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Insomnia and Sleep Problems

Introduction

 

It seems like life is getting more and more stressful all the time, with more and more demands for work, school, family and home responsibilities. As a result, we often cut back on the very things that are the most important, like getting enough sleep...

 

But getting enough sleep is essential. Studies show that getting enough sleep is essential for maintaining proper health. Furthermore, lack of sleep can cause numerous health and related problems. It is a risk factor for mental health problems such as depression, and can also contribute to cardiovascular and other conditions. Being sleep deprived also significantly increases your risk of being in a motor vehicle accident.

 

How much sleep should someone get? Every person is unique, and there is a wide range of what is considered "normal" sleep. The usual range is that some need as little as 6 hrs, whereas others need 10 or more. The average person needs about 8 hrs of sleep per night (Kryger, 2005).

 

How common are sleep problems?

 

About 30% of adults report troubles falling asleep, staying asleep or having unrefreshing (nonrestorative) sleep. About 10% of the population have sleep problems so severe that it causes problems or distress during the daytime.


Common Factors that Impair Sleep

 

Many factors can contribute to poor sleep:

 

  • Poor sleep hygiene: During most of human evolution, it would get dark at night, and that was the signal that it was time to sleep. But in our modern society, we have disrupted our regular cycles of light and darkness through artificial lighting, and activities such as shift work. When it is bedtime, we end up sitting in front of televisions or computers, which tricks our brains into thinking it's daytime, which thus impairs our sleep.
  • Lack of exercise: Being physically active is another signal for sleep at bedtime, but in our modern society, instead of regular physical activity, we sit for hours at school, the office or at home.
  • Stress: We live in a stressful society, which leads many people to worry at bedtime, either stressing about the day that just passed, or about the next day.
  • Normal aging: People tend to sleep less and sleep lighter as they grow older. As we age, our ability to sleep diminishes, but our need for sleep stays the same. Furthermore, as people get older, they tend to need to go use the washroom in the middle of the night, which an impair sleep.
  • Medical problems: Many different medical conditions can affect our sleep, and in particular there are sleep disorders such as restless legs syndrome, obstructive sleep apnea.

 

"Stimulus Control" Method

 

The "Stimulus Control" Method is a simple, yet very powerful technique that has been shown effective for helping with sleep (Morin, 1987). Because there are only five steps in this method this is a good basic strategy to start with.

 

There are five steps;

 

  1. Go to bed only when you feel sleepy, no matter how late the hour
  2.  Use your bed only for sleeping.
  3. If you don't fall asleep in 10 to 20 minutes, get up and go to another room.
  4. Use your alarm clock to get up at the same time every morning, regardless of how little sleep you got the night before.
  5. Don't nap during the day.

 

During the first night of the stimulus-control procedure you may need to get out of bed 5 times or more. You may not sleep at all, and you will feel tired the next day. At this point you might think that the remedy is worse than the original problem. It takes determination to keep up with the procedure. But by the 2nd, 3rd, or 4th night, sleep deprivation will cause your body to fall asleep more quickly. Most people need about two weeks to undo the maladaptive pattern that they have gotten into.

 

Winding Down and Getting Ready for Sleep

 

In case the Stimulus Control method is not enough, then here are some more basic strategies:

 

Do's for Sleep

 

