sleep


I get to think and talk about insomnia a lot, because it is such a common symptom in my therapy clients (at least three-quarters of them) and because I’ve had plenty of it myself over the years. (Here is my advice for insomniacs.) Based on my experience, I’d like to propose a pattern of insomnia that I believe is the most common and hardest to overcome kind of insomnia: structural insomnia.

Imagine you were held prisoner for an interrogation. Your captors might try to make you pliable by depriving you of sleep. Maybe they don’t let you lie down, or force you to do some kind of work instead of sleep, or force you to drink caffeine to keep you awake, or use lights, sounds, music, or movement to keep you from sleeping. The lack of sleep you experience would be structural insomnia: lack of sleep created by your waking or sleeping environment, or by bad scheduling.

That would be a pretty cruel way to treat someone else, but when we do it to ourselves it seems pretty normal. Here are some of the most common ways we torture ourselves with structural insomnia:

We create sleeping spaces that are not dark, quiet, still, and/or comfortable.

We use caffeine less than 6 hours before wanting to fall asleep. It takes your liver 6 hours to process caffeine. You have to give it enough time to do it’s job.

We expose ourselves to light right up to when we want to fall asleep. Light tells your brain it’s day, which keeps it from producing the hormone that pressures and allows you to fall asleep.

We work up to the last minute, or stew on something provocative. You have to give yourself some mellow transition time between being on the ball and asleep.

We do not allow ourselves enough time fall asleep and sleep adequately before we have to wake up in the morning. This is a big one! If you need to wake up at 6am, you must be lying down in the dark, doing nothing but trying to fall asleep by 9:30pm in order to get 8 hours of sleep. And that’s if you can fall asleep in 30 minutes. If you know it takes you two hours to fall asleep, you need to schedule ten hours in bed to get your eight.

We wake up at night and shine light in our eyes. Phones, clocks, TV, refrigerator lights, etc.

We set an object right by our head that will randomly light up, play music, buzz, or make other alarm-like sounds. Phones, of course. Turn them off.

If you agree that it would be torture, or at least mistreatment, if you did this stuff to someone else, consider not doing it to yourself!

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In the vast majority of cases, sleeping is like peeing. You stop when you’re done.

I say this to almost anyone I hear complain about oversleeping. I’m not a sleep expert, but I have read a fair amount of sleep research in my study of psychology and psychotherapy. That research suggests that except in conditions like severe depression or narcolepsy, “oversleeping” should be reserved to mean sleeping past an appointment, like “overpeeing” can really only mean overfilling your urine sample cup.

It’s important to sleep until you are done sleeping and when you can’t avoid restricting sleep, to make up for it later. This is true for how your body functions, how your brain functions, and your overall well-being. If you don’t believe this, you are either ignorant of or ignoring the evidence. Try searching “sleep restriction” and “metabolism,” “cognition,” or “well-being.” There is a good-sized mountain of evidence. (If you don’t like reading academic writing, try searching “sleep” at TED.com or reading Sleep Thieves by Stanley Coren.)

And yet, I wake up to an alarm every weekday, and have done so for many years. This is clearly incongruent with my beliefs about sleep. Waking up to an alarm clock is just another way of purposefully restricting sleep.

So here’s the plan: I’m giving myself 10.5 hours in bed every night, from 9:30pm until my alarm goes off at 8am, until I start waking up naturally before my alarm. It means giving up an hour or two of socializing, exercising, reading or writing each evening, which feels like a lot. It feels like giving my life completely to work, getting ready for work, and sleep. On the other hand, I could end up feeling better and being healthier, and I could stop being such a hypocrite. My wife is on board with the project, so it has some chance of success.

I’ll post again about it in a few weeks.

Some of my oldest memories are of lying in bed, late at night, wishing I was asleep: sleep-onset insomnia. I’m happy to say that I have largely overcome this malady. I have a sizeable bag of tricks to help me out with it (read about them here), the most important of which is having gotten over my fear of insomnia, which had become the primary source of sleeplessness. For the last several years I’ve had trouble getting to sleep just a few times a year.

For the last couple months, though, I’ve been experiencing “terminal insomnia,” AKA waking up too early and failing to fall back asleep. Most of my tricks don’t apply here. It sometimes helps to stay in bed until my alarm goes off–occasionally I will fall back asleep. Sometimes cuddling helps, too, but I’ve found nothing consistent so far. It’s become a problem: I’m getting married next week and sleep debt tends to make me clumsy, grouchy, and stupid–not the way I’d like to show up for this event!

So I complained about it to my therapist today and he gave me his hypothesis: I am chronically and habitually productive. Productivity is a way of life  for me and it’s infiltrated my groggy, should-be-going-back-to-sleep mind. He is right. I am on the go all day. It never occurs to me to slow down, much less take a nap, and that was exactly his prescription:

“I wonder what would happen if you cultivated a habit of trying, even to a ridiculous degree, whenever you noticed being really tired , just saying, ‘OK, I’m just going to lie down. I’m just going to quit what I’m doing and lie down.’ Even if it seems indulgent or incovnenient. Just ‘F*** it. I’m lying down, I’m closing my eyes, I’m relaxing. If I sleep, I sleep–it doesn’t matter. I’m just going to relax.’ Look at your tiredness as a sort of enlightened messenger, giving you the gift of saying, “Stop it! Stop working so hard. Just lie down right now and be irresponsibly lazy. Just lay out.’

