Saturday, October 13, 2012

Sleep Restriction Therapy

Insomnia is a common symptom of Endometriosis and, to be honest, most chronic illnesses. About 30% of the general population suffer from it in some form. Especially women. Insomnia is a general term for difficulty with sleeping. This can indicate a lack of feeling rested, struggling with falling asleep, or waking up several times a night. To oversimplify, it is a pervasive feeling of sleepiness. It can be acute (brief), chronic, or in-between. On rare occasions, a person may have insomnia for no reason at all (no  mood issues such as anxiety or any medical problems to explain sleeplessness); this is called primary insomnia. Primary insomnia is very rare. Much more common is that someone has insomnia as a symptom of some underlying issue. Thus, when treating insomnia, doctors will often try to get at the underlying issue.

However, what if that issue is, in reality, quite unsolvable? When it is a symptom of an incurable disease, there really is not much that can be done about the cause. Treatment becomes about managing the symptom of insomnia because the disease responsible is hard to tackle. In these cases, relaxation/sleep hygiene techniques can be helpful, but some patients may permanently rely on sleeping medications. This is what I had to do for almost a year. Lupron had aggravated my insomnia into such severity that I became completely dependent on Ambien. I could go days without sleep if unmedicated, or at least was up until daylight. No matter what I tried (yoga, reset of circadian rhythm, exercise, sleep hygiene, etc.) nothing worked. It was awful. Only with Ambien was I able to get nightly sleep. However, Ambien does not really give restful sleep, and it leaves you groggy the following day. Its users risk serious side effects and it is habit forming. I myself developed a temporary dependence. Well, not wanting to sleep this way, I decided I did not want to live my life like this, and I sought aggressive help.

Cognitive therapy was my solution. My major was in Psychology, but my focus was in 'Neuropsychology: Brain, Behavior, and Cognition'. I relished reading research on brain plasticity and using cognitive therapy to change brain functioning. Thus, when my sleep doctor suggested this solution, I enthusiastically agreed. (The best part actually was that we could both use the medical terms and jargon on the subject and have pretty intense conversation over it, which I think was fun for both of us.). He very clearly communicated that it would be a difficult therapy to undergo and that I would not enjoy it. However, he also was fairly confident that it would work.

Cognitive Behavioral Therapy uses conditioning and thought exercises to change the reactions of the human mind. The therapy methods are simple but complicated, and today I would rather focus on this specific application. So allow me to try to focus...

My brain was not responding properly to bed time; rather than going to sleep, it would rev up. Not with worry or anxiety, but rather with simply more thoughts than I had time for. This was partially due to my body chemistry but also had to do with with my unintentional conditioning my body to only seek rest when relaxing--not to sleep. Too much bed-rest from surgery and pain, too many sleepless nights where I could not leave bed but could not sleep either, and, overall, just too much time spent in bed without sleeping, had taught my brain that bed time did not equal sleep time. With the underlying disease contributions to my insomnia, along with this bad conditioning, sleep, for me, became a dream (pun intended). So, the goal of this therapy was to change to how my brain reacted towards bed time. To compensate.

How it Works:

