Sleep Soundly Every Night, Feel Fantastic Every Day (13 page)

 

Our goal was to help Ally start again with sleep habits and rituals that supported her health. We began with sleep hygiene, stimulus control, and a cognitive behavioral therapy (CBT) technique called cognitive restructuring.

Ally was instructed to eliminate all caffeine including chocolate within 12 hours of bedtime. She was to refrain from looking at the alarm clock at night and put it in a place where she could hear it but not see it. Following the protocol, Ally removed the television from her bedroom, refrained from using any electronic devices within two hours of bedtime, and no longer did her work in bed at night. In fact, we wanted her to associate her bedroom with sleep and nothing else.

As part of stimulus control, we instructed her to follow this sequence:

1.
 
Not to nap during the day.

2.
 
Get into bed when truly sleepy.

3.
 
After 20 minutes, if wide awake, leave the bedroom.

4.
 
Go into another quiet room to read or listen to soothing music.

5.
 
Return to bed when she once again felt sleepy.

Ally was told to recognize and write down her numerous dysfunctional beliefs about sleep, such as,
“If I don't get enough sleep I'll be miserable. I know this is destroying my health. I must have at least eight hours of sleep to function. All my problems are due to my poor sleep.”

Next, she was to write and rehearse in her mind more positive modifications of these negative thoughts, such as,
“I've been through this before, and I'm able to function. I've had
this problem for a while and my health is excellent. I can't blame everything on my sleep. My doctor explained to me that we need five and one-half hours of what is called core sleep to function adequately. We may not feel great but we can function. He explained that most insomnia sufferers underestimate the time that they are actually asleep.”

It took a few months but she kept at it. We could see in her sleep diaries that she was falling asleep sooner and staying asleep. At first she went from five to six hours total sleep. In the end it was seven and one-half hours and she felt great.

There were minor relapses over the next few years, but she would then reinstitute the techniques she had been taught, and in very little time she would be back to seven to eight hours of quality sleep.

This is why we prefer CBT as opposed to medications for people such as Ally. CBT is a form of psychotherapy or counseling, with varied techniques to help you regulate the way you think, as well as behaviors. CBT is used for persistent insomnia as the primary disorder, as well as with coexisting disorders. CBT is long-lasting because it reverses the actual underlying behaviors, associations, and dysfunctional beliefs. Medications seem to work while being taken, but most people's problems return when medications are stopped. We'll discuss CBT techniques in more detail later in this chapter.

You also may be one of the 30% of the population with insomnia. This sleep disorder includes:

1.
 
Inability to fall asleep.

2.
 
Inability to stay asleep.

3.
 
Early morning awakenings and not feeling renewed or refreshed.

4.
 
Feeling as though your sleep is of poor quality or is nonrestorative.

These sleep patterns affect your ability to function each day. You may wake up tired and be less mentally alert. However, most insomniacs are not sleepy, which is more like feeling drowsy or tired. They are more likely to complain of fatigue, which is not the same thing. They feel as if they have no energy and have to push themselves to get things accomplished. Do you remember a scary night from your childhood in which you laid awake, still, and alert all night? That constant, vigilant state is hyperarousal that places the nervous system on an extremely taxing chronic alert. Imagine holding that tension for days, for weeks, and then for months. How many would be capable of functioning normally? In short, insomniacs hold such tension and thus suffer from frequent and severe fatigue.

Maria was a resilient woman who lost her mother at age 17. She stayed with her best friend and her family, graduated from high school, and hit the streets. After years with the wrong crowd, Maria finally found a good job with a strong, mentoring employer who sent her to college and helped her achieve healing with a therapist through the company's medical program. The street girl went straight, married a policeman, and presently has two children, Jenny, age four, and Matt, age two. She had already experienced the new mother's sleepless syndrome, by the time she came to see me.

“Doctor, I am here because I was diagnosed with a rare form of rheumatoid arthritis last week, and I haven't slept a wink since. I've already been to a nutritionist, understand this will be a life-long disease, and I worry. All night I pretend to talk to my husband while he snores away. Then I talk to my dead mother, and sometimes to God about what
will happen to me. What will happen to my children? The pain is supposed to get worse over the years … I need help. When I lie awake all night, I cry all day. My husband thinks I am going off the deep end, but I tell him it is just no sleep. No sleep and I cry. Thinking of my kids with no mom, I cry … can you help me?”

