Sink into sleep : a step-by-step guide for reversing insomnia [Second ed.] 9780826148155, 0826148158

Table of contents :
Cover
Title
Copyright
Contents
Foreword
Preface
Acknowledgments
Part I: Hope
Chapter 1: Will This Book Help You?
The Techniques Work
Improvements are Faster than You Might Think
Yes, There are Some Possible Side Effects
Good Sleep Can Be Maintained
You are Not a Hopeless Case—There are No Hopeless Cases
You are Not Too Old to Start
There Probably Isn’t a Chemical Imbalance
You’ve Been Taking Sleep Medication. That’s Okay
You Have Other Health or Mood Issues. That’s Okay
Circumstances When this Book May Not Be Enough
Chapter 2: What Is Insomnia?
The Difference Between a Bout of Poor Sleep and Insomnia
You are Not Alone
Chapter 3: Common Concerns About Insomnia
Oh No, I’m Not Getting 8 Hours of Sleep! How Much Sleep Should I Be Getting?
Are We a “sleep-deprived Society?”
Does it Matter if We Don’t Get Enough Sleep?
Chapter 4: Sleep Hygiene: What It Is and Why You Probably Don’t Need It
Chapter 5: Sleep Therapy: What It Is and Why You Need It
Part 2: First Things First
Chapter 6: Measuring Your Sleep Problem—Keeping a Sleep Diary
A Note About Personal Electronic Sleep Trackers
Logging Your Sleep With a Sleep Diary
Julie’s Example
Your Turn
Chapter 7: What Type of Insomnia Do You Have?
Initial Insomnia
Multiple Awakenings
Middle Insomnia
Terminal (End-of-Night) Insomnia
More Than One Type
Your Sleep Quality
Moving On
Chapter 8: Knowing Your Numbers
Your Baseline Total Sleep Time
Your Baseline Sleep Efficiency
Julie’s Baseline Total Sleep Time
Julie’s Sleep Efficiency
Chapter 9: Things to Take Care of Right Away
Naps
Alcohol
Sleep Medication
Sleep Medication and Alcohol
Part 3: Solving Your Insomnia
Chapter 10: The Essential Elements of Sleep Therapy
Uncovering Your Natural Sleep Processes
Associating Your Bed With Sleep
Putting the Elements Into Action
Chapter 11: Starting Sleep Therapy
About Steps 5 and 6
You Should Know
Week 1
Chapter 12: Moving From Week 1 to Week 2: Adjusting Your Bedtime
The First Week is Done
What Sleep Efficiency Did You Achieve?
Adjusting Your Bedtime
How Did Julie Do?
Week 2
Chapter 13: Moving From Week 2 to Week 3: Readjusting Your Bedtime
The Second Week is Done
What Sleep Efficiency Did You Achieve?
How Did Julie Do?
Week 3
Chapter 14: After Week 3: Adjusting Your Bedtime Again. This Should Be It!
The Third Week is Done
What Sleep Efficiency Did You Achieve?
How Did Julie Do?
Your Overall Progress
Moving on From Here
Week 4 and Beyond
Chapter 15: Do You Still Have Insomnia?
Initial Insomnia
Multiple Awakenings
Middle Insomnia
Terminal (End-of-Night) Insomnia
Your Sleep Quality
Your Progress
Chapter 16: Maintaining Your Progress (And Maybe Even Improving More!)
Part 4: What to Do With Your Mind
Chapter 17: Calming the Racing Mind
The Racing Mind
Developing an Observer’s Mind
Chapter 18: It’s the Thought That Counts
Part 5: Sleep As You Gothrough Life
Chapter 19: Women’s Sleep
How Insomnia Starts
The Menstrual Cycle
Pregnancy
Delivery and Postpartum
As the Child Grows
Working For a Living
Menopause
Retirement
The Good News
Chapter 20: Men’s Sleep
Testosterone and Sleep
Sleep-Related Erections
Infant Care
Sleep Disorders
Aging
Work, Travel, and Sleep
Chapter 21: Nutrition, Exercise, and Sex
Nutrition and Sleep
Exercise and Sleep
Sex and Sleep
Part 6: Sleep In Special Circumstances
Chapter 22: Health Conditions
Chronic Pain
Heart Disease
Cancer
Seasonal Allergies
Being Overweight
Type 2 Diabetes
Digestive Discomfort
Breathing Problems
Kidney Disease
Neurological Disorders
Is CBT-I Always Helpful When We Have Medical Problems?
Chapter 23: Depression, Anxiety, and Traumatic Stress
Depression
Anxiety
Traumatic Stress
Part 7: Sleep Substances
Chapter 24: Sleeping Pills
Prescribed Sleep Medication
All Together
Chapter 25: Over-the-Counter Sleep Aids, Herbal Remedies, and Cannabis
Over-the-Counter Sleep Aids
Natural Health Products
Cannabis
Part 8: Useful Background Information
Chapter 26: Sleep Stages and Their Measurement
Sleep Stages
Sleep Cycles
Sleep Stage Composition of a Night’s Sleep
Sleep Measurement Techniques
Personal Electronic Sleep Trackers
Afterword Good Luck and Good Night
Index
Bibliography

Citation preview

SINK I NTO SLEEP SECOND EDITION

A S T E P - BY- S T E P G U I D E FOR REVERSING

INSOMNIA

J u d i t h R . D av i d s o n , P h D , C P s yc h

SINK INTO SLEEP

SINK INTO SLEEP A Step-By-Step Guide for Reversing Insomnia SEC ON D E D IT ION

Judith R. Davidson, PhD, CPsych

An Imprint of Springer Publishing

Copyright © 2021 Judith R. Davidson Demos Health is an imprint of Springer Publishing Company, LLC. All rights reserved. First Springer Publishing edition 2013 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the Web at www.copyright.com. Cover illustration: Sky photo on cover and Author photo by Aïda Sulcs. Springer Publishing Company, LLC 11 West 42nd Street, New York, NY 10036 www.springerpub.com connect.springerpub.com/ Acquisitions Editor: Beth Barry Compositor: Amnet Systems ISBN: 978-0-8261-4815-5 ebook ISBN: 978-0-8261-4816-2 DOI: 10.1891/9780826148162 20 21 22 23 24 / 5 4 3 2 1 Medical information provided by Demos Health, in the absence of a visit with a health care professional, must be considered as an educational service only. This book is not designed to replace a physician’s independent judgment about the appropriateness or risks of a procedure or therapy for a given patient. Our purpose is to provide you with information that will help you make your own health care decisions. The information and opinions provided here are believed to be accurate and sound, based on the best judgment available to the authors, editors, and publisher, but readers who fail to consult appropriate health authorities assume the risk of injuries. The publisher is not responsible for errors or omissions. The editors and publisher welcome any reader to report to the publisher any discrepancies or inaccuracies noticed. Library of Congress Cataloging-in-Publication Data Names: Davidson, Judith R., author. Title: Sink into sleep : a step-by-step guide for reversing insomnia / by Judith R. Davidson, PhD, C.Psych. Description: Second edition. | New York, NY : Springer Publishing Company, LLC, [2021] | Includes bibliographical references and index. | Identifiers: LCCN 2020031379 (print) | LCCN 2020031380 (ebook) | ISBN 9780826148155 (paperback) | ISBN 9780826148162 (ebook) Subjects: LCSH: Insomnia—Treatment. | Sleep disorders—Treatment. Classification: LCC RC548 .D38 2021 (print) | LCC RC548 (ebook) | DDC 616.8/4982—dc23 LC record available at https://lccn.loc.gov/2020031379 LC ebook record available at https://lccn.loc.gov/2020031380

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For Rick

Contents

Foreword  Helen S. Driverix Prefacexi Acknowledgmentsxv HOPE

1. Will This Book Help You?

3

2. What Is Insomnia?

11

3. Common Concerns About Insomnia

15

4. Sleep Hygiene: What It Is and Why You Probably Don’t Need It

21

5. Sleep Therapy: What It Is and Why You Need It

23

FIRST THINGS FIRST

6. Measuring Your Sleep Problem—Keeping a Sleep Diary

27

7. What Type of Insomnia Do You Have?

37

8. Knowing Your Numbers

43

9. Things to Take Care of Right Away

49

SOLVING YOUR INSOMNIA

10. The Essential Elements of Sleep Therapy

57

11. Starting Sleep Therapy

65 vii

viii

Contents

12. Moving From Week 1 to Week 2: Adjusting Your Bedtime

71

13. Moving From Week 2 to Week 3: Readjusting Your Bedtime

83

14. After Week 3: Adjusting Your Bedtime Again. This Should Be It!

91

15. Do You Still Have Insomnia?

99

16. Maintaining Your Progress

103

WHAT TO DO WITH YOUR MIND

17. Calming the Racing Mind

111

18. It’s the Thought That Counts

119

SLEEP AS YOU GO THROUGH LIFE

19. Women’s Sleep

129

20. Men’s Sleep

143

21. Nutrition, Exercise, and Sex

149

SLEEP IN SPECIAL CIRCUMSTANCES

22. Health Conditions

159

23. Depression, Anxiety, and Traumatic Stress

171

SLEEP SUBSTANCES

24. Sleeping Pills

183

25. Over-the-Counter Sleep Aids, Herbal Remedies, and Cannabis

191

USEFUL BACKGROUND INFORMATION

26. Sleep Stages and Their Measurement

199

Afterword: Good Luck and Good Night205 Index207 Additional Resources (see below for online access information) Extra Forms Bibliography

Additional Resources: the Extra Forms and Bibliography can be accessed by visiting the following url: http://connect.springerpub.com/content/book/978-0-8261-4816-2

Foreword

hen you can’t sleep, everything matters. This book by my colleague and friend Dr. Judith Davidson provides insight for those seeking the ability to sink into W sleep. Dr. Davidson has specialized in the field of insomnia for more than 20 years. Judith never rests on the topic of sleep; she continues to deepen her knowledge in the field, all the while sharing her expertise with her patients, her peers, and students. It has been a pleasure to work with, and learn from, Judith over the years.

Judith’s extensive clinical, research, and teaching experience has enabled her to provide insomnia sufferers with a practical guide to sleeping well. Insomnia is a significant burden to individuals, their family, and society, affecting approximately 20-25% of adults three or more times a week. Sink Into Sleep encapsulates that knowledge in her own gracious style, providing insomnia sufferers with powerful techniques for overcoming their own late-night struggles. Judith begins by clearly and succinctly describing the biology underlying sleep processes, giving the reader the basic understanding that is necessary to master the techniques of satisfying sleep. Age, being female, and genetics are known risk factors for insomnia, and each of these topics is discussed in this book. She also addresses key influences, such as the impact of various conditions including chronic pain, depression, cancer, and heart disease, as well as breathing disorders and movement disorders. Although the book focuses on nonpharmacological treatment for insomnia, Dr. Davidson also outlines the pros and cons of sleep medications. In the second edition, recognizing the pillars of health along with sleep, she has included a chapter on nutrition and exercise, as well as sex. Updates in research and current hot topics encompass sections on traumatic stress, orexin, and cannabis.

ix

x

Foreword

From laying the foundation by describing biological sleep processes and cognitive therapy, Judith guides the reader through 6 steps to solid sleep. The techniques she describes are grounded in research and evidence-based outcomes. The tools that she provides enable readers to self-monitor and measure their weekly progress toward optimizing their sleep. In one of her anecdotes, a man describes regaining sleep as being tapped by a “velvet hammer”: Judith’s calm, considered approach allows sufferers to beat the desperate frustration of seemingly perpetually elusive sleep. For once, I am grateful when a book puts me to sleep, and I hope Sink Into Sleep does the same for you. Helen S. Driver, PhD, RPSGT, DABSM, CCSH Past-President, Canadian Sleep Society (CSS) Manager, Sleep Disorders Laboratory and EEG & EMG Services Kingston Health Sciences Centre and Department of Medicine Queen’s University Kingston, Ontario, Canada

Preface

y career began in a sleep lab. I was hired in 1981 by Dr. Harvey Moldofsky to work in the sleep clinic at Toronto Western Hospital. A year earlier, I had taken M a fascinating course called The Psychology of Sleep, taught by Professors Alistair

MacLean and John Knowles at Queen’s University. This course inspired me to apply to every sleep laboratory I could locate. At that time, sleep labs were few and far between, and so I was fortunate to land a job in one. I was involved in all of the day and night activities of the sleep lab, which included hooking people up with electrodes and putting them to bed so that we could see if they had a sleep disorder such as sleep apnea, periodic limb movements, narcolepsy, or unusual behaviors during sleep. We also did research studies with volunteers who agreed to have their brain waves and blood studied so we could look at the effects of sleep and sleep deprivation on the immune system. I realize now just how much I learned back then in that lab. That experience turned out to be my stepping stone to many more years in the ever-expanding world of the science of sleep. I have never strayed far from sleep. My master’s thesis focused on the effects of sleep deprivation and naps on people’s performance and mood. My PhD thesis was done with cancer patients. I surveyed 1,000 people with cancer about their sleep. About one-third of them reported sleep difficulty that affected their daytime functioning. By matching up the types of insomnia and the reported reasons for the sleep difficulty to the best available techniques, I developed a Sleep Therapy program for cancer patients. The program worked well to restore people’s sleep; it also helped to reduce their fatigue. This was very encouraging. I then had the privilege of being a postdoctoral fellow with Dr. Charles Morin, a world leader in the field of insomnia, in Quebec City. Following that fellowship, I had a private psychology practice for a time, and then worked for a decade in an interdisciplinary family practice setting. I provided Sleep Therapy to people of all descriptions and health circumstances. xi

xii

Preface

Over the years it has become very clear to me that certain techniques reverse insomnia, regardless of whether we have cancer, chronic pain, heart disease, depression, anxiety, or any other human ailment. Dealing with insomnia when you have other health issues is just a variation on dealing with insomnia when that is your only problem. These days, I focus on connecting people who have insomnia to effective treatments so they can sleep well, and so they know how to maintain their good sleep. A big part of this is boosting access to effective treatments, through the training of professionals, and informing people about the techniques. That is why I have written this book. It is my sincere hope that this book provides you with what you need to sleep well. Be encouraged, even if you have had insomnia for many years, that the techniques that I will show you have been scientifically studied for years and they are effective for improving sleep. In fact, together, they are the best treatment for persistent insomnia. One of the main concepts of this book was inspired by an encounter I had years ago with a gentle, elderly man at a cancer center. When I asked about his sleep, he told me that during his cancer treatments, he had weeks and weeks of sleepless nights. However, just after the series of treatments ended, a wee angel had swept down and knocked him tenderly on the head with a velvet hammer, restoring his sleep from that point onward. I will not forget the twinkle in his eye and the smile that stretched from ear to ear. Sleep had found him. Indeed, sleep is something that we cannot actively search for, because in doing so, it evades us. Trying too hard to control sleep pushes it away. Rather, we can make the circumstances favorable for sleep, and then involve our minds in other things, and be delighted when it comes. This is the “velvet hammer” concept. The techniques in this book are designed to let your internal sleep–wake rhythms operate naturally, without interference. By relying on them, rather than over-thinking or trying to control sleep, you too will find that something changes, allowing the velvet hammer of sleep to descend. Since the publication of the first edition of Sink Into Sleep, I have heard from many people with insomnia and also from clinicians—physicians at sleep centers, family physicians, psychologists, social workers, psychiatrists, pharmacists, and trainees in these professions. I’m so glad that many people are finding the book to be valuable. I have received questions from readers, such as what to do if sleep restriction does not seem to be helping and how long to keep using it; I have heard from clinicians that more cognitive therapy content would be helpful. For this second edition, I have kept all this feedback firmly in mind. The first sections of Sink Into Sleep that guide you in using cognitive behavioral therapy for insomnia (CBT-I) have been updated, and I specify the possible side effects of sleep restriction therapy and the time limits of its use. I have added a new chapter devoted to cognitive therapy (Chapter 18). Chapters 19–25 provide evidence-based information on sleep in men and women, health conditions, mental health, and sleep medications. These have been extensively updated, based on the scientific literature

Preface

xiii

that has emerged since the first edition. There is a brand new chapter on sleep in relation to nutrition, exercise, and sex, viewing healthy sleep in the context of a healthy lifestyle. CBT-I is increasingly recognized as the most effective and safe treatment with lasting positive effects for persistent insomnia. Since the first edition of Sink Into Sleep, several professional bodies have reviewed the scientific evidence and pointed to CBT-I as the first-line treatment for chronic insomnia disorder, among them the American College of Physicians and the European Sleep Research Society. Guidelines specify that CBT-I should be the main intervention and that sleep medication be considered adjunctive or second-line. It would be nice to have in-person CBT-I available at every street corner, however access remains limited. I hope that Sink Into Sleep provides all the sleep information you are looking for and allows you to gain all the benefit that CBT-I has to offer. Judith R. Davidson P.S. The names and characteristics of individuals described in this book have been altered. P.P.S. The bibliography for the second edition was so big that we decided to put it online. I invite you to to view the research on which the information in this book is based. It is available on Springer Publishing Company ConnectTM and can be accessed by visiting the following url: http://connect.springerpub.com/content​/ book/978-0-8261-4816-2.

Acknowledgments

or the second edition of Sink Into Sleep, thank you to Brenda Bass for reading all the chapters as they came off my desk as drafts. David Gardner, Professor of PsyFchiatry and Pharmacy at Dalhousie University, thoroughly reviewed the chapter on

sleeping pills, and I have incorporated many of his suggestions. Thank you very much, David. I enjoy collaborating with members of the Queen’s Family Health Team in their provision of CBT-I to patients. Erin Desmarais and Cynthia Leung have been wonderful, and I thank them for reviewing the new cognitive therapy chapter and for valuable feedback on sleeping substances. Helen Driver and Eileen Sloan reviewed the updated women’s sleep chapter; I so appreciate your expertise. From Queen’s University, I want to acknowledge Wendy Craig, former Head of the Department of Psychology, and Tess Clifford, Director of the Psychology Clinic at Queen’s for their support of my academic pursuits and clinical supervisory activities. I wish to thank Caroline Pukall for her suggested readings on sex and sleep. At the Sleep Therapy Service, I am very fortunate to work with bright, capable, hard-working graduate students who inspire me all the time. For their recent contributions to the clinic, and for advancing the quality and accessibility of CBT-I, I thank Robyn Jackowich, Madelaine Gierc, and Katherine Fretz. Thank you to Aïda Sulcs, my friend, for the photographs. My husband, Rick Beninger, provided helpful comments on several chapters. Thank you, Rick, for your important feedback, kindly given. I greatly appreciate the support of this edition from Beth Barry, Publisher, and Jaclyn Shultz, Associate Editor, at Springer Publishing Company, Demos Health. Once again, my running friends have kept me moving and laughing throughout another year.

xv

HOPE

CHAPTER 1

Will This Book Help You?

ou may be at your wits’ end, thinking that you have tried everything to sleep better, and nothing has really worked. Or you may be optimistic, believing that there Y are things you have not yet tried that may improve your sleep. Or you may be some-

where in between. Wherever you are, it’s perfectly fine to be there. The strategies in the next chapters work even, or especially, if you are a bit skeptical to begin with. If you are “at your wits’ end”—hang in there. Just by opening this book, you are demonstrating hope and a belief that things can change for the better. All that’s needed is having your mind open to the possibility that your sleep will improve. However, you don’t need to be gung ho about it. In fact, it is better if you are relatively relaxed and take somewhat of an observer stance. If you are thinking, “That’s not me! I can’t relax,” take a deep breath and consider the notion that your body and mind do have the capacity for good sleep, and that by using some specific techniques, you will encounter evidence of this. If you are “optimistic”—then, good for you! Keep that style of thinking. You can use your energy and enthusiasm to design your own sleep program. You need to have a bit of patience, though, as this is not an overnight fix for your sleep. Rest assured that you will see positive results as you consistently apply the techniques. If you are “somewhere in between”—not completely discouraged and not overly enthusiastic—you may be in the best position to benefit from sleep strategies. You have the energy to try some things, but in a somewhat experimental way, with an 3

Sink Into Sleep

4

ability to work with “what is” and an openness to discovering how sleep therapy works and to identifying the techniques that work best for you. THE TECHNIQUES WORK Years of research have revealed that certain techniques reliably lead to improved quality and quantity of sleep and increased satisfaction with sleep. Together these techniques can be called “cognitive behavioral therapy for insomnia,” which I will now call CBT-I. In the mid-1990s two important reports were published on these techniques. These reports were based on meta-analyses. In a meta-analysis, the research data from many studies of a given treatment are carefully combined to provide the overall story on the treatment’s usefulness. In these particular meta-­analyses, the authors reviewed studies that had compared CBT-I techniques with no treatment or with a placebo treatment. These two meta-analyses were carried out independently, one in North America and one in Australia. It was exciting when the results came out (they were published within months of each other). The reports reached similar conclusions: CBT-I produced significant improvements in sleep for people with insomnia. With CBT-I, people fell asleep faster, were less likely to wake up during the night, and had a longer nightly sleep duration. More exciting was the evidence that sleep improvements were well maintained, and sometimes enhanced, 6–8 months after people had learned the techniques. Since then, many more reviews and meta-analyses have confirmed that there is sound scientific evidence for the effectiveness of CBT-I techniques. The recent body of research tells the same story, that people with persistent insomnia who use the techniques reduce their time to fall asleep, their awakenings during the night, and their time awake in bed. They get more solid, satisfactory sleep. Because of its proven effectiveness, medical guidelines in North America and Europe now recommend CBT-I as the first-line treatment for persistent insomnia, above any sleep medication. That means it is the first-choice, standard treatment. We also now have more evidence that CBT-I’s benefits are not limited to research facilities: it works very well when provided by nurses, psychologists, or other health professionals in real-life clinical settings, like family doctors’ offices. Furthermore, we now have confirmation that people who do self-help CBT-I, by following a program like the one in this book, improve their sleep significantly. They fall asleep faster, sleep more solidly during the night, and experience enhanced sleep quality. People tend to like these techniques, preferring them to sleep medication. In sum, the evidence is consistently positive for the effectiveness of CBT-I. It is high time that these techniques were widely accessible to people who need them. IMPROVEMENTS ARE FASTER THAN YOU MIGHT THINK Many people who need these techniques do not know about them. Family physicians are the health professionals who most often hear about sleep problems. But family physicians are very busy people; they usually do not have the time to learn or to support patients with sleep treatments other than drugs. They sometimes

Will This Book Help You?

5

prescribe sleeping pills, also called hypnotic medication. Hypnotic medication is good for the short term only, up to 4 weeks. This book will show you how to deal with and overcome your insomnia if you have insomnia that has lasted longer than 4 weeks. The approaches I will introduce you to don’t work overnight. However, it does not take long to see improvements in your sleep with CBT-I. Most people in the clinic start sleeping better within 2 weeks of trying the techniques. After discovering the strategies that work best for their situation, they simply fine-tune them. The vast majority of people who use these techniques no longer have insomnia after 5 weeks. Perhaps 5 weeks will feel like a small investment of your time given the benefits of good sleep for years ahead? You are about to find out. YES, THERE ARE SOME POSSIBLE SIDE EFFECTS Although CBT-I is the best and most durable treatment we have for insomnia, it can have side effects. When people carry out “sleep restriction therapy,” which is a component of CBT-I, they sometimes experience excessive sleepiness, reduced vigilance, and slowed reaction time. These effects are especially likely to occur at the beginning of the program, and they disappear when sleep is no longer restricted. If the notion of sleep restriction sounds awful to you, it may help to know that this is not total sleep deprivation by any means. The technique is designed to limit the degree of sleep restriction to what has already been occurring with your insomnia. Sleep restriction therapy is also meant to be used for a short time (usually 2–4 weeks), and should not be continued if your sleep has not improved substantially in that time. When we get to the chapters that involve sleep restriction therapy, I will be reminding you to avoid driving or other dangerous activities when you are sleepy. GOOD SLEEP CAN BE MAINTAINED There is evidence that by using CBT-I approaches, people not only maintain their good sleep over time—the current research has followed people up to 2 years—but they often see their sleep continuing to improve! My experience is that once people understand their sleep problem and identify the combination of simple strategies that works for them, they remember and use these strategies when faced with occasional sleep difficulty months and years later. By doing so, they prevent relapses into full-blown insomnia. Let me now address a few concerns that are quite common when people first consider CBT-I. YOU ARE NOT A HOPELESS CASE—THERE ARE NO HOPELESS CASES People sometimes feel that their particular case of insomnia is hopeless. This idea is expressed by people who have had poor sleep for many years despite having tried “everything.” First, let me say that even if you have had long-term insomnia, these techniques still work. The research results are somewhat unclear about

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6

whether or not you will take a bit longer to improve your sleep, but is very clear that you will still benefit. In some of my research with insomnia expert Charles Morin, people arriving at his clinic had been experiencing sleep difficulty for an average of 11 years! It is not uncommon for people to arrive at our Kingston clinic with insomnia that began decades ago, for example, when they were studying for exams as a young adult or when they had a baby who is now grown-up. People whose insomnia had persisted for many years have used these techniques very successfully. Many people who come to the clinic have already tried various strategies to obtain better sleep. Usually they have tried very reasonable approaches like avoiding caffeine, having a warm bath in the evening, using relaxation apps, listening to music, doing yoga, getting cardiovascular exercise to tire themselves out, stretching, avoiding stimulating activities in the evening, and turning off their electronic devices an hour before bed. They also have tried strategies while in bed trying to sleep, like counting sheep, deep breathing, listening to music, turning on a fan for white noise, and so on. One person was convinced that slowly stretching the whole body just before sleep, like a cat, promotes sleep. However, I have noticed that cats tend to stretch after rather than before sleeping. (To be like a cat we would need to make three turns before settling down and then spend a few moments licking our feet!) Although such strategies may be helpful, they do not cure chronic insomnia. They may be helpful for people when they are feeling stressed and have situational insomnia, but research has shown that they are not enough to reverse persistent insomnia. Many of the strategies of CBT-I are not yet well known but that will soon change. The effective strategies are the ones that I will introduce you to in the chapters ahead. YOU ARE NOT TOO OLD TO START This is not just an approach for young people. There is abundant evidence that middle-aged and older adults with insomnia benefit from CBT-I and that the beneficial effects endure. As we age we are more and more likely to have difficulties sleeping through the night. CBT-I improves sleep quality and reduces time awake during the night. We have seen people in their 80s successfully improve their sleep with CBT-I. It is safer than using sleeping medications. Sleeping pills can cause side effects that are particularly worrisome for older people, including memory problems, unsteadiness, falls leading to broken bones and other injuries, impaired driving, and addiction to the medication. THERE PROBABLY ISN’T A CHEMICAL IMBALANCE The body, including the brain, shows signs of “hyperarousal” with insomnia. For example, there may be increased levels of the hormone cortisol, increased heart rate, and increased strength of high-frequency brain waves. However, these are correlations rather than cause-and-effect relationships. The cases where a chemical imbalance in the brain produces persistent insomnia are rare. Although insomnia

Will This Book Help You?

7

can accompany illness, there are not many conditions that directly and specifically cause insomnia through a chemical imbalance. The closest thing might be a disease called “fatal familial insomnia,” which causes an inability to sleep. This is a genetically inherited prion (infectious protein) disease. The incidence of this disease is so rare that it is not documented; it is definitely less than 1 in 100,000 and probably less than 1 in 1 million. If you have this disease, you would have already turned yourself over to physicians for help. So, if you are reading this book, chances are that your sleep difficulty is not caused by a chemical imbalance. It is more likely related to factors that I outline in the chapters ahead and will therefore respond to CBT-I. YOU’VE BEEN TAKING SLEEP MEDICATION. THAT’S OKAY Research shows that the same CBT-I techniques work regardless of whether you are taking sleeping medication or not. Based on what we see in the clinic, people who take prescribed sleeping pills occasionally, or on fewer than half the nights in a week, reduce their use of sleep medication gradually over a few weeks as they use CBT-I and discover that they can sleep without the medication. It is a bit different for people who have been taking sleeping medication every night for several months or years. If you are one of these people and are reading this book, it means that you are not entirely happy with your sleep and therefore your nightly use of sleeping pills is no longer helping. In this case, I encourage you to consider slowly withdrawing from the medication in consultation with your family physician and/or pharmacist. Longterm use of sleep medication can lead to tolerance (needing more of the drug to get the same effect) and dependence (not being able to sleep without the medication). If you are ready to discontinue sleep medication that you’ve used nightly for several months, it is of utmost importance that you do so in a gradual and planned way with medical guidance. This means over weeks or months. Otherwise there will be uncomfortable withdrawal symptoms including much-worsened insomnia. You can do CBT-I as you follow a medication tapering schedule designed by your pharmacist or physician. You will thereby be immediately learning sleep techniques that will replace the need for medication. YOU HAVE OTHER HEALTH OR MOOD ISSUES. THAT’S OKAY If you are a normal human being, you have other problems besides trouble sleeping. Research shows that CBT-I is useful even if you have some mild to moderate symptoms of anxiety or depression or some long-lasting medical problems like chronic pain or cancer. In fact, there is some evidence that people with coexisting health or mood conditions show greater improvements in their sleep with these techniques than do people who have “just” insomnia! Chapters 22 and 23 will describe how to tailor your program to your situation. All that being said, there are some specific circumstances in which this Sleep Therapy program may not be enough to help your sleep.

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Sink Into Sleep

CIRCUMSTANCES WHEN THIS BOOK MAY NOT BE ENOUGH If you are severely depressed and have not received any treatment yet, you need to visit your family physician and get advice on the best available treatment. By severely depressed, I mean feeling so low that you are having difficulty getting out of bed every day, not functioning as usual, not able to go to work, or feeling hopeless or suicidal. You should know that support is available and that there are effective treatments for depression, some involve medications, and some involve psychotherapy (e.g., cognitive behavioral therapy or interpersonal therapy). Your family physician is the first person to talk with about the options in your community. Another situation in which you may need special support and assistance is bereavement. If someone close to you has recently died, then you are likely to be grieving and this needs time and special attention; it is not the best time to do this program. If you have experienced or witnessed an extremely traumatic event that has left you feeling vulnerable and jumpy, distressed or detached, and you have intense recollections, flashbacks, or nightmares related to the trauma, then you need to receive support from someone who understands trauma. That being said, recent research indicates that you can benefit from CBT-I, so it is really up to you whether you do CBT-I now or later. In any case, I recommend that you also have support from a counselor or therapist with expertise in trauma. If you need alcohol or other non-prescribed substances or drugs in order to get through the day, or if your use of these substances is interfering with your day-today functioning, then the CBT-I techniques will probably not be appropriate for you. That is because most, if not all, recreational drugs affect sleep directly and compromise people’s ability to follow this program. If you are a smoker, the CBT-I techniques will probably help your sleep. However, I recommend for your own health and well-being that you consider a smoking cessation program. There is support in your community; start with your family physician or your local health unit. I would not recommend that you try to stop smoking or any other psychoactive substance at the same time as taking this sleep program. Changing one behavior at a time is much more manageable. If you are troubled by obsessions (have difficulty letting go of certain thoughts, impulses, or images—ones that go around and around in your head or that pop into your mind when you don’t want them there) or by compulsions (feeling compelled to do certain things over and over before you feel comfortable, such as checking, counting, pairing things up in your mind, washing your hands many more times than needed), you should know that there is help for these obsessive-compulsive symptoms. It would be wise to receive help for them first, before following this CBT-I program. Your family physician would be the place to start if you have not already received help. If there is a medical condition that directly causes the insomnia, for example, untreated hyperthyroidism or acute, unrelenting pain due to a bone fracture or

Will This Book Help You?

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injury, then the insomnia will likely continue until the condition is treated or controlled. Also, certain medications such as corticosteroid medication can cause sleeplessness. If your insomnia started around the time of a new medication and it persists only with the medication, then discuss this with the physician who prescribed that medication, your family physician, or your pharmacist. They may suggest alterations to the dose, timing, or other factors that will allow you to return to good sleep. Sometimes other sleep disorders masquerade as insomnia. These other sleep disorders have treatments of their own. Periodic limb movement disorder is a problem in which the person’s legs twitch or make small jerks repetitively during sleep. This can disrupt sleep even if the person is unaware of the movements, and can cause an unsatisfying, light sleep. Many people who have restless legs syndrome—a restless feeling in the legs that urges them to walk or move around—also have periodic limb movement disorder. Sleep apnea is another fairly common sleep disorder, which involves loud snoring and a cessation of breathing for repeated periods of at least 10 seconds. This sleep disorder, especially when severe, can disrupt sleep, cause daytime sleepiness, and affect how you function at work, school, or home. Sleep apnea needs to be treated so you can feel better. Treatment starts with visiting your family physician. They may refer you to a clinical sleep laboratory. There are effective treatments for these sleep disorders so it makes good sense to receive help for them. You can always come back to this CBT-I program if you still have insomnia after you have received help for the other sleep disorders. By the way, there is NO NEED to go to a sleep laboratory if insomnia is your only sleep problem; that is, if you and your physician do not suspect another type of sleep disorder. You will probably not sleep in the lab—a finding that will confirm what you already know! There is another sleep–wake disorder called delayed sleep phase syndrome. This occurs when people’s internal 24-hour rhythm of sleep and wakefulness is delayed compared to what they wish it were. These are people who have always been “night owls” and had trouble getting up in the morning. Young adults are more likely than middle- and older-aged adults to experience this. If they had their choice, they would have a late bedtime (e.g., 2:00 a.m.–6:00 a.m.) and a late wake time (e.g., 10:00 a.m.– 2:00  p.m.). When they can sleep at their preferred times, their sleep is normal. However, when they try to conform to usual school or work hours, they run into problems. They go to bed earlier than is natural for them, they take a long time to fall asleep, and they have great difficulty getting out of bed in the morning, even with several alarms. If this sounds like you, you will be more likely to benefit from a technique designed to advance your sleep rhythms than from CBT-I. A professional at a sleep clinic with expertise in the treatment of circadian rhythm disorders will be able to help you. This usually involves carefully scheduled exposure to bright light. If you are under a lot of pressure right now due to continuing stress at work or at home, or if there is an ongoing conflict, you may want to seek support with these specific issues from a good counselor. If these issues are not resolved or at least

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stable, they may overwhelm your body’s ability to benefit from CBT-I just now. If you travel frequently to different time zones, then some of the most powerful strategies will not be easy to carry out, so it is best to start this program when you are based at home. Insomnia is very common among shift workers. Most shift schedules place a demand on your sleep–wake system. Some of these involve too much variation in your sleep timing for the techniques in this book to solve your sleep problem. This is true if you are currently working rotating shifts that require you to have very different bedtimes and rise times (for example, having to change your bedtime by 4 hours or more) within a 2-week period, or if you work permanent nights and you then revert to being awake during the day on your days off. These types of shift schedules are hard on the body and the mind, so look after yourself well. It is best to get help from an organization or circadian rhythm specialist with shift-work expertise. From them, you can learn strategies for sleeping as well as possible, and for maintaining other aspects of good health such as nutrition, exercise, recreation, connections with family and your community, when you have shifting work and sleep schedules. For other types of shift work where there are no overnight shifts (for example, you move between day and evening shifts) and you can have a fairly stable bedtime and rise time, then the techniques in this book should be helpful for you. Finally, if you have too hectic a schedule that does not allow you time to focus on the program for a few minutes each day, then you may want to delay starting this program to a time when you can maximize your success with the strategies. If all the issues in this section are either not relevant to you, or you have dealt with them, then it is time to move ahead into your insomnia treatment program! Let’s start with some information about insomnia.

CHAPTER 2

What Is Insomnia?

t is normal to have a bout of poor sleep, light sleep, or seemingly no sleep at all under certain conditions. For example, if we have just lost someone due to illness, Ideath, divorce, or a relationship break-up, we will no doubt lose sleep. If there is

conflict with people at work, too much work, difficult decisions to be made, arguments at home, or worries about children, we are bound to lose some sleep. If we have been exposed to trauma or dangerous situations where we feared for our lives, then we are also likely to lose sleep or have a light, vigilant sleep. If we are thinking too much—studying, cramming for an exam, trying to solve complex problems—we may lose sleep. If we travel to another time zone, our sleep will take some days to adjust (this is “jet lag”). We usually have poor sleep on the first night in a strange bed (the so-called “first-night effect”). If we are head over heels in love, then we are sometimes so excited that we hardly sleep. When we have babies, who of course require care and feeding at night, we get very little sleep for several months. These are just some examples of situations when it is normal to not sleep well. The times when we are temporarily sleepless will depend to some extent on our individual predisposition to sleep disruption, our experience, and the aspects of life that stress us. For example, if job interviews stress you, as they do most of us, then it would not be surprising to have a poor night of sleep in anticipation of the interview. When you look at these examples of sleepless nights from a biological perspective, it makes perfect sense that we can override our sleep drive when we need to be vigilant, to solve problems, to look after babies. It is an evolutionary adaptation that has allowed us to survive. Think of our ancient ancestors who had to be vigilant for 11

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predators or invaders. Similarly, the sleep behaviors of monkeys and apes, including the choice of sleeping sites and who gets up and out of the tree first in the morning, is very much determined by the need to protect the group against leopards and other predators. This ability to alter sleep behavior is crucial for survival. Likewise, in humans, the ability to stay awake is sometimes crucial and often useful. We want to maintain our ability to stay awake, or to awaken from sleep when there is a good reason. But when this happens repeatedly and needlessly, then this becomes a problem called insomnia. THE DIFFERENCE BETWEEN A BOUT OF POOR SLEEP AND INSOMNIA Insomnia is a complaint of difficulty falling asleep or staying asleep that impairs our functioning or causes distress. It is frequently accompanied by fatigue. So, compared to a bout of poor sleep, insomnia is a sleep problem that takes on a life of its own. Basically, it is persistent, unsatisfactory sleep that has daytime consequences. When insomnia occurs at least 3 nights per week and lasts for 3 months or longer, it is technically called “chronic” insomnia (Don’t be put off by that label, chronic does not mean irreversible!). When I refer to insomnia in this book, I am speaking not about sleep difficulties that are situational or short-term, but about those go on for weeks, months, or years. I probably don’t need to tell you that when sleep difficulty persists, we don’t feel on top of the world. People with insomnia report low mood, irritability, poor concentration and memory, reduced physical well-being, and some difficulties interacting with other people. They also report having more fatigue-related car crashes than people without insomnia. People with insomnia seem to be able to perform mundane tasks of daily living, but they tend to have less enjoyment of their activities and show less “cognitive flexibility”—they tend to think more narrowly and less creatively—than people who sleep well. Although they are often able to perform work and other activities well, everything feels like it takes more effort. In sum, when people don’t sleep well for a long time, their mood, functioning, and quality of life are impaired. Researchers who have observed people with insomnia over time—months or years— find that they are more likely than people without insomnia to use medical and mental health services. We know from several studies that insomnia increases the likelihood of subsequent development of clinical depression. The links between health, including mental health, and sleep are the subject of increasing numbers of research studies. Often, insomnia starts as a bout of poor sleep triggered by an event or circumstance like the ones described at the beginning of this chapter. The bout turns into insomnia as other factors come into play. These factors are often behaviors or thoughts that hinder the arrival of sleep. It is these behaviors and thoughts that can be altered to help you get back to sleep. So, the good news is that regardless of the initial triggers of the sleep difficulty, insomnia can be reversed!

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YOU ARE NOT ALONE Although being awake in the middle of the night can be isolating, you should know that each night there are many other people on the planet who are wide awake. At least 1 in 10 people in your time zone will be awake at the same time due to insomnia. As many as 25% of the North American population report sleeping problems and about 10% have chronic sleep issues. This is a substantial portion of the population. It might also help to think about all the night workers out there. For example, consider all the people in your time zone who are keeping the hospitals, care facilities, and factories running at night. In addition, you can think about all the people on Earth who are in more easterly time zones who are already “up and at it.” You may be the only one awake in your house in the middle of the night, but you are definitely not the only one awake!

CHAPTER 3

Common Concerns About Insomnia

s insomnia develops, you may start to worry about not sleeping. One of my friends had a stressful management position over which she started to lose sleep. A She then feared that the lack of sleep would negatively affect her work performance. This made it even more difficult for her to sleep because the thought of underperforming increased her anxiety. You can see how this can become a cycle of worry and sleeplessness.

Let me go over some of the common worries that are linked to insomnia. By examining these topics in the light of day, rather than ruminating during a sleepless night, we achieve a more balanced view of our sleep problem and its effects. Stressful thoughts at night have a way of expanding to fill the dark spaces around us. The following information will help to bring your sleep-related worries down to earth. The research on which this is based is cited in the Bibliography which can be found on Springer Publishing Company ConnectTM and can be accessed by visiting the following url: http://connect.springerpub.com/content/book/978-0-8261-4816-2. OH NO, I’M NOT GETTING 8 HOURS OF SLEEP! HOW MUCH SLEEP SHOULD I BE GETTING? People often ask me, “How much sleep should I be getting?” or “How much sleep do we need?” They are usually looking for the answer to be a certain number of hours per night. Expecting the answer to be in hours is somewhat like asking “How much

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food do we need?” and expecting the answer to be in pounds or kilograms. If someone asked you how much food we humans need, would you say “3 pounds per day?” Not likely. Rather, you might say “It depends.” It depends on the person’s metabolism, how much energy they have expended that day, how old the person is, what time of day it is, what type of food it is, how nutritious it is, how hungry the person is, and so on. Why, then, do we so often hear “We need 8 hours of sleep a night”? The need for sleep, like food, depends on many factors. It depends on individual differences in sleep duration, our age, how active we were that day, how much sleep we got the night before, how sleepy we are, what type of sleep we achieve, its quality, and what time of day or night we go to bed. The range of sleep durations among individuals is wide, just as there is a wide range of heights and shoe sizes; some people get along fine with 4 hours and some with 10 hours. In North America, Europe, and Australia, the average duration of sleep is closer to 7 than to 8 hours per night. This is the average. When asked about their sleep duration, a sizable portion of the population (5%–30%) respond that they sleep 6 hours or less. Another substantial portion (10%–35%) report sleeping 9 hours or more. Also, it is important to know that our sleep duration changes throughout our life span. As we age, we get less sleep. For example, someone who got 8 hours per night as a 20-year-old may now be getting 6 hours at age 60. I’ll discuss some of the reasons for this decline in sleep duration with age later (Chapters 19 and 20). Other things that affect sleep duration will be discussed along the way, but I think you see the point—that the optimal duration of sleep is highly individual and depends on many factors. In a nutshell, the amount of sleep that you need is the amount that allows you to feel rested and alert during the day, whatever that duration is at this point in your life. You will discover how to estimate your optimal sleep duration as you proceed with the program in this book, and it will not necessarily be 8 hours. ARE WE A “SLEEP-DEPRIVED SOCIETY?” A New York Times headline in 1994 read “Health Alarm for a Sleep-Deprived Society.” This is an example of media stories that stick in our minds about our society having a chronic sleep debt. The story goes that since Edison’s invention of the light bulb in 1874, we have been getting less and less sleep. This is because our 24-hour activities, televisions, electronic devices, and modern busy lifestyles push sleep to dangerously short durations. Is this really true? Let’s look at the question of whether sleep duration is decreasing over the decades. Some research studies have found a trend for reduced sleep. For example, a study from Finland that examined the sleep duration reported by people from 1972 to 2005 found a reduction of 5.5 minutes every decade. A study from the United States reported that nightly sleep duration dropped by 13 minutes between 1985 and 2012. However, several other surveys have found that the average sleep duration has not gone down significantly. For example, a study from Britain found very little difference between sleep durations reported in the late 1960s and those in 2003; an American study did not find evidence of shortened sleep over the years 1975 to 2006.

