Can't Sleep? Chronically sleep deprived? What Really Works for Insomnia

The best medicine for insomnia.....isn't medicine at all.

Sure prescription and non-prescription medications may help for a short period of time, but often they are not to be used for more than a couple weeks because they can create new problems.

Sleepless nights

And while some supplements definitely help (e.g. magnesium, melatonin, chamomile etc.) and we should take them to help sleep and maximize health in other ways, often they just peel back a layer of two from insomnia and don't solve the problems that are causing sleep issues to begin with.

But that does not mean that we are stuck with our problems with sleep. There are lots of other things that are very important to do.

Rule out any medical problems:

First it is very important to find and deal with any health problems that may be impacting sleep. So always start with your primary care provider. They will want to do a clinic visit, ask you many questions, and to do an examination. In most cases they will need to order some lab tests to help rule out any physical health problems so you can get to root cause of your sleep problems and solve them.

Some health problems that are often causes of or significantly impact insomnia and/or daytime fatigue include; sleep apnea, hyperthyroidism, low vitamin D levels, anemia and many more.

So check in with your PCP and make sure that you have had any tests needed to rule out medical issues impacting sleep. And if you have sleep apnea, follow your treatment plan or you will be caught in a sleep disorder cycle of poor sleep and daytime fatigue along with a host of many other health problems.

It is also important if you grind your teeth to check in with your dentist and to get a mouth guard.

At the same time as you have medical problems ruled out or treated, you can do a lot of other things that have been show scientifically to help with sleep.

The best way to manage sleep problems is by learning and using Cognitive Behavioral Therapy for Insomnia (CBT-I) tools and techniques which are highly effective for dealing with chronic insomnia and focus on changing the thoughts and behaviors that cause or worsen sleep problems.

What are CBT-I tools and techniques?

CBT-I tools and techniques are specific things you can do to help figure out and swap out thoughts and behaviors that are causing your insomnia with ones that will help instead. These include:

• Sleep Restriction

• Stimulus Control

• Relaxation Training

• Cognitive Therapy

• Sleep Hygiene Education

How Effective is CBT-I?

CBT-I is recommended as the first-line treatment for chronic insomnia by several professional organizations, including the American College of Physicians and the American Academy of Sleep Medicine. Studies have shown that CBT-I can significantly improve sleep quality, reduce the time it takes to fall asleep, and decrease the amount of time spent awake during the night.

OK. You have spent enough of your life moments dealing with sleep problems. Let's get onto the CBT-I tools and techniques that actually help.

Sleep restriction 

With sleep restriction, you figure out how many hours you are actually sleeping now, and your typical sleep start and stop times. This is called your "sleep window". Then you only get into bed a few minutes before the start time and have lights out and try go to sleep immediately. And then you get up out of bed at the time you typically wake up. You don't do anything else in bed aside from sex and sleep (no TV, smartphone, computers, etc.). Then every week you increase your time in bed by 30-60 minutes until you are sleeping up to 9 hrs. If you get to 7 or 8 hrs and you are unable to sleep longer after a week, you stop at that amount of sleep and stick with that routine. You don't ever go back to hanging out in bed not sleeping. And if while adjusting your sleep window you have trouble falling asleep, you will want to do a sleep meditation. You can use ear buds or play the meditation out-loud. You can find free meditations on YouTube that work very well. The sleep talk down works very well for this purpose https://www.youtube.com/watch?v=U6Ay9v7gK9w  No matter what you do, don't get out of bed unless you have to go to the bathroom or have a similar need. And don't turn on the TV or use your phone. It's OK to just rest in bed with your eyes closed and while that does not provide us with all the benefits of sleep, it is far better than doing brain stimulating activities like watching a show or scrolling on social media. Using sleep restriction strengthens your physical desire to sleep that naturally occurs the longer we are awake. It is important that you do not artificially limit sleep for a long period of time like many weeks or months. You definitely want to limit this process to a few weeks to reset your ability to fall asleep easily in bed. And if you feel like you never sleep at all you can simply start with 4 hours and work your way up to a longer period of sleep. Or if you go to bed much much later than you should, you can start working your sleep time backward one hour a week to the time that is best for you.

Pro tip:

If you like tech gadgets, I highly recommend that you use a smart watch that has the ability to monitor your sleep. You can learn a lot of things buy simply looking at the biometric data a smart watch provides you. And you don't have to buy a very expensive model either. There are many less expensive watches that do a great job at monitoring sleep. And some phone apps can monitor sleep, help with relaxation exercises and more. So tap into tech if you enjoy gadgets to bring your sleep program to a new level.

