. The modern sleeping pills are fantastic for their effectiveness, safety, and generally their non-addictive properties. People who seem to need are those with medical illness, mental illness, or those who have tried everything and still can't sleep or function. Like any medication, the risks and benefits must be weighed by you and your doctor.

The practices of cognitive behavioral therapy (CBT) include setting a regular wake up time, limiting time in bed, not being awake and frustrated in bed, and practicing some type of mental relaxation technique. Until you have such a routine as part of your life, you won't be able to get off sleeping pills. Getting off the sleeping pills is hard, and you will not sleep well for some time, so these techniques are to both help you sleep and to help you cope.

If you have a psychiatric or medical illness, beyond jus the stresses of life, you probably need to be on an antidepressant or other medication. CBT is not a cure for real depression, bipolar disease, or other serious problems.

SO: When you have been doing CBT techniques like those in our Can't Sleep Café or in other CBT programs for a few weeks, you can begin to get off the pills. This blog is not a detailed method, but in general, there are 3 ways to do this. First, you can stop them suddenly. This is not dangerous for Lunesta, Ambien, or Sonata in the recommended doses.

But if you are on an older pill like Valium or Halcion, or if the doses of the new pills are high, then you need specific advice from your doctor. Second, you can keep taking them nightly but trim the dose down, say cut it in half every week for 3 weeks to zero. Third, you can start skipping nights, and gradually get to where you only take a dose every 3rd night for a while. Some people can only go this far, but it is probably better than nightly use.

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Cell phones and insomnia

You probably saw the news: Radiation from cell phones can wreck your sleep.

The researchers say that they have a good study and a good conclusion; the cell phone manufacturers, who sponsored the study say that it is flawed and inconclusive. What's a sleep doctor to do?

The details of the study are not published, as far as I can tell. The study was conducted by researchers in Sweden and in Michigan. The study involved 35 men and 36 women aged 18 to 45. Before sleep they were exposed to radiation similar to that of a cell phone—but not an actual cell phone. Others in the group were treated in the same way but did not receive the radiation (sham radiation or control group). About one-half of the people considered themselves "electro-sensitive," but none of the participants could tell if they were receiving the real or the sham radiation.

Again, I was not able to find details today about the exact protocol used. Sleep was assessed with standard sleep studies as far as I can tell. Subjects who received the radiation took longer to reach sleep wave (deep) sleep, and had less of this deep stage of sleep. The researchers concluded that radiation from a cell phone adversely affects sleep.

I do not know if this is true—it is only one study and it should be considered preliminary. I am not sure if people who are "electrosensitive" are the same of normal people, for example. I will await the final report on this study, and another one before making recommendations.

Could radiation affect sleep? It is theoretically possible. We tested a radiation device from Symtonic a few years ago as a way to treat insomnia, but it did not help. Wikipedia has a good review of the possible health effects of radiation.

For now, it might make sense to use a "hands-free" approach, which places the radiation farther away from your  brain, and has also been recommended as safer while driving.

-- Solve Your Insomnia Problem and Get Back To Sleep Tonight! --

Sleep, insomnia, and meditation

The most commonly asked question on the Sleep Forums is probably "what can I do to sleep better?" People usually mean that they have trouble getting to sleep or staying asleep, or waking up too early. Usually they ask because they don't want to take a sleeping pill such as Ambien. Often the questioner wants a non drug therapy or a natural supplement.

Most of us answer that the best method for improving sleep is "cognitive behavioral therapy," or CBT. CBT can be accomplished with a one-on-one therapist or through an on-line site called cbtforinsomnia.com. You can read about it on the Revolution Health pages and try some of the advice on your own.

CBT has several components, but one of them is some sort of relaxation practice or meditation practice. Today, I want to talk about these a little bit, and give some links to CD's that teach meditation, relaxation, or mindfulness techniques.

