Sleep Soundly Every Night, Feel Fantastic Every Day (15 page)

Sleep hygiene simply refers to the habits you put in place for better sleep. People can develop counterproductive behaviors referred to as poor sleep hygiene. Constantly looking at the alarm clock, going to bed and staying in bed when not sleepy, attempting to sleep later on weekends or nonwork days, and consuming alcohol to help get to sleep are but a few of these counterproductive behaviors. If you haven't already instituted the suggestions outlined in
chapter 3
, do so now.

Set a specific schedule of going to bed and waking up. The insomniac's internal circadian clock is out of sync with the sun cycle. To reset your internal clock requires a consistent time for sleep and waking. Your body thrives with a consistent routine.
Chapter 6
on circadian sleep disorders explains in detail why the brain and body function best on a set schedule.

With chronic insomnia, you tend to develop negative sleep-preventing behaviors, like severe anxiety surrounding the rituals of going to bed and the bedroom environment. A good night's sleep becomes impossible. In fact, some find it easier to sleep in a foreign environment, such as a hotel or at a friend's house that does not contain stimuli that trigger their anxiety about sleep. I find that some actually sleep better in our sleep lab than at home. Sleep specialists call this Reverse First Night Effects.

This treatment focuses on reducing exposure to things that cause wakefulness at night, and the goal is to establish immediate sleep and an optimal sleep–wake cycle. This therapy helps an insomniac to reprogram negative associations about going to bed, the bedroom rituals, and the environment, into a pleasurable or desirable activity for the specific goal of sleep. Instructions for this therapy include:

1.
 
Go to bed only when sleepy.

2.
 
Get out of bed when unable to sleep.

3.
 
Go to another room and return to bed only when sleep is imminent.

4.
 
Curtail all sleep-incompatible activities.

5.
 
Rise at a regular time every day, regardless of the amount of sleep the night before.

6.
 
Avoid napping.

This method ensures the time spent in bed corresponds to the actual time you are sleeping, and not the total time spent in bed trying to sleep. You are in bed only to sleep, and you limit the time in your bed not sleeping. You go to bed later but maintain the same wake time, and then increase the time in bed over a specific period, according to your sleep expert's guidance, until you sleep all night.

For instance, you sleep only six hours but spend eight or more in bed. In sleep restriction therapy, the sleep specialist will start you at six and one-half available hours for going to sleep and waking up. The specialist checks your sleep diary weekly to see if you are sleeping more than 85% of the time spent in bed. If yes, then he will extend your total sleep time available in bed by 15 minutes. This sleep time will be extended or shortened weekly, depending on whether you are sleeping more or less than the 85% of time available to sleep.

CBT is a form of psychotherapy or counseling, with varied techniques to help you regulate your thoughts as well as behaviors around sleep. The focus on thinking about how you feel and act helps you become more aware of negative thought patterns that prevent you from changing behaviors. In time, you'll learn how to regulate behaviors using CBT techniques. CBT is used for persistent insomnia, as the primary disorder, along with coexisting disorders.

Some insomniacs develop numerous dysfunctional beliefs about sleep. Thoughts listed on
page 71
are just a few common examples of what I hear every day from my patients.

  
I know if I don't get eight hours of sleep I'll be miserable all week.

  
Insomnia is going to severely impact my health.

  
I just know I won't be able to function.

  
I'm going to lose my job.

Is it any wonder that these people cannot get good sleep? In fact, these negative experiences and counterproductive behaviors stimulate the production of stress hormones, making sleepless nights even worse. Cognitive restructuring challenges the person to validate the reality of his or her proclamations.

A sleep specialist may challenge or query in friendly ways: “Let's get a reality check. Show me the evidence for that belief. Let's track your week and see how that thought plays out.” The point is to empower the patient to notice and observe, record, write or keep track, and then be accountable to report and process the findings with the sleep expert. CBT is based on the premise that incorrect thoughts lead to emotional suffering and habitual thoughts become embellished. A diary or record of the thoughts and feelings helps you identify and change the habits that do not work for you (see facing page).

Seventy to eighty percent of people with insomnia find CBT provides reliable and prolonged benefits.

This is great for people in locations that do not have sleep specialists and others trained in nonpharmacological treatments of insomnia. These programs are conducted online, and you communicate with someone trained in CBT. You will be offered various nonpharmacological techniques such as stimulus control, sleep restriction therapy, and cognitive restructuring. Your therapist will review your progress weekly and make online recommendations. The treatment period may vary, but the average is eight weeks.

In my experience, many insomnia sufferers show an inability to close down the day emotionally. They refer to it as being too stressed. In a book called
Sound Sleep, Sound Mind: 7 Keys to Sleeping through the Night,
Barry Krakow, MD, postulates that an inability to identify, feel, and process emotions is what sets many with insomnia apart from good sleepers. The insomniacs think about emotions rather than experience and process them. This leaves them going to bed with their brain on overdrive. Dr. Krakow's theory is that if we learn to feel and process our emotions during the day, we will sleep better at night. Certainly, it would seem to be a better way than medications.

Here are three exercises to help you wind down and release emotional tension at the end of the day:

1.
 
Noticing
: When a parent notices a child acting out for attention, a common phrase is “I notice that you are … paying attention, eating your green beans, picking up your toys.…” Noticing the small things is a practice of paying attention, and when you pay attention to your emotions, they dissipate. With your eyes open or closed, feel your way through your body, starting at your head and moving down. Notice if your neck holds a pain, your shoulders are burdened, your expression is tight, your chest feels heavy, or your gut is angered and so forth. When you do notice an emotion, stay with it; or move into the center of it and notice how much lighter the emotion feels.

2.
 
Noticing with Words
: The “name it and tame it” aspect of emotions includes self-talk. Close your eyes and feel your way through your body, noticing each important emotion as it rises. Then, speak softly the noticing statement:
“I notice my shoulder feels angry. I'm angry at not finishing the conversation with my boss. I accept
[or acknowledge, own, release]
my anger
.” Then, you feel your way to the
next emotional area:
“I feel twinges in my gut. The twinge is the emotion disgust. I was disgusted with the way the child in my classroom pushed another, and I did not speak up strongly enough. I acknowledge this emotion.”

3.
 
Writing What's on Your Mind
: The idea of noticing and accepting our emotions before sleeping is to get the inside out. Writing in a journal may be easier than verbal or visual noticing activities. When you write what is on your mind or in your emotions that bothers you, this form of self-acceptance or acknowledgment in physically writing out the emotions releases any pent-up energy around the issues, as you keep writing long enough to feel the tension dissipate and your breathing become more relaxed.

Any training that helps you relax such as deeper, effective breathing, biofeedback, yoga stretches, guided imagery exercises, and light hypnosis sleep tapes, can be very effective in assisting you to sleep. You choose what you like to do, and would look forward to doing because you would feel better, more relaxed, and quieter inside. These factors motivate you so you don't feel like you “have to” work harder at sleeping or “do one more thing!”

For people with hyperarousal syndrome, several relaxation therapies can help them to retrain this anxiety pattern. I suggest patients undertake this type of intervention with support and guidance, or at least an accountability partner, because a commitment over time is required to establish new patterns in the body. Here are two relaxation approaches: