Insomnia Awake Sleep

Sleep…..or rather the lack of it! – Insomnia.

Sleep – A self-help approach to insomnia

Insomnia is a disorder in which there is an inability to fall asleep or to stay asleep as long as desired. (NOT Sleep Deprivation where one might be kept awake by noise etc.)

While the term is sometimes used to describe a disorder demonstrated by polysomnographic (sleep studies) evidence of disturbed sleep, it is often defined as a “yes” to either of the questions:-

 “Do you experience difficulty sleeping?”

or

“Do you have difficulty falling or staying asleep?

 

Why do we need sleep?

When asked, after 50 years of research, what he knew about the reason people sleep, William Dement, founder of Stanford University’s Sleep Research Center, answered,

“As far as I know, the only reason we need to sleep that is really, really solid is because we get sleepy.”

But we do need sleep as do ALL animals and lack of it can have deleterious effects.

Normal sleep is almost certainly not what you imagine – even great sleepers will wake several times in the night to use the bathroom, turn over etc. (when was the last time you heard of a good sleeper falling out of bed? They don’t, instead they have a brief period of wakefulness that even they can’t remember and turn over safely! – our problem as insomniacs is that we have longer periods of wakefulness thus remember them more and even if we do sleep in-between these awakenings we tend to merge these memories into a prolonged period, forgetting the bits of sleep in between!)

The stages of sleep cycle around Non Rapid Eye Movement (3-4 stages) sleep (NREM) and Rapid Eye Movement Sleep (REM)

Sleep proceeds in cycles of REM and NREM, usually four or five of them per night, the order normally being N1 → N2 → N3/4(SWS) → N2 → REM. There is a greater amount of deep sleep (stage N3/4) earlier in the night, while the proportion of REM sleep increases in the two cycles just before natural awakening.

NREM stage 1: (alpha wave activity.) This is a stage between sleep and wakefulness. The muscles are active, and the eyes roll slowly, opening and closing moderately.

NREM stage 2: (theta wave activity) In this stage, it gradually becomes harder to awaken the sleeper

NREM stage 3/4: (delta wave activity. Stage 3 <50%, Stage 4 > 50%) This stage is called slow-wave sleep (SWS) The sleeper is less responsive to the environment; many environmental stimuli no longer produce any reactions. (Stage 3 is the transition between the lighter sleep of stage 2 and the deeper sleep of stage 4)

REM: The sleeper now enters rapid eye movement (REM) where most muscles are paralyzed and it is harder to arouse than at any other sleep stage. An adult reaches REM approximately every 90 minutes, with the latter half of sleep being more dominated by this stage. REM sleep occurs as a person returns to stage 1 from a deep sleep. The function of REM sleep is uncertain but a lack of it will impair the ability to learn complex tasks. (Dreams almost always occur during REM.)

TREATMENTS

Medication treatments include over-the-counter (OTC), hormonal and prescription drugs. OTC and hormonal therapies are widely available but have little to no effect on chronic insomnia. The active ingredient in most over-the-counter sleep medications is diphenhydramine (e.g. Nytol ® and common cold /allergy medications that also produces drowsiness.) It can help occasional sleep difficulties (e.g. acute insomnia) but is not effective for chronic insomnia. Melatonin, a natural hormone, is also used to promote sleep but has very limited effects on chronic insomnia. Prescription sleep medications (sedative-hypnotics) are commonly used to treat insomnia. These medications are sometimes effective in the SHORT term but have been shown to be less effective than behavioural treatments, particularly over the long term. Prescription sleep medications also have a number of problems. Most of these medications are dependence-producing and can be addictive. Over time, you may need to take more of the medication to get the same effect, and stopping the medication can ‘rebound’ making the insomnia worse. In addition, sleep medications tend to cause drowsiness and difficulty waking in the morning, can affect concentration, memory, and reaction times and especially in the elderly can lead to increased falls and their sometimes serious consequences. For all of these reasons, most doctors and sleep experts do not consider prescription sleep medications to be the preferred treatment for chronic insomnia.

