Sleep Strategies Tuesday: Worry, Relaxation and Distraction

Today is the 2nd day of a week of posts about simple sleep strategies.

 

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Meet Otis, our Tibetan Terrier.  He’s going to help me demonstrate some of the concepts I am writing about.  He’s a wonderful dog, and I must say he seems to have a very strong circadian rhythm 🙂  Plays hard and sleeps hard!

 

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Relaxation

Can’t fall asleep if you’re not relaxed, right?  There are a million ways to relax, breathe, stretch, read, pray, meditate, talk, etc.  Maybe listen to some peaceful music.  Go outside and look at the stars.  For good sleep, keep things low light, low noise and low tech.  As you relax, allow your natural sleepiness to engulf you.  How about a warm soak to mellow you out?  It can be a great way to release physical stress and tension.  However, like exercise, a warm soak increases your body temperature, so it may work best at least a couple of hours before bed to give you time to cool down.

 

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Worry

Worry a lot at night?  About all sorts of things?  Like if someone might steal your tennis ball?  Or even worry about not sleeping?  Deal with that racing mind with some mental organizing during the day.  Make a “worry list”.  Get a pad of paper, jot down some worries, then jot down a couple of possible solutions to each worry.  Keep them simple and practical.  If you are worried about your finances, don’t put down that you are going to start playing the lottery every day, or that you’re going to start a Ponzi scheme and invite all your friends to join!  Again, simple and practical.  How about committing to reviewing your expenses and saving $10 next month on something? Put the list away and then at bedtime remind yourself that you already did some really good worrying!  Then, most importantly, knock off one of your worry solutions the next day.  With worries literally off your mind (and onto paper), you can then think about more pleasant things at night (see “Distractions” below).

 

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Distraction

Had a difficult time explaining this concept to Otis, so I like to imagine he is fondly remembering his puppy-hood with his big buddy, Gus!

For you, with worries off your mind and your body relaxed, all there is to do to fall asleep is to distract yourself.  Good sleepers, when asked how they fall asleep so easily, often say they don’t try.  They just let go – let everything go, both physically and mentally.  But, as you know, you must think about something when you go to bed.  Clearly, thinking about anything stressful is not advised.  But in my experience working with insomnia patients, an active approach can be very effective.  Humans have this amazing ability to recall events in great detail, so choose an event or experience that was really great:  a wonderful vacation you once had, part of a book or movie you like, or a visit with an old friend as some examples.  Get out an old photo album after dinner and jog your memory.  Then take one of those images to bed and replay it in your mind.  You can be as creative and detailed as you want – it’s your brain after all!  Want to visit Paris after reading an article in a travel magazine?  Sure!  How about taking along an interesting historical figure with you too.  And hey, who says you have to fly coach?  Book your seat in First Class… you get the idea.

Distraction can be fun!  If you want to count sheep go ahead.  That just sounds really torturous.

So what’s most important to you for getting to sleep or back to sleep: reducing worry, relaxing, or distracting yourself?

Til Morning,

Michael

Sleep Strategies Monday: Caffeine and Exercise

Good morning!  This week I thought I’d post a couple of simple sleep strategies each day.  These strategies fall generally into the category of “sleep hygiene”, but also will contain elements of other behavioral sleep strategies.  I took the liberty of injecting a chuckle or two…just to make sure you’re paying attention!  And like I tell my patients, don’t shoot the messenger 🙂  Enjoy the week!

Til Morning,

Michael

 

Caffeine (And Other Things We Consume)

I know, going right for Jugular on this post!  But caffeine is in all sorts of stuff, not just coffee.  Sodas, candy, even some medications can contain pretty high amounts of caffeine, and it can keep us alert a lot longer than we think.  In fact, if it were discovered today, caffeine would probably require a prescription from your doctor.  It’s usually no big deal when used in the morning, but if you’re having trouble getting to sleep it’s the last thing you need later in the day!  And just to remove more fun from your life, smoking (stimulant/coughing), alcohol (knocks you out, then fragments last part of sleep), and junk food (indigestion, stomach pains, stimulant) are also bad for your sleep.

Experiment by reducing/adjusting these substances to see if they are affecting your sleep.  If you’re trying to sleep better, it’s definitely the place to start!  Caffeine can be slowly tapered down, but alcohol and nicotine reduction should be done under the supervision of your regular doctor.  And there are lots of resources available for those wanting a better eating plan for themselves.  It’s all good for sleep, and that’s very good for you!

So are you a late-latte type, or a morning-mocha type?  Or both??