  1. The basic set up: I kept a sleep diary to track my progress, to give both my doctor and I an idea of what my progress was. It was also to establish a baseline (pre-therapy) of how bad my sleep issues were. I began practicing more ritualized sleep hygiene. I can go over this in a follow up post, but basically I had 'bed-times' for what activities I could do up until a certain time (e.g., I was not allowed to work on my book within two hours of bed time, same with class work). 
  2. I had to pick a five hour time frame in which I was allowed to be in bed. Any other time of day, I was not permitted to be in my bed. I picked 2:00 am to 7:00 am. Not only was this my only allowable bed time, but it was also my only allowable sleep time. No napping, no 'resting my eyes', no sleep whatsoever, except from 2:00 am - 7:00 am in my bed. This is how the sleep restriction takes place. And this is how you teach your brain that it has a specific time and place for falling asleep.
    1. I'll admit that for the first couple of weeks, it was incredibly difficult to not accidentally fall asleep. I'd take my dogs on walks, clean the house, put on a loud movie, but while it seemed impossible for my brain to shut off at night, it loved to disengage during the day time. This is called delayed sleep phase disorder. More commonly, you would call a person like this a night owl. People like me can thrive on just five hours of sleep but we usually can't sleep until very late at night (e.g., five am), which does not fit the common schedule of the workplace/life. 
  3. The goal was to be able to fall asleep within 20 minutes of being in bed. If I could not, I needed to get up for fifteen minutes, leave the room, and then return. Why? Because this is part of teaching my brain that it cannot be awake in bed. When you 'lie awake at night' you are reinforcing to your brain that that is an appropriate activity in bed. 
  4. If, for three nights in a row, I could fall asleep within 20 minutes, I could take back my bedtime by a half hour (e.g., instead of 2:00 am, I could get in bed at 1:30 am). If I took longer than twenty minutes even for one night, I had to slide back to the previous slot (though not beyond the original 2 am). The goal was to get three nights in a row of quick falling asleep, because then I could get more sleep for that night and the following nights. This was a pretty good incentive. Additionally, it gave my brain the steady conditioning it needed to respond.
    1. Now, with the extreme sleep deprivation I was experiencing, you would think this would be easy. That within a few days I would be out in minutes. But I am talking about severe insomnia here. It took about four weeks before I was able to move my bedtime to 1:30 am. Usually, this therapy is only supposed to take about four weeks, so do not be daunted by my month of sleep deprivation. I have other sleep issues (sleep terrors, sleep walking, panic attacks, sleep apnea) so these all could have factored into the extra time. 
  5. Keep this pattern up until you reach your desired bed time. Until you are steadily able to fall asleep when needed, do not change your wake up time. If you wake up early and cannot fall back asleep, it is okay to get up early, but do not sleep in. Even if, for example, I had a late night out and did not get back until 3 am. I would still just get into bed and wake up at 7. The wake up time is not a choice. 
  6. Currently, my bedtime is 12:30 am. I should be at midnight, but I have needed to take a lot of pain medication this week (Ultram) and it makes me very sleepy, so I have been accidentally napping (Yikes!). However, I am not discouraged, because I am having an infinitely better time falling asleep than I was six weeks ago. I am more rested and look forward to bedtime.
Important Points
  • The schedule is everything
  • Get daily exercise in some form. Sleep is always easier when you exercise; just make sure not to do it too late in the day (as this can keep you up). 
  • Practice sleep hygiene; these are rituals that help cue your body it is time to settle down. For example, nightly showers, brushing teeth, dimming the lights, etc.. I really think I should do a post on this ASAP, and I will link it from here once that is done.
  • Do not get discouraged; it is a hard therapy to stick with, but the results are invaluable. 
  • Make sure those around you respect what you are doing. I warned my family and loved ones that I would be doing sleep therapy that would probably make me really cranky. I communicated that I always needed to be up at 7:00 am. Little things like that can garner some support and/or, at the least, respect for what you're doing. 
  • Keep a daily journal of foods/activities/pains/sleep, if you suspect there is some pattern contributing to your sleeplessness. I didn't keep up the sleep journal because there really wasn't a pattern. Just random issues that would pop up. However, I'm sure it would have been more helpful had I done so (and I regret discontinuing it). 

So there it is. My sleep therapy. The thing, the first thing, that my insomnia has EVER responded to. It's been amazing. I look forward to sleep now. So please, if you are struggling with insomnia, I highly recommend giving this a try. If you have any questions/comments/concerns, please feel free to contact me (either by commenting, my Facebook page, or my Email). I have a follow up with sleep doctor soon (Dr. John Staheli of the Central Utah Sleep Clinic) and will see if he has any comments/advice he would like to pass on. Thank you for reading and good luck!!!

Side note--something that also helped me sleep better was I got a new 3-inch Biopedics Memory Foam Mattress Topper. I was able to find mine on sale and I'm so glad I bought that instead of a new mattress (which would have been much more spendy). This one is pretty similar to what I got and it's on sale it looks like. Funny side note, my dog used to hate my bed, since I got this topper he's in the bed all the time.


