What are some of these non-drug behaviors to treating insomnia?

Dr. Stepanski: The behavioral treatments encompass a whole lot of changes. One of the biggest changes that we focus on is trying to limit the amount of time people spend in bed. When people start to sleep poorly, they tend to make a lot of changes that they think are gonna change them and maybe in the short term do help them, but in the long term make things worse.

For instance, if I’m having trouble sleeping, I might decide I’m really tired tonight. I’m going to go to bed early, and I’m so tired I’m going to stay in bed extra late. I’m going to, later on during the day, try and take naps. I’m going to drink extra coffee because I feel so tired during the day. I may try to self-medicate with alcohol at night and see if that helps me get to sleep. So lots of these things that people do actually take them in the wrong direction. As soon as you’re spending 10 hours or 11 hours in bed at night, from the time you first get into bed until the time you get out of bed, then it means you’re guaranteed to spend a certain amount of time awake. If you were a seven-hour sleeper your whole life, and you’re in bed for 11 hours, then you’re awake for four — even on your really, really best night. You’re going to sleep your seven and be awake for four. So people end up on schedules that are very different from the schedules they kept back when they were a good sleeper.

The other thing that people then start to do is they engage in activities in the middle of the night. So they start to watch TV. They might get something to eat during the night. When people are sleeping well, they go to bed at 11, and they fall asleep in 10 minutes. They sleep through till six or seven. They wakeup feeling rested. It doesn’t occur to them to get up at two in the morning and eat leftover pizza or watch TV, watch a movie, start engaging in their hobby, you know, things like that. But as soon as you spend any amount of time or any number of nights awake from 1 to 3, well then you start to do things like that. You get up and you might check your e-mail. You might see what’s on TV and channel surf. And to some extent, people start to get engaged in activities that might actually wake them up and stimulate them. Certainly eating is like that. Anytime you have something to eat during the night, it’s a very reinforcing kind of an activity, because people usually are eating their favorite foods. So then on subsequent nights they get into that habit. And it might be on night one they eat something and they fell back to sleep faster, so they think, “Well, I think that helps me.” So then they get up, and they start eating every night with that hope. Then after a while they realize it’s not really doing them any good.

So the original problem that started their troubled sleep, it might be bereavement, it might have been job stress, it might have been jet lag, or some very common trigger for bad sleep is gone now. That effect is gone. But now what they have are all the effects of all these other changes that they’ve made, both to their sleep and wake schedule. And there are lots of activities, habits and behaviors that people start to engage in once they’ve had bad sleep for some period of time that have to be eliminated for them to return to being a good sleeper again.

That being said, what are the things people shouldn’t do if you want a good night’s sleep?

Dr. Stepanski: What we do with people a lot is provide education and talk about how to look at their sleep to understand, say, how their biological clock is going to trigger a time when they can get to sleep and the time when it wants to be awake. We help them understand the effects certain kinds of behavior might have right before they go to sleep or what they do to them during the night. We help them to figure out what are they doing right and what are they doing wrong, because a lot of things won’t necessarily be clear to us. We can’t think of necessarily every single thing to ask somebody.

So do you get up and listen to music and dance at night? It turns out people will do things like that and unless we kind of explain what we’re trying to get at they won’t identify that as, perhaps, a problem behavior. We try to teach people to look for those things. The general rule is going to be not to engage in any activity right before bedtime — and I mean within an hour or two of bedtime or during the night — that’s going to be inherently stimulating, either physically or mentally. So even though people think of surfing on the Internet as being a very sedentary, low-key kind of activity, it really isn’t. People are pointing and clicking and going to things that interest them, and that that mental stimulation will wake them up and keep them awake longer than you would think. Same with video games and things like that. Even though a person is laying on the couch engaging in that kind of activity, it will actually get them revved up, and they’ll have a harder time then falling asleep afterwards. We work with people to identify a whole lot of activities like that.

