Insomnia: 6 strategies to sleep better

 

 Balm of hurt minds, great nature’s second course, chief nourisher in life’s feast.

William Shakespeare ¹

Sleeping problems are another effect of severe stress which can exacerbate physical and emotional pain. Disturbed sleep is a symptom of increased physiological arousal. The main effects of lack of sleep are fatigue, depression and concentration and memory problems. Fatigue and depressed mood leads to increased susceptibility to pain and stress and decreased ability to cope. Good sleep enhances your ability to resist pain through the increased energy and functioning it brings. Good sleep is not a luxury; good sleep is also necessary for physical rejuvenation, immune functioning, mood and thinking. Learning how to sleep better is thus one of the most basic strategies for reversing the vicious cycle of stress and pain.

What is sleep and why do you need it?

Human sleep is a complex, multi-staged process involving two basic types of sleep; rapid eye-movement sleep (REM) and non-REM sleep (NREM). Sleep begins with a gradual descent though drowsiness, light sleep and eventually into deep sleep. These first four stages (NREM) are the most restful and involve decreased heart rate, body temperature and brain activity. NREM occurs during the first third to half of the night and is the most restorative type of sleep. The amount of NREM sleep you need increases when you are sleep-deprived. REM sleep involves increased brain activity and increased physiological activity, including rapid eye-movements. REM sleep is when dreaming occurs. REM sleep is also thought to be necessary for memory consolidation. REM sleep occurs cyclically throughout the night, alternating with NREM sleep about every 80-100 minutes. Most people sleep about seven hours, two of which will be in REM sleep.

The sleep cycle is determined by an innate 24-hour body ‘clock’ known as a circadian rhythm. The term comes from the Latin circa or ‘about” and ‘dia’ which means day; it literally means ‘about a day’. Circadian rhythms are affected by the amount of light your body receives. At night your body produces certain hormones, in response to darkness, which trigger sleep. In the morning, sunlight stimulates wakefulness. Circadian rhythms can be disrupted by stress, jetlag, shift-work and even being woken up by an alarm clock. Your sleep cycle is also partly determined by your body’s own in-built homeostasis mechanisms.

Your sleep cycle is also determined by your chronotypte – whether you are a morning or a night person. Morning people (or ‘Larks’) function best in the morning and prefer to go to bed early and rise early. Larks represent about 20% of the population. Another 20% of people are night people (‘Owls’) who function best at night and prefer to go to bed late and wake later. The other 60% of people fall somewhere in-between those two extremes. Knowing your chronotype is important; if you are an Owl, but have to get up early for work every morning, you are going to need to schedule a nap in the afternoon and perhaps a couple of sleep-ins come the weekend.  Night people seem to be more sensitive to disruptions in their sleep rhythms. If you are a Lark, working night-shift is probably not such a good idea.

The exact purpose of sleep is still not fully understood, but it certainly has a restorative role in recharging our physical and emotional selves. Restful sleep is known to be necessary for;

•      the production of serotonin and other mood-enhancing chemicals.
•      the production of growth hormones and other substances necessary for maintenance of the physical self
• immune functioning (through the production of Interleukin-1).
•    memory consolidation and learning.

The importance of sleep for health has long been recognized. The Talmud (an ancient Jewish text) lists sleep as one of the most important activities for healing a sick person.² Good sleep can help reduce physical pain.³

Sleep can also be a time for mental rejuvenation and inspiration. Many people find solutions to life problems during dreams, or after ‘sleeping on it’ – remember Aron Ralston’s story from chapter three?. When Stephen Hawking, the famous mathematician and astrophysicist, was first diagnosed with the muscle-wasting disease ALS[1], he was told he had two years to live. At the time Hawking was a bored, directionless 21-year-old. Devastated by the prospect of a slow physical decline followed by an early death, Hawking fell into a deep depression. Then one night he had a dream he was about to be executed. When Hawking awoke and reflected on this dream he realised that even though he might not have a choice about how he died, he did have a choice about how he lived. Although Hawking still felt there was a cloud hanging over his future he began to live life more fully. He became engaged and put more effort into his research. He devoted himself to his work about the origins of the universe and went on to write a best-selling book, A Brief History of Time. Hawking’s dream helped him to see his situation differently and find a way through his feelings of depression. It probably saved his life.

