Sleepless in America

Managing Jet Lag

John Cline, Ph.D. — Mon, 16 Nov 2009 14:21:54 +0000

Jet lag occurs as a result of rapid travel over several time zones so that there is a temporary mismatch between the internal timing of the sleep/wake cycle and the external time demands for the sleep/wake schedule of the changed time zone. Typical symptoms include disturbed sleep, impaired functioning and decreased alertness. Those who have to travel to new time zones for business or pleasure often experience these symptoms. Is there anything that can be done to help speed up the recovery from or reduce the impact of jet lag?

In general, it takes about 1 day to acclimate to each time zone crossed. Some laboratory studies suggest that bright light can help shift the circadian rhythm by as much as 2 to 3 hours per day, potentially speeding up recovery from jet lag. Crossing one or two zones usually does not result in major symptoms. Crossing three time zones is usually enough to cause significant symptoms. These symptoms may last a few days to more than a week. Traveling around the world can result in significant symptoms that persist for weeks. Of note, it also appears that it is more difficult to adapt to jet lag as we get older. Shift workers also tend to have a more difficult time with jet lag.

The main thing to keep in mind is that travel across time zones forces "phase shifts" in the circadian rhythm. Eastbound flights force a phase advance. This means that you will have to go to bed at an earlier circadian time to match the clock time in the new time zone. For example, if you travel east over 3 time zones your usual bed time of 10:00 PM now falls at a circadian time of 7:00 PM so that it will be difficult to fall asleep. In the same way, a local clock time of 7:00 AM is the circadian time of 4:00 AM so that it will be difficult to wake up and be alert. Westward travel tends to be less difficult than eastward travel as it is easier to stay up later than go to sleep earlier. In this case 10:00 PM local time falls at a circadian time of 1:00 AM and 7:00 AM clock time is the circadian time of 10:00 AM. An eastbound flight forces a phase advance with sleep onset problems and daytime fatigue while westbound flights force a phase delay with fatigue and sleepiness.

There are two useful approaches to reducing the severity and duration of jet lag symptoms. There are preventative strategies carried out before travel to help prepare for and so reduce the impact of jet lag. There are also ameliorative strategies to cope with and reduce the effects of jet lag. Both of these involve behavioral strategies, use of photo therapy, and possibly melatonin. The recommendations below are best for trips across three to six time zones. Travel over more than six time zones is more complicated when using phototherapy and melatonin. In this situation, unless very carefully timed, light therapy or melatonin could actually make jet lag worse rather than helping. It is probably best to consult a sleep specialist to help you work out the more complex schedule of use needed for these kinds of trips.

You may have encountered very complex schedules for the use of bright light and melatonin but people often find these too complicated to actually use. The techniques described below are relatively simple and generally easier to use.

Short duration trips involving travel across three or more time zones may not give enough time to significantly recover from the time shift before the return trip. In this case, it is probably best to try to maintain your regular sleep/wake schedule to the degree possible and plan meetings and activities at times that you will be most alert.

Preventative behavioral strategies involve beginning to shift the internal clock by changing the sleep schedule before travel. For eastward travel this would involve going to bed earlier and getting up earlier for a week before travel. Important meetings or vacation activities should be scheduled in the afternoon in the eastern time zone. Another strategy is to arrive several days before important activities to give time to acclimate to the new time zone. Westward travelers can benefit by beginning to gradually go to bed later and get up later during the week before travel.

It is important to decrease the effect of travel itself on jet lag. Many of the uncomfortable aspects of jet lag occur due to the stress of travel which can also affect the circadian system. Drinking a good deal of water can help as dehydration actually makes it more difficult for the body temperature adjust to the new time zone, making falling asleep more difficult. Avoidance of caffeine and alcohol on the trip will help prevent dehydration.

Sleeping medications do not shift the circadian clock, however, they can sometimes be helpful in adjusting to the new bed time. They may help improve sleep and reduce some symptoms of jet lag. Caffeine has often been used to promote daytime alertness when dealing with the typical decreased alertness characteristic of jet lag.

Unless you are staying for a very brief time in the new time zone, as described above, or are able to control your schedule so that you can use bright light effectively, it is best to try to adjust to the new time schedule even if your body does not agree. Exposure to the local sun light, meal and activity schedule will tend to resynchronize the circadian rhythm to the local time.

With regard to phototherapy, after traveling east, the recommendation is for exposure to morning sun light and decreased light in the evening hours. This will tend to advance the sleep schedule so that you will want to go to sleep earlier. For westward travel, evening light exposure may help by making it easier to stay up until the new bed time. Some frequent flyers may want to purchase light boxes and these can be used prior to travel to help prepare for the trip. The light boxes can be used several days before travel. If going east, you should use bright light in the morning and if going west, use it in the evening. Be sure to pay attention to all health warnings associated with the use of light boxes such as the safe amount of eye exposure, being sure that the box has proper shielding for ultraviolet wavelengths and not using it unless under the supervision of your physician if you have a history of mania.

There is some evidence that melatonin both helps shift the circadian clock and helps consolidate sleep. When traveling east, melatonin 0.5 mg can be taken in the evening to help advance the circadian clock. I do need to point out, however, that melatonin has not yet been shown to be fully safe and effective and no FDA approved indication currently exists for it.

Jet lag is a feature of the modern world that affects many people. Use of a few behavioral techniques can help assure that you don't end up sleepless, in say, Seattle.

Jet Lag

John Cline, Ph.D. — Mon, 19 Oct 2009 15:56:37 +0000

You may have seen the recent Saturday Night Live skit about ‘Muammar al-Gaddafi' attributing his rambling UN speech to jet lag. While the skit was funny, jet lag is not.

