46R:  TYPE OF PROBLEM FALLING ASLEEP                              [Rev 3-18-2019]

 This section follows Section 11 and organizes Step D1.

This section is focused on selecting techniques for falling asleep as the primary problem – although some people may also have problems with early waking or interrupted sleep. It is divided into several subsections

1. Overview
2. Gathering more information
3. Bedtime symptoms
4. Choosing an intervention or treatment

46a. Overview

This is probably the most common complaint that people have about insomnia. They go to bed but not to sleep. They lie around, frustrated and upset.

They may obsess about upcoming events, mistakes they have made, dangers, etc., and believe that the mistake or upcoming event is what is keeping them awake. It may be true: a person’s guilt about a mistake may be so stimulating that sleep is elusive. It is also possible, however, that the inability to sleep provides an opportunity to ruminate about dangers, failures and mistakes.

Broad psychological issues have already been considered in Section 10. Anxiety and depression can have an impact on the ability to sleep at night, as can other psychological disorders. In those cases, the person’s insomnia can be seen as an extension of his/her daytime issue. A person is anxious all day, and it continues into bed. However, during the day, anxiety can be energizing, which may even partially support daytime activities. Being anxious and energized when you are trying to go to sleep interferes with the task at hand.

Here, we want to examine the context of going to bed and to sleep for a patient. Ask for a narrative that begins some time earlier and continues until the person actually falls asleep. Ideally a person gets into bed when he/she is already sleepy, does nothing to interfere with falling asleep, and it just happens.

Things that interfere can include…

• Being too rested to sleep.
• Being too tense and worried.
• Being too “revved-up” – physiologically aroused – to calm down
• Trying too hard, as though it might be possible to “will” oneself to sleep.
• Getting caught up in other in-bed activities, like eating, watching television or working on a computer.

You can ask,

• What happens?
• What do you do?
• What’s it like?

If we can identify the things that interfere with a person’s ability to drift into sleep, we may be able to recommend a remedy.

46b. Gather More Information

It can help to gather more information about bedtime and the time leading up to it, such as…

• What the hours leading up to bedtime are like – what is the person doing, and for how long? An hour-by hour accounting can be helpful.
• What is the person typically thinking when going to bed? What happens in bed?

Most people can split their daily life into some variant of daytime – wind down – sleep. We may need to look at the whole day and its possible effect on the person’s ability to sleep. Start with the wind-down in the afternoon or evening.

We can break it down, at least for some people, into…

• Trip home or other transition time
• Dinner
• After-dinner activities (television, reading, putting children to bed, etc.)
• Bedtime preparation
• Bed
• Sleep

Different people will divide their pre-bed time in other ways. What is common is that if we only focus on the last two steps, we may miss information about insomnia-related activities and habits.

To pursue this, you can ask, …

• When does your regular (work, school, etc.) day end?
• What are the identifiable parts or periods in the rest of the day for you?
• What happens in each part, and how long does it last?

You can use that information to create hypotheses about conditions, activities or thoughts the person can change. It is possible that a person is engaged in activities that make going to sleep difficult, and that changing habits can encourage better sleep.

If it seems relevant, bring in the rest of the day.

Here is a possible form you could use to record these periods, for one or several nights.

 

 

Evening Activities                    Name___________________          day_______ date_______

Time                          What Happened

__________       ______________________________________________________________

__________       ______________________________________________________________

__________       ______________________________________________________________

__________       ______________________________________________________________

Etc.

In reviewing these entries, we are looking for any issues that prevent a person from falling asleep

46c. Bedtime symptoms

The next question might be something like, “What happens when you go to bed?”

Three common issues people are likely to raise are

• Being emotionally engaged in daytime thoughts – anxious, angry, guilty, etc. A person may obsess about past or future events, relationships, ideas, etc.
• Being physiologically agitated – “revved-up”. A person “just can’t wind down”.
• Not being tired at bedtime. The person may not be especially agitated, but sleep just won’t come

Many activities can contribute to the problem – things inconsistent with being ready to fall asleep:

• Watching television news or crime shows or horror movies can lead to increased arousal or agitation
• Exercising after dinner may be too physiologically stimulating
• Internet involvement can also be arousing and engaging, and the light of the screen can fool our brains into thinking that it’s still daytime
• Putting children to bed can be both energizing and emotionally arousing, especially if it involves interpersonal conflict
• Eating spicy foods or drinking coffee or alcohol can lead to digestive issues that are energizing
• Talking to an ex-husband or ex-wife can be emotionally distressing or engaging
• Falling asleep in front of the television can interfere with fatigue, making it more difficult to be fully exhausted when you get into bed.

The possibilities are endless. Treatment may depend on what the person is thinking or doing, and an approach that searches for issues is most likely to find some sources of a person’s insomnia.