  •  Find out your soothing activities. Figure out what types of activities will help you "wind down" in order to get to sleep.
  •  Winding down routines. Give yourself some "wind-down" time before going to sleep, e.g. at least 1-hr or so if you are having difficulties falling asleep.
  • Avoid stimulating activities.
  • Establish a regular bedtime routine. Go to bed at the same time each night and try to get up at the same time in the morning. Following a regular evening routine of brushing your teeth, washing your face, and setting your alarm will help to set the mood for sleep.
  • Consistency and routine. Your body's internal clock likes routines. Have the same, regular bedtime routine every night. Keep the same routine on weekdays and weekends.
  • Regular exercise: Exercise may deepen sleep, but avoid exercising too close to bedtime as this can be overstimulating. Some find that exercising 4-6 hours before bedtime is ideal.
  • Relaxation: Listen to relaxation music, or meditate.
  • Warm bath: Taking a warm bath to relax 1-2 hours before bedtime. In general, people find warm baths soothing, whereas hot, cool or cold baths are stimulating.
  • Problems with worries? If you have too many worries that make it hard to sleep, try:
    • Writing down a list of things to take care of the next day
    • Setting aside "worry time" earlier in the evening to deal with the worries. At that fixed time, perhaps for 30 minutes, write down the problems you are thinking about. Then write down what you would like to see different or better for your problem. Then tell yourself, "Okay, there's nothing else I can do tonight. I've written my plans down, and will focus on this tomorrow. Tell yourself you are not allowed to think about these things any more prior to bedtime"
  • Reading: Read a nice, relaxing book. Avoid reading anything that is too stimulating!
  • Do you get thirsty at night? Have a glass of water by your bedside so that if you get thirsty at night, you can have a quick sip rather than have to wake up and get out of bed. But don't drink to much, or you'll need to go to the bathroom in the middle of the night.
  • Be aware of your sensory needs. Every person has a certain need for a certain amount of sensory input (e.g. sound, touch, sight, smells, etc).
    • Sound
  • Some people are sensitive to sound, so they need to keep their bedroom quiet. Strategies include getting earplugs.
  • Some other people may need some sound stimulation, so they need to have sound, e.g. background noise from a fan, radio or television turned to a "static" setting, or a white noise generator, or a relaxation CD (e.g. those that have water, wind or rain sounds).
  • Play quiet, relaxing music. Make your own CD of soothing, relaxing music.
  • Visual strategies.
    • Some people find it helpful to keep things darker in the evening, and in their bedroom. Strategies include getting lights with dimmers in the evening to dim the lights before bedtime. While sleeping, some find it helpful to wear eyeshades, or blindfold. Others find it helpful to have good blinds to keep the sunlight out.
    • Consider decreasing visual stimulation in the bedroom. This might mean cleaning up and tidying your bedroom so that it doesn't have an overwhelming amount of distractions. For example, if you have stimulating things such as a television or computer, consider removing them. Use "natural lighting" fixtures when possible. When it's bedtime, dim the lights in your room.
  • Touch
  • Temperature - Avoid extreme room temperature or humidity; keep it moderate. Some find that humidifiers help. In general, cooler temperatures help facilitate sleep, but individual preferences vary widely.
  • Olfactory or smell strategies
  • Try aromatherapy strategies such as a drop of lavender oil on a pillow
  • Movement strategies.
    • Rocking rhythmically in a rocking chair with the lights dimmed and listening to quiet music (combines movement, visual and auditory strategies.
    • Avoid vigorous exercise before bedtime, because it may get your adrenaline running which then keeps you from being sleepy.
  • Warm drink at bedtime. Drinking a warm drink at bedtime may be helpful because it raises the body temperature slightly. Later, when the core body temperature falls, this plays a role in helping with sleep. This is also believed to be the reason why (mild) exercise can help with sleep. (Note that in the past it used to be believed that drinks such as milk have tryptophan which helps with sleep, but this is longer the case. The amount of tryptophan in a glass of milk is felt to be too low for sleep; in fact, it is felt you'd probably have to eat the equivalent of ten turkeys in order to have enough tryptophan to help you sleep! Note that eating a turkey dinner does may one sleepy, but this is felt to be on the basis of all the blood going to your digestive system to help digest the turkey!)

 

Don'ts for Sleep

 

  • Don't sit too long in front of television or computer screens: Watching television or using the computer is used by some people. However, be careful because this can make many people more stimulated, as the brightness of the TV or monitor can trick the body into thinking its daytime. New studies show that blue light is particularly potent at tricking our biological clock, making the computer a particularly powerful at sabotaging our sleep, because of the common blue background. If you are having troubles with sleep, try to avoid exposure to television or computer before bedtime.
  • Avoid stimulants before bedtime: Stimulants, such as 1) Nicotine, and 2) Caffeine (coffee, tea, and cola) should be avoided at least 5 hours before bed time. Studies have shown that one or two small cups of coffee consumed in the morning can affect the quality of sleep that same night. Replace caffeinated beverages with caffeine-free or decaffeinated beverages such as herbal tea, mineral water, fruit and vegetable juice, or decaf coffee. On the other hand, some people actually do find caffeine is soothing. Many of these individuals tend to be those with attention-deficit disorder (ADD), or attention deficit hyperactivity disorder (ADHD).
  • Don't drink too much before bedtime: Don't drink too much in the evening, because then you might have to wakeup in the middle of the night to go to the washroom.
  • Don't drink alcohol: Don't drink alcohol 4-hrs before bedtime - although it is a depressant and may help you fall asleep, it tends to cause poor quality of sleep by impairing our ability to make it to deep sleep, leaving us feeling more tired the next day. If you are suffering from insomnia, it is probably best to avoid alcohol completely.
  • Don't be a clock watcher. If you need an alarm clock, put it where it can be heard, but not seen.
  • Don't try to sleep: In other words, if you are lying in bed trying to sleep, then get up and do something else until you are feeling sleepy.