Consider the possible impact of jet lag on real life political leaders as they travel half way around the world to engage in sensitive negotiations. They need to be at the top of their game, not groggy with brain fog. What about the effects that jet lag may have on the complex business schemes that are transacted daily by fatigued, time pressured and jet lagged executives? "Deal or no deal" can be a difficult decision in the best of times - let alone when red-eyed and raw with jet-lag. And what about those of us with simpler goals? We want to enjoy our fun in the sun, but many vacationers may find it difficult to enjoy a significant part of their vacation because they have a slow recovery from their lengthy flight.

Jet lag is a type of circadian rhythm disorder that is new to the modern world. Circadian rhythms evolved to allow organisms to benefit from preparing for predictable changes in the environment before they occur. As an example, for a creature that has to find food during the day, having a mechanism to wake up as the sun is rising, even on cloudy days, is very beneficial. The circadian or 24 hour system can slowly adapt to changes in the environment, say for example, as the period of daylight shortens in northern latitudes in the fall and winter. Jet lag is a disorder unknown before the 20th century as no one before the invention of the airplane could travel fast enough to cross enough time zones to affect the circadian system. With older forms of transportation, the circadian system has a chance to slowly shift to keep up with changes in the difference between the internal and external clocks - as when sailing ships slowly made their way around the world. Jet lag affects east-west travel rather than north-south travel as there is no change in time zone with north-south travel. Being very far north or south can, of course, lead to other circadian problems, such as those experienced by Antarctic scientists who spend months in the dark.

Jet lag occurs when there is a temporary mismatch between the internal timing of the sleep wake cycle and the external time demands for the sleep wake schedule of the changed time zone. Symptoms are usually experienced if three or more time zones are crossed and appear within a day or two of being in the new time zone. Generally, the more time zones crossed the worse the symptoms and the longer they persist. With travel of seven time zones or more the internal clock may shift opposite of the direction of travel. This results in severe and prolonged jet lag. A significant problem is exposure to light at inappropriate times as this can shift the internal clock in the wrong direction. Symptoms typically include disturbed sleep, impaired functioning and decreased alertness. Traveling eastward is usually more difficult to adjust for than westward travel. This is the case, at least in part, because you can generally force yourself to stay up later but cannot make yourself fall asleep.

To see how this works, imagine a transcontinental round trip from New York to Los Angeles. On the first night of the trip there is a three hour time change so that when the clock in Los Angeles says is it 11 pm, your usual bed time, your internal clock, set to New York time, feels that it is 2 am. This is disruptive to sleep but generally less so than the reverse trip. After several days in Los Angeles the internal clock shifts to match the external demands of the west coast time zone. In west to east coast travel, the clock in New York says it is 11 pm, your usual bed time, while your internal clock feels that it is 8 pm - an hour when it is usually very difficult to go to sleep. Generally, it takes about one day in the new time zone to acclimate to each time zone shift. Symptoms of jet lag are further complicated by the often stressful conditions of long distance travel - long flights spent in an uncomfortable sitting position, unfamiliar environments, poor quality food, excessive use of caffeine and alcohol and so on.

For most people, jet lag can be endured and will gradually correct itself with enough time in the new time zone. For people working in the airline industry, serving in the military or who have business or government work that requires frequent travel, jet lag may be a greater concern. For example, some female airline personnel have been reported to experience menstrual symptoms associated with frequent travel. And we can only imagine what damage has been done to international relations and what poor business deals have been worked out by overly stressed, jet lagged people. In the next post I will discuss ways of speeding up the process of coping with jet lag. In the meantime, Bon Voyage!

Delayed Sleep Phase Disorder Part 2: Treatment

John Cline, Ph.D. — Fri, 25 Sep 2009 03:24:15 +0000

Kristin was late to school again, as she had been so many times before. Since she didn't go to bed until 3:00 a.m., she wasn't able to get out of bed at 6:30 a.m. for school. This time she had to meet with the principal. The message was clear: take care of this problem or you will fail and not graduate with your class. After discussing this problem with her parents, she agreed to see her pediatrician who recommended an evaluation with a behavioral sleep specialist. The diagnosis was clear. Kristin has delayed sleep phase disorder. A letter was sent to the principal asking for a temporary later start time for school while she was working on her sleep problem. This request was granted by giving her a study hall in the morning with prior approval to miss this class if necessary. This reduced her stress considerably and helped her better focus on her school work and on the sleep program.

The sleep specialist recommended immediately limiting use of the computer and sending text messages to friends to no later than 9 p.m. Not wanting to fail this school year, she reluctantly agreed. Her parents obtained a recommended bright light box that she would start using every morning upon awakening. She started taking an over the counter supplement of melatonin, although the sleep specialist noted that this is not an FDA approved treatment and over the counter supplements are not closely regulated by the government. She also kept a sleep journal, started going to bed 15 minutes earlier every few days and used a very loud alarm to get out of bed in the morning. Although it was difficult, over a period of a number weeks she was able to "reset" her circadian clock. She eventually was going to bed around 11:00 p.m. and was able to get herself up at 6:30 a.m. She still tended to sleep a bit later on the weekends but maintained a regular 11 p.m. bed time most nights of the week, including weekends. This took some ongoing effort on her part. She almost never missed her morning study hall. She finished the school year with reasonable grades and graduated with her class.

Kristin's treatment highlights a number of the techniques used to "reset" the circadian clock and end the nightmare of delayed sleep phase disorder. The techniques are described in greater detail below.

