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by Susan Roberts, AARP The Magazine, June 14, 2006
I remembered sleep. It was that thing I did when I was younger: innocently, effortlessly, arrogantly. Now that I was 50, sleep had become something I pursued with almost religious fervor, like a knight in search of the Holy Grail.
The problems started in my late 30s. A run of stressful events along with shifting hormones and an anxious temperament conspired to drive sleep maddeningly out of reach. Several nights a week I would lie in bed in an agony of wakefulness, obsessing about the day ahead, now undoubtedly ruined by a lack of sleep. In hopes of luring the angels of slumber, I assembled a small arsenal of sleep aids: a pillow filled with millet hulls, a light-blocking eye mask, a fan whose soothing hum drowned out street noise. I developed elaborate bedtime rituals, downing herbal sedatives, listening to hypnotic CDs, practicing yogic relaxation techniques.
And still sleep eluded me. I stumbled through days muzzy-headed and cross, struggling to speak in full sentences. But what could I do? I had tried everything short of drugs, and I was reluctant to go that route. And so I resigned myself to a life of sleep deprivation, assuming this was just one more hidden tax of aging.
Then came the news reports linking lack of sleep to a host of dreaded conditions: hypertension, diabetes, memory loss, obesity. Suddenly sleeplessness was a major health scourge—and sleep, the great panacea. Every time you turned on the TV, there were tantalizing ads for new, safer sleep drugs. Health columnists described nonpharmaceutical approaches reputed to work just as well. Given this groundswell of new interest and information, I decided it was time to attack the problem head-on, to go to school on sleep. The project turned much of what I knew about sleep on its head.
I remembered sleep. It was that thing I did when I was younger.
Insomnia encompasses a variety of disturbances that prevent a person from getting a good night’s sleep. These can include difficulty falling asleep, frequent awakenings, or awakening too early. According to the National Institutes of Health, 10 to 15 percent of the general population struggles with chronic insomnia. A 2003 National Sleep Foundation poll found that 44 percent of older adults experience one or more nighttime symptoms of insomnia at least a few times per week. (As we age, we require as much sleep as we ever did, but we have a harder time getting it because of waning levels of the hormone melatonin and other factors. Older people—men more than women—also increasingly lose access to the deeply restorative, slow-wave phase of sleep.)
For many insomnia sufferers poor sleep is the result of medical problems or the medications used to treat them. For example, chronic pain is a common sleep disrupter, as are asthma and other respiratory illnesses, and major depression alone accounts for some 15 to 20 percent of insomnia cases. Numerous medications have sleeplessness as a side effect, including many drugs used to treat cardiovascular disease, arthritis, and cancer. Plus, insomnia may be caused by certain treatable ailments. These include obstructive sleep apnea, a dangerous condition characterized by snoring and a tendency to stop breathing; restless legs syndrome, marked by tingling or twitching in the legs and a compelling urge to move them; heartburn or gastroesophageal reflux disease (GERD); and menopausal hot flashes or night sweats. Of course, having a spouse with any of these conditions can disturb sleep as well.
What I had, however, was primary insomnia. It seems that some of us have “hyperaroused nervous systems”—like cars with high idles—which make it difficult to drop off to sleep at night. This group includes disproportionate numbers of women and people over 55. While many of these folks could be helped by simply improving their sleep hygiene (basic sleep-promoting practices; see Try This First), I required stronger measures.
Most promising on this score was cognitive-behavioral therapy for insomnia, or CBT-I, a form of brief psychotherapy that helps people correct mistaken beliefs about sleep and change ineffective sleep habits. Jack Edinger, Ph.D., a psychologist at Veterans Affairs Medical Center in Durham, North Carolina, has conducted a number of studies comparing CBT-I with other treatments, including sleep hygiene and progressive relaxation (that is, the tensing and releasing of various muscles, starting at the toes and moving up the body). While those approaches often helped people get to sleep, they didn’t help them stay asleep, he said. By contrast, just two to four sessions of CBT-I resulted in marked improvement in his subjects’ sleep maintenance, with even better results at a six-month follow-up. Other studies have found CBT-I to be as effective as drugs in the short term and more effective in the long run.
“Patients keep getting better and better,” says Michael Perlis, Ph.D., director of the University of Rochester (New York) Sleep and Neurophysiology Research Laboratory. Perlis notes that CBT-I’s ability to change “tender” sleepers into robust ones often creates a kind of conversion experience in both practitioners and patients. His confidence was inspiring. “Of all the problems that come with age, this is one of the most fixable,” he says.
