Self Help Library

PART II – SLEEP HYGIENE

This is part two of a four part series on understanding and overcoming chronic insomnia.

Quiz

1. True or False: Raising body temperature by exercising ½ hour before bedtime can help us fall asleep.

2. True or False: Raising body temperature by taking a warm bath ½ hour before bedtime can help us fall asleep.

Answers and explanations provided at the end of this article.

What is Sleep Hygiene?

Sleep hygiene is the practice of preserving your sleep health.  When working with insomnia patients, I review two general categories of sleep hygiene: bedroom factors and lifestyle factors.

Bedroom Factors

• Alarm clock
• Air quality
• Temperature
• Noise
• Light
• Bed comfort

Lifestyle Factors

• Caffeine
• Nicotine
• Alcohol
• Diet
• Exercise
• Work
• Travel

After reviewing these factors together, we discuss possible changes to their routines that may improve sleep.  Making these changes often requires sustained effort over time to develop healthy habits.  Try to be consistent and patient.  Remember that improvements in your sleep won’t necessarily occur overnight.  Some sleep hygiene changes take weeks or months to translate into better sleep.

Sleep Hygiene as a Frontline and Long-Term Treatment

Improving sleep hygiene makes sense as a “frontline” approach, or the first approach to try, because of its favorable risk/benefit ratio.  There are very few risks associated with making improvements to your bedroom routine and lifestyle, but the potential benefits in terms of how you sleep, feel, and function can be great.

The most important concept to keep in mind with sleep hygiene is long-term commitment to the changes.  The benefits of sleep hygiene tend to be subtle in the short-term, but more pronounced in the long-term.  In contrast, sedative medications can have a pronounced impact in the short-term, but become less and less effective in the long-term.  Even if you utilize other additional strategies to manage insomnia in the beginning, sleep hygiene will be an important part of the equation for success in the long run.  I urge my patients to not underestimate the importance of sleep hygiene.

Specific Examples of Sleep Hygiene in Practice

Alarm Clock: Bianca used to wake up many times throughout the night and compulsively look at her alarm clock to see what time it was.  When she saw the time on the clock, she would become frustrated, and sometimes stare at the alarm clock for hours.  When it finally went off, she would dread getting out bed, feeling exhausted.  A simple change Bianca was able to make was to turn her clock so she could no longer see the time display from her bed.  When she woke up, she practiced distraction and relaxation strategies instead of looking at her clock.  With practice, she was able to fall back asleep within a few minutes when she woke up.  (Note: Waking up and falling back to sleep a few times per night is considered normal for healthy sleepers.)

TV in Bedroom: When I first began working with Jeff, he had a flat screen TV mounted on his bedroom wall that he watched every night (and sometimes in the mornings and daytimes on the weekends).  Jeff vehemently defended his TV in the bedroom as a necessary tool to help him decompress after a stressful day and fall asleep.  He was unwilling to compromise and make a change in this arena.  After some success with other strategies to improve his sleep, Jeff experimented with not watching TV in his bedroom.  Begrudgingly, he acknowledged that his sleep was more restorative after committing to watching TV only in the living room, and going right into bed when he began to feel sleepy on the couch.  It was still a sacrifice for him because he missed the TV in the bedroom, but his improved energy and mood were worth it to him.  Eventually, he moved his flat screen TV to a place where he could watch it while exercising on his elliptical trainer.

A Healthy Bedtime Routine

The last tidbit of sleep hygiene advice that I will share is from a great book on the topic of sleep hygiene by Michael Breus called Good Night: The Sleep Doctor’s 4-Week Program to Better Sleep and Better Health. One of the strategies described in the book is the 20/20/20 bedtime routine used during the last hour before getting into bed.

• 20 Minutes: Prepare for tomorrow (lunch, clothes, reminders, etc.)
• 20 Minutes: Bedtime routine (pajamas, wash face, brush teeth, etc.)
• 20 Minutes: Relaxation (prayer, meditation, deep breathing, imagery, etc.)

Answers to Quiz

1.  False.  Actively raising your body temperature by exercising raises your core body temperature which may take a few hours to cool down.  An increase in your core body temperature will tend to keep you awake.  Therefore, rigorous exercise before sleep is generally considered poor sleep hygiene.

2. True. Passively raising your body temperature by taking a warm bath usually raises the temperature of your skin tissue, which cools down more quickly.  A slight drop in body temperature can induce sleepiness.  Thus, a warm bath before sleep is considered good sleep hygiene.

I hope the insights I’ve shared thus are helpful for you.  As always, be kind and compassionate with yourself. Managing your sleep health is a life-long process.

Jim Carter, Ph.D.

Clinical Psychologist

Specialty Behavioral Health

San Diego, CA

PART I – DEFINITION AND CAUSES OF CHRONIC INSOMNIA

This is part one of a four part series on understanding and treating chronic insomnia.

Insomnia Quiz- Part I

1. True or False: The amount and quality of our sleep can affect hormones related to craving food and satiety.

2. True or False: Animals can die from extended sleep deprivation.

Answers to quiz and explanations provided at the end of this article.