Behavioural therapy is considered by the medical and scientific community to be an effective treatment for primary insomnia. There are several studies to indicate that cognitive-behavioural treatment of insomnia is effective and includes the following components:

  • Cognitive restructuring: If you try too hard to sleep or worry about how tired you will be the next day you will find it MORE difficult to sleep, BUT by not trying you still sleep! (A technique of ‘eyes open’ can be all that is needed – try to stay awake and paradoxically you will often find yourself nodding off!!) By changing your thoughts and beliefs about sleep, particularly unrealistic sleep expectations, you can reduce the pressure to get a good night’s sleep and make it easier to fall asleep.
  • Sleep hygiene: Certain lifestyle and environmental factors can disrupt normal sleep. Eliminating or reducing disruptions to normal sleep (e.g. loud noises, temperature changes) or activities that negatively affect sleep (e.g. drinking caffeine, smoking cigarettes, engaging in excessive activity or exercise before bed) can improve the quality and quantity of the sleep you get.
  • Relaxation training: Tension and anxiety are often associated with insomnia. The use of relaxation techniques before bedtime can help to reduce tension and help the body fall asleep more easily.
  • Stimulus control: The “stimulus” or signal to fall asleep should be lying down in bed. Unfortunately, over months and years of lying in bed awake, people with insomnia have learned that lying in bed is a trigger for being awake, not for falling asleep. By using the bed primarily for sleep and getting out of the bed if sleep does not occur after a short time, the bed and bedroom can again become the signal for your body to fall asleep.
  • Sleep scheduling: As sleep difficulties arise, many people try even harder to “catch up” on missed sleep by sleeping later, taking naps during the day, or going to bed early. Unfortunately, these efforts only serve to further disrupt the normal sleep-wake cycle and result in a worsening of the insomnia. By setting a consistent wake-up time and delaying time to bed, a regular sleep pattern can be re-established. Delaying time to bed also makes you more ready to fall asleep when you finally go to bed. As sleep improves, the amount of time in bed is then increased gradually until a normal sleep pattern is restored.

 

COGNITIVE RESTRUCTURING

Cognitive restructuring: Although some problems are resolved by trying harder to fix them, trying harder to sleep can make it more difficult to do so. By changing your thoughts and beliefs about sleep, particularly unrealistic sleep expectations, you can reduce the pressure to get a good night’s sleep and make it easier to fall asleep. The diary page below can help those particularly with ruminating thoughts and anxiety at night which interferes with getting off to sleep or waking in the middle of the night with troublesome and alerting thoughts.

The idea is to deal with the ‘Bad Stuff’ as well as appreciating the ‘Good Stuff’ we have experienced throughout the day. The ‘To Do’ list is to help us ‘park’ some thoughts and anxieties to be dealt with the next day – if you keep this with a pen beside the bed then this could be added to if necessary – If a task is ESSENTIAL (E)  it might be best to do this before bed or prioritise this. Otherwise the ‘Desirable’(D) and ‘Optional’ (O) tasks can be recorded as aide memoirs for tomorrow. The ‘Constructive Worry’ section can help turn around negatives and make them more positive. When we have problems, we tend to use our problem solving skills to make our lives better and relieve ourselves of anxiety. It is not surprising that some of us may use our problem solving skills at the wrong times and places, namely bedtime. We may think about a problem, trying to solve it, but unfortunately, the anxiety caused by the problem will keep us awake. Constructive worry is a method for managing the tendency to worry during that quiet time when sleep is supposed to be taking over. During the early evening (at least 2 hours before bed) take about fifteen minutes to do this exercise. Here’s how it is done:

  1. Write down a problem facing you that has the greatest chance of keeping you awake at bedtime, and list them in the “Concerns” column.
  2. Think of the next step that might help you fix it. Write it down in the “Solutions” column. This need not be the final solution to the problem since most problems have to be solved by taking more than one step. You will be doing this again tomorrow night and the night after until you finally get to the best solution.
  • If you know how to fix the problem completely, then write that down.
  • If you decide that this is not really a big problem, and you will just deal with it when the time comes, then write that down.
  • If you decide that you simply do not know what to do about it, and need to ask someone to help you, write that down.
  • If you decide that it is a problem, but there seems to be no good solution at all, and that you will just have to live with it, write that down, with a note to yourself that maybe sometime soon you or someone you speak with will give you a clue that will lead you to a solution.

Finally note down what went well and plan for more of this the next day. When completing the next day’s diary check off the to-do list etc.