Stimulus Control

Stimulus control means getting rid of things that stimulate our brains and make us feel awake and having patterns and routines that teach our brain to sleep correctly. Here are some important concepts:

-Only use your bed for sex and sleep as mentioned above

-Go to bed/sleep and wake/get out of bed at the same time every day (even on days off)

-If you can't sleep get out of bed for 20 minutes and do a quiet activity to reset, then go back to bed using the techniques again

-When your alarm goes off (or if you wake a few minutes early) get right out of bed

-NO ELECTRONICS 1-2 HRS BEFORE BED! Very hard to do but definitely not impossible

-The use of light therapy is very helpful! Start your day with bright blue light for an hour or two. Then switch to bright white. Around sunset switch to warm white and dimmer lights. Towards bedtime, dim the lights more. And as you go to bed use red light instead of white. These changes in lighting can be easily accomplished with smart bulbs. And you can create automated programs so you don't even have to think about it. Getting outside in sunlight early in the day can also be very helpful. And you want to make sure that you don't have any chargers or other electronics lighting up in your bedroom at night or light coming in the window at night. You also want to use dim or red lights for your nightlights. They are important to have outside the bedroom, so that you don't trip if you have to use the bathroom. But don't turn bright lights on during sleep hours. And if you can't adjust the lighting try blue light blocking glasses in the evening as there is some new research into this that is very promising.

-Unless you are under medical orders to take a nap, no napping during the daytime. Use deep breathing, exercise, and other stimulating activities to wake yourself up if you are sleepy during the day

Relaxation Training 

It is pretty much impossible to sleep if you are not relaxed. So learning how to relax is essential. One way is to use progressive muscle relaxation. Basically when you get into bed, if you can't immediately fall asleep, tighten every muscle in your body that you can as tightly as you can. And after a few seconds gradually start to relax your muscles one area at a time. You can start from the bottom of your body to the top (feet to head). Another thing to do is to use guided imagery which is listening to someone tell you how to imagine things that are calming and soothing before during or after the progressive muscle relaxation. There are numerous free videos on YouTube that guide you through progressive muscle relaxation and guided imagery all at once. Here is one example https://www.youtube.com/watch?v=fDZI-4udE_o

Cognitive Therapy 

I tell my patients that if they don't control their mind, their mind WILL control them. An untrained mind is like an untrained puppy. So learning to take control of our thoughts is very important for just about everything in our lives. But while it sounds like it is complex to "reprogram" our brains, it really isn't. I can't remember where I learned this, but it is so important. "We only have so much real estate in our brain." Funny concept but it is so true. While humans can certainly have more than one thought at a time, typically there is only one primary thought in their head. And while that primary thought can hop from one topic to the other pretty easily, we can leverage this and use it to our advantage. Imagine what you are programming your brain to do when we have the typical insomnia thoughts. "I am never going to fall asleep. I am not going to get any rest tonight. I am not going to be able to get up in the morning. My whole day will be ruined tomorrow because I can't sleep. etc. etc." Can you see how programming our brains with these thoughts is hurtful? So when you are in bed at night and sleep will not come, and your mind is on something other than sleep, use cognitive therapy tools and techniques to help. Basically, have a short and concise helpful phrase that you can repeat over and over. You can do this in your head, whisper it, or you can say it out loud if needed. Something as simple as, "Everything is OK. Just rest." and just keep repeating that over and over. It is also good to "brainwash" your brain with ideas like, "I love to sleep and dream. It feels good." By using cognitive therapy to rewire your thoughts, you crowd out or push out the thoughts that are hurting you and replace them with thoughts that are helpful. While there are other aspects of cognitive therapy for sleep, and it can often help to work with a licensed therapist specifically on sleep, you can get started with this easy and powerful tool today.

Lifestyle changes

Sleep hygiene routines and tools are very important in getting adequate quality sleep.

-As discussed above, having a sleep routine is critical

-Include more than your start and stop times for sleep in your routine

-Plan your evening routine to include activities like a warm bath, lavender aromatherapy, quiet evening activities and the like to help your brain recognize that the time for sleep is coming

-Similarly, plan your morning routing to include activities that wake you up (see below)

-Have no caffeine for the second half of the day

-No heavy meals within 3 hrs of bedtime

-Get physical activity all or at least most days of the week

-Get outside for fresh air and sunshine every day that you can, particularly in the morning

-Keep your bedroom dark (as discussed above), quiet, and VERY cool (you don't want to be shivering cold but a very cool room helps our bodies sleep better)

-Know that memory foam materials for mattresses and pillows allows our body heat to build up under us as the night goes on so avoid these or add a mattress pad that is cooling

-Not an easy proposition, but encourage pets to sleep in their crates or beds rather than in the bed with you the more bodies in the bed, the more body heat, movement and noise will impact your sleep consider sleeping separately if being in bed with your sleep partner is causing you to lose sleep

-Stay on your sleep schedule even on weekends, holidays, and when traveling

-Limit travel only to what you really want and and need and know that being away from your home and routine can cause disruption to your sleep try to stick to your routine when traveling and definitely get right back into your normal routine the first day you are home even if it takes a few days to get back on track

-When traveling to different time zones continue to follow your routine at the usual times you do back home for shorter trips for longer trips you will need a new routine while you are away

-Keep a sleep diary to try to identify what is causing you to lose sleep at night and share this with the clinicians treating your sleep problems

-Use over the counter and prescription sleep aids rarely as often they can cause rebound insomnia making your problem worse in the long run

It is important to tackle insomnia from many different angles as one approach is often not enough. But if doing all of these things at once is overwhelming, just pick on thing at a time and add a new tool or technique every week. After all, your chronic insomnia did not start yesterday. It probably has developed over many years. So it may take some time to get your sleep under control. But small changes over time add up. And before you know it, your improved sleep quality and duration will cause your mental health to improve in significant ways.