The To-Do List: A Sleep-Friendly Bedtime Activity?

If you’ve got insomnia, you’ve probably heard of “worry lists.” Sleep doctors for years have been urging insomniacs to write our worries down before going to bed, claiming this will alleviate anxiety and sleep will come more easily.

Really? Write about looming deadlines and all the upcoming functions I have to prepare for before I go to bed? That’s sure to send my anxiety through the roof! (not to mention keeping me up for hours).

But the idea may not be as counterproductive as it sounds.

Insomnia because you're worried about tomorrow? Make a to-do-list in the eveningIf you’ve got insomnia, you’ve probably heard of “worry lists.” Sleep doctors for years have been urging insomniacs to write our worries down before going to bed, claiming this will relieve anxiety and sleep will come more easily.

Really? Write about looming deadlines and all the upcoming functions I have to prepare for before I go to bed? That’s sure to send my anxiety through the roof! (not to mention keeping me up for hours).

But the idea may not be as counterproductive as it sounds, a new study suggests.

Nighttime Challenges for Insomniacs

No one likes arguments or bad days at work, but experiences like these can be doubly disruptive for people with insomnia. At night these upsetting events cycle over and over in your head, making it hard—sometimes impossible—to sleep.

Likewise, it can be hard to sleep when you’re looking at challenges ahead. Tests to study for, deadlines to meet, presentations to deliver, events to organize, flights to catch—any unfinished business, especially lots of it, can keep you wakeful long into the night.

Could making a to-do list before going to bed relieve anxiety about tasks ahead and enable sleep to come more quickly? The jury is still out concerning insomnia sufferers per se. But a new study of healthy, normal sleepers conducted at Baylor University and Emory University Medical School suggests it might be helpful.

Polysomnography and a Pencil-and-Paper Task

This study—the first part of a larger study—was simple in design. Participants were recruited on campus and screened for various disorders, including sleep disorders. Sixty participants aged 18–30 were chosen (three were later disqualified). They were randomly divided into two groups.

The evening of the study, participants in both groups went to a sleep lab, where technicians prepared them to undergo an overnight sleep study, wiring them up for polysomnography.

After that, participants in one group were given a sheet of paper and told to spend the next five minutes writing down everything they had to do the next day and in the next few days. Participants in the other group were given a sheet of paper and told to spend five minutes writing down everything they’d accomplished that day and in the past few days.

The sheets were then collected. Lights went out at 10:30 p.m., and participants’ cerebral activity was monitored through the night.

To-Do List More Helpful Than List of Accomplishments

The results were all significant:

  • Participants who made a to-do list at bedtime fell asleep faster than those who wrote about completed tasks. (On average, the to-do list makers fell asleep in about 16 minutes while the others who listed accomplishments fell asleep in about 25 minutes.)
  • Among participants who made the to-do list, the greater the number of items on their list, the faster they fell asleep.

So making a detailed to-do list might actually be a good activity to add to your wind-down routine at night.

Results in Perspective

Other studies suggest these findings aren’t as unusual as they may seem. Researchers studying adults in highly stressful situations, such as having a son or daughter diagnosed with cancer, found that the more specifically parents could map out concrete steps they were going to take to contend with the child’s problem, the less stressed out they felt. Another study showed that first-time pregnant women who could simulate in detail how their labor would go were less worried than women that were less successful in simulating labor.

But back to doctors’ advice about worry lists: It seems to me there’s a difference between a worry list and a to-do list. The one sounds problem focused while the other is focused on solutions—which may make a difference in their effects.

At any rate, if you have insomnia and at night your mind is constantly drifting toward tomorrow and all the things you have to do, try writing down the steps you’re going to take to make things happen before you get in bed. It might relieve your anxiety and slow your busy brain just enough to hasten sleep.

Sleep (Re)Training for Insomnia

What does falling asleep feel like? Good sleepers may never bother with the question. One minute they’re conscious and the next minute they’re out. But if you have chronic insomnia, falling asleep (or back to sleep) can feel like a tiresome slog.

Insomnia sufferers may actually lose touch with the feeling of falling asleep. So Sleep Technologist Michael Schwartz created a smartphone app to put people back in touch and increase their confidence and ease in falling asleep.

