Sleep Hygiene September || Take 2 Tips: Get some help

FEB 2014 || JOURNAL OF CLINICAL SLEEP MEDICINE
Impact of Brief Cognitive Behavioral Treatment for Insomnia on Health Care Utilization and Costs
"The results of this study suggest that the utilization of health care services by individuals with chronic insomnia can be reduced to some extent by delivery of bCBTi."

AUG 3 || KSAT NEWS
Consumer Reports researches different way to help insomniacs fall asleep
“ 'Cognitive behavior therapy has been shown to improve the amount of sleep you get, as well as how often you wake at night,' Dr. Orly Avitzur, Consumer Reports medical director, said."

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Sleep Hygiene Tip of the Week: Practice SLEEP AWARENESS WEEK by mastering sleep hygiene

People still struggle with the term "sleep hygiene," even if they might actually be practicing it adequately. Maybe it has to do with the word "hygiene," which most people apply more to bodily functions and dental care. 

It might be easier to think of "sleep hygiene" as similar to the idea of "eating clean." That is, making choices that are beneficial and which reduce your risks of adverse effects.

(This is the curator's very informal definition of "clean eating" by the way; others will say "no processed foods" or "scratch cooking only" or some such, but the point is to practice eating that will enhance overall health.)

In the case of "sleep hygiene," think of all the ways one can prioritize sleep so that ideal quality and quantity can be achieved, which will go a long way toward enhancing overall health and well being. 

The term itself is not new and has origins in very early discussions about sleep health. Famous sleep researcher Dr. Nathaniel Kleitman began to write about the "hygiene of sleep" in the 1930s, when the concept of practicing behaviors and creating environments that encouraged good sleep was first discussed in his circles. His book, Sleep and Wakefulness (1939), included a chapter entitled "The Hygiene of Sleep and Wakefulness" and referenced even earlier discussions about sleep hygiene going back to Macnish (1834), Manacéine (1897), and W.H. Burnham (1920).

It wasn't until 1977 that the term became useful in the mainstream with Peter Hauri's publication of Current concepts: the sleep disorders, when he used an entire chapter to define sleep hygiene as the effects of environment, food, exercise, and medication on the sleeping process. Hauri was a psychologist who was famous for focusing on insomnia; he sought nonpharmacological treatments for sleeplessness that are now the basis for behavioral theories today for treating insomnia. He passed away in 2013 but not before leaving a legacy of books about sleep health including the bestselling title, No More Sleepless Nights. 

To usher in this year's SLEEP AWARENESS WEEK, we give you these various definitions of "sleep hygiene" for you to ponder.

Google: 

LexBook.net

"Sleep hygiene is the controlling of 'all behavioural and environmental factors that precede sleep and may interfere with sleep.' It is the practice of following guidelines in an attempt to ensure more restful, effective sleep which can promote daytime alertness and help treat or avoid specific kinds of sleep disorders. Trouble sleeping and daytime sleepiness can be indications of poor sleep hygiene or sleep habits. The International Classification of Sleep Disorders-Revised states on page 74: 'The importance of assessing the contribution of inadequate sleep hygiene in maintaining a preexisting sleep disturbance cannot be overemphasized.' In the ICSD-R, the diagnosis inadequate sleep hygiene is classified as an extrinsic sleep disorder, code 307.41-1." 

McGraw-Hill Concise Dictionary of Modern Medicine

"Sleep Hygiene: The maintenance of habits conducive to sound sleep and rest; for good SH, naps should be limited, exercise, proper nutrition, caffeine, alcohol, nicotine, worrying, etc, minimized before sleeping." 

Medicine.net

"Sleep hygiene includes simple steps that may improve initiation and maintenance of sleep, such as maintaining a regular sleep schedule, making the bedroom an inviting place to sleep, avoiding alcohol, large meals, or smoking prior to going to bed, and exercising regularly (but not in the 4-5 hours prior to bedtime)." 

National Sleep Foundation: 

"Sleep hygiene is a variety of different practices that are necessary to have normal, quality nighttime sleep and full daytime alertness."

 Wikipedia: 

"Sleep hygiene is the recommended behavioral and environmental practice that is intended to promote better quality sleep."

[Credit:  Irish, Leah A.; Kline, Christopher E; Gunn, Heather E; Buysse, Daniel J; Hall, Martica H (October 2014). "The role of sleep hygiene in promoting public health: A review of empirical evidence". Sleep Medicine Reviews. doi:10.1016/j.smrv.2014.10.001. PMID 25454674.]

