Recently it seems that every one of the classes I teach (remotely) starts with a discussion of sleep problems. In one group, in which several members said they’d been awake at 3 am, someone joked, “We should just have class then, since we’re all probably more alert at 3am than we are right now, after another night of not sleeping.”

The idea isn’t totally crazy, according to a leading behavioral sleep specialist Dr. Donn Posner, an adjunct associate professor at Stanford University School of Medicine and president of Sleepwell Consultants, who told me in an recent interview, “If you’re having troubles sleeping in the middle of the night, get out of bed, get up, and do something fun.”(But, it turns out, this doesn’t mean a planned weekly meeting. We’ll get to that in a minute.)

 As Dr. Alon Avidan, a neurologist who directs the UCLA Sleep Disorders Center, said in an interview for the Washington Post, “With covid-19, we recognize that there is now an epidemic of sleep problems.”

After hearing similar complaints from clients, friends, family, and other colleagues, I decided to look into what makes it so hard for us to sleep right now, and what we can do about it.

Dr. Posner, who lectures about sleep all over the world, told me that the reason for getting up when you’re wide awake in the middle of the night is so that you don’t turn your bed into a trigger for being awake. And that’s exactly what you are doing, he said, “if you’re awake in the middle of the night, holding onto that mattress for dear life trying to make yourself go back to sleep.” This desperate attempt to make yourself sleep is called “sleep effort” – which, he says, is doomed to fail.

He told me that when he gives a lecture about sleep health, he always asks who in the audience falls asleep without difficulty. And then he asks them how they do it. He said that no one can ever answer that question, because sleep is a function of our bodies that we cannot control. He told me, “Just as you can’t make your heart beat or make yourself breathe, you can’t make yourself sleep. Good sleepers do nothing to make themselves sleep. Trying to make yourself sleep, becoming fixated on your sleep, is a perpetuating factor that keeps your insomnia alive.

So if it’s an automatic function, what makes it so hard for many of us to get a good night’s sleep? And why is the pandemic making it worse?

Dr. Posner explains his approach to insomnia on the podcast Ten Per-Cent Happier with Dan Harris

On the podcast he tells us that we all have a bad night’s sleep from time to time. That’s normal. But when it lasts longer it can transform into acute (or short term) insomnia, which, if it persists and is not addressed, can become chronic insomnia.

According to the US Government’s National Institutes of Health,   “Insomnia is a common sleep disorder. With insomnia, you may have trouble falling asleep, staying asleep, or getting good quality sleep. This happens even though you have the time and the right environment to sleep well. Insomnia interferes with your daily activities and may make you feel unrested or sleepy during the day. Short-term insomnia may be caused by stress or changes in your schedule or environment. It can last for a few days or weeks. Chronic (long-term) insomnia occurs three or more nights a week, lasts more than three months, and cannot be fully explained by another health problem or a medicine.”

Dr. Richard Barth, a sleep specialist in San Francisco who studied with Dr. Posner (and who, full disclosure, is my brother) told me that “sleep effort” is one of the things that perpetuates sleeplessness, turning acute insomnia into chronic insomnia.  And my PT colleague Dr. Boris Dubrovsky, a sleep specialist  in New York City who is Board-Certified in Behavioral Sleep Medicine and an associate director at NY-Presbyterian Brooklyn Methodist Hospital writes that the three most common factors in making insomnia chronic are “spending a lot of time trying to sleep, spending a lot of time thinking about sleep, and spending a lot of time fearing not being able to sleep.” 

Dr. Posner said that there are many precipitants of sleep problems. “You could probably open the dictionary, put your finger down on a word, and find something that causes insomnia.” Illness, physical pain, a change in your environment, a psychological stress like stress in your work, tax time, a change in your life. He adds that even good things can be stressors that interfere with sleep – getting married, expecting a baby, or other things that make us happy can also be stressful.

The pandemic, of course, is a major stressor accompanied by numerous other stresses, like worries about our own health and that of loved ones, financial concerns, new patterns (often not particularly pleasant) of working, crowded and tense home situations, loneliness, anxiety, and so on. The ongoing disturbance has created wakeful nights even for people who normally sleep well.

Not sleeping in times of danger is natural and, from an evolutionary perspective, even healthy.  In an article published in last year  in the journal Brain Sciences, a group of researchers from around the US and the UK wrote, “Evolutionarily speaking, …if it is not safe to sleep, one should not sleep (regardless of the duration of prior wakefulness and/or time of day).” They cite two early sleep specialists,  Spielman and Glovinsky  who developed the initial model for CBT-I (Cognitive Behavioral Therapy for Insomnia), who wrote, ‘No matter how important sleep may be, it was adaptively deferred when the mountain lion entered the cave.’ But extended periods of not sleeping, as we all know, brings many other concerns, including inability to do our work, increased anxiety and depression, and possible health problems. So what can you do to get a good night’s sleep on a regular basis, despite the mountain lion of the pandemic at the front door?

I am neither a sleep specialist nor a cognitive behavioral therapist. But in researching ways to help clients deal with pandemic-initiated insomnia, I repeatedly encountered comments like this one from Dr. Dubrovsky , who writes that research shows CBT-I to be “the most evidence-supported insomnia treatment to date.”

Similarly, Dr. Brandon Peters, a board-certified neurologist and sleep medicine specialist writes, “Cognitive behavioral therapy for insomnia (CBTI) is …now recommended as the first-line treatment for chronic insomnia, even before the use of sleeping pills.”

