More than 60 million Americans struggle to get a good night sleep. [1] That translates to almost 1 in 3 American adults struggling with insomnia, according to the American Academy of Sleep Medicine. [2]
Insomnia is one of the most common complaints that my patients report. Some patients have trouble falling asleep, while others have trouble staying asleep (or early morning awakenings), and some have both complaints.
Insomnia can be caused by anything from stress and anxiety to depression (or bipolar disorder) to medical conditions, pain, prescription medications, supplements, caffeine, nicotine or may simply be due to poor sleeping habits. [3] Therefore, when a patient reports that they are having trouble sleeping, we must uncover what factors and possible diagnoses are responsible.
This assessment of insomnia starts with a thorough diagnosis of both psychiatric and medical conditions. [You can read more about the process of how I diagnose depression here.] In brief, this includes a diagnostic interview, or series of interviews and, if needed, may include other tools such as laboratory testing, sleep studies (polysomnography), sleep logs, collateral information from significant others and referrals to other medical specialists.
As part of the initial assessment, I focus on my patients’ routines and behaviors that may be contributing to their difficulty sleeping. Many of my patients who have been suffering from sleep problems for an extended period of time are shocked to discover that their own behaviors may be making their sleeplessness worse. Sleep hygiene is the term used to define good habits and healthy behaviors that have been found to improve the ability to fall asleep, stay asleep through the night and feel rested during the day.
Poor sleep hygiene is probably more common than you would have guessed. As many as 1 in 10 patients who present to sleep-clinics are found to have insomnia due to poor sleep hygiene. [2] I estimate that the prevalence of insomnia caused (or worsened) by poor sleep hygiene is higher in patients that present to a Psychiatrist. This is because Psychiatrists (and primary care physicians) are on the front lines of the treatment of insomnia and patients have almost always tried initial treatment options before receiving a referral to a sleep clinic.
Accordingly, before considering any medication treatment options, I always educate my patients about sleep hygiene and give them the tools and time required to improve any of their behaviors which may be causing or worsening their insomnia. Sleep hygiene suggestions can be found with a simple Google search. However, I compiled a list of the most common suggestions I make to my patients to help them improve their sleep hygiene and ability to get restful sleep.
Here are my 14 Sleep Hygiene interventions for insomnia: [4]
A) Create a stable sleep pattern
1. Maintain a regular sleep/wake schedule.
It is most important to try to get up and go to bed at the same time every day and to avoid lying in bed while awake for extended periods of time. I recommend only getting into bed when you are ready to sleep and setting an alarm to get up at the same time each morning, regardless of how much sleep you get that night. This will help reset your natural circadian rhythm and train your mind and body to get sleep during the specific period of time you are in bed.
2. Do not attempt to “make up for lost sleep” on weekends or holidays.
This will disrupt the normal sleep cycle you are trying to establish! You may have noticed it is harder to fall asleep Sunday nights, and harder to get up on Monday mornings, if you stay up later on the weekends than you typically do during the week.
3. Do not nap during the day.
If you nap during the day, your nighttime sleep requirement will be correspondingly shortened. Only nap during the day if you have good reason to believe that doing so improves your quality of life. [5]
B) Encourage a non-disruptive sleep environment
4. Keep the bedroom dark and at a temperature that is comfortable.
I recommend increasing your exposure to bright light in the morning and during the day. Conversely, it is also important to decrease your exposure to bright light in the hours before bedtime and during nighttime awakenings. This will help your body to establish a normal circadian rhythm, which is essential for getting a restful night sleep. [6]
5. Block out noises that can disturb sleep.
Try to avoid loud noises prior to bed and during sleep. If you have noisy roommates, neighbors, or a bedmate who snores, consider earplugs or “white noise” made by fans, air conditioners or a “white noise” machine. [6]
6. Reduce pre-sleep tension.
If you have been napping, you can now use that time for mindfulness and relaxation. If you have not been napping, set aside some time during the day to make a list of the things you will worry about tomorrow and the things you will accomplish before bed. This will provide you with the opportunity to get your worrying out of the way before you get into bed. Now you can do something relaxing before and after your head hits the pillow.
