1. SOME INFORMATION ABOUT SLEEP [Rev 3-20-2019]

Part of Step A includes finding out what the patient knows and how it affects his/her ability to sleep. This section appears right after an exploration of prior attempts to treat the patient’s insomnia in Section 3. It is followed by a treatment overview in Section 40.

Before moving on, it is important to find out what the person knows and doesn’t know. The more he/she knows, the more effective the patient-therapist collaboration and exploration can be.

This includes

  • Accurate information about sleep and insomnia
  • Lack of information. This might be a good time for some psychoeducation about sleep and insomnia, and information might allow the person to self-correct without further professional treatment. That would be ideal.
  • Prior experience and what the patient has learned from it. The information from Section 3 is part of this, but it also includes information the person may not have acted on.
  • Misconceptions, that could distort the patient’s experience and expectations of sleep.

It is not clear how best to organize these materials, since there are a wide range of possible gaps and misconceptions for any person. Perhaps the best is just to list them for now.

4a. Some Forms of Misinformation

Errors in thinking can lead to cognitive arousal, which can perpetuate insomnia. It can also lead to ineffective treatments, or no treatment at all. Examining and correcting those errors can make it easier for a person to sleep.

Here are a number of common misconceptions that can be identified and corrected. Some relevant information appears in Part 4b.

Common misconceptions include

  • Thinking that they must get a “normal” amount of sleep each night or they are going to be in trouble. The definition of “normal that they use may not apply to individuals. (See VII below)
  • Thinking that it is normal to lose sleep, and minimizing its impact on daily life. This idea has been institutionalized in the training of some professions, such as medicine and law. (see VII below)
  • Seeing insomnia as virtuous “I can go for a week on three hours of sleep a night.” (see VIII)
  • Thinking that waking during the night is a serious problem. It might be, if the person actually loses a lot of sleep time. It might not be a problem, if he/she can easily return to sleep. (See IX)
  • Thinking that loss of sleep for one night or a few nights is a sign of a serious insomnia problem. It might be, but it might not. See Section 2 (Aso VIII below).
  • Having an ineffective theory about the cause or source of the problem. An erroneous theory can lead to ineffective treatments, discouragement and despair. Or to blaming and resentment without change. (See I and II)
  • Seeing loss of sleep as a sign of loss of self-control (Morin, 127#1), leading to loss of self-esteem and depression (See IV).
  • Thinking of sleep as an urgent need, because poor sleep causes loss of energy, poor performance, and a bad mood. (Morin, 127 #2) This may be true in general but inapplicable to amount of sleep loss that the person is experiencing. (See VIII)
  • Overstating the dangers or damage of sleep loss (Morin, 128; VIII below)
  • Overstating the frequency of nights of poor sleep (Morin, 128) Treatment: Use a sleep diary (see X).
  • Thinking that occasional insomnia is a chronic problem (Morin, 5; also VII below.)
  • Believing that the treatment of choice is some kind of medication.

 

4b. Some Issues and Information

The following provides some conceptual background in preparation for the rest of the book. Some of it may be directly of value for patients to know, and may offer patients the possibility of self-control. Some may better be used as therapist background. The rest of this book goes into more detail about these and other issues that could be affecting a person’s ability to sleep.

  1. FALLING ASLEEP

Sleep can’t be forced. A person can’t get unconscious by a conscious act of will power. The attempt is both energizing and anxiety-producing. It has to happen to a person who has already made the conditions favorable. Basically, it involves shutting down daily life and letting the unconscious take over. You have to be resting, physically and mentally.

This involves setting up your life so you are naturally sleep when you want to be. Most of the action occurs during the rest of the day. If preparation has been neglected, getting to sleep at bedtime can be more difficult.

 

  1. HOW MUCH SLEEP DOES A PERSON NEED?

As recently as 20 years ago, textbooks were reporting that people need about 7 ½ hours of sleep a night in order to function well, but that there were wide differences in need (Hauri and Linde, 10). More recent research supports the idea that, while people can get by for extended periods of time with much less than seven hours of sleep, there are likely to be serious consequences to their functioning, their health, and their very survival.

In 2015, the National Sleep Foundation provided a recommendation that adults need between 7 and 9 hours of sleep a night. Some earlier reports confused time in bed with time sleeping. Since it typically takes time for people to fall asleep, the time in bed should be longer than 8 hours a night. Other reports may have been influenced by the habits of extremely rare individuals, who can manage to hold out with a few hours a night. As Walker (p.263) puts it, “Concluding that humans…need less than seven hours of sleep…appears to be a wishful conceit, and a tabloid myth.”