Some of these techniques, such as keeping a sleep journal, gradually going to bed earlier and not looking into bright light sources like computers late at night can be used by any one who finds that they are going to bed and getting up later and later. Other techniques such as phototherapy, oral melatonin and chronotherapy should be used under the direction of a sleep specialist or a physician familiar with these techniques. This is because careful attention must be paid to the timing of these interventions so as to not make sleep problems worse. Calculating the appropriate times requires sound knowledge of the sleep/wake cycle and circadian rhythms. In addition, phototherapy must be used with extreme caution by anyone with a history of bipolar disorder as use of the light source at an inappropriate time could contribute to the onset of a manic episode.

Delayed sleep phase disorder occurs when there is a delay in the major sleep episode relative to the desired clock time. As a result, the person has a hard time falling asleep and getting up at a normal time. Often people with this problem will use sleeping pills or alcohol to try and get to sleep sooner but this rarely works. Alcohol usually makes the problem worse. It is still unclear to what degree both genetic and environmental factors impact on the development of this disorder but both are most likely involved. People with this disorder may experience depressed mood and have great difficulty functioning at school or work. A delayed sleep phase occurs when people are habitually going to bed later and getting up later than the desired clock time. (An advanced sleep phase, often seen in the elderly, is the opposite. The bed time and rise times occur earlier in the day than is normative.) People with delayed sleep phase disorder typically go to sleep between 2:00 and 6:00 a.m. Delayed sleep phase disorder may last from months to decades, usually starts in adolescence and rarely starts after age 30. A typical goal for treatment would be to have a sleep schedule with a sleep period of 11 p.m. to 7 a.m.

Sleeping medication is sometimes used temporarily in an effort to induce sleep at a normal time. This often is not very successful and usually results in daytime grogginess. It is most helpful to people who also have some degree of insomnia.

Morning Phototherapy involves exposure to bright light upon awakening. It helps to increase morning alertness and advances the sleep phase in the evening. An inexpensive way to get exposure to bright light (depending on weather conditions, the location and season of the year) is to open the window shades or take a walk in the bright morning sun. Alternatively a specially designed bright light box may be prescribed. These boxes provide between 2,500 and 10,000 lux. Depending on the brightness level, they are used for periods of 30 min to 2 hours. Precise timing of use is critical and is related to the core body temperature minimum. The light is administered about 30 minutes earlier every other day to help gradually advance evening sleep onset. This treatment can be effective in 2 to 3 weeks when combined with evening light avoidance, but often requires ongoing treatment to maintain gains.

Evening light avoidance involves greatly reducing room lighting and light exposure in the evening. This is necessary to prevent worsening of delayed sleep onset. It may even be necessary to use protective eyewear, such as sun glasses, in the evening when driving home from work to reduce light exposure.

Ingestion of oral melatonin later in the day has the effect of advancing the onset of sleep. Proper timing is again critical and is dependent on the dim light melatonin onset which occurs about 14 hours following the habitual wake time. A reasonable estimate for the appropriate time to take melatonin for the purpose of advancing sleep onset is about 8 hours after the natural wake up time. A lower dose is recommended in order to get the clock resetting effect without creating strong drowsiness as may occur with higher doses.

Chronotherapy can be used if there is a flexible enough daytime schedule. Sleep onset is delayed 2 - 3 hours on successive days until the desired bed time is reached. Obviously, this will be difficult for anyone with a regular work or school schedule. It may be possible to do over a vacation. Once a regular bedtime is established it must be rigorously maintained. Relapse is possible and the process may need to be repeated.

Cognitive behavior therapy is useful to help people improve their sleep hygiene such as keeping a better sleep schedule, decreasing excessive caffeine use and adhering to evening light avoidance. People with delayed sleep phase may also have conditioned arousal that contributes to concomitant insomnia that may be usefully addressed by cognitive behavior therapy.

Maintenance is extremely important. Keeping a regular bedtime and morning rise time as well as continuing to have morning light exposure and avoiding evening light are critical to maintaining the hard won gains of therapy.

Delayed Sleep Phase

John Cline, Ph.D. — Mon, 31 Aug 2009 02:14:22 +0000

Kristin was running late again. Could she possibly make it to school on time? Her school has a very strict morning start time and she had often missed it. If she is late, not only will she be locked out of her first period class, but she could be suspended this time. She's already had several warnings and fears this could be her last. Why had she stayed up so late last night texting her friends?

Kristin has been having a hard time getting to school on time because she doesn't go to bed until 3 a.m. This is not because she has a hard time falling asleep once she gets in bed. She does not have insomnia. She only has trouble falling asleep if she goes to bed before 3 a.m. At 3 a.m. she is able to easily fall asleep. She does not find it easy, however, to get up at 6:30 a.m., which is the last possible time she can get up and still make it to school on time. In fact, her mother and father practically have to pull her out of bed to get her up. When she does make it to school on time, she often falls asleep during her morning classes. By the time of her afternoon classes, she finally seems to wake up. She is tired all the time and can be irritable. Her grades have suffered as well. On the weekends she still goes to bed around 3 a.m. but sleeps until 1 or 2 p.m. The weekends are the only time she feels rested. She dreads Sunday night knowing what will happen Monday morning.

The sleep problem Kristin is having is one of the circadian rhythm sleep disorders and one that is very common among young people. Circadian rhythm sleep disorders often lead to poor sleep among teens, as I discussed in a previous blog. The primary feature of the Circadian Rhythm Sleep Disorder, Delayed Sleep Phase Type (Delayed Sleep Phase Disorder) is that the major sleep episode is delayed as compared to the desired clock time. That is, the bedtime is at a notably later time than the "normal" time to retire. Instead of sleeping from, say, 10:30 p.m. to 6:30 a.m., the person with delayed sleep phase may sleep, as in Kristin's case, from 3:00 a.m. until whenever she is forced to get up. This can lead to problems such as difficulty falling asleep if trying to go to bed at an earlier time; insufficient sleep if having to get up earlier than the delayed morning rise time; and extreme difficulty waking up when necessary due to social demands such as school or work.

