Better Health & Living: Article: Fall & Stay Asleep Naturally

Issue: April 2007

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Fall & Stay Asleep Naturally

Welcome to insomnia boot camp.

by Sarí Harrar

Published in health •in_focus •METRO •METRO Story | 0 Comments, Talk about this article »

Hampton, 58, a real estate agent and insurance broker from Cynthiana, Kentucky, took his last sleeping pill on November 21, 2005. The next day at a Louisville sleep center, he began a cognitive behavioral therapy program designed to reverse insomnia. “I found out I was a poster boy for bad sleep habits and attitudes,” he says, laughing. “I had literally taught myself how not to sleep. The first week or so was rough, but within six weeks, I was sleeping through the night and waking up feeling great. I haven’t needed a pill since.”

Sleep researchers say CBT-I—the name given to a form of cognitive therapy that retrains your mind and body like an intensive “insomnia boot camp”—could help up to 80 percent of the nation’s 14 million chronic insomniacs finally sleep all night. Now, sleeping pills or antidepressants are the usual treatments, but many experts wonder whether either should be recommended for long-term use because of their rare but often serious side effects.

“Insomnia is a clear and present danger,” says CBT-I researcher Michael Perlis, PhD, associate professor of psychiatry and psychology at the University of Rochester and director of the university’s sleep research laboratory. “It raises the risk for traffic accidents, depression, substance abuse, and probably for health problems such as high blood pressure, cardiovascular disease, and metabolic syndrome. It makes going about your daily life really difficult.”

A growing stack of research suggests that CBT-I works as well as or better than drugs for insomnia. In a recent Harvard study, after eight weeks of therapy, participants fell asleep twice as fast as they had before their training started. CBT-I cut middle-of-the-night wakeup time from an hour to less than 30 minutes in a Duke University study of 75 troubled sleepers. “Research shows that it’s as good as pills for short-term insomnia and may be better for chronic insomnia and for insomnia that’s the result of health conditions such as chronic pain or cancer,” says Dr. Perlis.

Everything You Know About Sleep Is Wrong

A six- to eight-week CBT-I program attacks insomnia on multiple fronts, using sleep restriction to reset your body clock, better pre-bed habits to prep for slumber, and forbidding most “stimulating” activities in bed (sex is okay; paying overdue bills with Jay Leno isn’t). The goal: to make you stop doing all the things that actually keep you awake.

“People with insomnia try very, very hard to fall asleep, but common misconceptions get in the way,” says psychologist Ryan G. Wetzler, PsyD, a CBT-I practitioner and director of behavioral sleep medicine at Sleep Medicine Specialists in Louisville. “Many insomniacs actually don’t need 8 hours of sleep a night—they toss and turn because they really need 7, or occasionally just 6. As a result, their sleep is fragmented into short pieces—they sleep awhile, then wake up. The longer they spend in bed worrying, the more their minds associate the bed with problems. They may nap more or sleep late when they can, which just throws off their body clocks even more. And they may do more things in bed while they wait to fall asleep, such as reading, watching TV, or working on a laptop.”

When Doug Hampton met with Dr. Wetzler, he discovered that a chance event 24 years ago triggered his insomnia, but his own fix-it strategies made it a chronic problem. In 1982, he was working as a real estate agent when the prime interest rate hit 22.5 percent. “It was very challenging. I thought about it all the time, and I just stopped sleeping,” Hampton says. After several months, he was a full-fledged insomniac. He reinforced his sleeplessness by reading in bed for several hours at night (a “stay awake” signal), by wearily watching his bedside clock when he woke up during the night (clock watching “trains” your brain to rouse itself and check the time), and by staying in bed and worrying when he couldn’t sleep (sending the message that bed was the perfect spot for fretting). Now, he reads in an armchair in the family room, turns his clock so he can’t see the display, and gets up if sleep won’t come—all techniques he learned in CBT-I.

6 Boot Camp Basics

Use a sleep diary. Keep track of how long you’ve spent in bed, your nod-off and wakeup times, and how often you wake up during the night and for how long. Many insomniacs spend 80 percent or less of their in-bed time asleep. The goal: 90 percent or better.

Move your bedtime. CBT-I practitioners aim for “sleep consolidation”—as much unbroken sleep as possible. You may be asked to go to sleep later than you normally do for the first week or so, yet still wake up at the same time each morning. Your bedtime may be pushed back as little as a half hour or as much as 2 to 3 hours. “The point is to have you in bed only for the amount of time you’re really spending asleep,” says Cincinnati psychologist Stephen Billmann, PsyD, a CBT-I practitioner. At first, you feel even more sleep deprived than before. But after four or five nights, your body begins to adjust—you fall asleep faster, wake up less frequently, and fall back to sleep sooner if you do wake up in the middle of the night. Once you begin sleeping more solidly, your therapist will set earlier and earlier bedtimes until you arrive at your optimal turn-in time for a full night’s sleep.

Find your personal “sleep number.” About 80 percent of Dr. Billmann’s patients are “6- or 7-hour-a-night sleepers who thought they needed 8 hours,” he says. “Telling people they need less sleep sometimes makes them really angry. We use the sleep log to see, over time, what they really need.”

Kill the sleep stoppers. CBT-I participants are asked to reserve the bed for sex and sleep, to turn clocks with lighted displays toward the wall, to avoid caffeine after about noon and forgo most alcohol, and to spend some time unwinding with a relaxation technique, a boring book, or a warm shower before bed. The goal: To tell your body it’s bedtime and short-circuit middle-of-the-night worry cues (such as checking the time). “We’re also taught to get out of bed if we can’t sleep,” Hampton adds.

Develop new sleep attitudes. “Insomniacs often have performance anxiety,” Dr. Billmann says. “The whole point of getting to sleep is suspending judgment about everything—about how well you’re relaxing, about how long it takes, about your dreams, about your wakeup time.” In CBT-I, participants learn not to stress if sleep comes a little later and not to blame a short night of sleep for the next day’s stresses.

Learn to relax. Any calming technique—including yoga, meditation, progressive muscle relaxation, and others—done at any time of day can help your body learn to release stress and help you sleep. Having a relaxation strategy at the ready can also help if nighttime tension interferes with nodding off.

Find a Certified Practitioner

Check the list of behavioral sleep medicine experts certified by the American Academy of Sleep Medicine at www.aasmnet.org/. Or look for diplomates of the American Board of Sleep Medicine who are psychologists or psychiatrists at www.absm.org/diplomates/listing.htm.