Maria's case is a classic example of transient, or acute adjustment insomnia. Maria was so anxious over her medical diagnosis that she could not sleep. This had been going on for less than a month so it had not yet become chronic. Maria was smart to come to the Sleep Disorders Center early on in her lack of sleep. She had not yet developed sleep-preventing behaviors such as napping during the day, excessive caffeine intake to stay awake, or clock watching in response to her inability to sleep, to mention just a few of the symptoms that would develop if her insomnia persisted, as Ally's had.

This is one of the situations where I provided a short-term use of an approved sleep medication. I gave Maria an initial two-week prescription for a sleep aid to use only if she was unable to fall asleep after several hours. Research has shown that restorative sleep does improve the physical and mental stressors Maria experienced. I also discussed sleep hygiene and bedtime relaxation techniques. I asked Maria to call me within two days to let me know how it worked for her. I also referred her to a therapist as it was obvious that more than just a sleep aid was necessary to help her cope long term with her diagnosis.

For patients like Maria, early intervention is incredibly important, which is why I let such patients clearly know that a short-term medication is step one of a larger coping process. If Maria continued to go without sleep, it was unlikely that therapy would be of much help. In fact, the acute condition was more likely to develop into chronic
insomnia associated with depression, a disorder which is very common in chronic pain disorders and much more difficult to treat.

Tom's primary care physician referred him to me for several reasons. Tom, an insurance agent who worked long hours, was overweight and had been waking up in the middle of the night for months. An inability to maintain sleep is a common symptom of insomnia. Tom's doctor wrote in his records that he had been unable to stay asleep for at least four months, had trouble focusing at work, and had great fear of a heart attack because of his lifestyle. Tom's wife had slept in a separate bedroom for some time due to Tom's snoring, so there was no one to observe Tom's awakenings or to verify any of his symptoms.

According to Tom, he woke each morning somewhere around 2:30 to 3:30 a.m. He reported waking up and feeling anxious. His mind would be racing and his thoughts frequently turned to work. In fact, he frequently took out his laptop and reviewed the next day's work. He was a smoker, and if working on the laptop did not ease his anxiousness, he would light up a cigarette, as it seemed to relax him.

After a while, Tom turned off the laptop and the lights to go back to sleep. It rarely worked. In fact, most of the time after waking at 3:00 a.m., Tom stayed awake in bed until 6:00 a.m. when he needed to get ready for work. Those early morning hours for Tom were grueling because of his racing mind.

His sleep habits on the weekend were no different except that he stayed in bed until 8:00 a.m. His anxiety rose in those early morning hours. His daytime mental abilities were foggy and unfocused. He was moody. Finally, Tom was so frustrated by the lack of sleep and the lack of results of
his efforts that he dreaded going to the bedroom. He had become so anxious about his inability to fall asleep that now he was having trouble falling asleep. His primary care physician was wise to send Tom to me first because sleeping well could turn his life around, and Tom was desperate to do so.

To determine Tom's problem, I needed to sort through several symptoms. Early morning awakenings had become a chronic problem with negative consequences such as fatigue and irritability. Tom had poor sleep hygiene such as caffeine intake, alcohol use, and staying in bed and doing work-related activities when unable to return to sleep. He also had an insomnia severity score of 27, which was consistent with very severe insomnia, and a General Anxiety Score (GAD-7) of 16, also high, and consistent with his reports of his racing mind. There was no indication of depression from his assessment.

After we'd identified the symptoms, my job was to sort through them and reverse the situation. The process was time-consuming, but the detective work is well worth the end result. Possibilities included a breathing disorder, sleep apnea, or a rapid eye movement (REM) sleep disorder.

To narrow things down, Tom first needed to work on his poor sleep hygiene and learn how he had developed the counterproductive habits. I explained

  
How the blue light from his laptop in the middle of the night would put an end to any chance of returning to sleep.

  
That the nicotine of his cigarette was a major stimulant promoting wakefulness.

  
That he could not make himself return to sleep, and the harder he tried, the more anxious and awake he became.

  
That lying in bed not sleeping was far worse than getting out of bed and doing something peaceful and soothing.