With a Delayed Sleep Phase Disorder, the person's bed time is usually delayed until after 2 a.m. and may be as late as 6 a.m. Adequate functioning is very difficult during the day if the person has to get up at regular times for work or school. Often there is heavy use of alcohol or sleeping medication in an effort to initiate sleep at an earlier time. The sleep architecture is generally normal if the person is allowed to keep an uninterrupted sleep schedule. This means that the stages of sleep are about the same as someone sleeping on a "normal" schedule, just at a different time of the day.

This disorder often starts gradually and leads to a "resetting" of the circadian (24 hour) biological "clock." It often develops as the person stays up later working on a computer, texting friends who also have sleep problems, playing video games or watching TV. Not only do these activities keep the person up but they expose the eye to a significant amount of light later and later in the day. The circadian clock is most strongly set or "entrained" by light. The presence of bright light is a signal for humans to be awake, just as it is in other diurnal animals. For us, darkness is the signal to sleep. Historically there was not much light after the sun went down and sleep generally came easy. Today we can have very bright light sources impinging on our retinas at any time of the day and this can easily, to our detriment, shift the circadian clock.

While the prevalence of delayed sleep phase disorder is currently unknown, it is clearly more common among adolescents and young adults. Among these young people, the prevalence is reported to be 7% to 16%. About 10% of patients that present to sleep disorders clinics with a complaint of chronic insomnia have a Delayed Seep Phase Disorder.

In the next blog I will discuss what Kristin did to treat her Delayed Sleep Phase Disorder and to stop being- sleepless in America.

Cognitive Behavioral Therapy for Insomnia Part 5: Sleep Hygiene

John Cline, Ph.D. — Tue, 28 Jul 2009 13:46:26 +0000

This is the fifth and final post on the cognitive behavioral approach to treating insomnia. Sleep hygiene involves following simple rules designed to promote better quality sleep so as to enhance daytime functioning.

Poor sleep hygiene relates to a number of habits that can have a detrimental effect on sleep. These are familiar to most people and include drinking coffee late in the day, watching the clock through out a restless night and having a noisy bed room environment.

A number of things that are usually included under the heading of good sleep hygiene are related to avoiding substances that can disrupt sleep, preventing excessive nocturnal mentation that can be arousing and prevent sleep onset, not taking daytime naps as they can decrease nocturnal sleep drive, keeping a regular sleep schedule to promote regular drowsiness and wakefulness, and preventing too much time spent in bed while awake or in low quality sleep. Good sleep hygiene can also include efforts to regularize the circadian (24 hour) schedule and to cope better with nocturnal awakenings.

Rules for Good Sleep

1. Limit evening alcohol to one or two drinks with none after 7 pm. Alcohol initially helps people fall asleep and may deepen sleep. Later, however, as alcohol leaves the body some withdrawal symptoms occur and sleep is fragmented resulting in frequent awakenings and very poor sleep. The more you drink the longer it takes for the alcohol to be metabolized out and the more severe the sleep fragmentation will be.

2. Have no more than 2 cups of coffee a day and none after 2 pm. Caffeine persists in the body for a considerable length of time. Caffeine has a stronger effect of disrupting and fragmenting sleep than of preventing sleep onset from initially occurring. This is why some people will say that the can drink a double espresso with dinner and have no problem falling asleep. The question is how good is their sleep later in the night?

3. Exercise 20 to 30 minutes a day, preferably in the late afternoon, within 3 to 6 hours of bed time. Exercise initially raises body temperature and several hours later there is a compensatory drop in body temperature. It is in the evening as body temperature falls that we become sleepy. If exercise occurs in the late afternoon it will help maximize drowsiness around bed time. Exercise also helps decrease stress, a major inhibitor of sleep.

4. Keep the bed room on the cool side. If the bed room is too warm it will be difficult to cool down so that you can fall asleep. A cool, but not too cold, room will help promote the cooling that makes sleep possible.

5. Try to expose yourself to bright light in the morning. This entrains the circadian or 24 hour clock system. Morning sun or bright light helps you feel more alert in the morning and promotes drowsiness in the evening.

6. Keep the bedroom both quiet and dark. Noise and bright light disrupt our ability to fall asleep. Keeping the bed room noise free and as dark as possible helps natural sleep occur.

7. Orient the clock face away from you. Clock watching can be very disruptive of sleep. This is because of the stress caused by being aware of the slow passage of time during the night. This increases arousal and makes it harder to fall asleep.

8. Have a light complex carbohydrate snack about an hour before bed time. Good examples are cheese and crackers. The snack should be about 100 to 200 calories. Be sure that if you have gastric reflux or diabetes that it is medically advisable to have such a snack. The snack can help prevent hunger that may disrupt sleep later in the night.

9. Avoid drinking liquids after 8 pm. This will help decrease the need for night time visits to the bathroom.

10. Have enough room in bed so as to not be disturbed by a bed partner's movement. As discussed in a previous post, many people are sleeping separately today due to a bed partner's snoring or sleep related movements. Even if these are not an issue, having enough room to spread out and get comfortable is important.

Good sleep hygiene is a central component of an effective cognitive behavioral approach to treating insomnia. It may not, however, always be sufficient to overcome a deeply entrenched sleep problem. Other techniques previously reviewed may be needed, as well as the help of a trained behavioral sleep disorders coach (specialist). With good sleep hygiene most people will be on the way to better sleep, and so to better, more fulfilling daytime functioning.

