Posted tagged ‘psychophysiologic insomnia’

Busting the myth of “I can’t sleep”

July 19, 2016

Q:  I want to sleep more than anything else, but just can’t.  Seems I lie in bed for hours and hours, and no matter what I do can’t fall asleep.  Any ideas?  I just want to sleep!

A:  First, let’s clarify. Yes you can sleep. The fact is you can’t not sleep, even if you tried.  Maybe you mean you can’t sleep when you want for as long you want, but in reality sleep at some point becomes irresistible for us all.

The experience of those with severe untreated obstructive sleep apnea demonstrates this fact well.  Those with untreated OSA can’t sleep for more than a few minutes at a time before waking themselves up, often gasping for air.  They may compensate by getting dozens if not hundreds of microsleeps throughout the night and often throughout the day — a potentially very dangerous situation for anyone with this condition who drives or operates machinery.  Microsleeps are of course a poor substitute for normal sleep, but it demonstrates how one way or another your mind and body will simply not be denied sleep, no matter what you do or don’t do.

The key is, of course, managing the inevitable sleep process for the best results.

The frustration you are expressing is understandable.  There is nothing quite like the agony of being dead tired in bed, wanting to sleep, but aggravated at our inability to do so when we want.

What we can’t do is try and force sleep. That tactic usually backfires as one becomes more alert, more frustrated, more angry at one’s inability to sleep. A frontal assault just doesn’t work.

There are better ways.

We suggest you’ve got to outflank this insomnia to beat it. Take at indirect approach. Outsmart it.

This is usually done by attacking insomnia at its true roots.  First, see a doctor to ensure you are either treating or have ruled out any underlying medical issues.  But don’t be surprised if you have none.  Most insomnia is not caused by a legitimate medical condition.  In that case, you may need to incorporate nonmedical strategies.

These typically include CBT sleep training methods. Such cognitive behavioral methods usually consist of some combination of stimulus control, sleep hygiene, consistent sleep timing, stress management, relaxation training, and control of anxiety.  Any of these issues, if not properly managed, can and will disrupt sleep.

Sleep is more than anything else a process of letting go.  Of not doing more than doing.  The process is the direct opposite of forcing.  But rest assured there is help, including effective methods that are entirely drug free.

Acknowledging the fact that yes in fact you can sleep may be an important first step in a permanent solution for you.  By controlling your thoughts, behaviors, and your environment you can in effect “stack the deck” in your favor for better sleep when and for how long  you want.


My problem isn’t falling asleep … how do I STAY asleep?

May 18, 2016


Q:  My problem isn’t falling asleep, my problem is staying asleep.  I sleep for about an hour at a time, then I wake up.  This happens several times per night.  Sometimes it seems like it takes me hours to fall back asleep after I wake up.  How do I help myself sleep better through the night?

A:  There could be several causes for this.  Let’s start with the easiest solution:  How much time are you allowing in bed?

The normal sleep duration for adults is 7 to 9 hours.  If you only need 7 hours of sleep and allow 9, then yes you can expect to be tossing and turning for a couple of hours — because  you are spending more time in bed than you need.

A second common issue that might be responsible is napping excessively.  Too much sleep during the day will in effect rob you of sleep at night.  We suggest napping is OK, providing it is done early in the afternoon and for no more than about 10-15 minutes.

Another potential cause for this is simply aging.  As we age, the strength of our circadian rhythm — which along with homeostatic sleep drive largely controls sleep — tends to somewhat diminish.

Normally the circadian alerting signal is at its lowest ebb during the early morning hours, so that after a few hours of sleep, and when the homeostatic sleep drive is reduced, we tend to stay asleep.  But as we age, the strength of the circadian rhythm tends to somewhat flatten, meaning we may experience lighter sleep with more frequent awakenings.  This by itself is nothing to worry about.

The best way way to strengthen your circadian rhythm and synchronize it to your sleep drive is to establish a consistent sleep-wake schedule that provides no more time in bed than you need.  Using a daily sleep log will help you customize your sleep schedule to best fit your personal needs.

Finally, getting a handle on both stress and a racing mind will help you fall back asleep if and when awakened during the night.  There are proven methods to manage stress that are drug-free, as there are ways to turn off a racing mind.

