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United States24554 Posts
[Guide] Sleep and Insomnia
This guide comes in three parts. Part 1 goes in this post. Parts 2 and 3 will follow in subsequent posts.
edit: I have added a section on shift work: http://www.teamliquid.net/forum/viewmessage.php?topic_id=96030
Part 1: General Information about Sleep and Sleeping Problems
Introduction:
My goal in writing this guide is to provide tl with useful information on a topic that is grossly misunderstood. Sleep quite obviously affects everyone. Furthermore, about one third of adults experience insomnia. Recently Consumer Reports has claimed about one half of adults report problems with sleep. After pain and headaches, it is the most frequent health complaint. And yet, doctors are not trained to diagnose or treat insomnia! It has become so ubiquitous that they dismiss it as a normal part of life. You can probably blame this to a severe lack of funding for research on insomnia until very recently. Fortunately, recent studies have been allowing for many breakthroughs in developing treatment for those with sleeping problems. This guide will be useful for most readers including many of those who don't consider themselves to have symptoms of insomnia.
I recently begun researching this topic (I have had sleeping problems myself for a long time) and am amazed by the work of Gregg D. Jacobs. He is one of the only people I've ever found to actually have research based answers to all the 'fact or fiction' questions on sleep that are poorly answered by conventional wisdom. His work has convinced me that most (if not all) people can greatly improve their sleeping problems on their own without the use of drugs or medical experts. This guide will provide you with many of the tools necessary to begin this process.
Why a drug-free approach to treating insomnia?
Medical science has yet to find a successful long-term treatment for insomnia. Sleeping pills can be useful when used correctly, but are generally considered unsafe and have side effects that outweigh their benefits in the long term. Until recently they were fairly dangerous (addiction, etc), and they stop working over time. Less obviously, they weaken the belief that insomnia can be cured or reduced by non-external factors. However, the most important problem with sleeping pills as a permanent solution to insomnia is that they don't treat the causes of insomnia. Once you stop taking sleeping pills, control over your sleep schedule will return to a level equal to or worse what it was before you started taking the pills. I won't go on a tangent about how medication is over-prescribed (at least in the USA) but you can be sure the drug companies play a role in the development of our current culture where sleeping pills are prescribed incorrectly by doctors on a regular basis. Drug-based approaches to curing patients are generally acceptable for acute and infectious illnesses, but they prove to be less effective than drugless approaches when treating today's chronic health problems.
What about psychotherapy? Will that help me?
Not only is psychotherapy expensive and time-consuming, but it is usually ineffective in treating insomnia. This is because insomnia is not usually caused by psychological problems. Furthermore, wrongfully believing that your insomnia is caused by problems of the psyche induces feelings of helplessness and lowered self-esteem which can contribute towards increasing the severity of insomnia symptoms. Most importantly, there is no scientific proof that psychotherapy is effective for treating insomnia. Of course, there may be times when psychotherapy is appropriate, so keep that in mind.
What about over the counter sleep aids?
While common name-brand medications like Tylenol PM, Excedrin PM, and Anacin PM are regarded as much safer than prescription sleeping pills, there is little scientific evidence that these pills are actually effective. However, even if they are effective at helping an insomniac fall asleep, they suffer from the same problems as prescription medicine of wearing off over time and not treating the source (cause) of the insomnia. When you stop taking the pills you will revert back to your tendencies to have poor sleep.
Another boom in OTC sleep aids was found about a decade ago with pharmacies selling melatonin. "Melatonin Madness" struck with a force rarely seen during any typical self-help craze. However, the claims about the effectiveness of melatonin as a treatment for insomnia were highly exaggerated. Apparently, only a few studies were used to back the drug companies' claims, and those studies were, in some (if not all) cases conducted by employees of the drug companies. There were just as many (if not more) scientific studies which showed that melatonin is not effective in the long term for the treatment of insomnia. A little misinformation goes a long way. One interesting aside: melatonin was popular because it was cheap, available over the counter, and promoted as natural. This 'natural' product was practically a hoax which put millions of innocent consumers at risk. Perhaps natural is a word that gets misused or abused too regularly.
So far nothing seems to actually work in treating insomnia. What DOES work?
There is actual scientific evidence (recently) that effective drug-free treatment of insomnia is possible. It focuses on addressing the causes of the insomnia. I am basing my suggestions off of a program conducted at the Harvard Medical School over the course of ten years which has shown great success in treating insomniacs. They claim that 100% of their patients reported improved sleep, and 75% claim to have become normal sleepers. While this could be slightly exaggerated, I have confidence that these results are genuinely indicative of leaps and bounds of improvement, and great success in the discovery of effective treatments for insomnia.
What are some techniques that are helpful?
- View insomnia as a learned problem that can unlearned
- Change/prevent negative and/or stressful thoughts about sleep
- Improve stress management
- Elicit the relaxation response: an inborn biological response that allows for the voluntary production of brain-wave patterns that induce sleep
- Strengthen the brain's sleep rhythm by reducing excessive time in bed and getting out of bed at the same time every day (when possible)
- Receive exposure to bright sunlight and specific times of the day
- Exercise at specific times of the day
- Unlearn habits of trying to sleep
- Use naps to boost mood/performance
- Develop a sense of control over sleep*
*much more important than you might think
Teach me about sleep.
