If you climb into bed when you’re feeling tired, sleep like a log, and

get up refreshed in the morning, you are one of the lucky ones. For

many, their beds are the scene of nightly battles, struggling to wrest

enough sleep to get through the next day. In fact, according to the

National Sleep Foundation’s 2002 "Sleep in America" Poll, over the

year preceding the survey, 58 percent of adults reported that they are

affected, a few nights a week or more, by at least one symptom of

insomnia – either difficulty falling asleep; waking often during the

night; waking early and being unable to fall back to sleep; or waking

up feeling unrefreshed – with 35 percent reporting this every night or

almost every night. In addition, 68 percent of American adults slept

less than the recommended eight hours; 15 percent used either a

prescription or over-the-counter medication to help them sleep at

least a few nights a week – up from 11 percent in 2001; and 37 percent

reported being so sleepy during the day that it interfered with their

daily activities a few days a month or more.

Perhaps as a result of their nightly battles, Americans today seem to

be getting more savvy about sleep problems, and medical and

psychological professionals are responding with new expertise and new

facilities. American Medical News reported in 2004 that membership in

the American Academy of Sleep Medicine had more than doubled since

1993 to nearly 4,900 and that the number of accredited sleep

facilities had jumped from three in 1978 to 678 in 2003, with nearly

one-third of that growth since 2000 alone.

In 2003 the American Academy of Sleep Medicine offered certification

for the newest sleep specialty, behavioral sleep medicine, and

Princeton psychologist Elaine Wilson was among the group of nearly 50

who were certified in 2003 and 2004. Affiliated with the Princeton

Sleep Center at the University Medical Center at Princeton, Wilson

also has an independent practice and bases her work on the research of

Arthur F. Spielman, Gregg Jacobs, and others,

To effectively deal with sleep disorders, which are on the rise due to

"obesity, stress, and society in general," says Wilson, people must

have realistic expectations about sleep. She notes that everyone wakes

up several times a night, but "if you are awake for less than a

minute, you usually don’t realize it." As we get older, however, we

awaken more often, and by age 75, it can happen more than two dozen

times a night. If you do find yourself awake, she suggests, it

sometimes helps to tell yourself, "everyone wakes up – this is

normal." What is unusual is being awake more than 15 minutes. For

research purposes, the diagnosis of insomnia is that a person is awake

for more than 30 minutes during the desired sleep period, whether that

occurs at the beginning, middle, or end of the night, on the majority

of nights.

Everybody has a bad night now and then, but the question is: what

should people do in response? For acute insomnia of less than two

weeks, says Wilson, they have two choices: visit a doctor for a

sedative or do nothing. The "tough-it-out" approach might be the

strategy of choice: "If you don’t compensate for sleep loss, it’s

quite possible that the system will restore its own balance," says

Wilson. She even supports a judicious use of caffeine to keep going

during the day. But after a month, a person should seek treatment.

Before beginning treatment, Wilson assesses the cause of the insomnia.

If there are underlying medical or psychiatric conditions, they need

to be dealt with as well. "But just because there is a medical or

psychological component doesn’t mean I wouldn’t use behavioral

techniques," she observes. "Working on insomnia directly might improve

a medical problem or head off a worse mental health problem."

The first technique she uses is called "sleep scheduling" or "sleep

restriction." It boils down to spending less time in bed. "It is

simple," she says, "but difficult to implement." The patient is asked

to wake up the same time every day, thereby resetting the 24-hour

clock-the circadian rhythm that determines what time you get tired, go

to sleep, and wake up. The patient also sets a late hour for going to

bed, thereby compressing the sleep time temporarily. "The goal is

efficient sleep, where people are asleep most of the time they are in

bed."

Consider a patient who comes to Wilson sleeping only five hours a

night, with sleep broken in the middle or at the end. "We would

restrict them to six hours in bed," she says. If 7 a.m. is the desired

wake-up time, then for the next week, the person would go to bed at 1

a.m. "This is drastic for some people, who say, ‘I’m not in bed

enough; I’m not getting enough sleep,’ but pretty quickly it starts to

consolidate – it’s like stuffing sleep into a box." Then the patient

backs up on the go-to-bed time until the sleep starts to fall apart,

with seven hours probably a reasonable goal for unbroken sleep.

The next technique is stimulus control, whereby patients begin to

teach themselves that "the bed is for sleeping (and sex) only." Lying

in bed with insomnia has the opposite effect, teaching the patient

that "the bed is where I lie rolling around, or even the bed is my

torture chamber." She advises her patients not to lie in bed awake for

too long: "If it goes more than 20-30 minutes, get up and do something

restful until you are sleepy." Then get back in bed. "Sometimes if you

get up for awhile when you don’t feel sleepy, the bed just feels

different when you get back in," she observes.

