Today, a special patient edition of the Carlat Psychiatry Podcast – A seven-step guide to better sleep. Share it with your patients or – if you’re like the 1 in 4 of us who suffer from insomnia – try it yourself.
KELLIE NEWSOME: No one has perfect sleep, but how do you know when your sleep system is so broken that it needs repair? In this podcast, we’ll teach you how to repair your sleep, but first lets clarify what it means to have a broken sleep system, or as doctors call it – primary insomnia.
There are 3 types of insomnia
- When it takes more than half an hour to fall asleep
- When you wake up in the middle of the night or early morning and can’t fall back asleep
- When your sleep is such poor quality that you don’t feel rested even when you get it.
But all of us have a rough night from time to time, and insomnia is only a disorder when it happens repeatedly, and here we have numbers:
- At least 3 nights out of the week, for at least one month
Sounds kind of arbitrary, but there’s some logic to those limits, and it has to do with the most common cause of insomnia.
CHRIS AIKEN: When things are going well, our inner clock corrects itself after a night of poor sleep. The clock is set by neurohormones like melatonin, cortisol, and about a dozen other chemicals that rise and fall over a 24 hour cycle. The clock is pretty smart, and it usually resets itself if we let it go about its business. We can get in the way of that repair when we do things to compensate for a night of poor sleep. Things like sleeping in or napping to catch up, drinking more caffeine, or worrying if we’ll able to sleep the next night.
Those are all natural reactions to insomnia, but they make the problem worse in the long term. It’s like trying to catch your breath. If you think too much about your breathing, and try too hard to get just the right amount of air in, you’ll end up feeling more short of breath than before. Best to trust your lungs to do their job. Sometimes they’ll draw in too much oxygen, or too little, but they’ll self-correct and smooth out any bumps along the way. You’ll see this theme throughout this podcast: Part of sleeping better is trusting your body to do its best. It may not be perfect, but it generally does a better job than we can.
There are two therapies for insomnia. The first is sleep hygiene – it’s like first aid – a series of basic steps that work well when the problem is just beginning. That can keep a few nights of bad sleep from turning into months or years of sleep disorder. If “first aid” doesn’t work, you may need something stronger, like cognitive behavior therapy for insomnia, or CBT-insomnia. CBT-insomnia is a specialized psychotherapy that is best done with a therapist, so we won’t go into all the details here but we will guide you toward some good resources for it at the end. For now, let’s get into First Aid for Insomnia.
First Aid for Insomnia
KELLIE NEWSOME: There are seven steps to take when you have trouble sleeping.
1. Get out of bed at a regular time, even on weekends, and even when you’re sleep deprived.
This will help keep your inner clock running on time. Sleep is a 24 hour cycle, and the cycle is anchored in the time you get out of bed in the morning. Not just “get out of bed,” but put your feet on the floor and stand up. Your circadian clock starts ticking when you stand up and move around.
CHRIS AIKEN: But what if you didn’t sleep well, and getting up in the morning means you’ll be sleep deprived? That’s OK. There are two biological forces that help us fall asleep at night
- Sleep drive
- Circadian rhythm
The circadian rhythm is the 24-hour cycle that starts with getting out of bed. It’s also set by light and darkness, so keeping the evening lights low and the morning lights bright helps keep it on track. “Sleep drive” is the force that builds up the longer we stay awake. It’s literally your body’s natural sleep medicine – adenosine. Adenosine levels start to rise when you wake up and build throughout the day, making you more and more sleepy as they do. If you’re sleep deprived, and get up early and avoid naps, your adenosine will rise, making it more likely that you crash into sleep at the end of the day. This is one of the ways that the body self-corrects.
KELLIE NEWSOME: But wait a minute. Isn’t sleep deprivation bad for you? Shouldn’t I sleep in for my health?
CHRIS AIKEN: Here the answer is clear. Sleep deprivation is bad for your health, but only if it goes on too long. If you sleep in in the morning, it will prolong the problem, but if you allow yourself a little sleep deprivation for a day your body will self-correct. Now, we’re not saying that you’re definitely going to fall asleep the next night. What we can tell you is that following these steps will make the insomnia and the sleep deprivation that comes from it go away faster. And we have some reassuring medical news for you.
One reason that insomnia is bad for your health is that it increases inflammation. Inflammation is when your immune system goes to war with your own body – causing obesity, depression, and chronic diseases like diabetes and heart disease. What’s interesting is that following these steps – allowing some short-term sleep deprivation in order to fix a long-term problem – actually lowers inflammation and improves immune function… the result is better physical health and fewer viral infections because a healthy immune system fights off infections.
2. Avoid daytime naps
It’s tempting to nap when you don’t sleep well, and no doubt it will make you feel better in the short-term, but napping will prevent your body’s natural recovery mechanisms from kicking in for the same reason that sleeping in does. When you nap, you drain all that adenosine – the body’s natural sleep medicine. And you’ll confuse the internal clock. If you nap from 1pm to 3pm, your body will think that 3pm is the new morning!