Simply learning about sleep/insomnia and realizing all the erroneous things you thought you knew can be an effective treatment for insomnia. For many patients this is not sufficient in treating insomnia, but I personally felt much better about sleep simply by being less ignorant about the topic.
Sleep is not merely a constant state of inactivity. It comes in five distinct stages which each serve different purposes. Recent research has allowed us to unlock the mystery of sleep (to an extent) with the use of EEG recordings which measures electrical activity in the brain. Sleep is much more dynamic than was previously believed. For a healthy sleeper (or simply during a good night's sleep) you begin by closing your eyes in a 'relaxed wakefulness' which triggers brain-wave patterns referred to as 'alpha.' You are not truly asleep but you reach a state of physical and mental relaxation. After a few minutes in this state, you drift into Stage 1 sleep. This is the transitional state between being awake and being truly asleep. You are both relaxed and drowsy. Your muscle tension lessens, your breathing and heart rate slow, your body temperature drops, and slow eye movements occur (this is not REM). A slower brain-wave pattern is generated, called 'theta.' This state of sleep could be considered akin to daydreaming.
Has anyone ever accused you of falling asleep during a boring lecture? Have you ever seen another person "drowsing"? If awoken, the person will quite likely deny that they were actually asleep, and might just claim that they were drifting off. Stage 1 sleep is easy to awaken from, and is not true sleep. After a few minutes in this state you enter the conveniently named Stage 2 sleep. This is a deeper sleep where you are more detached from the outside world. The brain alternates between attempts to maintain awareness and 'turning off.' This stage is still fairly light as we can be easily awakened from it.
It will take about thirty to forty five minutes of Stage 2 sleep before you can continue to stages 3 and 4. They are what we consider deep sleep which is a very important term that will come up again and again. It is harder to awaken from this stage. After another forty five minutes or so, we revert back to State 2 (sleep works in cycles). A few more minutes pass and then you enter dream sleep. I won't go into detail about the dreams themselves (that has occurred many times on tl I believe) but you can rest assured that whoever told you REM (rapid-eye movement) occurred during dream sleep was correct! REM is not fully understood, but it seems to be the case that eye movements track what is going on in dreams to some extent. Despite still being soundly asleep, the body's systems become active again during this state. Heart rate, blood pressure, etc, all increase and become irregular. Measured brain activity during this state is similar to being awake! An interesting aside: penile erection in males (and clitoral engorgement in females for the three or so of you who are reading this) occurs during REM. This is probably a physiological arousal rather than a sexual one. When testing for impotence, REM sleep proves to be very useful. If penile erection occurs during REM sleep, then the impotence is most likely due to psychological rather than biological causes. Other than this, we cannot move when we dream because our muscles are paralyzed. Dreams seem to be the result of an active brain in a paralyzed body.
This cycle I've outlined repeats every ninety minutes or so. In a good night's sleep, you will progress through about six cycles. Deep sleep, like interest on a loan, tends to be front-loaded. You get more dense deep sleep in the early parts of the night, and less towards the morning hours. As the night progresses, deep sleep diminishes and periods of REM become longer and more predominant. I personally have noticed this on good nights of sleep. Since sleep is generally lighter in the latter half, early wakeups are more likely to occur in the early morning hours. Most people actually wake up for a brief moment in between cycles, but fall back asleep immediately and don't remember the waking.
Another question worth answering is, why do we sleep? This is still grossly understood by modern science. One logical explanation is that our ancestors slept because it forced them to be inactive at times when it was disadvantageous to be awake (too dark to perform daily operations like hunt/gather). Sleep also diverts some blood from the brain which allows muscular regeneration to quicken. Your immune system also is more active when you sleep, which might explain why sick people tend to sleep more than healthy people.
Deep sleep is the most vital stage (3 and 4). We are more likely to get deep sleep than REM sleep (since it's front-loaded) and are most inactive during this stage. There is evidence that deep sleep is the stage of sleep that is most likely to be 'made up' if it has been missed in a prior night. REM is also important, though. This is the stage where we are believed to store/process much of the information that we have gained throughout the day.
Another important thing to learn about the workings of sleep is the relationship it has to body temperature. Despite what you may have learned, the body's temperature does not stay at about 98.6 degrees F (37 C). Temperature is lowest in the early morning hours, and then begins to climb before you wake up. It continues to increase until mid-afternoon, and then dips (think siestas). It rises again and peaks at about 6pm (assuming you are on a normal sleep schedule). It then declines steadily until its daily low at about 4am. The variation (if you are healthy) is about one and a half degrees total throughout the day. You might have heard this referred to as the 'circadian rhythm.' It is linked to our daily activity, alertness, and sleepiness. As you can tell, we tend to be more alert/active when body temperature is higher, and more relaxed or asleep when body temperature is lower. 'Night people' tend to experience a peak in body temperature later in the day, and therefore perform better in the evening. Morning people experience the opposite, an early increase in body temperature, and are more active/alert in the morning. As you may already know, sunlight plays a major role in the regulation of this cycle. When the eyes detect light, melatonin decreases, and body temperature increases. When eyes are in a darker setting, melatonin increases, and the body temperature declines.
Another thing you want to understand is that the human brain has two systems which dictate how/when we sleep. There is a wakefulness system that dominates for our sixteen waking hours in a normal sleeper, and a sleeping system which dominates for the remaining eight hours, or so. Even when we are asleep, our wakefulness system is partially active, and so we are never truly detached from the outside world. You might be able to sleep through some noises easily, and be awoken by others. This is the result of your brain's wakefulness system knowing (rightly or wrongly) what outside cues to respond to even while you are asleep.
Aging plays a role on how we sleep. As we get older, we tend to get less sleep. Also, sleep quality tends to decline. Eventually it gets bad enough that naps are required to compensate (old people). I'm not going to explore this topic further since most readers of this guide are not elderly people (sorry physician).
What are the types of Insomnia?
1) Problems falling asleep
2) Waking up during the night or early morning unable to fall back asleep
3) Poor quality of sleep
How do I know if I qualify for #1? #2?
Generally, people with 'sleep-onset insomnia' lie in bed for, on average, an hour and a quarter in order to fall asleep. 'Sleep-maintenance insomnia' occurs
when you wake during the night and lie unable to sleep for approximately thirty minutes (or more). You could experience one, two, or possibly all three of
these types of insomnia, and your insomnia can change over time. In order to truly be diagnosed as an insomniac, you have to not just meet these requirements, but you also have to perceive detrimental consequences from disturbed sleep that extend into your day, such a irritability, fatigue, drowsiness, and impaired productivity or performance. If you have trouble falling asleep but are fine during the day, then you are simply someone who needs less sleep.
Do men and women suffer equally from insomnia?
No. Aside from affecting elderly people more than younger people, females are more likely to suffer from insomnia than males. Aside from hormonal differences, mere differences in the willingness to acknowledge insomnia between men and women could be a strong factor.
I'm an insomniac. Sum me up in a couple of sentences.
Most likely, your wakefulness and sleep systems are improperly balanced: the former is too strong, and the latter too weak. Your daily variations in body temperature probably are not as large as in a healthy sleeper. When you try to sleep, you fail (due to not being physiologically prepared) and think about your inability to sleep, which triggers further inability to sleep. Thinking triggers your wakefulness system. If your mind is racing when you fail to fall asleep, don't assume it is the cause of your problem... it could actually be the result of you trying to fall asleep. Don't blame yourself for being unable to turn off your mind (if you ever have).
What if I occasionally exhibit symptoms of insomnia?
That's fine. Occasional sleeping problems are normal and can be trigger by regular life events such as the loss of a loved one, divorce, or loss of a job. This insomnia usually goes away after a few days or weeks, but it can degrade into a long-term case. If this happens to you, you become a chronic insomniac. Generally, if you are worried about the sleep loss from temporary insomnia, then you are more likely to slip into a vicious cycle. Many people try to take actions to prevent this from happening, and actually exacerbate the problem. Note these common responses to insomnia that can be detrimental to your recovery:
- Going to bed early and/or sleeping later to 'catch up' on sleep
- Believing that you can sleep if you try harder to sleep
- Relaxing in bed by reading or watching television
- Taking naps
- Using alcohol to fall asleep or caffeine to stay awake after feeling fatigued by insomnia
- Reducing physical activity due to fatigue caused by insomnia
Do people with mental health problems tend to be insomniacs?
Insomnia is a frequent symptom of many psychiatric disorders, including depression. Insomniacs are also, on average, more likely to exhibit depression and anxiety than normal sleepers. However, insomnia patients don't suffer from any more depression or anxiety than patients with other chronic illnesses. Furthermore, in many cases where a patient is an insomniac and suffering from depression, it is found that the depression is a consequence of the insomnia rather than the cause.
Tell me more about sleeping pills and other sleep aids.
I am prepared to talk more about this topic upon request (there are actually more safe sleeping pills than there used to be) but it is not a necessary discussion for helping insomniacs. I've already identified medicinal sleep aids as a poor approach to sleep problems. If you want to learn more about sleep aids, let me know.
Can my bedroom become a learned cue for wakefulness?
Yes. Doing pretty much anything in your bedroom/bed that triggers your wakefulness system can be detrimental to your sleep patterns. Doing work, watching tv, or discussing emotionally charged topics (such as Idra's opinion of foreigners) while in bed can make it harder for you to fall asleep. To illustrate this principle with an extreme example, imagine if you experienced daily whippings while lying in your bed. Your mind would associate the bed with the horrible experience, and you would feel uncomfortable and unable to fall asleep in your bed. The same thing applies to everyday situations.
How important are my beliefs about how I sleep?
Very. Negative stressful thoughts about sleep exacerbate insomnia. You need to learn how to recognize these distorted or overly negative thoughts and replace them with realistic and positive thoughts. This will relax you and improve your sleep.
I know exercise is important. Why?
Daily exercise helps to maintain your daily body temperature rhythm. A sedentary lifestyle will flatten out your body temperature variations and make you suffer from symptoms of insomnia. There have been lots of discussions about exercise on tl and I will refrain from going into more detail about how to exercise effectively.
What's the problem with alcohol?
Ask yourself these questions:
- Have you ever felt you should cut down on your drinking?
- Have people annoyed you by criticizing your drinking?
