Interminable Terminal Insomnia, Part II
When a clinician's bag of tricks is no match for her early morning waking.
Posted Jan 10, 2016
Welcome back Abigail Strubel, MA, LCSW, CASAC, who opened up her personal account battling an unnerving sleep disorder — waking up, often for good, in the middle of the night — in Part I of this two part series. Be sure to start with Part I if you haven’t read it yet. You don’t want to read the end of the story first! —Michael Terman
SO THERE I WAS, NIGHT AFTER NIGHT, WAKING UP AT 3 A.M. despite my best efforts at sleep hygiene. My new therapist suggested a different approach.
Cognitive Behavioral Therapy for Insomnia
CBT-I, as it's known, is a very practical approach to retraining your body and brain for better sleep. When you wake up, if you don't fall asleep again within a few minutes, get up and out of bed. Do something relaxing — read or listen to soft music — that doesn't involve any screens (computer, smart phone, or television).
After ten minutes, return to bed. See if you fall asleep again. If you don't, get out of bed and again do something relaxing for ten minutes, then get back in bed. It's helpful if you try to cool down a bit by not covering yourself with a blanket or comforter; feeling cool makes the body feel sleepy, and lying down after cooling down can lead to sleep more quickly.
Once again, Dr. Terman questioned my interpretation: “Feeling cool, the sensation?” he asked me. Sleep onset comes naturally when deep body temperature falls according to a person’s circadian rhythm. In order to do so, body heat has to escape via the skin. Capillaries in the skin need to dilate to allow the release. One major site of release is the feet! So if you’re having trouble losing body heat, try warming up your feet with snug socks to help the capillaries dilate. (Dr. Anna Wirz-Justice, a Board member of the Center for Environmental Therapeutics, demonstrated this effect in the lab for initial insomnia, but the study did not extend to terminal insomnia.) Skin temperature actually rises as your core cools. Now, if your circadian rhythm is preparing to wake you up before the light of day, the body temperature process is reversing too early, the core is warming up, and the capillaries are tightening to retain heat in the core.
Folk remedy: if you keep those feet warm it may delay the morning circadian process and help to extend your sleep. And of course there’s a physiological remedy as well, that works across the body, not just the feet. Melatonin production by the pineal gland acts to dilate the skin capillaries, helping the core to stay cool while heat escapes from the surface. The tiniest amount of fast acting pill-form melatonin can do the job at 3 a.m., and quickly ease you back into sleep for a few more hours. Anything more — which is far more than the pineal gland ever produces at night — and you’re at risk for oversleeping, or feeling a cloud over your head the next morning if you have to wake up for work. This is a new twist on treatment for terminal insomnia, and I do plan to try it.
It's natural to feel skeptical that CBT-I, a behavioral intervention, as opposed to a chemical — naturally derived or manufactured, like melatonin — could really fix a problem that feels so physical. But I'd seen studies that suggested CBT-I was effective in more than 70% of cases of insomnia. And I found that when I rigorously practiced the protocol – out of bed when awake, read for 10 minutes, back in bed, repeat as needed – I usually slept better, or at least more.
However, even though I was able to use CBT-I to fall back asleep after waking, I still kept on waking. After several days of exhaustion, if the waking had been particularly bad, I occasionally took a small dose of trazodone to get at least one full night's sleep and powered through the resultant sedation the following morning. That’s the drawback of taking a sleeping pill in the middle of the night: the next morning is cooked.
A Brief Reprieve
Gradually, the early morning waking stopped without any intervention on my part. By the early days of summer, I was sleeping through most nights.
Several things changed in my life, including my job. In November 2015, I was about to start a new position helping place homeless veterans in permanent housing. I set up my light box and took the AutoMEQ self-assessment at cet.org to determine the optimal time to use it (6 a.m., which was fine with me; I'm a morning person).
After Standard Time began, I waited for the onset of my SAD symptoms: a sense of slowing down, lower energy, a dreariness of mood, difficulty concentrating, cravings for sweet and starchy foods, and terminal insomnia. To my surprise, only the last symptom emerged. Otherwise, I felt energized, clear-headed, and cheerful, undertaking new professional challenges with aplomb. My craving for sweets isn't exactly limited to Standard Time, but it didn't seem to get any worse.
Yet I started waking up earlier and earlier each successive morning. Going to bed at 11:00 p.m., first I found myself awake at 5:30 or 5:00 a.m. Gradually this pushed back, 4:00 a.m., 3:30 a.m., 2:00 a.m.—and finally 1:30 a.m., night after night. Dr. Terman thinks that even though the AutoMEQ recommended light at 6 a.m., it was too early for me, and I should have waited an hour, which could retain the good effect on mood and energy while preventing my waking from shifting earlier. The AutoMEQ, he emphasized, gives a ballpark estimate for when to take light therapy according to your circadian rhythm, but often the patient has to adjust the timing earlier or later for best results.