KELLIE NEWSOME: But wait a minute. I heard that napping was healthy, particularly in old age. And don’t some cultures take a siesta every afternoon?
CHRIS AIKEN: Yes, napping can be healthy, but not if you have insomnia! If you have insomnia, cut out all naps until the problem goes away. Then, carefully add them back in. If you sleep fine, continue them. But if they disrupt your sleep, you should seriously consider putting them to rest.
3. Only use the bed for sleep and sexual intimacy
The idea here is to train your body to associate the bed with rest. A lot of people with insomnia say that they can only fall asleep on the sofa. What’s going on there is that they’ve come to associate the bed with struggle – the struggle to fall asleep. So don’t study in bed, read in bed, or worry in bed – you only want to be in bed when you’re falling asleep or close to it.
Or having sex. We’re not going to take that away, and an orgasm actually cause sleep-inducing neurohormones to rise.
But sex is also a form of exercise – it gets your heart rate and respiratory rate running. Shouldn’t you avoid exercise before bed?
CHRIS AIKEN: Maybe, but that’s not as big a deal as it’s made out to be. Exercise is very helpful for sleep. It’s particularly good at deepening sleep quality. But what about right before bed? A half dozen studies have looked at that, and here’s what they found. Exercise deepened sleep, even when done just before bed. The only problem it caused was mild – people it took a little longer to fall asleep if they exercised right before sleep and had a racing heart when they got into bed. The best time to exercise for sleep is in the early morning or late afternoon, but if you have to do it before bed, it’s better than not exercising at all.
4. Avoid caffeine, particularly after 2pm
Remember adenosine? That’s the chemical that makes you sleepy and goes up the longer you stay awake. Well here’s news: Caffeine works by blocking adenosine. If you have insomnia, you need all the help you can get, and you don’t want anything to come between you and your adenosine. But don’t stop caffeine abruptly – doing so can cause withdrawal headaches and a lot of other problems. All things in moderation, and all things gradual. If you do use caffeine, try to cut it off by 2pm. Caffeine has a half-life of 2-9 hours, which means that after 2-9 hours your caffeine levels fall by 50%, and after 10 to 45 hours it leaves your body entirely. There’s a lot of variation there because everyone metabolizes caffeine differently.
Another tip is to switch to tea. Tea has less caffeine, and it also has a helpful antioxidant called L-theanine which reduces anxiety, lowers blood pressure, and promotes sleep.
5. Avoid alcohol at night
Alcohol is not really a sedative. It’s more complex than that. Let’s look at how alcohol affects the brain over time. Right after you drink it, alcohol’s first effect is stimulating, making people more active. Then it makes them drowsy. But if they fall asleep with it, it lightens the sleep, and the goal here is not just to get sleep but to get restorative sleep. An alcohol induced slumber won’t improve your memory, concentration, and energy like you need sleep to do. Then, as alcohol leaves your system, it can make you suddenly wake up at 3 in the morning, often dehydrated and hung over.
We’re not denying that there’s a small benefit buried in all those risks – that alcohol can make you fall asleep. But even that effect is short lived, because tolerance quickly builds up where you need more and more or it doesn’t work at all.
6. Set the stage for sleep
The brain needs time to shift from wide awake to sound asleep. You can gradually shift it there by setting the stage for sleep in the half hour before bed (or two hours if you can muster the time). Here are the ingredients:
- Get it darker. Lower the lights and avoid blue light. Blue light is the wavelength that keeps us up at night, and it’s also the type of light that pours out of computers, screens, and energy efficient bulbs. Often this light looks white, but there’s a lot of blue in it. For some low cost, good quality blue light glasses, go to psycheducation.org and search for the post “Dark Therapy in 6 Steps.”
- Pitch darkness when asleep. That post also has tips for getting your bed room pitch dark, which is very important for sleep. Even a nightlight can disrupt sleep, as well as mood and health. In one study people who slept with a night light on had twice the risk of depression two years later, and they also gained more weight because evening light interferes with metabolism. Those risks all go up the more light there is in the room. If you have to have a light on, the Dark Therapy page suggests some brain friendly nightlights that won’t interfere with sleep.
- Temperature. A drop in temperature will make your sleep chemicals rise. This works even if you stay warm by bundling up under the covers. How cold? Sleep doctors recommend 60-65 degrees fahrenheit. That’s cold. But if you don’t want to pay a high energy bill try a fan – the wind chill will lower the effective temperature and create some white noise as well.
- Sound. Some people find it helpful to use white noise, nature sounds like waves or crickets, or relaxing music before bed. But does it work? The studies say yes, and here’s how they proved it. They asked half the people to listen to relaxing classical music, and focus on the notes as they drifted asleep. The other half were guided to do something else that might help, like audio books or muscle relaxation. In these studies, music worked better and by a pretty big degree – about the same degree of effect we see with sleep medicines. A good tune to start with is Weightless by Marconi Union. It’s on Spotify and youtube, and we’re playing it in the background right now. This song was a collaborative effort between sleep researchers and musicians, and it studies it lowered blood pressure, reduced anxiety, and helped people fall asleep faster than comparable songs like Enya. Just don’t drive while listening to it.