Definition of Insomnia

The general definition of insomnia can be quite simple – the inability to initiate or maintain restorative sleep. When we use this definition, insomnia is the most common sleep problem in the industrialized world and roughly 30%-40% of persons complain of insomnia at some point in their lives.  Although concise, this definition tells us little about the significance, cause, or prognosis of the insomnia.  Over the past few decades, researchers have attempted to clarify the definition in several ways.  The Fourth Edition of Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association specifies that the insomnia occurs for at least one month and causes impairment in function, and is not due to other medical, psychiatric, or sleep disorders.  When the DSM-IV criteria are added, the prevalence estimates drop to about only 6%.  Even more specific criteria are defined in the Second Edition of International Classification of Sleep Disorders (ICSD-2).  According to the ICSD-2, insomnia is one of eight categories of sleep disorders.  Within the ICSD-2 category of insomnia, there are several specific types including acute insomnia, paradoxical insomnia (sleep state misperception), behavioral insomnia, and psycho-physiological insomnia, to name a few.  Recognition of these subtypes is useful because each has unique causes and specific treatments that may be effective.

Although there are no universally accepted criteria for defining the presence of insomnia, I generally use the following two specific thresholds to identify persons who may benefit from treatment for insomnia:

1. Difficulty falling or staying asleep at least 3 times per week, for at least 1 month:

• Delay of 30 minutes or more to fall asleep, or
• Awake for 30 minutes or more during sleep period; and

2. Daytime consequences of disrupted sleep:

• Fatigue, sluggishness, or
• Somatic complaints, or
• Stress about poor sleep, or
• Mood disturbances, or
• Poor concentration, or
• Impaired performance

Factors that Cause and Maintain Insomnia

If you ask an endocrinologist about what causes insomnia, she’ll probably tell you about the involvement of the hypothalamic-pituitary-adrenal axis, levels of adrenocorticotropic homorone and cortisol, the biochemical factors associated with aging and gender, diseases, etc.  Ask a sociologist about what causes insomnia and he may inform you about the impact of industrialization including light pollution, noise pollution, stress associated with increased demands and expectations, etc.  In reality, all of the different factors are relevant because sleep is a fragile bio-rhythm affected by many things in our lives.  Thus, there are probably an infinite number of causes of insomnia, and we are all likely to experience insomnia at some point in our lives.

According to the cognitive behavioral model of insomnia, regardless of the specific factors that may have initially caused the insomnia, there are often common factors that are likely to maintain insomnia.  These factors are described below.

Environmental Factors: There are many environmental factors that can influence your sleep.  Some of the more obvious ones are noise, light, comfort of your bed, and compatibility with bed partners’ sleep routines.  Other factors that are less apparent but equally important include temperature, consumption of food, activity, and perceived presence of danger.   Especially important for behavioral insomnia are social pressures to stay awake so that we can interact (e.g., texting or chatting online), attend events (e.g., parties) or meet demands of work.

Homeostatic Pressure: Homeostatic pressure is the desire for sleep that develops by being awake over time.  It is similar to the concept of hunger that develops by not eating over time.  If you eat a larger meal with more calories, you will not be hungry for a longer period of time after the meal.  Likewise, if you sleep for a longer period, you will not be sleepy for a longer period of time when you awake.  Homeostatic pressure is affected primarily by how much you sleep – when you sleep less, it builds and when you sleep more, it decreases.  Among persons with healthy sleep, homeostatic pressure increases and decreases predictably and rhythmically on a daily basis.

Circadian Rhythm: The circadian rhythm is a biological rhythm that interacts with cues in the environment (zeitgebers) to regulate our daily sleep and wakefulness.  It helps us wake up and fall asleep around the same time each day, but also allows us to adjust to normal variations or big changes such as relocating to a different time zone.  The benefits of the rhythm can be strengthened by maintaining a consistent sleep wake schedule and exposure to bright light.  Aligning the circadian rhythm with the rhythm associated with homeostatic pressure can also help to achieve and maintain healthy sleep patterns.

Conditioned Arousal: Conditioned arousal refers to learned associations between cues in the environment and levels of arousal.  When you experience insomnia, cues in the bedroom environment can become associated with feeling alert, or even frustrated.  As a result, it’s likely to begin feeling more physiologically aroused as you prepare for sleep or when you wake up during your normal sleep time.  Fortunately, you can learn relaxation strategies to decrease your levels of arousal and develop new behavioral strategies to decrease the associations with cues in your environment.

Attitudes About Sleep: As insomnia continues, you may understandably develop more negative attitudes about sleep.  It is common to believe that you are losing control, you are unable to improve your sleep, or to feel like giving up on making changes.  If left unchecked, these negative attitudes can increase your level of arousal and discourage you from seeking and continuing with effective treatments.  Therefore, learning to recognize and challenge unhealthy attitudes can be critical for your success with overcoming insomnia.

Answers to Quiz

1. True. Getting less quality sleep increases a hormone level that induces craving for high calories foods (ghrelin) and decreases a hormone level that signal we are full from eating (leptin).  Therefore, healthy sleep can be critical for maintaining healthy body weight.

2. True. Animals that are deprived of sleep for extended periods die.  Sleep is an essential need for survival, similar to other needs such as water, food, and shelter.