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.
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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.
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.
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.
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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