THE WISDOM OF SLEEP: Dr. Andrew Weil

Curator's note: Alternative medicine guru Dr. Andrew Weil offers millions of Americans alternative options for achieving maximum health that are less invasive and do not rely on pharmaceuticals. One of the practices he often suggests for people struggling to fall asleep is a simple yogic breathing exercise known as the 4-7-8 breath.

I personally have used a variation of this technique as a "sleep aide" for over 30 years, especially on nights when anxiety runs high and the mind struggles to shut off. It absolutely works for me. 

For those of you who have occasional trouble falling asleep, I cannot recommend this treatment enough. 

Please click here to find a video where Dr. Weil illustrates this simple breathing technique.

If you aren't clear on the value of using breathing exercises for relaxation and sleep, please consider that deep breathing is part of a variety of techniques practiced in cognitive behavior therapy (CBT). The latest research shows that CBTi (cognitive behavior therapy for insomnia) is generally more successful for treating insomnia than using pharmaceutical aids like Ambien (which are not meant for long-term use, anyway).

INSOMNIA: What is CBTi? A quick guide to non-drug therapy for insomnia

Many people believe the only treatments available for chronic insomnia require drugs. The truth is, there is a non-drug therapy for insomnia which has been around for a while that can be very effective in treating insomnia. CBTi stands for Cognitive Behavioral Therapy for Insomnia, and it is often used by psychotherapists who have training in sleep medicine to treat insomnia disorders. Sometimes it is used in conjunction with sleep aids, but it can also be used with patients who are trying to wean themselves off of hypnotic drugs in an effort to try to sleep better naturally. 

Essentially, CBTi is a structured behavioral training approach which helps insomniacs to identify and replace thinking and actions which lead to or aggravate preexisting insomnia. This practical therapeutic training can help insomniacs discover, then overcome the root causes of their sleeplessness. 

Some techniques for CBTi can include (this list is not exhaustive): 

• Biofeedback. Observing your biological signs (heart rate, respiration, muscle tension, etc.) so you can see what needs to be adjusted, using a take-home device.
• Relaxation training. Mind and body helps, such as meditation, self-hypnosis, yogic breathing, muscle relaxation, etc. 
• Sleep hygiene. What we talk about all the time in SHC: better lifestyle habits lead to better sleep habits! 
• Sleep restriction. This is the strategic decrease of time in bed which helps to reset the sleep drive. Usually requires sticking to an odd schedule for a while.
• Sleep space improvement. It's not silly to rethink sensory comforts like bedding, lighting, even aromatherapy.
• Stimulus control therapy. This helps break down thought processes ("racing thoughts") that encourage resistance to sleep. 
• Relapse prevention. Behaviors can return; a good CBTi therapist can offer tools to prevent this from happening.

CBTi may not work immediately as it requires behavioral modification, unlike a sleep aid like Ambien, which you just take at night and (with any luck) fall asleep. For people who are impatient to find sleep again, these are therapies that require time and earnest effort. If you are resistant to the notion of using therapy to fix your insomnia problems, consider this: 

However, the problem with the vast majority of drugs used to facilitate sleep is that they have unsafe side effects, can negatively interact with other maintenance drugs and are often only meant for short-term use as they can be addicting or easily habituated to. For many insomniacs, drugs simply do not work because they are at best a temporary, Band-Aid solution, whereas the value in CBTi lies in the fact that this therapy can help address and conquer the underlying reasons for not sleeping.

CBTi also works for other kinds of sleep problems, such as adult acclimation to CPAP therapy, pediatric difficulties with falling or staying asleep and anyone suffering from recurrent nightmares.

Below is a quick list of excellent, in-depth resources on CBTi. If you have insomnia and have had no luck with prescription or over-the-counter sleep aids and your friends' home remedies aren't working either, please consider giving CBTi a try. Most insurance will cover it, and you can often meet with more than one practitioner in a free consult to determine if they are a good match for you. Ask them what kinds of therapies they support and get patient testimonials, whenever possible.

NATIONAL SLEEP FOUNDATION || Cognitive Behavior Therapy for Insomnia

SLEEPDEX || Cognitive Behavioral Therapy for Insomnia

STANFORD HEALTH CARE || Cognitive Behavioral Therapy for Insomnia (CBTi)

MAYO CLINIC || Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills

AMERICAN ACADEMY OF SLEEP MEDICINE || "Cognitive behavioral therapy is an effective treatment for chronic insomnia." Published June 9, 2009; accessed March 28, 2015.

