Whole9 guest post by Emily Deans M.D., a board certified psychiatrist with a practice in Massachusetts and she teaches psychiatry at Harvard Medical School.
In Part I of this series, we reviewed the importance of good sleep to brain health (summary: you die without it) and some basic sleep hygiene points managing the sleep cycle and circadian rhythms. But let’s say you try and try, you eliminate caffeine and you only drink a single beer at noon on Sunday while watching the football game. You don’t shine flashlights into your eyes at night and in fact every single source of light in the bedroom is darkened with duct tape so it’s like being in a crypt.
But, maybe you still sit awake ruminating about work or kids or school or some other problem. Or maybe you fall asleep just fine, but you wake up at 2am and can’t get back to sleep. Then you’re a wreck from sleep deprivation and the idea of going without caffeine in the morning makes you want to stab the cheery herbal tea drinker in the next cubicle. Or maybe you are stuck on some sort of hypnotic sleep medicine or rely on a good dose of alcohol before bed. Or perhaps you sleep like a log but when you wake up you feel awful, unrested, with a raging headache.
Sounds pretty terrible, but there are solutions, so keep reading.
Sleep Restriction Therapy for Chronic Insomnia
If you can’t get to sleep or can’t stay asleep and all the strategies previously discussed have not helped, you may want to consider sleep restriction therapy. This technique is tough but effective and is for chronic insomnia, not short-term issues. If you have bipolar disorder or another physical or mental health condition, it is imperative that you talk to your doctor before trying it. Sleep restriction can lead to a manic episode.
First, keep a sleep diary (here’s a printable version from the National Institutes of Health) or use a sleep tracker like those included with the FitBit or a smartphone app such as Sleep Cycle. Figure out how much time you are actually sleeping (6 hours? 4?) of the time spent in bed, then for the next night you are only allowed to sleep (or be in bed) that amount of time. So yes, if you are sleeping four hours, go to bed at 2am and wake up at 6am, and absolutely, positively, do not nap. Sleep debt will continue to build, making it easier to go to sleep the next night, and anxiety and phobias about tossing and turning in bed being tortured by insomnia will gradually fade. Slowly move the going to bed time by 15 to 30 minutes earlier each night, stopping at a certain restricted time if you have insomnia again. Wait until you are sleeping that six hours again, then keep creeping that bedtime earlier.
Managing light at night (i.e. Wear those blue blockers if you are up late) is particularly important if you are using this strategy, because bright light in the middle of the night or early am can affect even the next night’s sleep. For those dependent on sleep meds, combining sleep restriction with a gradual reduction in the medicine over a period of weeks can get you off the pills. Sometimes slowly reducing the sleep aid and adding a natural hypnotic supplement such as magnesium can help with the psychological dependence of needing a pill to go to sleep.
If you need more specific advice about sleep restriction, try these resources:
- Sleep Foundation
- CBT for Insomnia
- Local sleep clinics often have therapists or groups in sleep therapy if you need personalized advice
Non-restorative Sleep Issues
What about the non restorative sleep? You sleep 10 hours but still feel wretched in the morning. If you are obese or have chronic allergies, a receding chin, and particularly if you snore or wake up gasping for air, you may have sleep apnea. Diagnosis and treatment will require going to your doctor for evaluation and treatment with a sleep study and possibly a CPAP machine. Since sleep apnea can lead to pulmonary hypertension, heart failure, and sudden death along with all the myriad of health problems associated with sleep deprivation, it’s best to bite the bullet and get evaluated as soon as possible. Sleep medication will help you sleep better, but it also depresses the same respiratory drive that is waking you up to get oxygen to your brain, so topping off untreated sleep apnea with heavy duty alcohol or sleep medicine is a terrible idea.
Other folks with non-restorative sleep include people with certain subtypes of depression, hypothyroidism, ME/CFS (now called SEID), or fibromyalgia. Treating the underlying condition is important, along with gentle exercise for fibromyalgia, and regular exercise in the case of depression. Excessive exercise should be avoided in properly diagnosed ME/CFS as it tends to make exhaustion even worse.
Finally, if you have acute insomnia from a death in the family or major stress, it actually might be a good idea to use sleep medicines as short term aid under medical supervision. Acute insomnia can become debilitating chronic insomnia, but short term is the key. In general, no more than 7-10 days is needed to become dependent on medicine for sleep. Also, the risk and side effects of chronic sleep medication may be less than the risks of insomnia in certain conditions such as bipolar disorder, but that’s a personal discussion between you and your doctor.
Good luck and happy sleeping!
Emily Deans M.D. is a board certified psychiatrist with a practice in Massachusetts and she teaches psychiatry at Harvard Medical School. She writes articles about nutrition, lifestyle, and mental health at Psychology Today. You can also find her on Twitter at @evolutionarypsy. (Please note: she can’t give medical advice over the internet, so please don’t request it.)
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