- Have you ever felt bad our guilty about drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
If you answered yes to any of these questions then you should consider receiving professional evaluation and treatment. Although alcohol can sometimes serve as a short-term sleep aid, it suffers from the same problem as sleep medication in that it doesn't provide a long-term solution. It also often contributes to improper sleep which can trigger early wake-ups. Additionally, you've undoubtedly heard of the dangers of alcohol abuse.
Nobody on tl smokes of course, but can smoking matter?
Yes. Smoking before sleep or during a wake-up can keep you awake. Nicotine is generally not your friend when you are trying to sleep. Smokers have been found to have more sleep problems than nonsmokers, however that does not demonstrate causation. It has been found, however, that smokers who quit smoking usually experience improved sleep.
What sleep environment do I need?
You need a room that is not routinely disturbed by noises, and is set to a comfortable temperature. The room should be dark (unless you need to sleep with the light on like GTR) and you should use a comfortable bed that is large enough for your partner, if necessary.
Does stress affect sleep and cause insomnia?
Yes, it can. Those who cope well with stress tend not to have a problem, but others who have negative emotional and physical responses to stress experience disturbed sleep, health, and well-being. To put it bluntly, stress and insomnia are inextricably linked: insomnia often begins in response to a stressful life event, it is one of the first warning signs of excessive stress, and many chronic insomniacs have more trouble sleeping after a stressful day.
Can medical problems affect sleep?
Well yes, of course. But even when you have a very good reason for why you are having trouble, your thoughts and behaviors still play a role in how well you sleep. Doctors can help you with physical problems, but you need to subscribe to the ideas of this guide in order to win the mental battle. I am not going into detail about physical and other health problems that can affect sleep since you should consult your doctor about these types or problems (for example, asthma or sleep apnea).
Do a lot of people on tl have Delayed Phase Disorder?
Probably. Delayed Phase Disorder is the tendency to be unable to fall asleep until 3am or 4am, but then get a good 7-8 hours of sleep. The opposite can also occur where you have trouble staying awake past 8pm (elderly people for example). These problems can be treated with artificial bright-light boxes that simulate the sun and adjust your body temperature cycle to a more appropriate time. However, bright-light boxes are not required. This is especially true on bright mornings where you can go outside in order to jump-start your wakefulness system (just don't wear sunglasses).
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United States24554 Posts
Part 2: Changing your Thoughts and Behaviors
If thinking can cause insomnia, can it also cure it?
Yes. That's one of the main ways to treat insomnia: changing how you think about sleep.
Tell me about the Placebo Effect.
First consider this case from a study conducted in the 1950s on the placebo effect: A pregnant woman was suffering from nausea and vomiting. Her doctor gave her a 'new' medication and told her it was effective. He said it would quickly relieve her symptoms. Within 20 minutes, the woman's symptoms had subsided. Little did she know she had taken Ipecac, a medication that induces vomiting! It was the woman's belief in the drug that had relieved her symptoms. This is why new medications are tested alongside placebo pills. Many studies show that virtually all health problems improve when given a placebo. The power of your mind and body as seen here can also work in your favor when treating insomnia. Belief in your ability to overcome it by following the guidelines of this guide will relieve the symptoms even before you adjust your everyday practices!
What are Negative Sleep Thoughts?
As you would guess, NSTs are thoughts about having trouble sleeping, or being worried about the effects of getting too little sleep. Here are some examples:
- I didn't sleep a wink last night
- I must get eight hours of sleep
- My insomnia is going to cause health problems
- I'm dreading bedtime
- Why does sleep come so easily for everyone but me?
- I feel miserable because I didn't sleep well
- How will I function today after such a horrible night of sleep?
- I can't sleep without a sleeping pill
These are often generalizations or exaggerations that misrepresent our problems. The reason why they are bad is they tend to occur when we are trying to get to sleep. They make us feel anxious and/or frustrated which triggers the stress response and therefore your wakefulness system. NSTs are generally automatic, but most importantly are often inaccurate or distorted (especially in the quite/darkness of night). NSTs seem like a natural/logical reaction to sleep problems, and yet they are 100% detrimental and only hinder your ability to sleep. One of the main purposes of this guide is to help deal with NSTs.
How can I use Cognitive Restructuring to deal with NSTs?
The goal of Cognitive Restructuring is to exchange some of your NSTs with more accurate and more positive thoughts about sleep. In turn, you will become less anxious or frustrated and will sleep better. Cognitive Restructuring is not denying insomnia or lying to yourself about it. It is simply making your views on sleep less distorted and negative.
Do I need eight hours of sleep?
The amount of sleep we need varies from person to person. However, many people think that they need to target eight hours every night, and that they will suffer the next day if they fail to get eight hours of sleep. This is, in fact a myth, as we will see. For now, let's determine if you get enough sleep already:
1) Do you need an alarm clock to wake up?
2) Do you habitually sleep late on weekends?
3) Do you frequently fall asleep during meetings, lectures, boring or sedentary activities, or while watching television?
If you can say 'no' for all three questions then congratulations, you are probably getting enough sleep already. If you are trying to get more sleep you might be aiming for more than you actually need. Some people need less than six hours of sleep each night. The most important thing to keep in mind about the eight hour sleep myth is that getting less than eight hours of sleep on a couple of nights is fine, even if your ideal sleep amount is eight hours. Your brain is much better at making up for missed sleep than you may think. Your mind and body are both also much more capable after missing some sleep than you think.
