The COVID-19 pandemic has disrupted lives in so many ways. Health worries, financial/job worries, school worries, relationship worries all are stressors. These stressors easily can interfere with your proper sleep. Sleep problems are not new for Americans. Estimates are that 27% of adults report trouble falling asleep or staying asleep. We spent an estimated $41 billion on sleep aids and remedies in 2015. While there is no definitive answer as to how much sleep any one person needs, sleep experts tell us we need enough sleep to stay awake and alert the next day without caffeine. For most of us, we don't function well with less than seven hours. With continued sleep shortages, you can harm your health through depression, heart disease, obesity, and Type 2 diabetes. Of course, the most frequently prescribed aids are sleeping pills and I will not be discussing these. Rather, there are several sleep issues of a non-pharmacological type discussed recently. In an article in the Monitor on Psychology for February 2016 titled "Young and sleep deprived" by Karen Weintraub, she reported research indicating that adolescents need 8-10 hours per night but on average get less than seven hours a night. Adolescents go to sleep later than older adults but have to get up early for school systems which not infrequently start at 7:30 or 8 AM. This interferes with their normal metabolism. Of course, school hours have undergone major changes given the closure of various school districts during the pandemic. Among diverse recommendations when schools reopen have concerned start times. Moving start times for school have been shown to help with increased attendance rates, decreased disciplinary action, improvement in academic performance, decreased sleeping during class, and increased attention. These are significant factors related to the well being of our youth. There appears much research to support the recommendation to push back school start times by as much as 75 minutes. The message appears clear that the later the start time, the more positive outcomes occur. Note that all this occurs without any pharmacological sleep aids.
For adults who would like to sleep better and reduce reliance on pharmacological aids, there is Cognitive Behavior Therapy for Insomnia (CBT-I), a form of behavioral treatment that focuses on changing habits that disrupt sleep. The treatment has been mentioned in various consumer magazines such as in the February 2016 issue of Consumer Reports magazine, titled "Get more ZZZs, naturally". There was a review of CBT-I in the journal Annals of Internal Medicine several years ago indicating that the treatment helped people sleep on average 26 more minutes per night and reduce their need for medications. It also was noted that the American Academy of Sleep Medicine recommended CBT-I over sleep medications as a treatment of first choice for chronic insomnia. I have been using CBT-I principles for many years for referred patients with insomnia as part of their total presentation, whether anxiety, depression, or post traumatic stress disorder (PTSD). In fact, it almost always is worthwhile to address sleep problems. While many providers think sleep problems will remit if the anxiety or depression is treated, that is not always true. There needs to be a focus specifically on sleep problems. Of course, I always recommend that you consult first with your primary physician to rule out any physical causes of your insomnia. So what is involved in CBT-I? As mentioned, CBT-I has a goal to improve sleep habits and behaviors. The cognitive part of CBT-I teaches you to identify and modify beliefs that affect your ability to sleep. For example, this may include learning how to control or eliminate negative thoughts and worries that keep you awake. The behavioral part of CBT-I helps you develop good sleep habits and avoid behaviors that keep you from sleeping well.
There are various techniques some or all of which you may need depending on your condition. These include:
1. Stimulus Control Therapy. This is a technique I have used frequently and is a part of CBT-I. This method helps remove factors that condition the mind to resist sleep. For example, you might need to set a consistent bedtime and wake time and avoid naps, use the bed only for sleep and sex, and leave the bedroom if you can't go to sleep within 20 minutes, only returning when you're sleepy. You need to be very motivated for this one but it will help you get better control of the sleep/wake cycle. I remember one patient who got up 25 times the first night after not falling asleep within 20 minutes. That was the highest number I ever saw but improvement for the patient came rapidly over the next week.
2. Sleep Restriction. This is a strategy in CBT-I. Lying in bed when you're awake can become a habit that leads to poor sleep. This technique decreases the time you spend in bed, causing partial sleep deprivation, which makes you more tired the next night. Once your sleep has improved, your time in bed is gradually increased. The trick here is not to take naps the next day as your progress then is completely undermined.
3. Sleep Hygiene. This method of therapy involves changing basic lifestyle habits that influence sleep, such as smoking or drinking too much caffeine late in the day, drinking too much alcohol, or not getting regular exercise. It also includes tips that help you sleep better, such as ways to decrease your activities an hour or two before bedtime
. 4. Sleep Environment. These are ways you create an improved sleep environment, such as keeping your bedroom quiet, dark and cool, not having a TV in the bedroom, and hiding the clock from view. You also may need to stow away your cell phone or laptop to minimize interruptions. The light they emit also is known to interfere with sleep.
5. Relaxation Training. This method helps you calm your mind and body. Approaches include meditation, imagery, progressive muscle relaxation (PMR) and others. I have written in other posts about such techniques as they reduce stress reactions and they can be very helpful here as well. I have used PMR extensively in assisting with sleep improvement often in combination with the other techniques above. For more discussion of such approaches, please see our book (I Can’t Take It Anymore: How to Manage Stress so It Doesn’t Manage You; Paul G. Longobardi, Ph.D., and Janice B. Longobardi, R.N., B.S.N., P.H.N.), available on Amazon at https://www.amazon.com/dp/1542458056. For more information about the authors, book, or stress management, please visit our website at www.manageyourhealthandstress.com.
6. Biofeedback. This method allows you to notice physiological signs such as heart rate and muscle tension and shows you how to change them. Some sleep specialists may have you take a biofeedback device home to record your daily patterns.
7. Paradoxical Intention. Paradoxical intention, courtesy of famous therapist Victor Frankl, involves avoiding any effort to fall asleep. In fact, it really involves trying to stay awake. Have you ever been somewhere, maybe even a meeting, where you are worrying that you need to stay awake but continue to fall asleep? Paradoxically, worrying that you can't sleep can actually keep you awake. Letting go of this worry can help you relax and make it easier to fall asleep.
Whatever method or strategies you employ, good sleep is critical to your health, productivity, and well being. Per the research with adolescents, adjust your sleep cycle depending on whether you are an early or late riser so as to get enough sleep. Also, consider cognitive behavioral strategies as a first treatment for insomnia before resorting to medications. You may be amazed at the power you have over this process.
As always, change your thoughts and change your results. Sleep well my friends.
Dr. Paul Longobardi
For information on these and related topics, please see my website at www.successandmindset.com.