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“O sleep, O gentle sleep. Nature’s soft nurse, how have I frightened thee.

That thou no more will weigh my eyelids down.

And steep my senses in forgetfulness?”

   - Shakespeare

 

 

     As a psychiatrist, I primarily address depression, anxiety, and other disorders of mood and thought.  Still, it may be that the most common complaint I hear is about disturbed sleep. I frequently find myself focusing on sleep problems before addressing depression and anxiety because, as I like to point out, it doesn’t matter what medication I give someone, they are not going to feel well if they are not getting restful sleep. Not only can insomnia impair cognitive function, productivity, and mood, it can kill you. Sure, it can increase risk of things like heart disease, stroke, and dementia, but it can also be acutely deadly. There is evidence that many fatal car accidents are likely caused by microsleeps, very brief episodes of sleep, that are just as dangerous as driving drunk.

 

     There are situations that negatively impact a person’s sleep quality that are very difficult to do anything about including significant chronic pain, unpredictable schedules, and some sleep disorders that are likely at least somewhat genetically programmed into the system. However, the majority of what causes sleep to be a problem has to do with habits, routines, and environment. 

 

     Sleeping well is a skill, and you can either be good at it or bad at it. Many of us grow up without being taught how to sleep well, without structure, routine, and good sleep habits becoming ingrained from the beginning. It is also possible to be pretty good at sleeping, but to have insomnia triggered by a stress or disruption of some kind that leads to a feedback loop in which poor sleep worsens mood, thinking, and functioning in ways that in turn worsen the sleep problem. A downward spiral of insomnia. 

 

     Like many things in the realm of psychiatry and neurology, it is easy to think about sleep as being a black-and-white issue. Many people simply tell me that they don’t sleep well and that they need a pill. There are instances in which a pill can be a helpful strategy in the short run, but if you require medication to sleep well, then some number of things are wrong with your sleep and it is important to investigate what they are and to develop strategies to address them. That is basically the approach utilized in what is called CBT-i, cognitive behavioral therapy that is specifically designed to address insomnia.

 

     The problem of insomnia is as complicated and unique as is each individual and requires real work, time, and practice to change. As I began to write about the topic of insomnia, I found that I had a lot to say. I decided not to spend time focusing on theory and sleep stages and EEG findings. I wanted to create something very practical; a guide for identifying sleep problems and doing something about them. These are the things I discuss and educate patients on every day. I’ve provided a lot of information and advice in this document, but if you just want to see the Cliff’s notes version, skip to the end. Let’s start with the most common complaint of all: “I can’t shut my mind off!”

 

     This is a problem referred to as psychophysiological insomnia. During the daytime, we have lots of distractions, many things to focus our concentration and attention upon. But at night, it is just you and your thoughts alone in the dark. Whether you find yourself going over relatively benign thoughts such as tasks that will need completed tomorrow, or you fall into terrifying scenarios and fantasies about all of the possible things that could go wrong (catastrophic cascades of internal narrative about financial ruin, illness, dangers lurking and threatening us and our loved ones), these thoughts activate our minds and bodies resulting in a fight or flight reaction that can be mild and almost imperceptible changes in heart rate, blood pressure, and muscle tension, or as profound as full-blown panic attacks.

 

     If I asked you to sit for a few minutes with your eyes closed, imagining somebody that you love in a car accident, even though you know this is not actually happening, you will begin to experience a physiological response. Your heart rate will increase, your palms will get sweaty, your stomach may feel upset. Our thoughts, our imaginations, trigger the same areas in the brain that the real life experience would affect. So the solution is to avoid getting lost in negative thoughts while laying in bed at night. Easy, right? Afraid not. 