Are insomniacs good at estimating how much sleep they get?
Generally no. Insomniacs are consistently found (on average) to overestimate the time it took to fall asleep and underestimate the amount of sleep they got. When an insomniac is lying in bed unable to fall asleep their NSTs make them feel very unhappy, and time perception is altered. Recall what Einstein said:
"If you are sitting on a hot stove a minute seems like an hour, but if you are doing something pleasurable an hour can seem like a minute." Altered time perception also creates a vicious cycle (as is often the case with insomnia) because believing that falling asleep is taking a long time will make it harder to fall asleep.
Talk about Sleep Loss.
Why does insomnia bother you (if you are an insomniac)? Most insomniacs will answer that they are worried it will adversely affect their daytime functioning. Not only is this view harmful, but it results from a number of popular misconceptions about the effects of sleep loss (often due to inaccurate one-sided media reports). Some sleep researchers have claimed that Americans are sleep deprived, are accumulating a dangerous 'sleep debt,' and need at least eight hours of sleep per night. But why do we never hear about all the other research which has claimed that there is no consistent scientific evidence that insomnia causes significant health problems (nobody has ever died from insomnia)? People also often attribute daytime problems to insomnia even though many other factors such as stress, exercise, nutrition, alcohol, medication, sunlight, time of year, and heredity play a much greater overall role in daytime functioning. Insomnia gets blamed way too much for things that it is not wholly responsible for (although I'll admit getting very little sleep one night can feel pretty crappy in the morning). Learning not to blame insomnia for your misfortunes will minimize NSTs and help you relax. Your sleep will improve along with your confidence in your ability to control your sleep.
If you still aren't convinced that sleep loss is much less of a problem (by itself) than you originally thought, consider this. Many sleep researchers believe (based on substantial scientific evidence) that humans have a remarkable tolerance for sleep loss (at least on a temporary basis). Studies conducted to measure the adverse effects of sleep loss on daytime performance concluded that they could not find any significant reduction in performance as a result of missed sleep. After one sleepless night, the only activities which will suffer are monotonous or sedentary tasks such as driving, or the ability to produce creative solutions to problems (When I started working full time while involved in many other things, I found myself having trouble driving in the morning without almost falling asleep at the wheel; this would not have happened if I was doing a less sedentary or monotonous activity).
But what about if I miss a lot of sleep over many nights/weeks?
People who miss a lot of sleep do not experience any major side effects aside from feeling very sleepy. Of course, feeling very sleepy can be a problem when taking a final exam! However, it is much easier to manage your NSTs when you realize that missing sleep is nowhere near as detrimental or dangerous as you previously thought.
Are you sure? What about if I miss 2-3 hours of sleep EVERY night for month after month after month? That is okay?
That's what transatlantic yacht racers do. They minimize their sleeping time to approximately five and a half hours in order to win the race. The racers are able to meet all of the challenging demands of their journey despite the reduced sleep and maintain their health throughout the race. Physicians undergo residency training with extremely long hours which often require thirty-six hour shifts responding to emergencies. Despite the extremely demanding requirements of their job they are able to work satisfactorily while receiving significantly reduced sleep.
Do insomniacs have more trouble during the day than good sleepers?
Generally no. Studies on insomniacs indicate that insomniacs do not exhibit poorer daytime performance compared to good sleepers. Insomnia generally won't impair your daytime performance or alertness (these insomniacs were generally found to average five and a half hours of sleep; this seems to be a magic number!).
Why does five and a half hours matter so much?
Put simply, we need to get our core sleep. Core sleep adds up to about five and a half hours. If you miss your core sleep, then you very well might feel more significant adverse effects during the day. Fortunately, core sleep does not have to be uninterrupted. If you get woken up in the middle of the night, you are still capable of going back to sleep and getting more core sleep (although not immediately).
Does this mean that you should panic if you realize you are going to get less than five and a half hours of sleep? Certainly not. Even if you are getting as little as three hours of sleep per night (as is the case with some demanding professions or at certain times), you can function without significant consequences (think of the Apollo 13 astronauts who slept three hours a night and yet performed the operations to get the ship back to Earth safely).
What if I miss out on some core sleep for one, or several nights?
This is very important: if you miss core sleep one night, your brain will do everything possible to get it the next night. The night after sleep loss, there will be more deep sleep and less light sleep. It becomes easier to get deep sleep when you really need it. Skipping some core sleep is like skipping breakfast or lunch... sure you generally don't want to do that but it happens sometimes and you just deal. When I first learned about the brain's ability to make up missed core sleep more effectively I became very relieved and found that I had made a big dent in my NSTs. Simply being less ignorant about what happens when you miss sleep made a big difference for me.
Talk about the effect of insomnia on daytime mood.
Although insomnia is found not to significantly affect daytime performance, it does affect your daytime mood. After missing a lot of sleep you may find yourself to be irritable, frustrated, anxious, mildly depressed, fatigued, or less motivated. Nobody wants to feel like this, of course, but did you realize that this was the most significant threat of missing sleep? Realizing that missing sleep will, at worst, affect your mood tomorrow should help you become less anxious and reduce your NSTs.