9 comments:

  1. You've given me soooooooooooooooo much hope.

    God bless you.

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    1. Oh, I am glad to hear that :). Please let me know if you have any questions, and I would love to hear how the therapy works for you.

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    2. Hi. Congrats on your success with Sleep Restriction. I have always had insomnia. I tried treating it with sleeping pills or benzodiazapines, but they never really helped much. I went to a sleep clinic about a month ago and I started sleep restriction therapy about 3 weeks ago. My sleep schedule was started at 11 - 6:30 am. The first week i didn't get much sleep at all - maybe 5 hours a night. Then the second week i got a bit more - maybe 6 hours of sleep. Now this week i seem to be going back to sleeping just 5 hours a night. I am kind of getting discouraged. I called the sleep doctor and he said to cut back on my time in bed even more. I'm afraid to do this because I really need to sleep (even though more time in bed doesn't necessarily equate more sleep). I was just wondering how long it took you to finally establish a better sleeping pattern. I watched A LOT of tv last night up til an hour before bed so I was thinking maybe that's affecting my sleep. Also, I had two glasses of wine the day before so I also thought maybe that's also affecting my sleep. Just looking for some encouragment!

      Thank you,

      Joy

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    3. Joy, I'm not certain if you can see this, I actually only now saw it because it was replied to another comment (my blog system alerts are slightly different). Anyhow, I am hoping you can and please email me at bedriddenhead@gmail.com, I would love to chat and see how things are going/went.

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  2. Your experience was very helpful to read about- thank you for sharing. I'm going to email you a question.

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  3. Thanks for sharing. This is the only way I can rid myself of insomnia too (over 20 years of it and getting much, much worse). I have a drawerful of sleeping pills but I'm too scared to ever take them. I decided, no way. I've done this therapy before but I chose to wake up way too early (for exercise). Just can't do it. I'd rather go to bed later, which works great for this kind of therapy. So, I'm keeping a log and started last night with a decent wake-up call, 6 a.m. Went to bed at midnight (sooooo haaaarrd) but I did it. Slept until 4:08 am (but man was it a sound sleep). Don't even remember going back to sleep and woke up refreshed at 6:08 am. I'm going to do this right this time because I know how great it works. Really funny about your dog! Good luck everyone. This is worth it. --Rayca

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  4. Have been trying sleep restriction for almost 4 weeks now (only giving myself 5.5 hours in bed) and while I can usually sleep for 4 hours at a time (this is an improvement), I have yet to have more than a couple 5 hour nights in a row. How long do you think I should keep going before going to bed earlier? I am afraid to start adding time because I might go backwards in my progress. I am also wondering if it makes sense to further restrict my time in bed? Bottom line I want to know how long this is supposed to take?

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  5. Thank you for a very encouraging post!
    Did you ever consider to reduce your time in bed further to 4,5 or 4 hours? And did the results come gradually or sudden towards the end of your forth week?

    I am in the beguinning of my fourth week of sleep restriction and stimuli control. I don't get very much effect, allthough my time in bed is now only 4,5 hours. I wonder if I shall go further down to four hours, or wait another week to see if things change. It's a little bit scary to reduce time in bed to only 4 hours, because I am allready very tired! I am quite sure that the reason why it takes such long time for me is that I spend much time lying on my coach, because of back and neck problems. Guess I have to walk around in the house for the last two hours...

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    1. Anon, if you are still trying this therapy, or willing to try again, you can restrict your bed time to as little as 3 hours without having severe side effects. However, it's not so much a question of the time 'you choose', but the time you can spend in your bed sleeping. When you don't sleep, you get up and do another activity, right? Start keeping track of the amount of time you do sleep, and set that as your initial restriction. Most people will respond to 4-5 hours restriction, but some need less (I've read as little as 2). Figure out the amount of time your body can optimally sleep in bed, then use that as your sleeping time.

      Also, any exercise is good for this therapy (as long as it isn't too soon before bed). Walking is a low impact exercise that does a lot of good, so it's a great idea for you to do this :).

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