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.
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.
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.
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.
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.
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.
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.
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.
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.
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