BASIC FACTS ABOUT INSOMNIA
About 20 – 40% of the adult population complains of sleep difficulties and about one in six individuals (17%) consider it a serious problem. Insomnia is the second most prevalent health complaint after pain.
Insomnia is usually defined as either:
- Sleep-onset latency (or the time it takes to transition from full wakefulness to sleep) averaging more than 30 minutes per night;
- Total time awake after sleep-onset averaging more than 30 minutes per night;
- Early morning awakening before the desired wake-up time with an inability to fall back asleep;
- Poor quality of sleep.
In order to meet the criteria for insomnia, an individual must also complain of impaired mood, performance or daytime functioning.
BASIC FACTS ABOUT INSOMNIA AND SLEEP
One night of total sleep deprivation can make you sleepy, but has remarkably little effect on daytime performance. Even extended sleeplessness causes remarkably little pathology aside from extreme sleepiness. During a recently published clinical study, a volunteer stayed awake for 264 hours, or 11 days, and showed no demonstrable abnormalities. Even after this length of sleeplessness, 2-3 nights of extended sleep returned the volunteer to normal.
For most individuals, performance can usually be maintained with 60-70% of normal sleep. For an eight-hour sleeper, that is 4.5 – 5.5 hours of sleep. A number of studies have shown that insomniacs actually perform as well on tests of cognitive performance as good sleepers.
If you are not sleepy during the day, you may be trying to get more sleep than you need. A number of studies have shown that insomniacs are not sleepier than good sleepers during the day.
The major effect of moderate sleep loss is irritability and fatigue, often due to stressful appraisals about sleep loss. Most individuals have experienced sleep loss due to socializing, recreational activities, travel, etc., that was not appraised as stressful. However, tossing and turning during the night and then appraising sleep loss as stressful will adversely affect daytime mood. Thus, for moderate sleep loss, the perception of sleep is more important than the amount of sleep. The less you fear insomnia, the better you will sleep.
Insomniacs tend to overestimate the time it takes to fall asleep and underestimate their total sleep time, probably due, in part, to their tendency to perceive light sleep (Stage 2) as being “awake.” The average good sleeper awakens, on average, 4-6 times per night. In other words, you are probably getting more sleep than you think. Attributing mood and daytime functioning entirely to sleep can actually make your insomnia worse. It is important to realize that nutrition, exercise, stress, and many other factors also affect our daily functioning.
TIPS FOR INSOMNIACS
ESTABLISH A REGULAR BEDTIME AND AWAKENING TIME
A regular bedtime routine and stable in-bed time are very important to establish in order to overcome your sleep problem. It is even more critical that you get up the same time each day, even after nights when you slept very little or not at all. Therefore, we suggest that you set an alarm clock each evening, before you know how you will sleep that night. Get up at about the same time both during weekends and weekdays. While this is very difficult in the beginning, over weeks and months, it will help establish a routine for your sleep/wake cycle.
AVOID THE BEDROOM CLOCK
It is very difficult to relax and fall asleep when you see how time is slipping by. When you go to bed, set the alarm for the next morning, but then turn the clock around or hide it in a dresser drawer. Similarly, put away your watch. If you need to be up by a certain time, make sure your alarm is set properly. Usually, one sleeps best away from all time pressures. This also applies to those who have long awakenings during the night.
AVOID TRYING TO SLEEP
The more you TRY to sleep, the more awake you will become. Lying in bed frustrated and unable to sleep needs to be avoided at all costs. As long as you lay in bed comfortable and relaxed, continue to do so. If you find yourself awake for more than “20 mental minutes,” get out of bed and go to another room. Once out of bed, you can engage in reading or listening to music to help you relax and distract your mind from your worries. The reading material or music you select should not be very stimulating. Remember the goal is to relax and allow sleep to come. Once you begin to feel drowsy, return to the bedroom to sleep. Repeat this procedure as often as necessary until you fall asleep. This procedure to help you learn to sleep in your bedroom environment is called “stimulus control.”
SHORTEN YOUR TIME IN BED
The longer one stays in bed beyond the time that is actually required for sleeping, the more shallow and unsatisfactory sleep gets. It will be difficult in the beginning to cut down on your bed time to no more than 6-8 hours per 24 hour period, because your body may be used to getting more time in bed than that. However, if you can endure the shorter bedtime hours for a few weeks, your sleep will become considerably deeper and more refreshing. Obviously, the time out of bed has to be spent active and alert. If you simply substitute dozing somewhere else for time spent in bed, this will not help. Also, the time spent napping during the day is included in the above total. Do not take naps for longer that one hour, as longer naps can significantly affect sleep-onset that night.