“And you’ll have to deal with the resistance in you too. The well-trained hard, hard worker in you will say “Now’s not a good time… maybe later,” and the challenge is to say “F*** you. I’m not buying it. I’m lying down. For at least five minutes I’m going to lie down, deep breath, deep relax, and invite myself to doze if it happens.

“It’s the next logical progression of getting over the fear of insomnia: The next step is getting over the fear of being tired. OK, I’m building into my lifestyle being tired and loving myself in my tiredness. If I’m tired, I lie down. Why the hell not?

“I want you to take it on as a spiritual practice. Seriously. A spiritual practice of just interrupting productivity as often as possible in order to be lazy and relaxed and tired and just let the earth hold you up. When you lay down, experience the earth holding you up and receive that kind of support. You are a very diligent, principled and hard-working fellow, Nathen, and we have noticed. We got the message. You’ve got that covered. You’ve acheived that already and can let your pendulum swing back in the other direction.”

He’s right that it won’t be easy. As I’ve been writing, I can feel the familiar tiredness in my face and arms, weighing me down, and I’m choosing to write instead of lie down. Well, maybe I will go lie down and finish this later…

I bought Sleep Cycle for my iPod touch because it sounded right up my alley. It uses the accelerometer in i-devices to measure how much you move while asleep to track your sleep cycles. Then it wakes you up when you will be most alert. How cool is that?

Well, it is pretty cool, but not because it tracks your sleep cycles, or because it wakes you up alert. First of all, sleep cycles are defined by brainwave patterns, not by movement. Perhaps it’s a decent analog–I’ve read that claim–but the charts that Sleep Cycle produces from my nights of sleep don’t look much like the examples of EEG readouts of sleepers.

Where in this graph was I dreaming? It looks like I fell asleep and woke up pretty abruptly, and was awake for a short period just after 6 am, but that’s all I can tell. I can also say that the app does not always catch it when you wake up. I’ve gotten out of bed to pee and not made a spike out of the sleep zone.

It is also not really useful for its primary purpose–to wake you up during the period that you will feel most rested. You set an alarm for the latest you want to wake up, and then a period of time during which it would be acceptable to wake up. The alarm is supposed to go off at the point in that period when you are moving enough to indicate that you are in shallow sleep. Supposedly, if it waited longer and let you go back into deep sleep, you would wake up groggy because of it.

Perhaps it’s just me, and perhaps it’s just that I’ve been in grad school, but I found that I never preferred to be woken up before I really needed to be up. I did not notice any benefit from being woken up when I started to move instead of when I had just enough time to get ready for school. Luckily, you can set it for “normal alarm clock mode” with no “wake-up phase.”

Still, Sleep Cycle is cool for a couple of reasons. First, It tracks how much time I give myself for sleeping. It starts counting when you set the alarm at night and stops when you wake up and keeps track. That’s how I know, for example, that I gave myself an average of 8 hours and 35 minutes to sleep in for the 155 nights before Reanna moved to Eugene. (It doesn’t work with two people in bed.) (And that included my last 125 days of grad school–not too bad!) That means I averaged fairly close to eight hours of sleep a night, with an estimated average sleep latency of 30 minutes. And that brings me to the coolest part.

As a chronic, intermittent insomniac, I’ve always wanted to know how long it actually takes me to get to sleep. Now I have a pretty good idea, thanks to Sleep Cycle. Many of my graphs look something like this:

I started trying to sleep just after 1 AM and drifted off around 1:45. I probably would have told you that I lay awake for at least an hour. Here’s another:

That looks like about an hour of insomnia. Don’t be fooled by the little initial drop–that was me lying very still, trying to sleep, before starting to toss and turn.

To finish off, here are a few other graphs, just so you can see some of the variety:

We don’t really know but the DSM estimates between 1 and 6% of children and many fewer adults have this experience. You are more likely to have this happen if you are related to someone who has had this happen, but we have no idea why. It usually just goes away in adolescence. If my parents had been the type to take their kids to mental health professionals, I almost certainly would have gotten this diagnosis as a kid. If so, and if my parents had been the drug-giving kind, I might have been prescribed a benzodiazepine (like Valium) for it. Generally, though, it can be treated by comforting your child when they wake up like this, until it goes away. If you think there might have been a triggering event for the condition, therapy might be helpful.

Here are the criteria, quoted word-for-word from the Diagnostic and Statistical Manual of Mental Disorders IV-TR, page 639:

Diagnostic criteria for 307.46 Sleep Terror Disorder

A. Recurrent episodes of abrupt awakening from sleep, usually occurring during the first third of the major sleep episode and beginning with a panicky scream.