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Researchers at the University of Sydney in Australia wanted to know once and for all: are we sleeping less now than we used to, or not? In 2012, they published a systematic review of all the relevant studies, examining data from 15 countries. For six countries (Austria, Belgium, Finland, Germany, Japan, and Russia) nightly sleep duration decreased by 0.1–0.6 minutes each year, whereas for seven countries (Britain, Bulgaria, Canada, France, Korea, Poland, and the Netherlands) duration increased by 0.1–1.7 minutes each year. For two countries (United States and Sweden) the results were mixed—sometimes there was a decrease, sometimes an increase, sometimes no change. A separate review by an American group, published in 2016, of instrumentmeasured (sleep lab or actigraphy) rather than survey-measured sleep duration, also failed to find any consistent change in sleep amount over the past five decades. So, the story about reduced sleep durations over recent decades is highly questionable. What we do see clearly in modern societies is that long work hours are associated with short sleep, regardless of the decade. For example, full-time workers are more likely than part-time workers to have short sleep. People who have high job demands and long hours (e.g., over 55 hours per week) are more likely to have short sleep than people who work regular hours (35–40 hours per week). From this, we can predict that men or women who have extra-long days because they are taking care of the home and children and/or caring for elderly or disabled family members are also getting less sleep than those with less pressing and time-consuming demands. What about further back, centuries ago? It is difficult to know how long people slept in comparison to today because we must rely on anecdotal and non-standardized records. Before the widespread availability of electricity in the Western world, our sleep, work, and meal times would have depended more on patterns of natural light and darkness. Anthropologist Gandhi Yetish and colleagues recently studied the sleep of three “pre-industrial” societies without electricity, who hunt, gather, or grow their food in Tanzania, Namibia, and Bolivia. The sleep of these peoples may reflect that of humans around the world in pre-modern times. Interestingly, they sleep 5.7–7.1 hours per night, no longer than we do in our modern, electrified world. Sleep starts on average about 3 hours after sunset, as air temperature drops, and people wake up for the day before sunrise. Historically, sleep duration in western societies probably varied widely by occupation, wealth (which determined whether you could afford candles, oil lamps, and other artificial light sources), latitude, and season. Although we cannot be sure about the average duration of sleep over the centuries, we can speculate that sleep duration was more related than it is now to seasonal changes in the timing of dusk and dawn and the weather. There is some historical evidence that people in pre-industrial Europe had a “first sleep” (starting sometime between sundown and midnight), were awake for a time in the middle of the night, and then had a “second sleep” early in the morning. Despite having two sleeps, it seems people did not achieve more or better sleep than what we get now. These days, our sleep duration is less related to our natural environment, and more related to the amount of work we do. I don’t think we need to sound any alarms.

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DOES IT MATTER IF WE DON’T GET ENOUGH SLEEP? We Become Tired and Irritable but We Can Function

When we don’t get enough sleep, we are likely to be grouchy. We are also likely to feel tired. Things feel a lot harder to do. A study by psychologist Dr. Gary Zammit in New York City found that people with insomnia described low mood—feeling unhappy and having less interest in being with other people. They reported poor concentration, tiredness, mental slowness, and lethargy. They also felt accident-prone and clumsy. The good news is that, although things seem a lot harder, research shows that people with insomnia can function quite well. Their performance has been measured numerous times on a variety of tasks, such as reaction time, concentration, short-term memory, and motor tasks (those requiring movement). With insomnia, reaction time may be slower, problem solving, and some aspects of memory may be affected. However, the majority of tasks are done just as well by people with insomnia as by good sleepers. Still, people with insomnia feel that things are harder to do and require more exertion. They often feel that they haven’t done as well as they would have liked, or as well as they actually have. All this suggests that we can usually get the job done—whether it be schoolwork, housework, or job work—although we may feel that it takes extra effort. We are functional, but tired, sad, and irritable. No doubt about the irritability; it is a frequent companion of insomnia! Links Between Insomnia and Illness

Some people worry that they will get sick because of poor sleep. When I wrote the first edition of Sink into Sleep, I pointed to the lack of findings showing clear connections between insomnia and illness. Since then, the picture has changed. A study from the University of North Texas found that college students with insomnia had a lower immune response to an influenza vaccine than students without insomnia, suggesting that insomnia makes it easier to get the flu. Studies of longer-term health conditions now indicate that insomnia may increase people’s risk of developing heart disease and type 2 diabetes. These studies followed large numbers of people with insomnia over years and compared their health to people without insomnia. In general, people with insomnia are estimated to have 1.2–1.5 times the risk of these conditions than people without insomnia. This does not mean that everyone with insomnia will develop these diseases. It simply means that the likelihood is somewhat higher than in people without insomnia. Research is now underway to see if reversing insomnia through cognitive behavioral therapy for insomnia (CBT-I; the approach in this book) can lower the risk of these diseases. Certainly, CBT-I will improve your sleep, and this can only benefit your health. Finally, we know that one night of sleep loss does not significantly or obviously impair our health. Staying awake overnight, rather than sleeping, is accompanied by

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only subtle changes or even enhanced immunity in the short term. There may be some shifts in the levels and activity of some immune system cells, but there is no clear evidence that a full night awake makes us any more susceptible to infection or disease. This probably reflects a natural beneficial phenomenon that protects us from immediate dangers. For example, in our ancestral days, it may have allowed us to stay awake overnight to escape from predators or other dangers, and to stay healthy during this period. We Have Some Control Over This Moment Only

You can let go of worries about your past years of insomnia and concerns about future nights by realizing that you can only have some control over the night that is here. Worry about past or future nights serves no purpose other than impeding sleep tonight. You can tell yourself that this one night of sleep, even if it is poor, will not have devastating consequences on your daytime functioning or health. You can also reassure yourself that by using the techniques in this book, you will be doing the best thing to improve your sleep now. Our Sleep Rebounds

When we lose sleep one night, we can recover most of what we’ve lost the next time we sleep. Studies in which people are deprived of all sleep for one or more nights show that recovery sleep is a long, deep sleep. When people are selectively deprived of either deep “slow wave” sleep or rapid eye movement (REM) sleep (see Chapter 26 for a description of sleep stages), they do not necessarily regain the duration of lost sleep on the following night. However, their sleep systems enter these stages earlier and with greater intensity on the following night. So, if you lose some sleep on one night, it’s good to know that your body has built-in mechanisms to restore it.

CHAPTER 4

Sleep Hygiene: What It Is and Why You Probably Don’t Need It

ygiene” means “principles of maintaining health; the practice of these” (Concise Oxford Dictionary, 1982). In Greek mythology, there was a goddess “H called Hygeia, the daughter of Asclepius, the god of medicine. She was the goddess

of health, and her name is the origin of our word “hygiene.” In the strict sense, “sleep hygiene rules” are tips for maintaining good sleep health. They include things that your grandmother may have told you, such as don’t eat a big meal before you go to bed. In my experience, people with persistent insomnia don’t need these tips because they already know them. And they have already used them and found that they have not been enough to cure their sleep problem. The research concurs: Sleep hygiene alone is not effective for reversing chronic insomnia. So, why am I including sleep hygiene in this book? I thought I should at least mention these tips because people do expect to see them in a book about sleep and they are sound pieces of advice. These are the types of recommendations, or the “top tips for better sleep,” that you see in magazines. They can be helpful for people who usually sleep well but who have occasional or situational sleep problems in order to prevent further problems. By following them, you certainly eliminate some of the factors that can interfere with sleep. If you have been dealing with insomnia for months or years, I’ll bet you are already doing these things. 21

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Make your bedroom conducive to sleep. Consider the comfort of your bed, the air temperature, and levels of noise and light. I’m sure you’ve thought of these things. Minimize interference with your sleep by your bed partner, children, or pets. This is important but more easily said than done! Caffeine is a stimulant and should be discontinued 6 hours before bedtime. Know the foods, drinks, and medications that contain caffeine. I’m sure you already know that coffee, tea, cola, and dark chocolate all contain quite a bit of caffeine. You may have already cut out caffeine in the afternoon and evening. Nicotine (e.g., from cigarettes) is a stimulant and should be avoided near bedtime. There are many more health reasons to avoid smoking but this is the sleeprelated one. A light snack may be sleep-inducing, but a heavy meal close to bedtime interferes with sleep. Avoid consuming chocolate, large amounts of sugar, fatty foods, and fluids close to bedtime. This is probably what Grandma told you. Do not exercise vigorously just before bed. You are probably not doing gymnastics until 11 p.m. and then hopping into bed at 11:15 p.m. Be active. It is absolutely true that exercise can improve sleep. I’m sure you are aware of the many benefits of physical activity for mental and physical health. A brisk walk or some cardiovascular exercise on a regular basis, any time of day (morning, afternoon, or evening), can be helpful for your sleep, but it may not be enough to reverse persistent insomnia. See Chapter 21 for more on exercise and sleep. Take time to relax and unwind in the evening prior to going to bed. Don’t work intensively on a project that’s due tomorrow and then expect to drop off to sleep immediately. That makes sense. Turn off electronic devices at least one hour before bed. The mental and/or social stimulation of mobile phones, TVs, laptops, desktops, iPods, iPads, or game consoles can keep you awake late into the night, not to mention the light exposure (especially blue light) that impedes the onset of sleep. You probably know this.

CHAPTER 5

Sleep Therapy: What It Is and Why You Need It

t the very beginning of this book, I introduced you to something called cognitive behavioral therapy for insomnia, or CBT-I. This is the set of techniques that has A been shown to be effective for relieving persistent insomnia and that form the foundation of this book. “Sleep Therapy” is the term I use for the specific program laid out here, which combines the most powerful and effective components of CBT-I. Until recently, these techniques have been relatively unknown, but that’s changing as people with insomnia and health professionals become aware of them. These are the most reliable and effective techniques we have available to reverse persistent insomnia and that’s exactly why you need them.

Let me tell you what to expect. Sleep Therapy starts with looking at what your sleep is like now. This is a crucial part of the program because this information will determine subsequent strategies. The first part of the program, called FIRST THINGS FIRST, involves recording your sleep using sleep diaries to assess the nature of your insomnia. You will then do some simple calculations to determine how much sleep you are getting now, and how “efficient” or solid your sleep is. You will also check to see if and how factors like alcohol, sleep medication, or naps may be affecting your nighttime sleep. After you have looked at your current sleep patterns, you will move on to the second part of the program, called SOLVING YOUR INSOMNIA. Here, you will learn how to uncover, or rediscover, the biological processes that allow you to sleep. I will show 23

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you how to tailor your bedtime and rise time in order to get solid sleep, and how to associate your bed with great sleep. The procedures will be summarized in Six Steps to Solid Sleep, the main techniques of Sleep Therapy. You will monitor your progress using sleep diaries, and learn how to make adjustments to your bedtime as you start to sleep well. After you have used the Sleep Therapy techniques for 3–4 weeks, you will step back and evaluate if you still have insomnia or not. Most people experience vastly improved sleep by that point. The initial strategies in this book are called “sleep restriction therapy” and “stimulus control”; they are the most powerful tools for reversing persistent insomnia, and they show results fairly quickly. They provide you with evidence, early in the program, of your innate ability to sleep well. That’s why we start with them. We then move on to the third part of the program, called “WHAT TO DO WITH YOUR MIND.” This deals with the active-mind component of insomnia. Almost everyone I’ve met with insomnia describes having a racing mind in bed that interferes with their ability to sleep. I’ll be showing you how to calm your mind and to challenge the most frustrating and recurring thoughts that occur when you are trying to sleep. With some practice of these relaxation and “cognitive therapy” techniques, you will know how to move your mind into a state that is more conducive to having sleep arrive, to having the velvet hammer descend. So, let’s begin.

FIRST THINGS FIRST

CHAPTER 6

Measuring Your Sleep Problem— Keeping a Sleep Diary

he most useful and efficient way of starting your sleep program is by understanding your current sleep–wake patterns. This way, you can match your particular T situation to a plan that will allow you to see your sleep improve as quickly as possi-

ble. As I was preparing the first edition of Sink into Sleep, my friend Julie (not her real name) was having sleep difficulty. In fact, she had been struggling with insomnia for several years and it had gotten worse over the past year. She was waking up several times each night, often with menopausal hot flashes. After each arousal she would be awake for several minutes to hours. Occasionally, she was waking up much earlier in the morning than she wanted to. Also, over the previous year, she had started to have trouble falling asleep at her bedtime on certain nights. She decided to try Sleep Therapy and to go through my draft book, chapter by chapter. She agreed for me to follow her progress and to use her calculations and experiences as examples for future readers. Now, as I now write the second edition of Sink into Sleep, Julie is reviewing each chapter, this time as a former insomnia sufferer. I will use Julie’s situation as an example that you can refer to as we proceed from here. Thank you, Julie. All right, let’s start with the measurement of your sleep. The standard measurement tool for insomnia is the “sleep diary.” Sleep diaries are not really diaries, but simple logs based on your recollection of your last night’s sleep. Because you are the expert on your insomnia, you are the best person to report on each night’s sleep in order to measure your sleep problem. As I mentioned in Chapter 1, you do not need to go to a sleep laboratory unless your physician suspects another type of sleep disorder, 27

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such as a problem of excessive sleepiness or breathing disorders during sleep. In fact, people with insomnia who go to sleep labs usually have trouble sleeping in the lab, which simply confirms their insomnia. Each morning’s sleep diary entries take 2 minutes or less to do. Do it when you first wake up—as soon as your vision clears, your hand-eye coordination allows you to pick up a pen, and as soon as your mind is alert enough to know what is going on. Most people find that this is not a difficult task; some people even enjoy it. Although you will probably have a fairly good sense of what time you went to bed and what time you got up in the morning, you will probably have only a fuzzy idea of what happened in between. That’s fine. You only need to estimate what happened in between. For example, there is no way you can tell how long it took you to fall asleep exactly. You were drifting into a less-conscious state at the time and so, of course, it is hard to say precisely when that happened. Likewise, the number of times you woke up may not be clear, let alone the duration of those awakenings. Again, don’t worry about this. You can “guess-timate.” Avoid looking at the time during the night; checking the clock increases alertness and hinders sleep. If you have a clock on your bedside table, turn it away from you. If you have a cell phone or other electronic device that you use for keeping track of the time, turn it off and put it away, preferably in another room. Your rough estimate of the times and durations is all that is required. Research and experience tell us that your approximations are perfectly adequate for the job at hand. In order to get familiar with your sleep–wake patterns, you need to record at least 1 week’s worth of sleep diaries, representing 7 nights, before you try any of the therapeutic techniques. This initial measurement of your sleep will provide you with a “baseline” measure. This is important information on which you will be basing your program of sleep improvement. So, although you may be eager to move on to the sleep strategies, trust that it is worth the time to gather your baseline sleep data; it will contribute to the effectiveness and efficiency of your personal Sleep Therapy program. A NOTE ABOUT PERSONAL ELECTRONIC SLEEP TRACKERS Although the sleep information obtained from consumer wearable devices is appealing, at the time of writing this, these trackers are not yet ready for use in Sleep Therapy. They tend to misclassify wakefulness during the night, and they are untested in people with insomnia. See Chapter 26, section on sleep trackers, for more information. Until they are found to be reliably useful in this context, the tried-and-true method of using sleep diaries to track sleep and measure your response to Sleep Therapy is best. Also, there are benefits to tracking your sleep actively, using your own impressions, rather than having a device do it for you. When people actively track their behavior, this can be quite therapeutic in and of itself. You take more ownership of it, and you have more trust in your own judgment. Since the very definition of insomnia depends on your own experience of your sleep, sleep diaries are the best way to capture this information. Let’s get started with your very first sleep diary.

Measuring Your Sleep Problem—Keeping a Sleep Diary

29

LOGGING YOUR SLEEP WITH A SLEEP DIARY At the end of this chapter, you will see a blank sleep diary, labeled BASELINE. This is what you will be filling in. You can also print out a sleep diary from Extra Forms which can be found on Springer Publishing Company ConnectTM and can be accessed by visiting the following url: http://connect.springerpub.com/content/book/ 978-0-8261-4816-2. The diary has enough room to track your sleep for 7 nights.1 You will see that the top section of the sleep diary is for date information. Then, there is a section called “Sleep timing” that has 7 questions about the timing of your sleep. The next tab is “Sleep quality,” with a single question. Then, you will see the bottom section with headings for naps, alcohol, and sleep medication. Note that there are 7 vertical columns, one for each night of the week. Complete a column each morning, when your sleep is fresh in your memory. ●

●

Start with Sleep Diary for the Week of: Record the month and day (and year if you want) of the first night of the week being reported on. For example, if you begin to fill in your sleep diary on September 21 about last night’s sleep, you would enter September 20. For Day of the Week put in MON, TUES, WED, THURS, FRI, SAT, or SUN, depending on which night you are reporting on. For example, if you are starting on a Friday morning to report on Thursday night’s sleep you would put “THURS” in the space at the top of the first column. This will allow you to track your sleep over the week and see any trends that emerge; for example, whether your sleep is different on weekends than it is on weekdays. (Your week of recording does not need to start with Monday; it can be any day of the week that you choose.) Section on Sleep Timing

●

●

●

●

QUESTION 1: Unless you are using a 24-hour clock system, make sure you put down a.m. or p.m. This will help you later when you are calculating how much time you spent in bed. QUESTION 2: This is the time between when you went to bed and when you turned out the lights, intending to go to sleep. For many people, lights-out time is when they intend or want to go to sleep. However, some people (especially before starting Sleep Therapy) turn out the lights before they intend to sleep because they are doing something else in the dark (e.g., watching a movie, having sex, listening to a podcast). In this case, enter the elapsed time between when you got into bed and when you intended to go to sleep. QUESTIONS 3, 4, and 5: It is difficult to measure these things, so just provide your best estimates. QUESTION 6: This is the time from when you last woke up in the morning until you got out of bed to start the day.

1 If your sleep varies a lot from week to week, or you don’t think that 1 week will adequately represent your sleep, then you will want to keep sleep diaries for 2 weeks (14 nights). You can download sleep diaries from Extra Forms which can be found on Springer Publishing Company ConnectTM and can be accessed by visiting the following url: http://connect.springerpub.com/content/book/978-0-8261-4816-2.

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30

●

QUESTION 7: As for Question 1, unless you are using a 24-hour clock system, specify a.m. or p.m. Section on Sleep Quality

●

For the Quality of My Sleep: Rate the overall quality of your sleep from 1 to 10, where 1 = very poor and 10 = excellent. Section on Naps, Alcohol, and Sleep Medication

●

● ●

Naps: Specify the time and duration of any naps you had. This includes all naps, including ones that were unintentional (e.g., you dozed off in front of the television). Alcohol: Specify time, type, and amount taken. Sleep Medication: Specify time, type, and amount taken. Include anything you took to try to sleep, including prescribed medication, herbal products, or something you bought at the drugstore.

Feel free to use the space at the bottom of each column to record things that might have affected your sleep, like a headache, unusual medication, the days you were sick with a cold, a late-night phone call or text that left you feeling stressed. If you think something may have affected your sleep, write it down. At this point, it might be helpful for you to see what Julie did. So, I will describe some aspects of her week and show you how she filled out her baseline sleep diary. JULIE’S EXAMPLE I saw Julie on a Tuesday and gave her the sleep diary form. She started filling in the first column that morning, and answered the questions about her previous night’s sleep. The previous night was Monday, so she wrote “MON” at the top of the first column. During the week that Julie was recording her first sleep diary, it was spring and the weather was fine, and work-related stress was low. Despite being relatively untroubled, Julie developed a headache on Monday evening. She went to bed at 8:30 p.m., thinking the headache would go away on its own, but she woke up in the night with a hot flash and the headache. After throwing off some blankets and trying not to disturb her husband, she took a headache medication (she jotted this down at the bottom of Monday’s column). She had two more awakenings that night, and one of those happened with another hot flash. When she woke up for a third time, she felt cold and she pulled up her previously tossed blankets and went back to sleep. There were 4 other nights on which she was aware of hot flashes. On Tuesday night, she took half of a 7.5 mg tablet of zopiclone at 10:55 p.m. She took this because she was up late and wanted to make sure she got enough sleep prior to a meeting that was on her agenda for first thing the next morning. The zopiclone had been prescribed by her family doctor for occasional use. This helped Julie to fall asleep quite quickly that night.

Measuring Your Sleep Problem—Keeping a Sleep Diary

31

On Wednesday, Julie had a phone call from her 23-year-old son that left her feeling somewhat stressed. When she woke up at 4:30 a.m., her mind went to her son’s situation, what he had said, what she had said, what she wished she had said, and what she was planning to say next time she spoke to him. And then she wondered when she could speak with him next. She never did get back to sleep and got up at 6:00 a.m. anyway to get ready for work. On Thursday evening, Julie went out with her husband to a fast-food place and ate too much pepperoni pizza. She felt a bit nauseated when she went to bed at 9:00 p.m. and it took her a while to fall asleep. She took an over-the-counter nausea pill that night, hoping it would help her to doze off. On Friday, Julie went to bed quite early—at 8:15 p.m.—because she was tired. You can see that she took about 45 minutes to fall asleep and she woke up twice, both times with hot flashes. The second time she woke up, she stayed awake for about 90 minutes before falling back asleep. During that time, her mind was drifting around, including to thoughts about her work and about her son. She woke up at 5:00 a.m. and was unable to get back to sleep, even though it was the weekend and she would have liked more sleep. On Saturday night, Julie relaxed with her husband and some friends at home. She had three glasses of wine over the evening. She went to bed later than usual, and fell asleep quite quickly, although she had several awakenings later in the night. On Sunday afternoon, after spending 3 hours gardening, Julie lay down on the couch at about 4:00 p.m. and slept for an hour. You can see this was recorded as a nap. Later that evening, Julie felt the work week looming and she wanted to make sure to get enough sleep. So, she went to bed at 8:00 p.m. It took her about 2 hours to fall asleep. During this time, she was thinking about the work on her desk and planning how she would structure her day. She was also starting to feel anxious because the very thing that she was trying to get—enough sleep—was not happening. You may think that Julie’s sleep is better or worse than yours. That’s okay. Everyone’s different. Regardless of the severity of insomnia, the same sleep therapy techniques will work. YOUR TURN Now it’s your turn. You can start right now. Take a minute, and think back to last night. What day of the week was it? Fill in the DAY at the top of the first column. Now you are on your way! Fill in the rest of the column if you can. If you can’t remember last night’s sleep, start the sleep diary tomorrow morning. After you have filled in the first column, place the sleep diary beside your bed or at the breakfast table so you will remember to record your information each morning for the rest of the week. Be patient with this process. In an attempt to move ahead with the baseline recording process, some people have tried to remember their entire previous week of sleep and have filled in the whole diary at one sitting! In doing so, they have usually missed details that turn out to be important later on. So even if you think you know your sleep patterns inside out, take one night at a time, and record your information. It is worth the investment of time. This process will allow you to really understand your current sleep patterns. Along the way, you may very well discover one or two things you hadn’t noticed before.

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BASELINE (Julie) Sleep Diary for the Week of: April DAY of the WEEK

SLEEP TIMING

Which night is being reported on?

1.  I went to bed at (clock time): 2.  I turned out the lights after (minutes): 3.  I fell asleep in (­ minutes): 4.  I woke up ___ time(s) during the night. (number of awakenings):

SLEEP QUALITY

5.  The total duration of these awakenings was (minutes): 6.  After awakening for the last time, I was in bed for (­ minutes): 7.  I got up at (clock time):

19 MON.

TUES.

8:30 pm

11:30 pm

15

0

60

10

3 hot flashes

1

75

90

1

10

6:01 am

6:00 am

4

6

0

0

/

/

/

10:55 pm zopiclone 1/2 of 7.5mg

The quality of my sleep was: 1 = very poor; 10 = excellent

Naps Number, time, and duration

Alcohol Time, amount, and type

Sleep Medication Time, amount, and type

Notes:

headache - took pain medication early in the night

Measuring Your Sleep Problem—Keeping a Sleep Diary

33

WED.

THURS.

FRI.

SAT.

SUN.

10:45 pm

9:00 pm

8:15 pm

11:15 pm

8:00 pm

0

15

15

0

20

45

60

45

5

120

0

1

2

4-5 hot flashes

3 hot flashes & washroom

0

90 hot flashes

95 hot flashes

25

70

90

10

120

135

3

6:00 am

6:00 am

7:00 am

7:15 am

6:03 am

4

4

4

5

3

0

0

0

0

1 at 4:00 pm for 60 mins

/

/

/

6-8 pm 3 ­glasses of wine

5:00 pm 1 glass of wine

/

8:50 pm 1 Gravol

/

/

/

woke 4:30 am review of a conversation

felt nauseated at bedtime

woke 5:00 am

woke 5:00 am

34

BASELINE Sleep Diary for the Week of:  _____________________ DAY of the WEEK

SLEEP TIMING

Which night is being ­reported on?

1.  I went to bed at (clock time): 2.  I turned out the lights after (minutes): 3.  I fell asleep in (­ minutes):

SLEEP QUALITY

4.  I woke up ___ time(s) during the night. (number of awakenings): 5.  The total duration of these awakenings was (minutes): 6.  After awakening for the last time, I was in bed for (minutes): 7.  I got up at (clock time): The quality of my sleep was: 1 = very poor; 10 = excellent

Naps Number, time, and duration

Alcohol Time, amount, and type

Sleep Medication Time, amount, and type

Notes:

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Measuring Your Sleep Problem—Keeping a Sleep Diary

35

CHAPTER 7

What Type of Insomnia Do You Have?

C

ongratulations! You have a week’s worth1 of data about your sleep. Your completed sleep diaries will provide very interesting and useful information. Let’s go through your baseline sleep diary and see what it tells you. You will be looking at certain rows of your sleep diary now, and other rows in the subsequent chapters. I will guide you through your sleep diary, pointing out what to look for. We will follow the same sequence that I use when I examine people’s sleep diaries in the clinic, which is not necessarily the same order in which you filled out the sleep diary. Our first mission is to identify what type of insomnia you have. On page 41, you will see a place to record what type(s) of insomnia you have. See the chart called “My Baseline Insomnia Types.” You probably already have a sense of whether you have trouble initiating sleep (trouble falling asleep) or maintaining sleep (waking in the middle of the night or waking up too early) or both. However, let’s take a closer look at some of your baseline sleep measures to confirm your specific insomnia type(s). This will also allow you to compare your baseline sleep to your sleep after Sleep Therapy. INITIAL INSOMNIA Read across your sleep diary at Question 3 and see how long it took you to fall asleep each night. Did it often (on 3 nights or more) take you longer than 30 minutes to fall asleep?

I will talk about 7 nights of sleep diaries, but if you collected 14 nights, you would do the same for all 14 nights.

1

37

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38

If so, you are experiencing “initial insomnia.” Since Julie took a long time to get to sleep on 5 nights, she answered YES to this question.

3. I fell asleep in (minutes):

60

10

45

60

45

5

120

If you too answered yes, then circle “Initial Insomnia” in the right-hand column of the chart called “My Baseline Insomnia Types” on page 41. MULTIPLE AWAKENINGS Cast your eye across the diary at Question 4. Look at the number of awakenings you had each night. Did you often (on 3 nights or more) have more than three awakenings per night? If so, you can describe yourself as having “multiple awakenings.” Julie answered this as NO because she had only 1 night with more than three awakenings.

4. I woke up ___ time(s) during the night. (number of awake­ nings):

3 hot flashes

1

0

1

2

4–5 hot flashes

3 hot flashes & washroom

If you often had more than three awakenings, then circle “multiple awakenings” in the right-hand column of the chart called “My Baseline Insomnia Types” on page 41. MIDDLE INSOMNIA Look at how long you were awake each night in Question 5. Is this number often (on 3 nights or more) greater than 30 minutes? If so, you are experiencing “middle insomnia.” Julie answered YES to this question because 5 nights involved long awakenings.

What Type of Insomnia Do You Have?

5. The total duration of these awake­ nings was (minutes):

75

90

39

0

90 hot flashes

95 hot flashes

25

70

If you too had long awakenings on 3 nights or more, then circle “Middle Insomnia” in the chart called “My Baseline Insomnia Types” on page 41. TERMINAL (END-OF-NIGHT) INSOMNIA Look over the times that you were awake in bed in the morning at Question 6. Was this often (on 3 nights or more) 30 minutes or longer? If so, was this because you woke up earlier than you had wanted? If you are often waking up more than 30 minutes too early, then you can say you have “terminal” insomnia. If the word “terminal” sounds too ominous, feel free to call it “end-of-night” insomnia. Note that terminal insomnia only applies to you if you are waking up earlier than you had intended. You can also have long times for Question 6 if you are lying around in bed in the morning after the alarm has gone off, or just relaxing in bed rather than getting up. Do not count such lying around times as terminal insomnia; just count the nights on which you woke up too early by more than 30 minutes. Julie had 3 nights when she awakened much earlier than she had wanted to, so she answered YES.

6. After awakening for the last time, I was in bed for (minutes):

1

10

90

10

120

135

3

If you too answered yes, then circle “terminal insomnia” in the right-hand column of the chart called “My Baseline Insomnia Types” on page 41.

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40

MORE THAN ONE TYPE You have just looked at your baseline sleep diary for initial insomnia, multiple awakenings, middle insomnia, and terminal insomnia. It is quite common for people to have more than one type of insomnia problem. In the chart you may have circled several (up to four) types; these are your insomnia types at baseline. Have a look at them. You will return to these categories later, after you have finished Sleep Therapy, to see if you still have any of these types of insomnia. YOUR SLEEP QUALITY Your impression of how you are sleeping is, of course, one of the most important measurements. In your sleep diary, the section in the middle of the form captures this information. Look across the days of the week; what are your “quality” ratings? Take your most common rating. If your scores are all over the map, calculate the average (by adding them up and dividing by 7). Julie’s most common rating was 4.

The quality of my sleep was: 1 = very poor; 10 = excellent

4

6

4

4

4

5

3

Record your most common rating (or the average) in the chart on page 41 where it says “The quality of my sleep.” This estimate of the quality of your baseline sleep will be very useful later on to compare with your future ratings as you proceed with Sleep Therapy. MOVING ON It is very, very useful to have a measure of your sleep at the starting point of the program. I hope this chapter has allowed you to identify your current insomnia type(s) and to rate your sleep quality. Next, you will be looking at several other aspects of your baseline sleep diary, and doing some arithmetic in order to obtain two values that will allow you to tailor the Sleep Therapy procedures specifically for you.

What Type of Insomnia Do You Have?

41

Julie’s Baseline Insomnia Types: What type of Insomnia do I have?

Circle all that apply

Long time to get to sleep (more than 30 minutes)

Many awakenings

Initial Insomnia Multiple Awakenings

(more than 3)

Long time awake during the night (more than 30 minutes)

Waking up too early (more than 30 minutes)

The quality of my sleep

Middle Insomnia

Terminal Insomnia

Most common rating:

4

My Baseline Insomnia Types: What type of Insomnia do I have? Long time to get to sleep (more than 30 minutes)

Many awakenings (more than 3)

Long time awake during the night (more than 30 minutes)

Waking up too early (more than 30 minutes)

The quality of my sleep

Circle all that apply Initial Insomnia Multiple Awakenings Middle Insomnia Terminal Insomnia Most common rating:

CHAPTER 8

Knowing Your Numbers

wo “nifty numbers” is what my friend Ryan called them. By following the instructions in this chapter, you will come up with two numbers that are essential for T Sleep Therapy. As we saw in Chapter 5, Sleep Therapy combines the most effective

components of Cognitive Behavioral Therapy for Insomnia (CBT-I); it involves tailoring your bedtime and rise time for your sleep needs, and associating your bed with great sleep. Knowing your numbers will allow you to tailor your sleep improvement procedures for you and you alone. Ready to find out what these two numbers are? Drum roll, please! The first number is your “total sleep time,” which is how much sleep you are getting now. The second number is your “sleep efficiency,” which is how solid your sleep is. You can use your baseline sleep diary to estimate fairly accurately your baseline values for total sleep time and sleep efficiency. So, now’s the time to find a calculator. You will be doing some straightforward arithmetic. The calculations may look complicated, but they are definitely easier and much faster than doing a page of your income tax return. I will be showing you Julie’s information so you can see how it’s done. Don’t expect to have the same or similar numbers as Julie did. Everyone is different. YOUR BASELINE TOTAL SLEEP TIME

I will now show you how to estimate your baseline sleep duration based on a night from your sleep diary. From your baseline sleep diary, choose a representative night—a night that you would consider to be an average night, not your worst or best night. Put a big asterisk or star at the top of that column so you can easily refer to it. 43

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44

Calculating your Baseline Total Sleep Time and Sleep Efficiency

SLEEP TIMING

BASELINE Representative Night 1.  I went to bed at:

Date:

(clock time)

2.  I turned out the lights after: (minutes)

3.  I fell asleep in: (minutes)

4. I woke up ____ time(s) during the night. 5. The total duration of these awakenings was:

(minutes)

6. After awakening for the last time, I was in bed for:

(minutes)

7.  I got up at:

Calculations

(clock time)

A

B

C

Total Time in Bed

Total Awake Time

Total Sleep Time

Time between your bedtime (#1) and rise time (#7).

Add the numbers above in this column

A minus B

(minutes)

(minutes)

Convert hours to minutes by multiplying by 601

(minutes)

D

Sleep ­Efficiency

C/A × 100% For example, if you were in bed for 8 hours and 20 minutes, this is the same as 8 x 60 + 20 minutes = 500 minutes.

My sleep ­efficiency is

A self-calculating electronic form is available at www.sinkintosleep.com.

%

Knowing Your Numbers

45

Next, turn to the chart called “Calculating Your Baseline Total Sleep Time and Sleep Efficiency.” You are going to take your baseline representative night and copy the answers you had for Questions 1 to 7 onto the top part of this chart where you will find the same seven questions. They are in the same order as on your sleep diary even though they are not all lined up vertically; you need to do a bit of zigzagging to enter the seven numbers. This is merely to keep the clock times in one column and the minutes in another column. Next, go the lower part of the chart where it says Calculations and sections A, B, and C. Here you will be coming up with your Total Sleep Time. You will be subtracting the number of minutes you were awake from the number of minutes you were in bed. If you prefer to have the calculations done for you, please go to www.sinkinto​ sleep.com for an electronic self-calculating version of this form. Start With Section A: Total Time in Bed

Total Time in Bed is the time between when you went to bed and when you got up in the morning. To determine this, look at the clock times you have entered in the column above A and figure out the difference. You will likely come up with the number of hours and minutes you were in bed. However, you need this number to be in minutes. So, convert hours to minutes by multiplying by 60. For example, if you were in bed for 9 hours and 20 minutes, this would be (9 hours × 60 minutes/hour) + 20 minutes = 560 minutes. Enter your Total Time in Bed on the appropriate line. Now for Section B: Total Awake Time

For Total Awake Time, add up the times in the column above B. These are the lengths of time you were awake during the night. Keep them in minutes. Put your answer on the appropriate line. For Section C: Total Sleep Time

For Total Sleep Time, take your answer for A and subtract your answer for B. This gives you your amount of sleep in minutes. You will probably find it more meaningful to now express this in hours rather than minutes. So, divide by 60. Then round to the nearest half hour. For example, if your Total Sleep Time is 370 minutes, this would be 370/60 = 6.1 hours. This rounds to 6.0 hours. Other examples of rounding to the nearest half hour: If you had 5.7 hours, this rounds to 5.5 hours. If you had 5.8 hours, this rounds to 6.0 hours.

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Now you have the number of hours, to the nearest half hour, that you are sleeping at baseline. Put this value in the box at the top of the next page for safekeeping. You will be using it when you begin Sleep Therapy.

My Baseline Total Sleep Time (in hours, to the nearest half hour):

If these calculations seem daunting, follow Julie’s example first (near the end of this chapter) and then do the calculations for your own representative night. Note that you will be using minutes as units until you get to the last step, when you will convert minutes into hours. YOUR BASELINE SLEEP EFFICIENCY Sleep efficiency is a measure of how solid your sleep is. It is the percentage of the time that you were asleep while in bed. Let’s say that last night I collapsed into bed, immediately fell asleep, slept without interruption, and then leapt out of bed as soon as I woke up this morning. I would have a sleep efficiency of 100%. In contrast, if I didn’t sleep at all—not even for 1 minute—I would have a sleep efficiency of 0%. Neither of these extremes is typical in real life, although sleep efficiencies can get very high and very low. To give you a feel for different sleep efficiency levels, a sleep efficiency of 30% is very low, a sleep efficiency of 60% is low, a sleep efficiency of 85% is quite high, and a sleep efficiency of 95% is very high. Proceed to section D on the chart to calculate your Baseline Sleep Efficiency. You take your Total Sleep Time (C, in minutes) and divide it by your Total Time in Bed (A, in minutes). Then multiply by 100 to get the percentage. This is your Baseline Sleep Efficiency. Place this value in the box below. If you would like an example, have a look at Julie’s calculations.

My Baseline Sleep Efficiency:

%

You will be able to compare your Baseline Sleep Efficiency with your future sleep efficiencies. Also, in upcoming chapters, you will see how to use your sleep efficiency values over time to direct your Sleep Therapy. JULIE’S BASELINE TOTAL SLEEP TIME Julie chose Thursday, April 22, as a representative night of her baseline week. She looked at the Sleep Timing section of her sleep diary for that night and copied her

Knowing Your Numbers

47

answers to Questions 1 to 7 into the chart called Julie’s Baseline Total Sleep Time and Sleep Efficiency. You will notice that the clock times are in the first column and the durations are in the second column of the new chart, in the exact same order as on the sleep diary. For Section A: Total Time in Bed

Julie calculated the time between 9:00 p.m. and 6:00 a.m. She was in bed for a total of 9 hours. She converted this to minutes (multiplied by 60), to get 540 minutes. For Section B: Total Awake Time

Julie summed the durations in the column above B; that is, she added up all the time she was awake during the night. She got 175 minutes. For Section C: Total Sleep Time

Julie took her Total Time in Bed (540 minutes) and subtracted her Total Awake Time (175) and got 365 minutes. To convert this to hours, she divided by 60 and got 6.08 hours. She then rounded this to the nearest half hour and got 6.0 hours. So, her Baseline Total Sleep Time was 6.0 hours. She put this in the box below.

Julie’s Baseline Total Sleep Time (in hours, to the nearest half hour): 6.0

JULIE’S SLEEP EFFICIENCY Julie went to section D. She divided her Total Sleep Time at C (in minutes) by her Total Time in Bed at A (in minutes). This was 365 divided by 540. She then multiplied by 100%. This gave her 68%. This was her Baseline Sleep Efficiency. She put this in the box below.

Julie’s Baseline Sleep Efficiency:

68 %

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48

Julie’s Baseline Total Sleep Time and Sleep Efficiency

SLEEP TIMING

BASELINE Representative Night 1.  I went to bed at:

Date:   Thurs Apr 22 9:00 pm (clock time)

2.  I turned out the lights after:

15

(minutes)

3.  I fell asleep in:

60

(minutes)

1 time(s) 4. I woke up ____ during the night. 5. The total duration of these awakenings was:

(minutes)

6. After awakening for the last time, I was in bed for:

(minutes)

7.  I got up at:

90 10

6:00 am (clock time)

Calculations

A

B

C

Total Time in Bed

Total Awake Time

Total Sleep Time

Time between your bedtime (#1) and rise time (#7).

Add the numbers above in this column

A minus B

Convert hours to minutes by multiplying by 601

9 hrs = (9x60) = 540 mins

540

(minutes)

175

(minutes)

D

Sleep ­Efficiency

C/A × 100% My sleep ­efficiency is For example, if you were in bed for 8 hours and 20 minutes, this is the same as 8 x 60 + 20 minutes = 500 minutes.

