If you are reading this because you have insomnia, you are not alone. Insomnia affects 80% of people at some time in their lives. Persistent insomnia, however, is a more challenging and frustrating problem and I am going to try to leave you with a few tips to help improve your symptoms.
There are a few caveats to get out of the way: If sleep seemed to get worse abruptly and then stayed poor, it is probably important to find out why. See your doctor. In some people poor sleep is a sign of a medical or other health condition.
Most people with persistent insomnia should consider getting psychological therapy. Even if a psychological problem was not the main cause of the sleep problem, prolonged insomnia often can affect the overall psychological state over time affecting not only the overall health but the recovery from the insomnia. Ironically, the more patients tend to resist psychological care the more likely they are to benefit from their services.
Treating ongoing insomnia can be very challenging because of the highly resistant nature of this condition. Often patients describe poor responses to sleeping medication, relaxation techniques, and other behavioral techniques. In fact, it is not unusual for some patients to claim that they have tried "everything" without success. It is under these circumstances a sleep professional needs to carefully go through the history and identify each and every intervention and assess the effectiveness of how each technique has been tried. For example, a relaxation technique is less likely to be very effective if the patient finishes 3 hours of work, brings the computer to bed to check e-mail for 45 minutes, sets the computer down, and then tries to relax for 10 minutes. When someone keeps their brain highly active and perhaps under emotional distress and then expects a sudden shift to total relaxation, it is as if that person expects slamming on the brakes, shifting into reverse, pulling the wheel to do a 180 in the middle of the highway will be relaxing for the passenger. Nearly all human brains require wind down time after stress and high level mental activity. In fact there is evidence that a very small percentage can immediately transition from high stress to relaxed brain state with very low levels of stress hormones. But I would be willing to bet that you are not James Bond so the rest of this advice does apply to you.
An evening routine requires putting away any work followed by declining intensity activities. Declining intensity means decreased speed, decreased physical demands, decreased psychological stress, etc. Paying bills definitely needs to stop at least an hour before bed. Cleaning out closets and shelves also needs to stop at least an hour before bed. Any work becomes the work that winds down the day. Folding laundry and leaving it in baskets for the next day, putting the last dishes in the dishwasher so it can be started, are reasonable tasks. Housecleaning will have to wait. Then brushing teeth and pajamas. Plan for 20-30 minutes of reading or watching television without any other activity. Avoid television in the bedroom. Then go to bed at a consistent bedtime. This bedtime may vary because of your work schedule. Roughly 10-11:30 p.m. works for most people if they don't have trouble going to sleep. If you have trouble going to sleep, go to bed an hour later.
In your room it should be dark, cool, comfortable, and quiet. If it isn't, fix whatever is disturbing you so it doesn't bother you. As I said, no T.V. We could debate the T.V. in the bedroom thing forever, but I would still say no. No computer. No smartphone. No iPad. No Playstation. Nothing with a screen. You can have your phone in your room, just don't touch it. If you were my kids I would tell you that the phone builds up a fatal electric charge during the hours of 10 p.m. and 6 a.m. and if they touch it they will die a grisly electrocution death. But they wouldn't believe me, because they grew up with me telling them ridiculous things like that. Just don't use electronics at night.
Give yourself some time to relax and fall asleep. You might be surprised by actually falling asleep. Sleep "how-to" books give specific amounts of time. I think that if you are watching the clock at night, it is counterproductive and promotes wakefulness.
Do not have a visible clock in the room. Your alarm clock can be in the room, but turn it away from you. Reminding yourself that it is 2 a.m. and you are not asleep is not useful at all. If you open your eyes and it is dark and your alarm has not rung yet, you still have time to sleep. That's all you need to know. The mental math of thinking how many hours you have been awake, how few hours you have left to sleep, how many hours you should be sleeping, how many nights it has been since you have slept well, and wondering when it will all crash down on you is not relaxing. Those thoughts are stressful.
So far:
General health exam by doctor and possibly psychologist
No alcohol or caffeine during the time we are intervening on your sleep
No tech
Wind down time for at least an hour
Regular bedtime
No visible clock
Next: if you wake up in the middle of the night and you can easily fall back to sleep, that's wonderful! However, if you are awake and can't sleep again, get out of bed and go to the living room or some other suitable, quiet room where you can be alone. Read something relaxing like a magazine or some fiction. If you read non-fiction make sure it is something that does not activate your brain excessively. Read about whales (unless you are a marine biologist) or something else pleasant. Read about the Dynasties of China. If you don't have a Kindle, consider getting one. But it's the middle of the night and Amazon (http://www.amazon.com/) delivers fast but not that fast. If you have a smart phone you can download the Kindle app and start reading books on your phone. The is the only exception I give to the No Tech rule. Now you can download thousands of books, many of them for free. Consider watching television. Watch something that pleases you. DO NOT WATCH THE NEWS! News channels have changed their formats over recent years and they are highly visually triggering and the flow of the information is jarring. Replace all of the interior windows of my standard transmission car with television screens that change channel every 3-5 seconds, configure the stereo so it plays 11 stations at once and then invite my 10 year old to drive at 90 miles per hour down I-90, grinding and clunking the gears all the way, and put Wolf Blitzer in the back seat interrupting everything all the time and we would have television news.
No TV news for you. It will not relax you. Watch Dirty Jobs or Mythbusters. Watch a movie. Get Netflix http://www.netflix.com/ and you can stream a ton of movies and TV series to your TV instantly for pennies per day. Relax. You are going to be up for a while. When you feel ready to go back to bed, go to bed and see if you can go to sleep.