Cognitive Behavioral Therapy for Insomnia Part 4: Sleep Restriction

John Cline, Ph.D. — Mon, 13 Jul 2009 12:36:25 +0000

Matt was lying awake in bed, again. It was 3:30 a.m. His wife and young children were soundly asleep. The hours passed slowly. Thoughts drifted through his mind as he reviewed the day's events. The next morning he could not remember clearly what he had been thinking about all those hours in bed. This night was like so many others he had experienced over the years.

Matt was going through what many people with insomnia experience. While he felt that he was awake for hours on end, more likely he was drifting in and out of light, stage one sleep and drowsy wakefulness. In stage one sleep it is possible to be aware of continued cognitive activity and believe that you are actually awake. This sleep gives some benefit, but is not highly restorative. Specific techniques have been developed to cope with this type of poor sleep. They focus on the concept of sleep efficiency. Sleep efficiency is defined as the percent of time spent in bed asleep.

Sleep restriction was developed by Spielman and his colleagues in the 1980's as a means of limiting time in bed to the actual amount of sleep obtained in order to increase sleep efficiency. Decreasing time in bed thus maximizes the percentage of time spent actually sleeping. After sleep has become deeper and more consolidated, time in bed is then gradually increased unit an optimal duration is reached.

Sleep restriction, or perhaps more accurately, bed restriction, is based on the assumption that sleep deprivation will increase the drive to sleep and to remain asleep. This may not fit with the experience of those with insomnia for whom sleep seems impossible no matter how long they have not slept. It does make sense, however, when you consider that people with insomnia often underestimate the amount of sleep they are getting, in part because they misinterpret light sleep as wakefulness. Another effect that sleep restriction has is to break up the relationship between being in bed and being awake. Over time, being in bed while awake can lead to conditioning effects such that the bed becomes a conditioned stimulus for arousal. By limiting the amount of time in bed to approximately the amount of time spent sleeping, the bed becomes a conditioned stimulus for sleep. Just getting in bed can then elicit sleep rather than arousal.

Initially the amount of time in bed is reduced to close to the average number of hours usually slept. The amount of sleep is determined by keeping a one to two week sleep journal as previously discussed. The assumption is that most insomnia patients underestimate the amount of sleep they obtain. If time in bed is restricted, sleep will also be restricted. Sleep drive will be increased and light, poor quality sleep will be decreased as greater sleep drive causes deeper sleep. This will result in increased sleep efficiency and fewer awakenings as sleep consolidation increases during the more limited time spent in bed. Over several nights the impact of this technique can be dramatic and often results in significant improvement in the quality of sleep. The full benefit of this technique may take several weeks to be realized.

As sleep becomes more consolidated and sound, it is possible to gradually go to bed earlier or possibly to sleep later by about 15 minutes a week until an optimal amount of sleep is reached. It is appropriate to increase time in bed once sleep efficiency has risen to about 85% and this level of sleep efficiency is maintained for several weeks. Some experimentation may be needed to determine the best bed time and morning rise time. It is generally best to set a fixed morning rise time that is maintained throughout the week including weekends and vacations and work backwards to a bed time based on the allotted number of hours of sleep. Normal sleep efficiency is about 90%. Once sleep efficiency has risen above 85%, awakenings have been reduced and no further improvement is gained by going to bed earlier or sleeping later, an optimal bed and rise time will have been determined.

It may be necessary to use light physical activity to stay up until the scheduled bed time. For example, avoid sitting in front of a TV if in the past there has been a tendency to fall asleep on the couch with subsequent lying awake after going to bed. In the hour or so before bed time begin to "wind down" by engaging in relaxing activities such as listening to music or doing relaxation techniques.

Sleep restriction is often best done under the supervision of a behavioral sleep therapist as it is contraindicated in people who have excessive daytime sleepiness. This is due to potential safety issues that may arise with sleep restriction such as drowsy driving, triggering seizures in people with seizure disorders, and possible negative effects on mood in people with bipolar disorder. With appropriate supervision, sleep restriction can transform "tossing and turning" into consolidated, sweet, refreshing sleep...

Cognitive Behavioral Therapy for Insomnia Part 3: Cognitive Restructuring

John Cline, Ph.D. — Mon, 15 Jun 2009 03:19:34 +0000

In the last post I discussed the use of stimulus control methods to help manage and overcome insomnia. This post will discuss the use of cognitive techniques in the treatment of insomnia. Some very tired people believe they will never be able to leave behind "the scourge of insomnia" and feel good again. History says otherwise. Cognitive therapy has been used since the 1970's to treat a wide variety of behavioral and medical problems such as depression, anxiety, and chronic pain. This approach to psychotherapy involves identifying and changing dysfunctional thinking processes. It works by increasing awareness of the thinking patterns involved in dysfunctional behaviors, recognizing the nature of the dysfunction and challenging the distorted thoughts- thus bringing about lasting change in experiences, emotions and behaviors.

The first step in using these techniques to treat insomnia is to understand the power of cognitive processes in our emotional states and general health. Most likely anyone reading this blog will be familiar with the impact of belief on health. Common examples of this are the placebo and nocebo effects. A placebo is a pharmacologically inert chemical that has a positive health effect because of the belief of the person taking it. This effect is so strong that specific placebo control methods must be used in pharmacological research that tests new medications. Likewise, negative beliefs about substances or behaviors can lead to unhealthy outcomes. This has been referred to as the nocebo effect. An example of a nocebo is the rapid death of individuals who have been cursed by a sorcerer in certain pre-modern societies. This has been documented by anthropologists and is a very real phenomenon. In a less dramatic way, beliefs about sleep and insomnia can affect the quality and quantity of one's sleep.