68   %

365

(minutes)

CHAPTER 9

Things to Take Care of Right Away

ow that you have established the nature of your insomnia in Chapter 7 and you know your numbers from Chapter 8, it’s time to check a few other things. These N are things over which you have direct control. So, if they are contributing to poor

sleep, they can be addressed right away. You will now be perusing your sleep diary for three things: naps, alcohol, and sleep medication. Not that any of these things is bad (they are often very good), you just want to make sure that they are not interfering with your nighttime sleep. If they are interfering, it is much easier to deal with them now, before you go further. Some of you will breeze right through this chapter because you don’t take naps, you don’t drink alcohol, and/or you don’t take any sleep medication. Many others will discover that your nap patterns are fine, or that your alcohol consumption or sleeping medication use is no problem. A few of you will find that there is something you can adjust now to start improving your sleep right away. In any event, you will find it helpful to carefully check these things. NAPS Look across your baseline sleep diary and see on how many days you napped. Some people never nap; if this is you, you can skip this section. If you did nap, were your naps inadvertent or intentional? If they were inadvertent (you fell asleep in front of the television, or you fell asleep after breakfast or at your desk), and you had several of these sleeps during the week, this can be a sign of “excessive daytime sleepiness.” 49

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Sometimes this happens when you are cutting short your sleep time due to work, family, or other demands. For example, if you are working at two jobs and you only have 4 hours available for sleep, or if you are staying up late to drive the kids around and then getting up at 4:00 a.m. to get more things done before everyone else gets up, then you are cutting short your time for sleep. This results in a sleep deficit that may cause you to be very sleepy and to fall asleep in various situations during the day. This is a fixable situation: You need to make sleep a priority and allow enough time for it. If you are not cutting short your sleep to do things, then your sleepiness and inadvertent naps are more likely related to a medical condition, a substance or medication you are taking, or a sleep disorder other than insomnia. Usually this type of excessive sleepiness does not occur with insomnia unless something else is causing it. To get help sorting out what is causing the daytime sleepiness, I recommend that you visit your family doctor to look into the source of the sleepiness and how to reduce or manage it. If your naps were intentional (e.g., you lay down for a nap on Sunday afternoon), then look at the timing of each nap. What time of day do you take your naps? Did you know that 1:00 p.m. to 4:00 p.m. is the prime napping “zone”? We humans are predisposed to nap in the afternoon. Several lines of evidence point to this. Midafternoon corresponds to nap time in many siesta cultures, the most frequent nap time of young children before they “grow out of” napping, and the most popular nap time for adults of all ages. There are physical signs, too, that an afternoon nap is normal and natural. For example, in the early afternoon, we experience the so-called post-lunch dip, which is a dip in alertness and work performance. Unrelated to food, it is a natural time to drift off to sleep. There is a subtle, transient drop in our body temperature at this time, indicating that our body is readying itself for sleep. The mid-afternoon is the time when people fall asleep most quickly during the day if given the opportunity in a sleep lab. Afternoon naps also have health benefits. They are associated with a reduced risk of heart disease. They also lead to improvements in mood and mental functioning. For example, not only does our alertness improve after a nap, so does our reasoning, aspects of memory, reaction time, and attention. Furthermore, naps in this zone are unlikely to interfere with your nighttime sleep. We know this from studies of naps and subsequent sleep. So, in general, for people who have regular nighttime sleeping hours, the period from 1:00 p.m. 4:00 p.m. appears to be the best time to take a napping. If your naps are earlier or later than this, consider moving them into the prime napping zone. Now, have a look at the duration of each nap. How long was it? I recommend setting aside no longer than 45 minutes for your nap period.1 This will allow you to get Having a nap period of less than 45 minutes is a general guideline. Just as normal duration of nighttime sleep varies among individuals, best nap durations probably do too.

1 

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about 30 minutes of actual sleep. This nap duration seems to be optimal for health. It also will help prevent you from experiencing grogginess when you wake up. The grogginess is called sleep inertia and it is more likely to happen with longer naps. Also, this nap duration is short enough to still allow the buildup of your biological sleep drive for your nighttime sleep. The sleep drive is, in some ways, like hunger. You don’t want to have a big meal in the afternoon if you are planning to have a banquet in the evening. You will want to have a snack instead so that your hunger has built up by the evening, allowing you to enjoy the banquet. To sum up, you will achieve your best sleep by limiting your nap period to 45 minutes or less, within the 1:00 p.m. 4:00 p.m. zone. If you are already doing this, then congratulations; you are a fabulous napper!

Naps Number, time, and duration

0

0

0

0

0

0

1 at 4:00 pm for 60 mins

Julie had an afternoon nap on Sunday, but it started at about 4:00 p.m. and was 60 minutes long. She decided to pay attention to her nap timing for the next week and to lie down by 3:15 p.m. so she would be up by 4:00 p.m. ALCOHOL If you don’t use alcohol, just skip this section. If you do enjoy a drink of any type of alcohol, take a look at your Baseline Sleep Diary and see on how many days you had alcohol, at what time, and what amount. Alcohol in low doses (e.g., one standard drink2) sometimes helps us to fall asleep quickly. However, alcohol disrupts sleep significantly later in the night; it leads to lighter sleep and more awakenings. All sleep stages are affected by alcohol, but the most obvious effects are on the rapid eye movement stage (REM; see Chapter 26). This stage is abnormally suppressed during the first part of the night, and it then “rebounds”—occurs with a vengeance—in the latter part of the night as the blood alcohol level drops to zero. Along with the REM rebound, there is sleep disruption, more dreaming, and sometimes an alarming state with nightmares, increased heart rate, and sweating. The more alcohol we consume, the greater the sleep disruption. The amount of sleep disruption also depends on many other factors like the exact timing of the drink(s), how much food was eaten with the alcohol, body size, weight, gender, age, liver health, genetic factors, and past patterns of alcohol use. Given all these factors that go into predicting the effect of alcohol on sleep, it is difficult to give exact recommendations about the quantity and timing of drinking that One standard drink is 5 oz. of wine (12% alcohol), 1.5 oz. of spirits (40% alcohol), or 12 oz. of beer (5% alcohol).

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will minimize effects on sleep. Basically, less is better, and earlier is better. A common recommendation is to not drink within 4 to 6 hours of bedtime. This is roughly the amount of time for a young man to absorb and metabolize two standard drinks, taken without food, so that the alcohol is no longer in the blood. This is just a rough guide. Alcohol can exert effects on sleep even after it is no longer in the bloodstream. One study had 10 men in their early 60s drinking three standard drinks at “happy hour” before dinner, 6 hours before bed. The researchers confirmed that the alcohol was no longer in their system at bedtime. Their sleep that night was compared to a control night with a non-alcoholic happy hour. Sleep on the alcoholic happy hour night was broken up, the sleep stages were altered (REM was suppressed), and there was more wakefulness in the second half of the night. All this happened, even though all the alcohol had cleared out of their blood before they went to bed! Essentially, alcohol interferes with the quality, quantity, and sleep stage composition of sleep, and these effects can last for many hours—well into the night and the next morning. Look at the nights with alcohol and without. Are there differences in those nights? Are they better, worse, or the same with alcohol? Based on what you discover, you may decide to do nothing at all, or you may decide to alter the timing or the amount of alcohol. If you had a drink each night, it will of course be difficult to compare with no-alcohol nights. If this is part of your lifestyle, then your body is accustomed to this pattern of alcohol intake. Someone who had wine with dinner every night asked me if she should keep sleep diaries for a usual week and then for another week without alcohol. I don’t recommend this. This is because your sleep will probably be more disturbed without the usual alcohol because your sleep system has become accustomed to having the alcohol on board. Taking it away may lead to a temporary worsening of sleep. If you are okay with your current pattern of alcohol use, and it is not more than one to two drinks, taken at least 4 to 6 hours before sleep, then you are probably fine in terms of effects on your sleep. In addition to effects on your sleep, other aspects of health can be affected by alcohol. At certain levels, alcohol use increases the risk of cardiovascular disease (increased chance of heart attack and stroke), cancer, liver disease, accidents and falls, and mental health problems. If you wonder whether alcohol is affecting your health, information is available to help you estimate your health risk. Contact your public health unit or check the Low Risk Drinking Guidelines at www.ccsa.ca/alcohol in Canada or the National Institute on Alcohol Abuse and Alcoholism website www.niaaa.nih.gov.

Alcohol Time, amount, and type

/

/

/

/

/

6–8 pm 3 glasses of wine

5:00 pm 1 glass of wine

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Julie had wine on Saturday and Sunday evenings. Looking at her baseline sleep diary, she noticed that after her three glasses of wine on Saturday night, she fell asleep quickly, but later in the night she had 4–5 brief awakenings. Julie decided she would drink fewer than three glasses of wine in case that was affecting her sleep. Make your own observations. Now’s your chance to change the amount or timing of your beer, wine or cocktail depending on what you see in this baseline diary. SLEEP MEDICATION If you are not taking any substances to help you sleep, you can skip this section. Are you taking a prescribed sleep medication? Are you taking an over-the-counter sleep remedy? If so, please read more about the various sleep medications in Chapters 24 and 25. In general, if you have been taking benzodiazepines (such as lorazepam, clonazepam, oxazepam, temazepam, etc.) or “z-drugs” (such as zopiclone or zolpidem) every night for more than 1 month, and especially if you are not happy with your sleep, then you may want to talk to your family physician about a slow withdrawal from this medication. A very slow schedule is necessary to prevent “rebound insomnia,” which is a worsening of your insomnia. Make sure you continue to track your use of these medications to see if your use goes down with Sleep Therapy. Most people who take these medications on an occasional basis find they need them less and less as they proceed with Sleep Therapy. If you do use sleep medications, it is important to take them only at or before your bedtime, and not in the middle of the night. If taken later than your bedtime, they may cause you to have a hard time waking up in the morning, and to feel groggy. This is because the medication has not had adequate time to leave your bloodstream, and is still affecting your central nervous system. For other situations of taking medication, over-the-counter aids, or herbal products, please read the relevant sections of Chapters 24 and 25 for further information.

Sleep Medication Time, amount, and type

/

10:55 pm zopiclone 1/2 of 7.5 mg

/

8:50 pm 1 Gravol

/

/

/

Julie took a sleeping pill on one night of her baseline week. She uses it occasionally. It seemed to help her fall asleep, and on that night, she had a pretty good sleep despite a long awakening during the night. She used an anti-nausea medication on another night, hoping that it would also help her to fall asleep.

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SLEEP MEDICATION AND ALCOHOL If you are taking sleep medication, it is dangerous to also drink alcohol. Both substances relax the nervous system, leading to reduced alertness, and slowed, shallow breathing. The combined effect can be hazardous and even lethal. So, if you take sleep medication, avoid alcohol that day and night. Also, be sure to read and follow the instructions on the medication label.

SOLVING YOUR INSOMNIA

CHAPTER 10

The Essential Elements of Sleep Therapy

wo essential elements form Sleep Therapy. In this chapter, I will explain these elements, which are based on sleep science and psychology principles. Many people T find this background intriguing. What’s more, it is always easier to carry out tech-

niques when you understand how they work. The elements of Sleep Therapy are: a) uncovering your natural sleep processes and b) associating your bed with sleep. UNCOVERING YOUR NATURAL SLEEP PROCESSES By understanding how sleep comes and goes in the natural state, we can see more clearly how to restore healthy sleep. Good sleep comes when our biological sleep processes can operate without interference. Let’s start by looking at two very important processes that regulate sleep and wakefulness.1 Sleep’s Homeostatic Process

Homeostatic processes are mechanisms in our bodies that maintain a state of equilibrium. For example, homeostatic processes control and balance the level of glucose In 1982, sleep researcher Dr. Alexander Borbély of Switzerland proposed a model of sleep regulation. It was called the Two-Process Model. Several other models have been proposed since then, some being more sophisticated variations or refinements, but most of them still rest on the assumption that there are two main processes. The Two-Process Model has been extremely useful in understanding our sleep and predicting the timing of our best sleep.

1

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in our blood, the water content in our tissues, and regulate our temperature, heart rate, and blood pressure. Likewise, we have a homeostatic mechanism that regulates our propensity to sleep. Basically, the longer we stay awake, the more likely we are to fall asleep and to stay asleep. This phenomenon is evident in toddlers when they are up way past their bedtime—they just fall asleep wherever they are. The parents have to cart them off to bed. The toddler’s deep and undisturbed sleep is the homeostatic sleep process at work. You, too, will be staying up past your usual bedtime in order to achieve good sleep. Shortly, I will guide you through the calculation of exactly how late you will need to stay up in order to start having your homeostatic sleep process working for you. Sleep’s Circadian Process

The second process is a circadian rhythm. The word circadian comes from Latin: circa = about, around; and diem = a day. These are rhythms that go through one cycle approximately every 24 hours. Why 24 hours? Because one light–dark cycle on Earth is 24 hours long, and like other species, we are well adapted to the rotation rate of our planet. These internal rhythms are so strong that they persist even if we are in a cave without light–dark information. They are controlled by an internal clock in a part of the brain called the suprachiasmatic nucleus of the hypothalamus. The specific timing of these rhythms is precisely cued by normal environmental patterns of light and dark, as well as the timing of our sleep and waking activities (such as eating, exercising, working, socializing). Several of our hormones have a circadian pattern of release, as do aspects of our heart function, kidney function, and immune system. Did you know that every 24 hours our body temperature rises and falls in a predictable way? This circadian fluctuation is quite small (up to about 1 centigrade degree) but is very reliable. Our sleep propensity has a circadian rhythm and it is linked to our temperature rhythm: We are most likely to fall asleep as our body temperature is declining in the evening and most likely to wake up as our body temperature is rising in the morning. Every 24 hours, there is a prime time to fall asleep. This is when you are likely to fall asleep quickly and stay asleep for the night. I will be showing you how to stabilize and strengthen your circadian rhythm of sleep–wakefulness in order to obtain optimal sleep. We Can Use These Processes to Sleep Well

The techniques that you will learn in this section are all about becoming familiar with your own sleep processes, removing interference with them, and strengthening them in order to maximize the chances of good, sound sleep. Remember that we do not achieve sleep by actively searching for it. Rather, we do things to optimize the conditions for good sleep. We leave the rest to our internal sleep processes. I will now explain the specific techniques that reverse insomnia, and you will see how your homeostatic and circadian sleep processes can work for you.

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Stay Up Late

Staying up late allows our homeostatic sleep mechanisms to shift into gear. You will be figuring out how late you need to stay up to get your homeostatic process working for you. We will use a technique called “sleep restriction therapy.”2 Decades of research and clinical experience have shown sleep restriction to be a top treatment for insomnia. Sleep restriction is actually about restricting your time in bed. You will set a “threshold bedtime” and “threshold rise time” that will limit your time in bed. You will use information from your sleep diaries to determine these times. As your sleep improves, you will adjust your bedtime from week to week. Setting your “threshold” bedtime and rise time for the first week of Sleep Therapy

To determine these times, follow the instructions in the next table. Julie’s table is shown as an example.

Julie’s threshold bedtime and rise time Pick your threshold rise time

Pick a rise time that you can maintain 7 days per week. It needs to work for you and, of course, be early enough to allow you to get to work, or start your activities on time.

Recall your total sleep time

a.

This is your threshold rise time

Take your total sleep time in hours (to the nearest half hour) that you calculated in ­Chapter 8, pages 45–46.

b.

Calculate your threshold ­bedtime

c.

Take your threshold rise time (a) and subtract (i.e., go backwards around the clock) your total sleep time (b).

6:00 am

6.0

hrs

If this number is less than 5.0 hours, then replace it with 5.0.

a-b=

midnight

This is your threshold bedtime for the first week

Julie’s threshold bedtime and threshold rise time. Bedtime:

midnight

Rise Time:

6:00 am

This technique was described in 1987 by psychologist Dr. Arthur Spielman and colleagues.

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My threshold bedtime and rise time Pick your threshold rise time

Pick a rise time that you can maintain 7 days per week. It needs to work for you and, of course, be early enough to allow you to get to work, or start your activities on time.

Recall your total sleep time

a. This is your threshold rise time

Take your total sleep time in hours (to the nearest half hour) that you calculated in Chapter 8, pages 45–46.

b.

Calculate your threshold bedtime

c.

Take your threshold rise time (a) and subtract (i.e., go backward around the clock) your total sleep time (b).

hrs

If this number is less than 5.0 hours, then replace it with 5.0.

a-b= This is your threshold bedtime for the first week

Enter your threshold bedtime and threshold rise time below. Bedtime:

Rise Time: 

Perhaps your threshold bedtime seems extremely late to you. People in our program sometimes drop their jaw in disbelief at having to stay up until 1:00 a.m. or 3:00 a.m. or whatever their threshold bedtime is for the first week. However, remember that this is just for a short time (the first week) to build up your homeostatic sleep process. It should seem a bit extreme.3 Think of that toddler who conks out after being up too late. You, too, will be staying up much too late. You will do this for a few days in order to allow your sleep to become solid, so you are sleeping like a log. You will be adjusting your bedtime, usually earlier, week by week. I will be showing you how to adjust your bedtime after the first week of Sleep Therapy. How will you stay up until the late hour that is your threshold bedtime? This is the question. Use your imagination now to think of what you will be doing with that extra time. Maybe there is a project you have wanted to do and never “got around to it.” Maybe you want to embark on something totally new, like reading a book on how to identify the various fir trees, or learning a new art form. Maybe you would like to fold some laundry or watch a late-night TV show. Maybe you want to write an oldfashioned letter to your aunt. You will now have some extra hours in the week to work with. Start planning your nighttime activities now for the first week of Sleep Therapy! If the initial threshold bedtime really scares you, make it 30 minutes earlier. It is possible that the technique will not work quite as well, but you will be less stressed and feel more in control.

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Get Up at the Same Time Every Day

If you already get up around the same time 7 days a week, good for you. This part will be simple for you and you are already helping your circadian sleep process. On the other hand, if you have rise times that change from day to day, your task is clear. You will need to get up and out of bed at your threshold rise time each morning of Sleep Therapy. Why? Having a set rise time 7  days a week is an excellent way of “entraining” (strengthening and anchoring) your circadian sleep process. When this rhythm is strong, you will be more likely to sleep well. It will allow you to consistently become sleepy in the evening as your body temperature falls, for you to sleep well overnight as your body temperature reaches its trough, and for you to wake up as your body temperature rises in the morning. Will getting up at the same time every day be difficult for you? Only if you love sleeping in late on weekends or days off. People who have to give up their sleep-ins sometimes find it helpful to think of the things they can do with the extra time in the morning. One person used it as an opportunity to enjoy the bird activity in her yard. You can drum up reasons for getting up. If it really is painful for you to get up at the same time every day of the week, you can think of it as short-term pain for longerterm gain. You will not have to do this for the rest of your life. You are using this procedure at this time to strengthen your circadian sleep process in order to optimize your sleep. Also, it might help to know that you don’t have to wake up at precisely the same time each morning; 10 minutes earlier or later is usually okay. ASSOCIATING YOUR BED WITH SLEEP This element of Sleep Therapy is based on something called “conditioning” or “learned associations.” These are connections we make in our mind (automatically) between two things that occur together on several occasions. For example, some people find that when they go home at the end of the day and enter their kitchen, they immediately feel like eating—even if they are not truly hungry—because they have come to associate that time of day and their kitchen with eating. You may have heard of Pavlov’s dogs, who started to salivate whenever a bell rang, after the bell had been paired with food several times. In the case of sleep, you want to learn to associate your bed with sleep. Your Bed Is for Sleep

When we have insomnia, our bed becomes associated with sleeplessness and the frustration that accompanies it. We can reverse this by starting to pair our bed with sleep and sleep alone, sexual activity being the only exception. The best way to do this is by following some basic instructions called “stimulus control therapy.”4 This Stimulus control therapy was originally developed by psychologist Dr. Richard Bootzin, who presented the technique at a conference in 1972.

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technique has been tested in many research facilities and clinics and is one of the most effective treatments for insomnia. I will now outline and explain the basic instructions for associating your bed with sleep. Something that happens to many people with insomnia is that they drift to another bed, or to the couch, in order to get better sleep. Sometimes this leads to good sleep in the new location, but it doesn’t help you to sleep well in your own bed. I recommend that you choose the bed that is the one you want to sleep well in, and use only that bed. This is the place you will be associating with good sleep. The following strategies will allow you to associate your bed with sleep and sleepiness. Go to bed only when sleepy and not before your threshold bedtime

A key word here is “sleepy.” Do you know how sleepy feels? Sometimes we forget what the physical signs of sleepiness are. For some people, sleepiness is experienced as yawning. Other possible signs are blurring eyesight and losing visual focus. For example, you might notice a blurring of the lines in a book you are reading. You lose concentration on what you are doing: You may find yourself reading a sentence or paragraph over and over again because you lost track. Your head may nod. You may feel like dozing off. The idea is not to go to bed until you feel some of the physical signs of sleepiness. This is because you want to associate your bed and bedroom with sleepiness and sleep. You may be wondering if sleepiness is the same thing as being tired or fatigued. In day-to-day conversation, people use these words interchangeably. However, as a sleep researcher, I am careful to distinguish them. “Sleepiness” is the tendency to sleep. “Fatigue,” on the other hand, is a physical or mental exhaustion that often comes from exertion. “Tiredness” is weariness, such as fatigue. Sometimes we feel drained, mentally or physically, and fatigued and tired, yet we are not sleepy. For this particular technique, it is important that you do not go to bed before you are actually sleepy. So, you go to bed when sleepy and not before your threshold bedtime. What is this bedtime? This is the threshold bedtime that you have just set for yourself for the initial week. So, you will need to stay up at least until the threshold bedtime and then only go to bed if you are also sleepy. If it is your threshold bedtime and you are not sleepy, then stay up until you are sleepy. Use the bed only for sleeping

Sexual activity is the only exception. Do not watch television, listen to the radio, use electronic devices, eat, or read in bed. This strategy is designed to help you associate your bed with sleep and not other miscellaneous things. Electronic devices that are banned from your bedroom include music players, any kind of screen or computer, cell phones, smart watches, e-book readers, and so on. If these are in the bedroom, they will not help your sleep. Remove them! If you use the alarm on your cell phone

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to wake you in the morning, then find an old-fashioned alarm clock to use instead. Turn off the cell phone and leave it in another room. Get Out of Bed When You Are Not Sleeping

Part of strengthening the association of your bed with sleep is to make sure that your bed is not associated with being awake. So, you need to be out of bed when you are not sleeping. Leave the bed if you can’t fall asleep or go back to sleep within 10–15 minutes

Return when sleepy. Repeat this step as often as necessary during the night. This helps you associate your bed with sleep, rather than wakefulness. Therefore, if you are awake for longer than 10–15 minutes, leave the bed. You do not need to, and you shouldn’t, watch the clock. The 10–15 minutes is a rough guideline. When you find yourself awake in bed after a few minutes, leave the bed. Go to another room and do something low-key and pleasant. You may decide to watch television. This may be stimulating rather than relaxing, depending on the program. If so, choose a less-stimulating activity. It is best to avoid the computer because the light from the screen can be alerting. Many people read a book, magazine, or newspaper. Don’t sit under a very bright light. Use a light that is bright enough to read comfortably, but not the brightest one in the house. Others do jigsaw puzzles, crosswords, or play solitaire with a deck of cards. Some people do household things, like folding laundry; I used to wash dishes. Carry on your activity until you experience physical signs of sleepiness and then return to bed. If you are then awake in bed again for more than 15 minutes, don’t get discouraged; just get up again and repeat the same steps. It is much easier to get out of bed in the night if you prepare yourself for this possibility. If it is cold, lay a housecoat or big sweater and your woolly slippers next to your bed so that you will be warm enough when you are out of bed. A basket with the things you will need during your wake episodes can help reduce decision-making during the night. Simply grab your basket, go to another room, and start your activity. What about other members of the household? Of course, you will go about your nighttime activity quietly so as not to disturb others’ sleep. You may want to let certain people, like your bed partner, know what you are doing so that they understand. You can say that you are following instructions about going to bed and getting out of bed as part of a program to improve your sleep. You can tell them not to worry about you if they notice you coming and going from the bedroom. Get out of bed when you wake up in the morning

No lounging around in bed after you wake up in the morning! The reason you want to get up right away is that you do not want to associate your bed with being awake.

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It is important to not spend extra time in bed. Some people find it very difficult to get moving out of bed after they wake up, especially on weekends. It is pleasant to lie there, warm and comfy. However, for the good of your future sleep, try to roll out of bed within 5 minutes, and start your day. Think of something to get up for—a cup of coffee or tea perhaps, or a bath, a stroll down the street, a flip through the newspaper. PUTTING THE ELEMENTS INTO ACTION Now that you know the essential elements and the basic strategies of Sleep Therapy, you are well prepared to put Sleep Therapy into action.

CHAPTER 11

Starting Sleep Therapy

ere’s where you put all of this knowledge together and move right along to better sleep! You will be using the elements outlined in the previous chapter to H start sleeping well. I have summarized the strategies of Sleep Therapy in six spe-

cific steps. The first four steps are based directly on what you have just read in Chapter 10. Carefully go over these first four instructions now to be sure of them. Fill in your initial threshold bedtime at step 1 and your initial threshold rise time at step 2. The last two steps are additional strategies to support your progress with Sleep Therapy. Specifically, if the procedures make you very sleepy, there is an option to have an afternoon nap (step 5), and you will be tracking your sleep with a sleep diary (step 6). The steps of Sleep Therapy appear to be simple, but they require some time and effort. The effects may not be immediate, but if you follow the steps closely, after a few nights, you’ll see benefits. Don’t get discouraged if you initially have some disrupted nights. The most important factor that determines whether your sleep will improve is the consistency with which you follow the steps.

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Six Steps to Solid Sleep 1. Go to bed only when sleepy and not before your threshold bedtime. _____________ Fill in the threshold bedtime that you set in Chapter 10 (page 60).

2. Maintain a regular threshold rise time in the morning. _____________ Fill in the threshold rise time that you chose in Chapter 10 (page 60).

3. Use the bed only for sleeping. Sexual activity is the only exception.

Do not watch television, listen to the radio, use electronic devices, eat, or read in bed.

4. Leave the bed if you can’t fall asleep or go back to sleep within 10–15 minutes. Return when sleepy. Repeat this step as often as necessary during the night.

5. If sleepiness is overwhelming, you may take a short nap (set aside no longer than 45 minutes) in the afternoon, between 1:00 p.m. and 4:00 p.m.

6. Maintain a sleep diary. ABOUT STEPS 5 AND 6 If sleepiness is overwhelming, you may take a short nap (set aside no longer than 45 minutes) in the afternoon, between 1:00 p.m. and 4:00 p.m. Because you may be very sleepy during the day, especially when you first start this schedule, this is an option that may come in handy. Many programs recommend that you avoid daytime naps entirely because naps may make it harder to sleep at night. While this is partially true, we also know that humans are biologically predisposed to have a nap in the afternoon if circumstances permit. A short nap taken in the midafternoon, ending before 4:00 p.m., is unlikely to negatively affect your nighttime sleep. You do want to avoid multiple naps and naps that occur at times other than the prime nap “zone.” (See the rationale for the timing of your nap in Chapter 9.) So, if you are having a hard time with the initial sleep limits imposed by the first two steps of Sleep Therapy, you can always take a brief nap. If you are working at a day job, then it may not be possible to do so in that period. Many places do not yet appreciate the benefits of napping at work! If that’s the case, you may have to use the nap option on your days off. Maintain a Sleep Diary

Keeping a sleep diary will show you right away how your sleep improves as a result of your actions. So, track your progress by filling in a column of a sleep diary each morning. You can use the provided sleep diary or print one off from Extra Forms which can be found on Springer Publishing Company ConnectTM and can be accessed by visiting the following url: http://connect.springerpub.com/content /book/978-0-8261-4816-2.

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YOU SHOULD KNOW ●

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●

●

The start of Sleep Therapy may involve a degree of short-term sleep deprivation; you should be prepared for this. Some people choose to start it on a weekend so that most of the sleep deprivation will occur when they don’t need to be performing brilliantly. Start this schedule of going to bed and getting up from bed when you have an excellent chance of following it carefully. If you are just about to travel to another time zone, now is not the time to begin the six steps. Wait until you are settled back in your normal house, bed, and time zone. If work or home life is just too busy and stressful to be able to follow this plan closely, you may want to delay using this approach until it fits into your days and nights in a more manageable way. You may want to explain what you are doing to your family members, especially the person who shares your bed. Help them understand that you may have odd bedtimes and rise times for a while, but this is a temporary strategy to improve your sleep. Ask for their moral support!

WARNING The technique of limiting your time in bed is designed to build up your sleepiness drive. Along with increasing your sleepiness, it may reduce your attention, alertness, and vigilance and delay your reaction time, both at night and during the day. Avoid driving and other potentially dangerous activities while sleepy.

WEEK 1 So, now that you have your six steps to solid sleep in front of you with your threshold bedtime and rise time for the first week, here’s what you do. Follow these six instructions for a week. Remember, you can go to bed later than, but not earlier than, your threshold bedtime. Recall that you also need to be sleepy before going to bed. You can get up earlier than, but not later than, the threshold rise time. You need to keep track of each night’s sleep with a sleep diary—this is very important. Use the sleep diary (Week 1) at the end of this chapter or download one from Extra Forms which can be found on Springer Publishing Company ConnectTM and can be accessed by visiting the following url: http://connect.springerpub.com/content/ book/978-0-8261-4816-2. Make sure to put in the start date and your initial threshold bedtime and rise time at the top. You may be tired and sleepy and somewhat miserable for a few days. Hang in there, it will get much better! A typical pattern that people encounter is some sleep deprivation for the first 3–4 days and then their sleep improves markedly and they feel better. Using these techniques takes some perseverance, but know that it is worth it. Be kind to yourself and have faith that you are using the most effective strategies we have to reverse insomnia, and don’t think about it too much!

68

WEEK 1 Sleep Diary for the Week of:  ____________________ DAY of the WEEK

SLEEP TIMING

Which night is being reported on?

1. I went to bed at (clock time): 2.  I turned out the lights after (minutes): 3.  I fell asleep in (minutes): 4.  I woke up ___ time(s) during the night. (number of awakenings): 5.  The total duration of these awakenings was (minutes):

SLEEP QUALITY

6.  After awakening for the last time, I was in bed for (minutes): 7.  I got up at (clock time): The quality of my sleep was: 1 = very poor; 10 = excellent

Naps Number, time, and duration

Alcohol Time, amount, and type

Sleep Medication Time, amount, and type

Notes:

Sink Into Sleep

Starting Sleep Therapy

Bedtime: ______________   Rise Time: ______________

69

CHAPTER 12

Moving From Week 1 to Week 2: Adjusting Your Bedtime

chapter guides you forward after your first week of Sleep Therapy. I’ll also show you how Julie did. T his THE FIRST WEEK IS DONE Congratulations! You made it through the first week. This is really exciting. You’re well on your way to good sleep. Julie found that the most difficult part of the first week was staying up later than she was used to. She had been an early-to-bed person since childhood. So, this was a huge change. She loved reading but found she could not read during her long evenings because it would make her extremely sleepy. She tried watching some television and playing computer games but she got bored, although she did manage to do some paperwork that needed to be done. Everyone finds their own thing to do to stay awake until the threshold bedtime. Some people wash dishes, some watch television, some pay bills, some play solitaire, some tidy closets, and some even delve into art projects. One client brought in ceramic objects d’art that she had created by smashing old vases and cups and gluing the pieces in architectural designs on boards while she was staying up until her threshold bedtime of 3 a.m. Julie did not have so much fun, but she did see the benefits of staying up until her own threshold bedtime. She was impressed with how quickly she started to have solid sleep. Her husband noticed how rested she looked. This is not necessarily typical; not everyone looks rested after the first week. Many people 71

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72

are starting to get some solid sleep at this point but they look and feel tired. If you are not looking rested yet, don’t despair, you soon will be! Have a look at the following important indicators to see in what ways your sleep is starting to improve. Look at this week’s sleep diary and flip back to your Baseline Sleep Diary. Compared to your Baseline Sleep Diary, ●

Do you fall asleep more quickly now?

●

Do you have fewer awakenings?

●

Are you awake for less time during the night?

●

And what about your ratings of sleep quality? Have they gone up?

Julie noticed right away that her ratings of sleep quality were consistently 8 out of 10, whereas during the initial week they were mostly 4s. She also found that she was awake for less time during the night now. She had some brief awakenings but nothing compared to the hours she had been awake during the initial week. She concluded that after 1 week, her sleep was much better than it had been, although it was difficult and strange for her to stay up so late. Jot down your observations about your own sleep during the past week: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ It’s now time to move on to planning Week 2 of Sleep Therapy. In order to set your threshold bedtime for the next 7 nights, you will be using your current week’s data to calculate your most recent sleep efficiency. WHAT SLEEP EFFICIENCY DID YOU ACHIEVE? As you did for your Baseline Sleep Diary, choose a typical night from the week just past. Mark that column of your sleep diary so you know which one it is, and follow the steps here. Turn to the chart called Calculating Your Week 1 Sleep Efficiency. Now you will be copying your Sleep Diary answers to Questions 1 to 7 for your typical night into this chart. Do the calculations for A, B, C, and then D. Voila! Here is your sleep efficiency for Week 1 of Sleep Therapy. If at any point you realize that the night you chose is not really representative of the week, then you can try another night and see how close the sleep efficiencies are. If the nights are not consistent, then you may want to calculate all seven sleep efficiencies and take the average for the week. It is important that you get an accurate sleep efficiency that represents the week because you will be basing your next steps on this number.

Moving From Week 1 to Week 2: Adjusting Your Bedtime

73

Calculating Your Week 1 Sleep Efficiency

SLEEP TIMING

WEEK 1 Representative Night 1.  I went to bed at:

Date:

(clock time)

2.  I turned out the lights after:

(minutes)

3.  I fell asleep in:

(minutes)

4. I woke up ___ time(s) during the night. 5. The total duration of these awakenings was:

(minutes)

6. After awakening for the last time, I was in bed for: 7.  I got up at:

Calculations

(minutes) (clock time)

A

B

C

Total Time in Bed

Total Awake Time

Total Sleep Time

Time between your ­bedtime (#1) and rise time (#7).

Add the numbers above in this column

A minus B

(minutes)

(minutes)

Convert hours to minutes by multiplying by 601

(minutes)

D

Sleep Efficiency

C/A x 100% For example, if you were in bed for 8 hours and 20 minutes, this is the same as 8 x 60 + 20 minutes = 500 minutes. 1

My sleep efficiency is

A self-calculating electronic form is available at www.sinkintosleep.com.

 %

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74

Most people find that this sleep efficiency is higher than their initial sleep efficiency. If this is true for you, yahoo! This is a sign that the techniques are working well. If your current sleep efficiency is not higher than your initial sleep efficiency, then redo your calculations to make sure there is not a mathematical error. If you find the same results, then I suggest you do the following: ●

●

Review how closely you have been able to follow the Six Steps to Solid Sleep. If you have not been precise with the bedtimes and rise times, or with getting out of bed when you are not sleeping, this may be reducing the benefit of the technique. Life happens, and sometimes we have family responsibilities or other activities that interfere with the timing of going to bed and getting out of bed. If this has happened, you may want to use the same threshold bedtime and rise time for another 4 days, following the instructions closely. Keep a sleep diary and redo your sleep efficiency calculation for the 4 nights. Take a few moments to review the section in Chapter 1 titled Circumstances When This Book May Not Be Enough to make sure that there is not another factor that may be interfering with your sleep or your ability to benefit from this approach at this time. If something other than insomnia is causing your sleep difficulty, then that “something” probably needs to be addressed first. You can always come back to Sleep Therapy after your “something” has been addressed. ADJUSTING YOUR BEDTIME

You will now use your current sleep efficiency to determine your threshold bedtime for the upcoming week. Keep your rise time constant—the same as it was last week. Adjust your threshold bedtime according to the chart on the next page. Note: Never give yourself fewer than 5.0 hours in bed. So, now you have your threshold bedtime for the week ahead. In the clinic, sometimes people do this calculation and get a threshold bedtime that does not seem manageable. For example, Dave had great trouble staying up until 1:00 a.m., his threshold bedtime, for his first week of Sleep Therapy. His sleep efficiency for that week was 90%. According to the prescription of a new bedtime in the table on the preceding page, his new bedtime would be 15 minutes earlier (12:45 p.m.). However, Dave predicted this would be very difficult to do, and so we discussed what would be realistic and he thought that 12:30 would be doable. This is just to show you that you need to choose a threshold bedtime that is close to the one that is recommended, but also, of course, it needs to work for you. Because I am not with you in person to look at your sleep diaries and to help you decide on the best adjustment, you will need to use your judgment to choose a new threshold bedtime that is according to the prescription, or close to it, but is also reasonable for you. After all, you will be using that bedtime all week. Usually the adjustments are 0–15 minutes per week, but sometimes they are 30 minutes. Try to avoid adjusting more than 30 minutes. This will help ensure that your sleep continues to steadily improve.

Moving From Week 1 to Week 2: Adjusting Your Bedtime

75

Adjusting Your Threshold Bedtime Is your sleep efficiency...

If YES,

84% or less?

Set your threshold bedtime 15 minutes later this week, but always give yourself at least 5.0 hours in bed.

85% to 89%?

Keep the same threshold bedtime this week.

90% to 94%?

Set your threshold bedtime 15 minutes earlier this week.

95% or greater?

Set your threshold bedtime 30 minutes earlier this week.

My Week 2 threshold bedtime and rise time: Bedtime: 

        Rise Time: 

When you have decided on your new threshold bedtime for the week, record this, as well as your usual threshold rise time, in the chart Six Steps to Solid Sleep for Week 2 near the end of this chapter. Fill in your new bedtime at step 1 and your rise time at step 2. This will remind you of what you are aiming for this week. HOW DID JULIE DO? I will show you Julie’s sleep diary and her sleep efficiency calculations as well as her decision on a new bedtime. It is often much easier to follow the steps when there is a concrete example to refer to. You may notice that near the end of the week, Julie was drifting toward an earlier bedtime. This was because she was finding it very difficult to stay up until midnight. However, she was maintaining solid sleep so the desired effect was achieved. Her homeostatic sleep process was at work. Her sleep efficiency for Saturday night was 97%. Because this was greater than 95%, she moved her threshold bedtime earlier by 30 minutes. It had been midnight for Week 1, and she adjusted it to 11:30 p.m. for Week 2. Don’t worry if your sleep efficiency is not as high as Julie’s. Everyone is different; many people have a sleep efficiency between 75% and 95% after Week 1. If your sleep efficiency is below 75%, then review how closely you’ve been able to follow the Six Steps to Solid Sleep and re-read the section in Chapter 1 called Circumstances When This Book May Not Be Enough. Julie’s Week 2 threshold bedtime and rise time Bedtime:  

11:30 pm            Rise time:  

6:00 am

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76

WEEK 1 (Julie) Sleep Diary for the Week of:  DAY of the WEEK

SLEEP TIMING

Which night is being reported on?

1.  I went to bed at (clock time): 2.  I turned out the lights after ­(minutes): 3.  I fell asleep in (minutes): 4.  I woke up ___ time(s) during the night. (number of awakenings):

5.  The total duration of these ­ awakenings was (minutes):

6.  After awakening for the last time, I was in bed for (minutes):

SLEEP QUALITY

7.  I got up at (clock time):

May 3                        MON.

TUES.

11:45 pm

11:55 pm

0

5

5

10-15

0

0

0

0

30

30

6:01 am

6:00 am

8

8

/

/

/

/

/

/

The quality of my sleep was: 1 = very poor; 10 = excellent

Naps Number, time, and duration

Alcohol Time, amount, and type

Sleep Medication Time, amount, and type

Notes:

hard to stay up so late

Moving From Week 1 to Week 2: Adjusting Your Bedtime

                            Bedtime: 

Midnight    

77

  Rise Time:  6:00

am

WED.

THURS.

FRI.

SAT.

SUN.

12:00 am

12:00 am

11:30 pm

11:40 pm

11:45 pm

0

0

0

0

0

10

10

15

5

5

0

1

1

0

0

0

5 hot flashes

5 hot flashes

0

0

5

30

45

5

0

6:25 am

6:00 am

6:00 am

6:00 am

6:05 am

8

8

8

8

8.5

/

/

/

/

/

/

/

/

5:00 pm 1 glass of wine

/

/

/

/

/

/

Wow! A good sleep

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78

Julie’s Week 1 Sleep Efficiency

SLEEP TIMING

WEEK 1 Representative Night 1.  I went to bed at:

Date:  

Sat. from Week 1

11:40 pm (clock time)

2.  I turned out the lights after:

0

(minutes)

3.  I fell asleep in:

5

(minutes)

0 time(s) in 4. I woke up ____ night. 5. The total duration of these awakenings was:

(minutes)

6. After awakening for the last time, I was in bed for:

(minutes)

7.  I got up at:

0 5

6:00 am (clock time)

Calculations

B

A

C

Total Time in Bed

Total Awake Time

Total Sleep Time

Time between your bedtime (#1) and rise time (#7).

Add the numbers above in this column

A minus B

Convert hours to minutes by multiply­ ing by 601

  6 hours + 20 mins   = (6 x 60) + 20   = 380

380

(minutes)

10

(minutes)

D

Sleep ­Efficiency

C/A × 100% My sleep ­efficiency is 1 For example, if you were in bed for 8 hours and 20 minutes, this is the same as 8 × 60 + 20 minutes = 500 minutes.

97    %

370

(minutes)

Moving From Week 1 to Week 2: Adjusting Your Bedtime

79

WEEK 2 This week, you will be following the Six Steps to Solid Sleep again, using your new threshold bedtime. The steps are the same as before, apart from the adjusted bedtime.

Six Steps to Solid Sleep 1. Go to bed only when sleepy and not before your threshold bedtime. _____________ Fill in the threshold bedtime that you are now setting for Week 2.

2. Maintain a regular threshold rise time in the morning. _____________ Fill in your threshold rise time (usually the same as before).

3. Use the bed only for sleeping. Sexual activity is the only exception.

Do not watch television, listen to the radio, use electronic devices, eat, or read in bed.

4. Leave the bed if you can’t fall asleep or go back to sleep within 10–15 minutes. Return when sleepy. Repeat this step as often as necessary during the night.

5. If sleepiness is overwhelming, you may take a short nap (set aside no longer than 45 minutes) in the afternoon, between 1:00 p.m. and 4:00 p.m.

6. Maintain a sleep diary. Now it’s time to turn to the next blank sleep diary (Week 2) and label it with the date. Then, put your new threshold bedtime and rise time at the top. Having these times at the top of the sleep diary will make it easy for you to remember your mission. Keep track of your sleep for the next 7 days using this diary. Go for it! Reminders ●

●

●

Get out of bed as soon as you wake up in the morning. This applies to the situation of waking up in the morning earlier than your threshold rise time. For example, Julie woke one day at 5:30 a.m. and her threshold rise time was 6:00 a.m. She got out of bed at 5:30 a.m. and started her day. Otherwise, she would have spent 30 minutes in bed awake, which would have worked against her efforts to associate her bed with sleep. Remember to follow the Six Steps to Solid Sleep, which include getting out of bed if you are awake for more than 10–15 minutes during the night. Return when you are sleepy. Continue to exercise caution in your daily activities and avoid driving if you are sleepy.

These are the most common things I remind people of when they are heading into their second week of Sleep Therapy. Good luck this week.

80

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WEEK 2 Sleep Diary for the Week of:  __________________                                               DAY of the WEEK

SLEEP TIMING

Which night is being reported on?

1.  I went to bed at (clock time): 2.  I turned out the lights after (minutes): 3.  I fell asleep in (­ minutes):

SLEEP QUALITY

4.  I woke up ___ time(s) during the night. (number of awakenings): 5.  The total duration of these awakenings was (minutes): 6.  After awakening for the last time, I was in bed for (minutes): 7.  I got up at (clock time): The quality of my sleep was: 1 = very poor; 10 = excellent

Naps Number, time, and duration

Alcohol Time, amount, and type

Sleep Medication Time, amount, and type

Notes:

Moving From Week 1 to Week 2: Adjusting Your Bedtime

                                           Bedtime: ______________   Rise Time: ______________

81

CHAPTER 13

Moving From Week 2 to Week 3: Readjusting Your Bedtime

chapter guides you forward after your second week of Sleep Therapy. Of course, I’ll also let you know how Julie did. T his THE SECOND WEEK IS DONE Congratulations! You completed the second week. This is SO exciting! There will be only 1 or 2 more weeks to go of staying up late. If you didn’t stay up until precisely the threshold bedtime every night, don’t worry. Because of sleepiness, social events, work, children, and other demands, it is very difficult to be absolutely perfect with the schedule. I find that people are often very concerned about this, but if they are close to their threshold bedtime and rise time most of the nights of the week, then they do very well. After all, you are not in a research study, you are living your life, and you don’t have to be perfect. Look over your sleep diary for the week and make some observations. ●

How quickly are you falling asleep?