Regular practice of a relaxation technique is one way to reduce the body's response to stressful life events. A lot of people seem to think that it is a method to get you back to sleep, but this is not really true. Practicing regularly during the daytime can prevent some of the physical changes in the nervous system that perpetuate stress-related conditions such as insomnia and headaches. It might seem strange, but spending 20 minutes relaxing in the morning or during work can help your sleep at night.

A lot of people with insomnia are more fearful of the fear of not sleeping than they are about not sleeping itself. Some people just really hate being awake at night, but accepting this and realizing that it is normal to be awake at night to some degree is essential to long-term improvement of insomnia. For those people who become impatient, frustrated, anxious, or even angry about insomnia, a mental relaxation technique during the night can fill the time and prevent undue bodily responses that make getting back to sleep impossible.

-- Try The Program And Sleep Early Tonight! --

Safer use of sleeping pills

The recent FDA request for stronger warnings about sleeping pills makes one wonder how safe these medications are.  Should I take them at all?  How often?  What should I watch out for if I do take them?

Until very recently no sleeping pill was approved for long-term use due to fears of impairment and addition.  Recently Ambien CR and Lunesta have been approved for long-term use and at the same time prescriptions for sleeping pills have increased tremendously.  Some of this is due to direct to consumer advertising.  I believe that the large numbers of people taking these agents is the reason that these relatively rare side effects have emerged.   Generally they are probably safe.  However, for all the hype about how great sleeping pills are, few people really look at the down side.  If you want a different perspective, see HERE. 

In general, almost all sleep specialists believe that nightly use of any sleeping pill is a last resort.  It should only come after trials on other medications, patient education, cognitive therapy, and intermittent sleeping pill use.  At that point, nightly use might be appropriate with close monitoring from a physician, understanding that there are risks.

If you are taking or are considering taking a sleeping pill, here are some suggestions to make it safer:

1. When starting a sleeping pill always take the lowest dose at home, preferably with someone present.  Do not take it for the first time in a hotel, at a friend’s house, or on a plane.  (Next blog:  The Ambien traveller arrested for bizarre behavior, a true story.)

2. Do not combine any sleeping pill with other sedative medications including certain antidepressants and certainly alcohol.

3. Make your environment safe if you do try a sleeping pill.  Be sure that you could not wander out of the house or even your room.  (Don’t’ sleep on the top bunk.)

4. Be aware of what others notice, or be sensitive to possible signs that you were sleep walking.  For example, early signs of a problem might include forgetting a conversation or forgetting that you walked to the kitchen.  If there are such signs, reduce the dose.

5. Take the sleeping pills intermittently, such as 1 to 5 times per week.  Everyone can stand a bad night of sleep—if you think you can’t you need cognitive therapy.

6. The older you are the lower dose you need.  So if you’ve been on Ambien for 10 years, the level in your blood now is higher than when you began:  Reduce the dose.

-- Start Sleeping Well Tonight! --

Sleep walking and sleeping pills

Today the Food and Drug Administration will start requiring the manufacturers of several sleeping pills to list complications such as sleep walking in the information about the drug.  As most people know, numerous reports of abnormal behavior such as eating or walking or driving occur after use of certain medications.  This is especially clear for Ambien because it is the most prescribed agent, but can occur with many other medications such as Lunesta, triazolam, and temazepam.

I have personally had negative, embarrassing, and upsetting experiences with the problem of sleep walking after Ambien use, and I am happy to see a little backlash on what has been years of marketing and increased prescriptions.  As the New York Times article from Stephanie Saul states, prescriptions are up 60 % in the last 6 years.

My first experience was presenting a case to colleagues.  At our weekly conference I talked about a 55 year old woman whose family reported that she “sleep walked” after taking Ambien and would walk to the kitchen.  Because they were still awake, they would lead her back to bed.  Two of my senior colleagues in essence said that this was impossible and that the woman needed psychiatric help.  This was back in 1995 when Ambien was fairly new but even at that time there were isolated case reports.  In the next year, a physician friend told me that he ate a chicken one night during his sleep after taking Ambien and he stopped taking it

More recently, I had a tragic case of a woman who lived alone and got up in the night after taking Ambien and took a bath.  She left the water running and totally flooded her condo and did not have flood insurance.  She is probably losing her home.  Another very nice lady aged 60, drove from San Diego to Temecula (about 50 miles) during a night after taking Ambien, parked her car in a closed bank, and then woke up near morning.  She had no idea of how she got there. Obviously neither woman takes it anymore. 

