“I will bless the Lord who guides me; even at night my heart instructs me. I know the Lord is always with me. I will not be shaken, for He is right beside me. No wonder my heart is glad, and I rejoice. My body rests in safety.” -Psalms 16:7-9
Occupational therapists learn that rest and sleep are “areas of occupation” or components of life. In school, we learn that we can address patients’ concerns in the different “areas of occupation,” such as rest and sleep, work, self-care tasks, social participation, etc. The problem is that as students, we truly didn’t learn anything about the mechanism of sleep disorders, and therefore how to treat them. I also never saw sleep disturbances treated in a clinical setting. At best, a therapist would modify bedtime routines and increase physical activity during the day, and hope that would improve sleep disturbances.
Poor sleep is a common complaint for people with chronic health conditions. Disordered sleep can also lead to a host of other medical conditions. As Colleen Carney explains in her course “Understanding Sleep-Wake Disorders: Practical Tips for Improving Sleep,” sleep deprivation can lead to increased risk of type 2 diabetes, heart disease, high blood pressure, cancer, and a stroke.
With my own sleep problems, of not being able to fall asleep or stay asleep and extreme exhaustion during the day, I set out to learn more about this topic and how to remedy sleep disorders.
The following is what I learned from Colleen Carney, Ph.D., Director of the Sleep and Depression Lab at Ryerson University in Toronto, Canada.
The Difference Between Sleepiness and Fatigue
Being tired and fatigued are often confused for the same thing. There is a difference between feeling sleepy and fatigued.
Sleepiness is the feeling that you are about to fall asleep, and is common among people who have obstructive sleep apnea (OSA) and restless legs syndrome (RLS). These individuals can fall asleep pretty easily, almost anywhere (in some cases), and love to take naps.
People with insomnia, do not feel the feeling of sleepiness. People with insomnia typically feel fatigue more, which is a feeling of being mentally, emotionally, and physically exhausted, but not being able to sleep (in other words, you want to sleep terribly, but you cannot).
Feeling Constantly Sleepy?
I used to hope to have the kind of sleep where I would fall into bed, fall asleep within five minutes, and sleep throughout the whole night without waking. What I learned is that this type of sleep is actually dysfunctional, and indicative of sleep deprivation and potentially sleep apnea.
If you are someone who can fall asleep unintentionally, in less than 10 minutes, don’t remember waking up, and need a nap each day, ask your doctor for a referral to a sleep clinic for a sleep study. People with sleep apnea are 2-7xs more likely to be in a car accident by falling asleep at the wheel.
Obstructive Sleep Apnea
This occurs when there is muscle relaxation and a blockage of the airway, which results in no airflow for 10 seconds or more. Depending on how many times this happens throughout the night, a person can be diagnosed with mild, moderate, or severe obstructive sleep apnea.
Signs of Obstructive Sleep Apnea are:
– Do you snore? Is it loud?
– Do you fall asleep during the day?
– Do you have high blood pressure?
– Has anyone observed you stop breathing in your sleep?
Other signs, but not always the case:
– A BMI over 35kg?
– Older than 50 years old?
– Neck size larger than 40cm?
– Male?
I was diagnosed with moderate sleep apnea, when I was 33 years old with an average BMI, due to the back of my throat causing an obstruction. I don’t snore at all and I have almost no daytime sleepiness. So the signs, don’t always correlate with who is diagnosed.
Risk factors for OSA:
- Alcohol consumption
- Septum deviation, allergy, recurrent tonsil infections
- Weight gain, obesity
- Menopause
- Smoking
The GOLD STANDARD for treatment (the most effective treatment) is positive airway pressure devices or a CPAP device. There are other treatments, such as surgery, and a dental appliance, but they are not found to be effective.
The CPAP is not a sleep aid. It is a device designed to save lives during the day. Initially, you may lose sleep as you adjust to something new. There are many mask options for comfort, if you don’t like one. It takes time to adjust to something new, but it is worth feeling better.
Restless Legs Syndrome
An uncontrolled need to move legs, or movement (jerking) of legs.
Signs of Restless Legs Syndrome:
– Do you feel a strange, irritating sensation in your legs in the evening?
Risk factors for RLS:
- Family history
- Pregnancy (iron deficiency)
- Medications (SSRIs, and antihistamines)
- Iron deficiency
- Medical conditions (polyneuropathy, diabetes, OSA)
Recommended treatment are the medications Pramiprexole and Ropinirole.
Can’t Sleep Given the Opportunity?
Insomnia
Difficulty falling asleep and/or staying asleep, despite the opportunity to sleep. Affects functioning and causes distress. Occurring over at least a 3 month period, for at least 3 nights a week.
Doctors can diagnosis this condition with a sleep diary, after other conditions have typically been ruled out. I will share how to do a sleep diary below.
FYI: Fitness monitors cannot measure your sleep quality, only an EEG test can measure your various brain waves (beta, alpha, theta, delta). A monitor just measures your movement, and makes a prediction.
Risk factors
There are factors that can predispose someone to insomnia, such as perfectionism. Factors that can precipitate or cause insomnia include a stressor (either good or bad), such as working for a promotion, getting married, or an illness. Typically, once the stressor is resolved, the difficulty sleeping should go away. When it does not, and it becomes a chronic issue that is insomnia, and you should see your doctor. Perpetuating factors that cause insomnia to continue include:
- Spending too much time in bed (naps, sleeping in, or going to bed too early), relative to how much sleep you can get. This is a problem, because the body makes adenosine (a neurotransmitter) from the moment you wake up and get moving. Adenosine is responsible for creating the need to sleep, along with increasing deep and restorative sleep. So if you take naps, sleep in, or go to bed too early, then you are reducing your chances of deep and restorative sleep.