If these suggestions aren’t enough, you might try a comprehensive approach to sleep improvement, using CBT — cognitive behavioral methods.  CBT is the gold standard to treat insomnia as recommended by sleep professionals.  Such an approach will likely go a long way toward helping consolidate your sleep into one unbroken period.

Don’t get stressed by your pre-bed routine

September 15, 2015

Q:  I have a very rigid routine before bed that usually helps me sleep better.  Problem is, I’m so locked into this routine I’m afraid if I vary one iota I’ll have a horrible night.  Will I ever reach the point where I can travel or go to late night social events again and not disrupt my sleep?

A:  Short answer:  Yes, there’s a very good chance you can strengthen your sleep system to the point where you can be more flexible with your pre-bed routine.

Prebed sleep routines are important providing they are relaxing and help you transition to a rested state conducive to falling asleep.  However, if and when they get to the point you feel rigidly compelled to follow them — and getting out of line causes you stress — then the idea has backfired.

So no, you shouldn’t feel compelled to do exactly the same thing in exactly the same way every night.  Moreover, the positive stimulation of travel and social interaction at evening parties can help tire you out so you sleep better.  Such mental stimulation is an important part of overall good health.

To help you feel less locked in to your routine, you might begin by making very small changes now and then, just to add some variety.  This will help prove you can still sleep well even when you venture outside the boundaries of your normal routine.  Then you can with more confidence add in larger changes incrementally.

As you’ve discovered, a relaxing pre-bed routine is an important part of good overall sleep hygiene, and represents one of many proactive behaviors you can control to in effect “stack the deck” in your favor for better sleep.  Setting and keeping a consistent sleep schedule, minimizing negative sleep thoughts, controlling stress, and managing anxiety are all part of a comprehensive strategy to counter insomnia and improve sleep.

By diligently practicing these methods with time and patience, your sleep system will strengthen to the point where even if you travel or go to a party and disrupt your normal routine, the result will not be horrible.  By increasing your confidence in your sleeping ability, insomnia tends to diminish.  So even if you significantly vary your routine and your night is somewhat disrupted, it’s easier to respond with a “so what?”  You can let the worry go with the idea that you’ll sleep better the following night.

How aging affects sleep in adults

September 8, 2015

Most people know of the dramatic changes in sleep experienced by newborns and infants as they quickly grow.  Far fewer are aware of the less dramatic but ongoing changes in sleep experienced throughout life, yet these changes — while normal and expected — can and often do generate worry about sleep that often fuels insomnia.

Sleep really is a moving target throughout life, constantly changing.  A newborn baby might sleep 16 hours a day, but by adulthood that number on average is reduced by half.


Duration is only one parameter of sleep that changes.  The percentage of time spent in dream or REM sleep is also reduced by roughly half or more as we age, and the amount of time we spend in the deepest NREM stages is also significantly reduced.  The elderly in fact may spend the majority of the night in stage two, the lightest form of true sleep.

Middle-of-the-night awakenings can also become more problematic as we age, yet such wake-ups are normal and to be expected for even the best sleepers.  On an average night, even the most robust sleepers will awaken some 10 to 15 times, typically between the normal sleep cycles, and when changing sleep positions during the night.

As we age, some of us also tend to fret more about these normal interruptions in sleep.  Insomniacs, in particular, tend to worry that such benign awakenings might be some internal defect that’s robbing them of sleep.  Then, instead of falling back asleep quickly as normal sleepers do, insomniacs move toward a more alert state of worried wakefulness that makes sleep more difficult.  The difference is good sleepers pay no mind to such awakenings and fall back asleep quickly.  By morning they are typically forgotten.

In addition, hot flashes, arthritic pain, a decreased bladder capacity, any of the common health issues associated with age may cause more awakenings in the night.  And because sleep tends to get lighter and more fragmented, we can be awakened more easily by external noises that earlier in life we might have slept through.

This is why lighter sleep and more short-term awakenings can be expected as a normal consequence of aging.  For insomniacs, knowing it’s normal and not some internal problem may make it easier to accept such awakenings and let go the worry, thereby reducing insomnia’s negative fuel.