Perlis points out that the key to sleep is simple but paradoxical: “To stay asleep, stay awake.” As he explains, to sleep through the night an insomniac must build up a certain amount of sleep debt, which requires staying awake for at least 16 hours. It’s like pulling back the string of a bow: a certain amount of pressure is needed to send the arrow flying.
Thus, if you weren’t able to drift off until 3 A.M. last night, you don’t stay in bed till 10 A.M., hoping to catch up on your sleep. Rather, you get up at 7 o’clock as you had intended. Sure, you will be miserable today, but by tonight—or at least tomorrow night—you’ll be overwhelmed by exhaustion and sleep like a log.
This is the concept behind sleep restriction, the first pillar of CBT-I. Before beginning treatment, patients keep track of how much they actually sleep (not everyone needs eight hours), as well as how much time they spend in bed. Comparing these two numbers gives patients their sleep-efficiency percentage. For example, if you can sleep for only six hours but you’re in bed for eight, that’s a sleep efficiency of 75 percent. To increase this number to 90 percent or more, the therapist will cut back the time you’re in bed, so if you usually go to bed at 10:00, you’ll now go to bed at 12:00.
“The number one rule is: don’t be awake in bed. The more time you spend awake in bed, the worse your sleep will be,” says Rachel Norwood, M.D., a psychiatrist at the National Jewish Medical and Research Center in Denver. Norwood instructs her patients to use their beds only for sleep and sex. In behavioral psychology this is called stimulus control.
“You want the feel, the smell, and the sight of the bed to become cues telling your brain it’s time to go to sleep,” she explains. “If you muddy those cues so the bed can also mean it’s time to watch TV, talk, read, or lie awake and worry, the cues lose their power.” Just being in bed, the site of so many hours of fretful tossing and turning, can make insomniacs nervous, which is why many of us sleep better when we’re away from home.
A CBT-I patient who has lain in bed, unable to sleep, for 20 minutes must get up and go into another room to read. After 20 minutes the patient goes back to bed. The sequence is repeated until the patient falls asleep.
Obviously, this is not a treatment for the faint of heart. “Doing CBT is really hard work, and it is stressful for patients,” Norwood says. Much of the therapy is devoted to challenging patients’ catastrophic beliefs about what will happen when their sleep gets worse during the initial stages of treatment, and prying their fingers off dysfunctional coping mechanisms, such as reading in bed or napping. But if patients follow the protocol, they do improve. According to a study by Edinger and his colleagues, patients who received CBT-I treatment experienced a 54 percent drop in nighttime wakefulness, versus just 16 percent for those who underwent relaxation training. What’s more, the CBT-I patients kept improving over time. Notes Norwood: “They start to trust their sleep, and their anxiety releases”—leading to even better sleep.
The goal of the treatment is to establish a strong and regular sleep-wake cycle. This can be especially problematic for those who don’t have commitments to roust them out of bed in the morning. Norwood recalls one such patient who sat in her apartment all day: “Her days were not different enough from her nights.” The solution was to get the woman out of the house, engaged in activities—in other words, to ramp up the waking portion of the cycle in order to induce a stronger sleep response at night.
Inspired, I tried the techniques myself. Having tracked my to-bed and rising times for seven days, I settled on a sleep window of 12:30 to 7 A.M. I knew that falling asleep would be a challenge; I have always been someone for whom life becomes endlessly more fascinating in the hours after 10 P.M. Instead of tossing and turning as I usually did, however, I went into the living room to read back issues of The New Yorker (by a camping headlamp, so as not to overstimulate the retinas). But the really harrowing part came in the mornings, when I had to heave myself out of bed after just four or five hours of sleep and thus overcome a lifelong habit of sleeping in. I accomplished this feat only with strategic use of grande lattes and frequent repetition of the CBT-I mantra: “Worse today, better tomorrow.” On the sixth day I marveled to find my circadian ship righting itself. I fell fast asleep ten minutes after my head hit the pillow and didn’t awaken until the alarm went off the next morning.
With a more-or-less consistent application of the principles, I was able to string together a dozen such good nights. Pretty soon I was feeling that sleep was my natural birthright, something I could depend on just being there. I did not kid myself that I had this monster completely licked—for that, I would probably have to work with a therapist. But now I understood some fundamental truths about sleep. I was grateful and amazed.
“It is amazing,” Norwood confirms. “And it’s just a matter of understanding how the system works.”
Susan Roberts is a school psychologist in Washington, D.C.
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