Insomnia is defined as difficulty getting to sleep, staying asleep or waking up too early with inability to get back to sleep resulting in poor quality, non-refreshing sleep with day-time fatigue. While insomnia can have many causes (including substance abuse, medication side effects, environmental noise, shiftwork, obstructive apnea, and chronic pain), many cases of insomnia are the result of depression, PTSD related nightmares, worry, obsessive thinking, and feeling overwhelmed by stressors. People whose insomnia is driven by psychological issues often resort to supplements such as melatonin; benzodiazepines such as Ambien, Xanax, Lunesta, and Ativan; antidepressants like Trazodone, Mirtzapine, and Elavil; and atypical antipsychotics like Seroquel. All of these medications have restrictions, potential adverse interactions with other drugs; and a litany of potentially unpleasant and harmful side effects. Sleep medicine physicians typically go for a natural, non-drug approach to treating insomnia called CBT-i (CBT for insomnia). If you are experiencing persistent insomnia (especially for several months, which is a criterion for insomnia disorder in the DSM-5) it is a very good idea to see a sleep medicine physician.
The following are tips for helping yourself when you experience persistent insomnia, but they are no substitute for meeting with a sleep medicine physician. Avoid the following things for as long as reasonably possible before trying to go to bed – coffee, energy drinks, distressing media, and electronics that give off blue light like cell phones, tablets, laptops, and TV. Blue light suppresses the release of melatonin. Do not fall prey to performance anxiety regarding sleep, which means do not tell yourself that unless you fall asleep by a certain time and sleep for a preset number of hours you will fail at what you plan to do the next day. Sleep performance anxiety is worsened by clock watching, so put your clock away and set your alarm out of view so you will not be late for work. A cousin of sleep performance anxiety is catastrophizing which means vastly inflating the probability that fatigue-driven failure to perform well the next day will cause terrible consequences like losing your job or crashing your car. Sleep is a natural process that cannot be forced, and few things block good sleep more than sleep performance anxiety and catastrophizing. Learn to take the pressure off yourself. For example, think about all the times you were tired the next day from imperfect sleep but did not lose your job or crash your car.
A natural way to get tired enough to boost your urge to sleep is called sleep restriction. This refers to staying up later than your body is telling you to so that the quantity of adenosine in your brain has time to build up. Ways to delay sleep include gentle stretching/yoga, gentle breathing in and out through your nose or reading something non-stimulating like a magazine. Going to sleep extra early based on the thought that this will ensure alertness at work the next day is sure to backfire. For people who have been traumatized and who have recurrent nightmares, whether or not they meet the full criteria for PTSD, an excellent therapy is called imagery rehearsal therapy which can be done with a psychotherapist or sleep medicine doctor. This involves a series of sessions in which you gain control over your nightmares by rewriting them and practicing the improved ending during the day so you are ready to handle an emergent nightmare during sleep.