Nothing kept me asleep. A round or two of CBT-I would usually enable me to fall back asleep, but nothing — not the acutorture mat, not melatonin, not a bedtime calcium-heavy snack or warm shower, not avoiding caffeine and other stimulants late in the day — allowed me to wake up with my alarm clock.
I had to think outside the light box.
Music Hath Charms to Soothe, Right?
Music has a powerful effect on people's moods. King Saul hired young shepherd David to play the harp when the king was distressed, and lullabies have been used for millennia to soothe babies and children to sleep.
I wondered if adding soft music to my nightly acutorture routine could soothe me to sleep through the night, and spent a very pleasant few hours assembling a YouTube playlist I named “Relaxing.” It's heavy on Dan Fogelberg, Michael Bublé, Norah Jones, and James Taylor. That night, I clicked on “Play All,” lay on the mat for 45 minutes, gingerly lifted myself off, lay back down ... and slept through the night.
When you have terminal insomnia, waking up to your alarm clock is a fantastic feeling. I was jubilant, so proud of myself for developing an effective, non-pharmacological intervention. The next night I hit “Play All,” endured 45 minutes of torture, peeled myself off the mat, lay back down ... and woke up at 2:30 a.m. The next few nights were the same. Music wasn't the answer.
I kept the playlist, but apparently it was a one-hit wonder.
If Sound Doesn't Work, Maybe Smell Will
Aromatherapy is a great way to relax, relieve stress and recharge your batteries. Certain aromas have been shown to have strong effects on a person's state of mind, and inhaling particular fragrances can help clear troubling thoughts. A person who's relaxed can fall asleep more easily, maybe even stay asleep through the night. Or so I surmised. I thought aromatherapy might help. There are many ways to enjoy fragrances, but one of my favorites is essential oils. You can dribble a few drops into a warm bath or a humidifier, but I like to use an essential oil diffuser, a special tool that uses either heat or heat and water to disperse fragrance. My essential oil diffuser consists of a bowl atop a kind of lantern, into which you place a tea light. You pour water into the bowl, sprinkle essential oil on top of the water, and light the candle. The warmth of the flame makes the water evaporate, and the scent diffuses through the room.
I diffuse peppermint or eucalyptus when my sinuses are congested, floral oils like jasmine and geranium when I'm sad, and lavender when I'm stressed out. Lavender has been used for centuries to ease anxiety and promote relaxation.
So after sleep hygiene, acutorture, and music failed to keep me asleep, I tried lavender. I poured the water, sprinkled the oil, put on a sleep mask to block the light from the candle, and lay down with earnest hopes of sleeping through the night.
I went to bed at 11:00 p.m., and I woke up at 2:19 a.m. I tried adding lavender to my bedtime routine a few more times, but although my apartment and the hallway outside my apartment smelled wonderful, the results were no better.
It works for some people, though. Just maybe not for terminal insomnia. Dr. Namni Goel, who is on the Board of the Center for Environmental Therapeutics, did a sleep study using lavender vs. placebo (distilled water in the vaporizer) as her subjects — young adults, “normal” sleepers around 21 years old — went to bed shortly after 11 p.m. Everyone in the experimental group showed increased deep sleep and reported increased vigor on waking the next morning. The men also showed more REM sleep / dreaming, but somehow the women showed less. Dr. Goel concludes, “Lavender serves as a mild sedative and has practical applications as a novel, nonphotic method for promoting deep sleep.” But not for me and my demon.
I called my doctor and she updated my trazodone prescription. Although I would have preferred to find a non-pharmacological solution to my terminal insomnia, ultimately I wasn't able to. I plan to use trazodone to make it through Standard Time, then see if I can manage without it. Also on my agenda, trying light therapy a little later in the morning, and a microdose of melatonin when I wake up at the “hour of the wolf.” If they work, I’ll let you know!
ABIGAIL STRUBEL is a Columbia-educated clinical social worker and certified alcohol and substance abuse counselor who uses light therapy to cope with her annual seasonal affective disorder, and also manages chronic insomnia through acupressure and good sleep hygiene. She has worked with formerly homeless adults, ex-offenders on parole, recovering heroin users, and other interesting populations. Her approach to wellness is a fusion of all compatible treatments—alternative or not—that make people feel better while also objectively reducing medical problems.