SCHEDULE “WORRY” TIME IN THE EARLY EVENING
Reserve about 30 minutes during the early evening to be alone. During that time, sit in a comfortable chair and simply let your mind wander. If you hit on unpleasant thoughts, worries, or something that needs to be worked through or planned, write each such thought on a separate piece of paper, e.g., a 3x5 index card. When you have collected most of the thoughts that are currently listed on these cards, sort the cards into different categories. Then take each card and, in turn, think about what needs to be done. Try to settle as many worries and thoughts as you can by planning the next step you can do in each case. Make lists. Write down your decisions about each worry or thought on the appropriate card in black and white. Then, if that thought strikes you later in the night, you can tell yourself that you have thought about it carefully, that you have a plan, and that tomorrow you will carry out that plan. However, if the same worry occasionally comes back to you night after night, this usually indicates that your plan is not working. Try to come up with a different solution.
BASIC INSTRUCTIONS FOR RELAXATION TRAINING
Use a quiet, non-distracting environment to practice your relaxation techniques. Practice relaxation in a comfortable body position, preferably lying down.
Don’t worry about whether you are “successful” in achieving a state of deep relaxation. Maintain a passive attitude and permit relaxation to occur at its own pace. If distracting thoughts occur, simply say, “Oh well.” and return to focusing on relaxation techniques. This ability to let “relaxation happen” is called passive volition and will eventually facilitate sleep onset. During the first two weeks of relaxation training, practice the relaxation techniques once or twice daily, but not at bedtime. The afternoon is probably the best time to practice.During the third week of training, use the relaxation techniques once or twice during the day and then at bedtime when you turn off the lights and close your eyes to go to sleep.
When practicing the relaxation techniques at bedtime, combine the relaxation techniques with sleep scheduling and stimulus control (as described elsewhere). If you don’t fall asleep within 25 minutes, do not continue the relaxation techniques. Open your eyes, get out of bed and distract yourself by reading, listening to music, etc., until you feel drowsy. Then close your eyes and use the relaxation techniques again. Repeat this process until you fall asleep.
Regular daily use of relaxation techniques will have long-term stress-reducing effects, in addition to helping you fall asleep.
TRY TO EXERCISE IN THE LATE AFTERNOON OR EARLY EVENING
During the day, body temperature and metabolism increase; during the night, they decrease. In people who have problems with sleeping, metabolism and temperature do not drop as much during the night as they do in people who sleep well. Exercise, if performed intensively for about 20 minutes, increases body metabolism and temperature. Five to six hours later, metabolism and temperature then decrease much more than if you had not exercised. This helps your sleep. Therefore, we recommend exercising about five to six hours before you want to fall asleep. If you exercise right before sleep it will delay sleep onset because it leads to increased arousal.
TAKE A HOT BATH TWO TO FOUR HOURS BEFORE GOING TO BED
The idea is to increase your body temperature before bedtime, which will lead to a drop in temperature about two or three hours later. If you have a spa or Jacuzzi, sit in it for about 20 minutes or until you break into a good sweat. If you soak in your bathtub, make the water slightly hotter than is comfortable and keep it at that temperature for about 20 minutes by occasionally letting some cool water out and adding some hot water.
Before you perform the hot bath routine, check with your doctor. For the first few times that you do this, have someone else around during that time and soak for less than 20 minutes. Some people get dizzy or faint from hot baths, and if that happens to you, do not take hot baths.
EAT A LIGHT SNACK BEFORE GOING TO BED
There is good research showing that foods that contain the substance “tryptophan” (a naturally-occurring amino acid) may promote sleep. Foods that are high in tryptophan include turkey, milk, cheese, and bananas. If you find that you are hungry before bedtime or in the middle of the night, you may want to try a glass of milk (warm or cold), cheese and crackers, or something similar. This may help you to sleep better. Try it for a week or two and see whether it helps you.
AVOID TOBACCO AND CAFFEINE
Smoking clearly disturbs sleep. Heavy smokers who are trying to quit will find that you also sleep quite poorly during the process of withdrawing from nicotine. In a few weeks after withdrawal, however, you will sleep better. Caffeine is a powerful stimulant and can disturb sleep even several hours after consuming a caffeinated product. Measurable harmful effects on sleep can be seen 16 hours after consuming 200 mg of caffeine (the equivalent of a strong cup of brewed coffee). The practice of consuming 1 to 2 cups of coffee in the morning may be tolerated well by most people, but insomniacs may be sensitive even to small amounts of stimulants. Gradual withdrawal from caffeine should be considered (abrupt withdrawal may lead to headache), starting with the elimination of caffeine products after noon.