B0038M1ADS EBOK (17 page)

To improve sleep, practice good "sleep hygiene" skills. Sleep hygiene is
a medical term used to refer to the practical things you can do to improve
sleep. The other thing often considered for sleep problems is medication,
either over-the-counter or by prescription. However, it's important to be
fully informed regarding these medicines, as there are many problems
with limited effectiveness and side effects (sometimes serious).

A) Sleep hygiene: The following list provides the key elements of practicing good sleep hygiene, including the recommended standard information and other material that may prove beneficial. A lot of advice that's
given hasn't been extensively studied, and there are many assumptions
mental health professionals make about what's best for an individual that
might not be helpful (and may even make things worse). Give yourself
some time to try different things until you find the approach that works
best for you. It can take some time to correct sleep problems after combat
deployment, so take it easy.

• Have a comfortable place to sleep that's quiet, free from distractions,
and a good temperature for you to sleep soundly (generally on the
cooler side). The bed and bedroom should be reserved for sleeping
and having sex, nothing else. You should not work in your bedroom.
Having a comfortable mattress is very helpful.

• Establish a pre-sleep routine that includes going to bed at a regular
time. Do something relaxing before sleep. This may include a warm
shower or bath, light stretching, or a muscle relaxation exercise from
this chapter.

• The standard advice is to not keep a TV in your bedroom and not to
watch TV before going to bed. The rapidly changing visual images
of television can be stimulating to the brain and can disturb sleep.
If you're the type of person who prefers to fall asleep with the TV
on, try replacing it with some other form of "white noise" (see
next paragraph). If this doesn't work, or the TV provides a sense
of comfort, turn the volume low and select a channel where the programming is pleasant or innocuous and won't trigger negative
thoughts, memories, or feelings. If your TV has a sleep function, set
it to turn off automatically so it doesn't disturb you after you've fallen
asleep.

• Consider putting "white noise" in your bedroom. White noise is a
background sound that causes other noises to become less noticeable.
The simplest form of white noise is a floor or table fan (ceiling fans
are usually too quiet for this). If you don't like the air blowing on you,
point it in another direction. There are also inexpensive machines
that produce white noise sounds like the ocean, a waterfall, rain, or
wind. White noise helps to cancel out other types of noise around
you. For example, if there are other people in your house, noisy
neighbors, or outside traffic that disturbs you as you try to sleep,
white noise can make the bedroom seem quieter by reducing the
presence of other noises so you don't notice them as much. During
deployment, generators and air conditioners are great sources of
white noise, and warriors often find that after coming home, having
some white noise can help them sleep better.

• Don't toss and turn for hours. If you haven't fallen asleep, or you're
having trouble falling back asleep after waking up, give yourself
about thirty minutes, but if you're not asleep after that, get up and
leave the bedroom. The reason for this is to keep the bedroom as the
place where you sleep, not a place that has a bad association where
you frequently toss and turn or stay awake trying to sleep. The goal
is to train your body to associate the bedroom with sleep by going
somewhere else whenever you're not sleeping. That way, your body
learns that your bedroom is only for sleeping.

• When you leave the bedroom after thirty minutes of trying to
sleep, keep the TV, computer, BlackBerry, video games, and other
electronics off. These involve visual processing in your brain and
can be stimulating. Instead, find something quiet to do, such as
reading, listening to relaxing music, doing a puzzle, drawing, or
journaling. If you use your computer for writing, restrict its use
only to the word-processor program, and don't check e-mail, send messages, or go on the Internet. Again, you want to do something
that's quiet, reflective, and not stimulating. After doing this for a
while, you'll probably start to feel tired again. When you feel sleepy
enough, go back to bed.

• The best time to exercise is at the beginning of the day, but if you
exercise in the afternoon or evening, leave enough time to wind
down and cool off (at least an hour) before going to sleep.

• Eat big meals earlier in the day and limit yourself to a light snack
within a few hours of going to bed. This helps avoid heartburn
during the night. Drink fluids more than two hours before going to
sleep so you're less likely to wake up needing to go to the bathroom.

