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Normal Sleep - Insomnia - Health Effects of Insomnia - Behavioral Treatment for Insomnia - Sleep Hygiene - Relaxation - Stimulus Control - Cognitive Restructuring - Sleep Restriction and Scheduling - More Information

Normal Sleep

We sleep more than we do any other activity in our lives, yet some of the reasons why we need to sleep remain unclear. Sleep is important to restoring our physical and mental well-being.

Our body has an internal, natural clock (called "circadian rhythm") that promotes a regular sleep cycle. Unless disrupted, our body and mind naturally induce sleep and then wake from sleep on a consistent 24-hour cycle. Our sleep needs actually decline from childhood and level off in young adulthood. Individual, normal sleep needs vary from as few as 5 to as many as 10 hours per night (7 to 8 hours is the norm).

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Insomnia

When our natural pattern of sleep is disturbed, we experience insomnia -- a sense of having had inadequate sleep quality or quantity. Almost everyone experiences brief bouts of insomnia, often caused by stress or worries, physical discomfort, medication effects, or a change in our sleep schedule. These acute episodes of insomnia usually last only a few nights and our sleep schedule returns to normal after the situations that caused the sleep disruption have been resolved. About 10% of Americans, however, experience chronic insomnia -- sleep problems that last for months or even years. If a person experiences insomnia for a month or more, some form of treatment is typically needed to restore the person's sleep back to normal. Insomnia can be divided into two basic categories: primary insomnia and secondary insomnia.

Primary Insomnia

Primary insomnia refers to a sleep disturbance that occurs without any specific underlying condition that causes the insomnia. Individuals with primary insomnia experience a sleep problem without having any medical or psychiatric condition that is the cause of it. Primary insomnia is largely due to learned maladaptive sleep patterns and represents the most common form of insomnia.

Secondary Insomnia

Secondary insomnia differs from primary insomnia in that a specific condition can be identified as the cause of the sleep problem and should be evaluated by a physician. Some examples of secondary insomnia are:

• Sleep apnea is a sleep disorder caused by difficulty breathing during sleep. Persistent, loud snoring and frequent long pauses in breathing during sleep, followed by choking or gasping for breath are the main sighs of sleep apnea. For more information, visit www.sleepapnea.org .

• Restless Legs Syndrome is a sleep disorder characterized by unpleasant sensations (creeping, burning, itching, pulling or tugging) in the legs or feet, occurring mostly in the evening and at night. Moving the legs around tends to relieve the unpleasant sensation temporarily. For more information, visit www.rls.org .

• Sleep-wake schedule or circadian rhythm disorderers are sleep disorders caused by having sleep-wake schedules that do not match up with your natural sleep schedule. People who work the night shift may suffer from this problem

• Insomnia due to medical conditions: Many common medical problems and the drugs that treat them can cause insomnia, including allergies, arthritis, heart disease, hypertension, asthma, Parkinson's disease, attention deficit hyperactivity disorder, or hyperthyroidism. Physical discomfort (e.g. chronic pain) may also cause problems sleeping.

• Insomnia due to substance use or withdrawal: Many drugs and medications can cause sleep disturbances, either while taking them or while withdrawing from them. Alcohol, stimulants, sedatives, and even long-term use of sleep medications can cause insomnia.

• Insomnia due to an emotional problem: Insomnia can be a symptom of a number of emotional difficulties. If you find that you worry excessively about numerous minor matters or if you have experienced sadness or a loss of interest in activities for a number of weeks consult your physician.

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Health Effects of Insomnia

Although sleeping may not be as critical to our physical health as eating and drinking, insomnia has important negative effects on daily functioning. In addition to feeling tired and fatigued, insomnia affects mental functions including our ability to learn, remember, and concentrate. Excessive daytime sleepiness and decreased alertness from insomnia result in hundreds of thousands of automobile accidents each year. Inability to sleep regularly also affects mood and can lead to depression and other emotional problems.

Despite the distress and impairment from chronic primary insomnia, most people with this problem do not seek formal treatment by their physician. Instead, most people with insomnia try over-the-counter sleep aids. Although some of these medications may provide some temporary relief for a night or two, they are not effective or appropriate for long-term insomnia difficulties. For those few who do consult with their physician, sleep medications called "sedative-hypnotics" are often prescribed. Although these medications are helpful for short-term forms of insomnia, like over the counter medications, they are not appropriate for long-term use and are generally not effective for more chronic forms of insomnia. Many over the counter and prescription sleep medications are habit forming (addictive) if used for more than a few days. People using these medications gradually become tolerant or accustomed to the effects and must eventually increase the dose to get the same result. Stopping the medication leads to withdrawal and "rebound insomnia", in which the sleep disturbance is frequently worse than it was before using the medication. Follow you physician's advice about the use of medication sleep aids.