When we get to choosing a treatment, we may need to use information from the entire day as well as information about what happens in bed. Together these different perspectives may help us modify standard interventions or create new ones.

Two or all three of the above issues may seem to apply for a given person. It is up to us – and our patient – to decide which possible source of the patient’s insomnia to approach first. Having made that decision, we will then need to choose one or more interventions that are likely to have the greatest benefit to begin with, and go on from there.

 

46d. Choosing an intervention for difficulty falling asleep

The first temptation is to try to select treatments based on patient symptoms (obsessing, energized, physiologically restless, or just not sleepy). However, patients are so clever at picking symptoms that this enterprise can be confusing and overwhelming.

Instead, it seems more productive – although less direct – to make an inference about underlying sources and address them. We still can make mistakes, but the odds of being on target seem better.

The following table is a first step to selecting a treatment. Decide on a likely source of the person’s insomnia, then follow up in the paragraphs that follow. If you think that a treatment is likely to be helpful, go on to the section that discusses it more fully. The four sources to be considered are:

• Situation or Environment External disruptions or distractions can interfere with the process of winding down to sleep. Bringing them under control can make falling asleep easier.
• Emotional Pressures If the person can’t go to sleep because of worries, fears, guilt, or obsessive thinking, that emotion or thinking may need to be addressed directly. In this case, attempts to relax may be counter-productive, allowing the thinking to continue unimpeded.

• Circadian issues. Is the person either finishing the day too soon or extending it too late? If so, there are techniques to fit the day into a more effective pattern, that supports natural circadian rhythms.
• Physiological Drive. Is the person too alert and energetic at bedtime? If so, his or her physiological drive may not be supporting sleep at the appropriate time. We might need to suggest techniques that allow the person to be fatigued at the point of going to bed.

See Section 40 for more about each of these.

The following table offers possible treatment approaches for the various sources of insomnia. Each line of the table links to a brief description of the treatment in the paragraphs that follow, and those descriptions link to sections of text that follow the table and present them more completely

 

 

Source				Treatment	Sect	Tmt timing
Sit’n	Emot	Circ	Physiol
X				Alter environment	5	bedtime
	X			Worry time	19	afternoon, eve
	X			Passive observation	41	bedtime
	X			Psychotherapy	10	when available
		X		Light management	27	night, morning
		X		Adjust schedule	25	all day
		X		Limit bedroom use	20	all day
		X		Sleep phase issues	28	all day
		X		Melatonin	22	bedtime
			X	Regular exercise	23	daytime
			X	Relaxation	24	bedtime
			X	Buffer period	18	bedtime
	X		X	Sleep medication	36	bedtime
	X		X	Ways to unwind	21	evening, bed
	X		X	Yoga	39	daytime
	X	X		sleep restriction	29	bedtime
	X	X		Limit awake time	34	bedtime
	X		X	Bedtime rituals	37	bedtime
		X	X	avoid naps	32	daytime

 

The following paragraphs expand on the labels in the chart and refer ahead to other sections for more detail.

Alter the Environment: [Situation] The bed, bedroom, house or apartment, or neighborhood may be sleep-disruptive in some way – too entertaining, dangerous, or otherwise stimulating. Evidence comes from examination of the circumstances that prevail at bedtime. Treatment involves modifying the environment to eliminate or reduce the disruption. This was discussed in Section 5, but it may bear re-examination at this time

Worry Time: [Emotional] A person may have difficulty falling asleep because worries that have been ignored during the day come up when the person relaxes. It may help to have the person set aside time each evening to address any unresolved issues, so sleep can develop naturally at bedtime. The time should be well in advance of bedtime, when the person is still alert and able to focus. For more, see Section 19.

Passive Observation: [Emotional] When thoughts, expectations and fantasies are major issues at bedtime, a person can simply observe them come up and keep track of them, without participating in either creating them or trying to find solutions to problems they pose. After a while, they may simply fade and sleep will be possible. See  Section 41.

Psychotherapy. [Emotional]  This link may not be necessary, because the assumption here is that the examination of a person’s insomnia occurs in the context of ongoing psychotherapy. However, dreams, fantasies and obsessive thoughts are fodder for psychodynamic work, and that should be noted. See Section 10 for more. You can have the person keep track of themes that keep coming up, thoughts that interfere with calmness, and explore them in therapy. Often they will appear in dreams. It can be helpful for the person to keep a pad and pencil next to the bed, and sit up and record the thought or dream. This can also be a technique for dismissing it temporarily: “Now I won’t forget, and I can deal with it tomorrow.”

Light Management: [Circadian] The person’s day may end with bright light exposure, or the entire day may be spent in dim lighting. His/her body may not be able to react to daily fluctuations in light as a basis for determining when it is time to sleep. Evidence for this issue might come from asking about the person’s daily activities, and especially activities in the hour or two immediately prior to bed. Look for the person’ light exposure throughout the day, and also exposure to bright or blue light sources immediately prior to bedtime. If either looks like a possible problem, go to Section 27.