You may find this sleep diary useful:-

Sleep Diary

 

STIMULUS CONTROL

Since anxiety about not sleeping perpetuates insomnia the main goal of stimulus control is the reduction of the anxiety or conditioned arousal we may feel when going to bed. If conditioning has occurred so that getting ready for bed or getting into bed arouses negative associations and increases arousal then it will be very difficult to fall or stay asleep. These negative associations can result in suddenly feeling wide awake upon getting into bed or when trying to fall back asleep after waking during the night. Stimulus control can be helpful in these situations. It is designed to break up these negative associations and instead develop positive associations between pre-sleep rituals and the sleep environment, and feeling sleepy. Pavlov’s experiment with dogs involved a bell ringing just before their food was given them. After a short period he noted that the dogs would salivate in anticipation when the bell was rung even if no food was given. So it is with sleep. If our sleep pattern is disrupted, even for a relatively short period through illness or stressful events etc. the negative associations can become ‘ingrained’ and the short term ‘acute’ insomnia become ‘chronic’ – long lasting. The set of instructions aim to re-associate the bed/bedroom with sleep and to re-establish a consistent sleep schedule. All waking activities should be done in a waking space and NOT in the bedroom such that the bed/bedroom is associated ONLY with sleep and sleepiness. We should use the bed/bedroom only for sleep and sex , get into bed ONLY when sleepy and get up after 15 minutes when unable to sleep. Rise at the SAME time each morning and avoid all daytime naps.

The stimulus control instructions are designed to re-associate bedtime with the rapid onset of sleep and to establish a regular sleep-wake schedule that is consistent with the circadian (24 hour) sleep/wake cycle. The instructions are:

  1. Only go to bed when sleepy. Thoughts about how you don’t feel like sleeping, how bad it will be tomorrow if you don’t sleep tonight, going over everything you have to do in the morning and so on just create arousal and make it harder to fall asleep.
  2. If after about 15 minutes you are unable to fall asleep or awaken and find it difficult to fall back asleep, leave the bed and go to another room and engage in a relaxing activity such as some light reading or using a relaxation technique until you do feel drowsy. Then return to bed and repeat as often as necessary until you do fall asleep. It is important to not watch the clock while doing this. It is your subjective estimate of time that is important.
  3. Use the bed only for sleep and sexual activity. Do not engage in sleep-incompatible activity in bed such as eating snacks, watching TV etc. These activities will result in arousal and make it difficult to fall asleep. Repeatedly engaging in these kinds of activities helps condition arousal to the bed environment when instead you want to condition a feeling of relaxation to being in bed.
  4. Keep a regular morning rise time no matter how much sleep you got the night before. This will help regularise the circadian (24 hour) schedule and if you don’t sleep well one night, the drive to sleep will be higher the following night but only if you don’t dissipate it with low quality, light morning sleep by staying in bed later than planned.
  5. Avoid napping. This prevents reducing sleep drive earlier in the day that can make it harder to fall asleep at night.

Evidence shows that you might see that your sleep pattern to alters so  that – Week 1-2 worse, Week 3-4 back to baseline, Week 5 – better.

 

SLEEP HYGEINE

This adds to the stimulus control model and below are some do’s and don’ts – often advice given is wrong and doesn’t work, however all these interventions have been shown to have some benefit. Some individuals may get more from some than others.

  • Don’t drink caffeine after 4pm (t 1/2 = 6 hours – so half your caffeine load will still be in the system 6 hours later, 1/4 in 12 hours etc. Some of us may be slow metabolisers and thus the t1/2 may be even longer.) NO Coffee, Tea (inc. Green tea), Cola or even Hot Chocolate & Coca which may be sold as bed time drinks but contain caffeine! Caffeine is a stimulant for the central nervous system and will help keep you awake making it harder to get to sleep, sleep for a shorter time, shortens the amount of NREM stage 3/4, (deep sleep) you have and gives you more REM /’dream sleep’ at first, but less overall. Both are important for proper rest. Other physiological effects of caffeine include making your heart beat faster, you urinate more,  your body temperature rises (see below) and your digestive system produces more acid. As a rule of thumb : 1 cup of coffee = 1 Red Bull = 2 cups of tea = 4 Cola (2 in some sugar free versions) It’s not just drinks but some foods too, although not often listed on the packs.

 

  • Do have a hot bath. The circadian rhythm of core body temperature is a well-documented physiological phenomenon. Already in 1842, Gierse had shown that his own oral temperature revealed a maximum temperature in the early evening and a minimum in the early morning hours with a maximum-minimum range of 0.9°C. It is thought this drop in temperature helps the induction of sleep so by increasing this drop by first raising body temperature with a hot bath is helpful. However it is recommended you bathe 2 hours before going to bed to benefit maximally.