Second, it is important to have accurate information about sleep and insomnia in order to be able to recognize and challenge negative, distorted thoughts regarding it. In a previous post I discussed how insomnia is actually a problem of over-arousal and that insomnia mainly affects daytime emotion and quality of life ratings and does not generally pose a health risk to the person suffering from it. Some additional facts are also important to know. People with insomnia tend to overestimate how long they take to fall asleep and underestimate how long they actually sleep. Negative thinking, especially the fear of the effects of not sleeping, increases arousal. This makes it difficult to sleep and causes the experience of trying to sleep, feel miserable. For example, thoughts such as "tomorrow will be terrible if I don't get enough sleep tonight" are likely to make it very hard to relax and then fall asleep. Stress tends to prevent cycling into deep sleep so the person may spend long periods of time in poor quality light sleep in which there may be an awareness of ongoing non-productive thinking. Little wonder that upon awakening it seems that no sleep has occurred as this light sleep is misinterpreted as wakefulness. Negative sleep thoughts can also affect daytime functioning as with the thought, "today is going to be very difficult because I didn't sleep well last night." This becomes a self-fulfilling prophesy and the day ends up being very difficult due to negative expectations and irritable mood.

Third, it is necessary to improve one's ability to be aware of these thought processes. Developing the ability to pay attention to the steady stream of negative cognitions is a step towards being able to challenge these thoughts. Just take a moment to notice your thoughts as you are lying awake in bed at night or are feeling fatigued and irritable during the day. Carefully note the thoughts and their emotional impact. This will set the stage for using cognitive restructuring to change your thinking about sleep and insomnia.

Cognitive restructuring will involve challenging negative sleep thoughts at night and during the day with accurate information. For example, the thought "tomorrow will be terrible and I won't be able to function because I can't sleep tonight" can be challenged with true statements such as "I probably am getting more sleep than I think and I have been unable to sleep like this many times in the past and have always been able to get through the day." During the day thoughts such as "this is going to be terrible because I got such bad sleep last night" can be challenged with thoughts such as "I may not feel that good but I will be able to function just as I have so often in the past."

With regular application of this process, inaccurate and unhelpful dysfunctional thoughts can be changed. As this occurs the stress related to not sleeping at night will be decreased making it easier to fall asleep and get a good night's rest. During the day the recognition that you don't have to feel terrible because of poor sleep can relieve some of the irritability and depression that are a regular part of insomnia.

With the use of cognitive restructuring, many people can begin to overcome their insomnia. If you find that these negative thoughts are especially entrenched, it may be necessary to work with a trained behavioral sleep specialist who can guide you through this process.

So, yes you can change your thinking habits, work to alleviate insomnia and feel good again. In the next post another technique, bed restriction, for managing insomnia will be discussed.

Cognitive Behavioral Therapy for Insomnia Part 2: Stimulus Control

John Cline, Ph.D. — Tue, 26 May 2009 14:05:07 +0000

In the last post I discussed ways to evaluate your sleep. After determining what your sleep pattern is and what factors are contributing to your insomnia, you are prepared to start working actively on getting better sleep. One of the most effective cognitive behavioral techniques available for this purpose is "stimulus control." This method was originally developed by Richard Bootzin and is one of the most widely used interventions for insomnia. The approach has been somewhat modified by other researchers and professionals but the basic concept is the same. Stimulus control is designed to overcome the conditioning that occurs with repeated and unsuccessful attempts to sleep that result in negative associations being built up between the preparation for sleep and the sleep environment with the effort to fall asleep.

The idea of conditioning started with Pavlov's experiments with salivation in dogs. The dogs were given meat powder so that the saliva produced could be studied. It was discovered that the dogs would begin to anticipate the presentation of the meat powder if there were any regularly occurring cues that the food was about to be given. If a bell regularly rang a few seconds before the meat powder was delivered, the dogs learned to start salivating at the sound of the bell in anticipation of the food. This is a reliable and basic form of non-verbal learning that occurs in all animals including humans. Many basic emotional states are conditioned by the pairing of frequently co-occurring events. An emotional or physiological response can thus be conditioned to events in the environment. Advertising depends on the ability of our nervous systems to associate products with the positive or negative emotional states depicted in commercials. Notice also the importance of repetition in this type of advertising- as you see the same commercial again and again and again....

So it is with sleep. When sleep is disrupted for a period of time, for example over a month or more, there is ample opportunity for negative associations to develop between pre-sleep rituals or the bed environment and the physiological process of trying to fall asleep. This is, of course, the environment in which insomnia usually develops - a precipitating event, usually some form of stress or sleep disruption - leads to the onset of acute insomnia. If the insomnia persists it can become chronic and continue long after the original stress or disruption has ended. A major factor in the process of insomnia becoming chronic is the development of conditioned associations between the process of trying to fall asleep and the sleep environment.

If conditioning has occurred so that getting ready for bed or getting into bed arouses negative associations and increases arousal then it will be very difficult to fall or stay asleep. These negative associations can result in suddenly feeling wide awake upon getting into bed or when trying to fall back asleep after waking during the night. Stimulus control can be helpful in these situations. It is designed to break up these negative associations and instead develop positive associations between pre-sleep rituals and the sleep environment, and feeling sleepy.