The problem is actually lessened as you learn to manage your NSTs. When you wake up, if you have negative thoughts about how your day will be, then you can expect your day to be every bit as bad as you anticipated. But if you recognize that only your mood is at risk and that you can greatly reduce the negative effects of sleep loss on your mood simply be realizing that the problems you have are relatively minor, then you will feel much better throughout the day and also better prepared to tackle sleep the next evening. We've all had trouble sleeping the night before an exciting day we were looking forward to; we should have had a worse mood due to sleep loss but we had a positive attitude in the morning which allowed us to enjoy our day with no side effects. Even on regular days we can make use of this.
How can I begin the process of Cognitive Restructuring to help reduce my NSTs?
Well, simply by reading the guide up to this point you might already be feeling better about sleep and having reduced NSTs. Of course, this is not the best you can do. If you are truly a sufferer of insomnia then you will want to make a daily effort to recognize and replace your NSTs. NSTs are automatic so identifying them is not always easy. The program used by Gregg Jacobs for treating insomniacs involves keeping a daily journal where you record and reflect on your NSTs (you can refer to his program, but you very well might not need to; this guide's goal is to help you!). Even without use of a journal you can make a conscious effort to identify NSTs and scrutinize them until you find more positive and realistic thoughts that are more appropriate. Something I found was that each NST you replace with a positive one makes it easier to continue the process of cognitive restructuring! Here are some tips:
1) Rather than think "I don't think I can fall back to sleep" a more realistic thought might be "I always fall back to sleep sooner or later"
2) Rather than think "I'm not getting as much sleep as I need" think "I need less sleep than I thought"
3) Rather than think "I already can't get 7-8 hours of sleep" think "I'll be fine as long as I get my core sleep, and even if I miss some of that I'll be able to make it up easily. All I need is a positive attitude about my ability to manage sleep and my daytime mood will not be affected that much.
Simply by making a conscious effort to reduce NSTs and replace some of them with realisitic positive thoughts, you might experience a significant improvement in sleep, and you haven't even altered your physical behavior or schedule! Of course, every patient is different, but I personally found this to be true. I remember one evening recently drifting off to sleep thinking "I'm hacking at falling asleep" which is really lame but illustrates my point.
What's next? What habits and physical changes should I focus on?
So after reading up until this point you aren't a perfect sleeper? Don't worry, we still have many ways to work in improving our sleep. The first is to recall what I said about the bedroom being a cue. Some people get into bed and their mind essentially says "oh good time for bed" and they fall asleep immediately. For other people, their mind remembers all the other times they were in that physical situation yet weren't asleep. Thus, for the latter person, the bedroom is a cue for wakefulness. There are many ways you can change your daily life to prevent this from persisting.
The first suggestion is one that you've undoubtedly heard before. Establish a regular rising time. This is not a requirement for all sleepers, but is a good way to get yourself out of a sleep rut. Just as we learned that the body temperature cycle is delicate for insomniacs (promoting establishing a consistent rising and bed time), you can also consider that time can be a strong cue that helps us know when to fall asleep and wake up. By establishing and maintaining a consistent schedule (when it is possible) we subconsciously associate 7am with the time we always wake up, and 11pm with the time we always go to bed (insert your own schedule).
The second suggestion is to use the bed only for sleep. The best case scenario is for your mind to link 'being in bed' with 'being asleep.' This is not always easy to accomplish in a short period of time, especially if you have for most of your life used your bed for activities other than sleep such as watching tv, reading, or browsing tl. Some people can perform these activities in their bed without sleep problems, but if you are an insomniac then you should avoid using your bed for activities (Gregg Jacobs has said that lovemaking is a suitable exception). Furthermore, if you are having trouble falling asleep, then long periods of lying in bed and thinking are detrimental to your recovery from insomnia. Have a light, relaxing activity that you can go to in a dimly lit room (maybe even your bedroom so long as you get out of bed) prepared while you are working on treating your insomnia that you can revert to if you have been unable to fall asleep and you are feeling uncomfortable about it. Remember, the negative thoughts you have while struggling to fall asleep induce stress and wakefulness. The fastest route to sleep may be one out of your bed. However, do not allow yourself to fall asleep somewhere else unless you want that to be your new permanent bed. As you notice improvements in your sleep through cognitive restructuring, you might find that you don't even need to have relaxing activities planned. Taking a little bit longer to fall asleep is fine if you feel comfortable with it and know that you are effectively managing your NSTs.
I'm an insomniac; should I budget more time for sleep since it's a very important thing for me to work on?
No. In fact, people with sleeping problems should consider reducing time allotted for sleep. Don't go to bed early to get a head start on sleep. Calculations such as "It takes me 2 hours to fall asleep so I better go to bed at 9 to fall asleep by 11" are not how you should be coping with insomnia. Insomniacs should never go to bed to try to escape boredom either. This isn't based in research, but I personally think a person who is trying to learn to reduce their insomnia is better off with 6 hours in bed that is mostly sleep than 8 hours in bed that earns a little bit more sleep at the cost of an hour and a half of being awake in bed. In the long run it will pay off.
How should I get ready for bed?
Keep in mind, you cannot just throw a switch and turn on your sleep system. If you are doing something stimulating or active, it will be a couple of hours before you can expect to fall asleep. You may need to avoid computer use (sucks I know) shortly before going to bed since the lighting will trigger wakefulness and inhibit sleepiness. Keep yourself in dim lighting as much as possible prior to going to bed. Don't do work at full speed and expect to sleep after that. Everyone needs to wind down and relax.