 

     First of all, sometimes we have genuinely stressful, frustrating, even terrifying situations unfolding in our daily lives, and shutting off thoughts about them at night is going to be difficult no matter how skilled we are. Psychophysiological insomnia often happens when life is going along pretty well, we are trying to simply get a normal night of sleep, and yet our mind wants to find scary things to worry about. Ironically, sometimes it is the frustration of not being able to fall asleep, or even the fear of that possibility, that ends up causing the insomnia. It can be important to sort out whether or not someone is genuinely stressed, just prone to nighttime worries, or has an untreated anxiety disorder that may require medication and therapy. 

 

     The feeling of helplessness at being unable to control thoughts often leads to a habit of finding either sedation or distraction in another form. Taking sleeping pills, drinking alcohol, looking at our phones, turning on the TV, getting up to eat, smoking a cigarette. These are all strategies that I frequently hear about. Unfortunately they are trading one problem for a different problem. Sedation is not the same as sleep. Drugging the mind and body with central nervous system depressants and alcohol often leads to tolerance and worsened problems including rebound insomnia. Distractions like phone and TV stimulate the mind with light and sound. Eating increases metabolism which increases alertness, and of course things like caffeine and nicotine are stimulants that have the opposite of the desired effect. If you are struggling with sleep, you should drink no caffeine after noon, and should consider cutting it out altogether. So many people fall into the loop of sleeping poorly, then relying on excessive caffeine throughout the day to provide artificial energy. The effects of caffeine can last in the system for up to 12 hours after your last drink.

 

     Before even getting into bed at night, it is important to do as much as possible to set yourself up for successful sleep. You’d be surprised how many people tell me that they basically never leave the bed or couch throughout the day and then are frustrated that they are unable to sleep well at night. Some degree of physical activity is necessary to deplete energy enough to be able to get to sleep. Following a schedule is vital. The body works on rhythm. Getting to bed around the same time every night and getting up around the same time every day helps tremendously. You have to teach your nervous system what to expect when it gets into bed. We each have our own particular chronotype. This is the sleep/wake pattern that our individual systems and genetics are programmed to follow. Some people are night owls. Some are early birds. I often see patients whose insomnia stems from living a lifestyle that does not match their chronotype. 

 

     Another very important aspect of healthy sleep is to observe a wind down period prior to getting into bed. Many people seem to engage with busyness, frantic activity, or conflict with people in the home or online, then they get right into bed and expect to fall asleep. For at least an hour prior to bed you should be sitting somewhere other than your bedroom, in a comfortable position, with the lights down, watching TV or reading until you begin to feel good and sleepy. A frequently overlooked but very important strategy is getting things in order prior to the wind down period. If you get good and relaxed, but then you have to put your laundry for tomorrow in the dryer, find your phone charger, and clean up a few messes before getting into bed, that kind of ruins the point of the wind down. If you tend to worry or write to-do lists in your head at night, consider writing them down in a worry journal an hour of two before bed to purge them from your mind ahead of time. 

 

     If you get into bed every night and lay there in the dark worrying, that’s what your brain will come to expect. This is the reason that sleep restriction is important. If you lie down to go to sleep and after 20-30 minutes you are unable to shut down and drift off to sleep, you should get out of bed and remove yourself from that environment. The goal is for the brain to associate getting into bed with going to sleep, not getting into bed and worrying. You wouldn’t sit at a dinner table waiting to get hungry and you shouldn’t lay in bed waiting to get sleepy. Go watch something boring on TV or read until you feel tired and are ready to give it another try. This may take some time but eventually the habit and the association can form in the brain: bed equals sleep.

 

     When you are having difficulty shutting your mind off at night, it is important to have alternative options that do not cause things like addiction, stimulation, or tolerance. Counting sheep is always an option, but perhaps some better things to learn and practice might be meditation, progressive muscle relaxation, or guided imagery. Just like any skill, these strategies take time and effort to get good at. Think of meditation, an effort to focus attention on the feeling of breathing, as something similar to trying to walk on a balance beam. At first you will repeatedly fall off, meaning that you will find yourself back to being lost in negative thinking and worry. The goal is not to tell yourself that it isn’t working and give up, the goal is to notice you have fallen down, get back up on the beam, and keep at it over and over and over until you are able to remain on that beam, to remain focused in a calm state of mind long enough that the body and nervous system can enter sleep.