●

How many times are you waking up?

●

How long are you awake during the night?

●

How are your ratings of sleep quality? 83

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84

_______________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ WHAT SLEEP EFFICIENCY DID YOU ACHIEVE? As you have done before, choose a typical night from the past week. Mark that column of your sleep diary so you know which one it is. Turn to the chart called Calculating Your Week 2 Sleep Efficiency. Now you will be copying your sleep diary answers to Questions 1 to 7 for your typical night into the top section of this chart. Do the calculations for A, B, C, and then D. Now you will have your sleep efficiency for Week 2 of Sleep Therapy. If you are not sure if the night you chose is typical, you can always choose another one and compare the results. Pick the one that seems the most representative. Once you settle on an estimate of your current sleep efficiency, you will now set your threshold bedtime for the upcoming week. Keep your threshold rise time constant— the same as it was last week. Adjust your threshold bedtime according to the following chart. Note: If your sleep efficiency has not improved over the past 2 weeks, don’t continue to restrict your sleep. This technique is not meant to be used for weeks on end. Put an end to your torture, and skip ahead to the section on What to Do with Your Mind.

Adjusting your Threshold Bedtime Is your sleep efficiency

If YES,

84% or less?

Set your threshold bedtime 15 minutes later this week, but always give yourself at least 5.0 hours in bed.

85% to 89%?

Keep the same threshold bedtime this week.

90% to 94%?

Set your threshold bedtime 15 ­minutes ­earlier this week.

95% or greater?

Set your threshold bedtime 30 ­minutes ­earlier this week.

My Week 3 threshold bedtime and rise time: Bedtime: 

        Rise Time: 

Moving From Week 2 to Week 3: Readjusting Your Bedtime

85

Calculating Your Week 2 Sleep Efficiency

SLEEP TIMING

WEEK 2 Representative Night

Date:

1.  I went to bed at: (clock time)

2.  I turned out the lights after: (minutes)

3.  I fell asleep in: (minutes)

4.  I woke up ___ time(s) during the night. 5.  The total duration of these awakenings was: (minutes)

6.  After awakening for the last time, I was in bed for:

(minutes)

7.  I got up at: (clock time)

Calculations

A

B

C

Total Time in Bed

Total Awake Time

Total Sleep Time

Time between your ­bedtime (#1) and rise time (#7).

Add the numbers above in this column

A minus B

(minutes)

(minutes)

Convert hours to minutes by multiplying by 601

(minutes)

D

Sleep Efficiency

C/A x 100% For example, if you were in bed for 8 hours and 20 minutes, this is the same as 8 x 60 + 20 minutes = 500 minutes. 1

My sleep efficiency is

A self-calculating electronic form is available at www.sinkintosleep.com.

 %

Sink Into Sleep

86

When you have decided on your new threshold bedtime for the week, record this  and  your usual threshold rise time in the chart Six Steps to Solid Sleep for Week 3. HOW DID JULIE DO? Julie found that her sleep continued to improve. In Week 2, she had very few awakenings during the night and her ratings of sleep quality were mainly 7s and 8s. She found that a bedtime of 11:30 p.m. still felt very late. However, she discovered that she could use the extra time for doing some writing—a creative endeavor—that she had not found time to do for several years. That made it easier. Julie calculated her sleep efficiency for Wednesday; it was 81%. Then she realized that she had woken up earlier that morning than most other mornings, so she chose another night as her typical night. She chose Saturday, which seemed more typical and calculated a sleep efficiency of 93%. Based on this, she advanced her bedtime (moved it earlier) by 15 minutes, to 11:15 p.m. This was just fine with her, because she had found it tough to stay up until 11:30 p.m.

Julie’s Week 3 threshold bedtime and rise time Bedtime:   11:15 pm             Rise time:   6:00 am

Moving From Week 2 to Week 3: Readjusting Your Bedtime

87

WEEK 3 Time to move on to Week 3! Just like last week, you will be following the Six Steps to Solid Sleep.

Six Steps to Solid Sleep 1. Go to bed only when sleepy and not before your threshold bedtime. _____________ Fill in the threshold bedtime that you are now setting for Week 3.

2. Maintain a regular threshold rise time in the morning. _____________ Fill in your threshold rise time (usually the same as before).

3. Use the bed only for sleeping. Sexual activity is the only exception.

Do not watch television, listen to the radio, use electronic devices, eat, or read in bed.

4. Leave the bed if you can’t fall asleep or go back to sleep within 10–15 minutes. Return when sleepy. Repeat this step as often as necessary during the night.

5. If sleepiness is overwhelming, you may take a short nap (set aside no longer than 45 minutes) in the afternoon, between 1:00 p.m. and 4:00 p.m.

6. Maintain a sleep diary. You are now familiar with the process: Do your best to stay up until your threshold bedtime and to get up at your threshold rise time. Move to the next sleep diary form (Week 3), put in the date, and put your new threshold bedtime and your regular rise time at the top of the diary. Keep track of your sleep using this form for the next 7 days. Good luck. Reminder ●

Continue to get out of bed as soon as you wake up in the morning. This will help your sleep efficiency to remain high.

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88

WEEK 3 Sleep Diary for the Week of:  DAY of the WEEK

SLEEP TIMING

Which night is being reported on?

1.  I went to bed at (clock time): 2.  I turned out the lights after (minutes): 3.  I fell asleep in (­ minutes):

SLEEP QUALITY

4.  I woke up ___ time(s) during the night. (number of awakenings): 5.  The total duration of these awakenings was (minutes): 6.  After awakening for the last time, I was in bed for (minutes): 7.  I got up at (clock time): The quality of my sleep was: 1 = very poor; 10 = excellent

Naps Number, time, and duration

Alcohol Time, amount, and type

Sleep Medication Time, amount, and type

Notes:



Moving From Week 2 to Week 3: Readjusting Your Bedtime

Bedtime: ______________   Rise Time:______________

89

CHAPTER 14

After Week 3: Adjusting Your Bedtime Again. This Should Be It!

chapter guides you forward after your third week of Sleep Therapy. Again, I’ll let you know how Julie did. T his THE THIRD WEEK IS DONE Congratulations! You made it through your third week, and I bet your sleep is looking pretty good right now. Julie was finding that her sleep was good most nights. On 3 nights she slept right through without awakening and on the other 4 nights she had one brief (5–10 minute) awakening. She had one bad night—when she was awake for about 60 minutes before falling asleep and then she awakened early at 3:15 a.m.— but this was the exception. The other nights were very good. WHAT SLEEP EFFICIENCY DID YOU ACHIEVE? You are now at the point of making smaller adjustments to your bedtime. This is fine-tuning. As you have been doing, choose a typical night from the past week, mark that column of your sleep diary. Enter your sleep diary answers for Questions 1 to 7 in the top section of the chart called Calculating Your Week 3 Sleep Efficiency. Calculate A, B, C, and then D—your sleep efficiency.

91

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92

Calculating Your Week 3 Sleep Efficiency

SLEEP TIMING

WEEK 3 Representative Night

Date:

1.  I went to bed at: (clock time)

2.  I turned out the lights after: (minutes)

3.  I fell asleep in: (minutes)

4.  I woke up ___ time(s) during the night. 5.  The total duration of these awakenings was: (minutes)

6.  After awakening for the last time, I was in bed for:

(minutes)

7.  I got up at: (clock time)

Calculations

A

B

C

Total Time in Bed

Total Awake Time

Total Sleep Time

Time between your ­bedtime (#1) and rise time (#7).

Add the numbers above in this column

A minus B

(minutes)

(minutes)

Convert hours to minutes by multiplying by 601

(minutes)

D

Sleep Efficiency

C/A x 100% For example, if you were in bed for 8 hours and 20 minutes, this is the same as 8 x 60 + 20 minutes = 500 minutes. 1

My sleep efficiency is

A self-calculating electronic form is available at www.sinkintosleep.com.

 %

After Week 3: Adjusting Your Bedtime Again. This Should Be It!

93

Keep your threshold rise time constant and adjust your threshold bedtime according to the chart below.

Adjusting your Threshold Bedtime Is your sleep efficiency

If YES,

84% or less?

Set your threshold bedtime 15 minutes later this week, but always give yourself at least 5.0 hours in bed.

85% to 89%?

Keep the same threshold bedtime this week.

90% to 94%?

Set your threshold bedtime 15 ­minutes ­earlier this week.

95% or greater?

Set your threshold bedtime 30 ­minutes ­earlier this week.

My Week 4 threshold bedtime and rise time: Bedtime: 

        Rise Time: 

As before, write in your threshold bedtime and rise time in the chart called Six Steps to Solid Sleep (p. 95) for the upcoming week. HOW DID JULIE DO? Julie chose Saturday night for her calculations and got a sleep efficiency of 86%. She decided to maintain her bedtime at 11:15 p.m. and her rise time at 6:00 a.m. because her sleep was consistently good and she was not feeling sleep deprived. She calculated that she was getting about 360 minutes, or 6 hours, of sleep per night and that was enough for her to feel rested the next day.

Julie’s Week 4 threshold bedtime and rise time Bedtime:   11:15 pm             Rise time:   6:00 am

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94

YOUR OVERALL PROGRESS This is a good time to look over other aspects of your current sleep diary and compare them with your BASELINE sleep diary. Compared to your baseline week, ●

Do you fall asleep more quickly now?

●

Do you have fewer awakenings?

●

Are you awake for less time during the night?

●

And what about your ratings of sleep quality? Have they gone up?

●

Are you getting more sleep than you did before?

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Julie found that she was getting a bit more sleep than she had initially, and it was of much better quality. Reflecting on the changes in her sleep over the past 3 weeks, she was surprised that she only needed 6 hours of sleep per night. She had always believed that she needed more sleep than other people. Now she realized that she needed less sleep than many people and that it was okay to sleep for “only” 6 hours. Julie had been tired over the past year, and she had been going to bed earlier and earlier to try and get more sleep. She had grown up with and learned to believe the rhyme: “Early to bed, early to rise makes a (wo)man healthy, wealthy and wise.” However, the “early to bed” strategy had not improved her sleep. Rather, a later-tobed strategy, based on Sleep Therapy, was the answer. Not only did her sleep improve, but her daytime fatigue lifted. Other people noticed that she looked more rested than she had for some time. Her husband thought she was a changed person. She was not entirely sure if this was a compliment or not, but she guessed it probably was! MOVING ON FROM HERE By now, you have the know-how to continue to adjust your bedtime week by week if needed. You may need to make small adjustments of your threshold bedtime until your sleep, on almost all nights of the week, is of high quality and long enough so that you are refreshed and not sleepy the next day. Once this is reached, you will have discovered your own optimal sleep duration for this point in your life. Once again, congratulations. Julie continued to have a regular bedtime of about 11:15 p.m., and got up at 6:00 a.m.— this worked for her and she was satisfied with her sleep. Even though she continued to have some awakenings (e.g., for the bathroom or due to hot flashes), she was able to go back to sleep quickly. She told me: “I don’t worry anymore about falling asleep. I have trust in falling asleep.” Overall, she was more relaxed about her sleep.

After Week 3: Adjusting Your Bedtime Again. This Should Be It!

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At this point, Julie was wondering how to maintain her good sleep; she was a bit afraid that it would not last. Naturally, you may be wondering the same thing. It is important to know that you will be able to keep your good sleep going. You have learned the most important principles and steps that can always be applied to improve your sleep. It is helpful to set up a specific maintenance plan for yourself. Chapter 16 will guide you through this, allowing you to feel confident in your ability to maintain your good sleep. WEEK 4 AND BEYOND Here are your Six Steps to Solid Sleep. Insert your threshold bedtime and rise time for Week 4. You are probably close to a bedtime that is best for you at this point in your life.

Six Steps to Solid Sleep 1. Go to bed only when sleepy and not before your threshold bedtime. _____________ Fill in the threshold bedtime that you are now setting for the upcoming week.

2. Maintain a regular threshold rise time in the morning. _____________ Fill in your threshold rise time (usually the same as before).

3. Use the bed only for sleeping. Sexual activity is the only exception.

Do not watch television, listen to the radio, use electronic devices, eat, or read in bed.

4. Leave the bed if you can’t fall asleep or go back to sleep within 10–15 minutes. Return when sleepy. Repeat this step as often as necessary during the night.

5. If sleepiness is overwhelming, you may take a short nap (set aside no longer than 45 minutes) in the afternoon, between 1:00 p.m. and 4:00 p.m.

6. Maintain a sleep diary. You will find a blank sleep diary for Week 4 at the end of the chapter. After that, if you continue to monitor your sleep, you can download sleep diaries from Extra Forms which can be found on Springer Publishing Company ConnectTM and can be accessed by visiting the following url: http://connect.springerpub.com/content/ book/978-0-8261-4816-2. Note: I occasionally hear from people who have severely restricted their time in bed for several additional weeks. Do not do this! This technique should be doing its work by Weeks 3–4, and you should be getting close to your optimal sleep duration. Your optimal sleep duration is reached when you are getting quite solid sleep (e.g., about 85% sleep efficiency) and you are not feeling overly sleepy during the daytime. If you don’t feel you are progressing toward this, then discontinue sleep restriction. Continue to get out of bed when not sleeping, and move ahead to the section on What to Do with Your Mind.

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WEEK 4 Sleep Diary for the Week of:  DAY of the WEEK

SLEEP TIMING

Which night is being reported on?

1.  I went to bed at (clock time): 2.  I turned out the lights after (minutes): 3.  I fell asleep in (­ minutes):

SLEEP QUALITY

4.  I woke up ___ time(s) during the night. (number of awakenings): 5.  The total duration of these awakenings was (minutes): 6.  After awakening for the last time, I was in bed for (minutes): 7.  I got up at (clock time): The quality of my sleep was: 1 = very poor; 10 = excellent

Naps Number, time, and duration

Alcohol Time, amount, and type

Sleep Medication Time, amount, and type

Notes:



After Week 3: Adjusting Your Bedtime Again. This Should Be It!

Bedtime: ______________   Rise Time:______________

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CHAPTER 15

Do You Still Have Insomnia?

fter Week 4 of Sleep Therapy, I suggest that you check to see if you are now free from insomnia. You can do this by looking at the same things in your current A sleep diary that you did in Chapter 7, before you started Sleep Therapy. INITIAL INSOMNIA Look at your seven entries, across the week, in your current sleep diary at Question 3, and see how long it took you to fall asleep each night. Did it often (on 3 nights or more) take you longer than 30 minutes to fall asleep? If so, you are experiencing “initial insomnia” and you can circle “initial insomnia” in the right-hand column of the chart with the question “What Type of Insomnia Do I have Now?” on page 101. MULTIPLE AWAKENINGS Look across your current sleep diary at Question 4. Look at the number of awakenings you had each night. Did you often (on 3 nights or more) have more than 3 awakenings per night? If so, you can describe yourself as having “multiple awakenings.” If you answered yes, then circle “multiple awakenings” in the right-hand column of the chart with the question “What Type of Insomnia Do I Have Now?” on page 101.

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MIDDLE INSOMNIA Look at how long you were awake each night, which is at Question 5. Is this number often (3 nights or more) greater than 30 minutes? If so, you are experiencing “middle insomnia.” If this applies to you, then circle “middle insomnia” in the right-hand column of the chart with the question “What Type of Insomnia Do I Have Now?” on the next page. TERMINAL (END-OF-NIGHT) INSOMNIA Look over the times that you were awake in bed in the morning at Question 6. Was this often (3 nights or more) 30 minutes or longer? If so, was this because you woke up earlier than you had wanted? Do not count any mornings that you purposely lay in bed awake rather than getting up. Just count the mornings you woke up too early by more than 30 minutes. If you are waking up more than 30 minutes too early on at least 3 mornings, then you have “terminal” or “end-of-night” insomnia, so circle “terminal insomnia” in the right-hand column of the chart with the question “What Type of Insomnia Do I Have Now?” on page 101. YOUR SLEEP QUALITY On your current sleep diary, look at your sleep quality ratings across the days of the week. Take your most common rating. If, in Chapter 7, rather than having a “most common rating,” you calculated an average rating, then calculate your new average sleep quality rating now. Record your most common rating (or the average) in the chart on page 101 where it says “The Quality of My Sleep Now.” YOUR PROGRESS Take a long and careful look at this chart, and the same one in Chapter 7, p. 41. In comparing your answers to the same questions at baseline, what changes do you see? You probably deserve a big pat on the back about now. Time to move on to the chapter on maintaining your good sleep. If you are not satisfied with your progress after Week 4, I urge you to stop any sleep restriction. Instead, go to the section of this book on What to Do with Your Mind. If you think you may have a medical or sleep disorder (other than insomnia) that is interfering with your ability to benefit from the techniques I’ve already shown you, consult your family physician.

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After Sleep Therapy: What type of Insomnia do I have now? Long time to get to sleep (more than 30 minutes)

Many awakenings (more than 3)

Long time awake during the night (more than 30 minutes)

Waking up too early (more than 30 minutes)

The quality of my sleep now

Circle all that apply Initial Insomnia Multiple Awakenings Middle Insomnia Terminal Insomnia Most common rating now:

CHAPTER 16

Maintaining Your Progress (And Maybe Even Improving More!)

ften, people who are starting to improve their sleep worry that their progress is only temporary and that poor sleep will return. This was going through Julie’s O mind—she was feeling satisfied with her sleep but there was a little something telling her that this would not last. If you’ve had insomnia for several years, you may be especially prone to this fear of relapse. Now is the ideal time to look at maintenance strategies. Maintenance starts with reminding yourself that you have acquired new knowledge about your sleep and mastered the strategies that improve it. This is very important to remember; it means that you will never be back at square one.

Now, let’s take some very practical steps to anticipate what could happen. What is your fear? Is it that you will have a bad night? A totally sleepless night? A string of bad nights? Write down exactly what you think might happen: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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Based on what you now know, what could you do if this did happen? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________ 4. ______________________________________________________________________________

If you wish to get your sleep back on track, it is just a matter of recalling the Sleep Therapy steps that have already worked for you. Then, put them into action. When I ask people in my Sleep Therapy groups what they would do if they started to have some bad nights, they generally fill the whiteboard with ideas like this: ●

Stay up late, past my normal bedtime.

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Get up at the same time each day.

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Keep a sleep diary.

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Use visual imagery. (This is coming up in Chapter 17.)

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Get out of bed when I’m not sleeping.

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Don’t go to bed unless I’m sleepy.

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Do Clear-My-Head time. (Coming up in Chapter 17.)

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Reassure myself that one bad night does not forecast a string of bad nights.

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Know that I will function tomorrow even if I don’t have a good sleep tonight.

Sometimes, we actually choose to return to old habits, like reading in bed. This is just fine; it is, of course, your choice. This happened for a short time to Julie. As you know, she was sleeping well by staying up until 11:15 p.m. This was a much later bedtime than she had been accustomed to. One day in December, she told me she had “fallen off the wagon.” By this, she meant she had started to go to bed much earlier again because it was dark and cold outside, and she wanted to read in bed. She also felt comforted by going to bed earlier. With this resumption of early bedtimes, Julie was falling asleep fine but she was having some long awakenings during the night. At this point, she decided to keep doing what she was doing for a few weeks even though she knew what to do to make her sleep continuous. She knew she just had to read in her living room rather than in bed, and to stay up later. This is a nice example because it shows that if you have the know-how, you can apply it any time you choose. I want to point out that Julie felt somewhat sheepish about “falling off the wagon,” and this is a common feeling in this circumstance. I encouraged her to let go of this self-judgment. Indeed, you should do what you choose. Feeling guilty or being self-critical when you have poor sleep will serve no purpose other than to make your mind more troubled. So, have some kindness for yourself if poor sleep returns. Simply follow the Six Steps to Solid Sleep, shown on the next page, when you are ready, and your sleep will be back on track in no time!

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Note that you do not have to go back to the very beginning. I suggest using a temporary threshold bedtime that is based on your threshold bedtime from Chapter 14 (after Week 3): Make it 60 minutes later than that for 3–5 days. Keep a sleep diary. Extra sleep diaries can be downloaded from Extra Forms which can be found on Springer Publishing Company ConnectTM and can be accessed by visiting the following url: http:// connect.springerpub.com/content/book/978-0-8261-4816-2. After 3–5 days, adjust your bedtime according to what your sleep diary tells you. For example, if your sleep efficiency is very high, you would advance (make earlier) your bedtime. You will soon get back to solid sleep. Your goal is to get back to a point where you are having solid sleep that is long enough for you to feel rested, and not sleepy, during the daytime. In our clinic, people tend to keep sleeping well long after they complete our Sleep Therapy program. It is not uncommon for me to receive notes or cards from clients, months after the program, saying that they are still sleeping well. Also, from research, we know that after people learn cognitive behavioral therapy for insomnia (CBT-I), the techniques on which Sleep Therapy is based, they continue to benefit from them. For example, sleep researcher Dr. Charles Morin found, in a study with people aged 55 and over, that those who did CBT-I maintained their progress very well 2 years after they learned the techniques. Once you know the strategies for improving sleep, you can use them as needed. If you are curious about whether you can go back to some of your favorite habits like reading in bed, or sleeping in on the weekends, and still maintain your good sleep, you can always find out. Be a scientist. Try re-introducing one behavior at a time for a week, keep sleep diaries, and see what effect it has, if any, on your sleep. You are becoming more and more tuned into your own particular sleep–wake system. You are the expert on knowing what works best to maintain your good sleep.

Six Steps to Solid Sleep 1. Go to bed only when sleepy and not before your threshold bedtime.______________

Recall what your threshold bedtime was in Chapter 14 (page 95) and now make it later, for exam­ ple, by 60 minutes.

2. Maintain a regular threshold rise time in the morning. ______________

Fill in the threshold rise time that you had in Chapter 14 (page 95).

3. Use the bed only for sleeping. Sexual activity is the only exception. Do not watch television, listen to the radio, use electronic devices, eat, or read in bed.

4. Leave the bed if you can’t fall asleep or go back to sleep within 10–15 minutes. Return when sleepy. Repeat this step as often as necessary during the night.

5. If sleepiness is overwhelming, you may take a short nap (set aside no longer than 45 minutes) in the afternoon, between 1:00 p.m. and 4:00 p.m.

6. Maintain a sleep diary.

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Sleep Diary for the Week of:   ________________________                                             DAY of the WEEK

SLEEP TIMING

Which night is being reported on?

1.  I went to bed at (clock time): 2.  I turned out the lights after (minutes): 3.  I fell asleep in (­ minutes):

SLEEP QUALITY

4.  I woke up ___ time(s) during the night. (number of awakenings): 5.  The total duration of these awakenings was (minutes): 6.  After awakening for the last time, I was in bed for (minutes): 7.  I got up at (clock time): The quality of my sleep was: 1 = very poor; 10 = excellent

Naps Number, time, and duration

Alcohol Time, amount, and type

Sleep Medication Time, amount, and type

Notes:

Maintaining Your Progress

                                           Bedtime: ______________   Rise Time: ______________

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WHAT TO DO WITH YOUR MIND

CHAPTER 17

Calming the Racing Mind

“A ruffled mind makes a restless pillow.” Charlotte Brontë

s I write this, it is August and I am on vacation. I am sitting on a porch that looks out on a bay of the Northumberland Strait in Nova Scotia. In front of me are sand A dunes, packed with tall bright green grasses that are swaying in the breeze. Beyond the sand dunes is a great expanse of water, blue and gray. It is early morning and the tide is going out, exposing fawn-colored, rippled sand. The sky is mostly clear, but there are some small fluffy clouds. The air is soft and warm; the breeze feels gentle. Over to the right, along the beach, where the sea meets the sand, I see a great blue heron—a tall, thin bird with stick-like legs and long beak, waiting to see something appetizing in the water. To my left, about 200 meters in the distance, is a narrow spit of sand, which is becoming more and more exposed as the tide recedes. On this spit are six seals, sunning themselves and periodically slipping into the water. You may have a feel of the place by now. Do you?

Your ability to have a feel of this place demonstrates that you can take your mind to places that are different from where your mind was before. You can lead your mind to places of your choosing. And just by responding to my question “Do you?”, you are stepping back from your normal thoughts and adopting an “observer’s mind,” being aware of what your mind is doing—where it is, what types of thoughts and images are there. These two abilities—taking your mind to places that you choose, and having an observer’s mind—are very useful skills to develop. 111

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Developing these skills allows room for the “velvet hammer” of sleep to descend. Velvet hammer is a term used by a man who described to me how sleep had returned to him after a long bout of insomnia. He said a wee angel had gently knocked him on the head with a velvet hammer and this had restored his sleep. I like this image because it reflects the nature of sleep: It comes of its own accord, and not when we are searching for it. All we can do is to make the conditions conducive to sleep arriving and then leave the rest to our natural sleep processes. Overactive mental activity can be a big barrier to the velvet hammer, but it is one that is malleable. THE RACING MIND I often hear “My mind won’t shut off.” “I wish I could turn off my brain.” Many people with insomnia describe having racing thoughts at night. These thoughts are sometimes centered on stressful topics and trying to solve problems. Other times, the thoughts seem to be all over the place, not focused on specific issues; the mind flits from topic to topic. Naturally, an active mind interferes with sleep arriving; it prevents the velvet hammer from descending. What can you do with this racing mind? There are several helpful strategies for calming active thoughts. To begin with, it is helpful to take an observer’s stance, and notice where exactly your mind is going. Tonight, observe where your mind is when you are not sleeping. You may want to jot down your observations on a note pad next to the bed. The next day, look at your list. Thoughts or Worries About the Effects of Not Sleeping

Is your mind going to thoughts about not sleeping? Are there worries about what will happen if you don’t sleep? It is common for our fears and worries to grow and to become all-consuming in the middle of the night and to linger at the back of our minds during the daytime. In Chapter 18 (“It’s the Thought That Counts”), I will show you how to pinpoint your particular sleep-related thoughts and transform them into more realistic, less alarming thoughts. When Julie was working at her administrative job, she was acutely aware of the effects of not sleeping on her ability to do her job well. She needed to be on top of things, and to think clearly in order to make good decisions and interact with people effectively. At night, she worried: “If I don’t sleep tonight, I won’t be able to function tomorrow. I will perform poorly and it will be terrible.” After Julie identified these thoughts and evaluated her predictions, she came up with an alternate belief. Her new belief was: “I may not feel at the top of my game if I don’t sleep, but I can still function at work and get through the day okay.” This new, more realistic, thought was accompanied by less apprehension. It was actually a rather boring thought, and therefore less of a barrier to the velvet hammer. So, if you, too, have sleep-related worries or thoughts that keep you awake, the next chapter will be a good antidote. It may also be helpful to consider these three facts. First, everyone can only experience life one moment at a time, and so we have no influence over previous nights of

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poor sleep or any anticipated future nights of poor sleep. So, you can drop worries about those past and future nights. You have only this night that you can influence. Second, the effects of not sleeping, or sleeping poorly, for one night are less harmful than you might think (as discussed in Chapter 3). Third, with Sleep Therapy, which is cognitive behavioral therapy for insomnia (CBT-I), you are using the best treatment that exists for insomnia, and that is all you need to do right now. Trying to Sleep

Sometimes we try too hard to sleep. If you have ever told someone, “I was lying there, trying to sleep” or something similar, this implies that you are taking too much responsibility for controlling sleep. It is like trying to find happiness. Once we look too hard for it, it eludes us. It can’t be forced. Rather, it arrives when we are open to it, but not searching for it. So, you may be wondering, what can I do then, if I don’t try to sleep? The answer is: Just make the conditions good enough for your sleep processes to operate, using the sleep scheduling procedures of Sleep Therapy, and then let them do their thing. As you recall, if you haven’t slept within about 10–15 minutes, get out of bed and do something. Return when you feel the physical signs of sleepiness. No need to think about it. If you find that despite all this, you still feel you need to control your sleep, then this performance pressure may be the very thing that is preventing the velvet hammer of sleep from descending. For some people, this anxiety is lifted when they actually reverse what they are trying to do. Rather than trying to sleep, they try to stay awake. This is called “paradoxical intention.” If you feel you “must” sleep or “have to get to sleep” or you are “trying” hard to sleep, then give paradoxical intention a try, and see how long you can stay awake. Just by releasing the pressure on yourself to sleep, your internal sleep processes will be better able to do what they are designed to do— bring on sleep. Worries About Things Going on in Your Life

Are you worried about things that are happening in your life right now? It is very common to have worries about work, school, relationships, family, or health issues. If this is true for you, write these issues down. Then, consider which are productive worries and which are nonproductive. For example, if I am stressed about a deadline for a paper, this is a productive worry because I can start brainstorming to develop a plan for meeting the deadline or extending it. That is, I can probably use problem-solving techniques to resolve it. Whereas, if I am worried about what I said in a conversation and wish I had expressed myself more clearly, or if I have a large mortgage to pay down and know that it will take several years and there are vague uncertainties about my job prospects in 5 years, these are examples of nonproductive worries. It doesn’t matter how much time I put my mind on them, I cannot resolve them right now. As you might imagine, nonproductive worry takes energy and brain power but goes nowhere. It also adds to our frustration as we go around

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and around without a solution. These are the worries that you can learn to release and set free. For productive worries

A technique that many people find helpful is called “Worry Time.” I like to call it “Clear-Your-Head Time” because it can also be used for recurring thoughts, plans, or issues that you might not call “worries.” Clear-Your-Head Time involves sitting down in the evening with an old-fashioned (i.e., non-electronic) notebook, or a sheet of paper, and writing down all the things that come to mind, or are likely to come to mind, later that night in bed. You do this early in the evening, at least 2 hours prior to bedtime. After you have gotten all those issues out of your head and on paper (point form is good enough), then you come up with a solution, at least a temporary one, for each issue. You need to come up with something that will put that issue to rest for the night. For most issues, you will not be solving the whole thing during your Clear-Your-Head Time; you will just be deciding on what you do with that issue for the night. Solutions are things like: “I will phone Tim about that tomorrow at lunchtime.” Or “I can’t do anything more about that tonight so I will think about it some more tomorrow evening from 7:00–7:30.” This is a way of putting your issues to bed early so that they don’t pop up to disturb your sleep. If they do pop into your mind later while you are in bed, you can remind yourself that you have dealt with the issue(s) for the night and there is nothing left to work on now. All is well. Sometimes, things we have not anticipated—other issues—come into our heads while we are in bed. This is when I grab a piece of paper next to the bed and write down a word or two that summarizes the unanticipated issue and tell myself that I will deal with it tomorrow during my Clear-Your-Head Time. You may want to keep a blank sheet of paper or card with a pen next to your bed for this purpose. For nonproductive worries or miscellaneous thoughts

Nonproductive thoughts and worries are things that can be released and let go of at night. This is more easily said than done, I know. I find that the best way to release these thoughts is to use visual imagery. By this, I mean you will be using your ability to imagine things in your mind’s eye, just as you were able to see the scene at the Nova Scotia shore even though you weren’t there at the time. I will give you some examples of useful methods that you can try. For thoughts that go round and round in your head and are getting you nowhere, you can imagine each thought, or group of thoughts, being engulfed by a bubble which then floats upward into the sky. When I was having trouble letting go of certain patterns of thought that were interfering with my sleep a few years ago, I tried the bubble imagery. However, my bubble was too fragile and I saw it bursting and not doing the job of carrying away my thoughts. So, I then imagined a more resilient bubble—more like a rubber ball—enclosing my thoughts. I envisioned myself whacking this ball with a baseball bat into outer space. That was fine for a

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few seconds. But then my ball-balloon went right around Earth and returned from behind me! I was annoyed, but also amused. I then batted it again. This time it went around Earth, passed by me, and soared over the ocean. I then saw it fall and break into pieces as it hit the water. The pieces descended into the depths, becoming finer and finer as they sank toward the bottom of the sea. Along the way, the biodegradable pieces were eaten by fish until there was nothing left. Then, finally, I felt satisfied that I had let go of those thoughts! So you see that you can use your imagination to let go of even very stubborn thoughts. It’s like this quote from Mark Twain: “Drag your thoughts away from your troubles … by the ears, by the heels, or any other way you can manage.” Some people find it very helpful to “shelve” their thoughts for the night. They figuratively put them on the top shelf of a cupboard, often in a box. You can make it a shoe box, a square box, a hat box, or whatever size and shape of box you wish. The box can be whatever color or pattern that you imagine. The main thing is that you put away your thoughts in this safe place, where they can always be retrieved at another time (or not). You can have some fun with the details of this shelving process. Your imagination is the limit. What to Do With Your Mind After You Have Let the Issues Go?

You may now be wondering, “What do I do now that I have let go of the issues that were on my mind?” I suggest you take your mind into your sock drawer and see if you can see how your socks are arranged in there. Really! What do your socks look like? How do they sit in the drawer? Or you might want to imagine waves rolling in, and looking at each wave as it moves toward the shore. You could imagine looking at clouds in the sky and seeing shapes in them. Basically, occupying your mind with images is a way to step off the overactive-thinking train. You want images that are pleasant and somewhat boring. For some reason, counting sheep as they jump over a fence does not seem to help many people. However, you could imagine a flock of sheep standing in a field and, one after another, lying down to sleep. Did you know that sheep first drop down on their “elbows” and then lower their behinds? Sleep researchers have found that, as we drift off to sleep, we have what’s called “hypnagogic mentation,” which is most often fleeting visual images. These images are moving and may include shape patterns of things we have recently been watching. I have a hunch—this has not yet been scientifically tested—that if your mind is already in a visual mode, rather than a problem-solving, thinking mode, your brain is in a state more conducive to sleep arriving. So, when I have trouble sleeping, I try to go to visual images when I’m in bed, and do my thinking when I’m out of bed. DEVELOPING AN OBSERVER’S MIND Another approach to get out of problem-solving mode, or overactive-thinking mode, is by training your mind with meditation. There are many types of meditation and you can choose the type that suits you best. In meditation, we learn how

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to focus the mind on one thing, letting other thoughts and mental events float away. I will introduce you to mindfulness meditation. I find it is an antidote to today’s fast-paced, multitasking world. Mindfulness is about being aware in the present moment and without judgment. I will describe formal practice and informal practice. If you are new to meditation, then I suggest you start by doing formal practice during the daytime, sitting up. After you are comfortable with the methods, then you might do some informal mindfulness practice when you are awake in bed at night. (However, remember that you should never be awake in bed for longer than about 15 ­minutes.) Formal Mindfulness Practice

Formal mindfulness practice involves setting aside some time each day to focus the mind. Start by sitting comfortably, in a dignified posture, and focusing on the physical sensations of your breath. Without altering your breathing, simply observe it. You could choose to be aware of your chest or abdomen rising and falling, you could be aware of the sound of your breath, notice the sensation of the air as it enters the nostrils, or the air as it leaves the nostrils or the mouth. You might pay attention to the rate or depth of your breathing, or the period between each breath. Choose one of the many aspects of your breathing and focus your attention there. Your breath is always with you, so it is an ideal focus that can be used anywhere, any time. Throughout history, people have used the breath to focus the mind. If you are really focusing, you may notice that one breath is different from the next, and you may notice aspects of your breath that you have never noticed before. There is no need to adjust your breathing to make it deeper or slower; simply observe what you find. Some people find that they do not like focusing on the breath. For people in the clinic who are uncomfortable with this, I usually suggest that they notice the physical sensations of one hand clasped in the other, on their lap. So as you are sitting, you would notice the touch of one hand on the other, the points of contact, the warmth, the heaviness, and so on. An important part of any meditation is noticing thoughts or sounds or pains that distract us from the focus. It is completely normal to be distracted. Our minds are meant to wander. So, the idea is to accept these wanderings and, when you notice them, gently guide your mind back to the focus. It is important to do so kindly, without judgment. At first, you may have to do this hundreds of times during a formal practice. That’s entirely fine. It’s good to notice these distractions—that is part of the awareness. You are developing your observer’s mind. You could start with 5 minutes of formal practice and work up to 20 minutes per day. You can guide yourself using the exercise here, or play a mindfulness recording so that someone’s voice guides you through. Guided mindfulness meditations are available in CD format, or as audio tracks on websites or apps. Over time and with experience, you will probably find that you do not need printed or recorded instructions anymore; you will be guiding yourself in formal practice.

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A starter exercise in Mindfulness Meditation Practice ●

Set aside 5 minutes when you won’t be interrupted.

●

Sit in a chair, with your feet grounded on the floor.

●

Assume a dignified posture.

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Close your eyes and become aware of your breath.

●

●

●

To cue your awareness of your breath, you could start with a sigh or a release of air, and then notice the re-filling of your lungs. Notice how the belly rises as air comes in. Follow each subsequent breath and pay attention to your belly rising and falling. You may start to become aware of your nostrils and how the air feels as it enters your nose and how it feels when it is released. As you breathe, let yourself notice whatever there is to be noticed about each breath.

●

Silently count each breath, up to 10.

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Then, start again at 1 and count in rounds of 10. If you lose track, start again at 1.

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Each and every time your mind is distracted from observation of the breath, gently guide your mind back to your breath. After five rounds of 10 breaths, allow your eyes to open. Notice how you feel.

Repeat each day for a week. The next week, increase your time to 10 minutes. Continue to increase the duration of your practice by 5 minutes per week, until you reach 20 minutes per day. Informal Mindfulness Practice

Whereas formal mindfulness is a disciplined practice of setting aside a time each day to focus the mind on one thing, informal mindfulness is being aware, in our day-to-day existence, of our experience—whether it be physical sensations, our five senses, our thoughts, or our feelings. As with formal mindfulness, we do so without judgment. This sounds very big and all-encompassing, but it starts simply. It begins by just taking a minute now, whatever you happen to be doing, to be aware of how your body is, what is going through your mind, what sounds you hear, what your eyes see. Be totally immersed in the moment. Informal practice is incorporated into your everyday activities—you do whatever you are doing mindfully, rather than automatically. For instance, you might brush your teeth mindfully, wash dishes mindfully, put out the recycling and garbage mindfully, or interact with your pet mindfully. I suggest 1 minute because at first it is difficult to be totally mindful for even that length of time. As you get more practice, you will have more mindful minutes during the day. Being mindful allows us to be present now, rather than being caught up in problem-solving mode, planning mode, replay mode, or whatever other

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track our minds tend to go on. It allows us to experience life from moment to moment rather than being elsewhere in our thoughts. You can use informal mindfulness practice if you are awake in bed at night. Lying in bed, you could become aware of your breath, observing the same aspects that you observe during your formal practice during the day. If you are someone who does not like to focus on your breath, you might choose to notice other physical sensations like the points of contact between the bed and your skin, how each of those points feels physically—noticing things like warmth, softness/hardness, flatness—or notice how your legs and feet contact each other. As before, do not be disturbed by intruding thoughts, just notice them and let them go, like clouds in the sky, let them float by. And remember, get out of bed and do something if you are awake for more than 10–15 minutes.

CHAPTER 18

It’s the Thought That Counts

ay I’m in bed thinking, “Here we go again, I’m not sleeping AGAIN. This is SO frustrating. My partner is fast asleep, how unfair! I’m going to feel miserable S tomorrow.” I already feel discouraged just writing down these thoughts. If this kind of internal dialog is familiar to you, hang on, this chapter has methods to overcome this negative self-talk by replacing it with balanced thinking that includes some realistic optimism.

We humans have problem-solving, thinking brains that are always trying to make sense of our world. Thank goodness for that, as our survival and success in life depends upon these advanced mental processes. They help us recognize and avoid danger; they also allow us to form an understanding of events, ourselves, and our surroundings. When we have not slept well for many nights, it is normal to have thoughts about our insomnia—about how we “should” be sleeping, what it means to not sleep well, what consequences will occur without enough sleep, what tonight’s lack of sleep will mean for future nights, and so on. We think, we analyze, we stew, we get frustrated. For many issues that emerge in life, like having a snowstorm on the day of a meeting you’ve arranged, this type of mental activity helps reach a decision. We think about whether to hold the meeting, or to postpone or cancel it. We can make a decision that resolves the issue. However, the same type of mental activity tends not to solve our insomnia but actually does the opposite; it keeps us from sleeping. That is the paradox. So, how do we let go of this automatic mental activity that impedes sleep? In the previous chapter, we looked at several methods of calming the mind. Nonetheless, sometimes 119

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sleep-related thoughts persist and this is when we need to face them head-on, evaluate them, and respond to them in a new way so they are not so alerting and troubling. This chapter introduces you to the “cognitive therapy” component of cognitive behavioral therapy for insomnia (CBT-I). In a fascinating study from Glasgow, Scotland, researchers studied the thoughts running through people’s minds when they were having trouble falling asleep. They asked 21 people with insomnia to say aloud what was going through their minds— in real time—while they were in bed at home, not sleeping. Examining three nights’ worth of voice-activated recordings of these nighttime thoughts, the researchers were able to characterize the types of thoughts that arose. Broadly, they included problem-solving thoughts (thoughts about today, tomorrow, things to be done, family, friends, work-related issues), thoughts about one’s current state (about feeling exhausted, the need for sleep, efforts to sleep, importance of sleep, consequences of not sleeping, thinking about thinking, mind buzzing, uncontrollability of sleep, thinking about heart rate, headache, tension, restlessness, getting insufficient sleep), and thoughts about noises and other interruptions to sleep (thinking about sounds of the wind, wood creaking, clock ticking). It is the second type of thoughts— about not sleeping and the consequences—that receives the most focus in cognitive therapy for insomnia. This is because such thoughts lend themselves to unhelpful thinking trails that can become more and more worrisome and unsettling. For example, an unhelpful thinking trail could develop this way: “Sleep is so important… I’m not getting enough… I am going to get sick because of this sleep problem… I’m already not feeling right… I’m physically and mentally unable to sleep… There is something hugely wrong with me.” Some of the most common thinking trails involve themes of not getting a normal amount of sleep; the negative effects of not sleeping on daytime functioning, mood, and health; and a sense of lack of control over insomnia. This is all to say that if these types of thoughts are similar to ones you are having, you are not alone, and I invite you to discover much more helpful thinking trails by using the techniques outlined in this chapter. I’m going to show you how to identify your own sleep thoughts, how they interact with your feelings while you are in bed ready for sleep, and how you can take control. You will be revising these thoughts so they are less likely to interfere with sleep’s arrival. Sometimes, it is difficult to nail down the thoughts that are occurring at night as we wait for sleep to come. They are quick and automatic, like the multitude of thoughts that flow through our minds each day. So, the first step is to pause and notice them. The upcoming exercise will help you do this. Before we start, a few words about telling the difference between “thoughts” and “feelings.” In everyday life, thoughts and feelings co-occur and are intertwined. But for this exercise (and anytime you want to get in touch with what’s happening emotionally for you), it is very useful to untangle them. A thought is a mental event, the

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product of thinking. It could be an idea, a belief, or an automatic, fleeting thought that is triggered by an event. Here, you will be looking at the automatic thoughts that arise when you are not sleeping. For example, “I’m going to feel miserable tomorrow.” By contrast, a feeling is an emotion that is usually just one word. For example, “discouraged” or “frustrated” or “happy” or “lonely.” Feelings emerge quickly and they are often experienced in the body. Next time you feel frustrated, notice your body. Are your shoulders tense? Is your jaw tight? What’s happening with your stomach? Feelings are basic and instinctive and easier to identify than thoughts. Therefore, in the following exercise, I start with asking you about your feelings, and then ask you to identify your associated automatic sleep-related thoughts. 1. Remember last night (or another recent night) when you were in bed, wanting to sleep but not sleeping. Do you remember how you were feeling at the time? What emotion(s) were you experiencing? (For example, people with insomnia sometimes report feeling frustrated, annoyed, angry, helpless, depressed, anxious, worried, alone, troubled, discouraged.) Write those feelings here: ______________________________________________________

 Now, circle the one you felt most strongly. If you were to rate the intensity of that feeling at the time, what would it be on a scale of 0–100? ____________________ 2. Now, when you remember being in bed awake and feeling this way (your circled feeling), can you recall what thoughts you were having? Write down those thoughts.