The proper analysis for a person takes into account a number of factors beyond ability to survive and function. People with less than 8 hours a night of actual sleep – and certainly with less than 6 hours – don’t function as well as people who sleep a full 8 hours every night.

Older people need as much sleep as younger adults, but they may not get it. Commonly melatonin is produced by their bodies earlier in the day, and their circadian cycle moves to earlier bed and awakening. When they stay up as late as younger people, they may lose sleep. In addition, their sleep may be disrupted by awakenings due to poor health, pain, or weak bladders. Some of the commonly known problems of ageing, such as poor memory and weakened physical performance, may be insomnia-related.

A basic sleep record, kept for a week or two, should give some idea of what is normal for a given person. Keeping a written record helps a person pay more attention to sleep and provides a base for change.

The record should include enough information to determine the actual amount of sleep the person gets every 24 hour period, and how it is distributed. Some additional information can also be gathered, about issues that seem to be affecting sleep. When printing out the record form, add in other lines as they seem helpful.

Several issues come in here, including external demands, feelings of exhaustion and daytime sleepiness, and ability to function.

 

III. EVERYONE HAS TWO DIFFERENT SLEEP SYSTEMS

A person can’t fall asleep until internal conditions are right. We all respond to two internal sleep systems: a physiological drive based on not having slept and an internal circadian clock that lets us know that it’s the right time of day to sleep.

The physiological drive to sleep has the function of making sure we are ready to sleep when our bodies need it. It is typically lowest when we first awaken and increases throughout our day until it peaks at bedtime. Then it decreases as we sleep and restore our bodies. It is mediated by the chemical adenosine, which increases throughout periods of wakefulness and declines during sleep (Walker, 27). After about 8 hours of sleep, it is normally gone.

Figure 4.1 shows normal fluctuations in physiological energy throughout a 24-hour day. Energy is highest on awakening and slowly declines over time until bedtime. Then it is restored overnight.

Fig. 4.1: Physiological energy through an average day.

Note that this graph is purely conceptual, with no vertical scale. The idea is that arousal energy is consistently reduced as the day passes, until bedtime. During sleep, it is recovered.

Adenosine levels are affected by many things – our overall schedule, the amounts, kinds and timing of our exercise; our eating habits and physiological energy level; the effectiveness of our sleep, napping, and so on.

The internal circadian (“about a day”) clock tends to match our individual need for sleep to the historic advantage for humans to be awake during daylight hours and asleep at night. Many parts of our bodies have rhythmic patterns. However, the one organ that manages this process is the suprachiasmatic nucleus, a part of the hypothalamus. (Walker, 13-20). Although different people have slightly different clock-times, each person’s clock is quite consistent. Most are set for slightly longer than 24 hours and re-set every day to come into alignment with the external world.

As night approaches, the suprachiasmatic nucleus signals the pineal gland to begin releasing melatonin, which in turn signals the rest of the body to prepare for sleep. Melatonin itself doesn’t cause sleep (Walker, 23) – it provides a signal that coordinates many body functions.

Table 4.2 shows a person’s circadian arousal throughout a 24-hour cycle. Note that it is highest in the middle of the day and lowest in the middle of the night.

Fig. 4.2: Circadian drive throughout the day.

Our circadian clock is affected by external circumstances – especially by light and temperature. This links our internal clock to the repeated pattern of day and night. Other consistently repeated events, such as work hours and meal times, can also have a recalibrating effect on our internal circadian clock.

In the past, human life was linked to the day-night cycle of the planet. Now, our own ability to regulate light and temperature artificially can throw our bodies off. It helps for us to have bright light and warmth during the day and cool and dark at night; variations disrupt the circadian clock and may make sleep difficult.

Our circadian clock can also be thrown off by travel to another time zone, where natural variations in light and temperature are different from our current internal programming. We adjust, but it typically takes about a day for each hour of time difference (Walker, 25).

Our actual perceived sleep drive is a result of these two systems, (and other things). When both systems favor being awake, a person tends to be awake and alert. When both favor sleep, sleep comes more easily. When one system favors sleep and the other favors alertness, sleep may not come so easily.

Fig. 4.2 Combines physiological arousal with a person’s circadian cycle on a single graph, to illustrate how they can interact.

Fig. 4.3: Circadian cycle combined with physiological arousal

Overall arousal energy is depicted as the sum of heights of the two graphs – with a high point somewhere during the day and a low early in the bedtime hours. Note that this is also only conceptual, and the two arousal scales are not necessarily the same.