What about Napping?
Napping, like many other things with sleep, can work in your favor or against you depending on how it is used. Have you experienced a midafter-noon slump? Siesta cultures such as Spain encourage people to nap during this lull. Although this is encouraged by modern sleep research, it is often not possible in other cultures. I know I can't take a nap at my job.
Why do we feel like taking a nap at this time? It appears to be in our brain chemistry. We experience a drop in body temperature around this time. A logical explanation is that our ancestors were meant to avoid moving around in the mid-afternoon heat and naturally napped during that time to avoid overexerting themselves. Short naps also have been found to improve alertness, mood, and mental performance. The effects are greater if it follows a poor night of sleep. Just make sure the nap is no longer than forty-five minutes to avoid entering deep sleep. It also is suggested that you never nap after 4pm because that could reduce pressure for you to fall asleep that night. Even if you can't nap, a short period of rest and relaxation in the afternoon can have the same revitalizing effects without getting any actual sleep.
Tell me about Stimulus-control Techniques (more about Cues)
Have you ever eaten a large meal, walked into a movie theater, and then desired popcorn? This isn't just because popcorn smells nice. It is also because you have associated going to the movies with eating popcorn during many previous visits. There are many different stimuli that affect our mood or behavior. The one that we are focused on is how lying in bed can be a stimulus for struggling to fall asleep. How do we unlearn this? As suggested before, do not use the bedroom (or at least bed) for anything other than sleep (and sexual activity I suppose). If you use an activity in bed to help you fall asleep. limit them to twenty or thirty minutes and have a timer in place so your tv will turn off without waking you up again. Don't get into bed unless you feel drowsy. If you aren't ready for sleep, then make sure you stay away from activities that promote wakefulness. Practice identifying your own personal cues for drowsiness (such as eye lids dropping, head nodding, yawning, reading the same line in a book multiple times and not understanding it, etc) so you know when it's time to head back to bed.
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United States24554 Posts
Part 3: Managing Stress
I'm going to keep this part brief since stress could be considered its own topic. This is just to get you started.
What is the Stress Response?
The Stress Response is your body's natural, involuntarily physiological changes that occur whenever faced with a stressful situation (physical or mental). This can be very useful when escaping a predator, but is very detrimental in a society where we don't need rapid physiological changes. The more Stress Responses that occur in a day, the more likely that there will be sleep difficulties that night. There is a link between stressful lives and insomnia.
What is a Relaxation Response?
We can't always reduce the amount of stress our lives give us, but we can learn how to relax. It is possible to encourage your body to reverse the effects of the Stress Response. You've undoubtedly heard of or read about relaxation techniques involving closing your eyes, imagining or thinking about something very soothing, and breathing properly. There are countless methods for accomplishing this, and you might be surprised to learn that this can be very effective in reducing the body's negative reactions to stress. Many people practice yoga frequently, and that is less about contorting the body in funny ways, and more about using relaxation to remain healthy. There are actual scientific results which show that encouraging a relaxation response improves our health. I leave the choosing/locating of a technique for triggering the Relaxation Response as an exercise for the reader.
Can I use Cognitive Restructuring to help with Stress?
Before using Cognitive Restructuring, note that people constantly engage in internal self-talk that they are often not aware of. The tone of these internal messages has a big effect on how we feel overall. Cognitive Restructuring should be used to help prevent Negative Automatic Thoughts (NATs). Often during a stressful situation, our minds filter out any thoughts that don't contribute towards a negative view of the situation. These NATs overpower our thinking and make our stress become worse. To work on reducing your NATs, you should take similar steps to how you dealt with NSTs. The only difference is that NSTs were relating specifically to sleep and were easier to identify for this reason. NATs can be about pretty much anything that upsets you or stresses you out.
Your conscious goals should be to:
- Be more realistic and accurate in thinking about stressful situations
- Reduce tunnel vision under stress
- See stressful situations more clearly
- Minimize 'false alarms' in response to stressors
Identifying NATs is tough but you can try to identify them by determining what thought caused you to feel stressed. The next time you are stressed you should try to make a conscious effort to identify which thought set you off. Think about ways you could have thought about it different and bypassed some of the stress. You can play devil's advocate with these negative thoughts in order to discredit them or render them irrelevant. "Is this thought really true?" "What is really the worst thing that will happen? Am I exaggerating how bad this is?" "Am I using absolute words such as never, always, worst, terrible, or horrible?" (Recall that only a Sith lord speaks in absolutes!) These are all examples of questions you can ask yourself to help identify a NAT. Still another idea is to use the "double standard" technique where you ask yourself if you would have the same thought (NAT) when considering a friend in the same stressful situation as yourself. Placing yourself into another's shoes will sometimes make it easier to provide a realistic perspective to your situation and identify if thoughts are unfair or unnecessarily negative.
By using the Relaxation Response and Cognitive Restructuring to manage stress, you will see benefits not just in your sleep, but also in other areas of your health and daily life. Managing Stress is a very important part of living a healthy life.
Can you give me some more tips about being healthy/happy?