 

Regular Exercise

Exercise has been shown time and again to be one of the best things for sleep!  If you’re a bit of a couch potato, check with your doctor about doing some exercise.  One thing to remember though: even though some research has shown that exercise before bed does not seem to adversely affect sleep, if you’re having trouble getting to sleep, try to leave at least a couple of hours to cool down before going to sleep. You might consider planning your exercise earlier in the day, or during the time of day when you sometimes find yourself getting a little sleepy in order to keep yourself from taking a long nap.

Starting the day with a bit of exercise gets people going for the day.  Think of it as a way to amplify your Circadian Rhythm, the 24-25 hour natural sleep/wake rhythm we all have.  Shutting down melatonin production at the end of the night, getting some light, and getting some exercise will all help to make that wave of sleepiness in the evening stronger!

Are you getting any regular exercise?  Did you know it can really help your sleep?

Is Q For U?

As we move along in development of SleepQ, I thought it would be helpful to identify who might benefit most from sleep training with SleepQ.

A 2005 survey found that about 10-15% of adults have chronic insomnia. This is the on-going type, unrelenting, where sleeping pills don’t work (or are not wanted) and phrases like, “My insomnia seems to have a life of its own” and “I’ve tried everything” are commonly heard. What may have started with a temporary erratic sleeping schedule caused by one of life’s twists or turns has become a big problem. Confidence in sleep has plummeted. Sleep is less predictable. The time window for falling asleep becomes very short: “I fall asleep on the couch watching TV, then later race to fall asleep in bed because if I miss my window I’m up all night.”

As a relatively active person, the concept of sleep training made a lot of sense to me. Most insomniacs I educate clinically do not want to be told for the millionth time that caffeine and alcohol are bad for your sleep. Or that they need to exercise more (“I’m too tired all the time for that!”), or sleeping-in is bad (“I have to get SOME sleep sometime!”). SleepQ is a way to take control of on-going sleeping trouble in a very direct, tangible way. Following along with the successful research protocol from 2007 and 2012, the first step is to get sleepy. In the research, this was done by asking the subjects to get no more than 5 hours the night before training. With the SleepQ app, you can just wait until you have a rough night (probably not a long wait for some of you!). Then, choose a couple hours before bed (late afternoon or early evening when natural sleepiness is high) to do some sleep trials. Each trial will give you the opportunity to allow yourself a chance to fall asleep, briefly, and then get feedback as to whether or not you fell asleep. This feedback, over successive sleep trials, is how you gain confidence in your sleep. We are even designing the SleepQ app to 1) automatically adjust the training intensity, and 2) display summary results about how well you performed during training!

So, are you one of the 10-15% of adults I described?  Learn to fall asleep on Q!

Til Morning,

Michael

Active Sleep Therapy: Barbells Not Required!

In my last post, I discussed the way chronic insomnia is diagnosed as well as some of the failed strategies some people try to overcome it. As I mentioned before, many untreated medical and psychological disorders can cause chronic insomnia, so you must discuss your sleep with your primary clinician before initiating any type of treatment. Then, when considering what to do about your chronic insomnia, consider the components of cognitive/behavioral therapy for insomnia (CBT-I), the “gold standard” treatment for chronic insomnia:

1) Sleep Hygiene – good sleep habits (e.g., reduce caffeine and alcohol)
2) Stimulus Control – strengthen association between bed and sleep
3) Sleep Restriction – minimize time spent in bed awake
4) Relaxation – physical and mental
5) Cognitive Restructuring – address expectations, misperceptions and attitudes about sleep

Of these CBT-I components, stimulus control (SC) is considered the most effective, and interestingly SC is arguably the most active component. SC is a bit of sleep bootcamp – it takes some “doing”. How?

First, start by only being in bed when sleepy or asleep. Then:

1) leave the bed if alert, even if you were sleepy moments ago
2) do something quiet in low light (e.g., read, hobby, etc.)
3) only return to bed when sleepy again
4) repeat 1-3 as needed all night
5) get up at the same time every morning

SC can be challenging. We are usually on our own, dealing with nighttime alertness by ourselves while our bed partner snoozes away. We are instructed to leave the bed, probably the most comfortable spot in the entire house. It can be cold and dark. We are tempted to think, “No one will know if I just stay here under my covers, maybe turn on the TV…”

SleepQ app to the rescue!  The SleepQ app will offer at-home intensive sleep retraining (ISR). And ISR is essentially SC, repeated in a controlled, efficient manner. The SleepQ app will be powerful, fast-acting, convenient, affordable, and non-drug. It can be used at home on those afternoon/evenings following a rough night of sleep, when confidence in sleep is low but natural sleepiness is high, and the thought of another round of sleeping pills just doesn’t sound appealing.