A major problem for people with insomnia is to get their two systems to work together. Therapists can help people identify sources of disruption in the two systems and find a better balance that supports adequate sleep.

 

  1. ARRANGING TO BE SLEEPY AT BEDTIME

This involves – as much as possible – arranging both of a person’s sleep-wake systems to work together and favor sleep at bedtime.

It includes having a consistent bedtime, so the person’s circadian clock is set for sleep. Light management is important for this system – having bright light exposure when a person wants to be awake, and darkness for sleep. Temperature also matters. The bedroom should be cool, as a second physiological signal of bedtime. (See Section 5 on sleep environment).

The physiological need for sleep can also be managed. Regular exercise early in the day contributes to that. A person with insomnia should avoid taking naps, which lessen the physiological drive to sleep at bedtime.

Also setting up life so nothing interferes with being tired. No drugs that keep you alert (caffeine or nicotine). Less stimulating activities or thoughts toward bedtime. Some life-style issues are discussed in Step B and others in Step C.

The emotional issues that we have put off often come back as we are falling asleep and our daytime defenses relax. A person needs to find ways to manage those issues while still awake and alert.

We can look at several strategies for doing this, including keeping a record of the issues that come up at bedtime and exploring them in psychotherapy.

 

 

  1. MANY THINGS CAN INTERFERE WITH THE ABILITY TO SLEEP

Almost any stimulus that suggests the person should be paying attention can alert the conscious mind to go into action.

  • An unusual sound, smell, movement.
  • Physical pain of any kind suggests body danger and a need to deal with it.
  • A thought that signals danger, even a danger that isn’t imminent. An upcoming test, a guilty recollection.

Many things can wake you during the night – liquids late in the day, sugar or alcohol later on, that give you extra energy as it is digested during the night. Avoiding these things can help a person sleep soundly.

Many things can interfere with being relaxed – pets in bed, unusual noises in the night, etc. Correcting these issues can keep sleep from being interrupted.

 

  1. COMPONENTS OF NORMAL SLEEP

A person’s brain is very active during sleep; but the person is not consciously aware of it. Much of the activity is necessary for survival, but it can’t occur when the person is conscious.

Brain activity is commonly assessed using electrodes on the scalp and face, and displayed on an electroencephalogram (EEG). Brain waves of varying frequencies identify the depth of a person’s sleep at a given point in time. In the past, the results of each electrode were recorded on a continually moving roll of paper and examined later by a specialist who understood what information was on each line. More recently, they are summarized using computer algorithms.

There are two basic kinds of sleep, called [1] REM, or Rapid Eye Movement sleep, and [2] Non-REM, or NREM sleep. Non-REM is commonly divided for analysis into three levels, based on the depth of sleep and the length of the typical brain waves generated. The longest brain waves are generated during level three sleep, and the person is most difficult to awaken at that time (Walker, 42-43).

On an EEG output, relaxed wakefulness is characterized by alpha waves, which appear on a graphic representation as sine waves, at the rate of about 8-12 per second.

When you fall asleep, you typically pass through stage 1 fairly quickly, and into Stage 2, light sleep. Here, the alpha waves are interrupted by other phenomena, and theta waves appear. Theta waves, at 4 to 8 cycles per second, are a little slower than alpha waves. At the same time, your heart rate slows and your body temperature starts to drop. Your muscles have tone sometimes, sometimes not. You can awaken easily.

From Stage 2 a person can go into Stage 3 sleep, which is characterized by delta waves, at 4 cycles per second or less. This is called deep sleep or slow wave sleep. In deep sleep, physiological regeneration occurs, the immune system regenerates, and bone tissue grows. The person is generally not reactive to external stimuli, such as noise, touch or temperature change.

Throughout the night, there is a back-and forth between REM and various levels of Non-REM sleep, occurring in cycles of roughly ninety minutes each. Early on, the person spends most of the time in deep Non-REM sleep, with increasing periods of lighter sleep as the night progresses. REM sleep also increases as time passes, and there may be a few brief awakenings. Awakenings may or may not be remembered – they can involve changing position or going to the toilet. Sometimes, people awaken and have difficulty returning to sleep.

The various stages of sleep can be abstracted and graphed for a person. The graph is called a hypnogram. The following hypnogram shows a hypothetical path of sleep for one normal sleeper during one night. It begins with the person awake at bedtime, and going very quickly through stages 1 and 2 to the deepest sleep, stage 3. From there, the person passes through a succession of stages throughout the night, to being awake again, 8 hours later.

Fig. 4.4: Hypnogram for a normal sleeper.

This pattern of sleep stages is called the person’s sleep architecture.