 

Music for Sleep

 

Certain calming melodies and tones have been shown as effective and inexpensive ways to help produce sleep. A study by Dr. Gregg Jacobs from Harvard University has shown that listening to relaxing music can produce theta brainwaves that are similar to those in deep relaxation and stage 1 sleep. In fact, for half of the people he studied, music was as effective as meditation in producing these relaxation brainwaves.

 

Self-Hypnosis for Sleep

 

Many people find that self-hypnosis can be helpful for sleep. Here's one sample script for self-hypnosis:

 

  • Lie down on your bed in a comfortable position, which for most people is lying on your back, with your hands at your sides
  • Tell yourself that it doesn't matter how it turns out the first few times, and that each time you do this, it will be easier and faster, and you will drift into an even deeper sleep.
  •  Starting at your toes and working up to your head, tighten and then relax your muscles.
  • Breathe deeply and tell yourself you are becoming very relaxed. You could open your eyes if you wanted, but it's so much easier to keep them closed.
  • Imagine you're at the top of a flight of stairs, and at the bottom, is a soothing, relaxing place of sleep.
  • As you descend, count down, and gradually feel yourself getting more and more relaxed
    • E.g. "Ten: with every step down, I feel my breathing getting deeper, slower.
    • E.g. "Nine: with every breath, I feel myself feeling more relaxed.
    • E.g. "Eight: As I feel more relaxed, I am getting sleepy.
    • E.g. "Seven: More relaxed...
    • E.g. "Six: More sleepy...
    • E.g. "Five: Even more relaxed....
    • E.g. "Four: Even more sleepy...
    • E.g. "Three: Even more relaxed..
    • E.g. "Two: Even more sleepy...
    • E.g. "One: I am so relaxed that I am ready to fall asleep."
    • Snuggle in your bed... Relax... Sleep...

 

Tips:

 

  • Feel free to modify and change the script to suit your own needs; it doesn't matter what you say, just as long as its something that gets you more and more relaxed, calm, and sleepy.
  • Consider soothing background music, such as classical music or nature sounds
  • Consider writing down your own self-hypnosis script, and then making yourself a tape of it, with or without music playing in the background. Then you can just listen to your tape and relax to the sound of your own voice.
  • Consider finding a certified hypnotherapist to help you learn self-hypnosis techniques for sleep.

 

What to do during the daytime

 

In addition to strategies that you use at night, there are also various strategies you can do during the daytime that may help.

 

  • Waking up. Keep a consistent wake-up time.
  • Healthy diet and nutrition. Have regular, consistent mealtimes which helps set your body's internal clock. Some people find it helpful to avoid large meals at night
  • Keeping a regular schedule. Stick to the same sleep schedule as much as possible both on schooldays, workdays and days off (i.e. weekdays and weekends)
  • Have a regular bedtime routine. It is important to have a regular bedtime routine or ritual that lets you get ready for sleep. E.g. Putting on pajamas, brushing your teeth, reading a relaxing book, prayer, etc.
  • Napping. Avoid or limit daytime napping that might interfere with nighttime sleep. Generally, limit naps to between 10-45 minutes in length, as longer naps may cause deep sleep that will disrupt nighttime sleep. Best times for napping about between 2-6 PM; naps after 6 PM may also result in deep sleep which may affect nighttime sleep.
  • Exercise. Regular, moderate-intensity exercise is known to improve sleep quality. Take a brisk walk, do some gardening, or join an exercise class. Avoid exercise in the late evening before bedtime because it may over-stimulate the body.

