Posted by: counselorcarmella | September 17, 2011

A Boring Article On Insomnia To Help You Sleep

A topic that is frequently brought up in my office is not being able to sleep. It isn’t usually the thing that brings a person to counseling, but clients will express frustration about it. Not being able to sleep causes problems with focus, difficulty being able to think clearly, irritability, problems with motivation, memory problems, work performance problems, and a range of other issues. Its hard to deal with day-to-day life when feeling exhausted. People say they can’t enjoy family activities or intimacy and can’t give their best at work because they are distracted by feelings of fatigue.

Insomnia is  a problem falling asleep (onset insomnia) or staying asleep (middle insomnia or terminal insomnia, which is waking up too early and not being able to go back to sleep.)  People who have trouble falling asleep  tend to be prone to worry, can’t turn their brains off, and have trouble relaxing.  Middle insomnia is often associated with pain or having to  get up to use the bathroom, and terminal insomnia is often associated with depression. People who have experienced trauma may struggle with any of these types of insomnia due to hypervigilance or nightmares.

In adults, a sleep period of 8 to 8.5 hours is considered restorative, although there are individual variations in sleep needs. More than one-third of adults have insomnia at some time, while 10 to 15 percent report long-term problems with insomnia. Watch TV for an hour and you’re likely to see several commercials about prescription or OTC sleep aids or herbal products that are supposed to help with sleep. Insomnia varies in how long it lasts and how often it occurs. It can also come and go, with periods of time when a person has no sleep problems. Acute insomnia can last from one night to a few weeks. Insomnia is called chronic when a person has it at least three nights a week for a month or longer.

Many children and teens experience insomnia. Women are twice as likely to experience insomnia as men. Up to 50% of older adults experience sleep difficulties.  Insomnia is the most common. 

Clients frequently mention sleep issues to their counselor, but may not think to bring them up when visiting their doctor. In an effort to better identify individuals with sleep disorders, it is recommended that medical practitioners ask patients about their sleep habits during routine visits. The updated 2008 Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults provides a framework for the evaluation and management of chronic insomnia for busy clinicians. A complete history and physical examination should be conducted in the assessment of insomnia to detect any existing medical or psychiatric disorder. The history consists of detailed questioning about sleep habits including onset, duration, frequency, timing, aggravating or alleviating factors, medication and substance use, and family history of sleep disorder. Partners or caregivers can provide important information about the patient’s sleep habits, substance use, snoring, and unusual limb movement. The administration of a clinical sleep questionnaire that measures sleep quality may provide useful information. The Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI) are stable measures of sleep quality and sleepiness and are commonly used with patients with sleep disorders in the primary care setting.

The American Association for Sleep Medicine accredits centers and labs that treat people who have sleep problems. AASM accreditation is the “gold standard” for the field. It shows that a sleep center or lab maintains the highest standards in all it does. In 1977 the AASM accredited the first sleep disorders center. Today there are more than 2,000 centers and labs that are accredited by the AASM. They are providing trusted medical care in every part of the country.

The AASM also certifies behavioral sleep medicine (BSM) specialists. These doctors help people improve their sleep by changing how they think and behave. This is also where counselors come in. Cognitive and Behavioral treatments teach patients improved sleep habits and more productive assumptions about sleep. Studies have shown that these therapies are equally or more effective than are sleep medications. Combining meds on a short term basis with counseling can often be very helpful.

CBT therapies are generally recommended as the first line of treatment for people with insomnia. Part of this process is working with clients on “sleep hygiene.” Examples for improving sleep hygiene include:
Not drinking caffeine after 4 or so in the afternoon
Daily exercise so the body is tired by bedtime
Not watching TV or using electronics in bed (very challenging)
Waking up at the same time every morning, including on weekends and going to bed at the same time at night
Going to bed only when sleepy and when there is a high likelihood that sleep will occur
Putting the clock where you can’t see it
Leaving the bed and beginning an activity in another location if sleep does not result in a reasonably brief period of time after getting into bed (commonly ~20 min)
Avoiding exposure to bright light or energetic music at night
Eliminating daytime naps
 Having a bedtime routine that is relaxing
Not thinking about upsetting topics before bed
Not exercising or eating a big meal too close to bedtime
Making sure the bedroom is the  right temperature for you and that your  pillows and  sleep space are comfortable and doing what you can to reduce noise and activity that may disrupt your sleep (pets, kids, etc)
Thinking of things that start with each letter of the alphabet (foods, puppy names, cities, whatever) can give your brain something to do besides worrying about falling asleep

I talk with clients about these behavioral changes. I also talk with them about muscle relaxation exercises,  deep breathing exercises,  and meditation.  All of these can help with stress and relaxation.  Listening to  quiet music or  CDs of nature sounds can also  help  people to be less tense. White noise machines can be helpful. Prayer or reading a devotional before bed can give you something to think about as you’re going to sleep, but don’t start worrying as you’re praying. Ask for peaceful sleep and tell yourself (and God) that you are trusting Him with problems and concerns. 

