A Behavioral Approach to Insomnia
Sleep is a natural and necessary phenomenon for humans. You should not really have to do anything special to fall asleep, as the Circadian Rhythm (day-night cycle; biological clock) and the need for rest help us fall asleep. If this is not your case, then we invite you to continue reading on, as we may be of help to you.
After a good night’s sleep you should feel relaxed, with no unexplained bodily aches and pains, and with sufficient energy to face the new day. If for a prolonged period this is not so, then you may begin to suspect you may have some difficulties related to your sleep or even a sleep-related disorder.
To understand and treat insomnia we first need to learn about sleep. The need for sleep varies across the different developmental stages. Thus, a newborn baby will spend most of the day sleeping, for at this stage of development energies are required primarily for the growth process, as opposed to for interactive activities. As we grow older, and we become developed physically, the need for sleep stabilizes around eight hours per day when we reach maturity, that is, around age 20 years old.
Following the attainment of physical maturity, the body devotes relatively little energies to the maintenance of bodily functions and growth, and most to our daily, interactive activities. This will remain so for the next several decades, beginning a slow, but negative slope in terms of sleep requirement. The case is such that when we enter retirement age, around 65 years of age, we may need fewer than six or seven hours of sleep each day to recuperate our energies.
The process of falling asleep is what we call the “sleep ritual”. This sleep ritual consists of the preparations you engage in, such as your hygienic habits, and putting on your customary sleep clothes or pajama prior to going to bed. For some adult people, a ritual of putting to bed the offspring may be included, and, later on, some interaction or even sex with the spouse. All of these activities may be accompanied (before, after, or even at the same time…) by listening to music, reading, or watching TV.
One important characteristic of the sleep ritual is that of winding down activities. This is so because sleep requires a certain type of slow electrical wave pattern in our brain cortex that is characteristic of rest and relaxation, as opposed to the highly active pattern present during daytime activities.
This process of winding down eventually leads to what is called the “hypnagogic” period, in which we are in a sort of trance, as we are not fully awake, nor fully asleep yet. This period is experienced as a sort of drowsy state, with increasingly less frequent moments of awareness of self and of the environment, until you fall asleep. In the morning, the opposite process occurs, and is called the “hypnopompic” period.
The mundane pressures of life, the consequences of difficulties we may be experiencing (be them real or perceived), the state of our health and mental health, and even maladaptive patterns of behavior all affect the sleep ritual and the hypnagogic period, thus limiting our capacity to fall asleep. This situation facilitates the onset of insomnia, herein broadly defined as a disorder characterized by difficulties in the onset, duration, or quality of sleep.
Let us briefly explore some of these situations that produce insomnia. Pressures related to work performance, pressing debts, personal or family illness, and the occurrence of any number of catastrophic events, of any magnitude, worry us and activate the electrical activity of the brain cortex to the level of daytime activities. If this occurs during the sleep ritual or hypnagogic period, sleep will be inhibited.
In a similar fashion, certain physical and mental health disorders will activate our brain at the time we are the most intimate with ourselves, namely, when we go to bed, thus inhibiting sleep. These disorders may be at the phase of onset, or already be in full development, and include conditions such as certain physical symptoms or conditions (e.g., coughing, fever, urinary urgency, and diarrhea), or emotional problems, such as the major mood disorders, and the anxiety-related disorders.
Examples of maladaptive patterns of behavior include bringing work to the bedroom, arguing with the spouse or children shortly before or during the sleep ritual, thinking or even talking about the problems faced, financial matters, or pending future activities, reading a “thriller” or watching a most interesting TV program or movie, going to bed past the customary time, and watching the hours go by in your alarm clock. All of these behaviors are practical invitations to insomnia, and should be limited or, preferably, avoided.
What can we do? The most important point is to avoid self-medication, for drugs interfere with the natural sleep process. Further, if we recognize the elements of a mental health disorder, then the appropriate step is to consult a mental health specialist, who can then evaluate your situation and suggest the appropriate course of action.
Your therapist can suggest specific instructions for you to follow, and can even teach you muscular relaxation exercises to help induce relaxation and sleep, to inhibit unwanted, repetitive thoughts, and the ensuing tension and anxiety. Other techniques and procedures are available to your therapist, who will use them with you depending on your specific needs.
Of course, your therapist may deem it is necessary for you to take some medication to facilitate inducing your sleep. This type of approach should be carefully monitored, as the treatment should ideally be only for a specific, short-term period of weeks, not months or years.
In any event, you can help improve your sleep by following our recommendations given here even if you follow treatment with a specialist. If this is the case, just make sure you first consult with your clinician prior to following our instructions.