Adjust Schedule:  [Circadian] The person goes to bed at widely different times on different days, or gets up at widely different times, so his/her body is confused about when to sleep. Evidence might come anecdotally from the patient; or from the “Time to Bed” column of the second sleep log. Section 25 addresses this issue.

Limit Use of Bed: [Circadian] The bed may be used for a variety of activities other than sex and sleep. Some people read in bed, watch television, study, go over sales receipts, talk on the telephone, eat and drink, and so on. The bed has lost its unique function. Evidence might come from the patient’s answers to questions about what is happening in bed, either anecdotally or in reaction to the “Amount of Time to Get to Sleep” column in the second sleep log. This problem is addressed in Section 20.

Sleep Phase Issues: [Circadian] Here we consider people whose circadian cycles begin and end at different times from other people and the rest of their world. This can be a particular problem for elderly people, who tend to go to bed earlier and awaken earlier than others. The question is how to get their circadian cycles in synch with others or the world. For more, see Section 28.

Melatonin: This presents issues that are sometimes complicated. While melatonin (Section 22) may be related to sleep, taking melatonin supplements hasn’t been shown to help people with serious insomnia. Still, many people swear by it, and it is being pushed in the media. On the other hand, if a person’s circadian drive seems weak for some reason or the day-night cycle has recently changed, prescription melatonin can be used to supplement the signal that bedtime is approaching.

Regular Exercise:  [Physiological] It may be that the person simply isn’t getting enough exercise to be energized during the day and sleepy at night. Evidence: To track this, you might need to revise the sleep log to include a record of exercise and other physical activity in a day-by-day record. This is discussed in Section 23.

Relaxation Techniques: [Physiological] Here the general notion is for the he person to be able to create moments of physical and psychological calm, and to be able to use them to get to sleep. See Section 24.

Buffer Period: [Physiological] Making the transition to sleep may involve having a period of time – a half hour to two hours – in which to relax, do some activity that is intrinsically unstimulating, boring, relaxing, etc., as a way of preparing for bed. It may allow the energy of the day to dissipate and help to set the stage for a wind-down into sleep. This could include engaging in distracting or calming activities, such as reading and television, that the person knows will take him/her away from the strongly emotional issues of the day. See Section 18.

Sleep medications [Emotional, Physiological] have a mixed utility, typically being recommended for short-term relief of serious insomnia but usually not a good idea for long-term treatment of the problem. (See Section 36.)

Ways to Unwind  When trying to go to sleep, a person’s mind may refuse to turn off, even though the thoughts themselves don’t appear to be troublesome. It may be possible to engage in some kind of mental ritual that turns down the cognitive apparatus and lets the person drift away. See Section 21 for more.

Yoga [Emotional] can be used in at least two ways in the service of better sleep: (1) in the time immediately prior to bed, to prepare for sleep by focusing the person’s attention on the body and thinking and away from the world; and (2) at other times, as a way of working on relaxation and body toning. More on this is in Section 39.

Sleep Restriction [Emotional, Circadian] is a formal approach that combines several components. (a) the person gets up at a consistent time, no matter how sleepy; and (b) avoids naps, and (c) goes to bed late enough to fall asleep quickly. Based on the idea that some people have circadian cycles that are longer than 24 hours, it forces a person to adjust a 24-hour cycle. (See Section 29.)

Limit Awake Time in Bed: [Emotional, Circadian] The person may be so concerned about not getting enough sleep at night that he/she spends extra time in bed, in hopes that sleep will come. Evidence: The person may actually complain of how long it takes to get to sleep or how much obsessive thinking he/she engages in before getting to sleep. Or, the second column in the second sleep log could provide the information. Treatment might involve limiting time in bed, and having the person get up to do something tiring or distracting instead, as in Section 34.

Bedtime Rituals: [Emotional, Physiological] When the same routine is carried out in the same way every day, it can become a signal that bedtime is approaching, and one can fall into habit and anticipation of sleep. It helps if the rituals are done in a relaxed or calm mood. For more, see Section 37

Naps: [Circadian, Physiological] A person may be taking naps during the day, thus reducing the need for sleep at night. This could especially be true if the naps are long or late in the day. Evidence for this could simply be the person’s admission that he/she takes them, or it could appear in the sleep log, by adding up the total sleep time (nighttime plus naps). It could also be that days with naps are followed by nights with less sleep. To work on this issue, go to Section 32.

Links

• Menu
• Section 40: Treatment Overview
• Section 47: Choice of Treatments for Early Waking
• Section 48 : Choice of Treatments for Interrupted Sleep
• Step E