Insomnia sufferers relearn the feeling of falling asleepWhat does falling asleep feel like? Good sleepers may never bother with the question. One minute they’re conscious and the next minute they’re out. But if you have chronic insomnia, falling asleep (or back to sleep) can feel like a tiresome slog.

Insomnia sufferers may actually lose touch with the feeling of falling asleep, some have claimed. So Sleep Technologist Michael Schwartz created a smartphone app to put people back in touch and increase their confidence and ease in falling asleep.

Racing Thoughts and Brain Activity at Night

An independent study has found the smartphone app, called Sleep On Cue, to be accurate at detecting the start, or onset, of sleep. But let’s step back, for a moment, and imagine a typical insomniac night.

It’s after midnight and you’re obsessing about your deadlines tomorrow. Or you’re thinking about how to fight your way out from under all your student loans. The next thing you know the clock on your bedside table says it’s 2 a.m. In desperation, you stare at the clock face, willing time to stop. By 3 a.m. you’re still awake and hopping mad about it!

Maybe you have spent the last 4 hours with your entire brain spinning along in problem-solving mode. Chances are, though, that if on such a night you were undergoing a sleep study, your brain waves would tell a somewhat different story. Beta waves, fast wave activity commonly observed in people who are are thinking and solving problems, might be mixed in with alpha waves (slower waves linked to more relaxed states) and even slower theta waves, heralding the start of Stage 1 sleep.

Detecting the Lighter Stages of Sleep

But would it feel like you were actually sleeping? Research has shown that people woken up in Stage 1 sleep are often unaware that they’ve been asleep. In this liminal state, people can drift back and forth between sleep and wakefulness for quite some time before descending further into more sustained sleep, which is called Stage 2.

Stage 2 sleep is characterized by a predominance of theta waves and by features called sleep spindles and K complexes. Awoken in Stage 2 sleep, people are somewhat more likely to be able to sense that they were asleep.

But people with insomnia may not be as apt to report they were sleeping. Investigators have speculated that with all the nighttime baggage accompanying chronic insomnia—anxiety about sleep loss, lack of confidence in sleep ability, negative beliefs about sleep, increased beta wave activity during sleep—some insomniacs may simply lose touch with the feeling of falling asleep.

A Sleep Training Smartphone App

When a call went out for an inexpensive way to detect the start of sleep at home, Schwartz developed Sleep On Cue. A recent study comparing it to polysomnography (the test used in overnight sleep studies) found that Sleep On Cue was accurate at predicting the onset of Stage 2 sleep.

Why is this important? For one thing, the app (which costs $4.99) may prove to be useful in helping to administer intensive sleep retraining—an insomnia treatment developed in Australia—inexpensively in people’s homes.

But for readers of this blog, the immediate value of this app may lie in its potential to train or retrain insomnia sufferers to recognize what falling asleep feels like. This could alleviate some of the worry and anxiety about sleep and insomnia and thus make it easier to fall asleep and fall back to sleep.

Here’s How the App Works

Sleep On Cue works best, Schwartz says, if you conduct your training sessions when the pressure to sleep is high: late in the afternoon or early in the evening after a poor night’s sleep.

  1. Lie down and relax in bed, holding your smartphone in one hand. The phone will periodically emit a soft tone. Every time you hear the tone, give the phone a slight shake.
  2. When the app no longer detects movement, it assumes you’re asleep. Then, the phone vibrates to wake you up.
  3. The screen then displays this message: “Do you think you fell asleep?” Press “yes” or “no.”
  4. Next, you’re instructed to leave the bed for a few minutes. The phone will then vibrate to let you know when to return to bed for the next sleep trial. In this way, you begin to relearn what falling asleep feels like and gain confidence in your ability to do it.
  5. You decide when to end each training session. The screen then displays a graph with feedback about your sleep ability and your awareness of your sleep.

Here’s a link to the Sleep On Cue website. At $4.99, it’s not much of an investment and the payoff could be great.

If you’ve tried Sleep On Cue, did it improve your sleep and, if so, how?

Insomnia or Sleep Apnea, or Both?

Let’s say that after years of experiencing insomnia you go in for a sleep study only to find out you have obstructive sleep apnea. Who knew? You’re outfitted with a breathing mask, you wear it as prescribed, and your sleep improves . . . somewhat.

