I had the good fortune of listening to Dr. Thad Shattuck (Medical Director, Center for Sleep Disorder at St. Mary’s Medical Center in Lewiston, Maine) speak at the Maine Nurse Practitioner Association Conference a couple of weeks ago. I loved what he had to say and found his approach quite integrated. I thought I’d share the high points of his talk.

Normal sleep is comprised of N3, or slow-wave sleep, and REM cycles. Each cycle lasts 90-110 minutes, and we often wake briefly at the end of each cycle.

Sleep is controlled by two processes:
1. Homeostatic sleep drive, which is the pressure you feel to sleep. The longer you are awake, the sleepier you get; physiologically there is a buildup of adenosine
2. Circadian rhythm, which is the internal 24-hour clock that regulates your body. It’s strongly influenced by light and is often overlooked when people are treated for insomnia

Not all insomnia is the same, and not all poor sleep is insomnia. There are subtypes of insomnia and different types require different strategies.

Chronic insomnia, previously known as psychophysiological insomnia, is defined as: Difficulty falling asleep, or difficulty staying asleep, or waking up earlier than desired, along with daytime impairment that is either cognitive, emotional, social, and/or affects work. In chronic insomnia, symptoms occur at least three times per week, lasting at least 3 months.

Predisposing factors that contribute to chronic insomnia include biological traits, psychological traits, and social factors. Factors that precipitate chronic insomnia include medical illness, psychiatric illness, and stressful life events. Factors that perpetuate chronic insomnia include excessive time in bed, napping, and conditioning.

The cause of chronic insomnia is thought to be hyper-arousal resulting from an altered metabolic state, stemming from the hypothalamus. Most insomniacs describe feeling fatigued as opposed to feeling sleepy. They report having difficulty napping during the day. They worry about sleep during the day. Diagnosis is typically made based on history, and sometimes a sleep study is done.

The primary treatment strategy for managing chronic insomnia in adults, per the American College of Physicians, is cognitive behavioral therapy for insomnia, aka CBT-I. Components of CBT-I include addressing sleep hygiene (sleep habits), sleep scheduling (actually limiting the time in bed to sleep), stimulus control theory (going to bed when you are tired), cognitive restructuring (working through negative thoughts about lack of sleep), and relaxation therapy (including mindfulness training).

Behaviors thought to perpetuate insomnia include spending excessive time in bed, going to bed when not sleepy, engaging in non-sleep activities in bed, trying harder to sleep, blue light exposure before bed, and the belief that it is not possible to function without eight hours of sleep.

There are a few online resources for CBT-I treatment, including SHUTi, Sleepio, the Cleveland Clinic program, and CBT for Insomnia by Gregg Jacobs.

Four things you can try for better sleep:
Reduce your time in bed
Get up at the same time every day – this is proven to be most important in studies
Do not go to bed unless sleepy
Do not stay in bed unless asleep

If your sleep does not improve after two weeks, you can try adding melatonin for 2 weeks and then reassess. Medication should only be prescribed as part of a broader sleep strategy. You can try CBT-I either in person or virtually. There is better sleep to be had!


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