How stress affects your sleep

Severe stress and pain can all disrupt your ability to sleep normally. The most common forms of stress-related sleep disturbance include trouble falling asleep, night-waking, non-restful sleep and irregular sleeping patterns. Many sufferers of chronic physical or emotional pain find it difficult to fall asleep and when they eventually do, it may only be for two or three hours. There is also no routine; every night is different including when you fall asleep, how long you sleep, and when you awaken. The quality of sleep is also poor. Even after a supposedly normal night’s sleep, you may awaken feeling tired and as though you have not slept at all. Physiological studies of chronic back pain sufferers show they have an arousal disturbance in their brain waves so that they awaken feeling unrefreshed.⁴ Your chonotype can also change; early morning people suddenly find themselves unable to sleep at night and needing to sleep in.

Insufficient sleep disrupts the body’s natural ‘rest and repair’ cycle. Lack of sleep is known to be associated with decreased immune functioning, decreased ability to metabolise glucose (blood sugar), decreased cognitive abilities and even decreased emotional intelligence.^5,6 One group of researchers found that sleep-deprived people exhibited decreased self-regard, independence, capacity for empathy and impulse control, and found it harder to relate to others. Sleeping problems, particularly with stage 4 NREM sleep, have also been found to induce musculoskeletal pain.⁷  The fact that stress should have an impact on sleep is not surprising; sleep and wakefulness are part of a continuum. What happens while you’re awake affects how you sleep, and what happens while you’re asleep affects how you function while you’re awake.

The negative effects of stress on sleep may be magnified by early childhood abuse and neglect. Lack of secure emotional attachment or safety in childhood can inhibit the development of a normal sleep pattern. Adults who suffered stress in childhood are more likely to have sleeping problems. Even a temporary separation from the mother, such as with a hospitalisation, can have a disruptive effect on sleeping patterns in children.⁸  People who are already poor sleepers can be expected to have more disturbed sleep in response to present stress, and to find it harder to establish a healthy sleeping routine.

The mechanisms by which stress affects sleep include increased physiological arousal, biochemical imbalances and desynchronisation of circadian rhythms. As described in chapter two, stress causes a reduction in your levels of serotonin. Serotonin is necessary for the production of Melatonin, the neurotransmitter responsible for inducing sleep. The result is that sufferers of stress and pain feel sleepy when they should normally feel awake and awake when they should be asleep, rather like jet-lag. It’s not uncommon to feel tired during the day, but unable to sleep at night.

Six strategies for improving your sleep

Learning how to sleep well again can greatly reduce the impact of stress and pain. Improving your sleep requires retraining your body to fall asleep and stay asleep longer. One of the best-known methods of doing this is sleep hygiene. Sleep hygiene simply means making sure that you are going to sleep under the optimum conditions (e.g. in a quiet, darkened room with a comfortable mattress etc). The aim is to make it as easy as possible for sleep to occur naturally. Stress management is also an important strategy for restoring sleep. If your sleeping problems are caused by inadequately managed stress or pain, simply improving your sleep hygiene isn’t going to be enough. How can you sleep soundly knowing that something terrible might be about to happen any moment or feeling that your life is out of control? You must neutralize any present stressors which may be interfering with your sleep. This could mean deciding on a course of action to resolve a stressful situation, practicing relaxation before going to sleep, or just writing out your thoughts and feelings before going to bed. Trying to fall asleep whilst faced with an unresolved stressor is like trying to take refuge in a bear’s cave; it’s pretty hard to relax.

If you sleeping problems are being caused by severe stress or pain, sleep hygiene is unlikely to have much effect (because it’s not addressing the causes of your insomnia). In this case, you may need to develop a new sleeping routine, based on letting your body dictate when and where you sleep, as opposed to trying too hard to sleep normally. Have you noticed how stressful it is when you try to go to sleep and sleep doesn’t come? “Free-sleeping’ means giving up on the idea normal sleep and accepting that your body is incapable of sleeping for long regular periods. Instead, you sleep where and when you can. Last but not least, medication can be helpful in addressing sleeping problems. To summarize, there are six strategies for improving sleep;

1. Sleep hygiene
2. Stress management
3. Relaxation/self-hypnosis
4. Naps
5. ‘Free-sleeping’
6. Bilateral stimulation

Below you will find detailed instructions on how to implement these strategies. These strategies are designed to remove any obstacles to sleep, and maximize your ability to sleep. The ultimate goal is to facilitate restful if not normal sleep. But the main thing is try and create the conditions where you can get as much sleep as you can, regardless of how much pain you may be experiencing. As with changing any stress-related disturbances to normal functioning, it may take time for your body to return to normal, so you will need to be patient.