B. Intense fear and signs of autonomic arousal, such as tachycardia, rapid breathing, and sweating, during each episode.

C. Relative unresponsiveness to efforts of others to comfort the person during the episode.

D. No detailed dream is recalled and there is amnesia for the episode.

E. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The disturbance is not due to  the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

 

This video makes me want to get an EEG machine. It’s of Ken Wilber narrating footage of himself moving through a few different meditative states while hooked up to an EEG machine. (EEG machines show you a picture of the electrical activity from your brain from electrodes on your scalp.) He says what each state feels like, too. Pretty neat.

(Minor correction: He makes it sound like dreaming sleep is mostly associated with theta waves, which is not quite true. Dreaming sleep does have some theta activity, but it’s mostly beta or “beta-like” waves. Theta is strongly associated with stage 1 sleep, that 5 or 10 minute transition between waking and sleep. It’s a minor point, but I so rarely find corrections to make in his work, I thought I’d take this chance.)

I’m settling in for my second shift for my university’s crisis line, and my first overnight shift. It was a beautiful day, and it was difficult to drag myself into our underground lair, but here I am until 8 tomorrow morning. It’s a pretty nice little room, painted earth tones and with lots of nice nature photography framed on the walls. I have my own bathroom, TV, computer, fridge, microwave, bed, and, of course, coffee maker. I don’t plan on drinking any coffee. If no one calls, I’d like to be able to get to sleep tonight. I’m anticipating being able to sleep fine. It’s very quiet here, and the room gets very dark with the lights off. That is, unless someone calls–the phone rings very loudly. And it’s also possible that the possibility of getting a call will keep me up–I haven’t had a call yet. We’ll see!

The first thing I do is make sure the phones are working. We have two, one for crisis calls, and one backup. I have a backup colleague and two supervisors that I can call or text if I get in over my head. I can also bring them in on a three-way call, if it seems the right thing to do. I don’t anticipate that, but it’s nice to know I can. They are all very experienced at this job.

The next thing I do is look over the call sheets since my last shift. Every call gets its own sheet. It’s been pretty slow in the last week–only a few calls. It’s tempting to think that that means it’s unlikely I’ll get a call tonight, but I have no idea. I also looked back a couple months to see if there was any easily recognizable pattern for Friday shifts, but there wasn’t. Just in our current call sheet book we have calls going back about a year, and I believe that we have sheets for many years around somewhere. This line has been running for about 40 years. (And, unfortunately, the administration is shutting us down at the end of this term, for beaurocratic reasons.) I would love to enter all this info into a stats program and look for patterns! I don’t believe I would be allowed to do that, though. There would be no way to get consent from our past “research participants.” The line is totally anonymous.

The next thing I do is look at our “regular caller” book. I didn’t know this about hotlines, but there are people who use them regularly, mostly very isolated individuals, taking advantage of a free, professinal listening service to help them deal with their troubles. Pretty smart thing to do, really. It had never occurred to me. We have extensive files on these folks, sometimes going back decades. They have “contracts,” too–agreements they’ve made with us about how often and what times they can call, because they don’t tend to be in crisis, just needing some listening. The regular caller book has all the regular caller call sheets, a record of their current contracts, and a list of their calls with how much time they have left until a certain date.

Then I wait for someone in crisis to call. We define a crisis as a situation where a person’s stress overcomes their ability to cope. This can happen a lot of different ways. Our call sheets have the following categories, in addition to “other”: academic, alcohol/drugs, anxiety (popular one), bereavement/grief (another popular one), depression (popular), domestic violence, eating disorder, harassment/descrimination, homocide, information/referral, interpersonal/relationship (popular), loneliness, medical/somatic, psychosis, sexual abuse/rape, sexual concerns, sexually exploitive (this is where a caller tries to use us as a masterbation aid), sexual orientation/gender ID, and suicide (also popular).

When someone calls, I am to go through a six-step process with them. 1) Assess for immidiate danger (“Are you in a safe place to talk?”), 2) establish communication and rapport, 3) assess the problem (keep it to one–the biggest problem–and make it specific, as vague problems are almost impossible to solve), 4) assess strengths and resources, 5) formulate a short-term (tonight) and long-term (tomorrow) plan, and 6) mobilize the client, obtaining commitment to the plan and contracting for safety if they have been thinking about suicide. Throughout the process I am to be assessing the potential for suicidality, listening for clues like “feeling overwhelmed,” “worthless”–any indication that they might be thinking about hurting themselves. If that comes up, I have another process to go to. Maybe I’ll write about that in another post.

Well, wish me luck. I’m not sure what being lucky would be. It’s easy to hope for no calls–“no news is good news,” as my dad likes to say. On the other hand, if someone is out there in trouble, I really want them to call. I’d feel lucky to get to help someone out of a jam. That’s something to know. Crisis line workers want you to call if you need help. We’re not particularly doing this for the money. I make something like $85 per shift. Not a lot.

If no one does call, I’m planning to study until I get tired and then go to bed. I’ll let you know what happens. I won’t be able to tell you the details, of course, but I can say if I got a call.

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