But your insomnia symptoms are persistent, and you don’t have the kind of stamina you’d like during the day. What then?

Insomnia may persist even after successful sleep apnea treatmentLet’s say that after years of experiencing insomnia you go in for a sleep study only to find out you have obstructive sleep apnea. Who knew? You’re outfitted with a breathing mask, you wear it as prescribed, and your sleep improves . . . somewhat.

But your insomnia symptoms are persistent, and you don’t have the kind of stamina you’d like during the day. What then?

Insomnia and Sleep Apnea

Insomnia and obstructive sleep apnea (complete or partial reduction of breathing during sleep) are the two most common sleep disorders. Many people have one or the other, and some people have both. According to a new paper published in Sleep Medicine Reviews, 39% to 58% of people diagnosed with sleep apnea also report symptoms of insomnia.

The name for this problem is comorbid insomnia and sleep apnea, or COMISA. Having one of these disorders is bad enough: apnea often results in broken sleep and daytime sleepiness. Insomnia, beyond its negative impact on sleep, can sap your energy and dampen your mood. But the effects of COMISA on sleep quality and daytime functioning are worse.

Two acquaintances of mine—Matt and James—were initially diagnosed with sleep apnea. Their experiences were similar to the one described above: a sleep study, an unexpected diagnosis of sleep apnea, and nightly use of a CPAP machine (the machine with the pressurized breathing mask). But despite receiving treatment for sleep apnea, their trouble falling asleep and lack of daytime stamina persisted. Neither one was satisfied that his sleep problem had been fully addressed.

A Complicated Affair

The relationship between sleep apnea and insomnia is not simple, according to a summary of research presented at the 23rd Congress of the European Sleep Research Society last fall. Some studies suggest that insomnia should be thought of as secondary to sleep apnea. Frequent awakenings in the middle of the night (also called middle insomnia) are often prompted by interruptions in breathing. In such cases treatment for the apnea—with an appropriate CPAP device—can correct both the breathing problem and the nighttime awakenings, resulting in continuous breathing and consolidated sleep. Voilà, the two problems are solved.

In other instances, co-occurring insomnia and sleep apnea appear to be distinct disorders requiring separate interventions to turn the situation around.

A Study Involving Insomnia Subtypes

Erla Bjornsdottir and colleagues conducted a 2-year prospective study in which they followed over 700 sleep apnea patients undergoing CPAP treatment to assess how their insomnia symptoms changed over time. Changes in participants’ insomnia symptoms varied according to the subtype of insomnia they had:

  • In participants with middle insomnia, CPAP treatment significantly decreased their middle-of-the-night awakenings. This is further evidence that in people with COMISA, symptoms of middle insomnia are probably a consequence of sleep disordered breathing. Treatment with CPAP alone may alleviate both problems.
  • In participants with initial insomnia (trouble getting to sleep at the beginning of the night), CPAP treatment did nothing to relieve their insomnia symptoms. This suggests that disordered breathing is not the cause of the initial insomnia, and that people who have it should also be treated for insomnia (with cognitive behavioral therapy for insomnia—CBT-I—for instance).
  • In participants with late insomnia (early morning awakenings), CPAP treatment did not lessen their early awakenings. This suggests that late insomnia in people with COMISA is not due to disordered breathing and should be addressed separately.

Now back to Matt and James: Matt, while using his CPAP machine, went through CBT-I hoping to overcome his residual insomnia. Overall he was satisfied with the result. Read more about his story in chapter 8 of The Savvy Insomniac: A Personal Journey through Science to Better Sleep.

As for James, the last I knew of him, he was sliding a bit in his use of the CPAP. But he was talking about returning to a sleep specialist to get more help. I hope he made that appointment.

If you have a CPAP machine, how has your sleep and quality of life changed since you started using it?

Insomnia: How Do You Score?

You may know you’ve got insomnia. But could you prove it?

Researchers use pencil-and-paper tests to assess different aspects of sleep: sleep quality, insomnia severity, sleep reactivity, and sleep-related beliefs. If you’re unfamiliar with these questionnaires, you may find it interesting to look at them and see how you score.