Then enjoy a peaceful night of worry-free, deep, restorative sleep…right on Q!

What do you say…who’s in?

Til morning,

Michael

Is There a Test For That?

Working as a Licensed Sleep Technologist for many years and more recently as a Certified Clinical Sleep Educator, I keep abreast of changes in the diagnostic criteria for various sleep disorders. For example, Sleep Apnea severity is measured as the number of breathing “events” noted during a sleep study, usually when the airway becomes obstructed and air intake is reduced for at least 10 seconds. When the number of events is more than 5/hour, it is usually clinically significant. For Narcolepsy, a fairly normal sleep study followed by daytime nap testing showing rapid sleep onsets and REM sleep episodes (two or more) leads to the diagnosis. These two examples are very much generalizations, more to the story as they say, but they give you an idea of how two sleep disorders are diagnosed.

Diagnosing chronic insomnia (10-15% of adult population) is different. There really is no medical test for chronic insomnia, so the diagnosis is fairly subjective. After factoring out significant medical (waking or sleeping) and psychological disorders, the diagnosis of chronic insomnia considers the person’s estimation of poor nights, including frequency (three or more nights per week) and duration (for more than a month). For sleep onset insomnia, average time to fall asleep of more than 30 minutes is the threshold. For sleep maintenance insomnia, it is an average time needed to fall BACK to sleep of greater than 30 minutes that earns the diagnosis.

An overnight sleep study is typically not needed to diagnose chronic insomnia. In my experience, most people just come to a point where they know something is wrong with their sleep. Worry and anxiety about sleep develop. Over time, sleep, which was once just something that happened automatically and never a cause of concern becomes an issue.

People often begin to try things – they feel they should actively DO something, anything, to sleep better. Here are a few of the more common strategies that I hear from patients, and the rationale given:

Strategy: Going to bed earlier
Rationale: I want to try to make up for lost sleep
Problem: Links the normal sleep cue of going to bed with being awake

Strategy: Staying in bed when alert at night
Rationale: In case I fall back to sleep I want to be in bed
Problem: Increases frustration with getting back to sleep; makes the bed a “battle ground”

Strategy: Watching TV at night
Rationale: I want to be distracted
Problem: TV emits light, especially blue light, which stimulates the brain

Strategy: Sleeping-in
Rationale: It is oh so comfortable!
Problem: It shifts the circadian rhythm and essentially causes jet lag

Strategy: Taking naps
Rationale: Any sleep is better than none, right? And sometimes naps just happen.
Problem: Naps shift the circadian rhythm and make sleep at night more difficult

Strategy: Becoming less active during the day to conserve energy
Rationale: Resting is almost as good as sleep, right?
Problem: Sleep is different than just resting, and regular exercise is a great way to improve sleep

So have you tried any of these strategies? Can you actively DO anything to reduce ongoing trouble sleeping? The answer is a resounding Yes!

Tune into SleeponQ.com – the next post will have the answer!

Til morning,

Michael

Sleep and Dreams? IDK!

In my many years working in the field of sleep disorders, I have often been asked two questions: 1) What do my dreams mean? 2) Why do I always wake up and can’t get back to sleep? The short answer to both is simply, “I don’t know.” Or as my kids would say: “IDK”. Honestly.

The truth is that sleeping and dreaming are two of the most physiologically complex processes that happen to us, and so without further investigation and questioning, I always stick with IDK. Because studying dreams is difficult at best, I typically recommend finding a book on dreaming theories and picking the one you like best. Into deep thoughts and the subconscious mind? Try Freud or Jung. Comfortable talking about computer processing, organization and file cabinets? Look into Pavlides and Winson. Neurons and synapses? Check out Hobson/McCarley.

I’ve never really been into dream interpretation, probably to my detriment. I guess that’s the practical, midwest side of me (born in Nebraska). What does your dream mean? IDK. Just be glad you got some REM!