The stimulus control instructions are designed to re-associate bedtime with the rapid onset of sleep and to establish a regular sleep-wake schedule that is consistent with the circadian (24 hour) sleep/wake cycle. The instructions are:

1. Only go to bed when sleepy. Bear in mind being sleepy is not the same thing as being tired. It is important to be aware of this difference. Sleepiness is signaled by behavioral signs such as dropping eyelids, involuntary head nodding and yawning. This rule helps prevent lying in bed engaging in negative sleep thoughts. Thoughts about how you don't feel like sleeping, how bad it will be tomorrow if you don't sleep tonight, going over everything you have to do in the morning and so on just create arousal and make it harder to fall asleep.

2. If after about 20 minutes you are unable to fall asleep or awaken and find it difficult to fall back asleep, leave the bed and go to another room and engage in a relaxing activity such as some light reading or using a relaxation technique until you do feel drowsy. Then return to bed and repeat as often as necessary until you do fall asleep. It is important to not watch the clock while doing this. It is your subjective estimate of time that is important. It is also important to not engage in stimulating activities such as watching late night horror movies on Fear Net.

3. Use the bed only for sleep and sexual activity. Do not engage in sleep-incompatible activity in bed such as eating snacks, watching TV (especially the evening news with the reports of the several murders that happened in a nearby neighborhood earlier today), or working on your IRS tax audit. These activities obviously will result in arousal and make it difficult to fall asleep. Repeatedly engaging in these kinds of activities helps condition arousal to the bed environment when instead you want to condition a feeling of relaxation to being in bed.

4. Keep a regular morning rise time no matter how much sleep you got the night before. This will help regularize the circadian (24 hour) schedule and if you don't sleep well one night, the drive to sleep will be higher the following night - if you don't dissipate it with low quality, light morning sleep by staying in bed later than planned.

5. Avoid napping. (There is more to napping that will be discussed in a future post but for now the stimulus control instruction is to avoid it.) This prevents reducing sleep drive earlier in the day that can make it harder to fall asleep at night.

With the use of stimulus control many people can begin to overcome their insomnia. In the next post further techniques for managing insomnia will be reviewed.

Cognitive Behavioral Therapy for Insomnia Part 1

John Cline, Ph.D. — Mon, 11 May 2009 13:04:16 +0000

In previous posts I discussed the problem of insomnia and its treatment with medication and cognitive behavioral therapy. In the next several posts I will review in greater depth a number of the techniques used by behavioral sleep specialists to effectively treat insomnia. These methods have been tested in rigorous clinical research and are used daily through out the country, either as part of a self-help program or in formal therapy to manage and overcome insomnia for many weary people seeking relief from this persistent and potentially debilitating sleep disorder.

The major components of a cognitive behavioral treatment of insomnia are stimulus control, sleep scheduling, sleep restriction, cognitive therapy, relaxation therapy and sleep hygiene education. A number of other techniques are also effective in managing insomnia and will be reviewed in future posts.

Before reviewing each of these techniques it is important to note that insomnia takes different forms in different people or may affect the same person in different ways over time. Insomnia can involve difficulty falling asleep, difficulty staying asleep, non-restorative sleep or some combination of all of these. It is therefore a good idea to take stock of your sleep pattern and do a careful self-evaluation prior to implementing a plan for conquering insomnia. For example, if the primary problem leading to insomnia is the presence of negative thoughts about sleep that result in over-arousal and thus prevent sleep onset, then it will be more effective to focus efforts on challenging these negative thoughts and replacing them with more accurate, positive sleep thoughts sleep than to focus on sleep hygiene issues that may not be the problem. Changing these thoughts will reduce over-arousal and make it easier to fall asleep.

So the first step in evaluating one's insomnia is to do a careful self-analysis of one's sleep pattern and the factors that affect it. This will help rule out potential other sleep disorders and help identify behaviors and cognitions that are negatively affecting sleep.

First, note the possible presence of other psychological, medical or sleep disorders. Major psychological problems that can negatively affect sleep include mood disorders (e.g., major depression), anxiety disorders (e.g. generalized anxiety or post traumatic stress disorder) and abuse of substances (e.g. alcohol). Medical problems that can affect sleep include thyroid disorders (hyperthyroidism), chronic pain and diabetes. In addition, women may experience significant sleep disruption due to the hormonal changes associated with menopause. It is also possible that the side effects of certain medications used in the treatment of medical conditions, including those purchased over the counter, may interfere with sleep. A number of other sleep disorders can also significantly contribute to poor quality sleep including sleep apnea and restless legs. If any of these are suspected it is important to have them evaluated and properly treated by your health care providers. Even if these conditions are contributing to insomnia, cognitive behavioral techniques may still be very helpful in correcting problems related to behaviors and thoughts that may be maintaining insomnia.

Second, learn more about your sleep pattern. Keep a sleep journal for a week or two to get a better idea of your sleep pattern and factors affecting it. It may be helpful to note such factors as the use of caffeine, tobacco and alcohol, naps taken, timing of meals, time of getting into bed, time of turning out lights to go to sleep, awakenings during the night, time of waking in the morning and time of getting out of bed. The journal helps identify areas that may need to be changed. For example, are you spending a lot of time in bed reading or working on bills before turning out the lights to go to sleep? Are you taking long late afternoon naps and how does this affect falling asleep at night? Does having a cup of coffee with dinner seem to make a difference in your sleep?

Third, carefully note your thoughts about sleep. These thoughts can occur while lying awake in bed at night or during the day while at work. When these thoughts occur at night and prevent falling asleep they are referred to as "excessive nocturnal mentation" and are a primary cause of insomnia. These thoughts often take the form of "if I don't get to sleep I will not be able to function tomorrow." This is upsetting, causes arousal and makes it virtually certain that sleep will not come easily. When they occur during the day they often are along the lines of "I got a terrible night of sleep last night and so today I am going to feel terrible." This line of thinking contributes to the negative mood often associated with insomnia.