You should analyze your sleep ritual. What do you attribute your loss of quantity or quality of sleep to? What do you normally do or engage in? Is each activity geared towards sleeping, or is it somehow contrary to it? Try to avoid the inappropriate behaviors, and maximize your pattern of behaviors so as to facilitate the onset of sleep.
Try to go to bed at the same time, and to follow the same bedtime ritual every day so as to create a habit. When you get ready to go to bed, try to not engage in any activity that is not directly devoted to going to sleep. Do not start watching a movie that you will want to finish viewing. The same advise applies to those books you cannot stop reading. The idea is to wind down, to “turn in”, and not to activate your brain.
Remember that what works for you may not work for others, so experiment and find out what works best for you. You will know you are successful because your sleep will improve.
The following are some activities that facilitate the onset of sleep:
- a pleasant evening walk, especially with someone you care for before bedtime
- a strenuous physical workout anytime during the day
- a cooling or warm bath before going to bed
- laughter at bedtime
- avoid excess alcohol, tobacco, other licit or illicit drugs, in particular, stimulants, and drinks with caffeine, especially close to bedtime
- drink milk (hot or cold, without stimulants such as caffeine-containing coffee, tea, or chocolate)
- low-level ambient light or darkness at bedtime
- slow, relaxing music at a comfortable low volume while in bed
- reading for relaxation while in bed
- muscular relaxation exercises throughout the day and at bedtime
- relaxing or erotic/sensuous massage at bedtime
- sex with a partner or self-masturbation at bedtime or if you wake up in the middle of the night
The bed should be primarily for loving and sexual activities with your partner and for sleep. Do not use it to tumble around or to “fight the bed”. If you find that you cannot fall asleep even after following your sleep ritual, then get out of bed, find a not-so-comfortable chair, and with minimal reading light, start reading the most boring material you can find. Yes, boring. Do not go back to bed until you feel very sleepy, even if you feel pressed to sleep because of your activities the next day. Anyway, the pressure to sleep is what is probably provoking the lack of sleep. Repeat this procedure as often as necessary.
If you have difficulty falling asleep, wake up in the middle of the night, or wake up too early in the morning, rather than activating your brain thinking about work or life-related activities, try to enjoy the calm and stillness of the moment, do your relaxation exercises, count sheep, count numbers from one to ten, pray, or even hum as in chanting. But engage in any of these activities to effectively block the activation of your brain, rather than as a tense or anxious response to the sleep disturbance.
If you sleep poorly or not enough hours, the next day do not sleep during the daytime. It is better to maximize the sleep deprivation so as to facilitate the re-establishment of your normal sleep pattern. In other words, if you are sleep-deprived, the next day it will be easier for you to fall asleep at the appropriate time.
Some conditions merit special consideration. These are “jetlag”, rotating or night schedules, and what is known as “seasonal affective disorder”. Jetlag occurs when you travel in a relatively brief period of time to a different time zone, particularly a very distant one. Your body is still reacting as if in the previous time zone, and this may cause sluggish behavior and sleep difficulties. Jetlag usually only lasts a few days and typically resolves without special treatment. However, you can improve your condition by exposing yourself to one or two hours of strong solar or artificial light during the daytime, and by following the instructions given in this publication. Of course, while doing this, the use of adequate sunglasses and solar filter for your exposed skin are required.
Rotating or night schedules typically benefit the corporation and not the employee. The natural order for humans is to follow the Circadian Rhythm and be active during the day and asleep at night. Since machines do not really require this daily rest period, and there is the need to maximize production, humans are made to adapt to working with these machines at times when they should be playing, resting, or asleep. Theoretically, time will help the person get used to the new schedule, as humans are quite adaptable. However, we do not yet fully know the consequences for human beings of these types of schedules.
Seasonal affective disorder refers to significant emotional and behavioral changes which affect the individual and which occur in association to environmental changes typical of the different seasons of the year, especially in reference to the number of available hours of daylight. This is an emotional disorder, and is best treated by a mental health specialist.
It is advisable to track your efforts to improve your sleep. An easy way to do this is to keep a pencil and paper next to your bed and each morning record the number of hours slept and the quality of your sleep, from 1 to 10, with 10 being a fully relaxing and restorative night sleep. Record also the number and approximate duration of sleep interruptions.
After two or three weeks following this program, evaluate your results. If your sleep has improved to a level you are comfortable with, then you have accomplished your goal, and you are already enjoying again a good night’s sleep. If not, then it is time to consult your mental health specialist. It is recommended that you inform this specialist what you have already done to self-help yourself, as this will be very valuable information to help you recuperate or improve your natural sleep.
© 2006 Angel Enrique Pacheco, Ph.D., C.Psych. All Rights Reserved.
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