Sleep hygiene

Sleep hygiene involves creating the right conditions for sleep to happen naturally. Sometimes, sleeping problems can be exacerbated by your surroundings or routine. Noise, light, timing, even the type of mattress you have, can all affect your ability to fall asleep and stay asleep. The following sleep hygiene tips represent generally accepted wisdom for how to get a good night’s sleep. These are guidelines and my not be practical for everybody. Review this list and see if there is anything you can do to make it easier for your body to fall asleep.

• Make sure you feel safe and secure

As stated, you cannot relax and fall asleep if you are worried about your safety or that something bad is going to happen. Beyond obvious considerations of physical security, try to make your bedroom into a place where you can shut the door on your worries and cares. Create a mental boundary between your place of sleep and the rest of your life. Know that you cannot sleep and think about your problems at the same time. In fact, some research suggests that if you stop thinking and get some sleep, you are more likely to find solutions to your problems.

• Get to bed as early as possible

Our systems, particularly the adrenal glands, do most of their recharging between11pmand1am. In addition, your gallbladder dumps toxins during this same period. If you are awake, the toxins back up into the liver, which then backs up into your entire system and causes further disruption to your health. Before the widespread use of electricity, people would go to bed soon after sundown, as most animals do, and which nature intended for humans as well.

• Sleep late

Try to avoid setting your alarm for earlier than6am. Prepare the night before if getting up at6amwill be a rush for you. If you must get up before 6am, reset your body clock by ensuring darkness and quiet for an early-to-bed schedule and waking up to bright lights. Remember, sunrise is the trigger for your body clock.

• Develop a sleep routine

Try to go to bed at roughly the same time every night. Try to have a bed-time routine wherein you give your mind and body time to wind down in preparation for sleep and you create a pattern of going to sleep at roughly the same time every night.

• Create an environment conducive to sleep

A cool, dark environment is best. Keep your bedroom at a comfortable temperature and minimise noise or distractions. It is better to read something relaxing than watch TV before going to bed. A comfortable mattress is also important.

• Avoid caffeine and alcohol

A recent study showed that in some people caffeine is not metabolised efficiently and therefore they can feel the effects long after consuming it. So an afternoon cup of coffee (or even tea) will keep some people from falling asleep. Know that the ‘nightcap’ has a price. Alcohol may help you to get to sleep but it will cause you to wake up throughout the night.

• Take a bath

Warm baths (not showers) before bedtime can help. When body temperature is raised in the late evening it will fall at bedtime, facilitating sleep.

• Listen to white noise or relaxation CDs

Some people find the sound of white noise or nature sounds, such as the ocean or forest, to be soothing for sleep. (The author’s Calm and Confident CD is good in this regard – see appendix B).

• Exercise

Exercise is thought to be conducive to sleep, but preferably not too close to bedtime, i.e. at least four hours before bedtime.

• Do not lie awake in bed

If you cannot get to sleep for more than 30 minutes get out of bed and do something boring in dim light until you are sleepy. Do not lie awake worrying. If your mind is overactive in this way try setting aside a ‘worry-time’ before you go to bed, perhaps writing out your worries in a journal.

Stress management

Stress management means dealing with any current stressors which are keeping you awake at night. The kinds of stressful situations which can inhibit sleep include unresolved trauma, chronic pain, illness, relationship problems and any situation which poses a threat to your goals and security. As mentioned, it’s simply unrealistic to expect yourself to sleep normally whilst facing a major unresolved stressor. Dealing with stressful situations is not easy; that’s why they are stressful situations. But you can acquire the knowledge, confidence and support to help you overcome whatever threats or challenges are facing you. You should have found the activities from the safety and support chapter helpful in this regard.

It can be helpful to review the stressful situation from a problem-solving point of view. Is the stressful situation something you have any control over? Do you have all the information you might need to know how to resolve that situation? Are you holding on to any self-limiting attitudes or beliefs which might be holding you prisoner to this situation? Is there any reasonable action that you can take to ameliorate the threat or improve your situation? If the situation is not one that you can control, and assuming you have done everything you possibly can to resolve it, what is the point of continuing to worry? If  none of that works, then you may just have to accept that you are in a stressful period and adopt a different sleep routine (see ‘free sleeping’ below).