During Stage 3 Non-REM sleep, the thalamus blocks sensory input to the cortex, which begins to generate the delta brain waves of deep sleep. Because sensory input is blocked, people in deep sleep are difficult to awaken. Brain metabolism and blood flow decrease also, and a person awakened during Stage 3 sleep may be groggy for a time, until normal functioning can return.

Non-REM sleep is the vehicle for a number of functions, one of which is memory pruning and consolidation in the cortex. Hormones released at this time help muscles re-build and damaged tissues heal.

With age, the proportion of deep sleep typically declines. This may have implications for the poorer health of older people (Wallace, 95-96).

REM sleep is sometimes called “dream sleep” because it is the part of sleep during which people consistently report dreaming if they are awakened. Humans need on average about 20-25% of sleep time to be REM sleep (Walker, 72).

REM sleep is also called “paradoxical sleep” because a standard EEG of brain activity strongly resembles the EEG of alert wakefulness, except that the person isn’t awake. Much of the person’s brain is activated, (Walker, 195) including the visual and motor parts of the cortex, the hippocampus (short-term memory), the amygdala (emotion) and emotional centers in the cortex. However, several parts and functions are de-activated: conscious awareness, logical control by the prefrontal cortex, all the voluntary muscles, and the production of noradrenaline, (which creates the experience of stress). Activation of the emotional centers helps us evaluate the importance of experiences. Reduction in stress may help preserve sleep while re-experiencing emotional events of the day, and paralysis of the body prevents us from taking action on our thoughts while we are unconscious (Walker, 208).

Dreams are close to consciousness, and we sometimes remember them, either spontaneously or by design.

Recent research (Walker, 74-75) shows that REM sleep is important in the development of a person’s emotional understanding of self and others, the ability to manage our own emotions, and the ability to recognize and respond to interpersonal cues (Walker, 74).

Back to sleep architecture: note that early in a typical night’s sleep, there is more Non-REM sleep, and later on there is more REM. Type of sleep appears to be linked to a person’s circadian clock. On the nights that a person goes to sleep later than usual, some of the benefits of deep sleep will be lost (Walker, 46).

At the other end of the night, people who cut short their morning sleep are more likely to lose REM and its benefits. Using an alarm clock to awaken may truncate the REM period and undermine the person’s re-working of daily emotions and events.

Some research has shown several other consequences of loss of REM sleep, including weight gain, migraines and increased difficulty in emotion management and perception of emotions in others. If deprived of sleep for a long-enough time, animals and humans are increasingly damaged, eventually dying through infection or organ failure (Walker, 259)

REM is a time of increasing neural connectivity, in which remote ideas are associated. This activity is needed every night, to re-evaluate daily events, and to make sense of emotionally important events and ideas. People have a greater proportion of REM sleep in certain specific developmental periods, such as the first year of life, and the time just before puberty, possibly in preparation for upcoming developmental needs.

 

VII. SLEEP AND MEMORY MANAGEMENT

We have two basic ways of storing factual information, short-term and long-term memory. During the day, factual information is collected, organized, and stored in the hippocampus (Walker, 109). However, the hippocampus has limited storage capacity and must be emptied regularly to allow for new information. Also, the cortex, where long-term storage occurs, needs to be continually updated in order to manage daily life effectively (Walker, 45).

The slow waves of deep Non-REM sleep carry memory packets from temporary storage in the hippocampus to long-term storage in the cortex, clearing out the hippocampus in the process. Most of this work is done in early sleep cycles, and it is usually completed after about 6 hours of sleep. The more Non-REM sleep a person has, the more that will be transferred to the cortex and remembered the next day.

There is some selectivity about what memories can be transferred, and the material that is remembered is saved in the context of other long-term memories. Selective forgetting clears out memories we don’t need any longer, and makes others more accessible (Walker, 120).

Some memory transfer will also occur during naps as short as 20 minutes long, when they include Non-REM sleep (Walker,115). Taking naps allows for some memory consolidation and can free a person to learn more during the same day (Walker, 110).

In some studies, people awakened during REM sleep reported dreams whose emotional content resembled the emotional issues of the previous day. However, dream content was different from the prior day’s experiences, and the stress was gone. A psychoanalytic perspective would say that the dream content is disguised.

Thus it appears that in REM sleep, emotional material stored in short-term memory is re-activated in dreams, but without the experience of stress that they might have produced during the day. It is possible that stripping the stress from them allows them to be moved to long-term memory in the cortex.