Learning better, more realistic concepts of the normal sleep process is a key part of the solution for many insomniacs.  Many find that better understanding by itself is often helpful in restoring lost sleep.

Is there a connection between depression and insomnia?

July 13, 2015

Q:  I have been diagnosed with depression.  What I don’t understand is if insomnia is only a symptom of depression and not a disease by itself, how did I get insomnia in the first place?

A:  You are right that insomnia is invariably only a symptom of something else going on deeper that is causing the sleep problems.  You are also right that insomnia is often correlated with depression, although the direction of causality is often not clear.

Are we depressed because we can’t sleep?  Or is it we can’t sleep because we’re depressed?  Maybe a little of both?

Medical surveys show up to 80% of patients with depression have insomnia, and those with chronic insomnia are up to three times more likely to develop depression.  The conditions seem to be two distinct but overlapping phenomena.

In treating insomnia some doctors prescribe pills to unnaturally force sleep, but many healthcare professionals take the position that in some cases sleeping pills may do more harm than good.  That’s because sleeping pills by themselves are only treating the symptom (sleep), not the true underlying cause for the insomnia, and tend to reinforce the idea that the solution to insomnia is external and resides out of one’s self-control.

On the other hand, depression is a legitimate psychiatric condition that is treatable with drugs as well as cognitive therapy, and by successfully treating depression sleep may well improve.  Interestingly, studies have also shown nondrug cognitive therapy can actually work better and faster than drugs to both lift depression and improve sleep, and the results can be sustained long term.

One compelling reason why cognitive therapy is so effective on both insomnia and depression is because both conditions are often characterized by underlying patterns of recurring negative thought distortions.

Distortions of rational thought are often at the root of many psychiatric disorders like depression and generalized anxiety disorder, both of which are correlated with insomnia.  Similarly, negative and often inaccurate thoughts specifically about sleep also tend to fuel and perpetuate insomnia.

One of the best self-help resources on cognitive therapy for depression is the book “Feeling good:  New mood therapy” by psychiatrist David Burns.  In his book Dr. Burns cites his own research as well as the findings of other medical researchers showing sometimes nearly immediate and lasting improvement of depression symptoms as the patient comes to understand how his or her underlying concepts and attitudes are unrealistic, distorted, and overly pessimistic.

The same holds true with sleep.  The nondrug methods in a good cognitive behavioral therapy-based sleep training program combine cognitive therapy with powerful behavioral tools like stimulus control and sleep hygiene.  Together, the two are an exceptionally effective way to improve sleep.

So your question somewhat defies a direct answer.  But you should be reassured that both your depression and insomnia are treatable as you come to grips with their true root causes.

How negative thoughts feed insomnia

March 18, 2015

One of the great accomplishments in cognitive psychology over the past several decades is arguably the defining of recognizable categories of thought distortions by psychiatrists Aaron Beck and David Burns.  Distortions of rational thought are often at the root of many psychiatric disorders like depression and generalized anxiety disorder.  Similarly, negative and often inaccurate thoughts specifically about sleep also tend to fuel and perpetuate insomnia.

In his book “Feeling good:  New mood therapy” (one of the top self-help books ever published), Dr. Burns lists 10 of these very common categories of thought distortions.  And it’s probably safe to say nearly all of us have succumbed to one or more of them at one time or another.

As one example, consider “disqualifying the positive”.  This occurs when you only see the negative aspects of a certain situation you are in, and completely overlook any positives as if they don’t count.  It’s not a valid or accurate representation of what’s truly there, and such distortion tends to feed worry and anxiety — sometimes to the point of being debilitating.

Moreover, seeing the situation more accurately can work to almost immediately lift one’s spirits and reduce depression.  Dr. Burns cites clinical evidence showing more rational understanding actually works better than drug therapy.

Specifically for sleep, insomniacs are prone to many common but inaccurate distortions of thought that tend to feed insomnia.  Such as, “I must fall asleep RIGHT NOW because I’ve got this very important (presentation, job, assignment, exam, project due, etc.) tomorrow, and if I don’t get a solid 8 hours I’ll be a complete wreck tomorrow!”

Which of course makes it nearly impossible to sleep at that point.