In addition to the behavioral changes that we make, one of the biggest changes that occurs in someone who’s had trouble sleeping over time are what we call cognitive changes — ways that they think about their sleep. Probably the single biggest problem that occurs is that when people are sleeping well, they wake up at two in the morning. They might check the clock and say, “Oh, thank goodness, I can go back to sleep. I’ve got hours to go before I work.” They then roll back over and they go right back to sleep. It doesn’t occur to them to worry about it. If you’d had trouble maintaining sleep with waking up during the night for every night for a couple of months, when you wake up at two in the morning, you look at the clock and go, “Oh my God. What’s going to happen now? I wonder if this is going to be another bad night like last night. I hope I get back to sleep fast.”

People start to catastrophize and start to think a lot about the problem and that automatically raises their arousal level and their tension level. And so the likelihood they can then get back to sleep is going to be very reduced. So we have to do a lot of work on getting people to approach their sleep in a different way and not to approach it as something where they’re trying harder to sleep better. Because as soon as you try hard, you’re more awake and you’re not going to do well.

If they’re trapped in this, how can you change someone’s thinking?

Dr. Stepanski: That’s where it all works together. First of all we make behavioral changes. We actually help people to sleep better in the first place so that their sleep isn’t as bad as it has been. And so with that, they can start to back off of worrying about it as much. On top of that, we take a look at their concerns and their fears.

Very often people have blown it out of proportion to some extent. That is, they feel like, “I’m going to lose my job if I don’t get better sleep. My performance is going to be so bad that I’m going to get in trouble at work or in trouble with my family. My wife will leave me if I feel like this all the time because I have no energy.” When we really explore it, what’s typically the case is that they are the only ones that notice that they feel tired and fatigued during the day, but no one else is aware that they’re having as hard a time getting through the day as they might be.

So there’s some degree of catastrophizing that’s going on and blowing the circumstances a little bit out of proportion. And that’s especially a risk at 2 or 3 in the morning. I mean, everybody at that time doesn’t necessarily have the same perspective on things. If you’re laying awake at 2 in bed thinking about what you have to do the next day, that always seems like a lot bigger deal than it will the next morning. The next morning will come. You’ll get up, you’ll go to work, you’ll do everything like you normally do, and you’ll do it fine. You know, you may be tired but you’ll get it done and you’ll come home. But at 2 in the morning, it seems overwhelming. It seems much more difficult than you can do. And that’s true for everybody. It’s just that most of us are sleeping through that period, and we don’t have to be awake at 2 in the morning thinking about what do I have to do tomorrow and this week, and what big problems do I have to solve and that’s just not a time you want to do that.

So we want to teach people don’t do that. That’s one of the reasons behind not letting yourself lie in a dark, quiet room wide awake for an hour or two. That that’s just doing damage to yourself. If your body’s wide awake and you’re lying in a dark quiet room, you’ll think about all the things that you have to do coming up that day, that week, and any big problems you have.

What should you do if you are lying in bed and do wake up at 2 in the morning? What do you recommend?

Dr. Stepanski: The rule is if you’re feeling calm and peaceful, like you might doze back off, then you stay in bed and that’s fine. But if you’ve been lying there about 20 minutes and you have that feeling like you’re wired, you’re not falling asleep now, or you may not fall asleep any time soon, that’s when we tell people get out of bed and go do something relaxing and then return to bed once you feel sleepy again. Most people understand that difference. They know those times when they feel comfortable. They may have been laying there for a while, but they feel comfortable like they’re about to doze off and that’s fine, then they want to stay there. But that wired feeling and lying in that dark quiet room is a bad combination.

When you say go do something relaxing, what would that be?

Dr. Stepanski: We’ll have people do something again. It’s gotta be just engaging enough that it holds their attention. So if they’re watching TV, it’s a show that holds their attention as opposed to just sitting on the couch thinking, “Oh my gosh, I wish I was back in bed. I wish I was sleeping,” checking their watch to see how many hours they have left before they have to get to work. You know, that kind of thing. It has to be an activity that holds their attention but isn’t inherently stimulating. We tell people not to engage in work things like doing a load of laundry because then, again, you want to stay up until it’s finished. And don’t engage in your real work because that usually, again, is too stimulating. It wakes people up way too much, and then they really can’t get back to sleep after that.