• If you're having nightmares or waking suddenly with the feeling of
dread, consider putting a small nightlight in your room (an alarm
clock light works well also) to help orient you to where you are. If
you're experiencing nightmares, particularly if they're repetitive and
involve the same disturbing images or themes, write them down and
think of ways to modify the images in your mind. For example, if
you're having repetitive images of combat, think of the good things
you've experienced and the people you loved and appreciated. Also,
it's useful to know that disturbing nightmares are often related to
stress and to the body being revved up. Any stressful situations going
on in your life that cause anxiety, frustration, anger, increased blood
pressure, or increased heart rate make it more likely for nightmares
to occur. Don't ask why you get particular nightmare images. Dreams
and nightmares are not mysterious processes, and are strongly
influenced by what's going on during the daytime. For example, if
you're having any conflicts at work or with your spouse or partner,
you might have disturbing wartime images at night. Nightmares are
common after combat; they're related to physiological changes in
your body and how your mind processes disturbing memories of
stressful experiences. Learning the various skills in this book can help
with recurrent nightmares. One other thing that you can consider
for nightmares is to ask your doctor for a medicine (e.g., prazosin)
that reduces blood pressure, slows the heart rate, and helps reduce the revved-up feeling that can be associated with nightmares (see
section C below for more details).

• Watch your caffeine intake. Drink caffeine beverages only in the
morning and early afternoon. This includes coffee, tea, energy
drinks, and many types of sodas. Read the label if you're not sure
if it contains caffeine. Many popular sodas contain caffeine, and
it's important to cut down on their use if you're having any sleep
problems.

• Understand how alcohol or drugs affect sleep. Use of alcohol is one
of the most common reasons for sleep difficulties. (See the last skill
in this chapter for more details.)

• Keep a "sleep log" notebook nearby, and when you wake up, record
the time you awoke, the amount of sleep you got, and any dreams
or nightmares you had. Also, write down what you did to help you
sleep, what worked and what didn't. Over time, this type of log can
be very helpful, particularly if you go to a medical professional for
sleep problems.

• Most important, feel free to ignore any of the advice above if it
isn't working, or if there's something else you've found that's
more helpful. Everyone has to learn what works and doesn't work
for them. You want the bedroom to be a place that's comfortable
and doesn't increase your anxiety every time you lie down to go to
sleep. If the standard advice doesn't work, it doesn't mean there's
something wrong with you; it may mean that the standard advice isn't
any good. If you find that sleeping on the floor or sofa works better
for you, then do that. Do whatever works for you to make yourself as
comfortable as possible (within the limits of your living situation and
the needs of others living with you).

As an example of the last point, a marine senior officer I worked with
found himself regularly waking at 2:00 a.m. thinking of all the messages
that he had to send to his subordinates. He would sleep fitfully after 2:00
a.m., finally getting up at 4:00 or 4:30 to take care of the messages before
exercising and going in to work. He was chronically fatigued, and this affected his ability to keep his temper in check. Despite the advice to not
get on e-mail in the middle of the night, I recommended that he immediately get up and get out of bed when he woke at 2:00 a.m. to take care
of his messages, rather than just lie there. When he started to do this, he
found that he could finish in about an hour and then fall back asleep for
two or three more hours. This change allowed him to get additional sleep
each night and improved his mood and energy.

B) Over-the-counter medicines: Over-the-counter medicines can be purchased without a prescription; however, be careful with these. If you're
considering trying an over-the-counter sleep medicine, know they don't
work very well, have a number of risks and side effects, and don't work any
better at higher than recommended doses. Over-the-counter sleep aids
include:

Antihistamines: Antihistamines are medicines most commonly used
in the treatment of allergies. Newer antihistamines, such as loratadine
(Claritin), cetirizine (Zyrtec), desloratadine (Clarinex), and fexofena-
dine (Allegra) cause minimal or no drowsiness and don't work as sleep
aids. Many of the older antihistamines, such as brompheniramine (e.g.,
Dimetapp), chlorpheniramine (e.g., Chlor-Trimeton, Singlet), dimenhydrinate (e.g., Dramamine), diphenhydramine (e.g., Benadryl, Nytol,
Sominex, Sleepinal, Compoz), doxylamine (e.g., NyQuil, Unisom, Nighttime Sleep Aid), clemastine (e.g., Allerhist, Tavist), are readily available
and are a main ingredient in over-the-counter sleep medicines because
they cause drowsiness. The antihistamine hydroxyzine (Atarax, Vistaril,
Novo-Hydroxyzin), available by prescription, works in the same way.