 

  • Don’t stimulate your brain IN bed. For the insomniac bed should be for sleeping and sex only! (No reading, radio, TV or even chatting!!) There seems to be little or no evidence that electronic devices in themselves affect sleep if used before going to bed. The worry was that bright lights help alert us. (The ‘blue light’ in particular – remember in the past when at night walking down the street you would notice the blue flicker of TVs in the neighbours houses?! New TVs are less bright and easier to dim as well as reducing the blue, highlighting the red and have a more soothing light and just sitting further from the TV will diminish the light intensity hitting the retina. (The intensity of light observed from a source of constant intrinsic luminosity falls off as the square of the distance from the object. This is known as the inverse square law for light intensity. )

 

  • Do exercise before bed. However not just before retiring to bed as this will alert your brain. It has been shown that even 30 minutes of brisk walking 2 hours before retiring to bed can help improve sleep, but NOT right away – it can take up to 3 months and is not related to the exercise itself, rather the way the brain’s sleep centre responds to this over time. Once your brain is ‘set’ missing an exercise session keeps this sleep benefit for a time, however will probably need ‘topping-up’ regularly.

 

  • Don’t stimulate your brain with nicotine or other stimulants. Smoking is bad for your general health and its stimulant effect can keep your brain ‘buzzing’.

 

  • Do make your bedroom ‘sleep inducing’ comfortable and welcoming, so tidy-up and make the bed every morning! The bedroom should have no distractions*, be quiet, dark and at a comfortable temperature. 18C, cooler than usual room temperature is ideal so your body can lose heat and help induce sleep much like the hot bath above. When re-establishing your sleep you should so far as is possible keep the bedroom for sleep only (and sex) so that when you enter the bedroom you are automatically tuned into ‘sleep mode’. (If possible don’t even undress/dress, do make-up or grooming and certainly don’t use as a home office etc.)

 

* No TV, Radio or reading of books etc.. Only use a silent alarm clock (without ticking) with a light that turns off automatically after a few minutes eg. a smart phone so long as it’s not used in the bedroom for alerting activities such as surfing the internet or checking emails – be strict with yourself! Even if you wake early you should set the alarm as we hope to need this in future and the avoidance of the anxiety that we might sleep through will be avoided)

 

  • Don’t drink more than a little alcohol in the evening. (some say none is best!) There is some evidence that quite low doses of alcohol (A small beer or glass of wine) can possibly be sleep-promoting by increasing total sleep time and reducing awakenings during the night. The sleep-promoting benefits of alcohol however rapidly reverse with more than this. Also there is some individual variation as previous experience with alcohol also determines whether or not alcohol is a “sleep promoter” or “sleep disrupter. Studies have shown that inexperienced drinkers become sedated while experienced drinkers are stimulated following alcohol consumption. So in insomniacs small doses of alcohol may improve sleep maintenance at first but one you become ‘experienced’ the effect wears off! Even if alcohol were to help you in the short term it is unlikely this will last for long. Alcohol interferes with the normal sleep process. When you drink a lot of alcohol close to bedtime, you can go straight into NREM stage 3/4 the deep sleep, missing out on the REM – the dream sleep. Deep sleep is when the body restores itself, and alcohol can interfere with this. As the alcohol starts to wear off, your body can come out of deep sleep and back into REM sleep, which is much easier to wake from. That’s why you often wake up after just a few hours sleep when you’ve been drinking. In the course of a night you usually have six to seven cycles of REM sleep, which leaves you feeling refreshed. However, if you’ve been drinking you’ll typically have only one to two, meaning you can wake feeling exhausted. Also if you drink a lot, you may have to get up in the night to go to the toilet and it’s not just the liquid you’ve drunk that you’ll be getting rid of. Alcohol is a diuretic, which means it encourages the body to lose even more fluid making you dehydrated waking with that dry mouth feeling but with a full bladder! Drinking can also make you snore loudly. It relaxes the muscles in your body, which means the tissue in your throat, mouth and nose can stop air flowing smoothly, and is more likely to vibrate. So, all in all alcohol can equal a fitful night’s sleep. However if you are drinking alcohol, try to avoid it too close to bedtime. Give your body time to process the alcohol you’ve drunk before you try to sleep – on average it takes an hour to process one unit, but this can vary widely from person to person.

 

  • Do Anchor your waking time. Since this is the only aspect of our sleep cycle we can control effectively we need to set this and get it ‘anchored’ so it doesn’t move – resetting your sleep pattern will occur around this. Whilst this resetting is becoming established you will need to rise at this time EVERY day – week-ends, holidays and even your birthday! And even if you haven’t had enough rest. Don’t judge your level of tiredness for at least the first hour of the day – even great sleepers will feel a bit sleepy when the alarm goes off!

