Addiction Treatment Blog

There are a number of steps that can be taken in the management of insomnia before resort is made in hypnotics. These include:

The elimination of all caffeine containing drinks

Such as tea, coffee, colas etc.

Ensuring quiet surrounds.

This is a particular problem for a shift worker, especially when he wants to burn the candle at both ends, or resents having to be on shift work. There are further shift work related difficulties – see point below on body awareness.

Relaxation exercises, in particular progressive muscular relaxation.

These are useful in their own right, but not particularly sleep inducing in the short term. They also require considerable patience and regular practice to master, as how they work depends on building up associations between relaxation and sleep. With regular practice, subjects find they drift off half way through their exercises. Cassette tapes or relaxation programmes promising sleep, however, rarely mention the fact that considerable hard work and patience is required. The failure of these methods to deliver, in the short term, seems to lead most subjects to feel frustrated or a failure and to abandon what is a useful skill.

Body awareness.

There is a regular cycle, operative in all of us called the basic rest activity cycle (BRAC) (1). This produces alternating peaks and troughs in arousal and activity at regular intervals. It can be seen most clearly in infants, who wake and sleep on a 3-4 hour cycle. In later life, this cycle continues so that we have our mid-morning sags and mid-afternoon dips, and also underlies the stages of sleep. Normally, we progress regularly through a series of stages of sleep, called stages 1, 2, 3 & 4 of non-REM sleep, and then REM sleep. In this process, we sink deeper into sleep and come back to the surface before sinking again, several times during the night.

What often happens in insomnia is that individuals go to bed and find themselves seeming to wake up as they lie there. This is no illusion, instead it is a correct perception of what is happening. Owing to difficulties in getting to sleep, the individual has waited until she is exhausted and gone to bed thinking she has thereby given herself the best chance possible for falling asleep. In fact, she is just about to ‘turn the corner’ and head into an upswing in the arousal curve which will make it very difficult to fall asleep. What is needed in such instances is for the individual to get out of bed before becoming too worked up about bot being able to drift off, and go downstairs, have a small snack or hot milk drink, read the newspaper or listen to something soothing and wait until she feels the first hints of a downward swing. What should not be done is to wait much longer than that.

A regular sleeping pattern makes this much easier to achieve. This is because the rest-activity cycle switches around to track cues from the environment indicating likely sleep onset times and rising times. Switching typically takes several days to a week or two dependent on how great the change from the former routine. The resolution of jet lag is based on just such switching. During the early morning another circadian cycle, the temperature rhythm, leads to a steady increase in temperature. Normally as we fall asleep, our body clocks programme a drop in temperature, and falling asleep is associated gearing up of a range of physiological functions in preparation for the day ahead. These, in part, are what lead to our waking up. It becomes increasingly difficult to get off to sleep in the face of this rise, which underlies the particular problems or shift workers, who have to sleep during the day.

The significance of this is that with practice it is possible to learn to read our bodily cues quite accurately. A complication of the treatment of insomnia with alcohol or drugs is that these agents will mask the bodily cues we might be better off, in the longer term, learning to read. Having said all this, on occasion our lifestyles get out of sync with our basic rest-activity cycles, at which times the inappropriate alerting effects of the rest-activity cycle can be usefully over-ridden by alcohol or hypnotics. This should only be necessary on a short-term basis, as the cycle realigns itself to a new routine.

Stimulus-control treatments.

This approach grew out of learning theory, which believes that behaviour is determined or at least shaped by associations. According to this, therefore, treatment should aim at building up associations between behaviours and sleep and reducing behaviours associated with being awake. This leads to advice such as never do work in the bedroom, remove the television, don’t read in bed, etc. Do nothing except sleep. (Leaving sexual activities in is not seen as a problem, although in theory it should be). This approach may often be helpful, although there are good rounds to believe that learning theory has little or nothing to do with automatic behaviours such as sleep or intercourse. Another explanation why this approach works may simply be that it gives some people the impression of control and this is sufficient to allay their anxiety and permit sleep.

Routines.

A number of the above techniques interface with the issue of the generation of maintenance of routines. Routines are probably the single most potent contributors to sleep. This becomes clear in the case of those individuals who routinely drink a cup of strong black coffee just before going to bed and who far from having problems falling asleep on it, would have much greater problems if they were denied their coffee. In this case, coffee has become part of the bedtime routine. In the case of many people on continuous treatment with a hypnotic, it is quite certain that the pills have stopped working physiologically and are now working because they have been incorporated in a successful routine. It is worth noting that essentially the same pills may be used during the day for anxiolytic purposes but in these circumstances people don’t fall asleep with them.

Paradoxical Intention.

This involves telling the individual to try and stay awake as long as possible. This may be particularly useful in those who have a performance anxiety where sleep is concerned. This technique picks up on the paradox inherent in sleep, which is that we have the impression we control it but actually have very little control one way or the other. This leads to a range of paradoxes. For example, giving good advice, such as don’t take your worries to bed is likely to be unhelpful, as it will only lead to the individual worrying about not worrying. This is an instance of the pink elephant principle, whereby telling someone to avoid thinking about pink elephants for a minute causes them to immediately think of pink elephants and almost nothing but pink elephants (2).

Forward Planning.

This technique advocates spending some time during the evening, reviewing the day and settling or at least noting worries. These may be reviewed and then symbolically filed or binned (2). The method appears to work, especially for people who have difficulties falling asleep, and is one that most cultures seem to have discovered. The Guatemalan Indians for instance used troubledolls for the purpose – hanging a separate worry on each of a number of dolls – and the German philosopher Immanuel Kant did something very similar.

The Use of Mantras and Yogic Breathing Exercises.

There is a vogue at present for techniques such as transcendental meditation (TM), which involves the creation or selection of personal mantra. This is a word or set of words which are chanted or thought about. Alternatively a breathing technique may be used. There are good grounds in current psychological theory to believe that such approaches induce sleep (3). In brief, these approaches, which are variations of the age-old remedy of counting sheep, act to suppress the intrusion into consciousness of thoughts that might be alerting. Current evidence suggests that this type of procedure works best when the problem is one of waking up during the night with subsequent difficulties in getting back to sleep. There is a note of caution that needs to be struck here. Just as with relaxation exercises, TM and yoga techniques are deceptively simple. Their mastery however requires weeks or even months of regular practice. They will not provide a quick fix for insomnia.

References

1. Waterhouse J M, Minors D S, Waterhouse M: Your Body Clock: how to live with it, not against it. Oxford: Oxford University Press; 1990.
2. Espie C: The Psychological Treatment of Insomnia. Chichester: John Wiley & Sons; 1991.
3. Levey A B, Aldaz J A, Watts F N, Coyle K: Articulatory suppression and the treatment of insomnia. Behaviour Research & Therapy 1991 29:85-89.