 

     None of this work is going to be very productive if it is being done in the wrong environment. So often people tell me that they are not sleeping well and upon some questioning I come to learn that they sleep on a broken down old couch, next to a dog that gets up four times per night, with noisy neighbors living upstairs and a street light blazing through the window, or some such unhelpful scenario. If you want to sleep well, you must sleep in a comfortable bed, in a room that is dark, quiet, and cool (ideal temperature is around 67°F). It can be reasonable to use white noise like a fan or nature sounds (rain, ocean waves) or possibly even one of the many podcasts designed to be soothing and boring to assist with sleep, but be cautious about stimulating the brain with sound. 

 

     I also sometimes hear people describe sleeping 8, 10, even 12 hours per night, yet still waking up feeling tired, achy, unfocused, unmotivated, and even depressed. This presentation always makes me question the possibility of something like sleep apnea. This is likely a highly underdiagnosed condition that can be relatively mild, or it can cause severe dysfunction and shave years off of someone’s life. It is more common in the case of obesity, when the weight of one’s body presses downward through the night making it more difficult to inflate the lungs or to clear the airway, but it can happen in someone of any weight depending on the structures of the neck. It can also be a case of what’s called central sleep apnea in which the problem is not the structure of the body but instead the signal that the brain is sending at night, telling the diaphragm to expand the lungs and to breathe. Sleep apnea can be diagnosed by undergoing a sleep study in a sleep lab overnight, but these days patients are sometimes able to undergo testing in their own homes. Using a CPAP machine and a mask to inflate the lungs throughout the night is sometimes necessary, but there are other interventions that can help as well. Treating sleep apnea can lead to a rapid and dramatic improvement in sleep, energy, focus, and overall quality of life.

 

     I do prescribe sleeping pills, but I always recommend that we use them temporarily to assist in making changes in sleep cycle and routines with the goal of eventually getting off of them and sleeping naturally. Sleep aids come in a variety of forms. The majority of over the counter medications such as Tylenol PM and Advil PM contain diphenhydramine, commonly known as Benadryl. Like many sleep aids, Benadryl is used for one thing (allergies) but also happens to be sedating. It is generally safe and non-addictive, but the sedating effect often does not kick in for several hours and can last well into the next day. It also tends to stop being sedating after frequent use, sometimes after only four or five doses in a row.

 

     Melatonin is also a very popular over the counter sleep aid. Our brains naturally release melatonin in response to external signals, primarily the decrease in sunlight in the evening and night. Unfortunately we are a darkness deprived society. Since the invention of artificial light, we tend to spend our days in offices where the lighting is weaker than sunlight, leaving us a little sleepy and unfocused, and then we spend our evenings and nights at home under lightbulbs and in front of screens when we need darkness to maintain our circadian rhythms. Exposure to natural sunlight in the morning and consciously dimming our lights in the evening can go a long way toward improved sleep. In the meantime, melatonin is a pretty safe option but it is not FDA regulated so there can be a lot of variability in the amount of melatonin that is actually in any given labeled dose. Users of melatonin commonly take between 3 and 10 mg nightly, sometimes higher, but studies indicate that 0.5 mg to 3 mg is enough to be effective but with less chance of causing some degree of resistance over the long term and decreasing our own natural production of the hormone.