 

If sleep is still a problem for you...

 

If your sleep problems are causing distress or problems, then see your family physician, who can take a closer look and make sure that there aren't any medical conditions contributing. If there is suspicion of a sleep disorder (e.g. such as restless legs, sleep apnea or others), they may refer to a sleep specialist for further evaluation. In some cases, physicians may also prescribe medications to help with sleep.

 

 

Various conditions can affect sleep, such as:

 

  • Sleep apnea (aka obstructive sleep apnea or sleep-disordered breathing), a condition where individuals have trouble with breathing while asleep, and where they often (but not always) have snoring and periods where they stop breathing in the middle of the night and/or snort themselves awake.
  • Restless legs syndrome, a condition where individuals report needing to move their legs before going to sleep, which impairs our ability to initiate and maintain sleep
  • Narcolepsy, a condition where individuals have "sleep attacks", which are episodes where a person just falls asleep suddenly, or have extreme, overwhelming fatigue and tiredness.
  • Stress and conditions such as major depression, or an anxiety disorder.

 

Signs of a Sleep Condition

 

See a doctor if you have the following symptoms:

 

  • You feel drowsy during the daytime (i.e. daytime somnolence), which is where you find it hard to stay awake during the daytime, e.g. where you may doze off in boring situations.
  • You usually take more than 30-minutes each night to fall asleep
  • You have troubles falling asleep, troubles waking up in the middle of the night, or you wake up too early in the morning
  • Your partner says that you snore loudly, snort, gasp, make choking sounds, or stop breathing at night (i.e. possible obstructive sleep apnea)
  • You have troubles falling asleep because of an irresistible urge to move your legs (i.e. possible restless legs syndrome)
  • You have been told that your legs or arms jerk often during sleep (i.e. possible periodic limb movement disorder).
  • You have episodes of sudden muscle weakness when you are angry or fearful, or when you laugh (i.e. narcolepsy).


Sleep conditions in children. Children can have sleep conditions too, though their symptoms are usually not as obvious. Note that children may not appear to have excessive daytime sleepiness, but rather than may appear distractible and hyperactive with sleep deprivation or sleep fragmentation. It is estimated that up to 30% of children with ADHD may be misdiagnosed and may actually have obstructive sleep apnea. If discovered, this can often be addressed with a simple surgical procedure.

 

Medications for Sleep

 

If trying behavioural strategies is insufficient, then there are various medications that can be tried for sleep.

 

These include:

 

  • Over-the-counter medications such as:
    • Benadryl (diphenhydramine): note that a recent study showed that diphendramine does not help sleep in infants (i.e. children under age 2) (Merenstein et al., 2005).
    • Melatonin is increasingly being used as a sleep aid. Many studies show that melatonin may be helpful for a variety sleep problems including insomnia and jet lag.

 

  • Prescription medications, which require a physician's prescription, and should only be used under the guidance of a physician. These include the following options: :
  • Zaleplon (not available in Canada)
  • Zolpidem (not available in Canada)
  • Zopiclone
  • Lorazepam
  • Temazepam
  • Medications that are extremely sedating, such as Trazodone; Risperidone; Quetiapine; Olanzapine.

Recommended Books

 

  • Say Good Night to Insomnia: The Six-Week, Drug-Free Program Developed at Harvard Medical School, Gregg Jacobs
  • No More Sleepless Nights, Peter Hauri
  • American Academy of Pediatrics Guide to Your Child's Sleep: Birth Through Adolescence, American Academy of Pediatrics

 

Internet Links

 

References

 

  • Morin CM, Azrin NH: Stimulus Control and Imagery Training in Treating Sleep-Maintenance Insomnia. Journal of Consulting and Clinical Psychology, v55 n2 p260-62 Apr 1987
  • Kryger MH, Roth T, Dement WC. Principles and Practice of Sleep Medicine. 4th ed.2005.

 

About this Document

 

Written by:

  • Dr. Michael Cheng, psychiatrist, Children's Hospital of Eastern Ontario; Assistant Professor, University of Ottawa
  • Dr. Elliot Lee, psychiatrist, Royal Ottawa Mental Health Centre, Ottawa; Assistant Professor, University of Ottawa

 

Disclaimer

 

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.

 

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