Sleep Hygiene: Long Term Treatment for Insomnia
Insomnia is a very common problem in the United States. About 30% of adults in the U.S. report some difficulties with sleep from time to time. Difficulty sleeping can be a tricky problem to address medically. Insomnia can be a symptom of many different illnesses (depression, lung disease, sleep apnea, heart disease, anxiety, chronic pain are some of the most common) and chronic insomnia itself can impair your physical and mental well being in different ways. Before you do anything else to address a sleep problem schedule an appointment with your primary care physician for an evaluation. Your doctor will be able to determine if there is an underlying medical problem that requires treatment in addition to your sleep problem. There are plenty of medications, both over the counter and prescription, which will provide some short-term relief from insomnia. Unfortunately, the human body is designed to adapt to any substance that is taken regularly for a long time. In the case of sleep medications this means eventually the medicine is not going to make you sleepy. The key to a long-term solution to sleep problems is behavior change. Here are a few simple principles that followed consistently can keep you well rested. This group of principles is usually called "sleep hygiene" by medical providers.
If you consider the need for sleep as similar to the need to eat, you will understand why consistent bedtimes, consistent awakening times and avoidance of naps are key behavior changes to make. Your “appetite” for sleep builds up over time, and if you “snack” on sleep by taking naps or sleeping in you decrease your appetite for sleep at your next bedtime. One of the first steps to implementing this strategy is figuring out how much sleep you are actually getting each night. Start keeping a sleep log for 1-2 weeks in which you write down the time you went to bed, the time you fell asleep, how many times you woke up during the night and how long you were up each time, and when you finally got out of bed for the day. Also write down any naps you took during the day and how long they were. Add up all of the time you were actually asleep (don’t count times you were lying in bed awake) and see the average amount of sleep per day (in hours) you’ve actually been getting.
Next decide when you will be getting up for the day. This should be the same time every single day, even on weekends. Yes, I know that is really painful to hear. Most of us love our opportunities to sleep in on the weekends. And maybe someday, when your sleep patterns are straightened out, you will be able to go back to the occasional luxurious weekend morning in bed. For now, while you are trying to get insomnia under control, get up on the weekends at the same time you would during the week. Now determine your bedtime. Your bedtime is determined by how much sleep you’ve actually been getting, not by how much sleep you wish you were getting. For example, if you have to wake up at 6am for work and you have been getting an average of 5 hours of sleep including naps, your bedtime will be at 1am.
1 AM! Yes, that is very late. And yes, you are going to be very tired by 1 AM. That is the point. Your body needs to build up its sleep appetite so that when you do finally go to bed you are able to quickly fall asleep and stay asleep. I can hear some of you thinking “But what if I can’t fall asleep at 1AM? I will be even more tired the next day!” Yes, of course you will be. But that’s okay too. In fact, it’s desirable, since it will increase your sleep appetite so that the next day when you try to go to bed at 1 AM you will be much more likely to fall asleep. Over time if you are persistent with this and continue to avoid naps you will find that you easily fall asleep at 1 AM and sleep solidly until 6 AM each night. Once your body is retrained to this habit, which means a week of sleeping soundly, you can start adding in some more sleep time by going to bed 15 minutes earlier. Only do this if you are still feeling tired during the day. If you are successful at sleeping soundly for 5 hours and 15 minutes for a week and still feel tired then move your bedtime up another 15 minutes. Continue this pattern until you reach a point of sleeping soundly at night and feeling rested during the day. The name for this technique is called “sleep restriction” and it works well for people who are willing to commit to it.
Worry is one of the major banes of sleep. Worry activates your brain and increases your alertness, which is exactly the opposite of what you need to do to fall asleep. Worry at bedtime tends to fall into two categories. People worry about different events in their lives and people worry about not sleeping well.
If you find yourself worrying at bedtime about daily events or about things you need to do tomorrow, your best tool might be a pen and paper. Write down lists, thoughts, ideas, problems and anything else that is buzzing around your brain keeping you awake. Writing these things down reassures your brain that you will not forget in the morning and gives it “permission” to let go and relax so you can fall asleep. It can also help to remind yourself that you have done everything you can about these issues, that you will work on them more tomorrow, and that worrying isn’t helping anything. Some people find that these techniques are enough to halt their worries. If you still find yourself worrying at bedtime and writing things down isn’t helping, I recommend seeking assistance through a mental health professional, since you may have an actual anxiety disorder that requires more treatment.