Now, circle the thought that is most connected to your emotion. Let’s call that your main unsettling sleep thought (your “m.u.s.t.”). 3. Now, consider if your m.u.s.t. falls into any of the thinking traps that are common when people have insomnia. Fortune-telling: Foretelling events and your feelings.

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e.g., Predicting that your sleep will be poor or absent and that you will feel awful tomorrow. “I’m not going to sleep tonight and I’ll have a miserable day tomorrow.” Catastrophizing: Seeing the situation as extremely negative. e.g., Thinking or worrying about long-term irreversible health or personal problems related to insomnia. “My sleeplessness is causing me to be irritable with my family and I’m becoming an angry and depressed ogre; My body is breaking down without sleep and I am likely to have a heart attack or to get cancer.” Underestimating your ability to manage your sleep: Thinking that your sleep is totally out of your control. e.g., “I’ve tried everything; nothing works. My sleep problem is controlling me.” Setting a standard: e.g., Thinking that you should or must get 8 hours of sleep each night. “I need to get 8 hours of sleep to feel good and to get things done.” Other: Perhaps your thought does not fall into one or more of these traps. That’s all right; if it’s connected with distress about sleep, it’s a good one to work on. 4. Challenge your m.u.s.t. Be like the lawyer for the other side. Here are some ways to challenge thoughts that fall into the common traps. Fortune-telling: Are you 100% sure of your future tonight and tomorrow? Is there any room for other possibilities? Catastrophizing: Is there any clear evidence that your insomnia is causing permanent health problems? Underestimating your ability to manage your sleep: Is there any evidence that there are things you are doing now that help reverse insomnia? Setting a standard: How do you know that you need 8 hours of sleep? Does everyone need 8 hours every night? Other: Is your statement entirely realistic and balanced? Can it become less unsettling while being realistic and true? 5. Create a counter-statement to your m.u.s.t. You may have to draft a few possibilities before deciding on one. This statement will be less extreme, more realistic, and much more boring than your m.u.s.t. It is important that this counter-statement not be just the opposite of your m.u.s.t., and it is not “positive thinking.” Your new thought will be a balanced statement that acknowledges aspects of your unsettling thought but takes a more neutral perspective. You can always look back at Chapter 3 for some scientific evidence to back up your new

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statement. Once you are content with this counter-statement, you can call this your main adaptive sleep thought (m.a.s.t.). Circle your m.a.s.t.

6. While thinking your m.a.s.t., re-rate the level of your circled feeling (0–100): ________. Compare it to the rating you had at step 1. Has it changed? If it has stayed the same or increased, you haven’t yet found an adaptive sleep thought. Try other counter-statements until you have settled on one that brings down the intensity of the feeling. 7. Write down your m.a.s.t. and repeat it to yourself so that you will remember it.

8. Put it into action at night. As you get ready for bed, get into bed, or are lying awake in bed at any point in the night, notice if your m.u.s.t., or some variation of it, is popping up. If so, replace your m.u.s.t. with your m.a.s.t. Remember that your adaptive sleep thought is solidly based in reality. Repeat your m.a.s.t. and reassure yourself. 9. PRRR. I really like the soothing sound of a cat purring, and maybe you do too. The PRRR1 acronym reminds you to Pause, Recall, Replace, and Reassure. Pause—and notice your thoughts. Recall—Remember that your m.u.s.t. was not helpful and your m.a.s.t. is both realistic and helpful. Replace—Tell yourself your m.a.s.t. Reassure—Reassure yourself that you are doing just fine. 10. Repeat the steps if you’d like to work on another unsettling sleep thought. You can use the Finding Adaptive Sleep Thoughts worksheet. Extra worksheets can be found on Springer Publishing Company ConnectTM and can be accessed by  visiting the following url: http://connect.springerpub.com/content/book/ 978-0-8261-4816-2. I’ve included an example based on a real person with insomnia. Note that the new statement, the m.a.s.t., is much less extreme. It is rather boring. That’s what you want! PRRR was inspired by psychologist William J. Knaus’s “PURRRRS,” a technique for people with procrastination. Knaus WJ. 1998. Do it Now: How to Break the Procrastination Habit. New York: John Wiley & Sons.

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Example: Adaptive Sleep Thoughts Worksheet Situation: Not sleeping

Feelings:

Strongest Feeling: anxious

• worried • anxious • fearful • discouraged

Intensity rating (0–100) now: 85

Intensity rating (0–100) later: 40 Thoughts associated with strongest feeling:

I won’t be able to sleep tonight. What a disaster. I won’t be able to function at work tomorrow. I’m never going to be able to sleep again.

Circle your main unsettling sleep thought. Does this thought involve fortune-telling, catastrophizing, underestimating your ability to manage your sleep, setting a standard, or other?

I underlined the most relevant ones.

Counter-statements: It is not 100% certain that I will never be able to sleep again. In fact, I probably will be able to sleep sometime. I don’t have to think about all the future nights now. One night at a time; I am using some Sleep Therapy strategies that work so I’m doing what I can. Choose one that is realistic and that lowers the intensity of your feeling.

Your main adaptive sleep thought: One night at a time. I am using some strategies that work so I’m doing what I can.

Remember to PRRR tonight!

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Adaptive Sleep Thoughts Worksheet Situation: Not sleeping

Feelings:

Strongest Feeling: Intensity rating (0–100) now:

Intensity rating (0–100) later: Thoughts associated with strongest feeling:

Circle your main unsettling sleep thought. Does this thought involve fortune-telling, catastrophizing, underestimating your ability to man­ age your sleep, setting a standard, or other?

Counter-statements:

Choose one that is realistic and that lowers the intensity of your feeling.

Your main adaptive sleep thought:

Remember to PRRR tonight!

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Adaptive Sleep Thoughts Worksheet Situation: Not sleeping

Feelings:

Strongest Feeling: Intensity rating (0–100) now:

Intensity rating (0–100) later: Thoughts associated with strongest feeling:

Circle your main unsettling sleep thought. Does this thought involve fortune-telling, catastrophizing, underestimating your ability to man­ age your sleep, setting a standard, or other?

Counter-statements:

Choose one that is realistic and that lowers the intensity of your feeling.

Your main adaptive sleep thought:

Remember to PRRR tonight!

SLEEP AS YOU GO THROUGH LIFE

CHAPTER 19

Women’s Sleep

Y

ou guessed it—women are more likely than men to have insomnia.1 At least, they report it more often on surveys. About 11% of women have persistent insomnia that is severe enough that it interferes with their functioning, and many others are simply dissatisfied with their sleep. Some estimates are as high as 61% for the percent of women who have some kind of sleep problem. Why are the rates high in women? Well, perhaps women have a greater awareness of their sleep and well-being, and perhaps they are more likely than men to acknowledge and report physical and mental distress. Biological factors may also come into play: pregnancy and menopause are times when sleep is apt to be especially disturbed. In addition, although many men are active in family caregiving, women tend to be more involved in nighttime care of babies, children, and older relatives. This nighttime vigilance for the needs of young ones and/or older adults can contribute to sleeplessness, even after the children have grown up and the nighttime caregiving ends. Also, many women are pulled in several directions by demands of work, home, and family; this sets the stage for nighttime worries and problem-solving mental activity that can prevent sleep from arriving. HOW INSOMNIA STARTS A family history of insomnia increases the likelihood of developing insomnia, especially if your mother had sleep difficulty. The extent to which this reflects genetic

Find the original research for this chapter and others in the Bibliography found on Springer Publishing Company ConnectTM. This can be accessed by visiting the following url: http://connect.springerpub .com/content/book/978-0-8261-4816-2 1

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predisposition and/or the environment in which you grew up is unclear; probably it is a combination of both nature and nurture. If you, like your mother, are prone to hyperarousal—overstimulation of mind and body—then you are more likely to develop insomnia. While you were growing up, if your mother did not sleep well, you may have picked up some sleep-hindering habits yourself, such as going to bed too early, having variable bedtimes and rise times, or worrying about not sleeping. Whatever the mechanism behind the influence of family history on your sleep, you are not locked into insomnia just because it runs in your family. There are many situations where the family is insomnia-prone but the person isn’t and vice versa. Also, if you do have insomnia you can certainly learn to sleep well by using cognitive behavioral therapy for insomnia (CBT-I), the basis of Sleep Therapy, regardless of your family history. By adolescence, about 5–10% of girls have insomnia. A study of adolescents, age 13–16 years, in Detroit, Michigan, found that before the onset of menses, girls and boys had similar rates of insomnia. It was after girls started menstruating that their rates of insomnia climbed steeply, surpassing that of boys. Girls ended up being 2.5 times more likely to have insomnia than boys. Whether this increase in insomnia rate is linked to hormonal changes that occur at puberty in girls or to social developmental changes (e.g., young teen girls being more excited about social relationships) is unknown. This is an area we need to more fully understand, especially because there are signs that adolescent insomnia is not just a fleeting period of poor sleep; it tends to linger. THE MENSTRUAL CYCLE Some girls and women experience worse sleep in the 3–4 days before their menstrual period than at other times in their cycle. This is especially likely if you have premenstrual symptoms like depressed mood, irritability, appetite changes, and feeling tense or on edge. In most women, the sleep changes are quite subtle and may even go unnoticed. However, when periods involve pain and cramping, sleep is more obviously affected. Women with painful periods are more likely than other women to experience poor sleep, unpleasant dreams around their period, and greater sleepiness in the 2 weeks before their period. For painful periods, nonsteroidal anti-inflammatory medications (e.g., ibuprofen, naproxen sodium) can be helpful for both relieving the pain and improving your sleep quality.

What about sleep when you take oral contraceptives? The effects have rarely been studied, but the few bits of research show negligible differences between sleep with oral contraceptives compared with sleep without oral contraceptives.

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PREGNANCY Changes in a woman’s sleep are evident within 11–12 weeks of pregnancy. This is not surprising given that the first trimester—the first 3 months of pregnancy—may bring nausea and vomiting (formerly called morning sickness), back pain, and a need to urinate more frequently. Women often feel fatigued, and more than half are excessively sleepy during the first trimester. Most pregnant women nap: in a survey of 2,427 pregnant women, 78% said they napped at least once per week. On average, they napped 2–3 times per week and slept for about 90 minutes each time. The sleepiness is probably related to high levels of the hormone progesterone, which, in addition to protecting the lining of the uterus for the fetus, promotes sleep. Consistent with women’s reports of poorer sleep quality at night, sleep laboratory measures show a reduction in deep, slow wave sleep and an increase in the number of awakenings during the first trimester. In the second trimester—the middle 3 months of pregnancy—there is usually some relief from the nausea. Other physical pressures develop including abdominal discomfort, lower back pain, movements of the baby, pressure on the bladder, heartburn, cramps or tingling in the legs, and shortness of breath. These changes lead to further sleep disruption and awakenings. Researchers are divided about whether deep sleep increases, decreases, or stays about the same as the pregnancy progresses. It would be nice to think that it increases, and provides super-restful sleep for the mother-to-be but this may be wishful thinking. What is clear is that there are more frequent awakenings as the pregnancy advances. By the third trimester—the last 3 months of pregnancy—almost all women wake up at night because of physical discomfort or a need to urinate. In late pregnancy, the most comfortable sleeping position may be on your side with a pillow between your knees. Try different pillow arrangements to see what is most comfortable for you. If you are sleepy during the day and circumstances allow it, lie down for a nap.

Women are often aware of dreams during their pregnancy. It is not uncommon to have dreams about the baby; one study found that 35–40% of pregnant women reported having such dreams. Nightmares may also occur and sometimes these disturbing dreams involve the baby being in some kind of danger. Naturally, these dreams can be alarming for the mother-to-be. They no doubt reflect normal maternal concerns about the child’s safety. It may be reassuring to know that dreams do not predict the future but they may play a useful role in pregnancy. Dr. Rosalind Cartwright, one of the world’s preeminent dream researchers, believes that dreams help us to regulate our emotions, and that anxious pregnancy dreams may allow the woman to rehearse responses to possible difficulties and to process the natural anxiety around labor and delivery. It is very common to have some anxiety and fear

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about childbirth. A survey from British Columbia found that 79% of women who were very close to their due date, at 35–39 weeks of pregnancy, had moderate to high levels of childbirth fear. Those women who were most fearful had more stress in their lives and had fewer people around to help. They were also likely to be fatigued and to get less sleep. Therefore, this very common type of fear during the late stages of pregnancy can sometimes lead to further sleep difficulty. It is only recently that researchers have been examining the effectiveness of various strategies for sleep problems in pregnancy. North American studies are showing that the techniques of CBT-I—the same ones I’ve shown you in this book—are effective at improving sleep, and also mood, in pregnancy. Mindfulness, yoga, and relaxation techniques are also helpful for reducing sleep disturbance and improving sleep quality. Pregnancy increases the risk of developing some other sleep disorders. “Restless legs syndrome” involves uncomfortable sensations in the legs, like crawling, tingling, or aching, with a strong urge to move them. These sensations are most likely to happen when you are resting or lying in bed in the evening. They usually go away with movement such as walking or stretching. At least one-quarter of pregnant women experience restless legs. No one knows for sure why pregnancy can bring them on, but possibilities include the influence of reproductive hormones or low iron levels on the neurotransmitter (chemical messenger between nerve cells) dopamine, which is involved in movement control. When leg restlessness occurs, it usually starts in the third or fourth month of pregnancy and increases to a maximum by the sixth to eighth month. Interestingly, restless legs syndrome subsides in the ninth month and usually stops around the time of delivery. If you are someone who had restless legs prior to pregnancy, you can expect this problem to worsen during pregnancy and then return to pre-existing levels after the baby’s birth. How does restless legs syndrome affect sleep? Frankly, it is difficult to say how it affects sleep in pregnancy because there is already so much sleep disruption happening! However, this uncomfortable sensation in the legs, combined with the need to move them, may make it even harder for you to fall asleep. Those women who have restless legs syndrome have an 80% chance of also having “periodic limb movement disorder.” This occurs when one or both legs move repeatedly in a motion that involves the big toe flexing and the other toes fanning out. It can also involve flexing of the ankle, knee, and even the thigh. Usually it is just one leg moving at a time: one leg jumps or twitches for a while and later the other one may start up. These movements each last for 1–10 seconds and often continue at regular intervals of 20–40 seconds during the light stages of sleep. They can cause mini-arousals in your sleep and occasionally they contribute to nighttime awakenings. However, usually, they go unnoticed except perhaps by the person who shares the bed. Snoring is also a frequent companion of pregnancy. By the third trimester about two-thirds of women are aware of snoring at least sometimes, and many have

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breathing irregularities during sleep. These irregularities are called “sleep related breathing disorders.” They can include loud snoring, shallow breathing, and/or partial or full obstruction of the upper airway during sleep. Airway obstruction can cause you to stop breathing for short periods. Each episode of airway obstruction is called an “apnea” (which literally means “without breath”) and “obstructive sleep apnea” is the sleep disorder that is diagnosed if apneas occur with a minimum duration and frequency overnight. Breathing irregularities are especially likely to occur in late pregnancy and they generally subside after the baby’s birth, except in some women who already had them prior to pregnancy. Sleep related breathing disorders can disrupt sleep, increase blood pressure, and affect cardiovascular health. Women who are overweight are especially prone to this type of breathing disorder during sleep. If you suspect that you have breathing irregularities during sleep, whether pregnant or not, you should tell your doctor. So that’s the bad news about sleep in pregnancy. The “up” side of the story is that some of the sleep disorders that arise during pregnancy subside after the baby’s arrival. Now the baby becomes the source of big-time sleep disruption! DELIVERY AND POSTPARTUM Childbirth is a time when your sleep is bound to be totally disrupted. Face it: Your sleep will be wrecked. For the hours around the actual birth, no one can predict when and how much sleep you will get. It will be influenced by your physical state, your emotional state, the duration of labor, the type of delivery, the time of the baby’s arrival, prior sleep loss, how much excitement there is around you, and probably many other factors. Women just fall asleep when they can during this momentous experience. The “postpartum” period is the time shortly after childbirth. Now there are two ­individuals—mother and infant—with sleep patterns that are intertwined, each affecting the other. During this time, the demands of feeding and care of the newborn disrupt the mother’s sleep and her nighttime sleep is shorter than it was during pregnancy. However, breastfeeding is associated with deeper sleep in the mother, perhaps because of prolactin, a hormone that rises during pregnancy and postpartum and that allows breast milk to be produced. This may make it easier for the mother to return to sleep after nighttime awakenings. In addition, the mother now takes more naps. Researchers from New Zealand looked at sleep patterns of women for a week at different times during pregnancy (24 weeks and the week before delivery) and postpartum (one week and six weeks postpartum). Not surprisingly, they found that women got the least sleep in the week immediately after delivery. During that week, 70% of women were napping four or more times per day. Napping continues to be a common coping strategy as mothers move through the first weeks after childbirth. This is shown by an Australian study of mothers, about half of whom were having their first child, who logged their sleep at 6, 12, and 18

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weeks after delivery. At 6 weeks postpartum, women were awake during the night for longer than 90  minutes and were sleeping an average of 50 minutes during daytime naps. Nighttime sleep improved over time, so that by 18 weeks, time awake during the night had gone down to 60 minutes and nap duration to 15 minutes. By that point, daytime sleepiness had also lessened. As in late pregnancy, the period after delivery is a time when some women have anxious dreams about their baby being in danger. It is not uncommon to have dreams of losing or forgetting about the baby. When awakening from such a dream, mothers may go to check on the infant to make sure everything is okay. Again, such dreams reflect normal concerns about the welfare of the child, and they may actually be adaptive in helping mothers to express and work through their anxieties about mothering. Postpartum depression and anxiety occurs in about 9–15% of women within a year of childbirth. CBT-I can be helpful for improving both sleep and mood, and reducing anxiety, in the postpartum period. Consult your physician right away if you are experiencing symptoms such as low mood, being unable to sleep even when you have the opportunity, loss of interest in things, loss of appetite, constant worrying, or feeling tense or being unable to relax during the weeks or months after the baby’s birth.

The mother’s sleep improves as the baby grows. At 3 months of age, the baby’s sleep pattern becomes more regular and so does the mother’s. And at some point, usually by 6 to 12 months, the baby will be sleeping through the night. Hurray! The mother’s sleep generally improves but may not be as solid as it once was for some time—perhaps because she remains vigilant for the baby’s cries at night. Women who develop persistent insomnia sometimes identify childbirth as the starting point of their poor sleep. At my insomnia clinic, mothers of infants describe the enormous influence of their baby’s sleep and wake patterns on their own. Often mothers will try to grab a few winks while their baby is sleeping, if they can. Surprisingly, there is little research on the interaction of baby and mother sleep. We do know that a mother’s sleep is more likely to be disrupted than a father’s. Researchers from the Netherlands found that a mother’s insomnia was worse than the father’s before childbirth and it remained worse over the first year after childbirth. Rest or sleep when your baby sleeps. Forget about housework and other things that used to be important. Let the dishes pile up, and as my friend Helen says, “Let the dust bunnies gather dust.” If you have other young children, it may be tricky, but try setting a nap time or quiet time for

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everyone, including yourself, so that everyone takes the same rest period. When you are up for nighttime feedings, try to keep any type of stimulation to a minimum. Keep the lights low and make the atmosphere quiet and subdued, so that both you and your baby can get back to sleep easily. Also, give yourself a pep talk: you can still function okay even though you are sleep deprived. This won’t last forever; your baby will some day be sleeping through the night. Of course, all this is much easier if you have other adults to help you during the daytime, and someone to do some, or all, of the nighttime feedings. Not everyone is so fortunate, but if you do have people who are willing to help, let them, so that you can get some sleep.2

AS THE CHILD GROWS It will be no surprise to you that as the baby grows and becomes a toddler and then a preschooler that the mother’s sleep continues to be influenced by her child’s sleep. This relationship has seldom been researched, but one study did examine this issue using a survey. The results showed that the more disrupted the child’s sleep, the poorer the mother’s sleep was. Furthermore, mothers of children with sleep problems had a high number of child-related awakenings. Interestingly, the age of the child didn’t matter: the mother’s sleep was related to the child’s sleep disruption whether the child was a preschooler or a pre-teen. Of course, if there are several children in the family, there is likely to be even more sleep disruption for the mother. In general, mothers continue to be responsive to their children at night and as a result, their own sleep continues to be affected by the children’s sleep. When children reach adolescence, it may not be their sleep problem that affects the mother’s sleep so much as the late hours that the son or daughter keeps. Adolescents tend to have late bedtimes and late getting-up times, something called “phase delay.” This phase delay in their biological clock, combined with teenage social activity, sometimes leads them to come home late at night, after the parents are in bed. This can cause sleep disruption for the whole family, but perhaps especially for the mother who may be waiting up for her teenager to arrive home. WORKING FOR A LIVING Ever lie in bed thinking about problems at work? A large survey of Swedish workers showed that almost one-quarter of women had sleep disruption at least once per week because of work-related thoughts. Studies have confirmed that being a woman, having high work demands, and not having input into work decisions are all Thanks to Dr. Barbara Parker for sharing some practical tips for women during pregnancy and postpartum.

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associated with insomnia. On the other hand, having a supportive boss makes people less likely to have persistent insomnia. In general, you are more likely to have sleep problems if your job is demanding and you have little control, and when paid work and family life pull you in different directions. Since women frequently have demands on their time at work and at home, it’s no wonder that so many of us have sleep problems. With economic uncertainties and financial cutbacks, restructuring of workplace organizations is another big source of stress. Such upheavals in our workplaces increase the risk of insomnia. And, of course, any kind of job insecurity is likely to affect sleep in a negative way. For thoughts and concerns that keep you awake, try separating out the stressors that are within your control from the ones that are not. In the evening, at least 2 hours before bed, make a list of the concerns or issues that have been on your mind. Acknowledge the ones that are outside your control and write “nothing for me to do tonight” beside them. For the stressors and issues that are within your control, decide which ones you will take on. Sometimes we have to pick our battles. Break the chosen ones into very small steps. Steps could involve actions like calling a friend for advice, checking the Internet to see who your Employee Assistance Program provider is, making an appointment to speak with your boss, and so on. Next, write down when you plan to do the first step; for example, “tomorrow at noon.” Then put your list to bed for the night. Place it in a drawer. When you are in bed and any issue from your list comes to mind, tell yourself you have dealt with it for the night. Then gently move your mind toward visual images. For example, imagine walking down your street and seeing your neighbors’ homes and whatever else there is to be seen on your street.

MENOPAUSE If you are approaching, have reached, or passed menopause, and your sleep is disrupted, you are not alone! At least half (estimates are 50–80%) of women have sleep complaints during this time. When you think of how many women this represents in the population, the numbers are staggering. The prevalence of insomnia takes a steep rise at the time of the menopausal transition. Menopause is the time when menstruation ceases permanently, medically defined when no periods have occurred for 1 year. This occurs around age 50. That is one specific point in time, so when we speak about going through menopause, what we usually mean is going through the menopausal transition. This encompasses the

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time from the first signs of approaching menopause—when periods start becoming more irregular—all the way through to the time after menopause when symptoms like hot flashes are continuing to occur. The most obvious physical experiences of the menopausal transition are hot flashes and sweating. About 75% of women will experience hot flashes. These usually go on for 1–2 years, sometimes for 5 years, and in 9% of women, for many years. It is these hot flashes, which occur most often at night, that frequently disrupt sleep. You may find it interesting that the arousal from sleep usually occurs just before the heat surge that comes with a hot flash, rather than vice versa. Our understanding of the exact causes of hot flashes is still sketchy. Altered levels of neurotransmitters (chemical messengers between nerve cells) in the brain and falling levels of female hormones may lead to your internal thermostat being temporarily reset. This results in a release of heat that can be very uncomfortable. A hot flash can be accompanied by significant sweating, palpitations (irregular heartbeats), headaches, and nausea. It may be followed by shivering as the body’s thermostat resets itself. Some women have to get up and change the sheets on the bed because of the intensity of the heat surge and the associated sweating. Whatever the exact mechanism and physiology of hot flashes, it is clear that many women experience sleep disturbance in connection with them. Getting to sleep and staying asleep can both be problematic when hot flashes are happening. If your sleep is interrupted by hot flashes, try keeping the bedroom cool, using fans, and making your bed in layers that can be peeled off and put back on as needed. If you have a bed partner, communicate during the day about your hot flashes and develop a system so you are not fighting about bed covers at night! Some medications may be helpful for severe hot flashes that are interfering with your life and sleep. Hormone replacement therapy (HRT), prescribed by your physician, may be useful if it is started in the early stages of menopause. HRT involves taking a preparation of estrogen by itself or estrogen with progesterone. This is usually in the form of a pill, but is also available as a patch, gel, or vaginal ring. However, this treatment would only be started after a thorough discussion with your physician about the benefits and risks of this therapy as applied to you. Other medications that are sometimes helpful for reducing hot flashes are clonidine and selective serotonin reuptake inhibitors (SSRIs). These two types of medications affect levels of adrenaline and serotonin, respectively, two neurotransmitters that are involved in hot flashes. Make sure you discuss any kind of medication decision with your physician and ask as many questions as you need to. In studies of insomnia in women who had breast cancer, Dr. Josée Savard and her colleagues in Quebec City found that CBT-I worked well to improve sleep. Many of the participants had hot flashes, either because of naturally occurring menopause or premature menopause brought on by anti-estrogen cancer treatments. Dr. Savard observed that sleep improved with CBT-I, whether or not the woman had hot flashes at night (personal

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communication). This is evidence that CBT-I works to improve sleep for women who have hot flashes. My clinical experience tells me so as well. CBT-I can be used to reverse insomnia even with nighttime hot flashes.

Another thing that happens during the menopausal transition is that women become more and more likely to have sleep related breathing disorders, that is, breathing irregularities during sleep. As described earlier in this chapter when talking about pregnancy, these breathing irregularities can involve episodes of very shallow breathing through a partially obstructed airway or episodes of total closing of the airway (obstructive sleep apnea). When a woman passes menopause and enters the postmenopausal years, the likelihood of any of these sleep related breathing disorders is probably at least 20%. Even if you don’t wake up fully when the episodes occur, sleep may be lighter and more disturbed. The typical symptoms that women experience when they have this type of breathing irregularity are loud snoring, morning headaches, waking with a dry mouth, daytime sleepiness, lack of energy, disrupted sleep, and sometimes depression. The higher prevalence of disordered breathing during sleep in postmenopausal years is believed to be due to an increase in abdominal fat and the decrease in levels of the female hormone progesterone. Postmenopausal women who are overweight are especially likely to have obstructive sleep apnea. See your family physician if you suspect that you have any breathing irregularities during sleep. For example, if family members are telling you that your snoring is disturbing their sleep, if you think you may have stopped breathing for a time, or if you have woken up gasping, short of breath, or with a big snore, these would raise your suspicion of a breathing issue. You should know that there are very effective treatments available for sleep related breathing disorders. Your family physician can refer you to a sleep specialist who may order a sleep study (either overnight in the sleep lab or a home sleep apnea test using a portable monitoring device) to see exactly what is happening overnight. You may have heard of CPAP (sounds like “see-PAP”), which stands for continuous positive airway pressure. This is the most common treatment for obstructive sleep apnea. CPAP is air pressure applied through your nose and sometimes also through your mouth to prevent obstructions in the upper airway. It involves wearing a “mask,” or nasal “pillows” to deliver air while you sleep. The pressure of the air keeps your airway open. Don’t be scared off by this! Many people so enjoy their new-found sleep with this equipment that they are very grateful for it. CPAP is not the only treatment. Depending on the nature and severity of your breathing problem, an oral appliance, like a mouth guard, may allow your airway

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to remain unobstructed during sleep. Many women have only mild obstructive sleep apnea, and depending on what the sleep lab study or home sleep apnea test shows, “positional therapy” may be recommended. This is sleeping on your side, or with the head of the bed elevated. This strategy is sometimes enough to manage mild breathing problems overnight.

In addition to hot flashes and breathing irregularities, the other major aspect of a woman’s experience that can interact with sleep is her mood. One study of women who were approaching menopause found that depressed mood, anxiety, and worrisome thoughts about not sleeping were all related to poor sleep. It is always difficult to tell which comes first when it comes to insomnia and mood. Distress and low mood can lead to poor sleep and vice versa. It’s a circular relationship.

If you are having mood issues during the menopausal transition, there are some things that will help. First of all, know that you are not alone and you are not going crazy. Talk to other women to hear about their menopausal mood experiences. Talk to your physician or nurse practitioner so that they are aware of your mood and can assess whether you have clinical depression. Two main treatment approaches work for depression. One is an antidepressant medication. There are several categories of antidepressants and they are all about equally effective for improving mood. Each medication has its own set of potential side effects. Some antidepressants can make you sleepy and may be helpful for your sleep when taken at bedtime. If you are interested in trying antidepressant medication, then discuss this with your healthcare provider. They may suggest an antidepressant to try and will probably follow up with you again in a few weeks to see how it’s working. The other approach is psychotherapy. Psychotherapies that have substantial research evidence to back their effectiveness for treating depression are cognitive behavioral therapy and interpersonal therapy. Ask your healthcare provider or consult your community resources to find a qualified, and preferably licensed, psychologist or therapist. If you have anxious thoughts about not sleeping, see if you can pinpoint your main concerns and write them down during the daytime. Often, they seem more extreme or catastrophic during a sleepless night than they are when we examine them in the daylight. See if you can bring them down to earth using the cognitive therapy techniques in Chapter 18. Then, when you are in bed at night, you can remind yourself of your new, adaptive sleep-related thoughts.

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Of course, there may also be external sources of sleep disruption. Even if your children no longer live at home, there may be cats, dogs, grandchildren, and snoring bed partners. Caring for aging parents or an aging spouse, or caring for anyone with a disordered sleep schedule (e.g., a person with Alzheimer’s disease) will also disrupt your sleep. Your own illness or pain syndrome can also contribute to poor sleep. See Chapter 22 on health conditions and sleep. RETIREMENT Well, if some of your insomnia was work related, then retirement may bring you some relief. You may have fewer pressures on your time and mind, and you may be more relaxed. Operating against this positive aspect, unfortunately, is a general trend as we get older for our sleep to worsen. As we age, three main things happen to sleep: We wake up more often in the night, we get less deep sleep, and we wake up earlier. These occur to both women and men, but, in general, women seem to be more aware of, and bothered by, poor sleep. Some of the age-related changes are normal developmental changes including a reduction of neurons (nerve cells) and alterations in our biological sleep–wake control systems. In older adults, the internal circadian clock appears to be set earlier, making us more like “larks” rather than “night owls.” For example, say when you were in your 30s and 40s, you went to bed at 11 p.m. and got up at 7 a.m. Over the years, you find yourself getting sleepier earlier and earlier until you may be going to bed at 8 p.m. and waking up for the day at 4 a.m. or earlier. This is quite common and is really only a problem if this earlier sleep schedule does not fit with your preferred daytime routine. This “advanced” schedule that comes with aging does allow you to get up with the birds, but it gives you less time in the evening to do things with friends and family. If you want to stay awake later at night and to sleep later in the morning, put yourself under bright light in the evening and have relatively dim light in the morning. This pattern of light and dark exposure mimics a more westerly time zone (think Hawaii). Your internal sleep–wake clock will respond accordingly. You do not need a special light; being under any type of bright lamp or ceiling light in your home will do. To protect your eyes, do not look directly at the light. Be under the bright light for at least 30 minutes as late in the evening as you can. If there is still daylight in the evening after dinner, then take a stroll outside to get some natural brightness in the evening hours.

As we humans get older, we are also more prone to disruptions caused not just by insomnia, but by other sleep disorders. Earlier in this chapter, I wrote about restless legs syndrome, which involves those uncomfortable sensations in the legs with an intense urge to move them, especially in the evening. This is very common as we get older, and it is more common in women than in men. The vast majority of people

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who have restless legs also have jumpy movements of their legs during sleep, periodic limb movements (see description under pregnancy). You can have periodic limb movements without having restless legs, though. The prevalence of periodic limb movement disorder gets higher as we age: it has been estimated that about 45% of people over age 65 have it. The rates seem to be similar for men and women in this age group. These movements can lead to arousals from sleep and feeling that your sleep is not restorative. Sleep related breathing disorders become much more common as we age. As mentioned, after the menopausal transition, women are more likely to develop irregular breathing patterns during sleep. Not all women develop a sleep related breathing disorder as they get older, but the rates are quite high. A study in a sample of people aged 65–95 years showed that 56% of the women had significant breathing disturbances during sleep. This was especially likely to happen to women who were overweight. Sleep related breathing disorders in older women also tend to go along with high blood pressure and type 2 diabetes.

If you are very sleepy during the day so that you are falling asleep in different situations (e.g., while reading, while being a passenger in a car, while listening to someone talking), it is important that you let your physician know. There are many possible reasons for excessive sleepiness, and in most cases, the underlying causes are treatable. If you are snoring and if you are aware that you sometimes stop breathing during sleep, then you are high risk of having a sleep related breathing disorder and this definitely warrants a discussion with your physician.

Many medical disorders and pain conditions affect sleep (see Chapter 22). Also, many medications affect sleep. Of course, as we get older, we are more and more likely to be taking medications. Many prescribed and over-the-counter medications affect sleep. Examples include medications for high blood pressure, some decongestants, some heart medications (e.g., for rhythm disturbances), some antidepressants, stimulants, some asthma medications, corticosteroids like prednisone, pain medications containing caffeine, theophylline for asthma, nicotine patches used for smoking cessation, and thyroid medication at certain levels. Medications that can make your breathing worse at night include morphine-type medications used for pain and anything that sedates you, including sleep medications and formulations containing alcohol.

Read medication labels and discuss any medication concerns, including effects on your sleep, with your physician and/or pharmacist. They will have recommendations about the dosage, the time of day that you take the medication, or alternative treatments. For over-the-counter medications, the exact same advice applies.

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THE GOOD NEWS Effective treatments are available for most sleep disorders. For insomnia, women make up the majority of volunteer participants in treatment studies. Subsequently, much of the research data on insomnia and insomnia treatments of all kinds are based on the experiences of women. We know what the best treatments are for improving sleep. At this time, the best approach is CBT-I, the techniques on which this book is based. We know that CBT-I works to reverse insomnia during most stages of life including young adulthood, midlife, and old age.

CHAPTER 20

Men’s Sleep

lthough women tend to report insomnia in greater numbers, men have their share of sleep problems, too. So, let’s shine the spotlight on men’s sleep now. A Early discoveries about the nature of human sleep, and the effects of sleep deprivation, were largely based on research studies with male participants. For example, men comprised most of the volunteers in studies that revealed the existence of rapid eye movement (REM) sleep in humans. In their landmark paper, published in the journal Science in 1953, Aserinsky and Kleitman reported on “Regularly Occurring Periods of Eye Motility, and Concomitant Phenomena, During Sleep” that occurred in their 20 adult subjects, 18 of whom were men. Likewise, major advances in the understanding of our internal timekeeper and its relationship to sleep and wakefulness were based on studies of men (and a few women) in time isolation, either in labs or in caves. A few brave men stayed in isolation in caves for months to allow their physiological rhythms to be studied! Others subjected themselves to severe sleep restriction so that we could understand the effects of insufficient sleep on humans. These are just a few examples. Many men have volunteered in the name of sleep science, and at this point in history, we know quite a lot about men’s sleep. TESTOSTERONE AND SLEEP Testosterone, a hormone that occurs in much higher levels in men than in women, influences the development and maintenance of male sexual characteristics, including reproductive organs, body structure, beard growth, strength, sex drive, aggression, and mood. There are important connections between testosterone and sleep. Did you know that testosterone levels rise when you fall asleep? Levels continue to increase 143

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for about the first 90 minutes and then plateau, stay high during sleep, and eventually peak around 8:00 a.m. They start to go down in the morning and continue to decline during the day reaching a low at around 8:00 p.m. This rhythm of testosterone depends on sleep; without sleep, testosterone does not show the normal nightly surge. SLEEP-RELATED ERECTIONS Erections during sleep, mainly in REM sleep, occur in males from birth to old age. The average duration of a sleep-related erection is approximately 25 minutes. Because about four REM episodes occur over the night, the time spent per night in “penile tumescence” is around 90–100 minutes. As a man ages, the duration of these erections goes down slightly, but sleep-related erections and partial erections occur into very old age. Even though these events occur during REM sleep, the stage in which most of our dreaming occurs, they seem to be independent of the content of dreams. Moreover, they have different physiological control mechanisms than do sexually stimulated erections during wakefulness. Problems with sexual erections (“erectile dysfunction”) used to be assessed by measuring sleep-related erections; if erections were normal during sleep, then structural–mechanical problems were ruled out as a cause. (This in-lab measurement technique is still used in research but is no longer routinely used in the diagnosis of erectile dysfunction.) The function of sleep-related erections remains a puzzle. Some have speculated that they provide regular, lifelong practice and exercise for the muscles and nerve connections involved in erections. This may have given our ancient male ancestors a reproductive advantage over other males who did not experience this phenomenon. INFANT CARE Although many men are involved in the care of their babies, men’s sleep has seldom been looked at in this context. What we do know is that even before the baby is born, during the last third of their partner’s pregnancy, 15–24% of fathers-to-be report poor sleep. As you might expect, the father’s sleep disruption increases in the first month after the baby is born, but not as much as the mother’s. The father’s involvement in looking after the baby has benefits for the family’s sleep. Research shows that the more the father is involved in caring for the infant—both during the day and at night—the better the mother’s sleep and the fewer times the infant wakes at night. SLEEP DISORDERS Insomnia

When sleep is studied objectively, men’s sleep usually looks worse than women’s, but when asked about their sleep, men tend to have fewer complaints. Persistent, severe insomnia is reported by approximately 8–10% of men. Even though this is lower than the insomnia prevalence reported by women, this represents a substantial number of men in the population. As in women, insomnia is more likely to occur in men who have a medical condition (e.g., diabetes, heart disease, chronic obstructive

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pulmonary disease), a pain condition (e.g., arthritic joints), and especially depression, stress, or other mental health challenges. Some studies suggest that men who maintain a healthy weight and those who are physically active are less likely to have insomnia. For anyone with persistent insomnia, as I’ve said in previous chapters, research shows that cognitive behavioral therapy for insomnia (CBT-I) is the treatment of choice. The vast majority of men do not get effective treatment for their insomnia, either because they don’t seek help, or because CBT-I is not available in their community. So, here’s your chance to reverse insomnia using the CBT-I based Sleep Therapy in this book. With a little bit of time and effort, you will be able to achieve satisfying sleep. There are two sleep disorders that occur more frequently in men than in women. These are “sleep related breathing disorders” and “REM sleep behavior disorder.” I outline what these are, in case they apply to you or someone you know. Sleep Related Breathing Disorders

Two-thirds of men snore. What exactly is snoring? It is sound produced by the vibration of structures in the upper airway, such as the soft palate, the uvula, and the walls of the pharynx (back of the throat). Basically, membranous structures in the upper airway that are not supported by cartilage can flutter and contribute to snoring. Sometimes snoring is mild and only a nuisance. On the other hand, loud snoring can be a sign of “obstructive sleep apnea.” This is a sleep disorder in which people stop breathing (for periods of 10 seconds or longer) during sleep, several times per hour. Each period of breathing cessation is called an “apnea.” During an apnea, there is silence, which is broken by a loud snort as breathing resumes. If you have obstructive sleep apnea, you may be unaware of these breathing changes during the night. However, other people in your house may be aware, and your bed partner will certainly be aware. Sleep professionals use the general term sleep related breathing disorders to refer to obstructive sleep apnea and similar breathing problems that occur when the upper airway is partially or totally obstructed during sleep. The obstruction occurs when the muscles of the airway relax and collapse inward during sleep. Awakenings (often not remembered) happen many times per night as the body attempts to restore airflow. As a result, sleep is interrupted repetitively. The disrupted sleep makes the person very sleepy during the daytime. Sleep related breathing disorders are three times more common in men than in women. If you fall asleep easily much earlier than your normal bedtime, for example, in front of the television after dinner, and you struggle to stay awake at meetings or other events during the day, you may have excessive daytime sleepiness. Excessive daytime sleepiness, loud snoring, waking with snorts or gasping for air, and waking up with a headache are all possible symptoms of a sleep related breathing disorder and they warrant a trip to your family physician as soon as possible.