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Behavioral Treatments for Primary Insomnia

Although secondary insomnia should be addressed by a physician, people suffering from primary insomnia may be able to help themselves. Sleep disorder experts generally agree that a behavioral treatment is the preferred treatment for primary insomnia. The longer you have suffered with insomnia, the more likely it is that the behavioral treatment is the best treatment for you. A comprehensive behavioral treatment for primary insomnia generally includes the following components:

• Sleep hygiene

• Progressive muscle relaxation
• Stimulus control

• Cognitive restructuring
• Sleep restriction and scheduling

A number of well-controlled scientific studies have shown that these behavioral strategies are the most effective approach for chronic primary insomnia.

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Sleep Hygiene

Improving your sleep habits and your sleep environment is the next important treatment step. The following tips will help to improve your sleep quality.

• Avoid stimulants such as caffeine 4-6 hours before bedtime.

• Avoid drinking alcohol 4-6 hours before going to bed.

• Eat a light, easily digestible snack before bed but avoid large meals before bedtime.

• Avoid exercising within 3-4 hours of bedtime.

• Give yourself a quiet period or calm time for at least one or two hours before bed.

• Develop a regular pre-sleep routine.

• Improve the comfort of your bed if needed.

• Make your bedroom a place to sleep. Don't eat, read, drink, smoke, or watch TV while in bed.

• Reduce noise and disruptions.

• Reduce light in the bedroom.

• Maintain a regular temperature.

• If you can't sleep -- don't stay in bed. Get out of bed, move to another room, and return to your bed when you are tired.

• Avoid daytime napping. Daytime napping can alter your body's natural circadian rhythm, making it difficult to get to sleep when you should.

• Get up at the same time every day. Establishing a regular time that you get out of bed will help your body to establish a consistent bed time.

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Relaxation

Being physically relaxed before bed has been shown to improve sleep. For many people, all that is required is to do a relaxing activity for an hour or two before bed (take a bath, watch TV, read a book). Some people, however, have difficulty relaxing before bed. Listed below are three proven methods to help you relax.

• Diaphragmatic breathing: Slow deep breaths from your diaphragm (belly breathing) is a simple and easy way to induce relaxation. Sit comfortably and put a hand on your stomach (between your rib cage and your belly button). Take a slow deep breath and let your stomach expand, pushing your hand out as you breathe in. As you exhale, let your stomach go back down. Let your shoulders and chest relax. Your diaphragm does all the work. A few slow deep breaths should encourage relaxation.

• Visual imagery relaxation: Imagine yourself in peaceful and comfortable situations apart from your daily life where you leave your cares and worries behind. Imagine taking a walk in a beautiful, peaceful environment. For people who can imagine the situations easily, this is a good method of relaxation to assist with sleep difficulties. Pairing this exercise with diaphragmatic breathing can be very relaxing.

• Progressive muscle relaxation: Progressive muscle relaxation is a technique where you tense, hold and then relax your muscles, one muscle group at a time. Some people prefer this form of relaxation because it provides them with something to do as they relax and holds their attention better than the other types of relaxation.

Try these relaxation strategies to see which one works best for you. Also feel free to experiment with when best to do these relaxation strategies. Some people prefer to do these relaxation exercises an hour or two before bed to start their "wind down" period. Others prefer to use these relaxation exercises once they are in bed to promote sleep. With regular practice, you should find that you are able to induce a relaxed state with your body and mind in a relatively short period of time.

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Stimulus Control

Stimulus control breaks the association between "bed" and "sleeplessness". Many people with insomnia have come to associate the bed with being awake and anxious about sleeping instead of being relaxed and asleep. Because of all the time spent in bed not sleeping, you have learned to associate the bed with racing thoughts, agitation, alertness, restlessness, and sleeplessness. Some people notice that it is easier to fall asleep in a living room chair than in bed. Stimulus control treatment helps you re-associate the bed with sleep. There are three simple rules to follow as part of this treatment approach.

• Use your bed/bedroom for sleep and sex only; do not watch TV, listen to the radio, eat, or read in bed. Using your bed for watching TV, eating, reading, discussing family problems, doing leftover work from the office, or other non-sleeping activities, promotes wakefulness and strengthens your associations of your bed as a place to be alert and active. Barring these activities from your bed and bedroom will help promote the concept that "bed" means "sleep."

• Go to bed only when you are tired. People with insomnia often make the mistake of going to bed before they are sufficiently tired. As such, they are not able to sleep, and anxiety and ensuing sleeplessness result. Be sure that you are really feeling sleepy when you go to bed.

• Get out of bed if you can't fall asleep within 20-30 minutes; return to bed only when you feel sleepy. Repeat this step as often as necessary during the night. People with insomnia report that they often experience nights where they lay awake for hours on end "trying to sleep." With mounting anxiety, they look at the clock, calculate time left until morning, and worry about how awful they are bound to feel the next day. Such a pattern of behavior causes the bed to become not a place for restful sleep, but rather, a place of anxiety and frustration. To break this association, remember the "bed is for sleep only" rule. After a short period of not sleeping, you need to get out of the bed and the bedroom. After about 15-30 minutes of doing some quiet activity, you will want to assess whether you are sufficiently tired to return to bed again. Getting out of bed when you think you should be sleeping is probably a major change from what you have done, but this major change is necessary to relearn a natural sleep pattern.