 124884395 Sam Wordley

Source: 123RF Image ID: 124884395 Sam Wordley

Dr. Posner does not give “tips” for curing insomnia, because he says chronic insomnia requires professional evaluation and intervention from a certified sleep specialist. But he does say that there are some things you can do to keep a few wakeful nights from turning into chronic insomnia.

1. Don’t panic. Remember that we all have sleepless nights, and that we all manage to function the following day. Worrying about sleeping and “sleep efforting” will make not help – in fact, they’ll make it harder to sleep. If you don’t already have chronic insomnia the next suggestions should help you let your body do what it does naturally, so that you can get a good night’s sleep the next night, or maybe one after that.  

2. Structure your days. It is important to maintain a regular, structured schedule in our lives, including not just when we have our meals, but also when we exercise, when we work, and when we go to sleep and get up. The pandemic has altered structure for most of us – or taken it away altogether. Whereas you might once have had a morning routine of getting the kids up and ready for school, getting dressed, getting everyone out the door, picking up your morning coffee, and getting to work at a certain time, none of that holds true during the pandemic when we’re working at home and our children are going to school from home as well. Multiply that by all of the structure and routine that is part of our normal lives – all of which is missing right now – and of course our bodies and our psyches are suffering.

This is one of the problems that retirees sometimes have. The structure they’ve lived by for forty or fifty years (or more) is gone. We think retirement should be unstructured, but in fact, even if you’re playing all day long, you need a structure to your days – and nights.

Dr. Posner told me, “Try to exercise at the same time, or close to it, every day. Try to eat regular meals – grazing all day long is not good.” It’s also important to put some boundaries on your work. When you’re at home, it might seem that you can just keep going; but it’s important to have divisions between work and relaxation, just as you would if you went into an office every day.

3. Create a “Buffer Zone” at night. According to Dr. Barth, part of your daily structure should be a ‘buffer zone’ that you set up “approximately an hour before bedtime where you wind down, brush teeth, put on pj’s, stop work, get off the computer and other electronics, etc.”

4. Set and maintain a regular wakeup time. This last is perhaps the most interesting of Dr. Posner’s recommendations. While we have all read plenty about going to bed at the same time and getting a set amount of sleep every night, Dr. Posner told me, “Wake time is the single most important structure there is.”

“Waking up at different times throughout the week is the equivalent of ‘social jet lag‘”

He said that waking up at different times throughout the week is the equivalent of “social jet lag.” He gives the example of traveling across time zones. If one day you take a plane from the east coast to the Midwest, say New York to Chicago, and stayed over one night and flew back to New York; and stayed there for one night and flew to Los Angeles; and stayed there for one night and flew back to New York. Your sleep would be disrupted. And that’s what happens when you get up at 6am some days, and 8am others, and 10am or noon others. Your body reacts to being awakened at different times over the course of a week in the same way that it would to being in all of those different time zones in the same period of time.

Getting up at the same time, at least most days of the week, is one of the keys to dealing with insomnia. To “fix your sleep clock” you need to try to get up at the same time everyday. But once the clock is working, what Dr. Posner calls “well-oiled,” you can get up at the same time 5 days a week, and you can change the time on the weekend.

5. Don’t worry so much about how many hours you sleep. This is also a surprising one to many of us. Disagreeing with other sleep professionals, who he calls his “brethren in the field,”Dr. Posner said, “Many of us don’t know how much sleep we need.” We’ve been told that we need 7-9 hours of sleep a night; but the data is not so clear. The amount of sleep that an individual needs differs greatly.

6. Don’t make up for lost sleep. There is a chemical called adenosine that builds up in our bodies during the day to make us sleep at night. If you sleep later in the morning to make up for lost nighttime sleep, Dr. Posner says, you don’t give your body a chance to build up the adenosine to sleep for the next night. He says it’s okay to nap, for a short time (like 20 minutes) in the afternoon, when there is a natural dip in energy. But it should be short – a power nap – so that you don’t rob your body of the adenosine it needs for the night to come.

“Waking up at a regular time in the morning is the key to sleeping well.”

So to get back to my student’s joking suggestion that we have class at 3am in the morning? I asked my brother, Dr. Barth, if scheduling an activity in the middle of the night was a good plan. He said, “The idea of getting out of bed and doing something fun is so that you’re not working at going to sleep, since sleep effort creates insomnia. If you let yourself do something you enjoy, instead of lying in bed trying to chase sleep, your body will naturally start to get sleepy. Your eyes will start to close and you can go back to bed and fall asleep. And if you don’t, that’s fine, you’ll function the next day and the adenosine will build back up in your body so that you will sleep the next night, or maybe the night after. But if you schedule a work activity when you’re supposed to be sleeping, you give your awake time a purpose. You don’t want to start depending on being awake in the middle of the night to get your work done.” Okay, so no 3am classes. But doing a puzzle or an art project, watching a movie or reading a book, even if you don’t fall asleep, is fine, as long as you don’t try to make up the sleep later. Get up and get started at your regular time, and your body will build up the chemicals it needs to put you to sleep in the next night or two.

Bottom line? Troubles sleeping during the pandemic are normal and, at least evolutionarily, adaptive, since not sleeping was historically a healthy response to danger in the environment. The worries, stress, lifestyle changes, and shifts in our social and work life that have accompanied the virus all contribute to some sleepless nights for almost all of us. Following the steps above can help you override that innate response and get some better shuteye; but if they don’t work for you, if you’re still struggling with frequent insomnia, and if you’re still trying to effort yourself to sleep, it’s probably worth your while to consider getting an evaluation and treatment plan from a fully board certified CBT-I sleep specialist.

Copyright@fdbarth2021

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