These medicines are not habit-forming, but are likely to work best if
used only on an occasional basis. Although widely used for sleep, there
is very little research supporting their effectiveness, and they can cause
drowsiness the next day. Other side effects include dry mouth, blurred
vision, dizziness, forgetfulness, and urinary retention. These medicines are
not to be used by people who have a history of glaucoma, are pregnant,
or are taking certain types of medicines. There are obvious precautions
concerning driving or operating heavy machinery because of the drowsi ness. It's best to check with your doctor before taking these, and to read
the labels and package inserts to ensure that you're informed.

Herbals and supplements: These include melatonin, tryptophan,
L-tryptophan, and herbals, like valerian. Studies have produced mixed
results as to their effectiveness, but in general, if they do work, they only
help with falling asleep, not with staying asleep. They generally have minimal side effects, the most serious being an allergic reaction. Melatonin is
a natural hormone that increases in the body at night, helping to bring
about sleep, and then decreases when daylight returns. Unfortunately, taking this hormone as a pill has not proved to be very effective, although
some people report it helps with falling asleep and with jet lag. Tryptophan
or L-tryptophan is a basic amino acid that's important in the production
of a chemical in the brain called serotonin. Some people have found it
helpful for getting to sleep, but studies have been mixed. Valerian has also
shown mixed results, although it's a common sleep aid used in Europe.
At high doses, valerian can cause vivid dreams, blurred vision, changes in
heart rhythm, and excitability.

In summary, if you choose to try an over-the-counter medicine to
help with sleep, understand the risks. Side effects are higher with medicines that include antihistamines. Supplements or herbals have fewer side
effects, but if they show any effectiveness, it's generally only with falling
asleep, not with staying asleep. These medicines don't work any better at
higher than recommended doses.

C) Prescription medications: If you experience ongoing sleep problems
despite good sleep hygiene, and over-the-counter medicines have given
you no relief, then it's wise to go see a medical professional. The easiest
way is to see your primary care doctor, and then if further evaluation is
necessary, your doctor can provide a referral. Your doctor should evaluate if there are any underlying medical conditions that explain the sleep
problems before considering a prescription medicine. Medical conditions
that can cause sleep difficulties include sleep apnea, pain, restless leg syndrome, periodic limb movements, narcolepsy, alcohol abuse, depression,
anxiety, PTSD, and side effects of medications. If a decision is made to prescribe a sleep medication, there are several different choices, and your
doctor should inform you of the options and risks. However, don't agree
to take a prescription medication that may be addictive unless absolutely
necessary. There are five types of prescription medicines commonly used
to help with sleep.

Antidepressants: Some of the older antidepressants caused a lot of
drowsiness and proved to be more useful for sleep than depression. One
medicine that's commonly prescribed for sleep is trazodone (Desyrel).
This is often prescribed in doses ranging from 25 to 100 mg, much lower
than doses necessary to treat depression. Side effects can include dizziness, tiredness, blurred vision, gastrointestinal side effects (nausea, diarrhea, constipation), headache, dry mouth, muscle aches, and changes
in weight, among others. Trazodone is not addictive, which is a distinct
advantage over other prescription sleep medicines. Although it's widely
used in both men and women, there is one note of caution regarding its
use in men. Very rarely, trazodone can cause priapism, a condition where
the penis gets a prolonged and painful erection unrelated to sexual stimulation. If this happens, it requires prompt medical intervention in an
emergency department to prevent long-term problems such as impotence.
Fortunately, this is a very rare event, and the only thing that's necessary is
to be aware of it so if it happens you'll know what to do. Trazodone also has
potential interactions with other medicines, and additional precautions
and contraindications. Get as much information as you can by speaking
with your doctor and reviewing the package insert.