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Cognitive Restructuring: Changing Your Thinking

How we think about sleep can play an important role in how we deal with sleep difficulties. For this reason, an essential part of your sleep treatment involves 1) identifying your thoughts about sleep that tend to make sleeping more difficult and, 2) replacing these thoughts with more helpful thinking. One technique for examining your thinking is to treat your thoughts as scientific hypotheses or ideas. You may have had certain beliefs about your sleep for a long time. At this time you are being asked to consider alternative beliefs and determine which of these beliefs is best supported by the information available to you.

As you pay attention to your thinking about sleep and consider alternatives, you will probably notice two paradoxes to address:

1. The more important it is to get a good night's sleep, the less you sleep. Believing that a poor night's sleep is a disaster only generates more anxiety and worry about your sleep. Challenge this thinking and consider alternative thoughts that reduce the importance of sleeping on the rest of your life (i.e. "It's no big deal", "I'll be a little tired and cranky tomorrow but nothing I can't handle.").
2. The more you try to control your sleep, the less you sleep. Sleep is a natural body response. Telling yourself that you must sleep and trying to force yourself to sleep only puts pressure on you and makes your sleep worse. Focusing on what you can control (sleep habits, schedule, when you are in or out of bed) and letting go of what you can not control will allow falling asleep and staying asleep to happen naturally.

Now that you've become aware of the thoughts that make your sleep worse and have considered alternative ways of thinking, the next step is to practice these new thoughts. This challenging of new thoughts replacing old thoughts will take some effort because our thoughts are typically automatic and we are not accustomed to deliberately noticing them. Scheduling a time each day to examine the ways you think about your sleeping will be helpful in getting you to notice and challenge any maladaptive thought patterns. It is important to do this on a regular basis, as it can be easy to fall into old thought habits if you are not actively monitoring your thoughts. Like any new skill, it is important to practice it. Keep a diary of your sleep-related thoughts and your ideas on how to think differently. Once you have become accustomed to examining your thoughts, you will find that this is an excellent skill that will prove useful for helping you to approach your sleeping difficulties differently as well as for learning a healthier approach to other life problems as well.                                        

Think of ways you could view your situation differently. Your sleep may improve greatly by challenging beliefs that are not helpful to you and substituting these beliefs with healthier alternatives.

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Sleep Restriction and Scheduling

Sleep restriction regulates your bedtime and wake time in an effort to consolidate your sleep into a shorter and ultimately more restful time in bed. This approach is based on the observation that people with insomnia often try to compensate for their disturbed sleep by sleeping late in the morning, taking daytime naps, and/or spending excessive amounts of time in bed. While catching up on sleep through naps or sleeping-in mornings may be helpful for coping with temporary insomnia, on a long-term basis these strategies actually make insomnia worse by promoting an inconsistent and irregular sleep-wake rhythm.

To restore a regular sleep-wake schedule and increase the likelihood of falling asleep soon after going to bed, do the following:

• Set a consistent wake up time that does not change, not even on weekends or holidays.  Resist the urge to stay in bed longer to catch up on sleep.  A consistent wake-up time will eventually reset your internal sleep-wake cycle and improve your sleep.
• Do not nap.  Napping during the day increases the chances that you will have difficulty falling asleep.
• Restrict your time spent in bed to the amount of time that you actually sleep.  This is the most difficult advice for people with insomnia to follow, but delaying your time to bed until you are experiencing mild sleep deprivation promotes falling asleep faster.  You are getting the same amount of sleep as before, just consolidated into one period of sleep.  For example, if you find that you generally get only about 6 hours of sleep a night, then don't go to bed until 6 hours before your wake up time (always give yourself at least 5 hours in bed each night).   After a few nights of sleeping well on this schedule, gradually make your time to bed earlier until you are getting a full nights sleep.

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For More Information...

Sleep information from the National Heart, Lung and Blood Institute: www.nhlbi.nih.gov/health/public/sleep

The National Sleep Foundation (NSF) is an independent nonprofit organization dedicated to improving public health and safety by achieving public understanding of sleep and sleep disorders, and by supporting public education, sleep-related research, and advocacy.   www.sleepfoundation.org

A wealth of information and links on sleep, sleep disorders, sleep activism, sleep-related events and much more!  www.stanford.edu/~dement/index.html

A CNN article on the importance of getting enough sleep: http://www.cnn.com/2000/CAREER/trends/12/04/napping/index.html

Relief From Insomnia: Getting The Sleep of Your Dreams by Charles M. Morin, 1996

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