17:  TYPE OF PROBLEM FALLING ASLEEP                              [Rev 2-11-2019]

 This section follows Section 11 and organizes Step D1. What appears here is the beginning – it should also help choose from among the other treatment sections that Step D1 refers to.

General issues are raised in this section. For details on choosing techniques, follow links to associated specialty sections.

17a. Previously…

Here it is assumed that you have already asked about all the issues raised in Parts B and C as potential difficulties falling asleep, and have dealt with them as needed.

17b. The Next Step

If the person regularly has difficulty falling asleep, it helps 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. Here, let’s look at the wind-down time and its possible effect on the person’s ability to sleep.

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 some very important information that has an impact on the person’s ability to sleep.

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 this 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.

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.

EXAMPLE

 

A simpler form, possibly just a lined sheet of paper, could be for a single night,

Time                          Activity or Event

_________      __________________________________________________________

_________      __________________________________________________________

_________      __________________________________________________________

_________      __________________________________________________________

Etc.

In reviewing these entries, we are looking for a gradual pulling away from daily life, from emotionally-charged issues, from activities that increase the person’s arousal and energy level.

Many things could jump out of the page – things inconsistent with being ready to fall asleep:

  • Watching television news or crime shows or horror movies can lead to increased arousal or agitation
  • 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
  • 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. The treatment may depend on what the person is thinking or doing, and an uncovering approach that searches for issues is most likely to find sources of a person’s insomnia.

It pays to have a systematic approach to looking at sleep disruptions, in order to decide what treatment to suggest. Here we have been focusing on four categories

Circadian issues. Is the person either finishing the day too soon or extending it too late? If so, we will suggest techniques to fit the day into a more effective pattern, that supports natural circadian rhythms. This would include

25: Adjust schedule

20 Limit use of the bedroom

28 Deal with any sleep phase issues

Physiological Drive. Is the person too alert and energetic at bedtime? If so, the 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. These would include

24 Exercise regularly

  1. Try yoga

24 Use relaxation techniques

  1. Use bedtime rituals
  2. Have a buffer period before bed

Anxiety or Agitation 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. Relaxation may be counter-productive, allowing the thinking to continue unimpeded.

  1. Set aside worry time

41 Try passive observation

  1. Consider temporary use of medication

 

17c. Bedtime

The next question might be something like, “What happens when you go to bed?” People often remember what happens when they are trying to fall asleep, even if only for the previous night.

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 agitated – physiologically “revved-up”. A person “just can’t wind down”.
  • Not being tired at bedtime.

Even without considering examples, we can imagine that a person who talks to an ex-spouse before bed, or goes for a run, or watches stimulating television shows in bed at night may be too emotionally engaged to fall asleep, and a person who naps after dinner may not be tired at bedtime.

When we get to choosing a treatment in sections 44, 45 or 46, we may need to use information from the evening as well as information about what happens in bed. Together these different perspectives may help us tailor interventions that will help deal with the person’s sleep issues.

Two or all three of these 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.

 

OBSESSING

A person may be about to fall asleep and think of something that leads him/her to be worried, frightened, guilty, angry, etc. This can happen over and over, with different thoughts or memories. The person may be convinced that he/she is being kept awake by anxiety, guilt, anger or another strong emotion.

For many people, the next natural thing is to obsess about these thoughts and feelings, which compounds the problem. At some point, many people resort to drugs or alcohol to get to sleep, because they feel desperate, they are convinced that they understand their problem, and they think that they have “tried everything” to deal with it.

If the issue really is emotional, it may be due to particular thoughts or events, or it may be a function of the person’s daytime defenses, which prevent the working-through of experiences and emotions. The person may be able to put emotional issues aside during the day, but they come back to disrupt the ability to sleep.

It may also be that the person isn’t sleepy and starts thinking because he/she is lying there with nothing to do. Just lying there is disturbing, so disturbing thoughts come to mind. Before accepting the patient’s self-diagnosis, check on the amount of sleep that he/she is getting (see “Not Tired at Bedtime” below).