 

     The medication that I most frequently prescribe for insomnia, if over the counter options don’t work, is trazodone. This is actually an antidepressant medication, but it tends to be so sedating that we use it as a sleep aid. It is cheap, non-addictive, and can potentially kill two birds with one stone by helping with mood problems as well as insomnia. I meet many people who take trazodone for years and years, and while that is probably not dangerous, I don’t consider it a great solution to a sleep problem. Patients are often prescribed as needed medications like Xanax when they are dealing with the anxiety caused by a crisis in their lives, and then sometimes they continue the medication for years, even after the crisis has resolved. Similarly, it is not uncommon to see people taking sleep aids long-term even though the initial sleep disturbance may have gone away on its own if given a chance. Now they are so used to taking a sleep aid at night that they have trouble sleeping without it. Medications like Xanax, Klonopin, and even Ambien should be avoided for any longer than a few days to a week at a time because of the potential for addiction.

 

     When I meet someone who has been struggling with sleep, and I provide a sleep aid, I often point out that they may find it to be heavily sedating initially, at least in part because they have built up a sleep debt that their body is aching to pay back. Using a sedating medication can cause a crash or a hangover. From the time that we wake up in the morning, the chemical adenosine is gradually building up in the body and the brain, creating what is referred to as sleep pressure, accumulating throughout the day and making us feel increasingly sleepy. During restful, restorative sleep at night, the brain is removing the adenosine from the body leaving us feeling refreshed and energized in the morning. If we don’t get enough sleep, the adenosine does not get completely removed and we start adding to the debt.  Unlike a loan or a credit card, you can’t just pay it back later and consider it even. Good sleep helps to foster neuronal growth and connections, memory consolidation, and cellular repair, and you don’t make up for that just by grabbing a few extra hours on the weekend.

 

     Studies seem to indicate that taking occasional brief naps, perhaps 15 to 30 minutes, early in the day (late morning or early afternoon) can restore energy without interfering significantly with sleep at night. But longer naps later in the day can act like a sleep pressure release valve, clearing away some of the adenosine that has built up through the day and removing the pressure to naturally fall asleep at night. Very often people who are struggling with insomnia have very little insight into how much or how little they are sleeping or when they are experiencing sleep disruptions, and therefore have difficulty forming a plan of attack. Gathering information is vital. There are many options on the market, from simple work sheets and sleep logs to electronic monitoring rings, bracelets, and even sleep studies performed in a lab that can help inform you and your doctor in the quest for better sleep.

 

     To sum it up, the factors that can negatively impact sleep are complicated, but the strategies for developing and maintaining natural, healthy sleep are relatively straightforward.

 

1. Keep it regular. The body likes rhythm so go to bed at the same time every night, get up at the same time every morning, weekdays and weekends.
2. Use light and darkness to help regulate your cycle. Expose yourself to daylight, even on cloudy days, in the morning and through the day as much as possible, and keep artificial light to a minimum in the evening and night.
3. Wind down for 1 to 2 hours before bed. Develop healthy and consistent sleep rituals such as preparing ahead of time for the next day and jotting down worries and concerns in a worry journal to purge them in the evening before getting into bed and focusing on them instead of sleeping. Keep lights and activity low. Make it easy to get directly into bed when you feel tired.
4. Practice sleep restriction. Don’t do anything in bed except for sleep and sex. Keep your bedroom dark, cool, and quiet. If you are not asleep in 20 to 30 minutes, get up and do something relaxing or boring and don’t get back in bed until you feel sleepy enough to drift off.
5. Don’t shoot yourself in the foot. Minimize caffeine and nicotine. Avoid alcohol and sleep aids if possible. Don’t eat prior to going to bed. Get physical activity in the day.
6. Consider options for tracking your sleep. There are various types of bracelets, rings, and other devices that can be used unobtrusively to monitor your sleep/wake cycle which can give you more information about the possible triggers and variables that are negatively impacting healthy sleep.
7. Give it time. Insomnia can be very frustrating and create feelings of helplessness and desperation. Becoming a good sleeper is like any skill, it takes time and practice. If your brain is capable of learning to play Uno or cook a steak or draw a horse, it is capable of learning to sleep well. It just requires developing a plan and sticking to it.

 

Good luck and good night•