Let’s talk about some of the specifics just that keep coming up. Like when should you not take naps or drink caffeine?

Dr. Stepanski: There are a whole lot of things people should not do if they’re sleeping poorly at night. And, again, I think that this is a big point of confusion because a lot of people say, “I’ve been doing that for 20 years and, you know, that’s not a big deal,” like drinking coffee and this kind of thing. Well yeah, you can do whatever you want if you’re sleeping well. You’re getting away with it. But if your sleep has gone bad, you have to be much more careful and much more particular about your sleep habits.

If you’re sleeping poorly, then taking a nap is probably a bad idea because you’re only going to get so much sleep in a 24-hour period. If you get sleep during the day, you’ll get less sleep at night. And so if your goal is to get as much sleep at night as you possibly can, you should eliminate taking naps during the day.

Drinking coffee is another one of those things that people can get away with sometimes and maybe not at other times when their sleep is bad. The main thing is to try and stop drinking any coffee after noon, and really cut it off from then on because it can be partly long-acting and partly just the tension that people get from the caffeine can actually last longer than the caffeine itself. We usually use noon as our cutoff for someone who’s really having a hard time sleeping at night.

What about exercise?

Dr. Stepanski: We would usually say that you wouldn’t want to exercise, and I mean like aerobic exercise, within three hours of your bedtime as a minimum. Probably five hours would be more preferred — to have that much distance between when you’re doing aerobic exercise and the time that you’re sleeping.

And alcohol?

Dr. Stepanski: Alcohol is another common thing that people use to try and get to sleep, and it actually will allow them to fall asleep faster. The problem with it is that it wears off after a few hours and then when it wears off, people tend to have a rebound and they can wake up and then have choppy sleep after that. We know from doing EEG sleep studies that even people who think they slept well with alcohol didn’t get as good a sleep as they thought they did. And when people try to argue that they are sleeping perfectly fine with alcohol, we examine it and find out when they drink a lot, they’re taking a nap the next afternoon. So what’s that all about? You know, the bottom line is that the really didn’t get the kind of restorative sleep that we’re going after. The other thing is that it’s just obviously not a great long-term solution to the problem if you think about it.

What about a warm bath? You often see that recommended.

Dr. Stepanski: There is data to show that a very hot bath, about 45 minutes before bedtime can make a difference. And the way it makes a difference is by what’s called passive body heating. If you get your core body temperature elevated sufficiently, then you get out of the bath, your core body temperature starts to drop. And it drops naturally as you doze off. If it’s already dropping, it seems to help people get to sleep, but also sleep more deeply. The main effect is you will actually have deeper, better sleep. But in order to do that, it’s gotta really be a very hot bath, and you’ve got to soak in it for like half an hour, you know, before it’s time to go to bed.

OK, so not a warm one, a hot one. Is there anything to the warm glass of milk?

Dr. Stepanski: Nothing to that other than, you know, if it’s a comfort thing. My rule is not to eat anything extreme before bed. A couple slices of pepperoni pizza is probably not the best thing to do right before you go to bed. But a small snack for some people really makes a difference. Milk kind of fills the role of a small snack — nothing that’s going to cause any reflux during the night.

What do you do to get to sleep?

Dr. Stepanski: I’m doing pretty well on regular schedule. I get up at the same time every day. I’m not staying in bed really late on weekends and that kind of thing. And I know how much sleep I need. I’m about a seven-hour sleeper. So if I’m in bed about seven to seven-and-a-half hours, I’m going to end up getting pretty, getting to sleep pretty easily.

Do you watch TV or read or do anything mentally?

Dr. Stepanski: Sure. I do all that stuff in bed like you’re not supposed to. But again, if you’re sleeping OK, you can get away with that. And I, from time to time, do have trouble with sleep. I don’t do as well, and then I change that around, and I don’t do that stuff anymore. I kind of get it back on track again and then I ride it out. Then I’m back on track and do whatever I want.

This article was reported by Ivanhoe.com, who offers Medical Alerts by e-mail every day of the week.

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