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Being overweight increases the risk and severity of sleep related breathing disorders. Another thing that makes these breathing disorders worse is alcohol—it makes apneas longer and more frequent. Some sedatives and sleeping pills, for example, the benzodiazepines, may have similar effects. (See Chapter 24 on sleeping pills.) Smoking can also make upper airway problems worse. So, to minimize your risk, maintain a healthy weight, minimize alcohol, avoid sedatives, and become a nonsmoker if you aren’t already. Alcohol and smoking are both difficult habits to quit, and when you are ready, help is available. Relevant places to start would be your local health unit or your family physician. Sleep related breathing disorders are assessed either by an overnight stay in the sleep lab or by a home sleep apnea test using a portable monitoring device. A sleep lab study, or overnight “polysomnography,” involves spending a night in a sleep lab where a sleep technologist sets you up with electrodes and equipment that measure and record your sleep stages, breathing, heart rate, limb movements, and the level of oxygen in your blood. The technologist monitors the recordings through the night. At-home sleep apnea tests involve portable monitors that you set up at home to measure your breathing patterns and your blood oxygen in your own bedroom. They do not measure your sleep stages. In both cases, your breathing movements are measured by bands around your chest and abdomen that expand and contract as you breathe; your airflow is monitored by sensors placed beneath your nose; and your blood oxygen level is measured by a small sensor placed on the tip of a finger.

The treatment for sleep related breathing disorders depends on the results of the sleep assessment and the recommendations of a sleep specialist. Treatments include positional therapy, weight loss, continuous positive airway pressure (CPAP, pronounced “seePAP”), oral appliances, and in some cases, surgery such as tonsillectomy. With the correct treatment, the airway stays open all night, allowing you to breathe well and sleep well, and to be alert rather than sleepy during the daytime. As explained in the previous chapter on women’s sleep, CPAP, one of the most common treatments, provides air pressure support for the airway to prevent it from collapsing, and it is very effective for obstructive sleep apnea. I have heard many men with sleep apnea report that CPAP improves their sleep and they feel so much better during the daytime. Positional therapy I remember a nurse at the Toronto Western Hospital sleep lab, where I worked years ago, showing patients who had obstructive sleep apnea how to attach a sock containing a tennis ball to the back of their pajamas. It was usually done with a safety pin. This trick of the trade is still used today in order to prevent rolling onto one’s back during sleep. If you do roll back,

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there is an immediate reminder—a firm nudge—to avoid this position. Positional therapy means sleeping in positions that minimize sleep related breathing problems. One of the best positions is on your side. Another option is to sleep with your head and trunk elevated by 30 to 60 degrees. However, this elevation is not easily achieved unless you have a hospital bed or another type of adjustable bed, or you arrange the pillows “just so.” Sleeping on your side is probably the easiest solution.

REM Sleep Behavior Disorder

REM sleep behavior disorder (RSBD) is not nearly as common as sleep related breathing disorders. The chance of developing it increases with age; after age 60, the prevalence is approximately 1%. The large majority of diagnosed cases are in men over the age of 50. Big, sometimes violent, movements during REM sleep characterize this disorder. Normally in REM sleep, our muscles are relaxed and inhibited from moving. (See Chapter 26 for more on REM sleep.) This prevents us from acting out our dreams. With RSBD, the muscles lose the normal inhibition in REM and people do act out their dreams! As you might imagine, this can lead to injuries—­sometimes serious—to the dreamer and to anyone else nearby, especially the bed partner. If there is any chance you have RSBD, it is very important to seek medical help. If your family physician is not familiar with it, ask for a referral to a sleep center for an overnight sleep study. AGING With age, men’s sleep, like women’s, becomes shorter and more broken up by awakenings. So, don’t expect to get the same quality or quantity of sleep at the age of 60 as you did in your 20s. There are many contributors to these age-related sleep changes, discussed in Chapter 19. Testosterone production also declines with age; levels in the blood go down about 1–2% per year from midlife onward in men. This may account for the slight decrease in duration of sleep-related erections with age. A number of physical changes occur over time that some have called “andropause.” These changes are believed to result from declining testosterone levels, and they include decreased sexual desire and erectile quality, depression and fatigue, reduction in muscle and bone strength, increased fat, changes in skin and body hair, and altered sleep patterns. However, whether this is a clinical condition or just normal aging is debated, as is the use of testosterone replacement therapy for these changes. Testosterone treatment, or “androgen therapy,” has potential risks that have not been fully studied in older men, so be sure you talk to your physician about the risks and benefits of this treatment if you are considering it. With respect to sleep specifically, it is not clear whether androgen therapy helps. We do know that both low levels and high levels of testosterone are connected with sleep problems. High doses of testosterone, when used illicitly (for example, by some bodybuilders), can lead to significant sleep disturbance. Some types of prostate cancer are treated with “androgen deprivation therapy,” which is the opposite of androgen therapy. This is meant to reduce levels of testosterone in

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order to stop or slow the growth of prostate cancer cells. Several side effects can occur with this treatment, including weight gain, decreased muscle, breast development, loss of body hair, erectile dysfunction, decreased libido, increased emotionality, and hot flashes. Androgen deprivation is also associated with an elevated chance of having insomnia. Sex life can also be affected by all of this, but research indicates that after some adjustment to changes, some couples can adapt successfully and continue to enjoy sexual activity. Your physician can also help with advice on sexual aids, including medications; and some cancer clinics and other centers offer counseling to help restore sexual intimacy. Insomnia that occurs with cancer can be helped by CBTI, the type of program used in this book. Sleep problems can accompany many other medical conditions, and the most common ones are discussed in Chapter 22. WORK, TRAVEL, AND SLEEP As with women, men experiencing stress at work are at high risk of insomnia. Research indicates that men who work in environments with high levels of exposure to climate, hazardous chemicals, and noise tend to have more sleep difficulties. Also, stress at work with other people or with workload can contribute to poor sleep. If the demands of the job are high and your level of control over your work is low, your sleep is particularly likely to be problematic. There are many approaches to managing work-related stress. It starts with recognizing what is within your control and what is not. See, for example, box in Chapter 19 on “For thoughts and concerns that keep you awake” under Working for a Living. Take control of what you can: make sure you get enough exercise (See Chapter 21) and that you are eating healthy foods and avoiding substances that tend not to help, like alcohol, cannabis, and other drugs. You may find it very useful to talk to a friend in order to gain some perspective on the stressful situations at work. You can also explore your Employee Assistance Program or other resources for counseling. Courses on stress management are often available in the community. Meditation practice can help you be more aware of your experience in the moment and provide some relief from the strains of everyday life. Try to stay in touch with people rather than withdrawing. If you have persistent insomnia, you can always use CBT-I to restore your sleep. You might wait to do this until after any distressing crises at work have subsided or resolved. Work travel schedules often put severe limitations on sleep for both men and women. For example, professional hockey players not only have punishing physical requirements on the ice, but their schedules of home and away games are grueling. Playing games night after night, practices, and traveling to different time zones allow little time for rest and sufficient sleep. Insomnia becomes a problem and some players will take sleeping pills. The National Hockey League has a substance abuse and behavioral health program, and there is now emphasis on ways to rest and sleep without sleep medication. So, even extreme challenges to sleep that occur with work and travel schedules can respond to behavioral methods. They take more time and attention than popping a sleeping pill, but CBT-I methods are safer and much more effective in the long run.

CHAPTER 21

Nutrition, Exercise, and Sex

elcome to a new chapter, created for the second edition of Sink into Sleep. It’s here for a number of reasons. First, sleep is increasingly being recognized as W the third pillar of health, along with nutrition and exercise. All three health behaviors (yes, sleep can be considered a behavior) interact with one another. If your sleep is good, you are more likely to eat well, to exercise and to be healthy. Second, there are some fascinating new research findings about these interrelationships that I’d like to share with you. Third, sex has rarely been discussed in relationship to sleep, and I thought it was time to examine what we know, or don’t know, about this relationship. All right, let’s dive in. NUTRITION AND SLEEP Specific Foods and Sleep

A kiwi for your sleep? A study from China had 24 adults eat two kiwi fruits 1 hour before bed. After participants did this every night for 4 weeks, their sleep was compared to their pre-kiwi sleep. Many aspects of sleep improved, including time to fall asleep, time awake during the night, and sleep duration. Compared to many fruits, kiwis contain high levels of serotonin, a chemical that transmits signals between nerve cells, and some researchers think this may be the route to its effects on sleep. At this time, we have only this single study without a control condition (such as a placebo) on kiwis and sleep. So, it’s too early to put all our sleep eggs into the kiwi basket. In any event, kiwis are very healthy fruits, providing a good source of vitamins C and E. 149

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Tart (or sour) cherries have been investigated for possible sleep-promoting effects. In this case, it is not serotonin but melatonin, a hormone that our brains release in darkness that helps in sleep regulation, that is suspected as being the important constituent—tart cherries contain high levels of melatonin. Two placebo-controlled studies found sleep improvements in people who drank tart cherry juice for several days (1–2 weeks) in a row. In a third study (without a control condition), participants ate various types of tart cherries for dessert at lunchtime and dinner for 3 days. Their sleep duration increased and other aspects of sleep showed improvements, depending on the variety of cherry. Although these studies suggest that tart cherries may be helpful for sleep, the improvements in people’s sleep seem to be quite modest, and for those with insomnia, the beneficial effects appear to be smaller than those achieved with cognitive behavioral therapy for insomnia (CBT-I). Although kiwis might surprise you as a pre-bed snack, warm milk probably doesn’t. In many Western countries, warm cow’s milk has had a traditional role as a bedtime sleep aid. Surprisingly, few published studies exist on the effects of warm milk on sleep. However, in the 1970s, a handful of small studies looked at the effect on sleep of drinking a warm Horlick’s malted milk mixture before bed. Horlick’s (no longer produced in North America) contains wheat, malt barley, sugar, milk, and various vitamins and minerals. These studies found that Horlick’s was associated with somewhat less movement and sleep disruption, especially toward the end of the night. More recent studies have examined milk that is “melatonin enriched.” Normal cow’s milk contains tryptophan (an essential amino acid that our body uses to make serotonin) and melatonin. When cows are milked at night, their milk has higher levels of melatonin. Just as our internal melatonin levels rise with darkness, so do the cow’s. Comparisons of sleep promoting effects of night-milk (with high levels of melatonin) with day-milk (regular milk) have not turned up anything striking as an advantage for night-milk. Fermented milk has been found in one study to improve sleep in older people but only slightly compared to a placebo. In another study, data from Japanese Olympic-level athletes showed that sleep quality was correlated with drinking milk, but only in female athletes. The small number of studies on milk and sleep suggest that milk is not a super sleep inducer, but it may be somewhat helpful for sleep in some people. Perhaps you are wondering about turkey. There is a myth passed around at Thanksgiving, in places where it is celebrated, that turkey makes us sleepy because of its tryptophan. Although turkey does contain tryptophan, a precursor of serotonin and melatonin, so do many other foods like dairy products, eggs, sesame and other seeds, soybeans, oats, chicken, fish, and even chocolate. It is likely that the tryptophan from the turkey and other foods, along with the carbohydrates of festive eating, contribute to the sleepiness. When people eat a lot of carbohydrates, they tend to fall asleep more quickly. Why is that? Insulin is released when we eat carbohydrates, which makes the conditions more favorable for the entry of tryptophan into the brain where it is used to make serotonin and melatonin.

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Eating Patterns and Sleeping Patterns

Research on different types of diets and sleep has turned up some interesting findings. Not only does our diet affect our sleep, but our sleep patterns may affect what we choose to eat. People who eat a Mediterranean diet—one that includes daily fruits, vegetables, whole grains, and healthy fats like olive oil; weekly fish, poultry, beans, eggs, and dairy; and low amounts of red meat—tend to get enough sleep and are less likely than others to have insomnia. Eating high levels of saturated fats and sugars and low levels of fiber is associated with worse sleep: less deep (slow wave) sleep and more arousals. The timing of meals and snacks also matters. Eating a high fat and carbohydrate meal close to bedtime leads to a longer time to fall asleep. In large studies of associations between sleep and eating, it’s becoming clear that people who have poor quality sleep tend to eat more and have a less healthy diet. A study of more than 3,000 Japanese women found that poor sleep quality was associated with a high intake of sweets and noodles and carbohydrates in general, whereas good sleep quality was associated with eating a lot of vegetables and fish. Moreover, poor sleepers consumed more sugary and energy drinks and were more likely to skip breakfast and eat outside of three regular meal times. Another study of 2,632 Japanese men found that those who slept less than 6 hours per night were more likely to skip breakfast, consume a lot of fatty foods, and eat restaurant food compared to those who slept between 7 and 8 hours per night. They were also more likely to be obese. An American study with more than 15,000 men showed that having insomnia was linked to eating more food and having a poorer diet (having fewer vegetables and more unhealthy fats and sodium). A study of 459 postmenopausal American women found that the shorter the nighttime sleep was, the higher the intake of fat. There is also some evidence that morning people—those who are early to rise and early to bed—tend to make healthier food choices than night people. Later bedtimes are linked to greater caffeine and fast food consumption. These are just a few examples from the large world of research on nutrition and sleep. The interactions between sleep and eating are hugely complex and this chapter section just skims the surface. Broadly speaking, it seems that people with healthy eating patterns are more likely to have good sleep and vice versa. EXERCISE AND SLEEP Physical Activity and Sleep

Perhaps you are aware of the physical activity guidelines in your country. North American and World Health Organization (WHO) guidelines recommend that adults get 150 minutes of moderate- to vigorous-intensity aerobic physical activity every week. As examples, this would include brisk walking, bike riding, swimming, running, cross-country skiing, tennis, mowing the lawn, dancing, basketball, hockey, football, and many others. They also recommend strengthening activities for major muscle groups at least twice per week. Strengthening exercises include using free

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weights, resistance bands, gym machines, doing planks, pushups, squats, heavy gardening (especially digging and shoveling), climbing stairs, walking up hills, and others. The guidelines make it clear that more physical activity provides greater health benefits. This means that getting 30 minutes of aerobic exercise five days a week (150 minutes total per week) is good, but doing 45–60 minutes on those days, or 30 minutes on all seven days of the week, is even better. Let’s review the benefits: improved fitness and strength; and reduced risk of heart attack and stroke, high blood pressure, type 2 diabetes, osteoporosis, and obesity. In addition, there are significant mental health benefits. Exercise gives us a more positive outlook on life, increasing happiness and self-esteem. It reduces stress, anxiety, and depression and improves attention, memory, and concentration. But does exercise improve our sleep? Many research studies have been done on this topic, and broadly speaking, exercise has positive effects on sleep. Regular aerobic exercise—such as that recommended in guidelines—is associated with shorter times to fall asleep, longer sleep durations, and increases in people’s ratings of their sleep quality. It doesn’t seem to matter what type of exercise you choose or whether you do it in the morning, afternoon, or evening. Contrary to traditional cautions against exercising within 3–4 hours of bedtime, we now know that exercise within 3 hours of bed is unlikely to interfere with sleep. In fact, it may be helpful: a published review of 66 studies on exercise and sleep found that exercising less than 3 hours before bed led to more continuous sleep (less time awake during the night). As for strength training, it seems that regular strength workouts are associated with improved sleep quality according to people’s ratings. Those ratings go up when strength training is done more frequently (3 or more days per week), with greater intensity (e.g., heavier weights) and over a longer period of time (more weeks). Mind-body exercises such as yoga and tai chi are also associated with improved sleep quality ratings. Overall, the research tells us that people feel their sleep is improved when they exercise, regardless of the type of exercise. Any physical activity you enjoy is bound to provide health benefits including sleep benefits. Except, perhaps, if you have chronic insomnia—read on. Exercise and Chronic Insomnia

The sleep benefits of exercise may not be so evident if you have chronic insomnia. Are you someone who gets a lot of exercise and still has insomnia? You may be annoyed when someone says: “You’ve had lots of exercise today—you’ll sleep well tonight.” Many of the studies I’ve summarized here were done with people who didn’t have sleep problems, or who had some symptoms of insomnia but not long-standing clinically defined insomnia. Reviews that have focused on people with insomnia show that whereas they do feel that exercise improves their sleep quality, it does not necessarily improve other measures such as time to fall asleep and sleep efficiency. Based on the evidence, my advice for everyone is to follow physical activity guidelines for your overall fitness and health as this may also improve your sleep. If you have persistent insomnia, combine your regular exercise program with CBT-I and insomnia doesn’t have a chance.

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My cousin Ted asked me, “The guys that are playing old-timer hockey at 11 at night—is this good or bad for sleep?” It’s a good question. As you’ve probably found, if you’re wound up after a game, you need time to unwind (for example, by doing a crossword, watching television, or reading) before you go to bed. Otherwise you might be too stimulated to sleep. The research indicates that if you are already a good sleeper, your sleep may be a few minutes longer after playing an active sport when compared with a night without such activity; you might even get a minute or two more of deep sleep. The changes are usually quite subtle. If you have insomnia, we don’t really know yet whether playing a sport late at night will help or hurt your sleep. Try it out and see!

The Effect of Sleep on Exercise Performance

When we have good sleep, everything in life seems a bit easier. This includes our workouts and sports participation. On the other hand, when sleep is poor or short, exercise feels harder to do. Interestingly, research indicates that after sleep loss, our body’s maximum aerobic fitness and our muscle strength seem to be maintained. However, we are not at our best in terms of attention and reaction time, and importantly, our motivation may wane. In addition, if we have any pain (say we are trying to lift a heavy weight), we become more aware of that pain when we haven’t slept well. Loss of sleep may also reduce the rate of repair of our exercised muscles and may lead to a greater risk of overtraining and injury. In a study from France, 12 young men exercised on a cycle ergometer (like a stationary bicycle) for 40 minutes and then cycled with sequentially greater loads until they could cycle no more, reaching “task failure.” Compared to their performance after a normal night of sleep, after a night of sleep deprivation, there were no changes in the functioning of the exercising muscles. However, after the sleepless night, the men rated their exertion on the 40-minute cycle as greater, and they stopped cycling sooner on the task failure test. This and other research suggests that after sleep loss, exercise is harder to do, but our muscles are still able to work as usual. To sum up, when we sleep well, exercising is easier; when we do aerobic activities and strength training on a regular basis, we experience higher quality sleep. Thus, we have a two-way positive relationship between exercise and sleep. SEX AND SLEEP You would think that we would know more about the interaction of sex and sleep— two activities that typically occur in the same place (the bed) at around the same time (at night). However, there are not many studies that bridge the two subjects. In fact, sleep clinicians and researchers have tended to think about sleep as it applies to

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one person at a time and have largely forgotten that sleep often happens with another person. The 2013 International Bedroom Poll, conducted by the National Sleep Foundation, found that most people (56–75% in Canada, the United States, Mexico, the United Kingdom, and Germany) sleep with a “significant other.” Japan was different in that most respondents reported sleeping alone; only 38% slept with a significant other. When we share a bed with a sexual partner, our own sleep quality is influenced not only by our partner’s sleep, but also by our feelings of safety, intimacy, and relationship—sexual and otherwise—with that person. Whatever our gender or sexual orientation, sexual well-being is an important part of our overall health. Although the term “sex” means different things to different people (there is huge variation), the term “sexual function” encompasses the physical and mental aspects of sex including arousal, desire, orgasm, pain, satisfaction, and pleasure. One of the few studies to look at the relationship between sexual activity and sleep was done in Montreal. The study involved a small sample of five men and five women, all young adults aged 21–35 years, whose sleep was studied in the lab for three nights. The participants were given different instructions each night: to read in bed for 15 minutes prior to sleep; to masturbate manually for 15 minutes without reaching orgasm; or to masturbate until orgasm (which took on average 18 minutes). The researchers predicted that, compared to reading, after orgasm the participants would fall asleep more quickly, whereas after masturbating without orgasm they would take longer to fall asleep. Contrary to their predictions, sleep came to the participants just as quickly regardless of the pre-sleep activity. What’s more, there were no differences in any of the overnight sleep measures, including sleep duration, time awake during the night, sleep stages, or sleep efficiency, for the three conditions. The researchers must have been surprised by their findings. Folklore has it that men fall asleep more quickly than women do after sex. Very little research has been done on this. There is some evidence that men become quite sleepy after sex, and this may be connected with high levels of the hormones prolactin and oxytocin that occur after sexual intercourse. However, I have found no scientific study to show that men fall asleep faster than women after sex. It seems there are large differences among individuals—both men and women—in degree of sleepiness or alertness after sex. One study suggests that men, more so than women, think they fall asleep faster after sex, compared to no sex. Let’s leave it at that.

Intriguing new research from the University of British Columbia found that young women and men slept better when exposed to the scent of their romantic partner. The scent came from a T-shirt that had been worn by their partner and placed over their pillow. Although this study did not involve sex per se, it shows that an intimate partner may affect our sleep, even in their absence. There is something about the sense of closeness to another person at night that is important to us. In general,

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people with bed partners report that they sleep better when the partner is present compared to when that person is away. They hold this belief although, when their sleep is measured by electrodes or movement sensors, their sleep is actually better when they sleep alone! Sleep Disorders and Sexual Function

Women with insomnia or obstructive sleep apnea have high rates of sexual problems including sexual dissatisfaction and distress. Men with these sleep disorders have high rates of erectile dysfunction. What we don’t know yet is whether treating the sleep disorder will help the sexual problem, although there is some evidence that regular use of CPAP (continuous positive airway pressure) treatment for sleep apnea helps sexual function in men. There is a sleep disorder that definitely involves sex; it is called “sleep related abnormal sexual behaviors” or “sexsomnia.” The prevalence of sexsomnia is currently uncertain but believed to be quite low. It occurs mostly in men and involves sexual behaviors such as sexual speech, masturbation, fondling, or attempted intercourse during sleep. The behaviors occur from deep, slow wave sleep (see Chapter 26 on sleep stages) and the person has no awareness of the events nor memory of them in the morning. As you might imagine, this type of sleep disorder can lead to major interpersonal problems and, in some cases, assault charges from the bed partner. The person with the sleep disorder often feels shame, guilt, and depression. Help is available through specialized sleep centers. Of course, sexual problems can also lead to sleep problems, particularly insomnia. Worry about sexual problems can contribute to trouble sleeping. For example, it is common after menopause for women to have pain during sex due to changes in the vagina—thinning and drying of the walls of the vagina as levels of the hormone estrogen decrease. This discomfort and the related distress can increase the likelihood of insomnia, which is already an issue for many postmenopausal women (see Chapter 19). Any type of sexual problem has the potential to prevent us from sleeping well. Sex therapists help people with a wide variety of sexual issues including concerns about sexual arousal, desire, erectile functioning, premature ejaculation, sexual feelings, painful intercourse, and other issues. Does improving sexual functioning improve sleep? We don’t really know yet, but I would say “probably.” A recent online survey revealed that worse sexual functioning was linked with worse sleep. Looking from a positive perspective, this also means that those with better sexual functioning experienced better sleep. Just as we have seen with nutrition and exercise, sexual functioning is related to sleep bidirectionally: each influences the other.

SLEEP IN SPECIAL CIRCUMSTANCES

CHAPTER 22

Health Conditions

you are dealing with a health problem, chances are your sleep is also a problem. from all over the world show that people who have medical conditions IarefSurveys especially likely to have sleep problems. This book does not have space for every medical condition that exists, so I have selected a few conditions that are highly prevalent in North America and those most often reported by people with insomnia. I hope that I have included the ones that you are most interested in. The bibliography can be found on Springer Publishing Company ConnectTM and can be accessed by visiting the following url: http://connect.springerpub.com/content/ book/978-0-8261-4816-2. The connection between medical conditions and sleep is a complex and circular one. A medical condition can lead to a sleep problem, and a sleep problem can lead to a medical condition. Each can exacerbate the other. There is a particularly strong link between chronic pain and sleep difficulty. CHRONIC PAIN Chronic pain is pain that has lasted for 3 months or longer. You will know if you have chronic pain. It will be your constant, difficult companion. Some examples of chronic pain conditions are fibromyalgia; chronic back, neck, shoulder, or leg pain; recurrent headaches; rheumatoid arthritis; osteoarthritis; and ankylosing spondylitis (a rheumatic disease involving inflammation of the joints in the spine). There are many others. Sometimes pain remains in our bodies after a car crash, sports injury, or other incident. 159

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Most people with chronic pain have insomnia. Several research studies have shown that as pain intensifies, sleep gets worse, and as sleep gets worse, pain intensifies. You probably have noticed this connection. How to stop this cycle? You are most likely trying to manage the pain itself by trying to get comfortable at night through positioning your body in bed and/or using various means to manage the pain (exercise, medications, physiotherapy, and other helpful strategies). This may not be enough, however, to stop the cycle of pain and sleep disturbance. For this, I suggest cognitive behavioral therapy for insomnia (CBT-I), the set of techniques on which the Sleep Therapy program in this book is based. An important Canadian study, published in 2000, of people who had various chronic pain conditions, including back pain, neck pain, leg pain, and pelvic pain, found that people’s sleep improved very well with CBT-I. The participants were still sleeping well when they were studied again 3 months later. Subsequent studies have confirmed that CBT-I improves sleep in people who have chronic pain. This includes people with fibromyalgia and people with osteoarthritis. A study with older adults who had osteoarthritis showed that CBT-I worked very well to improve sleep and that sleep improvements were sustained 1 year later. It is particularly interesting that, in addition to improving sleep for the long term, CBT-I can also improve pain control. So, if you have chronic pain and insomnia, CBT-I is an excellent technique to use. The CBT-I–based Sleep Therapy program in this book may help you replace a vicious cycle of pain and sleep disturbance with a positive cycle of better sleep and better pain management. Some people ask me about exercise for improving sleep for people who have pain. The research results show that aerobic exercise—like walking, running, biking, aerobics, swimming, aquafit—reduces pain and fatigue and improves fitness and quality of life. Physical activity can improve people’s sleep quality although it will not necessarily eliminate chronic insomnia (see Chapter 21). I definitely recommend aerobic exercise for chronic pain and for your overall health and well-being, but if you want to reverse insomnia, add CBT–I. If you are fortunate enough to be able to participate in a multidisciplinary chronic pain program that includes cognitive behavioral therapy for pain (this is different from CBT-I but it may involve some of the same components, like relaxation and cognitive therapy), this is often very helpful for pain management. These programs may also involve physiotherapy, occupational therapy, dietary advice, and information on pain and pain medications. I do recommend these programs. Whether they also improve sleep substantially is not yet clear; they will certainly not make your sleep worse. If you want to be sure of improving your sleep, then CBT-I is what you want. HEART DISEASE Heart disease, or “coronary artery disease,” occurs when there is a build-up of plaque on the walls of the arteries (vessels that supply blood) to your heart. This makes the arteries narrower and the heart may not get the blood flow and oxygen that it needs.

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This can lead to chest pain or “angina,” shortness of breath, and fatigue. Sometimes people don’t have any symptoms and don’t know that they have heart disease. If you wonder about your own risk of heart disease, ask your family physician about this and ask what you can do to reduce your risk of heart attack or stroke.

Carol experienced a heart attack at the age of 69. She was slim, athletic, and had a healthy diet. This event turned her world upside down. Carol was the last person anyone expected to have heart disease. She underwent coronary bypass surgery. While in the hospital she had great difficulty sleeping and she was given some sleep medication at night. When she left the hospital and started her cardiac rehabilitation program, she found she could not sleep at home. She felt she had no control over her heart and was afraid of having another heart attack and dying during sleep. Now she had no control over her sleep. She decided to take our Sleep Therapy group program, and slowly but surely, her sleep returned over 3 weeks. She started to sleep well again, without any sleeping pills. She regained confidence in her ability to sleep, and not only was her heart repairing itself, but she was reassured that her sleep system was strong and reliable.

If you have heart disease, the research indicates that you are especially likely to have insomnia, including trouble falling asleep and waking up too early in the morning. There is also a higher-than-normal chance that you have some breathing irregularities during sleep. These sleep related breathing problems can include loud snoring, shallow breathing, and partial or full obstruction of the upper airway during sleep (obstructive sleep apnea). If you think you might have some breathing irregularities during sleep, it is important to see your physician as soon as possible. Treatment of these breathing problems can improve both your sleep and your heart health, including lowering your risk of heart attack. Whether or not you have breathing irregularities at night, you probably have insomnia. Research shows that CBT-I improves the sleep of people who have heart disease and insomnia. You might avoid staying up extremely late in case this puts extra stress on the heart, so when you are doing Sleep Therapy make sure that you don’t limit your time in bed to less than 5 hours. People who have had heart disease have safely and successfully done all steps of the Sleep Therapy program in our clinic. At the University of Ottawa Heart Institute, psychologists who work with patients in the cardiac rehabilitation program designed a CBT-I group program based on Sink into Sleep. They tailored it specifically for their patients by adding sleep-related information about heart disease, medications, and hospitalization for surgery, and supported patients in dealing with anxiety and fears about their heart and sleep. At the end of the six-session program, the patients were sleeping much better and they were feeling less anxious and depressed.

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Some medications that are used for sleep can affect the heart and some depress breathing, so be sure to discuss the risks and benefits of any sleep medications with your physician and/or pharmacist. See Chapter 24 for more information on sleep medication. CANCER Cancer is not one disease but a large variety of diseases; each type is different from the others. What they all have in common is that certain cells multiply too quickly. The particular cell type that starts multiplying too quickly determines the symptoms, the diagnosis, and where in the body the cells are most likely to spread. The treatment for the cancer depends on what type and stage of cancer it is. The most common types of cancer treatments are surgery, radiation, and chemotherapy. Many people who have had cancer have sleep problems. Although sleep problems have not been studied in all types of cancer, they have been studied in lung, prostate, breast, colorectal, gynecologic, and head and neck cancers. People with lung cancer and women with breast cancer are especially likely to experience sleep difficulty. Let’s talk about the types of sleep problems that are common and what to do about them. If you have insomnia, you are not alone. We found that almost one-third of people attending the cancer center in Kingston, Ontario, had insomnia. There are many reasons why insomnia often precedes, accompanies, and/or follows a cancer diagnosis. The most common contributors are thoughts and concerns—about one’s health, family and friends, and the future. It is not unusual to be anxious, worried, and to feel discouraged or depressed in response to a cancer diagnosis. There is often uncertainty about what’s next, fear of unfamiliar circumstances and treatments, and disruption of one’s normal routine. Understandably, this emotional upheaval can contribute to insomnia. Younger people who receive a cancer diagnosis are especially likely to be distressed and to have sleep difficulty. The physical and mental stress of some treatments for cancer can also lead to sleep problems. People who have had recent cancer surgery are especially prone to insomnia; we are not sure exactly why, but it may have something to do with staying in the hospital, which is disruptive to sleep. The insomnia that occurs with cancer is, more often than not, accompanied by fatigue and exhaustion. Sometimes physicians will prescribe sleep medication for short-term use when you have cancer. This can be very effective while you are dealing with the stress of the diagnosis and treatment. For the longer term, other options are more helpful. There is now abundant evidence that CBT-I works well for people who have had cancer. In fact, it is the main treatment recommended for insomnia that accompanies cancer.  The same CBT-I techniques that are in this book benefit people with cancer. Because it takes extra energy to carry out some aspects of Sleep Therapy, you will probably choose to do it after you have recovered from cancer treatments

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that sap your energy. With Sleep Therapy, people with cancer who have insomnia are sleeping well by the end of the program; their fatigue decreases, their mood improves, and they are functioning better during the daytime. When you start Sleep Therapy, take advantage of the afternoon nap if you are sleepy. As I described in Chapter 9, the prime nap zone is 1:00-4:00 p.m. Set aside no more than 45 minutes for your nap. This will provide up to 30 minutes of actual sleep time and still allow you to be sleepy again by bedtime.

Some other types of interventions for cancer patients are being studied for their potential benefit to sleep. Some studies of relaxation techniques, yoga, acupuncture, and exercise such as walking have shown improvements in sleep. However, these interventions have not yet been as carefully or extensively studied with cancer patients as has CBT-I. A Canadian study by Dr. Sheila Garland and colleagues found that both mindfulness-based stress reduction and CBT-I improved sleep, mood, and stress in people with cancer who had insomnia, but CBT-I led to greater and more sustained improvements in insomnia severity. So, CBT-I remains the best treatment available. Another common sleep problem for people who have had cancer is restless legs. Restless legs occur while you are resting in the evening and you must move around to deal with uncomfortable crawling, tingling, or aching sensations in the legs. It usually goes away when you stretch or walk around. In a survey we did at the regional cancer center in Kingston, this was the most common sleep-related problem reported by patients: 41% of people said they had restlessness in their legs. We are not yet sure why this number is so high. Stretching and moving around is how most people deal with this leg restlessness, and some people find a warm bath before bed to be helpful. About 80% of people who have restless legs syndrome also have periodic limb movements (repetitive arm or leg twitches or jerks) during sleep. People are usually unaware of these, but their bed partner may notice them. Such movements can cause miniarousals in your sleep. If you are very bothered by restless legs, I suggest that you tell your family physician. There are medications that can be prescribed to help reduce the interference of these leg sensations and/or limb movements with your sleep. SEASONAL ALLERGIES Many people have seasonal allergies—stuffy, running nose, and other symptoms in reaction to pollens from trees, grasses, or ragweed. Naturally, it is difficult to get to sleep at night when your nose is congested. You may also be waking up during the night with a stuffy nose and finding it hard to breathe. Research shows us that nasal congestion is at its worst in the latter part of sleep—the early morning hours. People

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who experience seasonal allergies are more likely than other people to have insomnia, to snore, and to have sleep related breathing problems. These problems include partially obstructed breathing and sleep apnea (breathing stoppages for short periods during sleep). The breathing irregularities at night are believed to be due mainly to nasal congestion. Your physician may prescribe medication (for example, corticosteroid nasal spray) for the nasal congestion and this, in turn, helps some people to get a better sleep. You should avoid taking types of antihistamines that cause sleepiness, like some cold and flu medications for nighttime symptoms, because these can leave you feeling sleepy during the day, and you are probably already tired and sleepy because of disrupted sleep. It’s best to talk to your physician or pharmacist about the options. BEING OVERWEIGHT If you are overweight, I’m sure you are aware of the many health benefits that come with losing weight. In terms of your sleep specifically, some very interesting relationships have been found between duration of sleep and weight. Shorter sleepers tend to have a higher body mass index and to gain more weight over time. In addition, short sleep and poor quality sleep seem to alter glucose metabolism (the way your body uses sugar) and may increase your risk of type 2 diabetes. Research also shows that short sleep is linked to appetite stimulation: It boosts levels of an appetite-stimulating hormone called ghrelin and reduces levels of an appetite-suppressing hormone called leptin. We do not yet know what causes what, but there are strong connections between short sleep (e.g., less than 5 hours per night) and being heavier and less healthy. I should point out right away that short sleep is not the same thing as insomnia (although you can have both). Short sleep usually occurs when people repetitively cut short their sleep because of life’s responsibilities, or because they stay up late into the night, absorbed by television, a book, or online activities and then have to get up early for school or work. So, the message is: make time for sleep, because curtailing sleep may affect your metabolism and hinder weight loss.1 If you are overweight you are also at higher risk of having sleep related breathing disorders, including episodes of partial or full obstruction of your airway (apneas) while sleeping. If you suspect you may be stopping breathing during sleep, or if someone has observed this, then talk to your family physician as soon as possible. Other signs of breathing problems at night include being sleepy—you fall asleep quickly any time you have the chance—and loud snoring. These are indications that you need to get this checked. If you do discover that you have sleep apnea or other sleep related breathing problems, there are very effective treatments that will help you sleep more continuously during the night and reduce your daytime sleepiness.

 If you are overweight and you have insomnia, it is okay to shorten your time in bed as part of Sleep Therapy because this will be temporary and will allow you to have optimal sleep in the long run.

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TYPE 2 DIABETES Many people with Type 2 diabetes have insomnia, especially the kind that involves waking up early in the morning. Sometimes the need to urinate at night several times, called nocturia, contributes to numerous awakenings. Not only does diabetes increase the chance that you will have insomnia, but the reverse is true as well. Having insomnia increases the risk of developing diabetes. This has been revealed by large studies that followed patients over several years. For example, researchers in Taiwan studied records of nearly 86,000 people from the national health insurance database and showed that those with insomnia were significantly more likely than others to subsequently develop diabetes. A study from Portland, Oregon, followed more than 81,000 people with prediabetes (higher than normal blood glucose levels) and found that those who had insomnia were 28% more likely to go on to develop Type 2 diabetes than those without insomnia. Other studies have found that among people who already have diabetes, having insomnia is associated with higher fasting plasma glucose levels and higher A1C levels, both measures of blood glucose control. Being overly sleepy during the daytime can also occur and sometimes this may be related to hypoglycemia (low blood sugar levels). Other sleep disorders that are quite common in people who have Type 2 diabetes are obstructive sleep apnea (repetitive stoppages of breathing during sleep) and restless legs syndrome (bothersome restlessness in the legs that is worse at rest and in the evening). Consult with your family physician if you think you may have either of these disorders. If you have sleep problems on top of diabetes, it may be harder to manage the diabetes and keep your blood glucose levels stable. You may be less inclined to be consistent with monitoring of blood glucose, taking medication, making good dietary choices, and getting exercise. The flip side is that you can take charge of this situation by improving your sleep. CBT-I can help you reverse insomnia. Getting regular, high-quality sleep can only help your blood glucose levels and your overall health. It can make it easier to carry out your diabetes self-care routines and increase your quality of life. DIGESTIVE DISCOMFORT If you are prone to having heartburn (gastroesophageal reflux disease or GERD) at night, chances are you also have some sleep difficulty. This nighttime heartburn is sometimes accompanied by acid reflux and a cough. In large studies, people who have these symptoms are very likely to have disturbed sleep, and people who have insomnia are likewise prone to GERD. Some experts believe that GERD and insomnia each make the other worse, forming a vicious cycle. There are medications that can be prescribed by your physician to reduce GERD at night, and once it is better, the research shows that sleep improves as well. If you still have some insomnia after the GERD is treated, and if there are no other major medical issues to deal with, then you can always use CBT-I, the Sleep Therapy program in this book, to deal with the unresolved insomnia.

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People with bowel problems are also prone to sleep disturbance. Ulcerative colitis and Crohn’s disease are types of inflammatory bowel disease, conditions that involve inflammation of the small and large intestine. The inflammation can bring abdominal pain, diarrhea, cramps, rectal bleeding, weight loss, and other symptoms. Irritable bowel syndrome, although not accompanied by inflammation of the bowel, occurs with diarrhea and/or constipation and recurrent abdominal pain. Compared to people without bowel problems, people with inflammatory bowel disease and people with irritable bowel syndrome describe poorer sleep—taking a long time to get to sleep and waking up several times at night—and have greater fatigue. People with these bowel disorders find that when their bowel problem flares up, their sleep becomes worse and when their sleep is poor, they are more likely to have a flare-up of the illness. There are many types of medical and lifestyle treatments for these diseases. It makes sense that when the bowel condition is stable, sleep is bound to be better; and conversely, getting a good night’s sleep can only be helpful for the bowel condition. We do not yet know for sure if CBT-I is effective for insomnia that occurs with bowel conditions. I would think that if your bowel disorder is not severe, you would be very likely to benefit from CBT-I. BREATHING PROBLEMS When we move from wakefulness to sleep, our breathing rate decreases, and the flow of air in and out of the lungs is reduced. These sleep-related changes are more pronounced when we have a breathing problem that further restricts respiration. You may have noticed this when you had a cold with a cough. You wake up a lot with coughing, especially toward the end of sleep. Many people with asthma find that it gets worse at night. There may be more coughing and wheezing, which are associated with awakenings and shortened sleep. In general, if breathing is difficult for any reason, then our sleep will be disrupted. This type of thing happens on a nightly basis when people have chronic breathing problems like emphysema (damage to the lungs) and chronic bronchitis (irritation of the bronchi that leads to coughing up sputum). Chronic obstructive pulmonary disease or COPD is a term that encompasses emphysema and chronic bronchitis. People with COPD often get very little sleep, and what they do get is disrupted. Their breathing problems get worse at night, especially during rapid eye movement (REM) sleep, and sometimes the amount of oxygen in their bloodstream drops, and this can be a concern because our cells require sufficient oxygen to function properly. It is not uncommon for people with COPD to also have obstructive sleep apnea (obstruction of the airway that causes stoppages of breathing during sleep). This creates what’s called “overlap syndrome,” and the reduction of oxygen in the bloodstream can be severe when these two conditions occur together. Fortunately, there are various treatments for these problems, and your physician can help here. There are also some techniques to manage shortness of breath that include “pursed lip breathing”—inhaling through your nose and exhaling through your mouth as if

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blowing into a straw. A nurse who knows about COPD can provide information and show you these techniques. Apart from breathing problems, insomnia itself is also common when you have COPD, especially if you are anxious or depressed. It is best to avoid sleeping pills because they can make breathing more shallow. Research shows that CBT-I works well for insomnia when you have COPD. New research indicates that it may also be helpful for people who have asthma. KIDNEY DISEASE People with kidney disease that has progressed to the point that they require dialysis have a very high rate of sleep disorders—insomnia, excessive daytime sleepiness, sleep apnea (breathing stoppages during sleep), and/or periodic limb movement disorder (repetitive arm or leg twitches or jerks during sleep). Most have a combination of these. Up to 80% of people who have advanced kidney disease have restless legs syndrome. This syndrome involves uncomfortable, restless sensations in the legs when sitting or lying down that worsen in the evening and are relieved by movement or stretching. Sleep in people with kidney disease tends to be short and fragmented. Sleep disturbance and kidney disease seem to follow similar courses—they tend to worsen together. For insomnia, researchers from Taiwan have found that CBT-I improved the sleep of people with kidney disease who were receiving peritoneal dialysis or hemodialysis. The patients’ fatigue levels also improved. These findings lead me to believe that the program in this book should be appropriate and helpful for people with kidney disease. Other approaches that might be helpful for sleep, but lack good-quality research, are exercise and acupressure. For people with kidney disease who are bothered by restless legs, studies suggest that exercise— either aerobic (such as fast walking) or resistance (strength) training—may be helpful. Your physician is the person to consult about medication options for restless legs or periodic limb movement disorder. Definitely consult your doctor if you suspect that you have sleep apnea or other nighttime breathing irregularities. NEUROLOGICAL DISORDERS I will summarize some of the findings about sleep when you, or someone you know, has Alzheimer’s disease, Parkinson’s disease, or multiple sclerosis (MS). Alzheimer’s Disease

Sleep disturbances occur in about 40% of people with Alzheimer’s disease. It is common for people to wake several times and for long periods at night. People with Alzheimer’s disease seem to have an accelerated aging of their sleep control systems in the brain, so that they get progressively less sleep at night and tend to take more naps during the daytime. Sleep studies show that they get only low amounts of deep (slow wave) sleep and REM sleep. See Chapter 26 for descriptions of sleep stages. Other research indicates that the internal control of circadian rhythms is weakened

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so that the 24-hour timing of sleep-wake patterns is not as regular. People with Alzheimer’s need assistance to use sleep improvement strategies. Studies have shown that some components of CBT-I are helpful: having a regular bedtime and rise time, reserving the bed for sleep, and limiting naps. In addition, daily exercise, such as walking, and natural light exposure during the daytime have been found to help. While the sleep of people with Alzheimer’s disease can be poor, their caregivers’ sleep may be worse. An estimated 60–70% of caregivers have sleep disturbances. Dr. Susan M. McCurry, a research professor at the University of Washington in Seattle, has done a lot of research on the sleep of people with Alzheimer’s and their caregivers. She found that caregivers’ sleep disturbances were related to the burden of caregiving: the greater the physical and emotional strain that arose for the caregiver in caring for a person with Alzheimer’s disease, the more likely they were to develop sleep problems. Having to be alert during the day and at night, and the strenuous mental and physical work required for Alzheimer’s disease care, make for very poor sleep. There is direct disruption of the caregiver’s sleep when the care recipient wakes up at night, calls out, or wanders in a confused state. Family caregivers may have worries, depression, and a reduction in pleasurable activities and in contact with friends. There is fear about what the future will bring and huge anxiety around decisions about placing the person in care. Having a break (respite care) to be able to have an afternoon nap, to do some exercise, and to see friends is very helpful for caregivers. Ways to specifically improve the sleep of caregivers have not been extensively studied, however aspects of CBT-I including stimulus control therapy (sleeping only in bed, leaving the bed when not sleeping), mild sleep restriction, cognitive therapy, and relaxation show promise. In addition, a program of brisk, regular walking may improve the sleep quality of family caregivers. Parkinson’s Disease

Daytime sleepiness and sleep difficulties, including insomnia, are very common for people who have Parkinson’s disease. As the disease progresses, the sleep disturbance tends to worsen. Medications used to increase the neurotransmitter dopamine (a chemical messenger that is low in Parkinson’s disease) are also associated with sleep problems, especially awakenings in the night. Sleep lab studies indicate that people with Parkinson’s disease get less sleep and are awake for longer periods during the night compared to those without the disease. It seems that CBT-I may be helpful: the small amount of research to date shows promise for CBT-I’s effectiveness for people with Parkinson’s disease. Some people have changes in REM sleep with Parkinson’s disease. REM is the sleep stage in which we do most of our dreaming. (See Chapter 26 for more information on REM sleep.) In general, people with Parkinson’s disease get less REM sleep and take longer to enter this sleep stage than people without the disease.