Fourth, look at your life style and how it may be affecting sleep. For example, do you have a very heavily scheduled day and so are going to the gym to exercise vigorously at 8 p.m. in the evening, hoping to be able to come home and fall asleep by 9:30 p.m.? Are you eating heavy meals right before bed time and then not being able to sleep because of gastric reflux? Do you stay up until 1:00 a.m. playing action packed video games knowing that you have to fall asleep quickly so that you can be up by 6:00 a.m. to go to work? These life style and behavioral issues may be a primary contributor to insomnia.

Finally, consider your stress level. Does the tension and pressure of your job or relationship continue to affect you as you are trying to fall asleep? The over-arousal resulting from a stressful life situation may significantly contribute to insomnia. Reducing general stress can help improve sleep. Stress management techniques can help greatly in this regard.

After you have a better idea of what your sleep pattern is and what factors are contributing to your insomnia you are prepared to start working actively on getting better sleep. If it is clear that you are going to need professional help to move forward, make an appointment to discuss this with your primary health care provider and ask for a referral to a behavioral sleep specialist. If it seems that some basic changes in life style or outlook can do the trick, then prepare to move forward. More techniques will be reviewed next time. If you want to get more in depth information about these methods I recommend reading Gregg Jacobs' Say Good Night to Insomnia or Peter Hauri and Shirley Linde's No More Sleepless Nights. A good reference for women dealing with issues such as menopause is Meir Kryger's A Woman's Guide to Sleep Disorders.

Helping Teens Sleep Better

John Cline, Ph.D. — Tue, 21 Apr 2009 11:33:22 +0000

In the last post I discussed some of the reasons why teens are often getting too little sleep and what the impact of getting too little sleep is for them. The question arises - what can be done to help improve sleep for teens? I will leave aside for now issues involving significant public policy changes such as setting later start times for school and focus on what teens and their parents can do now to improve sleep.

The first issue to consider and keep constantly in mind is why you would want to sleep more. After all, there are so many other, more interesting things to do - social events, sporting activities, school projects, the internet, and that great new TV show - that it can be a hard sell to convince yourself to put in the effort to set aside time to sleep more. The main reasons for a teenager to get more sleep are to feel better (improved mood), have better academic performance (improved cognitive function) and to do better in sports (improved physical fitness). Our bodies need food, water, air and sleep to survive. If you want optimal health and functioning, then sleep must be regarded as being as important as food and water.

How do you know if you are not getting enough sleep? Ask yourself the following questions:

1. Are you usually finding it very difficult to get up in the morning?
2. Do you find yourself often feeling moody, sad or depressed?
3. Do you often find it difficult to focus, concentrate, and pay attention in class or when doing school work?
4. Are you falling asleep in class?
5. Do you feel so fatigued it is hard to exercise?

Any of these can be caused by other medical or psychological problems but among teens a major cause is getting too little sleep. If any of these apply, a first step would be to get more sleep and see if you feel better.

The bottom line for improving sleep for teens is essentially the same as for adults, except that teens will need more time for sleep than older individuals. Instead of the 7 or 8 hours of sleep recommended for adults, teens should think in terms of about 9 hours per night. With school schedules and other activities it can be a challenge to set aside that much time. It is also a good idea to get this amount of sleep on a daily basis and not skimp during the week and then try to make it up on the weekend.

The best way to improve sleep is to pay attention to good sleep hygiene and general good health. So a good place to start is to plan your work schedule to avoid all-night study sessions and last minute preparation of reports. Regular exercise, especially in the later afternoon, is a great way to improve health and sleep quality but don't exercise too close to bed time as it is energizing and could keep you up. While a small snack such as a bagel or some crackers is generally fine about an hour before bedtime, avoid heavy meals or snacks too close to bed time as they can make you feel uncomfortable and keep you up. Use naps sparingly. But an afternoon nap of less than 30 minutes can help you feel more alert and not keep you from falling asleep at night.

Likewise, use caffeine, whether in coffee, tea, candy, headache medicine, alertness pills, or energy drinks, in moderation and not after 2 pm. What is moderation? No more than the caffeine in two cups of coffee (100 - 200 mg) daily. I shouldn't even have to note this one but nicotine is a powerful stimulant and not smoking is one of the very best things you can do for better sleep and health. Keep a regular bed time and morning rise time throughout the week. Start winding down about an hour before bedtime by doing relaxing things like meditating, using relaxation techniques or listening to calming music. Avoid frightening movies or upsetting news reports right before bedtime. Bright light keeps you up so start cutting down the light as you are getting ready to sleep. This also means not looking directly into a light source like a computer screen or TV. Make your bedroom a good place to sleep by keeping it dark, quiet and cool. As much as possible use your bed room only for relaxation and sleep - so keep those fast paced video games in another room. When you get up in the morning use bright light to help wake up by getting as much light as possible. Bright light suppresses sleep-inducing melatonin and helps you wake up.

As for parents, it is important to recognize the significance of sleep and support your teen in getting enough. You can't force a teen to sleep but you can set a good example and encourage better sleep. Be aware of the above signs of sleep deprivation. When children are little, get them off to a good start by keeping regular sleep schedules and teaching children about the importance of sleep. Your active support for the kind of good sleep hygiene rules noted above will also help your teen get the sleep he or she needs.

If sleep problems continue or don't respond to these approaches, discuss your concerns with your pediatrician. Referral to a sleep specialist may be appropriate. But for most kids, the simple, although not easy to implement, techniques noted above can prevent them from being sleepless in America.