Stress management also involves knowing how to manage the stressful feelings associated with the stressful situation. This could mean talking to a friend, practicing meditation or relaxation, changing your self-talk, exercising or taking up a hobby or some combination of the above. Sometimes stress can be caused by our expectations; if we can learn to look at the stressful situation differently, this can change how it makes us feel. Louise felt stressed and depressed because she couldn’t work and provide for her family financially after hurting her back at work. Louise could not accept that her role within the family had changed. After talking with her counsellor, Louise remembered why she got hurt at work in the first place; because she was trying to support her family. The realization that all along she had been doing her best for her family helped Louise to feel less bad about what had happened. Although she missed working, she found other ways to support her family, such as spending more time with her children, helping out at her children’s school, etc.

Relaxation and self hypnosis

As we have seen, one of the main effects of stress and pain is increased physiological arousal. Practising relaxation or self-hypnosis at bed-time can reduce tension and facilitate sleep. Relaxation helps create a buffer between the stress of the day and the letting go that is necessary for restful sleep at night. We looked at relaxation in the last chapter and you should already have considered adopting regular relaxation or meditation. Another specific technique for sleep is to use creative visualisation and self-hypnosis.

Bob used to prepare himself for sleep by imagining he was on a luxury cruise ship voyaging across the Pacific. He imagined he could feel the throb of the ship’s powerful engines and how he didn’t have to make any effort to get to where he wanted to. He thought of the ship’s bow cutting through the water, and the gentle rolling caused by the ocean swell. He imagined the feeling of protection that came from being on such a large vessel and how the massive walls of the hull kept him safe from the elements. From night to night, Bob added different elements to his fantasy. Some nights he imagined himself being lulled to sleep by the sound of the ocean outside; other nights he imagined visiting a tiny blue-ringed island and falling asleep on a deserted beach.

Of course, Bob never left his bedroom in suburbia, but by exercising his imagination he was able to lull himself into a relaxed state of mind and body, and ultimately fall asleep more easily. The human mind has the capacity to be a kind of virtual reality tool if you’re willing to use your imagination in this way.Try remembering or imagining an experience that stimulates feelings of security and relaxation. Ships and trains and even planes all derive their efficacy from the fact that they involve being transported to some place else, but you can just as easily build a fantasy around your favourite holiday spot or travel destination.

Self-hypnosis can also be helpful. Self-hypnosis involves focusing your mind on something neutral or relaxing, to the exclusion of all other thoughts or concerns, and using that as a stimulus for entering a more relaxed state. A simple but powerful self-hypnotic technique for sleep is ‘Mrs Erickson’s induction’ (Mrs Erickson was the wife of Milton Erickson, the famous hypnotherapist). The beauty of Mrs Erickson’s induction is that it uses your senses (sight, hearing and touch), to lull you into a relaxed sleep. Mrs Erickson’s induction is outlined under the ‘self-hypnosis for sleep’ menu item. It is very safe and surprisingly effective.

Another simple technique is to count backwards from 20 to 1 and keep repeating this until you fall asleep. Since your mind can really concentrate on only one thing at a time, this simple activity will block any worrying thoughts that might be keeping you awake and make it easier for your body to relax.

Taking a nap

Sleeping in the daytime is generally discouraged because it is thought to interfere with night-time sleeping. However, sleep experts have now realised that naps are normal and can help make up for lost sleep. Napping has been found to improve mood in sleep-deprived people.⁹ Even a nap as short as 10 minutes can reduce the effects of sleep loss.¹⁰ A 10-minute afternoon nap can stimulate significantly increased energy, alertness and performance. Cancer patients who took naps found they slept longer at night and had less pain.¹¹ Researchers found that subjects in a nap study felt that it was easiest to fall asleep at night and in the afternoon.¹²

The body is on a roughly 24-hour clock, which makes you wind down twice (peaking in periods separated by about 12 hours): in the night and in the afternoon. So the best time for a nap is 12 hours after the mid-point of the previous nights sleep. For normal sleepers this is around 3pm. Many famous people enjoyed naps, including Albert Einstein, John F. Kennedy,BillClinton and Winston Churchill. Winston Churchill used to say of his naps, ‘this gets me two days in one.’

There are two kinds of nap: brief ones taken to revive the brain and long ones taken to compensate for significant sleep loss. Long naps can help when you have accumulated a considerable sleep debt, for example, when you have been sleeping poorly for a long time. The only disadvantage of long naps is they cause what researchers call sleep inertia, a groggy feeling that can last about half an hour after waking. You should thus experiment with what length of time works best for you.Generally speaking, the ideal length of a nap is 10-45 minutes.