 

  • Don’t nod off or nap in the day. Even a ‘power-nap’ can alert us for hours (there ARE other ways – see below**) so ‘nodding-off’ in front of the TV in the evening is the worst! (get your family or significant other to prod you rather than get you a blanket – it really is the kinder thing to do!) Fatigue drives somnolence, it’s our sleep fuel! As we go through the day we accumulate the fatigue we need to feel sleepy – naps obviously reduce this and delay the time we reach our own individual threshold of when we feel sleepy. Typically we may need 17 hours of waking time to sleep for 7 hours. If we anchor our getting up time eventually we will start to feel tired at the same time in the evening (all other things being equal) Until then only go to bed when sleepy! (NB – you may have forgotten what that really feels like – see the ‘eyes open’ exercises.) During the day do things to keep you awake!

**Bright light, activity and fresh air will ‘energise’ and help wakefulness in the daytime. Use Caffeine in the morning to ‘get you going’ and 30-60 mins before you hit your ‘wall’ in the daytime – typically after lunch – BUT before must be before 4 pm!  Chewing can also help keep you awake (as opposed to eating!) and some gum even has caffeine in it!

 

RELAXATION TRAINING

Visualisation

1          Creating Your Destination.

The first step in creating a good visualisation is to imagine a very peaceful and tranquil place; one where falling asleep and staying asleep is simply the most natural thing in the world. It’s a place where, in spite of any efforts you make to try to stay awake, you just can’t. You may remember a place like that from your past experiences, or you can make one up. It could be…

  • a lakeside cabin,
  • a hammock on a tropical beach,
  • a soft, fluffy bed in a luxurious room,
  • a tent on a mountaintop,

There’s no right answer, the main thing is that the image feels right to you. Once you have settled on that image, make it as real as you can, using all of your senses. Imagine the colour of the lake, the smell of the water, the sound of birds singing or water lapping up against the shore, the slow swaying of the hammock or the soft warmth of the pillow……just keep adding details until you have the ultimate sleepy experience.

Now you might be thinking you’re done, but you are far from done. A peaceful, sleepy image is nice, but usually it’s not enough.

If you are tossing and turning at night with thoughts or worries circling around in your brain, and you call up this peaceful visualisation with the lake and the hammock and so on… your brain might say “hmm, that’s  nice,” but then will immediately revert back to its previous wanderings… it just won’t focus long enough for the image to do anything for you.

Then, of course, you’ll try harder to force yourself to concentrate on your visualisation, and that’s why we need the ‘Journey’ part.

2          Creating Your Journey.

Your Journey is the method by which you reach your Destination. The Journey part of your visualisation is not peaceful nor tranquil nor necessarily even pleasant. It is a hard, difficult process, with lots of anguish, monotony and discomfort. It can be a slow, arduous trek across cold, frozen tundra… an agonising hike up a rocky peak… a slow walk up a slippery hill in the rain… an exhausting rowing boat trip across a lake at night (with you at the oars)… It can be a breathless trudge up eight flights of stairs in a dark, decrepit old castle… a long cross-global trip running for aeroplanes in dreary airports… a tiresome bumpy train ride through endless industrial cities… It can be whatever you want… as long as it resonates with you and you understand the nature of the Journey.

The Nature of the Journey

The Journey is the price we must pay for getting to our desired destination. It works in both a literal and symbolic sense.

The Journey is the method by which you exhaust yourself both physically and mentally. The Journey makes you very tired. To be really effective, it should cause you some type of discomfort, frustration and hardship in the process.

This is what engages your brain and distracts it from its typical night-time thinking. If you think of the last movie you saw, you understand that it was the conflict, difficulties and anguish that really sucked you into it, even if it was a comedy. That’s the Journey part.

It’s essential for your own night-time “movie” to be really engaging to your brain.

3          Fighting off sleep.

To be really effective, your journey should include a couple of scenes where you are fighting sleepiness or tiredness. In other words, you must stay awake to complete the journey, but it’s a real struggle. This is a sort of reverse psychology that often proves useful in everyday life. To deprive yourself of something you want usually intensifies the desire. Deliberately depriving yourself (in your fantasy) of sleep by forcing yourself to stay awake and alert helps to increase the tendency to let go and give into the feeling of drifting off…

4         Dynamic activity.

Your visualisation should also include a steady, rhythmic, tedious activity, such as… walking, rowing, paddling, swimming, riding in a train or bus, climbing stairs or trudging up a steep hill etc.

5          Struggle.

You should also put in a struggle with the elements, whether it’s cold, wind, rain, fog or snow.