Another part of learning that the bed is for sleep is learning how to

fall asleep in bed. "You want to fall asleep on your own, not reading

a book," she says. "If you always fall asleep reading, then each time

you wake up, your body doesn’t know how to put itself back to sleep

and has to learn – like a child learning self-soothing."

Relaxation and cognitive techniques are also important, but not as

well documented as to effectiveness. Potential relaxation techniques

include yoga, progressive relaxation, biofeedback, and exercise. "All

are helpful," she says, "but may not do the trick." The relaxation

approach she uses is a three to five-minute deep-breathing technique:

"Normally it is enough unless there are significant anxiety problems."

In order to address worry and false beliefs about sleep, Wilson uses a

number of cognitive techniques. One approach is for people to

challenge the negative self-statements that prevent falling asleep or

staying asleep. She suggests her patients should think of statements

such as, "If I can relax, I can sleep." Or to counter the fear that

they’ll have a terrible day tomorrow, they might tell themselves that

most insomniacs usually function pretty well the next day. Another

possibility is to write down a "worry and to-do" list an hour or more

before bedtime. Then, when people wake up thinking about these issues,

they can say to themselves, "There’s a time and place for that, but

it’s not now."

For problems like jet lag or other shifts in the circadian rhythm,

Wilson supplements her usual approaches with melatonin, an

over-the-counter medication, or photo-therapy. Photo-therapy using a

light box, a device that can produce 10,000 lux, the equivalent of

bright sunshine, as opposed to normal indoor lighting, which is from

300 to 500 lux.

Those suffering from phase misalignment include shift workers (those

who work nights and those whose schedules change); young people (who

stay up late and then find it harder to fall asleep and to wake up);

and older people (who may find it easier to go to sleep earlier

because of a biological change in the circadian rhythm, but then wake

up earlier and earlier in the morning). The afflicted teenager might

use a light box for about 30 minutes in the morning or the older

person in the evening to switch the cycle. Light inhibits the release

of the hormone melatonin, which is associated with sleep onset. "A

light box can be purchased over the Internet for less than $200,"

notes Wilson.

Although research has not documented the effectiveness of melatonin as

a sleeping medication, there is some evidence that it is useful in

treating phase shift problems, and Wilson sometimes uses it in very

small doses in conjunction with light therapy.

Wilson does not usually recommend sleeping pills except as a

palliative until cognitive therapy kicks in. The two drugs that Wilson

believes are safest are Ambien and Sonata, because they have the

fewest side effects (see page 41). "I worry about older generation

sleeping pills – the benzodiazepines like Restoril or Valium, which

affect sleep architecture, taking away some of the deep sleep so

important for physical restoration and well-being," she explains.

Users can also develop a tolerance to these drugs, and they sometimes

have a hangover effect that can lead to falls or accidents.

Wilson is a first-generation American. She grew up in Great Neck, Long

Island, where her father was an attorney-turned entrepreneur. She

graduated from the University of Massachusetts at Amherst in 1968 and

has a master’s degree in psychology from SUNY Stonybrook. She worked

as a research associate and a lecturer in psychology at Princeton

University before getting her Ph.D in clinical psychology from Rutgers

University in 1979. She did an internship in clinical psychology at

the Palo Alto Veterans Administration hospital.

Is Wilson, herself, an insomniac? Not at all. She gets eight hours.

She got interested in the sleep field in 1990 when she spent a year on

the Stanford campus while her husband was at the Center for Advanced

Study in the Behavioral Sciences. On the advice of her colleague Ray

Rosen, academic director of the Sleep Disorders Center at Robert Wood

Johnson Medical School, she took a course there with sleep expert

William Dement. When she returned from California, Rosen supervised

her in behavioral sleep medicine, and she further expanded her

knowledge by talking to the experts, and joining the American Academy

of Sleep Medicine and attending its annual meetings. Then, when the

academy offered the new specialty, she was prepared: "I realized when

the new certification came in that I had the credentials and

experience to take the exam."

Despite the efficacy of behavioral approaches to insomnia, awareness

of them is limited in the medical establishment and Wilson feels

impelled to share this information more widely: "My big thing is to

get the word out to other professionals, even family doctors, so they

don’t automatically give medications."

She also urges individuals to learn what they can from published

sources. "Some of the materials can be used on a self-help basis," she

says, for example, "Say Good Night to Insomnia: The Six-Week,

Drug-Free Program Developed At Harvard Medical School" by Gregg Jacobs

and Herbert Benson and "No More Sleepless Nights" by Peter Hauri and

Shirley Linde.

These techniques are not a one-time band-aid, but something you can

come back to again and again, as life sends its hardballs and curves.

"The more you know about sleep disorders," says Wilson, "and the more

you understand the approach, you realize it is not just a disembodied

set of techniques, but one that you can apply again when problems come

back."

Elaine Wilson, 609-921-7395, E-mail: ElaineWlsn@aol.com.

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