The other question of why someone (you) might be waking up early every night is actually more solvable for me than the dream question. With an open Q&A discussion, common reasons tend to be alcohol, medications, stress, pain, circadian rhythm shift, sleep apnea, or age. And because I’ve learned not to play doctor, anyone with a sleeping problem such as frequent early awakening that cannot be resolved through better sleep hygiene (the normal do’s and don’ts of sleep) should run it by their doctor. Sleep (like wake) is a whole body process, affected by and affecting just about any other health conditions, and keeping your regular doctor informed is imperative. If/when organic medical conditions can be ruled out, then a powerful behavioral sleep strategy like Intensive Sleep Retraining (ISR) may be just the thing!

So keep an eye out for our SleepQ project coming to Kickstarter this fall. “IK” that “ISR” with “Q” will be a great help for those who want a better confidence in and awareness of their sleep, and less dependence on sleeping pills!

Til morning,



Michael


The Story of SleepQ (up til now)

Welcome to the very first blog post at SleeponQ.com! I am very excited to share some of my thoughts and experiences about my first 25 years as a sleep tech (#394), university instructor, lab manager, DME owner, and clinical sleep educator. I’ve seen a lot of discoveries about sleep over the years and I continue to learn about more all the time! And as you can see, I am developing a sleep-training device for helping people improve their sleep.

One of my passions has been helping people who have struggled with their sleep to learn simple behavioral strategies that can really help improve confidence in their sleep. These strategies involve the concepts of cognitive behavioral therapy for insomnia: sleep hygiene, stimulus control, sleep restriction, relaxation and worry reduction. These concepts can be learned by anyone with primary chronic insomnia, and they have been shown to be effective in the long run. However, these behavioral strategies can take a while to work, and there are not many fully qualified people trained to deliver them.

It was through some of my normal frequent searches for new and better applications of these cognitive behavioral concepts where I came across a study out of Australia that was investigating a behavioral procedure called Intensive Sleep Retraining (ISR). The researchers found that significant improvement in the sleep of chronic insomniacs could be made rapidly non-pharmacologically. With the theory that chronic (psychophysiologic) insomnia was a conditioned response caused by nightly difficulty falling or staying asleep, the researchers demonstrated that with feedback about sleep onset, subjects could rapidly gain confidence in and better awareness of their sleep. The keys were to have the subject sleepy when they began the sleep trials, and to let them sleep a few minutes before waking them with feedback about sleep onset.

With the main problem of ISR being logistical (how to offer it to the many people with insomnia), I began to brainstorm about home versions. Here is a rough outline of my thought process:

How can sleep onset be detected without expensive equipment?
When I fall asleep, it is often while reading, and I drop my book.
But the book makes a “clunk” and wakes me up right away.
What could be dropped that would let me sleep a few minutes before waking me?
What could someone use that would not be so “clunky” as a book?

After doing some research, I read where the famous artist Salvadore Dali would hold a spoon in his hand during naps in his chair. With a plate on his lap, Dali would drop the spoon onto the plate as he began to fall asleep, which woke him up. This lead him to have all sorts of creative images for his paintings. I found that sleep researchers back in the 1930s were comparing the dropping of hand-held objects to the new discovery of EEG (brainwaves), which slowed when awareness waned and sleep began. In 1939, Nathaniel Kleitman (the “father of sleep medicine”) experimented by dropping a wooden spool. He discovered the drop happened shortly after the EEG pattern changed from wake to sleep.

So I thought, “Maybe I needed a “smart” spoon or spool?”
I realized I needed something electronic with a sensor.
And I needed to find the right shape, size, weight and texture.
So I began dropping all sorts of objects off the side of my bed each night when I fell asleep.
I found that small, round, light-weight and low-tactile objects were the least likely to be detected when dropped.
I noticed that the sleepier I was, the less likely I was to detect that I dropped something. This was key.

I also noticed that objects always made a little sound when they hit the floor. But the more I padded the object for impact, the bigger and heavier it got. So I did what any good son would do: talked with Mom.

She said that people didn’t want to crawl around on the floor looking for this thing after they dropped it. She envisioned a tether attached to the bed. This also solved the sound issue. Brilliant!

I then enlisted the expertise of a local college engineering program (RCC in southern Oregon – great program!) to create a prototype device, which they graciously did, all for some of my wife’s delicious chocolate-chip banana bread. I call this device “SleepQ”, as in learn to fall asleep “on cue”. You can see a demo of the prototype in the video on the homepage. Late last year I found a business partner, and we’re now moving SleepQ ahead full speed! We found a wonderful product engineering firm and have initial design specs for a final version. But they need more than banana bread. So we’re gearing up for a Kickstarter campaign in Fall 2013. Please join us! Help millions of insomniacs to learn to fall asleep on cue. Yes – with SleepQ!

Until morning,

Michael