Sleep hygiene

Ironically and counterintuitively, what's required is to have focus and intention on concentrating on the breath or some other neutral or monotonous stimuli.​

Sleep hygiene is the practice of assembling all of the factors that contribute to healthy restful replenishing sleep.  

Americans are sleeping less in recent times than we did even 10 years ago. According to The Institute of Medicine insomnia occurs in 30 million Americans. There is speculation as to why but it’s fairly obvious. Our levels of stimulation from light, multiple distractions of sound and on-line offerings as well as lifestyles that have progressively moved away from the normal rhythms of natural sunrise and sunset all contributes to less healthy sleep. Worry is also a factor. People have greater stress re: work, finances, personal safety, climate distress and physical discomfort. Later hours and more sedentary lifestyles contribute to poor sleep and less relaxed body states that are necessary for sleep. People continue to overeat and use alcohol and simulants which serve to prevent solid deep sleep.

Following is a list of contributing factors which can inform you on how to increase the likelihood of getting good sleep.

  • General Health. It is important to have a full medical checkup and be sure there are no underlying disorders that can contribute to poor sleep. Obvious conditions that can impair sleep are sleep apnea, diabetes, alcohol or drug abuse, anxiety, major depression, benign prostatic hyperphagia (BPH or enlarged prostate), breathing difficulties from COPD and emphysema and acute or chronic pain. Your physician can assist you in identifying the possibility of other medical conditions which could affect your sleep.
  • Sleeping Environment. Many of my patients cannot go to sleep without the television on. They have become conditioned to wanting to have the sounds and light of the television on. Many of my younger patients are using the laptop or tablet to watch or read material on-line before going to bed. The blue light emanating form these devices disrupts the normal availability of melatonin, a neurotransmitter which is associated with sleep in the brain. A dark environment is best with little to no light entering the eye. It is better to not be able to see the clock at night so the temptation to fret over what time it is can be prevented. A cool comfortable temperature is important as well as a quiet environment. Sometimes ear plugs are useful. The bed should be comfortable and fairly firm for good spinal support. If you have a sleeping partner it is important to have enough room and not be distracted by their snoring or other behaviors. It is important to feel safe in your bed to allow your vigilance to relax. If one does not feel safe perhaps an alarm or a dog may be helpful. (the dog may pose another problem if it is not trained or overly reactive with barking to outside noises). It is important to not take on troublesome or stressful conversations or projects just before bed. Schedule time to take on these difficulties in the next day or two if possible.

Some sleep specialists discuss using the bed just for sleep and not for watching TV, using electronic devices or even reading. I would advise that reading in bed is a good precursor to sleep providing the reading material is not eliciting tension, fear or anxiety.

Distracting Thoughts.  Rumination is the recycling of thoughts in an attempt to process them or “solve” a problem typically which cannot be solved by thinking. When you’re attempting to fall asleep and you have a troublesome problem, worry or concern arising the nervous system gets activated and an alarm mechanism may kick in and relaxation becomes difficult. You’re activated and more awake with the unfortunate tossing and turning which then becomes more upsetting. At this point maladaptively people will turn on the television, go get something to eat or drink or just stay frustrated and not sleep.

Concentration. Ironically and counterintuitively what’s required is to have focus and intention on concentrating on the breath or some other neutral or monotonous stimuli. This requires training because most people have not practiced intense concentration and focus on the breath. This website offers several meditations and links to sleep inducing meditation exercises. What’s required is to redirect attention away from the troubling thought or issue. It takes practice to build this mental pathway. One useful technique which is effective is to count from one to twenty while breathing in and out with each count. If you lose your place (which is a good sign because it indicates you’re getting tired) you start over again at 1-inhale, exhale, 2-inhale exhale, 3 etc. until you get to 20. If still awake you do the count backwards from 20 to 1 in coordination with the breath.  There is a high probability that you will fall asleep doing this technique as it is highly effective. Most of my patients cannot do the full forward and backward counting/breathing sequence two times without falling asleep. There is a talk on this website which will cover this and some other techniques to facilitate sleep. Having an attitude of confidence that you will be able to learn how to fall asleep in spite of the habitual difficulties with insomnia is helpful. That confidence comes with practice. Studies show that patients who learn to manage and discard troublesome thoughts sleep better than patients on sleeping medication.

Use of stimulants or alcohol. Legal stimulants like coffee or tea is important to monitor especially if these beverages are ingested in late afternoon. Each person must experiment with their limit and sensitivity to coffee or caffeinated tea. There are those individuals who claim they can have a cup of coffee right before going to bed with no ill effect. If you are one of these individuals I would still encourage you to experiment with your use of these beverages and determine if sleep is deeper and more sound without them late in the day. Another problem with stimulants and alcohol is that they are dehydrating and act as diuretics. It is known from sleep studies that drinking alcohol impairs accessing deep stages of sleep. This is especially true if there are several drinks imbibed.  Interestingly some people use alcohol to facilitate mental relaxation in order to fall asleep. They may fall asleep but due to the dehydration, the need to urinate and disruption of accessing deep states of sleep they wake up during the night and do not feel rested in the morning. Obviously the use of stronger drugs like methamphetamines or cocaine can impair healthy sleep. Some prescribed medicines can interfere with sleep and so it is important to discuss this with the prescribing doctor or the pharmacist.

Bedtime Ritual. A bedtime ritual can assist in training the brain to learn to begin the process of winding down and getting to sleep. Routine helps the nervous system to access parasympathetic “cool down, calm down responses” which are necessary for the blessing of deep reparative sleep. Having a routine bedtime assists with getting to sleep and anticipating the learned context that “it’s bedtime, time to go to sleep”.  If you practice a brief meditation, body scan or counting technique as you are preparing to sleep this will also facilitate the ease of falling asleep. Getting enough sleep for you is a personal decision which may vary.  There are general recommendations that we aspire to get 7-8 hours of sleep. Some patients say they function just fine on 6 hours. That may be true, but more sleep would probably enhance their functioning.

Medications. Psychologists do not prescribe medications and it is best that patients discuss their medications or discontinuing medications with their physician before tapering or discontinuing.  Problems with medications like Ambien, Lunesta, Halcion which are classified as hypnotics include potential for oversleeping, being too drowsy to drive to work in the morning, being too drowsy to work or concentrate and is some rare cases to engage in sleepwalking and having amnesia regarding things that were said or done while under the influence. Medications classified as benzodiazepines include alprazolam (Xanax), clonazepam, Librium, lorazepam, valium and others are sometimes prescribed to assist with sleep. There are some risks associated with long term use of these medications and their potential to become habit forming. It is very difficult to get off of these medications if they have been used regularly and it is vital that patients work with their physicians to go on a medically supervised taper regimen if they wish to discontinue the medications. Alcohol should never be used in conjunction with these medications as they sedative effect can be potentiated and dangerous for health and potentially lethal.