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Something called REM sleep behavior disorder (RSBD), which involves moving around during REM sleep, is much more likely to occur in people with Parkinson’s disease than in the general population. In fact, often RSBD precedes the Parkinson’s disease diagnosis by years. Normally our movements are inhibited in REM sleep so that we don’t act out our dreams. People with RSBD lose some of this inhibition of movement and may enact their dreams. Dreams about being chased or threatened can lead to the person moving violently in bed, hitting, kicking, and colliding with furniture. The dream enactment can cause serious injuries to the dreamer and their bed partner. RSBD is usually treated with medication. It is important to get medical help for RSBD as early as possible. In addition, any hard or sharp objects or furniture near the bed should be moved out of grasping or hitting distance. The partner is safest when sleeping in a separate room. Multiple Sclerosis

Research suggests that at least 40% of people who have multiple sclerosis (MS) have insomnia. The most common reasons given by people for their insomnia are having to get up to urinate, pain and discomfort, and having a racing mind. Most people (estimates range from 60–90%) with MS are fatigued. Studies have shown that the greater the sleep disturbance, the more fatigued people are, especially for tasks that involve attention and thinking. Fortunately, CBT-I is now being used by people with MS, and all indications are that it is helpful for improving both sleep and fatigue. So, the techniques in Sink into Sleep should be helpful if you have MS. If you have mobility limitations, you can alter the instruction about getting out of bed when not sleeping and instead use visual imagery (see Chapter 17) when you are awake in bed. In addition to insomnia, people with MS have high rates of sleep related breathing problems, like obstructive sleep apnea (breathing stoppages during sleep) and restless legs syndrome (uncomfortable sensations in the legs that worsen in the evening when resting and are relieved by movement). If you think you may have either of these disorders, talk to your family physician or neurologist. IS CBT-I ALWAYS HELPFUL WHEN WE HAVE MEDICAL PROBLEMS? A member of my family, Alec, was 92 years old when various health problems started to limit his social and active lifestyle. He was dealing with congestive heart failure, which caused his legs to swell and his kidneys started to fail. He was having a very hard time sleeping. His doctor prescribed low dose trazodone for his sleep, which he took each night, but it did not really help. Even though his sleep was a big issue for him, I did not offer to show him Sleep Therapy techniques. He had very little energy and strength, needed oxygen from a tank, and assistance from a nurse to get into bed at night. This was not the time for him to be using Sleep Therapy techniques that involve getting out of bed when you are not sleeping, staying up to certain bedtimes, and keeping sleep diaries. This situation illustrates that CBT-I or Sleep Therapy is not always appropriate for people with medical conditions.

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I believe that it is not so much the type of medical condition that limits how useful the techniques are, but rather the overall energy and strength of the person to carry out CBT-I. The usefulness of the techniques also depends on the person’s interest in sleeping well and in using behavioral (nondrug) strategies to do so. To sum up, even though CBT-I has not yet been tested with all medical conditions, it probably works well to reverse insomnia regardless of the presence of medical conditions if you have the energy, strength, and motivation to do it.

CHAPTER 23

Depression, Anxiety, and Traumatic Stress

adness and anxiety are normal human emotions, and stress is a normal occurrence in our lives. When we’re feeling somewhat down, anxious, or stressed, we S can benefit from exercise (a wonderful natural mood-lifter), relaxation, recreation,

eating nutritious foods, allowing time for sleep, and talking to a friend. However, when the sadness continues or the anxiety mounts to the point that our ability to do our usual activities is challenged, these are clinical conditions, and we will benefit from professional help in addition to the self-care strategies just mentioned. As a result of cutbacks at her workplace, Marie had lost her job as an account manager, a position she had held for 7 years. Prior to this blow, she had been feeling considerable tension at work, as she and her coworkers faced uncertainties about the looming changes. She received some severance pay but this would not last for long; she didn’t know how she was going to continue to pay the rent and to support her two teenagers. When she left work on the last day, Marie felt like taking refuge at home. She just wanted the world to go away and her problems to solve themselves. She went to bed and stayed there, under the covers. She didn’t feel like getting up in the morning or the next morning. The shock and disappointment of losing her job turned into depression. Marie’s mood was low and she couldn’t see how things could improve in the future. The more she stayed at home, the harder it was to get out of the house. She started to feel vulnerable and panicky just thinking about going to the 171

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grocery store. Marie’s sleep was not good. She was unable to fall asleep, she was waking up during the night (sometimes in a panic), and she was waking up much earlier in the morning than she wanted to. Needless to say, the sleep difficulty did not help her situation. It only made her feel more distressed, fatigued, and discouraged.

Unfortunately, Marie’s situation is not unique. Clinical depression and anxiety are very common conditions. Let’s look at what they are, what happens to sleep, and what helps recovery of mood and sleep. DEPRESSION Depression often, but not always, begins with a loss or sudden change in the course of one’s life. It’s natural to feel sadness, anger, and discouragement when things go wrong, but when the blow is very big or extended over time, and/or we are particularly vulnerable to feeling low, the sadness can persist and develop into depression. Symptoms vary from person to person but depression involves low mood or a loss of interest in things that normally are pleasurable. It can also involve difficulty concentrating and making decisions, decreased (or sometimes increased) appetite, fatigue, self-blame, feeling discouraged, moving and thinking more slowly than usual, feeling agitated, having sleep difficulty, and having thoughts about death and suicide. If several of these symptoms continue every day for more than 2 weeks, this is what’s called “clinical depression.” If you think you may have clinical depression, it is important to get help as soon as you can. Start with your family physician or mental health professional; make an appointment to discuss how you’re feeling and the options for treatment. The degree of depression can range from mild to severe. In severe cases, people become quite hopeless, and getting professional help is imperative. It is difficult to help yourself when you are feeling so low. Insomnia usually goes along with depression. In general, when we are depressed, we may take longer to fall asleep, wake up more during the night, and/or wake up too early in the morning. Sleep lab studies show some changes in rapid eye movement (REM) sleep: It tends to start earlier in the night, and there’s more than usual in the first part of the night. The amount of deep (slow wave) sleep is usually reduced. With some types of depression, a different pattern occurs—one of hypersomnia (excessive sleep). For example, with seasonal affective disorder, which is depression that occurs with winter darkness and lifts with longer hours of daylight, people often sleep more than usual and have trouble waking up in the morning. Depression and Insomnia: Which Comes First?

Did you know that insomnia increases a person’s risk of developing depression? Physicians and psychologists used to think that insomnia was part and parcel of a

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person’s depression, that the insomnia came with the depression. However, now we know that insomnia often precedes depression. Over the last 30 years, many studies have followed people with insomnia and measured their mood at regular intervals over a number of years. These studies have found that, compared to people without insomnia, people with insomnia have a greater risk of developing depression. When the results from these studies were combined in what is called a meta-analysis, the overall risk was estimated to be two times higher in people who have insomnia. Following these findings, newer research is looking at whether depression risk can be lowered by treating insomnia with cognitive behavioral therapy for insomnia (CBT-I); so far the results are promising. That’s one of the reasons it is important to treat insomnia early; in doing so it may prevent the onset of depression. It used to be thought that if you had both depression and insomnia, you needed to fix the depression and the insomnia would take care of itself. We now know that insomnia does not necessarily go away on its own, even when the depression lifts. We also know that it makes good sense to treat both conditions and not to delay either type of treatment. How to Sleep When You’re Depressed

I’ll outline here what we know about treating insomnia in three forms of clinical depression: major depression (medically classified as major depressive disorder), seasonal affective disorder, and bipolar disorder. Major depression

This is the most common type of clinical depression. First of all, it is wise to get help for the depression itself. The two most effective treatment approaches are antidepressant medication and psychotherapy. You can do one, do the other, or do them both. Antidepressant medications are usually prescribed by your family physician or a psychiatrist, who will base their recommendations and prescription on your specific symptoms and medical history. Typically, the physician will explain the benefits and side effects of the medication, outline how long the medication usually takes to work, and suggest that you return to follow up within a few weeks. Psychotherapy is talking with a counselor or therapist. I recommend a psychologist or other mental health professional who is trained in techniques that are “evidencebased,” that is, they have been proven to work. Cognitive behavior therapy (CBT) is the most common evidence-based intervention for depression. Like CBT-I, CBT involves cognitive (thinking) and behavioral (doing) strategies, but the focus of therapy is quite different. For depression that is severe, antidepressant medication is often recommended as the first treatment. The antidepressant medication may allow you to gain a bit of energy and concentration; then you will be more able to engage with your support network and in psychotherapy if you wish.

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Guess what? If you are depressed and you also have insomnia, research shows that CBT-I works just as well as it works for people who are not depressed. Moreover, studies now show that, not only does sleep improve, but mood improves too! In 2008, a study from Stanford University showed that participants’ sleep improved and also that half of participants were no longer depressed after CBT-I. These positive effects on mood have now been confirmed by many other studies. It is remarkable that CBT-I improves mood, even though mood is not a specific focus of the techniques. This fortunate side-effect of CBT-I demonstrates the close interrelationship of sleep and mood. Seasonal affective disorder

As I mentioned earlier, with seasonal affective disorder, the sleep problem is usually hypersomnia rather than insomnia. The wanting-to-stay-in-bed-in-the-morning feeling that occurs in the dark months with seasonal affective disorder appears to be linked to a delay of certain circadian rhythms, including melatonin, cortisol, and sleep–wake tendency. For this, bright light treatment (usually taken in the early morning) can help lift mood and reduce the hypersomnia. The timing and details of this treatment are very specific. Professionals with training in behavioral sleep medicine and/or circadian rhythm interventions can provide specific advice for your situation if you have seasonal affective disorder. Start by asking your family physician. Bipolar disorder

Bipolar disorder is a certain type of mood disorder in which there are depressive episodes and also, less frequently, episodes of elevated (or sometimes irritable) mood during which the person has lots of energy, has grandiose ideas, and may engage in exciting and risky behaviors (such as over-spending, making ambitious plans, overindulging in alcohol or sex). Depending on how disruptive these episodes are to the person’s life, they are either called “manic” (severe) or “hypomanic” (less severe). During the depressive episodes, sleep is similar to that of people with regular clinical depression. During the manic/hypomanic episodes, sleep–wake patterns are altered significantly. The person may stay awake for many hours past their usual bedtime, or even all night, because they are absorbed in a project or doing something interesting. Sleep is not very long and not very deep. REM sleep may occur earlier in the night, and there may be more of it than usual. Bipolar disorder is usually treated with medication by psychiatrists and family physicians. If mood and symptoms are well managed by medication then insomnia is less of a problem. The full CBT-I program is not usually recommended for people with bipolar disorder. Importantly, there is a small risk of triggering a manic episode with sleep deprivation, and CBT-I does involve a type of controlled sleep deprivation when you stay up later than your usual bedtime. If you have bipolar disorder, make sure you are not reducing your time in bed to less than 7–8 hours. Researcher Dr. Allison Harvey and colleagues at the University of California at Berkley have developed a modified CBT-I program specifically for people with bipolar disorder. Their program

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emphasizes keeping a regular schedule, including a stable bedtime and rise time, having a wind-down period with dim light for 30–60 minutes in the evening before bedtime (with no electronic devices), and getting up right away in the morning. The relaxation strategies and the cognitive techniques discussed in Chapters 17 and 18 can also be beneficial. ANXIETY Feeling anxious is a normal human experience. Anxiety serves some useful purposes: it can direct our attention and energy to important tasks and it can help us deal with threats to our safety. The latter is achieved via the “fight-or-flight” response—a surge of the hormones adrenalin and cortisol, with a sudden increase in heart rate, breathing, and many other physiological changes—that allow us to have strength and energy to fight or to run away from danger. You may have heard stories of super-human feats performed by people in catastrophic emergencies, such as lifting a car off a child who has just been hit or plunging into raging waters to save someone who’s drowning. This is when that adrenalin rush plays a crucial role. However, when our anxiety gets away from us, and its level exceeds what the situation calls for, for example, when we panic even though we are not facing a life-threatening situation, then it can interfere with our well-being and functioning and be very uncomfortable. This is what is called “clinical anxiety.” There are several types of clinical anxiety; it is usually classified according to the types of symptoms that occur and/or the types of situations that provoke anxiety or fear. Examples are generalized anxiety, social anxiety, panic attacks, and specific fears or phobias. The anxiety becomes a disorder if it causes distress or interferes with functioning, for example, by preventing you from talking with people at work or being able to do the things you want to do in life. The following is some general information, but your physician or psychologist can provide specific diagnosis and treatment if you think you have clinical anxiety. The main approaches to the treatment of the anxiety itself are psychotherapy and/or medication. For psychotherapy, I recommend an evidence-based treatment (i.e., a treatment that has been proven to work through research) that is specific to the type of anxiety that you have. For example, cognitive behavior therapy including “exposure” techniques is often effective. Exposure is putting yourself in situations that make you anxious, starting with low-anxiety situations and working your way up to higher-anxiety situations while using strategies to relax, to manage your symptoms, and to feel in control. The experience of being able to tolerate the once-avoided situation goes a long way in reducing the anxiety. For medication advice, consult your physician. Certain types of antidepressants or anti-anxiety medications (benzodiazepines) are sometimes prescribed. These medications have pros and cons, which you should definitely discuss with your physician. Most people who have clinical anxiety also have insomnia: trouble falling asleep and/or trouble staying asleep. A common experience is having a racing mind when all you want is to fall asleep.

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How to Sleep When You’re Anxious

Most types of anxiety involve hyperarousal—the body and mind are on high alert. So, it’s not surprising that sleep difficulties accompany anxiety. Discovering how to reduce that hyperarousal can be one key to reducing the sleep problem. Relaxation techniques and cognitive therapy can help with this (see Chapters 17 and 18). When a pattern of hyperarousal and sleep disturbance has continued over time, then new sleep patterns need to be established. This is when the CBT-I strategies of uncovering your natural sleep processes, associating your bed with sleep, and knowing what to do with a racing mind come in. However, as we’ll see, severely restricting your time in bed as part of CBT-I may not be a good idea when you are prone to panic attacks. We also don’t know yet whether CBT-I is well suited for all people who have obsessions and compulsions (discussed later). For most types of anxiety, though, CBT-I seems to work very well to improve sleep. Generalized anxiety and social anxiety

Generalized anxiety is excessive anxiety and worry that is difficult to control, about a variety of issues such as events at work, family matters, your health, and anything else that is happening. Social anxiety is discomfort and fear of being watched and judged by others, really not wanting to be the focus of attention, and avoiding such situations (e.g., by not volunteering to give talks or not going to parties unless you are helping in the kitchen). For insomnia that occurs with these types of anxiety, CBT-I seems to work very well. Clinical studies of CBT-I show that people with elevated anxiety do just as well as anyone else at improving their sleep. What’s more, people are less anxious after they do CBT-I. So, the techniques in this book will be helpful. Chapters 17 and 18 are especially relevant for dealing with nighttime worries and racing thoughts. Panic attacks

Panic attacks are alarming anxiety episodes that come out of the blue. They are discrete periods of intense fear with physical symptoms that can include sweating, pounding heart, feeling short of breath, trembling, chest pain, nausea, dizziness, fear of losing control or dying, tingling, hot flashes, or chills. The first time it happens, people can think they’re having a heart attack. Sometimes panic attacks occur during sleep. These nocturnal panic attacks are sudden awakenings with fear, shortness of breath, rapid heart rate, and sweating. They are not associated with dreams, and from sleep lab studies we know that they do not occur in REM sleep. Rather, they occur in sleep Stages 2 or 3, often at the transition from Stage 2 to Stage 3 when breathing starts to slow down (see Chapter 26 for a description of sleep stages). Sometimes people develop insomnia because they are afraid to go to sleep and have another panic attack. To my knowledge, no studies of CBT-I have been done specifically with people who have panic attacks. If you have daytime or nighttime panic attacks, you will benefit

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from learning more about them and knowing how to deal with the frightening physical alarm signals that occur with panic. The more you know what panic attacks are, and use strategies like deep breathing and self-reassurance, the more they will subside. This is best done with professional help, for example with evidence-based therapies that involve cognitive, behavioral, and exposure strategies, specifically for panic. Once you are comfortable with dealing with the panic attacks, and they subside, your sleep may improve substantially. If it doesn’t—your panic attacks are well managed but you still have insomnia—then CBT-I would be reasonable to try. You should know that there is a chance that sleep deprivation may bring on panic attacks, so you will want to avoid severely limiting your time in bed, unless you want more exposure practice. Obsessions and compulsions

You may have heard of obsessive-compulsive disorder (OCD). People with OCD have obsessions or compulsions or both. Obsessions are intrusive, anxiety-provoking thoughts that keep occurring even though you don’t want them. Compulsions are repetitive behaviors or mental activity that are done to reduce anxiety, often in response to obsessions. For example, if a thought kept coming to mind again and again that you might set the house on fire (an obsession), this would naturally be very upsetting and frightening. You might take all sorts of precautions to make sure that the house does not catch on fire. For example, instead of checking that the stove is off and the toaster is unplugged once or twice, you would check them again and again, because of an uneasy feeling about them possibly being on. Again, for a specific diagnosis and treatment, seek help from your family physician or a psychologist. If you have OCD and you have insomnia, no one knows for sure whether your insomnia will benefit from CBT-I because there hasn’t been sufficient research yet. Until we know, I would focus on managing your obsessive-compulsive symptoms with medication prescribed by your physician, and/or evidence-based methods with a psychologist or other professional. My clinical experience tells me that it is difficult to benefit from CBT-I if OCD is severe, that is, if you are spending several hours each day being bothered by obsessions and/or compulsions. If the OCD is mild and/or well-controlled by medication, and insomnia remains an issue, then CBT-I may be helpful. I once saw a young man, we’ll call George, who had OCD symptoms focused on his insomnia problem, and his mind was always trying to fix the problem and control his sleep. He was determined not to use prescribed medications for OCD or for insomnia. He had tried many techniques and herbal remedies for insomnia. When he tried CBT-I, unfortunately his obsessions prevented him from letting go and trusting his innate rhythms

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of sleep and wakefulness to work for him. His overactive mind, trying to control things, got in the way. His sleep did not improve substantially with CBT-I. I have a hunch that if George had been open to taking medication prescribed by his family doctor for OCD, this may have reduced the obsessions enough to allow him to benefit from CBT-I.

Specific phobias

A “specific phobia” is a fear of certain things like snakes, heights, or riding in elevators. The little research that is available on whether CBT-I is helpful for insomnia when you have a specific phobia suggests that CBT-I works. A study by psychologist Dr. Lynda Bélanger from Université Laval and colleagues found that people with various types of anxiety benefitted from CBT-I for their insomnia, including 10 people who had specific phobias. TRAUMATIC STRESS In May 2016, a wildfire started to engulf Fort MacMurray, a community in northeastern Alberta, Canada. During the 16 months of firefighting, 88,000 people were displaced. This is just one of many recent natural disasters. Research on how people respond to such events has told us that within the first months of disaster, many people develop signs of anxiety, depression, and posttraumatic stress. Fortunately, over time (1–2 years), these symptoms subside for the majority of people. How is sleep affected in traumatic situations? In a research study led by researcher Dr. Geneviève Belleville, 379 evacuees from Fort MacMurray completed questionnaires about their mental health and their sleep. Three months after the fires started, approximately 60% had symptoms of posttraumatic stress. The most frequent symptoms were disturbing memories (in 77% of people), feeling upset when reminded of the stressful experience (77%), and trouble falling or staying asleep (72%). So, insomnia is very common during and following natural disasters. As I write this, we are in the midst of the COVID-19 pandemic. This health threat is affecting us all in some way. It’s normal to feel some distress; how much we are affected mentally will depend on our circumstances. I expect that many people will be having some problems sleeping. Based on the natural disaster research, we can expect that most people’s mental distress will diminish over time. We don’t yet know how long it takes for sleep to get back to normal. Fortunately, there are some effective techniques that can be used for sleep problems that persist following threatening events, including those that traumatize us. Read on. Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a set of symptoms that occurs, for more than 1 month, following exposure to a terrifying event in which there was a severe threat

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to personal safety, such as rape, abuse, war, and disasters. Symptoms can include persistent frightening thoughts, memories, and images related to the event, feeling detached and numb, being angry or irritable, and being “jumpy” (easily startled). PTSD can be very disabling. There are various therapeutic approaches and you need to receive help from your family physician and/or a mental health professional in order to get the right treatment for you. With respect to sleep, people with PTSD tend to get somewhat less deep sleep, experience longer periods of being awake during the night, and have an overall shorter sleep duration. In addition, sleep is often disturbed by nightmares. These nightmares can be helped by using a technique called imagery rehearsal therapy. This involves writing out the nightmare, changing the story in any way you like, writing down the new dream, and rehearsing the new dream—going over it in your mind at least 10–15 minutes per day. This technique effectively reduces the number and severity of nightmares. And our old friend, CBTI, has been shown by research to work well for insomnia that occurs with PTSD. For example, a study with patients in the San Francisco area found that CBT-I improved the sleep of people with PTSD and the improvements were maintained 6 months later. Indeed, a meta-analysis (a comprehensive review of randomized controlled studies on the topic), concluded that CBT-I was effective at improving people’s sleep. People were falling asleep faster and were awake for less time during the night. In addition, CBT-I led to significant improvements in mood and daytime symptoms of PTSD. My recommendation: If you have PTSD and are able to follow the CBT-I techniques, it’s definitely worth the effort. Remember Marie, the woman who became depressed after losing her job? One day, her 18-year-old daughter said, “I think you should see your doctor. I’ll drive you if you make the appointment.” Marie decided to pick up the phone. That was her first step on her path to feeling better. Over the next few weeks, there were ups and downs, but with medication, help from a psychotherapist, and then with CBT-I, she started to feel like her old self. Last I heard, Marie was preparing her résumé and was feeling hopeful.

SLEEP SUBSTANCES

CHAPTER 24

Sleeping Pills

“Curled in an attitude of peaceful contentment, the princess lies in deep slumber, her head on an ancient, dusty pillow.” George Balanchine

his describes the sleep state of Princess Aurora, the Sleeping Beauty, a sleep that began with a prick of the finger on a spindle supplied by the evil fairy Carabosse. T Don’t worry, Aurora is soon to be awakened by a prince’s kiss. Sleeping potions and

spells have figured prominently in fairy tales and other stories for as long as they have been written. Even Harry Potter used a “dreamless sleep potion” to aid his recovery after confronting Voldemort. These stories illustrate our fascination with the medicinal and magical methods of inducing sleep. It would be nice to think that by simply taking a pill or other substance, we could sink into a satisfying and restorative sleep. The truth is, this can happen in a few circumstances, but in most situations, it is not the best solution. I will go over the advantages and disadvantages of the current medications that are used for sleep to provide you with some basic background information.

As a psychologist, I do not prescribe medication myself. The information that I will review here is based on research and other scientific literature on sleep medications, and I will be covering general findings. For your specific situation, you need to consult with your physician and/or pharmacist for personalized advice that will take into account your age, medical history, current medical and psychiatric conditions, other 183

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medications, and other factors that are specific to you. Also, the availability of medications depends on where you live. What’s available in Canada, where I am, may be different from what’s available where you live. Also, the types of medications, their properties, and their availability are changing all the time. You can get up-to-date information from a pharmacist in your community or, for medications available in the United States, at www.nlm.nih.gov/medlineplus/druginformation.html. PRESCRIBED SLEEP MEDICATION The Benzodiazepine Receptor Agonists

These days, if your doctor prescribes a medication to help you sleep, it is most likely to be a benzodiazepine receptor agonist (BzRA). The BzRAs work by promoting the neurotransmitter GABA (gaba-aminobutyric acid), which reduces excitability in the brain. If your brain is in a less excited state, you are more likely to be able to sleep. Here is a table of BzRAs that are commonly prescribed for insomnia. You will see that there are two categories of BzRAs: the “z-drugs” and the “benzodiazepines.” Generic Name

Trade Name(s)

Type of BzRA

eszopiclone

Lunesta

z-drug

zopiclone

Imovane, Rhovane

z-drug

zaleplon

Sonata

z-drug

zolpidem

Ambien, Sublinox, Intermezzo, Edluar, Zolpimist

z-drug

lorazepam

Ativan

benzodiazepine

temazepam

Restoril

benzodiazepine

clonazepam

Rivotril, Klonopin

benzodiazepine

oxazepam

Serax

benzodiazepine

alprazolam

Xanax

benzodiazepine

The benzodiazepines are named for their common chemical structure: a benzene ring and a diazepine ring. The z-drugs, named for the z in their names, have a different chemical structure. Unlike the z-drugs, some of the benzodiazepines are also prescribed for anxiety disorders and to help people relax while undergoing medical or dental procedures. Despite these differences, both types of medication help to induce sleep by promoting the action of GABA. What distinguishes the various BzRA sleep medications is how fast they work and stop working on a given night, some taking less than 30 minutes for absorption and distribution to the brain, and others taking a little longer. Some leave the body quickly and others can build up over time when taken every night. Which one you are prescribed will depend on your particular situation and the prescribing practices of your physician.

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The pros

These medications can help you get some sleep the very night you take them. If you need sleep immediately, this type of medication will most likely help. For example, say a family member has died, and you are grieving and unable to get much sleep, but you need to arrange a funeral. This is when your physician may suggest one of the BzRAs. Generally, these medications are effective when you have sleep difficulty at the time of stressful life events, such as a relationship breakup, the diagnosis of a serious medical condition, or distressing work or family issues. The cons

The main disadvantages of BzRAs include their side effects and the risk of “dependence,” described below. Here are the potential side effects. “Hangover effect”: ●

Grogginess the next morning, daytime drowsiness, sleepiness

Problems with thinking: ●

● ●

memory problems (trouble remembering things that happen in the few hours after taking the medication and memory problems the next day) problems with attention and processing speed the next day older adults who take BzRAs for years may have a greater chance of developing dementia. (We don’t know the specific cause yet.)

Balance control problems: ●

muscle weakness

●

unsteadiness, stumbling

●

dizziness

●

falls (minor and serious, with risk of major bone fractures and head injuries)

Driving impairment: ●

increased risk of traffic accidents

●

impaired driving the next day

Respiratory problems: ●

increased risk of pneumonia when infected by the flu

Other serious problems: ●

withdrawal effects lasting days to months

●

“paradoxical reactions” such as feeling disinhibited or agitated

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For older people, these problems are especially serious as BzRA-induced dizziness and balance problems can lead to falls and bone fractures. Because of the effects on memory, these medications can be especially troublesome for people who already have memory problems, such as those with Alzheimer’s disease. The chance of nextday impairment is higher with the longer-acting medications (ones that take more time to clear the bloodstream, such as clonazepam, flurazepam, diazepam), with higher doses, and when the medication is taken in the middle of the night rather than at bedtime.1 So, side effects are less likely to be troublesome with low doses of shorter-acting medications, taken before bed every now and then rather than each night. It is also important to know that the side effects of BzRAs, described above, are made much worse by alcohol, cannabis, opioid pain medications (such as codeine, morphine, fentanyl, oxycodone, and hydromorphone), or other medications or substances that affect brain functioning; serious adverse events can occur if you combine them. After about 2 to 4 weeks of nightly use, BzRAs typically become less effective due to “tolerance.” This means the dose you have been taking starts to have less effect; therefore, you need a higher dose to get the same effect. This can lead to dependence, which occurs when you have great difficulty sleeping without the medication. Tolerance and dependence can occur with any BzRA. Because of this, and especially because of their side effects, medical guidelines specify that these medications not be prescribed for longer than 4 weeks. So, when physicians prescribe a BzRA, the prescription is usually for a limited number of pills to help you over the short term. If your doctor prescribes the medication to be taken intermittently (for example, 0–4 times per week), there will be fewer problems with tolerance. “Rebound insomnia” is sleep difficulty that occurs if you’ve been taking a BzRA every night for a while and then you suddenly stop taking it. Your brain has adjusted to the medication influencing your sleep patterns; without it, your sleep worsens as part of a withdrawal reaction. It can feel like your insomnia has returned and is worse than ever, leading you to think that you need the BzRA. Resuming the medication usually helps to reduce the rebound insomnia, but inevitably, only serves to prolong the cycle of BzRA dependence. Sometimes people think this rebound insomnia is proof that they can’t sleep on their own without sleep medication. This is untrue; rebound insomnia is a temporary withdrawal effect and it says nothing about your ability to sleep without medication. Some other withdrawal effects that people can encounter when stopping BzRAs, especially after taking them for several weeks, months, or years are a temporary increase in anxiety, distress, restlessness, agitation, irritability, and sensitivity to sounds and other sensory information. In the most severe cases of BzRA withdrawal, people can experience profound confusion and seizures. A slow taper off the BzRA can prevent rebound insomnia and other withdrawal effects. If you have been using the medication every night for more than 4 weeks, ask your healthcare professional or pharmacist for advice on how to reduce the dose in a This does not apply to medications that are designed to be taken during nighttime awakenings rather than at bedtime, such as a special formulation of zolpidem called Intermezzo.

1

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step-by-step way to avoid withdrawal effects. If you have been taking these medications for months or years, it is very important not to stop taking them abruptly. Rather, follow the slow, step-wise taper recommended by your health provider. Here’s how slow tapering is arranged at the interdisciplinary health teams I’ve worked with: the family physician refers the person who is wanting to reduce or discontinue BzRA use to the team pharmacist; the pharmacist meets with the person, looks over all their current medications, provides information about the tapering process, and designs a schedule for slowly reducing the medication. The person is always offered cognitive behavioral therapy for insomnia (CBT-I) at the same time as the tapering. Depending on the usual dose of the medication taken, it can sometimes take several weeks or months until the person is not taking the medication anymore. In the meantime, their sleep improves with the use of CBT-I strategies. Many people do not have access to such a health team. That’s all right. If you decide to reduce and discontinue your use of BzRAs, just know that the process is much easier when you follow physician and/or pharmacist advice about slowly tapering off the medication and when you also use CBT-I. You can guide yourself through CBT-I by following the Sleep Therapy strategies in this book. The Sedating Antidepressants and Antipsychotics

Sometimes, instead of prescribing a BzRA for sleep, physicians prescribe a low dose of an antidepressant or antipsychotic medication. As their names suggest, antidepressants and antipsychotics are used to treat depression and psychotic symptoms (like hallucinations or delusions), respectively. Some of them have sedative (calming, sleep-promoting) properties. Here are a few: Generic name

Trade name(s)

Type

trazodone

Deseryl and others

antidepressant

doxepin

Sinequan and others

antidepressant

amitriptyline

Elavil and others

antidepressant

mirtazapine

Remeron and others

antidepressant

quetiapine

Seroquel

antipsychotic

The pros

For people who are depressed, the sedating antidepressants can improve sleep, more so than some other classes of antidepressants (like the selective serotonin reuptake inhibitors or SSRIs). For people who do not have depression or psychosis, these medications can have a sedative effect at very low doses. It is debatable whether this type of low-dose treatment of insomnia is better than treatment with BzRAs. Stopping these medications after months or years of taking them is usually more straightforward than stopping BzRAs, although they should be gradually reduced, rather than stopped abruptly, over weeks.

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The cons

These medications were developed to treat mental illnesses including major depression, anxiety disorders, bipolar disorder, and schizophrenia. There are just a handful of studies of these medications when used to treat insomnia in people without these disorders. Although stopping these medications may not be as challenging as discontinuing BzRAs, you can still experience rebound insomnia and other withdrawal symptoms such as stomach and bowel distress, dizziness, and sweating, lasting for days. Side effects vary depending on the type of medication and dose prescribed. Get advice and information about the specific warnings and possible side effects if you are prescribed any of these medications specifically for insomnia. You may wish to ask about your risk of any of the following possible side effects: ● ●

daytime drowsiness and sleepiness dizziness, lightheadedness, orthostatic hypotension (low blood pressure when you stand up)

●

confusion

●

blurred vision

●

dry mouth

●

constipation

●

urinary retention (inability to empty the bladder)

●

increased appetite and weight gain

●

heart rhythm problems

In general, medical guidelines do not recommend these sedating antidepressants and antipsychotics for chronic insomnia because of their side effects, and because of insufficient evidence of their effectiveness for sleep. Melatonin-Based Products

Melatonin is a hormone that is released from the tiny pineal gland in our brain each evening, as darkness replaces daylight. It is involved in the regulation of the timing of our sleep. While our brains release it every night, it can also be manufactured and taken as a pill. The manufactured melatonin is called exogenous (outside the body), and it mimics the endogenous (inside the body) hormone. Exogenous melatonin can be purchased without a prescription in Canada and the United States, but in other countries, including the United Kingdom and Australia, a prescription is necessary. Ramelteon is a melatonin-like medication. It has a very similar chemical structure to melatonin and is known as a “melatonin-receptor agonist.” This means that it acts like melatonin at melatonin receptors (special sites on cell walls where melatonin binds) in the brain.

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Generic Name

Trade Name

Type

melatonin

(multiple names)

exogenous melatonin

prolonged-release melatonin

Circadin

exogenous melatonin that is released from the capsule over time, rather than all at once

ramelteon

Rozerem

melatonin-receptor agonist

The pros

Standard (immediate-release) melatonin can sometimes be useful for the prevention of east-bound jet lag and for certain shift work schedules, and it may be helpful in the short term (up to 1–2 weeks) for sleep difficulty. There is some evidence that it can help sleep in children who have attention-deficit/hyperactivity disorder and insomnia. Prolonged-release melatonin has been studied mostly in older people and is sometimes prescribed in Europe for people who are 55 years of age or older. Ramelteon may be helpful for some people who have trouble falling asleep at the beginning of the night. The side effects of melatonin and ramelteon appear mild compared to other types of sleep medication. Possible side effects (dizziness, fatigue, headache, nausea, drowsiness) are usually not a problem; they are less obvious than side effects of BzRAs and other prescribed sleeping pills. In addition, there seem to be no issues with tolerance and dependence. The cons

Although it can be helpful in certain specific situations as outlined above, immediate-release melatonin is generally not useful for chronic insomnia. Its effectiveness and safety for treating insomnia has not been studied as rigorously as other prescription-only medications. The existing randomized controlled trials have not shown much sleep improvement with melatonin compared to a placebo. As a group, these medications appear to be safe in the short term; in the long term (6–12 months), some minor changes in thyroid function and reproductive hormones have been reported. Because they mimic a natural hormone, it is possible that they may affect biological systems like reproductive hormone regulation, immune functions, and circadian rhythms, but safety issues appear not to be of major concern with melatonin-based products. Orexin Receptor Antagonists

Orexin is a neuropeptide—a signaling molecule in the brain—that is involved in the regulation of wakefulness and sleep as well as other functions such as appetite regulation. Specifically, orexin helps us to stay awake. Orexin receptor antagonists work by temporarily blocking orexin, thereby promoting sleep. Generic Name

Trade Name

suvorexant

Belsomra

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The pros

This type of medication does not seem to have the same type of side effects and tolerance concerns as the BzRAs and other medications prescribed for sleep. Research indicates that it can lead to some improvement in insomnia symptoms and can increase sleep duration. The cons

Being a newer sleeping medication, there are fewer studies of effectiveness and safety as compared to the more established types of sleeping pills. Well-designed (randomized controlled) studies show that sleep improvements occur, but they are not huge. For example, there may be a reduction of 5–6 minutes in time to fall asleep or time awake during the night, compared to taking a placebo. The most common side effect is daytime sleepiness. Other possible side effects are headache, dizziness, memory problems (not remembering some things that happened in the hours after taking the medication), anxiety, hallucinations, temporary muscle weakness, and sleep paralysis (not being able to move for a few minutes while waking from sleep). This medication should be avoided by anyone with narcolepsy, a sleep disorder in which orexin is lacking. In some cases, people with depression may feel more depressed, and even suicidal, when taking the medication. Therefore, as with other prescribed medications, before considering this type of sleeping pill, you should discuss the specific risks and benefits as they apply to you with your physician and pharmacist. ALL TOGETHER Unlike Sleeping Beauty’s sleep in which she stirs, wakens, and falls in love with the Prince, most real-life sleep substances come with side effects. Effects like morning hangover are common with the BzRAs and the sedating antidepressants. Melatoninbased products seem to have fewer side effects but they are not very effective for chronic insomnia. The newer orexin receptor antagonists seem to improve sleep but come with possible side effects, especially sleepiness the next day. Although some medications are helpful in the short term, no sleeping medication has shown itself to be entirely useful for chronic insomnia. Also, the timing and amount of certain sleep stages (see Chapter 26) such as rapid eye movement (REM) sleep can be affected by medications, including the BzRAs, the sedating antidepressants, and the orexin receptor antagonists. This means that the sleep you get with the medication is somewhat different from what your sleep would be if you were sleeping well without medication. If sleep medication does work, its effects don’t last after the medication is discontinued; it does not cure insomnia. Sleep medication is not a long-term answer for persistent insomnia.

CHAPTER 25

Over-the-Counter Sleep Aids, Herbal Remedies, and Cannabis

his chapter provides information on some substances that are not exactly “pills” but they are often marketed as sleep aids. They include over-the-counter prodT ucts, natural health products including herbal remedies, and cannabis. I often receive questions about them, so here’s the lowdown.

OVER-THE-COUNTER SLEEP AIDS When I first see people in the clinic, I ask what they have used in the past to treat their insomnia. Many have tried over-the-counter sleep aids; here are some common ones. Trade name(s)

Name of drowsiness drug

Type

Nytol, Benadryl, Tylenol PM, Excedrin PM, Advil PM, Unisom gel caps, Sominex, Unisom tablets, Wal Som, and others

diphenhydramine

antihistamine

Dramamine, Gravol, and others

dimenhydrinate

antihistamine

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The Pros

At this time, these products do not require a prescription and they are quite widely available through pharmacies. If you have seasonal allergies, these medications may help your sleep on those nights when your allergy symptoms would otherwise disturb your sleep. The Cons

Most of these sleep remedies rely on the drowsiness-inducing effects of sedating antihistamines. They might help you doze off and might even help you to sleep overnight for a few days, but there is little evidence that they are useful for chronic insomnia. Antihistamines are normally used to treat allergic symptoms like runny nose, nasal congestion, and itchiness. If taken for sleep, they will exert their antihistamine effects in the body even when you don’t need these effects. Side effects include: ●

dry mouth

●

increased heart rate

●

constipation

●

urinary retention

●

reduced attention and concentration

●

coordination problems

●

daytime sedation

Dimenhydrinate (Dramamine or Gravol) is normally used to prevent nausea. Although it can cause drowsiness, we don’t know much about its effects on sleep. It has similar side effects to those listed above and is not recommended for chronic insomnia. All these antihistamine-based products are especially risky for older people who are more likely to experience mental fogginess and balance problems, especially if they already are prone to such symptoms. Moreover, these products—especially if used on a regular basis—can lower levels of the neurotransmitter (chemical messenger in the nervous system) called acetylcholine and this “anticholinergeric” effect has been linked to dementia. NATURAL HEALTH PRODUCTS Here is a table of some natural health products that are sometimes used for sleep.