Worrying about not sleeping is the other major source of worry at bedtime for people with chronic sleep problems. In a sense, you develop performance anxiety about being able to go to sleep. You scrutinize yourself and your mental state, constantly looking for signs of approaching sleep. It’s a little like trying to sleep in a room with a very annoying roommate who keeps poking you on the arm every 5 minutes and whispering “are you asleep yet?” Of course you aren’t going to fall asleep with this person bothering you! There are two ways to manage this, and you will typically need to do both.
The first is to change your beliefs about sleep. Most people have heard over and over that adults need 7-9 hours of sleep per night for good health, and so they worry if they get less. People also worry about how they will feel and function after a night of poor sleep, and tend to tell themselves things like “I’m going to feel awful, I’m going to be a zombie, I won’t be able to focus, I’m going to get in trouble…” This last set of statements is called catastrophizing, and it is a way to really increase your worry and anxiety.
Let’s look at those beliefs more realistically. It is true that most adults need 7-9 hours of sleep on average for good health. The key words there are “on average.” One bad night of sleep is not going to ruin your health. And if you have accumulated many bad nights of sleep due to chronic insomnia, one more bad night isn’t going to significantly impact your health either. You also are going to manage just fine the next day. Look at your track record! How many days have you functioned on less than ideal sleep? Even if you don’t have chronic insomnia it’s probably quite a few. Think realistically about how you felt. Probably a little more tired, maybe a little achy. Maybe you drank an extra cup of coffee and maybe you made decisions a little more slowly. But chances are you were able to safely and effectively function throughout your day. It’s not a catastrophe to not sleep well; it’s just mildly unpleasant.
The second step in tackling worry about sleep is to get up out of bed and go do something else. It is very hard to stop the self-scrutiny and worry just lying there in the dark. Get up and do something sedentary and slightly dull for 20-30 minutes until you feel physically tired. Then go back to bed and lie down. If you begin worrying about sleep again then get up again for another 20-30 minutes and continue your dull activities. And remind yourself – not sleeping well is not a catastrophe. Try to reframe the situation as having some “bonus time” this evening to get something done that doesn’t usually get done. Reading is often a good activity but don’t pick up the latest best-selling page-turner. Instead choose something that is not too stimulating. Avoid TV and other screens since the light from these devices confuses your internal clock.
There are many daily routines that can either help or hinder your quest for a good night’s sleep. Try out some of the following ideas, starting with one that seems pretty easy to you and adding others as needed until you are slumbering blissfully. Continue using a sleep log to document how your sleep changes over time as you work on these different approaches.
Cut down on your caffeine use and do not drink or eat anything containing caffeine within 8 hours of bedtime. Remember that chocolate contains caffeine as well as tea, coffee and many sodas. Caffeine counteracts adenosine in your brain, which is one of the neurotransmitters that signals a need to sleep. Many people believe that their caffeine consumption is not affecting their sleep because they’ve always slugged down 6 cups per day. Caffeine’s effect on sleep does vary from person to person, but cutting out afternoon caffeine use for a week to see if it makes a difference is a pretty simple change.
Keep your bedroom cool, dark and quiet. Often running a fan to generate white noise and keep the surroundings cooler will improve sleep. Avoid having a TV or other screen technology in the bedroom. Some people have told me that the TV helps them fall asleep, but unfortunately the ongoing light and noise prevents them from entering into deep, restful sleep. If you have a bed partner who snores, consider a pair of earplugs.
Avoid alcohol and heavy meals for a few hours before bed. Alcohol often will make people sleepy but its effects tend to wear off after a few hours, at which point you are jarred into wakefulness. Additionally alcohol alters your “sleep architecture” which means it disrupts the normal pattern of light sleep, deep sleep and dream sleep that everyone needs for good health. Heavy meals can also induce a feeling of sleepiness but will also lead to heartburn, stomach discomfort and poor sleep.
Everyone knows exercise is good for you, right? Well, besides all the wonderful effects on weight, cardiovascular health, and mood regular exercise has been shown in many studies to dramatically improve sleep. Most studies look at 30 minutes several times a week and show significant gains in both quantity of sleep (number of hours) and quality of sleep (how restful). The standard advice is not to exercise for several hours before bedtime, since this could increase your alertness and make it hard to fall asleep. However this isn’t the case for everyone. If evenings are the only time you have to exercise, I suggest you try it for 1-2 weeks and see what effect it has on your sleep. I recommend starting small with your exercise goals. Choose something that seems fun and easy to you, so that exercise becomes a joyful part of your everyday routine.