-- Cure Your Insomnia And Sleep Tonight! --

In The Habit Of Being Awake At Night

Most instances of long-term insomnia begin with a stressful life problem.  In the case of a nice 50 year old woman I met yesterday, the problem began with her neighbors 3 years ago.  She had always slept pretty well before then and she had no medical disease, major anxiety or depression.  Then, her next door neighbor began to make a lot of noise at night. 

Every night for a couple of months she was awakened by the noise of cars, music, talking, and general activity, usually between midnight and 2 am.  This was very upsetting to her, partly because of having to get up at 530 am for work, and partly because her relationship with the neighbor became so unpleasant.  A few times, she called the police. 

After a little while, she asked her doctor for a sleeping pill.  Eventually, she began taking clonazepam 1 mg and zolpidem 10 mg every night, which helped quite a bit.  She found another house on a quiet street and moved.  After a total of 6 months the noisy neighbor problem was history. 

Unfortunately, the insomnia continued.  If she didn't take the sleeping pills she would lie awake for hours and she couldn't stand the frustration of being awake at night.  She worried about her job performance and her dependence on the sleeping pills.  Even with the pills she was waking up in the night, and began to go to bed earlier so as to get extra chances at sleep. 

Her type of insomnia is called by various names:  primary insomnia, conditioned insomnia, or psychophysiologic insomnia.  Once the brain is in the habit of being frustrated, awake, or upset while in bed trying to sleep, the habit can last forever.  After all, the brain's main function is to learn, and her brain learned that the bed at night was an unpleasant place.  Many sleep specialists believe that this negative conditioning process between the passive act of falling asleep and the bed environment is the cause of most insomnia. 

Our nice lady needs to slowly discontinue the sleeping pills under a doctors direction, and re-train her brain to sleep.  This is a long process for most people, involving sleep restriction, cognitive behavioral therapy, relaxation techniques, daytime bright light, and a healthy daytime lifestyle.  Most people can get better sleep by using a combination of these therapies and a lot of encouragement and motivation. 

-- Sleep Well Tonight with 90% Success Rate! --

Can’t sleep? Quit trying !

There have been so many questions about insomnia, and insomnia is such a huge topic (the most common sleep disorder), that today we will consider one little aspect of primary insomnia. Primary insomnia is insomnia not caused by a medical, sleep, or psychiatric disorder. 

To understand in more detail the symptom of insomnia, the many possible causes of insomnia, the association of insomnia with medical conditions, sleep disorders, mental health conditions, medications, and other factors, visit http://tinyurl.com/mds9p6.   

Many people with insomnia develop a vicious cycle of trying to sleep, becoming frustrated or anxious about not sleeping, trying harder to sleep, getting more frustrated, etc.  This cycle is so common that it occurs in almost all persons with insomnia to some extent, but in some, it is the major factor that causes the insomnia to continue for months and years.   

The act of falling asleep cannot be forced.  It is a passive--not an active—event.  It occurs if the “stage is set,” which means that the body/brain is sleepy, the time of night is right, and the environment is right.  Falling asleep is partly natural but also partly learned, and the brain needs the proper connection (or training) in the person’s past experience between trying to fall asleep and actually falling asleep. 

This means that when a person has bad experiences in bed trying to sleep the brain learns this, and the next time the person is in bed, the same thing will tend to happen.  The anxiety becomes associated with trying to sleep, and the cycle continues.  Imagine if someone was abused or tortured in bed; even years later after being otherwise better, it would be impossible to relax and fall asleep in that same bed.  It is extremely important to avoid frustration, anxiety, negative thinking, rumination, and other strong emotions when trying to fall asleep.   