Overall, we can conceptualize change in our thinking  as having three phases, that recur every day. We take in new experiences and information during the day, when we are awake, and we store it temporarily in the hippocampus. Then at night we strengthen the associations among some thoughts during REM sleep (Walker, 45). We also save some of it to long-term storage and eliminate less important connections during Non-REM sleep. All three phases are necessary, to retain and process information and ideas that are currently valuable and eliminate others that are not (Walker, 53). All three are to some extent modifiable.

 

VIII. DREAMS

Much of the emotionally important material from the previous day appears in dreams, This may allow the content to be reconsidered in novel ways.

The prefrontal cortex is disengaged during REM sleep, along with its rational evaluation of thoughts and its engagement with external reality. This is when we we dream, and our dreams often combine daytime thoughts and images with one another and the person’s personal history in novel ways (Wallace, 75, 132). Because of this, dreams can be a way of problem-solving and a source of creativity.

Psychoanalytic dream interpretation may be consistent with this understanding of dream construction. Here, the dream is broken down into its constituent images, emotions and actions, and the patient is asked to free associate to each of the component parts. The analyst then attempts to find underlying themes and issues that have been disguised by the dream-construction work. If we assume that the unconscious processes that construct the dream are neither random nor logical, it is possible that some important meanings can be discovered by following the associations made between daily events and emotions and long-term stored memories. The dream interpretation process may partly de-construct the patient’s dream in this way, and uncover issues that have been important enough to be saved repeatedly and re-used.

Dreams may be inextricably connected with REM sleep, as the psychic representations of the increased neural connectedness between relatively remote ideas and experiences.

 

  1. SLEEP NEED AND SLEEP LOSS

It is not a disaster to lose one night’s sleep or to have two or three nights of poor sleep (Glovinsky and Spielman, 19-20). After one night, a person might be very sleepy, motivation may suffer (especially if work is boring), and reaction time may be slowed.

After several nights of poor sleep, performance can decline, and a person can have trouble concentrating. Chronic sleep loss can lead to irritability, loss of attention, poor reaction time, poor motivation, lapses of judgment,and other serious difficulties (Glovinsky and Spielman, 21). These can have a serious impact on a person’s ability to function, and if the person is operating machinery, driving, or performing other skilled work, it could be dangerous to self and others.

 

  1. IT IS NORMAL TO WAKE IN THE NIGHT

Everyone goes through cycles of deeper and lighter sleep during the night. Different parts of each cycle have different functions – body repair, psychological repair, etc. A few people – especially children – may sleep soundly through the night. It means that their sleep never gets light enough for them to awaken naturally, and that there are no disturbances in the night serious enough to break into their sleep cycles.

Most people awaken several times – to roll over, adjust the covers, or go to the bathroom. Typically it isn’t a problem. The problem arises when they can’t return to sleep easily and quickly. If that happens a lot, it may have to be addressed in some way. Techniques for addressing the problem of interrupted sleep will be considered in Step B (See Section 48).

 

  1. MEDICATIONS

When a person is excessively tired, he/she is likely to become impatient about getting sleep. Agitation makes it harder to relax and fall asleep. It is tempting to take advantage of modern medicine for instant relief, and to gauge its effectiveness on how quickly it works. Physicians are likely to prescribe drugs because drugs are what they know, and because they believe that drugs are the most – or only – effective treatment for health problems (Jacobs, 7).

Some drugs work quickly and effectively. A person who begins using such a drug typically finds great relief and can quickly become dependent on it. Then the urgency to manage or alter the conditions for sleep tends to go away. But drugs only treat the symptom without getting at the source of the patient’s insomnia. The person may continue to manage his or her life in unhealthy ways and mask a serious, long-term problem using repeated quick fixes.

Drugs also have side effects. To reach their target organ, they pass through our blood, which circulated throughout the body. In doing so, they affect every part of the body and brain, in ways we often aren’t aware of.

Drugs often lead to dependency, and loss of self-control and initiative. They perpetuate the idea that a person’s insomnia is a psychiatric issues without examining that assumption (Jacobs, 8).

One common case is the use of anxiety medications. A person may feel anxious because of the inability to fall asleep, and come to believe that anxiety is the cause of his/her insomnia. Treatment with a sedating anxiety medication may help, both because it is sedating and because it treats the symptom. The person then is confirmed in the belief that anxiety is the cause, that he/she is anxious, and that anxiety medication is the answer. It is difficult to get many people to switch to other treatments when this one works so well; and stopping the medication can lead to rebound anxiety as well.

See Section 36 for more on this issue and Section 22 for a discussion of melatonin.

 

XII. EVERYONE HAS INSOMNIA OCCASIONALLY

 

4c. Links