- Inactivity
- Inconsistent bedtime and wake time. This affects the body’s clock of managing sleep and wake cycles.
- Sleeping outside of your optimal time for quality sleep. (ex. Staying up too late, when you are a morning person, or getting up too early when you are a night owl.)
- Hyper arousal (PTSD, anxiety)
Drugs that can contribute to insomnia
- Stimulants (diet pills)
- Blood pressure pills (antihypertensives)
- Asthma medication
- Chemotherapy
- Decongestants
- Antidepressants
- Hormones
Treatment
The GOLD STANDARD is Cognitive Behavioral Therapy for insomnia (CBT-i) and relaxation therapy techniques. The goal of this treatment is to improve sleep efficiency (time actually asleep).
Medications
The only medication that has evidence for helping with chronic insomnia are Benzodiazepines receptor agonists, but they are controversial as they are addictive (some are also showing a correlation with increased risk of cancer and dementia). They are recommended for short-term use, which is why CBT-i is so important in order to resolve the issue completely. CBT-i also helps with transitioning off of medication. If you are on these medications, do not stop them suddenly. See your doctor to taper them to avoid withdrawal or seizures.
Note: I use a baby dose of Trazodone (SARI drug) to help with falling asleep, but
it doesn’t help with staying asleep. I have to use CBD oil occasionally and Lifewave Silent Night patches. The CBT-i work has really helped me over all. My quality of sleep has improved a lot, based on my sleep diary assessment.
FYI: There are a lot of articles about “good sleep hygiene.” According to research, healthy sleep practices may be good for overall health, but are not effective in treating insomnia.
Sleep Diary
To complete your own sleep assessment, download the CBT-i coach app (free on iPhone and Android). Click on “My Sleep,” and then fill out assessment. Be sure to add at least five sleep diary entries, in order for the app to calculate your sleep prescription (found on the home page). To fill out the sleep diary, you can use a fitness tracker to indicate when you fell asleep, how many times you woke up, when you awakened, and when you actually got out of bed. If you do not have a fitness tracker, keep a notepad by your bed, and do your best to jot down the data in the morning.
The results will give you a prescribed sleep bedtime and wake time to reduce insomnia.
Once sleep efficiency improves to equal or greater than 85% (as indicated by the app, when filling out your sleep diary) and you are beginning to feel sleepy during the day, then you can increase the time in bed by 15- 30 minutes. If you present with symptoms of insomnia again, then decrease your time in bed again.
The app also helps with cognitive behavioral strategies. Below are further suggestions for improving sleep efficiency.
CBT-i Principles
- Go to bed only when sleepy, but not too early
- Concerned that you never feel sleepy? Over time sleepiness will build
from sleep deprivation, when you follow step 2. It will take time.
2. Get out of bed when you cannot sleep. Only stay in bed when you are asleep or
close to sleep.
- Over time the bed becomes paired with tossing and turning, and restlessness. By leaving your bed, you will begin to break the association that restlessness occurs in the bed.
- The goal is to match the time in bed, with the current average you are sleeping (as found in a sleep diary).
3. Get out of bed at a consistent time each morning
- This will help to reset your sleep and wake clock and can help to build your body’s need for deep sleep. Getting exposure to sunlight or a sun lamp in the morning also helps to reset your internal clock (increase energy).
4. Use the bed and bedroom only for sleep (and sex, unless that makes you too
alert).
5. Do not take daytime naps
- Taking naps will diminish your body’s sleep drive.
Need help getting your brain to calm down?
- Begin to “wind down” about 1-2 hours before bed (no stimulating activities, which may include looking at cell or computer screens).
- Schedule time to worry- write down concerns or problem solve issues preferably hours before bed.
- Relaxation practice- progressive muscle relaxation, diaphragmatic breathing, meditation, and guided imagery (See my Resource Guide).
- Cognitive Therapy
- Mindfulness practice
Engaging in hobbies, physical exercise (earlier in the day), socialize with friends and family can help to reduce stress and improve sleep issues.
Note: People with insomnia are more obsessed with thinking about sleep and
believe that it requires effort to get good sleep. The truth is that a “good” sleeper,
doesn’t have to try hard or think about it, he or she just sleeps. So, avoid trying
so hard (perfectionist mentality)!
Cognitive therapy tips to cope
These help to address stress from not getting quality sleep, and making changes to your sleep structure while implementing a new sleep routine. Also see my article Coping with Stress.
- Restructure your thoughts ( ex. “I’m just a bad sleeper.”)
- Ask yourself, what is the evidence that this thought is true or not true? (Remember also times, when you have slept ok)
- Is there an alternative explanation? (Maybe there is another reason or outcome)
- Is this thought useful or not? (If not, then decide to not listen to it)
2. Challenge thoughts
- Experiment by challenging your thoughts. (ex. If you believe that you need to nap, in order to get through the day, try coming up with an alternative belief of “if I avoid a nap, then my nighttime sleep will improve, and I can cope.” Try out your new belief, while using coping skills.
3. Coping cards
- Write down a fear or concern about sleep. (ex. “I cannot get up too early.”)
- Write motivational statements.
Ex. “Getting up early will help to improve my sleep.” “I can enjoy getting up, by making myself a nice coffee.” “I can meet a friend for a walk in the morning.” “It is hard, but I have to do this if I want to sleep better.” “I can handle this.”
FYI: If you are suffering from insomnia and depression or PTSD, it is very important to treat these conditions alongside of insomnia, in order to improve sleep quality. It takes time, but these techniques are shown to be effective.
References
Carney, C. Understanding sleep-wake disorders: Practical tips for improving sleep.
Institute for Brain Potential. Los Banos, CA.
Copyright @healingfaithfully 2019.
Nothing is Impossible 