If the person’s emotional reactions are first coming up at this point, you can focus on them from the perspective of Section 10, where a number of general sleep related issues are considered. You can also consider psychotherapy without a focus on sleep, with the expectation that better sleep may follow successful resolution of other issues.

Depression can also lead to loss of sleep, including difficulties falling asleep (Glovinsky and Spielman, 65).

A more targeted approach is to use one of the focus techniques (Section 44) to manage emotions at bedtime. If it is effective, further treatment may not be needed.

 

PHYSIOLOGICALLY AGITATED

For a person who is sleepy but who also has a surplus of energy at bedtime, calming techniques can be helpful. These have a common theme of placing an emotional and energy barrier between the activities of the day and the quiet of bedtime.

Start with a review of the information collected in Part b above. Resolution may only involve a change in schedule. If that diesn’t work, go to Section 45 to choose a technique that can help the person calm down.

 

NOT TIRED AT BEDTIME

The person goes to bed but can’t get to sleep. He/she may lie awake for hours waiting for sleep to come, trying to force it, getting more and more frustrated and worried. Will he/she ever get to sleep? Will he/she have any energy left tomorrow? What is wrong with him/her? Eventually, some kind of drug or alcohol starts to seem like the only solution.

For a person not to be tired at bedtime and at the same time not be either physiologically agitated or emotionally aroused suggests that…

  • He/she is getting enough sleep so that bedtime has lost its urgency.
  • Something happens at bedtime so he/she is suddenly awake and alert.
  • Sleep timing is inconsistent, so the body and mind are not prepared for it.

In this case, it pays to find out about the amount of sleep the person is actually getting and how it compares to the amount needed (cf: Misconceptions, Section 3). Some people may not realize that they are actually getting enough. Others may have organized their lives in such a way that their bodies are not expecting to sleep when it is scheduled.

What follows is similar to the approach of Part b above, with regard to actual bed time.

For starters, you can ask about last night: what time he/she went to bed, how long it took to fall asleep, what he/she was thinking, and so on. Also, what time he/she awoke this morning. From that you can get the number of hours of sleep. Also ask about naps yesterday and today, to see if the person is supplementing nighttime sleep during the day.

Next, ask whether last night is typical, and about napping on other days. Consider asking the person to make a simple sleep log for the following week, so you will have better data to work with. This has the advantage of getting data each day, when it is fresh, and helping the person think of sleep as a problem with a possible solution. This will help you both decide whether the times that the person sleeps at night are adequate, and whether naps (“Nap time the day before”) are interfering with the patient’s ability to be tired enough at bedtime.

 

Night Sleep Time           This Night Nap Time      Day Before Sum
Mon-Tue
Tue-Wed
Wed-Thu
Thu-Fri
Fri-Sat
Sat-Sun
Sun-Mon
Average

 

If the person seems to have irregular sleep times or has difficulty keeping track of the number of hours, you can change the table:

 

Day to Sleep Time        to Bed Amt.Time        to Sleep Day of Waking Time to  Get Up Naps During Day to Sleep
Sun Mon
Mon Tue
Tue Wed
Wed Thu
Thu Fri
Fri Sat
Sat Sun

In this table, the person would fill in the first line with the time going to sleep on Sunday, how long it took to get to sleep (an estimate), the time of awaking on Monday and the amount of time spent napping on Sunday. From that you can calculate the amount of time in bed Sunday night and the estimated amount of sleep per day.

It is commonly said that eight hours of sleep a night is normal, and many people may think that they are getting too little or too much. But different people need different amounts. A clearer record of the amount of sleep the person is getting can help determine whether he/she needs as much as he/she thinks.

Keeping a record also alerts the person to sleep times, and sometimes that additional awareness can be enough to suggest change in itself.

If the problem persists, continue with Section 46.