Free sleeping

If your sleeping problems are associated with chronic illness, pain or severe stress, you may find it impossible to achieve a normal sleep routine. In that case it may be best to accept that you are just not going to get a solid eight hours’ sleep a night and allow your body to dictate when and how long you sleep. Although this is not the ideal for most people, it is not so terrible, particularly if you are able to be flexible about the hours you sleep. Free sleeping means letting your body dictate when you fall asleep and just sleeping whenever you can. Thus instead of one 8-hour block of sleep every 24 hours, you might have three x 2-3 hour blocks of sleep at say, midnight, dawn and noon. With this method there is no routine or structure, you just let your body decide when it wants to sleep. This method potentially enables you to have your normal eight hours of sleep over a 24-hour period, just not at the usual times.

Of course everybody is different and this cycle may not exactly describe your sleeping routine. However, this pattern or some variation thereof, is common in sufferers of severe stress and pain.

Many sufferers of stress-related insomnia find it difficult to fall asleep in bed. The very act of going to bed with the intention of falling asleep seems to stimulate a state of alertness that prohibits sleep. Sleep should happen naturally, without your having to think about it. Many insomniacs find it easiest to fall asleep whilst they are doing something else, such as reading a book, listening to a pod-cast about their favourite subject, or even watching TV. The act of engaging in a mildly interesting, but not too interesting, mental activity seems to distract their conscious mind enough for their body to relax and the conditions for sleep to occur.

Make it easy for your self to sleep. Many chronic pain sufferers dread their beds; they are so accustomed to NOT sleeping in bed. There is no law that says you have to sleep in bed. You should sleep wherever and whenever you can – as long as it’s not whilst driving a car! You might fall asleep whilst reading a book in your favourite chair, that’s fine.

Jeanine had not slept for more than two hours straight for weeks because of her chronic pain. One night she was watching sport on late-night TV. It was a hot night and she could feel a gentle breeze coming through the open door. Something about the images and sounds from the TV, the gentle breeze, and the lack of other concerns, made her feel very relaxed, and she just fell asleep in the chair. Four hours later she was awoken by the sun peeking in through the open door. It was the best sleep she had had in weeks.

Listen to your body. As far as practical build your life around your sleep, not your sleep around your life. The quality of sleep will vary according to the time of day and the circumstances. Many people find that they sleep the deepest in the early morning, because they are exhausted. Because of how the normal sleep cycle works, free sleeping will not give you the same quality of restful sleep you would expect from sleeping a straight eight hours. However, it should at least enable you to get more sleep than you would otherwise. Later, when the crisis is over, you can worry about getting back to a more normal pattern of sleep.

Bilateral Stimulation

Bilateral Stimulation is a treatment component of EMDR which involves focusing your attention on bilateral visual stimulation (eg; hand-movements) or auditory stimulation (eg; audio tones) whilst also thinking about whatever stress or pain you want relief from. When used as part of the EMDR treatment process, Bilateral stimulation has been found to stimulate a rare trio of physical, mental and emotional changes including decreased physiological arousal, relaxation, feelings of drowsiness, decreased ability to worry and feelings of detachment from the problem. These changes may be part of the brain’s seeking system response to novel stimuli (see; ‘What is EMDR and how can it help you to feel better’ for more on this).

I have found that Bilateral Stimulation (Bls) on its own (ie; outside the EMDR treatment process) can facilitate relief from physical pain, stress and insomnia. Feedback regarding my self-help CD’s, which incorporate Bls, confirms this. See for example, the customer reviews section for ‘Calm and Confident’ on Amazon.com. Obviously the CD’s incorporate auditory stimulation as it is more convenient for self-use than eye movements.

In order to harness Bilateral Stimulation to help with sleep, you need to know how and when to use it. Without the right guidance listening to Bls would be about as effective as listening to a metronome or watching windscreen wipers. If you are unable to see a therapist, or just wish to use Bls independently, the best way to harness Bls is to purchase one of the CD’s I have produced which incorporate this facility. Many people find Calm and Confident helpful for sleep, but only the Change Your Brain Change Your Pain CD has the bilateral stimulation without talking. You can listen to a sample by visiting Music Samples and play the BLS Sample. If you suffer from complex trauma or dissociation you should check with your therapist first. If you are the sort of person who does not like new things you may find the sound irritating at first.

Adapted from; ‘Change Your Brain Change Your Pain’, by Mark Grant, 2009.