“New Developments in Cognitive Behavioral Therapy as the First-Line Treatment of Insomnia.” Siebern, Allison T, and Rachel Manber. Psychology research and behavior management 4 (2011): 21–28. PMC. Web. 28 Mar. 2015. [PDF]

NPR: SHOTS || Working With A Therapist Can Help When Sleeping Pills Don't

INSOMNIA: Guest Post on Sleep State Misperception, with Dr. Robert Rosenberg, DO

You Didn’t Sleep At All Last Night?
Actually, Maybe You Did: Insomnia, Reconsidered

by Dr. Robert Rosenberg, DO

"Alarm Clock." Public Domain Image.

Every year, I see many patients who tell me that they get only a few hours of sleep each night. In fact, I have had several swear they barely sleep at all. In most cases, they honestly believe this to be true. Interestingly, if we bring them into our sleep lab, many of these individuals will insist that they slept only a few hours when their electroencephalogram (EEG) indicates that they actually slept much longer.

This type of insomnia, called Paradoxical Insomnia, is also referred to as Sleep State Misperception. Previously it was considered a rare condition, present–or so we thought–in no more than five percent of insomnia sufferers. We now know this estimate to be incorrect. Furthermore, in several recent studies, the incidence is closer to 50% when defined as misperceiving-sleep-as-wake-time by at least one hour or more per night.

As a result, we are now coming to realize there are two basic types of insomniacs:

1) Those who sleep greater than six hours a night but perceive they sleep less;

2) Those who actually sleep fewer than six hours, but accurately estimate their sleep time.

Why is it important to differentiate between the two groups of insomniacs? Because those who actually sleep fewer than six hours a night are much more likely to develop hypertension, diabetes, and suffer earlier death than those who misperceive their sleep time. These findings are potentially revolutionary when it comes to our understanding of the diagnosis and treatment of insomnia. Consequently, we need objective data in order to differentiate these two types, since effective treatment approaches are different.

What I find fascinating is that those with the misperception of their sleep cycles are more likely to respond to CBT (Cognitive Behavioral Therapy), while those who actually sleep fewer than six hours–the short sleeper type–are more likely to require pharmacological therapies. Why? It appears that the short sleepers have an underlying level of physiological hyperarousal. They have elevated levels of stress hormones such as cortisol and adrenaline, while the misperception group seems to demonstrate more of a psychological basis for their insomnia.

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The good news is that in sleep medicine we now have accurate tools for differentiating these two types. We have a device called an actigraph that is worn like a wristwatch on the subject’s arm. It correlates movement with wakefulness and its absence with sleep. Even more astonishing is a new form of technology called the Sleep Profiler. It records the subject’s brain waves during the night at home, accurately differentiating sleep from wake and also the distinctive stages of sleep. In fact, I have used this form of technology in my own practice with great success.

Due to our new understanding of insomnia and these technological advances, we can offer our patients evidenced-based therapies. As with many other things in medicine, we are learning that in the treatment of insomnia, one size does not fit all.

--This article originally appeared in Everyday Health, 2.18.2014

________________________________

Dr. Robert Rosenberg, DO

Dr. Robert Rosenberg sees patients at his private practices, the Sleep Disorders Centers of Prescott Valley and Flagstaff, and contributes a regular column, Sleep Answers, at EverydayHealth.com. His book, Sleep Soundly Every Night, Feel Fantastic Every Day, was published in June 2014; a copy of it will be selected as a prize in this month's SleepyHeadCENTRAL giveaway. Follow Dr. Rosenberg here:

Twitter: @AnswersForSleep
Facebook page: AnswersForSleep

Introducing January's theme: ALTERNATIVES

The most common treatments for sleep health problems are:
  • Pharmaceutical (sleeping pills or antidepressants, in example)
  • Surgical (removal or reconstruction of the airway for better breathing, for instance)
  • Prescriptive devices (positive airway pressure machines or O2 therapy, in particular)

All of these, of course, require a doctor's prescription and this means that the patient must go through the medical system in order to receive differential diagnosis and traditional treatment.

And this is a good thing for many people who have serious sleep disorders. In fact, SleepyHeadCENTRAL still maintains that the gold standard approach to diagnosing and treating sleep health problems is to start that journey through traditional avenues which rely on evidence-based medicine. (See the SHC statement in bold, below.)

Sleep apnea is perhaps the sleep disorder which most requires the careful observation and direction of a host of medical professionals, such as primary care physicians, pulmonologists, allergy specialists and dentists; together, they can help patients recover from dangerous sleep breathing patterns that otherwise negatively impact their health directly over nearly a third of their lives (which is spent in sleep).