Finally, having to continue on in your journey despite exhaustion, hardship, discomfort and emotional anguish (“I’ll never get there… this is taking forever,” etc.) also seems to be an important factor.

6          Finally There.

When you reach your destination, you are so relieved just to be there. You can collapse into a warm bath, a warm bed, a waiting hammock, a soft arm chair etc.and if you want, you can also add on to your Destination various fringe benefits…

You can add magical qualities to your Destination….

You can watch as all your worries and care float away like leaves in the wind. You can lie under a big machine that sucks out all your problems and then injects you with a tranquilizing elixir. Whatever helps!

 

Progressive Muscular Relaxation

Progressive muscle relaxation (PMR) is a deep relaxation technique that has been effectively used to control stress and anxiety, relieve insomnia, and reduce symptoms of certain types of chronic pain. Progressive muscle relaxation is based upon the simple practice of tensing, or tightening, one muscle group at a time followed by a relaxation phase with release of the tension. The technique of progressive muscle relaxation was described by Edmund Jacobson in the 1930s and is based upon his premise that mental calmness is a natural result of physical relaxation. Progressive muscle relaxation can be learned by nearly anyone and requires only ten to 20 minutes per day to practice. There is evidence that this along with other relaxation therapies can aid sleep. Most practitioners recommend tensing and relaxing the muscle groups one at a time in a specific order, generally beginning with the lower extremities and ending with the face, abdomen, and chest. You can practice this technique seated or lying down, and you should try to practice with comfortable clothing on, and in a quiet place free of all distractions. Here is how PMR works;

  1. While inhaling, contract one muscle group (for example your upper thighs) for five to ten seconds, then exhale and suddenly release the tension in that muscle group.
  2. Give yourself ten to 20 seconds to relax, then move on to the next muscle group (for example your buttocks).
  3. While releasing the tension, try to focus on the changes you feel when the muscle group is relaxed. Imagery may be helpful in conjunction with the release of tension, such as imagining that stressful feelings are flowing out of your body as you relax each muscle group.
  4. Gradually work your way up the body contracting and relaxing muscle groups.

People who suffer from insomnia often report that practising progressive muscle relaxation at night helps them fall asleep. Progressive muscle relaxation is also an excellent tool to help learn about the body and the signals it may bet telling you. With practice and time, you can learn to accurately identify and diminish the signs and signals of stress and tension in your body.

 

SLEEP SCHEDULING

Sleep efficiency is the time one is actually asleep in bed, compared to how long in bed overall (%)

That is if you go to bed at midnight, get up at 8am but sleep only 6 hours the sleep efficiency is 75% (include time taken to get off to sleep and time awake) To help re-set our sleep we need >90%. To do this we first ‘compress’ what sleep we are getting into as short a period as possible. Since the only time we can fix is the waking/getting-up time we ‘anchor’ this at the earliest time we need to get up during the week and stick with it – even on weekends and holidays! – Don’t worry once re-set you will be able to have occasional lie-ins without breaking the rhythm of your new sleep schedule.

One way of thinking about this is by imagining that we need to have our ‘fatigue tank’ full before we are sleepy enough. Remember that ‘sleepiness’ and ‘tiredness’ can be subtly different – We may habitually feel tired at a certain time ‘it’s late, therefore I feel tired’ and many insomniacs who go to bed early to try and catch up on sleep have actually forgotten what ‘really sleepy’ feels like! (To get a ‘reminder’ of this try the ‘eyes open’ technique above, for one night.) If we have a ‘poor’ sleep schedule and habitually go to bed earlier than when our fatigue tank is full we may drift off but when the fatigue levels drop we may wake and then have to wait until our fatigue levels rise allowing further sleep when our ‘fatigue tank’ is refilled.

The chart below should be copied and filled in every morning  – over the next two weeks establish what you do now and calculate your ‘threshold time’. When you cross this threshold, it should be time for sleeping right through the night. Once you have decided on your anchored rising time you can calculate back using your average sleep time to restrict your time in bed to this. It is important whilst resetting your sleep to follow a 7-night per week schedule!

 

e.g. If you on average go to bed at 10:15pm and decide on a Rising time of 7:00am and you calculate on the chars below:

Average sleep time (A) = 6hr 30min = 390min

Total time in bed (B) = 8hr 45min = 525min

Sleep efficiency (A/B=C x 100%)      = 390 x 100/525 = 74% – Thus ¾ of time in bed is asleep and ¼ awake. We need >90% to reset our sleep!