I also help clients talk through whatever stressors or worries may be  contributing to their insomnia.  Scheduling a worry time for earlier in the day can be helpful. Journaling or thinking about concerns and what to do about them during this time keeps them separate from sleep time and you can remind your brain that it isn’t worry or get angry time when you’re trying to fall asleep. Resolving problems, having a plan for what they think might help, or  at least having some ideas about what might  be a step in the right direction, can help  clients relax and give their brains a break so they can sleep.

Many times, the harder clients try to sleep and the more they worry about it, the harder it is to  fall asleep and stay asleep. I  work with them on not worrying so much about  success or failure.  I often encourage clients to just  commit to “getting comfortable,” “relaxing,” or “just resting for a few minutes”  so that they aren’t feeling pressured to fall asleep and stay asleep for eight hours.  This can  make it easier to actually trick the brain into allowing you to fall asleep. I also encourage them not to keep checking clocks. Many clients dread the frustration of lying awake for hours and dreading the next day because they know they’ll be tired so we try and get them to get up and do something that is not overly stimulating when they can’t fall asleep. Tossing and turning in bed doesn’t help. If they sit on the couch and read or watch TV and happen to fall asleep, then great!

Many people turn to OTC meds and other substances  to help them sleep. Over-the-counter sleep aids (Benodryl, Unisom, Tylenol or Advil PM, etc) contain antihistamines that can induce drowsiness. But antihistamines may reduce the quality of your sleep, and they can cause side effects including feeling hung over the next day, dizziness, and other problems. Many clients want to  be prescribed something to help them sleep.  I  obviously refer them to a physician to discuss this, as counselors can’t prescribe medications.  The meds I  hear about most often are Ambien, Lunesta, which are marketted for sleep, as well as Vistoril (antihystamine), Trazedone (older type of antidepressant), and  Xanax (anti anxiety medication.) Some of these can be habit forming or be less effective over time. They may also cause problems like increased appetite, memory issues, dizziness, and next day drowsiness if taken too late at night. Recent pharmacological innovations in the treatment of insomnia have included extended-release and alternate-delivery formulations of existing hypnotics, as well as compounds with entirely new mechanisms of action. If chronic pain is contributing to sleep problems, this should be discussed with a physician, as well.

Of the many herbs promoted for sleep enhancement, only melatonin and valerian have been shown to consist of beneficial properties. Melatonin has been approved by the Food and Drug Administration (FDA) for treatment of circadian rhythm disturbances in adults. However, melatonin is unregulated and may vary in strength and purity across manufacturers. Your body naturally produces melatonin, releasing it into your bloodstream in increasing amounts starting at dusk and tapering off toward the morning. The safety of using melatonin for more than three months isn’t known. A psychiatrist recently told me that using the types of melatonin that dissolve in your mouth will allow your body to absorb it better without it having to go through being partially killed off by stomach acids and the digestive process. Valerian is another dietary supplement sold as a sleep aid. Some studies suggest it is helpful for those experiencing insomnia while others  indicate it is no better than a placebo. Warm herbal teas with mint and camamile in them or warm milk with honey may actually help promote relaxation and sleep. Many people think a drink will help them sleep. Alcohol is a sedative that may help you fall asleep, but it prevents deeper stages of sleep and often causes you to awaken in the middle of the night.

Insomnia is a frustrating and common problem. Well rested people are happier people more able to  engage with loved ones and take part in  activities they enjoy.  People who are not tired are more able to make good decisions, are safer on the roads, and  are more productive at work and in society.  Progress has been made and many clients do find that combining lifestyle changes, counseling, and medications helps them get a better night’s sleep. New treatments and  new research are coming out all the time that will help us  try and address insomnia more effectively. 

Info on Insomnia from MayoClinic.com
http://www.mayoclinic.com/health/insomnia/DS00187″>http://www.mayoclinic.com/health/insomnia/DS00187http://www.webmd.com/sleep-disorders/guide/insomnia-symptoms-and-causes</a
Tips for Helping You Shut Off Your Brain Before Sleep
http://psychcentral.com/lib/12-ways-to-shut-off-your-brain-before-bedtime/0006577

Wide Awake: A Memoir of Insomnia is an interesting and informative read on this topic as the author describes her efforts to find help for her own insomnia and to understand the condition.

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Responses

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  3. Really enjoyed the article! Good points, especially the plug for CBT. It really is what works for chronic insomnia.


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