How does this help? This sounds like what you were already doing, right? You were already staying up at bedime and staying up during the night. Then you would crash and sleep late some mornings when you were exhausted. Okay, now we are going to apply a schedule to your sleep. It works on the principle that your body, more specifically your brain needs sleep. If you deprive your brain of sleep it will build up sleep pressure and eventually it will fall asleep.
Let's take insomnia treatment X: Patient 1 comes in with complaints of not being able to sleep. The doctor straightens his collar, sticks out his chest and says, I can make sure you get a good long night of sleep. Patient 1 is brought into the sleep testing laboratory, is connected to testing electrodes and the technologist is instructed to keep the patient awake for 72 hours. At first it is no problem. The patient reads, watches T.V., talks on the phone, etc. By the end of 48 hours the patient is occasionally dozing off and needs to be watched. By 60 hours the patient needs constant supervision and stimulation like talking, lifting the hand, etc. The doctor indicates that it is time to let the patient sleep and they put her to bed. She sleeps for 16 hours straight and wakes up feeling very rested, but stiff and groggy. She has trouble sleeping the next night because of having just slept 16 hours, but for the next few days she sleeps with only mild difficulties. However, the problems slowly return and in a few weeks she is back to the way she was.
Insomnia treatment Y: Patient 2 comes in with similar complaints of trouble falling and staying asleep. The doctor advises relaxation, good sleep hygiene (behaviors) and schedules a 3 month follow-up appoinment. The patient expresses frustration because "I've done all of that". In fact, the patient has read a book and has tried a few of the recommendations for a night or two and got frustrated. The fact is that the patient is too frustrated to try anything that does not have tangible and clear results.
Insomnia treatment Z: Patient 3 will be treated with relaxation, sleep hygiene (appropriate sleep/bedtime behavioral therapy) and sleep scheduling also known as sleep restriction.
Sleep Restriction is one of the most effective and widely used treatments for insomnia. It works quickly, it has a sustained beneficial effect. It is often more powerful than medication but it can be used in conjunction with medication, if needed.
When Sleep Restriction is first explained to patients, they almost universally do not like it. The most favorable response is something akin to suggesting a colonoscopy. Other responses are vehement arguments against it. This is probably because Sleep Restriction seeks to take the already limited sleep in an exhausted patient and to substantially cut it down. It seems like the logic of: "Oh you are dying of thirst. Okay, I'll dump some of your last water on the ground." It is my job to explain why this protocol works.
Let's take an example:
Gretel gets home after a long day in the woods each day and makes dinner for her brother and her aunt. Then she has to clean up the kitchen, do some housework before she gets to relax. She likes to play "Pigs and Wolf" on XBox 360 and usually plays until after her witchy aunt goes to bed, typically after 11. Then she brushes her teeth and gets into bed. She thinks about how guilty she feels fattening up her brother, but her emotions are mixed because she doesn't want to get eaten. They could try to get away but the place is rent-free and meals included and that kind of deal doesn't come along every day. Plus, the old woman has serious diabetes. If she kicks the bucket, the candy house would be theirs. They could use the candy house to attract paying tenants and they would be set for life. With all of these thoughts on her mind she spends hours in bend tossing and turning and unable to fall asleep. When finally sleep comes to her the hacking cough of the warty nosed aunt wakes her and once again racing thoughts keep her from sleeping for quite a while. When she awakens she poorly rested once again, yet having to start her busy day.
For the sake of sleep math, let's say Gretel goes to bed at 11:30 p. m. and gets up at 6:30 a.m.
From 11:30 - 1 a.m. she is unable to sleep.
From 1 a.m. - 3 a.m. she sleeps.
From 3 a.m. - 4:30 a.m. she is awake again
From 4:30 a.m. - 6:30 a.m. she is asleep
Doing the sleep math: She sleeps 4 hours and she is awake 3 hours. She is in bed 7 hours. She is asleep 4/7 of the time she is in bed which is just a little more than half.
Patients would like us to be able to force them to sleep the other 3 hours. There isn't a wand in the Hansel and Gretel story or in my clinic. I can't make anyone sleep. We can teach relaxation, sleep hygiene, and occasionally give medicine. None of them will fix this by themselves. Sleep Restriction works well. Sleep Restriction is math.
If we have a fraction of 4/7 and what we want is that fraction to be closer to equaling one, but we can't change the numerator, then we have to change the denomenator. In other words, we have to decrease the amount of time in bed.
The solution is to tell Gretel to get earplugs to block out Aunt Witchy's noise. Then she needs to stop playing XBox so late. Third, her sleep schedule has to change to midnight to 5 a.m. This will eliminate both the insomnia at the beginning of the night as well as during the night.
At first she will still have the same insomnia, she will just have less sleep. However, after 2-4 days the pressure to fall asleep and stay asleep will overcome her insomnia disorder and she will fall asleep more easily and even if she wakes up she will return to sleep more easily. She needs to limit her sleep duration however to maintain an ongoing amount of sleep pressure over the next several weeks, thus the early morning awakening. When she is consistently falling asleep at midnight, not waking during the night and waking at 5 a.m. she will be getting 5 hours of consolidated sleep per night. This is much better than her 4 hours of fragmented sleep she was getting before. At this point she can start adding 30 min in the morning every 3-5 days alternating with 30 min in the night every 3-5 days until she is in bed 7 hours/night.
She can always repeat this protocol if she needs to do so. Typically, if a person has had do this protocol once there is a probability they will have to do it again. The good news is it is easier subsequent times.
Staying on a consistent sleep schedule it very important for people with insomnia.
An example would be:
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