7. Do not watch the alarm clock and worry about the time or lost sleep.
One of my mentors recalled that he plays a round of golf, in specific detail, in his head as he tries to fall asleep. He proclaimed he had never completed a full 18-holes before falling asleep. If you are not a golfer, try imagining yourself walking in your favorite park or beach… think about the sounds, smells, sights and tastes that you experience and encounter. The goal is to relax and not focus on falling asleep.
8. Develop a sleep ritual/routine that promotes relaxation.
It is important to do the same things each evening before going to bed for the night. This gives your mind and body the signal that it is time to prepare for sleep. In order to train your brain to associate sleep with getting into bed, it is important to limit your bedroom activities to those that promote sleep and relaxation. Therefore, you should only be using your bed for sleep (or sex). [5] Watching TV and using cell phones in bed has been associated with worsening insomnia. [7] Try turning them off before getting into bed. This may actually help both you and your significant other sleep better.
C) Dietary/lifestyle modifications
9. Maintain a healthy diet.
Going to bed hungry or eating a large meal before bedtime can worsen sleep. If hungry at bedtime, eat a light snack. One problem with consuming large meals, or the majority of daily nutrients late in the evening, is that it may increase susceptibility to obesity and other cardio-metabolic diseases, both of which can increase the risk of sleep problems. Additionally, going to bed hungry or eating a large meal before bedtime can worsen sleep by disrupting normal sleep/wake cycles. [8,9]
10. Avoid or minimize the use of caffeine.
It is recommended not to drink coffee, tea or soda at least four to six hours before bed. However, some people are more susceptible to the effects of caffeine and should not have any after lunch. In rare cases, I have had patients who continue to have difficulty falling asleep and had to avoid drinking caffeinated beverages after breakfast.
11. Avoid alcohol.
You may have experienced that a drink or two can temporarily make you more tired. However, alcohol causes a disruption in normal sleep in the second half of the night and decreased and delayed REM (rapid eye movement) sleep throughout the night. Alcohol can also make snoring and sleep apnea worse, further contributing to daytime fatigue. This may be why you feel less rested after a night of drinking, even if you do not feel “hung-over”. [10]
12. Maintain a regular exercise schedule.
For many people who have trouble sleeping, the best time to exercise is in the late morning or mid-day. For some people, “strenuous exercise” before bedtime can be too stimulating and may prevent them from falling asleep.
13. Avoid excessive fluid intake before bed.
This one is pretty obvious. Less fluid before bed, fewer times you will have to wake up and make a trip to the bathroom during the night.
14. Stop Smoking
This is undoubtedly the hardest recommendation on the list. However, this is just another reason you should quit smoking. We have known for decades that cigarette smokers are significantly more likely to report problems falling asleep, trouble staying asleep and daytime sleepiness. [11] Sleep disturbance may be more prevalent among smokers due to the stimulant effects of nicotine, nicotine withdrawal during the night, sleep disordered breathing conditions, and/or an association with psychological disturbance. [12]
With these suggestions for improving your sleep hygiene, you are well on your way to improving your sleep. If you have already tried these techniques and continue to have difficulty falling asleep, staying asleep, daytime fatigue, or all of the above, speak with your primary care doctor or obtain a referral to a Psychiatrist today. There are many non-medication and medication treatment options that can be utilized in an individual treatment plan to improve your sleep and quality of life.
Stay tuned!
Dr. Goldenberg
docgoldenberg@gmail.com
docgoldenberg.com
Twitter: @docgoldenberg
The Huffington Post: http://www.huffingtonpost.com/dr-matt-goldenberg-do-/
Here are some additional articles I have written regarding sleep:
1) Huffingon Post: "5 Things Easy Steps to Sleep Better Tonight"
2) Huffington Post: "7 (not so) Obvious Things to Avoid if You Have Trouble Sleeping"
3)"Getting to the Source of Your Patients' Insomnia", Medscape Psychiatry