- Scent. Aromatherapy can help sleep – scents taken in through the nose have real effects on the brain. The best-studied scents for sleep are lavender, bergamot, chamomile, and cypress. But this varies a lot by person, just like music does, so find what works for you or skip it if it’s not helpful. Also, don’t overdo it, a light aromatherapy is what works best.
- Calm. This last step is the hardest, so don’t sweat it if you can’t make it work! Anxiety, worry, and active problem-solving all put the brain on high alert, and that’s not conducive to sleep. This is part of the vicious cycle of insomnia. First you don’t sleep, then you worry about sleep, and the anxiety just makes you more alert and more awake. If you find yourself worrying at night and can’t fall asleep, let it be and move on to the next step, or work with your therapist to discover strategies to turn the worry down, like mindfulness, deep breathing, CBT, and progressive muscle relaxation.
7. Don’t force sleep, and only go to bed when you’re tired
Trust your body to sleep when it needs to. As long as you don’t nap in the day or fall asleep so early that you’re up most of the night, this principle will not steer you wrong. When insomnia goes on too long, people lose trust in their body’s natural sleep mechanisms. They try to take control of the sleep gears, but those were not designed for manual operation. The result is frustration and further breakdown of the gears.
There’s a good reason that the sleep gears weren’t designed for stick-shift mode. When you drive a stick shift, you have to be awake to operate the gears. Otherwise, the car would crash. That’s the paradox of insomnia. Falling asleep is about as complicated as landing an airplane. There is no way that your body would let you operate such delicate controls unless you were wide awake, which means you’d never fall asleep.
If you’ve been tossing and turning in bed and can’t fall asleep after about 20 minutes, get out of bed (just approximate – don’t watch the clock!). Move to another room and sit in the dark until you feel tired. Then get in bed and try again. If sitting in the dark is difficult, use a low-level yellow light and wear blue light blocking glasses.
These steps are not easy. And many of them are counter-intuitive, after all – we’re suggesting that sleep deprivation is your friend – not your enemy – when fighting insomnia, because sleep deprivation raises the biological drives that help you fall asleep. So why should you trust us? Well, dozens of well-designed studies have found that these steps work. But what if they don’t work? Then you may need something stronger, and that’s where cognitive behavioral therapy for insomnia comes in, or CBT-insomnia.
CHRIS AIKEN: CBT-insomnia uses the same principles as first aid for insomnia, but it applies them in a more rigorous and scientifically measured way. In this therapy, you’ll actually calculate a lot of cool metrics about your sleep, like Sleep Efficiency, and use those numbers to figure out exactly how much time you should spend in bed.
CBT-insomnia works as well as sleep meds in the short term, like after a few weeks, and over the long-term it works better than sleep medicine (Beaulieu-Bonneau et al, Sleep 2017;40(3) Mar 1). That’s why the American Academy of Sleep Medicine, the National Institutes of Health, and the American College of Physicians all recommend CBT-insomnia above sleep medication for insomnia.
CBT insomnia also improves depression, and makes antidepressant medication work better, because sleep and mood are so tightly linked.
You can use sleep medicine while working on CBT insomnia, or while following the steps in this podcast. In fact, if you’re taking sleep meds and they’re not working, you may need to add in one of these therapies. The question often comes up – do you need to do anything different when taking a sleep med? Not really – you just need to be cautious about getting out of bed after taking a sleep med. They are likely to affect your balance, and some can lower your blood pressure, so if you or your doctor think you are at risk for falls after taking a sleep med definitely skip the rule about getting out of bed when you can’t sleep.
KELLIE NEWSOME: While CBT insomnia works well, it is hard to find. Few therapists are trained in it. Ask your doctor or look for therapists with CBT training and ask them if they know about this specialized version of CBT for sleep. You can also find a certified therapist at www.behavioralsleep.org.
Because sleep therapists are so hard to find, a few apps have been developed for self-guided CBT insomnia. This works well if you are motivated, but if you have depression it may be difficult to do on your own. A good free app is CBT-I coach, and there’s also a prescription app called Somryst. That’s right, the same government agency that approves medications – the FDA – also approves apps. Somryst is not out yet but should be available in 2021, and with a doctors prescription your insurance company may pay for it.
Finally, there are self-guided books. Dr. Aiken has one, the Depression and Bipolar Workbook, which includes a full guide to CBT insomnia along with 2 dozen other techniques to improve mood and energy. Two books that focus just on sleep are Say Good Night to Insomnia by Gregg Jacobs or End the Insomnia Struggle by Colleen Ehrnstrom.
Artwork: We Come, We Eat, We Sleep (Detail We Sleep), 1999-2001 by NS Harsha