Which brings me to the title of this blog.  Yes, if you can’t fall asleep, you should quit trying.  That doesn’t mean giving up seeking the help and answers you need—in fact just about everyone with insomnia can be helped with a combination of therapies. 

BUT, it means that at the time, stop trying to sleep, relax, maybe get up and have a tea, stay calm, accept the situation, maybe meditate or pray, and later go back to bed and see if sleep comes.  This might or might not help sleep during that night, but it should help your attitude, and it helps prevent the insomnia-frustration cycle from worsening with time.   

Has anyone found that it helps to fall asleep by not trying to fall asleep?  We’ll continue discussing any and all sleep disorders in upcoming blogs.

-- Cure Your Insomnia and Sleep Tonight! --

Women more stressed by insomnia

Whether it's due to partners snoring, nagging consciences or the stresses and anxieties of modern life, new research has revealed that women are almost 20 per cent more likely to suffer insomnia than men.
A year-long investigation by the National Sleep Foundation (NSF) into the sleeping habits of more than 2,000 women aged from 18 to 64 has found that almost two-thirds had between one and three disturbed nights every week. Almost 70 per cent said they frequently experience a sleep problem.

This compares to 52 per cent of men who say they suffer insomnia a few nights a week or more.
The study reflects research in a new book by the founder of the American Academy of Sleep Medicine, Dr Meir Kryger, author of Can't Sleep, Can't Stay Awake: A Woman's Guide To Sleep Disorders. 'Unlike men, women have sleep problems related to hormonal and bodily changes from menstruation, pregnancy and menopause,' he said.

'Unfortunately, too often it is women whose sleep disorders are undiagnosed or misdiagnosed because of a lack of education among doctors about these unique problems. This failure by doctors to correctly diagnose female sleeplessness is meaning sufferers are putting their health at risk while contributing to dramatic rises in obesity and diabetes.

'Women lose sleep because of their role in the family and the demands of today's 24/7 world,' he added.
Kryger said that women's disorders are often missed because, although they have the same sleep disorders as men, the way they react to sleeplessness is very different. 'The problem is compounded by the likelihood that women will not even realise symptoms in themselves indicating that they have sleep disorders,' he said. 'For example, women with sleep apnea - temporarily stopping breathing while asleep - have symptoms of depression more often than men with apnea.'

Kryger claimed that female sleeplessness is frequently misdiagnosed by doctors because of a widespread belief that women rarely suffer sleep problems, combined with the fact that insomnia manifests itself differently in women to how it does in men.
Richard Gelula, the chief executive of the NSF, said: 'The NSF study found that women's sleep problems can affect virtually every aspect of their lives, leaving them late for work, stressed out, too tired for sex and little time for their friends.'

'Women of all ages are burning the candle at both ends and as a result they are sleepless and stressed out. Poor sleep [affects] every aspect of a woman's life, as well as her health. In fact, more than one half of the women polled reported that they felt sad or depressed in the past month and one third reported they recently felt hopeless about the future.'

The study revealed, however, women refuse to succumb to the strain of sleeplessness. Almost 80 per cent said that, when they experience drowsiness during the day, they just accept it and keep going. Two thirds said they achieved this by drinking caffeine-rich drinks, with one third admitting consuming three or more such drinks every day in an attempt to escape their exhaustion. Just 8 per cent admitted missing work at least once a month due to tiredness.

'While most women refuse to put work on the back burner when they run out of time or are too sleepy, they admit choosing instead to cut back on healthy activities as they struggle through their daily lives,' said Gelula.
Half of the women admitted that sleep and exercise are the first things they sacrifice. In addition, more than one third said they also reduce the amount of time spent with friends and family, stop eating healthily and don't participate in sexual activity when feeling tired.

'Worryingly, women admit driving while feeling exhausted,' said Gelula. 'More than one quarter said they have driven while feeling drowsy at least once a month in the past year, 10 per cent of whom said they drove in this state while a child was in the car.'

-- Cure Insomnia, Sleep Well Tonight --