Threshold time  = 12:30am     (That is 6hr 30min = 390mins before the Rising time of 7:00am)

Sleep Chart

You will need a clock or watch and a pen or pencil to record the minutes you have slept, however if like me you have difficulty converting Hours to minutes this may help! – Sleep Hours to Minutes

 

WHY Sleep Limitation and Sleep Schedules Work

The simplified science behind the importance of a strict sleep schedule is this: You need a certain amount of AWAKE time each day in order to sleep at night. That is time to fill our ‘fatigue tank’!  This is a reversal of how we usually think. Instead of thinking how much SLEEP you need, think of how much AWAKE time you need in order to fall asleep again.

If this time is not long enough, you’re your fatigue tank will not be full enough and you will not be able to fall asleep. Your goal is to keep this time awake as long as it needs to be.

So if you get up at 7:00, and you need at least 17 hours of awake time in order to sleep again, then you will not fall sleep until midnight.

If you keep pushing your wake-up time later and later, in an effort to get more sleep (because you can’t fall asleep until hours after you get into bed – if at all), then you will also be pushing the end of your awake time further and further ahead.

Look at it this way: your awake time is simply the time between your morning wake-up time and your night-time fall-asleep time.

Your AWAKE time has nothing to do with how much sleep you actually got.

So by sleeping later in your effort to get more sleep, you are continually pushing your AWAKE time to end later and later… Causing you to stay awake longer and longer at night… and if you sleep later in the morning to “catch up”… it becomes a cycle that shifts further and further into that 24-hour cycle that we call a day.

If you decide to try limiting your time in bed in the beginning, or if you never needed that much sleep even when you didn’t have insomnia, use the left columns to determine wake-up times.

If you decide to stick with a longer sleep schedule, use the right columns. While this chart is simple, sometimes it helps to have something visual and on paper.

Note: If you work odd hours, with a constantly changing schedule, you will naturally have more difficulty establishing a consistent sleep schedule, but try the best you can.

Exercise to tryEYES OPEN

Do your normal routine and then try to stay awake with your EYES OPEN, if you fall to sleep and awake try to stay awake again with eyes open. (This can help retune us to experiencing what sleepiness feels like.) That is do your normal pre-bed ritual, go to bed normally but keep your eyes open and if you fall asleep and wake later do the same all through the night but keeping your normal rising time. This is usually a ‘no lose’ exercise – if you try NOT to go to sleep but do drift off, you win and if you stay awake you may well be surprised how actually you do manage OK the next day better than your anxiety may have predicted – the normal rhythm of the day with sunlight, washing, eating etc. and the distractions of daily living will awaken you!

Exercise to try – THE 15 MINUTE RULE

The 15min rule – get up and do something enjoyable*until feel tired.

If you don’t TRY to get to sleep, you still sleep! Stopping trying can sometimes be all that is needed to abort insomnia! This helps to ‘quiet the mind’ and can help us to relearn what ‘sleepiness’ feels like.

*Note some ‘old fashioned’ approaches suggested “do something boring”!

However if enjoyable will be:-

  • Less anxious
  • Less draining – feel better next day (even if tired!)
  • Better quality of life – insomnia is not a punishment!

From the BBC We often worry about lying awake in the middle of the night – but it could be good for you. A growing body of evidence from both science and history suggests that the eight-hour sleep may be unnatural. In the early 1990s, psychiatrist Thomas Wehr conducted an experiment in which a group of people were plunged into darkness for 14 hours every day for a month.  It took some time for their sleep to regulate but by the fourth week the subjects had settled into a very distinct sleeping pattern. They slept first for four hours then woke for one or two hours before falling into a second four-hour sleep. Though sleep scientists were impressed by the study, among the general public the idea that we must sleep for eight consecutive hours persists. Margaret Thatcher was famously said to get by on four hours sleep a night, that put her in a group of just 1% of the population. In 2001, historian Roger Ekirch of Virginia Tech published a seminal paper, drawn from 16 years of research, revealing a wealth of historical evidence that humans used to sleep in two distinct chunks. His book At Day’s Close: Night in Times Past, published four years later, unearths more than 500 references to a segmented sleeping pattern – in diaries, court records, medical books and literature, from Homer’s Odyssey to an anthropological account of modern tribes in Nigeria.  Much like the experience of Wehr’s subjects, these references describe a first sleep which began about two hours after dusk, followed by waking period of one or two hours and then a second sleep. “It’s not just the number of references – it is the way they refer to it, as if it was common knowledge,” Ekirch says. During this waking period people were quite active. They often got up, went to the toilet or smoked tobacco and some even visited neighbours. Most people stayed in bed, read, wrote and often prayed. Countless prayer manuals from the late 15th Century offered special prayers for the hours in between sleeps. And these hours weren’t entirely solitary – people often chatted to bed-fellows or had sex. A doctor’s manual from 16th Century France even advised couples that the best time to conceive was not at the end of a long day’s labour but “after the first sleep”, when “they have more enjoyment” and “do it better”. Ekirch found that references to the first and second sleep started to disappear during the late 17th Century. This started among the urban upper classes in northern Europe and over the course of the next 200 years filtered down to the rest of Western society. By the 1920s the idea of a first and second sleep had receded entirely from our social consciousness. He attributes the initial shift to improvements in street lighting, domestic lighting and a surge in coffee houses – which were sometimes open all night. As the night became a place for legitimate activity and as that activity increased, the length of time people could dedicate to rest dwindled.