Being optimistic strongly contributes towards being healthy and happy. If you feel in control of your life, committed to things outside of yourself (family, pet, religion, community, etc), and view hurdles as challenges rather than threats, you will benefit greatly. Having close relationships with people is also very important for most people. Social support does not have to come from your direct family members so long as you have close friends who you can confide in. Elderly people can meet this requirement simply by getting a pet. Sufficient social support is found to drastically improve life expectancy for people of all ages.
Another note: anger is bad, laughter is good. Being angry can be appropriate when a situation truly calls for it, but it is never advantageous for the body itself. Try your best to manage/limit your anger. Realize that it isn't healthy. Laughter, on the other hand, is great. Being able to laugh at and enjoy most situations contributes towards greater health (and therefore better sleep at night). If you are someone who rarely is happy or laughing, then this is an area for improvement. Sometimes the best people to learn from for how to laugh and have fun are children... they do it naturally all the time.
Finally, doing service for others (charity, helping somebody without compensation, what have you) typically improve how we feel about ourselves. Altruism reduces stress, improves positive emotions, improves attitudes and feelings of contentment about what we have, increases self-esteem and sense of well-being, and promotes social support which reduces anger and social isolation.
Final words?
Hopefully many readers of this guide will have everything they need to manage their sleeping problems (or eliminate them). For those of you who still need help, this guide should have helped educate you to the point where you know exactly what area you need help with. Of course I encourage you to seek out additional information if you choose, but beware of all the poor information that exists out there about sleep.
Some specific topics I'd be willing to shed some light on if people request it:
1) Managing shift Work (working night shifts, etc)
2) Managing Jet Lag
3) Infants' and Children's Sleep
Please share with us your experiences, comments, and personal insights. If you find this guide was helpful, please tell us!
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I hesitate to say TLDR in a guide...especially since it looks like you put a lot of effort into it and might actually help me but.. TLDR
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United States24554 Posts
On June 14 2009 10:40 decafchicken wrote:
I hesitate to say TLDR in a guide...especially since it looks like you put a lot of effort into it and might actually help me but.. TLDR
Are you an insomniac? If so, it's this or a 200+ page book... choose between those or insomnia :3
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Holy damn, that's massive. Good stuff, micro. 
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tdlr, i read a bit of it, but yeah sleeping and waking up at the same time everyday helps, definitely
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Cure insomnia? no thx, I'll take the psychic powers.
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On June 14 2009 10:40 decafchicken wrote:
I hesitate to say TLDR in a guide...especially since it looks like you put a lot of effort into it and might actually help me but.. TLDR
How have I never seen you post before, I've been here a year
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NeverGG
United Kingdom5399 Posts
Wow a really detailed guide. I'm a terribly light sleeper myself, but not an insomnia sufferer thank god. I've recently moved into a room facing a main road, but it seems as though my body has gotten used to the slight noises from outside. It's strange how patterns emerge like that.
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Nice, that's a very detailed and practical guide. I think this is quite useful.
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I used to suffer from insomnia before I discovered TvT VODs
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9070 Posts
Will read this for sure, I have sleeping disorders and insomnia for 3 months or so. Thank you for making the guide
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On June 14 2009 11:04 Chef wrote:
I used to suffer from insomnia before I discovered TvT VODs
I agree lol
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On June 14 2009 10:50 n.DieJokes wrote:Show nested quote +On June 14 2009 10:40 decafchicken wrote:
I hesitate to say TLDR in a guide...especially since it looks like you put a lot of effort into it and might actually help me but.. TLDR How have I never seen you post before, I've been here a year
you probably suffer from insomnia and its affecting your memory. read above guide for help.
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On June 14 2009 11:12 disciple wrote:
Will read this for sure, I have sleeping disorders and insomnia for 3 months or so. Thank you for making the guide
I am pretty much suffering from insomnia for over a year with some breakes. I manage to get a proper sleep for a few days and then it is back for a few weeks...
Thanks for the guide. Hopefully it will help...
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micro, since you seem to be using insomnia in a general sleeping problems type sense, what do you call an acute temporary case of being almost totally unable to sleep? I had this happen to me twice in college, where I was basically unable to sleep more than 1-2 hours per day at most for about 2 weeks straight. The student health center referred to that as insomnia, and said basically that there wasn't anything that could be done other than wait for it to pass, and gave me some very light sleep aids to help make it manageable (trust me, going that long without significant sleep fucks you up hardcore). That's one case where it seems to me light sleeping pills are appropriate - I just used (at the Health Center's direction) an OTC dose of diphenhydramine hydrochloride antihistimine (anti-allergy) once a day when I wanted to sleep. It was enough to let me fall asleep for 6 hours or so for a few days until the issue went away and I could sleep normally again. I didn't see any mention of this in your guide (though I only skimmed the latter 2/3 of it), so I don't know if you want to add any kind of comment on that as a special case or something.
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ooh this will probably be the guide that helps me the most out all of the ones written, thank you!
Edit: i still can't believe there is a part 3 to this 
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THANK YOU SIR!!! I have been suffering from delayed phase disorder for as long as i can remember, coincidentally i live in vancouver where the sun is absent for most of the year. With this guide i will make things better.
edit: also i think Micronesia wins this guide thing, this is thoughtful guide since he knows so many TLers don't sleep right.
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On June 14 2009 11:04 Chef wrote:
I used to suffer from insomnia before I discovered TvT VODs
Amen to that.
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EPT
