A lady in her early 50s had come for a repeat of her zopiclone. She had been on it for years. When I suggested a trial of cutting down, she was quite resistant. She told me she would love to if there was something else I could do to help her sleep. She told me she had tried sleep hygiene.
I said I would find out, and would see her in 4 weeks with a solution.
I searched online for studies into the non pharmacological management of insomnia. After sleep hygiene, CBT for insomnia seemed to be the best approach.
Old me: Wait. What do you mean CBT for insomnia? Like the CBT for depression?
New me: Exactly. It’s about becoming aware of the distorting effect your mind can have processing what’s really happening, and how this fighting this distorted view is what makes life difficult. NHS choices mentions a few centres which did it.
Old me: But what exactly does CBT for insomnia involve?
New me: The treatments are summarised on NICE CKS. Most insomniacs can identify with one or more of the following patterns:
“I keep checking the clock throughout the night, and get more frustrated as I rack up sleepless hours”
“I take extra naps during the day to compensate for my problems sleeping at night”
“I lie in bed worrying that I’m not getting to sleep”
You can start by explaining a few things:
- Most of us get more sleep than we think we do. We remember tossing and turning and going to the toilet and checking the clock. We think this took up hours of the night. In reality, it was likely only a few seconds to minutes, but because it stays in your memory and you know 8 hours have passed overnight, on recollection your mind expands the time spent in the tossing and turning state.
- Had a rubbish night’s sleep? Great! This is an excellent opportunity. That could be the first step to sorting it all out. When you are really tired, stay awake. Don’t nap. Don’t go to bed early. When you finally collapse at a good bedtime, the time to onset of the first few stages of sleep is much shorter. You are basically KO’d before you get a chance to worry about the lack of sleep.
- There’s an interesting evolutionary theory about why we sleep at different hours through life. Imagine a cave with young children, teenages, middle aged people and seniors. Someone has to be awake at night to guard things. Children are useless. Teenagers go to sleep late and wake up late, so are ‘on call’ for the first bit of the night. The seniors go to sleep early and wake up early, so do the early morning shift. And the middle part of the night? Well, hopefully it should be OK. But if it’s not, middle aged people have lighter sleep (i.e. are more easily woken up) so spring into action only if actually needed. Like your A&E consultant on a night shift.
- That wasn’t really a point about insomnia.
- Did you wake up in the middle of the night? It might be natural. Historically some societies also had two sleep cycles. We’re all individual; there is no set sleep pattern that you have to follow.
- The reason I’m mentioning all this because rigid sleep expectations is a cognitive error that leads to dissatisfaction with sleep. So don’t worry about chasing a number of hours necessarily. If you feel good in the morning and during the day, you had enough.
Old me: So what behavioural change do you suggest?
New me: The first thing I’m suggesting is Sleep Restriction. In addition to strict sleep hygiene, the patient should avoid napping or having an early night. In fact, if they need to get up at 8am, they are only allowed to sleep after midnight. They might feel more groggy for the next day or ten, but eventually they will look forward to midnight and collapsing asleep. They will be too tired to care about not getting to sleep and instead just fall asleep.
Then after a while of undisturbed sleep until the alarm rings, you can set the bedtime gradually earlier until you find a level of sleep that maintains sleeping through the night with feeling fully refreshed. Bear in mind that this number of hours is not the be all and end all. The patient should realise that they will naturally compensate for any sleep deficiency in the next sleep cycle by drifting off quicker. It’ll all work.
Old me: What are you basing this on?
New me: Most of the principles are in Overcoming Insomnia by Edinger and Carney. You can prescribe this book from the library in our practice. There’s a manual to train you and a workbook to train the patient.
Old me: And how did you choose that?
New me: I discussed this with a sleep specialist from Sweden who had written several of the interesting papers in the field.
Old me: OK! Let’s do that now!
New me: You do that. There’s more to type up, but I’m off to sleep now. 11pm is my strict bedtime or I’ll need a nap tomorrow.