When segmented sleep was the norm

  • “He knew this, even in the horror with which he started from his first sleep, and threw up the window to dispel it by the presence of some object, beyond the room, which had not been, as it were, the witness of his dream.” Charles Dickens, Barnaby Rudge (1840)
  • “Don Quixote followed nature, and being satisfied with his first sleep, did not solicit more. As for Sancho, he never wanted a second, for the first lasted him from night to morning.” Miguel Cervantes, Don Quixote (1615)
  • “And at the wakening of your first sleepe You shall have a hott drinke made, And at the wakening of your next sleepe Your sorrowes will have a slake.” Early English ballad, Old Robin of Portingale
  • The Tiv tribe in Nigeria employ the terms “first sleep” and “second sleep” to refer to specific periods of the night

In his book, Evening’s Empire, historian Craig Koslofsky puts forward an account of how this happened. “Associations with night before the 17th Century were not good,” he says. The night was a place populated by people of disrepute – criminals, prostitutes and drunks. “Even the wealthy, who could afford candlelight, had better things to spend their money on. There was no prestige or social value associated with staying up all night.” That changed in the wake of the Reformation and the counter-Reformation. Protestants and Catholics became accustomed to holding secret services at night, during periods of persecution. If earlier the night had belonged to reprobates, now respectable people became accustomed to exploiting the hours of darkness. This trend migrated to the social sphere too, but only for those who could afford to live by candlelight. With the advent of street lighting, however, socialising at night began to filter down through the classes. In 1667, Paris became the first city in the world to light its streets, using wax candles in glass lamps. It was followed by Lille in the same year and Amsterdam two years later, where a much more efficient oil-powered lamp was developed. London didn’t join their ranks until 1684 but by the end of the century, more than 50 of Europe’s major towns and cities were lit at night.  Night became fashionable and spending hours lying in bed was considered a waste of time. “People were becoming increasingly time-conscious and sensitive to efficiency, certainly before the 19th Century,” says Roger Ekirch. “But the industrial revolution intensified that attitude by leaps and bounds.” Strong evidence of this shifting attitude is contained in a medical journal from 1829 which urged parents to force their children out of a pattern of first and second sleep.  “If no disease or accident there intervene, they will need no further repose than that obtained in their first sleep, which custom will have caused to terminate by itself just at the usual hour. “And then, if they turn upon their ear to take a second nap, they will be taught to look upon it as an intemperance not at all redounding to their credit.” Today, most people seem to have adapted quite well to the eight-hour sleep, but Ekirch believes many sleeping problems may have roots in the human body’s natural preference for segmented sleep as well as the ubiquity of artificial light. This could be the root of a condition called sleep maintenance insomnia, where people wake during the night and have trouble getting back to sleep, he suggests. The condition first appears in literature at the end of the 19th Century, at the same time as accounts of segmented sleep disappear. “For most of evolution we slept a certain way,” says sleep psychologist Gregg Jacobs. “Waking up during the night is part of normal human physiology.” The idea that we must sleep in a consolidated block could be damaging, he says, if it makes people who wake up at night anxious, as this anxiety can itself prohibit sleeps and is likely to seep into waking life too. Russell Foster, a professor of circadian [body clock] neuroscience at Oxford, shares this point of view. “Many people wake up at night and panic,” he says. “I tell them that what they are experiencing is a throwback to the bi-modal sleep pattern.”

So the next time you wake up in the middle of the night, think of your pre-industrial ancestors and relax. Lying awake could be good for you!

2 comments

  1. Unfortunately insomnia and sleep patterns can be habit forming. So a trigger many years before may lead to long term issues even when the initial problem has long gone. Therefore more effort and input is needed to change an ingrained habit than might be imagined. Good luck!

    Like

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