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Name

Type

valerian

herbal

hops

herbal

kava kava

herbal

lavender

herbal

L-tryptophan

amino acid (building block of protein)

The Pros

These preparations can be obtained fairly easily at health product stores (apart from high doses or non-oral administration of L-tryptophan, which need a prescription). L-tryptophan does not appear to have troublesome side effects, morning “hangover,” or tolerance. It may help induce sleepiness and help some people who have mild difficulty falling asleep and who are otherwise healthy (having no medical or mental health problems). The Cons

At this time there is insufficient evidence of the effectiveness of most herbal products for insomnia, mainly because they haven’t been well studied. A published review of research on valerian concluded that it is relatively safe, but not effective for insomnia. Use caution when trying herbal products because they are not regulated in the same way that prescription medications are, and information about effectiveness, optimal doses, and adverse effects from stringent clinical trials is often not available. The term “natural” product does not mean the same thing as safe. Some can have dangerous side effects, for example, kava kava can cause liver toxicity. Also, there is potential harm in combining some of these products with other types of sleep aids including prescribed medication. There are very few recent, rigorous studies of L-tryptophan, so it is difficult to make conclusions about its usefulness for insomnia. Several studies were done in the 1980s and their results were mixed—sometimes L-tryptophan was better than a placebo and sometimes it wasn’t. Thus, we have no consistent findings that L-tryptophan is useful for chronic insomnia. In general, there is no convincing evidence for the effectiveness of natural health products in alleviating insomnia. CANNABIS Archeological evidence of cannabis use—possibly for pain or to help with childbirth—was uncovered in a tomb near Jerusalem, dating from the third century AD. Egyptian papyrus records of the medicinal use of cannabis go way back to the 16th century BC We don’t know exactly when cannabis started to be used to help people

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sleep. We do know that many current users report that it is helpful for sleep, especially for falling asleep sooner and for sleeping longer. What does the research say? In the 1970s, several studies examined the effects of smoked cannabis on sleep patterns as measured in sleep labs. Some studies found that people fell asleep faster, while others found they took somewhat longer to fall asleep. There were inconsistent effects on the amount of deep (slow wave) sleep; the most salient finding was that smoking cannabis seemed to be associated with reduced rapid eye movement (REM) sleep (see Chapter 26 for a description of sleep stages). It was also found that when users stopped the drug, their sleep was disrupted. Research on the topic was relatively dormant for a few decades. Cannabis has many chemical components, and the main one that leads to mental effects, including the “high” and sleep-related changes, is tetrahydrocannabinol (THC). Another component, cannabidiol (CBD) is thought to have muscle relaxant, anti-inflammatory, and anti-pain effects. Starting in the 2000s, the spotlight turned again to cannabis and its effects as various prescription pharmaceutical preparations became available, containing set amounts of THC and CBD. In addition, cannabis became legal in some countries and states; in Canada, legalization happened on October 17, 2018. At the time of writing this in 2020, results from the research on the exact sleep effects of cannabis remain fuzzy. Most studies have been done with participants who have problems with persistent pain, muscle spasms, seizures, poor appetite, nausea, or posttraumatic symptoms. Sleep is often not the main focus of the research and it’s measured in various, often unstandardized, ways. There have also been variations in the dose and chemical composition of cannabis, mode of use (smoked, oral spray, capsule), timing of use in relation to bedtime, the participants’ prior pattern of cannabis use, and their medical and sleep histories. Generally speaking, the studies report that participants say they fall asleep more easily, have less sleep disturbance, and experience better sleep quality with cannabis. However, high-quality randomized controlled trials focused on sleep are lacking, so the scientific story remains unclear. The good news is that well-designed clinical trials are underway to examine more precisely the sleep effects of cannabis, and these studies should soon provide more reliable and detailed information.

Trade Name

Generic Name

recreational cannabis Sativex

Main Active Ingredients

variable amounts of THC and CBD nabiximols

THC and CBD

Cesanet

nabilone

synthetic cannabinoid

Marinol

dronabinol

synthetic THC

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Pros

Some people feel their sleep is improved with cannabis. Cons

There are several downsides of using recreational cannabis for sleep. Smoking cannabis can cause irritation of the respiratory system including chronic bronchitis (inflammation of the air passageways to and from the lungs) and increased risk of pneumonia. Vaping cannabis oil can cause severe, life-threatening lung damage. Regular use of any form of cannabis can lead to dependence and difficult withdrawal symptoms including irritability, insomnia, depression, and anxiety. Importantly, it can impair brain function, especially in people under the age of 21, whose brains are still developing. In addition, cannabis use is associated with increased risk of psychosis (serious mental disorder, which often includes delusions and/or hallucinations), especially in young people. In those who are genetically predisposed to schizophrenia, using cannabis may lead to the psychiatric illness appearing at an earlier age. If cannabis is purchased on the street, it is difficult to know its strength (the level of THC), which means that there is a risk of accidentally taking too much and experiencing overdose symptoms (extreme confusion, anxiety, paranoia, panic, increased blood pressure and nausea) and ending up in an emergency department. Cannabis use is also associated with an increased risk of car crashes, including fatal crashes. In contrast to recreational cannabis, the cannabis-based pharmaceutical preparations have known constituents, and their properties, effects, and side effects have been closely studied. Here are some of the more common side effects of nabiximols, nabilone, and dronabinol. ●

dizziness

●

fatigue, weakness

●

sleepiness

●

feeling “high”

●

lightheadedness

●

confusion

●

nausea

●

headache

●

trouble sleeping

●

cognitive (thinking) impairment, such as problems with memory or concentration

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●

blurred vision

●

difficulty speaking

●

eating more or less than usual

●

changed sense of taste

●

abdominal pain

●

constipation or diarrhea

●

loss of balance

●

hallucinations or delusions

●

depression

●

anxiety

To be clear, these medications are not prescribed for insomnia but rather for pain that can occur with multiple sclerosis, for nausea and vomiting associated with cancer chemotherapy, or for loss of appetite and weight loss in people with HIV infection. So, there you have it. The pros and cons. I hope that I’ve answered some of your questions about these substances that are often promoted as sleep aids, and that this chapter has been helpful for making wise decisions about your sleep and health.

USEFUL BACKGROUND INFORMATION

CHAPTER 26

Sleep Stages and Their Measurement

our sleep diary provides good information about your sleep timing, quality, and quantity, and is the best way to measure sleep if you have insomnia. For more Y in-depth examination of sleep by scientists or sleep medicine clinicians, special equipment is used to track sleep stages and cycles through the night. To determine sleep stages, three main measurements are used: brain waves, eye movements, and muscle tone. These are measured using electrodes that are attached to the scalp, the face near the eyes, and under the chin, respectively. The activity that is picked up by the electrodes is amplified and appears as wave forms on a screen. In the old days, the output from all the channels was printed by pens on big, folding chart paper that was moving at 30 mm per second through a polygraph. By morning, we had used a lot of ink and almost half a mile’s worth of chart paper! This huge stack of paper was then scored by flipping through the record and identifying the stages, page by page. Nowadays, the same information is collected and digitized by computer, and

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The author with a polygraph and moving char t paper to record sleep in the mid-1980s.

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technologists score the record by viewing it on the computer screen rather than on paper. SLEEP STAGES Wake

When we are awake, our brain waves are small and fast, mainly “beta” waves, which have a frequency of 12 cycles per second or more. As we become relaxed, we have more and more “alpha” waves, which are slower, at 8–12 cycles per second. While we are awake, our eyes are moving around a lot, and our muscle tension is high. Stage 1 (N1)

As we become drowsy and are drifting off to sleep we enter Stage 1 (or N1 for nonREM sleep Stage 1), which is really a transitional stage between wake and sleep. We are in Stage 1 for a short time (1–7 minutes) before falling asleep. During Stage 1, in addition to alpha waves, our brain waves are slowing somewhat and we start having some “theta” waves, which have a frequency of 4–7 cycles per second. Our eyes don’t dart around now; they start to roll slowly. Our muscle tone is still high. Stage 2 (N2)

Stage 2 occurs when some specific wave forms called “spindles” and “K-complexes” appear. Spindles are spindle-shaped clusters of waves that are 12–14 cycles per second. A K-complex is a large-amplitude wave that occurs every so often. Between the spindles and the K-complexes are waves that are low amplitude and fast. Our eyes don’t move very much in Stage 2 and muscle tone is lower than during Stage 1. When we reach Stage 2 sleep, we are considered to be officially asleep. We continue there for 10–25 minutes. Stages 3 and 4 (Deep Sleep, Slow Wave Sleep, or N3)

As Stage 2 progresses, high-amplitude slow waves occur more and more frequently. These are “delta” waves, which are slower than 4 cycles per second. When delta waves make up 20%–50% of the brain wave activity, Stage 3 is identified. Our eyes are not moving much and muscle tone is low. Stage 3 lasts just a few minutes and leads into Stage 4. Together, Stage 3 and Stage 4 are referred to as “deep” sleep, “delta sleep,” or “slow wave sleep (SWS).” Stage 4 is just like Stage 3 except that it has a greater density of delta waves. When delta waves make up more than 50% of the activity, Stage 4 is identified. We are in Stage 4 for about 20–40 minutes at this point.

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Rapid Eye Movement (REM) Sleep

After Stages 3 and 4, there is a brief “ascent” to Stage 2 before we enter the first REM period. REM is a distinct state, entirely different from the other (“non-REM”) sleep stages. Our brain waves are similar to those of wakefulness, with fast (beta wave) activity. Nearly all of our dreaming occurs in REM sleep. Our eyes dart around during bursts of activity (hence the name “rapid eye movement” sleep). These movements correspond to things we are seeing in our dreams. Unlike any other stage, our muscle tone is minimal. This is because all our postural muscles (the ones that allow movement to occur) are in a state of paralysis. Without this paralysis we would be acting out our dreams. The first REM period starts about 70–100 minutes after falling asleep, and it is short—about 1–5 minutes long. Arousals

It is normal to move around and perhaps even wake up briefly before or after a REM period. SLEEP CYCLES The sequence of sleep stages I have just described represents the first sleep “cycle.” We usually have about three more sleep cycles through the night, for a total of four. Each one is roughly 90–110 minutes long. The sleep stages occur in more or less the same order for each cycle. However, as the night goes on, we get less and less SWS per cycle and more and more REM sleep. By the end of the night we are spending most of our time in Stages 2 and REM. SLEEP STAGE COMPOSITION OF A NIGHT’S SLEEP The chart below gives you an idea of the relative amount of time spent in each stage of sleep over the whole night. It shows the total sleep duration and the percent of the night’s sleep in each stage. Because these numbers change as we age, I am showing you representative data for a typical 20-year-old and a typical 60-year-old. You will see that there are three main differences between these two columns: The older person has a shorter sleep duration, more wakefulness during the night, and less SWS (deep sleep) than the younger person. Regardless of age, about half the night is spent in Stage 2 sleep and about one-fifth is in REM sleep. Age 20

Age 60

Total sleep time

7.5 hours

6.3 hours

Wake during the night

3%

10%

Stage 1

5%

6%

Stage 2

50%

54%

SWS (Stages 3 and 4)

20%

10%

REM

22%

20%

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SLEEP MEASUREMENT TECHNIQUES Sleep Diaries, as you’ve seen, are the measurement tool of choice for insomnia. Polysomnography is measurement of sleep overnight in the sleep lab, with electrodes that are attached to the scalp, face, and chin, to determine sleep stages. It also involves apparatus to check your breathing, heart rhythm, blood oxygen levels (by a small sensor on your fingertip), and limb movements. Polysomnography is the most thorough method of diagnosing sleep related breathing disorders like sleep apnea and other sleep disorders like narcolepsy and REM sleep behavior disorder. It is not normally used for the evaluation of insomnia unless there is a suspicion of another sleep disorder that can be picked up by polysomnography. Actigraphy is another way that sleep can be measured, but only roughly. It is a movement sensor worn around the wrist like a watch. It collects data on movement over time. When there is a lot of movement, it is likely the person is awake; when there is little movement, it is likely the person is asleep. One of its benefits is that it can easily be used at home so a sleep lab stay is not required. However, it does not allow sleep stages to be identified so it is rarely used to diagnose sleep disorders. It can be useful for some types of sleep–wake research where there is no need for accurate measurement of sleep stages. Home sleep apnea tests involve portable monitors that you set up (with directions) in your bedroom to measure your airflow, breathing movements, and the level of oxygen in your blood overnight. These tests don’t monitor sleep stages. They are used to expedite the assessment of sleep related breathing disorders when the sleep specialist strongly suspects that the person has obstructive sleep apnea. PERSONAL ELECTRONIC SLEEP TRACKERS A few years ago, a patient told me that he had filled out his sleep diary based on the sleep tracker in his “Fitbit.” I was aghast! How could a tiny device on the wrist measure sleep accurately? This was my first exposure to what would become the major industry of personal wearable health-tracking devices. Let me tell you a little bit about what I have subsequently learned about consumer wearable sleep trackers. Mind you, the development of these devices is occurring so rapidly that as I write this, it is probably already old news. In 2019, an international research group, led by Dr. Massimiliano de Zambotti, published a review of consumer wearable sleep trackers. I went to hear them speak at the World Sleep Society conference in September that year. They reported that the first generation of wearables (such as Jawbone UP, Fitbit tracker original, Fitbit Ultra, Fitbit Flex, and Misfit Shine) could, using motion sensors, roughly tell when someone was asleep or awake. However, the major problem was that you could be awake—but not moving—in the middle of the night, and the device would classify that as sleep. Someone with insomnia recently told me that, realizing this misclassification, she

Sleep Stages and Their Measurement

203

waved her arm around in the air when she was awake in bed, just to let the device know she was awake! So, these are probably not so accurate for tracking sleep and wakefulness in people who have insomnia. Plus, waving your arm around in bed likely isn’t helpful for getting back to sleep! The same researchers reported on a new generation of sleep trackers that can record more aspects of your physiology, for example, skin temperature, skin conductance and heart rate. Some may, or will eventually, have the ability to detect changes in the pattern of heart beats, called heart rate variability. Such measures, in combination with motion sensors, could, in the future, potentially improve the identification not only of sleep and wakefulness, but also distinguish light sleep (N1 and N2), REM, and deep sleep (N3). At this time, the testing of these devices indicates that they are able to detect light sleep and REM but are not so good with deep sleep and wake. Again, if you have insomnia and your time awake is misclassified, then these data are unlikely to be helpful. We are really in the dark about how the devices function for people of different ages and with any kind of sleep disorder. That being said, at some future point, researchers, clinicians, and the consumer wearable industry may all agree on standards of sleep measurement using personal devices, and this will open up opportunities for everyone to know exactly what is being measured and to investigate how best the data can be used by people who have trouble sleeping.

Afterword Good Luck and Good Night

S

everal people have joked since this project began, “I hope your book puts people to sleep!” Usually falling asleep in response to someone’s writing is not a good sign. But in this case, I’ll take it as a sign that this book has done its job. So I sincerely hope it has put you to sleep, by showing you how to solve your insomnia. Good luck, and remember: no chasing after sleep. All that is required is to make the circumstances conducive to sleep by using the tried-and-true techniques found here, and then relax, occupy your mind with other things, and be delighted when sleep arrives. Good luck and best wishes for a good night.

205

Index

actigraphy, 202 adolescence insomnia in, 130 phase delay, 135 aerobic exercise, 151, 152, 160 afternoon naps, 50, 66 aging, and sleep, 140–141, 147–148 alcohol consumption, 30, 51–53 effects on health, 52 and sleep medications, 54 and sleep related breathing disorders, 146 allergies, seasonal, 163–164 alpha waves, 200 alprazolam, 184 Alzheimer’s disease, 167–168 amitriptyline, 187 androgen deprivation therapy, 147–148 androgen therapy, 147 andropause, 147 anti-anxiety medications, 175 antidepressants, 139, 173, 175, 187–188 antihistamines, 164, 191–192 antipsychotics, 187–188 anxiety, 171, 175–176. See also depression generalized anxiety and social anxiety, 176 and menopause, 139 obsessive-compulsive disorder, 177–178 panic attacks, 176–177 postpartum, 134 specific phobias, 178

apnea, 133, 145. See also sleep apnea asthma, 166, 167 baseline total sleep time, 43–45, 46–47, 48 bed, associating with sleep, 61–64 getting out of bed when not sleeping, 63–64 going to bed only when sleepy, 62 using the bed only for sleeping, 62–63 bedroom, 22, 62–63 bedtime adjustment, 74–75, 84, 93 threshold, 59–60, 62, 71, 74–75, 79, 84, 86, 87, 93, 94, 105 benzodiazepine receptor agonists (BzRAs), 184–187 benzodiazepines, 53, 184 bereavement, 8 beta waves, 200 bipolar disorder, 174–175 bowel disorders, 166 breast cancer, 162 breastfeeding, and sleep, 133 breathing irregularities, and heart disease, 161 problems, 166–167 and sleep allergies, 164 sleep related breathing disorders, 133, 138, 141, 145–146, 164 bright light treatment, for hypersomnia, 174 BzRAs. See benzodiazepine receptor agonists 207

Index

208

caffeine, 22 cancer, 162–163 cannabidiol (CBD), 194 cannabis, 193–196 caregivers, sleep disturbances of, 168 CBD. See cannabidiol CBT. See cognitive behavioral therapy CBT-I. See cognitive behavioral therapy for insomnia chemical imbalance, and insomnia, 6–7 childbirth fear about, 131–132 and sleep, 133 chronic obstructive pulmonary disease (COPD), 166–167 chronic pain, 159–160 circadian process of sleep, 58 Clear-Your-Head Time technique, 114 clinical anxiety, 175 clinical depression, 172, 173–174 clonazepam, 53, 184 clonidine, 137 cognitive behavioral therapy (CBT), 139, 173, 175 cognitive behavioral therapy for insomnia (CBT-I), 4, 18, 23, 43, 105, 132, 137–138, 142, 145, 148, 160 and age of patients, 6 cognitive therapy component of, 120 and drug tapering, 187 and hopeless cases, 5–6 improvements, 4–5 for other health and mood issues, 7 for patients with anxiety, 176–178 for patients with depression, 173–174 for patients with medical conditions, 161, 162, 163, 166, 167, 168, 169–170 for PTSD patients, 179 side effects of, 5 and sleep medications, 7 cognitive flexibility, 12 congestive heart failure, 169 continuous positive airway pressure (CPAP), 138, 155 COPD. See chronic obstructive pulmonary disease coronary artery disease, 160–162 corticosteroids, 9 COVID-19 pandemic, 178 cow’s milk, 150

CPAP. See continuous positive airway pressure Crohn’s disease, 166 daytime sleepiness, excessive, 49–50 deep sleep, 19, 167, 200 delayed sleep phase syndrome, 9 delivery, and sleep, 133–134 delta waves, 200 depression, 8, 172. See also anxiety bipolar disorder, 174–175 and insomnia, 172–173 major depression, 173–174 and menopause, 139 postpartum, 133 seasonal affective disorder, 174 diabetes. See type 2 diabetes digestive discomfort, 165–166 dimenhydrinate, 192 diphenhydramine, 191 doxepin, 187 dreams during postpartum period, 134 during pregnancy, 131 and RSBD, 169 dronabinol, 194, 195 drug tapering, 187 eating patterns, and sleeping patterns, 151 electronic devices, 22, 28, 62–63 electronic sleep trackers, 28, 202–203 end-of-night insomnia. See terminal insomnia erectile dysfunction, 144, 155 erections, sleep-related, 144 estrogen, 137 eszopiclone, 184 excessive daytime sleepiness, 49–50 exercise and chronic insomnia, 152–153 for chronic pain, 160 performance, effect of sleep on, 153 and sleep, 22, 151–153 exposure therapy, 175 family history of insomnia, 129–130 fatal familial insomnia, 7 fatigue, 62 feelings, 120–121 fermented milk, 150 fibromyalgia, 160 “fight-or-flight” response, 175

Index

first sleep, 17 first trimester, 131 food, and sleep, 149–150 functioning, and insomnia, 18 gastroesophageal reflux disease (GERD), 165 generalized anxiety, 176 GERD. See gastroesophageal reflux disease health conditions, 159 appropriateness of CBT-I, 169–170 breathing problems, 166–167 cancer, 162–163 chronic pain, 159–160 digestive discomfort, 165–166 heart disease, 160–162 kidney disease, 167 neurological disorders, 167–169 overweight, 164 seasonal allergies, 163–164 type 2 diabetes, 165 heart disease, 160–162 heartburn, 165 hockey players, 148 home sleep apnea tests, 202 homeostatic process of sleep, 57–58 hops, 193 hormone replacement therapy (HRT), 137 hot flashes, 137–138 HRT. See hormone replacement therapy hyperarousal, 6, 176 hypersomnia, 172, 174 hypnagogic mentation, 115 hypnotic medications. See sleep medications illness, and insomnia, 18–19 imagery rehearsal therapy, 179 infant care, and sleep of men, 144 inflammatory bowel disease, 166 initial insomnia, 37–38, 99 insomnia, 12 and bout of poor sleep, difference between, 12 chronic, 6, 12, 152–153, 188, 189 common concerns about, 15–19 medical conditions as direct cause of, 8–9 in men, 144–145 sleep disorders masquerading, 9 types of, 37–41 interpersonal therapy, 139

209

irritability, and insomnia, 18 irritable bowel syndrome, 166 kava kava, 193 K-complexes, 200 kidney disease, 167 kiwis, 149 lavender, 193 learned associations, 61 lorazepam, 53, 184 L-tryptophan, 193 lung cancer, 162 major depression, 173–174 medical conditions, and sleep, 8–9, 159 appropriateness of CBT-I, 169–170 breathing problems, 166–167 cancer, 162–163 chronic pain, 159–160 digestive discomfort, 165–166 heart disease, 160–162 kidney disease, 167 neurological disorders, 167–169 overweight, 164 seasonal allergies, 163–164 type 2 diabetes, 165 medications affecting breathing, 141 affecting sleep, 141, 168 and insomnia, 9 sleep medications, 4–5, 6, 7, 30, 53–54, 162, 183–190 and sleep related breathing disorders, 146 meditation. See mindfulness meditation Mediterranean diet, 151 melatonin, 150, 188, 189 melatonin-based products, 188–189 men, sleep of, 143 aging, 147–148 infant care, 144 sleep disorders, 144–147 sleep-related erections, 144 testosterone, 143–144 work and travel, 148 menopause, and sleep, 136–140, 155 menstrual cycle, and sleep, 130 middle insomnia, 38–39, 99 milk, 150

Index

210

mind, 111–112 observer’s, 111, 115–118 thoughts/worries about effects of not sleeping, 112–113 trying to sleep, 113 worries about things going on in your life, 113–115 mind-body exercise, 152 mindfulness meditation, 116 formal practice, 116–117 informal practice, 117–118 mindfulness-based stress reduction, 163 mirtazapine, 187 mood, 7, 139, 174 MS. See multiple sclerosis multiple awakenings, 38, 99 multiple sclerosis (MS), 169

periodic limb movement disorder, 9, 132, 141, 167 phase delay, in adolescents, 135 physical activity, and sleep, 151–152 polysomnography, 146, 202 positional therapy, 139, 146–147 post-lunch dip, 50 postpartum period, and sleep, 133–135 posttraumatic stress disorder (PTSD), 178–179 pregnancy, and sleep, 131–133 problem-solving thoughts, 120 productive worries, 113, 114 progesterone, 131, 137, 138 prolonged-release melatonin, 189 psychotherapy, 139, 173, 175 PTSD. See posttraumatic stress disorder pursed lip breathing, 166–167 quetiapine, 187

nabilone, 194, 195 nabiximols, 194, 195 naps, 30, 49–51, 66, 131, 133–134 National Hockey League, 148 natural disasters, 178 natural health products, 193 neurological disorders, 167–169 nicotine, 22 nightmares, 131, 179 nocturia, 165 nocturnal panic attacks, 176 nonproductive worries, 113–115 nutrition, and sleep, 149–151 observer’s mind, 111, 115–118 obsessive-compulsive disorder (OCD), 8, 177–178 obstructive sleep apnea, 133, 138–139, 145, 146–147, 155, 165, 166 OCD. See obsessive-compulsive disorder oral contraceptives, and sleep, 130 orexin, 189 osteoarthritis, 160 overlap syndrome, 166 over-the-counter sleep aids, 191–192 overweight, 133, 138, 141, 146, 164 oxazepam, 53, 184 panic attacks, 176–177 paradoxical intention, 113 Parkinson’s disease, 168–169

ramelteon, 188, 189 rapid eye movement (REM) sleep, 19, 51, 144, 147, 166, 167, 168–169, 172, 174, 194, 201 rebound insomnia, 53, 186 recovery sleep, 19 recreational cannabis, 195 REM Sleep Behavior Disorder (RSBD), 147, 169 respite care, 167 restless legs syndrome, 9, 132, 140–141, 163, 165, 167 retirement, and sleep, 140–141 RSBD. See REM Sleep Behavior Disorder seasonal affective disorder, 172, 174 seasonal allergies, 163–164 second sleep, 17 second trimester, 131 selective serotonin reuptake inhibitors (SSRIs), 137 sex and androgen deprivation therapy, 148 and sleep, 153–155 sexsomnia, 155 shift workers, insomnia in, 10 short sleep, 17, 164, 166, 167 sleep apnea, 9, 164, 167 home sleep apnea tests, 202 obstructive, 133, 138–139, 145, 146–147, 155, 165, 166 sleep cycles, 201

Index

sleep deprivation, 67, 70 sleep diaries, 23, 24, 27–28, 43, 49, 66–67, 72, 79, 83, 94, 105, 199, 202 example, 30–31, 32–33, 76–77 logging your sleep with, 29–30 section on naps, alcohol, and sleep medication, 30 sleep quality section, 30 sleep timing section, 29–30 sleep disorders and kidney disease, 167 masquerading insomnia, 9 in men, 144–147 and pregnancy, 132–133 and retirement, 140–141 and sexual function, 155 and type 2 diabetes, 165 sleep duration, 15–16, 201 over decades, changes, 16–17 sleep efficiency, 44, 46, 47–48, 72–74, 75, 78, 84, 85, 86, 91–92 sleep hygiene, 21–22 sleep inertia, 51 sleep laboratory, 9, 27–28, 146 sleep measurement techniques, 202 sleep medications, 4–5, 30, 53, 183–184 and alcohol consumption, 54 antidepressants and antipsychotics, 187–188 benzodiazepine receptor agonists, 184–187 for cancer patients, 162 and CBT-I, 7 melatonin-based products, 188–189 orexin receptor antagonists, 189–190 side effects of, 6, 162, 190 sleep quality, 30, 40, 99, 160 sleep related abnormal sexual behaviors, 155 sleep related breathing disorders in men, 145–146 and overweight, 164 in women, 133, 138, 141 sleep restriction therapy, 5, 24, 59 sleep stages, 199, 200–201 Sleep Therapy, 23–24, 27, 43, 65 after third week, 91–97 associating bed with sleep, 61–64 circadian process, 58 getting up at same time everyday, 61 homeostatic process, 57–58 moving from first week to second week, 71–81

211

moving from second week to third week, 83–89 naps, 66 natural sleep process, uncovering, 57–61 progress, maintaining, 103–107 sleep diary, 66–67, 68–69 staying up late, 59 steps of solid sleep, 66, 79, 87, 95, 105 threshold bedtime and rise time, 59–60 sleep timing, 29–30 sleep trackers, 28, 202–203 sleep-deprived society, 16–17 sleepiness excessive daytime sleepiness, 49–50 physical signs of, 62 during pregnancy, 131 sleep-related erections, 144 slow-wave sleep. See deep sleep smoking, 8, 146 snoring, 132, 138, 145 social anxiety, 176 solid sleep, steps of, 66, 79, 87, 95, 105 sour cherries, 150 specific phobias, 178 spindles, 200 SSRIs. See selective serotonin reuptake inhibitors stimulus control therapy, 24, 61–62 strengthening exercises, 151–152 substance use, 8 suvorexant, 189 sweating during menopause, 137 tai chi, 152 tart cherries, 150 temazepam, 53, 184 terminal insomnia, 39,  99 testosterone, and sleep, 143–144, 147 testosterone replacement therapy, 147 tetrahydrocannabinol (THC), 194 THC. See tetrahydrocannabinol third trimester, 131, 132–133 thoughts, 119–120 about effects of not sleeping, 112–113 about noises and other interruptions to sleep, 120 about one’s current state, 120 vs. feelings, 120–121 miscellaneous, 114–115 problem-solving, 120 sleep-related, 121–126

Index

212

threshold bedtime, 59–60, 62, 71, 74–75, 79, 84, 86, 87, 93, 94, 105 threshold rise time, 59–60, 61, 65, 67, 74, 75, 79, 84, 86, 87, 93 tiredness, 18, 62 total awake time, 45 total sleep time, baseline, 43–46 total time in bed, 45 traumatic events, experience in, 8 traumatic stress, 178–179 travel schedules, and sleep, 148 trazodone, 169, 187 trying to sleep, 113 turkey, 150 type 2 diabetes, 165

adolescence, 130 and child’s sleep, 135 delivery and postpartum, 133–135 insomnia, 129–130 menopause, 136–140 menstrual cycle, 130 pregnancy, 131–133 retirement, 140–141 working women, 135–136 work, and sleep, 135–136, 148 worries about effects of not sleeping, 112–113 nonproductive, 113–115 productive, 113, 114 Worry Time technique, 114

ulcerative colitis, 166 yoga, 152 valerian, 193 visual imagery, 114–115 wearable devices, 28, 202–203 women, sleep of, 129

zaleplon, 184 z-drugs, 53, 184 zolpidem, 53, 184 zopiclone, 53, 184

SINK INTO SLEEP SLEEP DIARY

Sleep Diary for the Week of:  ______________________                Bedtime: ______________   Rise Time: ______________ DAY of the WEEK

SLEEP TIMING

Which night is being reported on?

1.  I went to bed at (clock time): 2.  I turned out the lights after (minutes): 3.  I fell asleep in (­ minutes): 4.  I woke up ___ time(s) during the night. (number of awakenings): 5.  The total duration of these awakenings was (minutes): 6.  After awakening for the last time, I was in bed for (minutes):

SLEEP QUALITY

7.  I got up at (clock time): The quality of my sleep was: 1 = very poor; 10 = excellent

Naps Number, time, and duration

Alcohol Time, amount, and type

Sleep Medication Time, amount, and type

Notes:

SLEEP EFFICIENCY CALCULATION SHEET A self-calculating electronic form is available at www.sinkintosleep.com.

Calculating Your Sleep Efficiency

SLEEP TIMING

Representative Night 1.  I went to bed at:

Date:

(clock time)

2.  I turned out the lights after: (minutes)

3.  I fell asleep in: (minutes)

4.  I woke up _____ time(s) during the night. 5.  The total duration of these awakenings was:

(minutes)

6.  After awakening for the last time, I was in bed for: (minutes)

7.  I got up at: (clock time)

Calculations

A

B

C

Total Time in Bed

Total Awake Time

Total Sleep Time

Time between your ­bedtime (#1) and rise time (#7).

Add the numbers above in this column.

A minus B

(minutes)

(minutes)

Convert hours to minutes by multiplying by 601

(minutes)

D

Sleep Efficiency

C/A x 100% For example, if you were in bed for 8 hours and 20 minutes, this is the same as 8 x 60 + 20 minutes = 500 minutes.

My sleep efficiency is

 %

Table for Adjusting Threshold Bedtime Is your sleep efficiency...

If YES,

84% or less?

Set your threshold bedtime 15 minutes later this week.

85% to 89%?

Keep the same threshold bedtime this week.

90% to 94%?

Set your threshold bedtime 15 minutes earlier this week.

95% or greater?

Set your threshold bedtime 30 minutes earlier this week.

My threshold bedtime and rise time: Bedtime: 

        Rise Time: 

Six Steps to Solid Sleep 1. Go to bed only when sleepy and not before your threshold bedtime. _____________ Fill in the threshold bedtime that you are setting for the upcoming week. 2. Maintain a regular threshold rise time in the morning. _____________ Fill in your threshold rise time (usually the same as before). 3. Use the bed only for sleeping. Sexual activity is the only exception. Do not watch television, listen to the radio, use electronic devices, eat, or read in bed. 4. Leave the bed if you can’t fall asleep or go back to sleep within 10–15 minutes. Return when sleepy. Repeat this step as often as necessary during the night. 5. If sleepiness is overwhelming, you may take a short nap (set aside no longer than 45 minutes) in the afternoon, between 1:00 and 4:00 p.m. 6. Maintain a sleep diary.

Adaptive Sleep Thoughts Worksheet Situation: Not sleeping

Feelings:

Strongest Feeling: Intensity rating (0–100) now:

Intensity rating (0–100) later: Thoughts associated with strongest feeling:

Circle your main unsettling sleep thought. Does this thought involve fortune-telling, catastrophizing, underestimating your ability to manage your sleep, setting a standard, or other? Counter-statements:

Choose one that is realistic and that lowers the intensity of your feeling. Your main adaptive sleep thought:

Remember to PRRR tonight!

Bibliography

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CHAPTER 2  WHAT IS INSOMNIA? American Academy of Sleep Medicine. (2014). International classification of sleep disorders (3rd ed.). American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Anderson, J. R. (2000). Sleep-related behavioural adaptations in free-ranging anthropoid primates. Sleep Medicine Reviews, 4, 355–373. https://doi.org/10.1053/smrv.2000.0105 Morin, C. M., LeBlanc, M., Daley, M., Gregoire, J. P., & Mérette, C. (2006). Epidemiology of inso­mnia: Prevalence, self-help treatments, consultations, and determinants of help-­ seeking behaviors. Sleep Medicine, 7, 123–130. https://doi.org/10.1016/j.sleep.2005.08.008 Riedel, B. W., & Lichstein, K. L. (2000). Insomnia and daytime functioning. Sleep Medicine Reviews, 4, 277–298. https://doi.org/10.1053/smrv.1999.0074 Shekleton, J. A., Rogers, N. L., & Rajaratnam, S. M. W. (2010). Searching for the daytime impairments of primary insomnia. Sleep Medicine Reviews, 14, 47–60. https://doi.org​/ 10.1016/j.smrv.2009.06.001 Walsh, J. K. (2004). Clinical and socioeconomic correlates of insomnia. Journal of Clinical Psychiatry, 65(Suppl. 8), 13–19. Zammit, G. K., Weiner, J., Damato, N., Sillup, G. P., & McMillan, C. A. (1999). Quality of life in people with insomnia. Sleep, 22, S379–S385.

CHAPTER 3  COMMON CONCERNS ABOUT INSOMNIA Anothaisintawee, T., Reutrakul, S., Van Cauter, E., & Thakkinstian, A. (2016). Sleep disturbances compared to traditional risk factors for diabetes development: Systematic review and meta-analysis. Sleep Medicine Reviews, 30, 11–24. https://doi.org/10.1016​/j .smrv.2015.10.002

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CHAPTER 9  THINGS TO TAKE CARE OF RIGHT AWAY Aber, R., & Webb, W. B. (1986). Effects of a limited nap on night sleep in older subjects. Psychology of Aging, 1, 300–302. https://doi.org/10.1037/0882-7974.1.4.300 Aschoff, J. (1994). Naps as integral parts of the wake time within the human sleep-wake cycle. Journal of Biological Rhythms, 9, 145–155. https://doi.org/10.1177​ /074873049 400900205 Dinges, D. F., & Broughton, R. J. (Eds.). (1989). Sleep and alertness: Chronobiological, behavioral, and medical aspects of napping. Raven Press. Faraut, B., Andrillon, T., Vecchierini, M. F., & Leger, D. (2017). Napping: A public health issue. From epidemiological to laboratory studies. Sleep Medicine Reviews, 35, 85–100. https://doi.org/10.1016/j.smrv.2016.09.002 Gordis, E. (1997). Alcohol metabolism (Alcohol Alert No. 35). http://pubs.niaaa.nih.gov​/ publications/aa35.htm Landolt, H.-P., Roth, C., Dijk, D.-J., & Borbély, A. A. (1996). Late-afternoon ethanol intake affects nocturnal sleep and the sleep EEG in middle-aged men. Journal of Clinical Psychopharmacology, 16, 428–436. https://doi.org/10.1097/00004714-199612000-00004 Madsen, B. W., & Rossi, L. (1980). Sleep and Michaelis-Menten elimination of ethanol. Clinical Pharmacology and Therapeutics, 27, 114–119. https://doi.org/10.1038/clpt.1980.17 Milner, C. E., & Cote, K. A. (2009). Benefits of napping in healthy adults: Impact of nap length, time of day, age, and experience with napping. Journal of Sleep Research, 18(2), 272–281. https://doi.org/10.1111/j.1365-2869.2008.00718.x National Institute on Alcohol Abuse and Alcoholism. (1998). Alcohol and sleep (Alcohol Alert No. 41). http://pubs.niaaa.nih.gov/publications/aa41.htm

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CHAPTER 10  THE ESSENTIAL ELEMENTS OF SLEEP THERAPY Bootzin, R. R. (1972). Stimulus control treatment for insomnia. Proceedings of the American Psychological Association, 7, 395–396. Borbély, A. A. (1982). A two process model of sleep regulation. Human Neurobiology, 1, 195–204. Spielman, A. J., Saskin, P., & Thorpy, M. J. (1987). Treatment of chronic insomnia by restriction of time in bed. Sleep, 10, 45–56.

CHAPTER 16  MAINTAINING YOUR PROGRESS Rowley, J. T., Stickgold, R., & Hobson, J. A. (1998). Eyelid movements and mental activity at sleep onset. Consciousness and Cognition, 7, 67–84. https://doi.org/10.1006/ccog.1998​.0333 Stickgold, R., Malia, A., Maguire, D., Roddenberry, D., & O’Connor, M. (2000). Replaying the game: Hypnagogic images in normals and amnesics. Science, 290, 350–353. https://doi.org/10.1126/science.290.5490.350

CHAPTER 17  CALMING THE RACING MIND Morin, C. M., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999). Behavioral and pharmacological therapies for late-life insomnia: A randomized controlled trial. Journal of the American Medical Association, 281, 991–999. https://doi.org/10.1001/jama.281.11.991

CHAPTER 18  IT’S THE THOUGHT THAT COUNTS Morin, C. M., Vallieres, A., & Ivers, H. (2007). Dysfunctional beliefs and attitudes about sleep (DBAS): Validation of a brief version (DBAS-16). Sleep, 30(11), 1547–1554. https://​ doi.org/10.1093/sleep/30.11.1547

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CHAPTER 23  DEPRESSION, ANXIETY, AND TRAUMATIC STRESS Baglioni, C., Battagliese, G., Feige, B., Spiegelhalder, K., Nissen, C., Voderholzer, U., Lombardo, C., & Riemann, D. (2011). Insomnia as a predictor of depression: A meta-­ analytic evaluation of longitudinal epidemiological studies. Journal of Affective Disorders, 135, 10–19. https://doi.org/10.1016/j.jad.2011.01.011 Ballesio, A., Aquino, M., Feige, B., Johann, A. F., Kyle, S. D., Spiegelhalder, K., Lombardo, C., Rücker, G., Riemann, D., & Baglioni, C. (2018). The effectiveness of behavioural and cognitive behavioural therapies for insomnia on depressive and fatigue symptoms: A systematic review and network meta-analysis. Sleep Medicine Reviews, 37, 114–129. https://doi.org/10.1016/j.smrv.2017.01.006 Casement, M. D., & Swanson, L. M. (2012). A meta-analysis of imagery rehearsal for posttrauma nightmares: Effects on nightmare frequency, sleep quality, and posttraumatic stress. Clinical Psychology Review, 32(6), 566–574. https://doi.org/10.1016/j.cpr.2012.06.002 Cheng, P., Kalmbach, D. A., Tallent, G., Joseph, C. L., Espie, C. A., & Drake, C. L. (2019). Depression prevention via digital cognitive behavioral therapy for insomnia: A randomized controlled trial. Sleep, 42(10), zsz150. https://doi.org/10.1093/sleep/zsz150 Eidelman, P., Gershon, A., McGlinchey, E., & Harvey, A. G. (2012). Sleep and psychopathology. In C. M. Morin & C. A. Espie (Eds.), The Oxford handbook of sleep and sleep disorders (pp. 172–189). Oxford University Press. Gee, B., Orchard, F., Clarke, E., Joy, A., Clarke, T., & Reynolds, S. (2019). The effect of nonpharmacological sleep interventions on depression symptoms: A meta-analysis of randomised controlled trials. Sleep Medicine Reviews, 43, 118–128. https://doi.org/10​ .1016/j.smrv.2018.09.004 Harvey, A. G., Soehner, A. M., Kaplan, K. A., Hein, K., Lee, J., Kanady, J., Li, D., RabeHesketh, S., Ketter, T. A., Neylan, T. C., & Buysse, D. J. (2015). Treating insomnia improves mood state, sleep, and functioning in bipolar disorder: A pilot randomized controlled trial. Journal of Consulting and Clinical Psychology, 83(3), 564–577. https://doi​ .org/10.1037/a0038655 Ho, F. Y., Chan, C. S., & Tang, K. N. (2016). Cognitive-behavioral therapy for sleep disturbances in treating posttraumatic stress disorder symptoms: A meta-analysis of randomized controlled trials. Clinical Psychology Review, 43, 90–102. https://doi.org/10​ .1016/j.cpr.2015.09.005 Krakow, B., Hollifield, M., Johnston, L., Koss, M., Schrader, R., Warner, T. D., Tandberg, D., Lauriello, J., McBride, L., Cutchen, L., Cheng, D., Emmons, S., Germain, A.,

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CHAPTER 24  SLEEPING PILLS Brandt, J., & Leong, C. (2017). Benzodiazepines and Z-drugs: An updated review of major adverse outcomes reported on in epidemiologic research. Drugs in R & D, 17(4), 493– 507. https://doi.org/10.1007/s40268-017-0207-7

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CHAPTER 26  SLEEP STAGES AND THEIR MEASUREMENT Baron, K. G., Duffecy, J., Berendsen, M. A., Cheung Mason, I., Lattie, E. G., & Manalo, N. C. (2018). Feeling validated yet? A scoping review of the use of consumer-targeted wearable and mobile technology to measure and improve sleep. Sleep Medicine Reviews, 40, 151–159. https://doi.org/10.1016/j.smrv.2017.12.002 de Zambotti, M., Cellini, N., Goldstone, A., Colrain, I. M., & Baker, F. C. (2019). Wearable sleep technology in clinical and research settings. Medicine and Science in Sports and Exercise, 51(7), 1538–1557. https://doi.org/10.1249/MSS.0000000000001947 Jeong, I. C., Bychkov, D., & Searson, P. C. (2019). Wearable devices for precision medicine and health state monitoring. IEEE Transactions on Biomedical Engineering, 66(5), 1242– 1258. https://doi.org/10.1109/TBME.2018.2871638 Kang, S.-G., Kang, J. M., Cho, S.-J., Ko, K.-P., Lee, Y. J., Lee, H. J., Kim, L., & Winkelman, J. W. (2017). Cognitive behavioral therapy using a mobile application synchronizable with wearable devices for insomnia treatment: A pilot study. Journal of Clinical Sleep Medicine, 13(4), 633–640. https://doi.org/10.5664/jcsm.6564 Ohayon, M. M., Carskadon, M. A., Guilleminault, C., & Vitiello, M. V. (2004). Meta-­ analysis of quantitative sleep parameters from childhood to old age in healthy individuals: Developing normative sleep values across the human lifespan. Sleep, 27, 1255–1273. https://doi.org/10.1093/sleep/27.7.1255