Interestingly, empirical studies have found that particular negative belief about insomnia is simply not true.  In reality, we adapt and usually perform well even when sleep deprived; and this is true both in terms of physical performance and cognitive performance —  Insomniacs tend to perform just as well as good sleepers.

But for insomniacs, it typically doesn’t feel that way. Studies also confirm that insomniacs tend to feel like they don’t perform well, even when they do.

So the real difference is in mood and perception, not performance.

You typically don’t hear much about this side of insomnia, because the media tends to be so one-sided.  What we do hear about more or less constantly is how awful sleep deprivation is and how much damage it causes.  Worry and fear can sell a lot of sleeping pills and herbal sleep supplements.

But knowing the negative consequences of a bad night are typically limited mostly to mood and perception, and not necessarily to performance, helps to reduce anxiety about sleep.  And the corresponding reduction in worry often results in better sleep.

By reducing the pressure we put on ourselves about sleep, we can relax more easily, let go, and fall asleep easier.  And learning how to do this consistently and when you want is a permanent tool you can use for the rest of your life.

Better yet, this method of cognitive restructuring is completely drug free.

So if you are subject to sometimes sleepless nights and don’t have an underlying medical issue causing insomnia, consider using these clinically proven non-pharmacological methods for sleep improvement.  Doing so will help you understand how some of your thoughts — especially about sleep — are distorted and inaccurate.  By learning to safely let these negative thoughts go, you can help yourself sleep better.

Insomniac’s Resolution: Permanently Debunk “I can’t sleep”

January 5, 2015


The start of a new year is a perfect time for insomniacs (and anyone experiencing sleep difficulties) to make a clean start.  And one of the best ways to do this is to make a clean break from your old ideas about sleep that haven’t been working out too well, and replace them with better, more accurate ideas that enable better, more refreshing sleep.

If you are having trouble sleeping, there’s a very good chance one of your biggest myths to debunk is this:

“I can’t sleep.”

It would not be at all surprising if that is one of your chief complaints.  We hear this constantly, and it’s quite understandable.  After all, what torture it is to lie sleeplessly in bed, dead tired, night after night, tossing and turning for hour after frustrating hour.  “I can’t sleep” seems to sum it up perfectly.

Except it’s wrong.  Completely, spectacularly wrong.  “I can’t sleep” is actually only an illusion with no basis in reality.

The reality is you can sleep — unless you have reason to believe you are unlike every other mammal that has ever lived, or that you for some reason are unlike every human being to ever walk the face of the earth for all time.  You sleep.

You do in fact sleep.  You must.  Your mind and body require it.  Sleep is one of life’s most basic necessities, like air and water.  You need it to survive, and rest assured one way or another you will get it.

The experience of those with severe untreated obstructive sleep apnea demonstrates this well.  Those with untreated OSA can’t sleep for more than a few minutes at a time before waking themselves up, often gasping for air.  They may compensate by getting dozens if not hundreds of microsleeps throughout the night and often throughout the day — a potentially very dangerous situation for anyone with this condition who drives or operates machinery.  Microsleeps are of course a poor substitute for normal sleep, but it demonstrates how one way or another you will not be denied sleep, no matter what you do or don’t do.

So yes, even for the most extreme insomniacs sleep is unavoidable, even irresistible, at some point.  The key to making it better is to manage the inevitable sleep process for the best results.  And one key component of this sleep management process is to rid yourself of dysfunctional, inaccurate, and unrealistic thoughts — like “I can’t sleep” — that only work to feed and worsen the problem.

There are many variations of “I can’t sleep”, including “I absolutely must have 8 solid hours of shuteye in order to function well the next day”, or “I must have a sleeping pill (alcohol, melatonin or other substance) in order to sleep.  Nonsense.

For an insomniac, the lack of sleep is only the symptom, not the underlying cause of insomnia.  To think lack of sleep causes insomnia is like thinking a runny nose causes a cold.

Getting to the real root of the problem goes a long way to making it better, but it requires understanding insomnia’s true basis, which often is some combination of bad sleep habits and negative thoughts about sleep.

For many insomniacs, part of the lasting solution is learning to disregard distorted and inaccurate thoughts like “I can’t sleep”.