There are myriad other sleep disorders which equally require the expertise of sleep doctors, such as movement disorders of sleep, hypersomnias and neurological co-conditions like epilepsy or Parkinsonism. These are serious conditions which require solid, evidence-based diagnosis and treatment.

However, there has been a rise in alternative health practitioners which may also serve to meet a sleep health patient's needs, especially in the areas of naturopathy and functional medicine. It's not a dirty secret that some sleep problems may be treatable without going through the usual healthcare protocols. It may be that cognitive behavior therapy might be the best solution for managing anxiety for some insomniacs, for instance, or the employment of alternative pain management techniques which don't involve drugs at all in order for some patients to achieve necessary sleep in order to heal.

And in the end, this is what matters the most: healing.

The field of medicine is rapidly changing these days, and the focus is now on better patient outcomes and fewer returns to the hospital, which basically boils down to efficiencies in cost management and more proactive, educated patients.

In other words, doctors are now required to provide more value for their services, while patients are now required to take more responsibility for their lifestyle choices and treatment compliance.

If both doctors and patients don't hold up their end of the bargain, they can expect refusal of reimbursement by insurance companies.

A potential benefit of this shift in healthcare focus? It's no longer impossible to find MDs who are cognizant, even open-minded, to alternatives to traditional drugs, surgeries or device therapies, especially if these alternatives could result in long-term adherence and better patient outcomes.

Another potential benefit is that patients may, indeed, become far more health literate in order to be their own best advocates while participating in the healthcare system. And that is never a bad thing.

Insurance companies are also more open to covering complementary services as more studies are showing success with these techniques, which is good news for both quality practitioners and patients.

SleepyHeadCENTRAL remains firm in its belief that people with sleep health problems are best advised to approach a medical professional for an appropriate differential diagnosis for their problems. 

Evidence-based medicine should still be at the very forefront of individual healthcare as it relates to diagnoses, as it is never a good idea for patients to self-diagnose for ongoing sleep health problems. However, medical professionals they can approach may also include naturopaths or functional medicine practitioners as well as traditional MDs. 

Finally, all patients deserve to know they have treatment options that extend beyond traditional approaches. 

The best way for a patient to become their own best healthcare advocate these days is through mindful education and awareness about both traditional approaches AND alternatives to those pharmaceutical, surgical or device-driven treatments for sleep problems.

This is where SleepyHeadCENTRAL enters: ALTERNATIVES hopes to give you some food for thought as you examine how you can best approach your sleep health problems in the years to come.

Wishing you good sleep health in 2015!

~The Curator, SHC

Sleep Hygiene Tip of the Week || What alarm clock?

Ask yourself... do you really NEED to see what time it is in the middle of the night?

After all, if you WERE asleep, you wouldn't know, and it would be fine, right?

Insomniacs often suffer from something called "hypervigilance," a behavioral problem in which one cannot shut off the brain for the night. It's a problem related to anxiety; all sensory details are super present to the minds of these sleepers. Instead of willing away these thoughts in order to relax and fall asleep, these people burden their sleep process by allowing the mind to race. The good news: it can be easily fixed with some cognitive behavioral therapy or training in meditation, both which can empower the sleeper to consciously deter racing thoughts so the brain and body can do the work of sleep.

What does the alarm clock have to do with this? Paying conscious attention to the passage of time while you aren't sleeping can actually aggravate insomnia. If you are in the habit of checking the clock every time you wake up, you may be unwittingly putting yourself into a hyperalert emotional state (fed by stress hormones) which will just enhance your sense of wakefulness.

This is almost always a negative experience for people and can lead to emotional upset, anger, frustration, even depression and suicidal ideation. Once inside this constellation of emotional disaster, what are the odds you will ever get back to sleep?

SLEEP HYGIENE TIP OF THE WEEK: Turn your alarm clock around once you have it set (or, turn off the sound and vibration settings on your smartphone, then turn it face down on your nightstand so it doesn't present unwanted noise or light while you sleep). Retrain yourself to NOT check the clock every time you wake up.

Cut yourself some slack! It's normal and okay to wake up several times at night. You might need to change positions, fix your blankets, drink some water or use the restroom. No need to complicate these normal activities of nighttime sleep by adding the unnecessary pressure of clockwatching into the equation.You can try a number of things to fall asleep, such as doing a body check to relax muscles, counting your breaths and falling into a breathing pattern, or imagining fantasies like what your dream vacation might be like. Eventually you will retrain yourself to go back to sleep and no longer automatically check the clock every time your eyes open.