How do you score on tests given to people with insomniaYou may know you’ve got insomnia. But could you prove it?

There is no lab test for insomnia that would back you up.

An overnight sleep study, then?

Maybe—but probably not. Sleep studies don’t discriminate very well between insomniacs and good sleepers.

Genetic factors?

There may be genetic markers associated with insomnia, but researchers have no definitive understanding of what they are or how they add up to insomnia. The diagnosis of insomnia disorder is still made subjectively, based on questions and answers about sleep.

The list of questions doctors often ask to make the determination is fairly short and sweet.  But researchers use pencil-and-paper tests to assess different aspects of sleep: sleep quality, insomnia severity, sleep reactivity, and sleep-related beliefs. If you’re unfamiliar with these questionnaires, you may find it interesting to look at them and see how you score.

At the Doctor’s Office

If you take your complaints about sleep to the doctor, he or she may attempt to rule out other disorders before asking questions related to insomnia. You’ll get a diagnosis of insomnia disorder if

  • you have trouble falling or staying asleep, or sleep that doesn’t feel restorative, at least 3 times a week,
  • your sleep problem has persisted for at least 3 months, and
  • you experience impairment(s) during the daytime: moodiness, for example, or trouble concentrating or a lack of stamina that interferes with social, occupational, and other types of functioning.

Researchers, however, use pencil-and-paper assessment tools to evaluate subjects’ sleep and sleep improvements. Following are some of these questionnaires, downloadable as PDF files.

Pittsburgh Sleep Quality Index (PSQI)

In 1989 University of Pittsburgh sleep scientists introduced the PSQI in an attempt to quantify an aspect of sleep acknowledged to be important but difficult to measure.

The scoring of the PSQI questionnaire—with 19 self-rated questions—is a bit involved, but explicit scoring instructions are given at the end of the test. (Five more questions are to be answered by your bed partner or roommate if you have one. But these questions are not scored.) The 19 self-rated questions are divided into 7 “component” scores. The component scores are then added together to get the global score, which can range from 0 to 21. A global score of over 5 is indicative of poor sleep quality.

Sample question: During the past month, how often have you had trouble sleeping because you wake up in the middle of the night or early morning?

Insomnia Severity Index (ISI)

Some people experience insomnia occasionally while others experience it practically every night. The severity of a person’s insomnia may predict how likely he or she is to respond to various treatments. So it’s seen as a key variable to take into account when diagnosing insomnia and recommending a treatment, and when assessing improvements in study participants’ sleep.

Scores on this 7-item ISI questionnaire range from 0 to 28. Trouble sleeping is considered to be severe enough to warrant a diagnosis of insomnia disorder if scores are 8 or higher.

Sample question: How worried/distressed are you about your current sleep problem?

Ford Insomnia Response to Stress Test (FIRST)

The FIRST is the newest of the tests, introduced in 2004. This questionnaire is said to measure people’s overall level of “sleep reactivity,” a trait hypothesized to increase the likelihood of a person’s sleep being disturbed during stressful situations. The claim is that people who score higher on the FIRST are more likely to develop persistent insomnia.

FIRST scores range from 9 to 36. Scores of 20 and above indicate that stressful situations experienced prior to sleep—or the anticipation of stressful situations ahead—may routinely knock your sleep off track and make you vulnerable to chronic insomnia. Access this questionnaire by looking at Table 1 on the third page of this article about stress-related sleep disturbance.

Sample questions: How likely is it for you to have difficulty sleeping (a) after an argument? (b) before having to speak in public?

Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS)

If you don’t sleep well, you may find yourself having negative thoughts about sleep. Over time, these thoughts may coalesce into ideas, attitudes, and beliefs about sleep that give rise physiological arousal, making it harder TO sleep. In turn, the sensations of increased warmth, muscle tension, and faster heart rate that accompany arousal reinforce the negative thoughts, giving rise to a vicious circle.

The 16-item DBAS identifies misconceptions about sleep and assesses how big a role these and other cognitive factors likely play in perpetuating a person’s insomnia. A high score suggests that dysfunctional beliefs and attitudes may be a significant component of your insomnia, amenable to treatment with cognitive therapies.

Sample item: When I sleep poorly on one night, I know it will disturb my sleep schedule for the whole week.

If you’re curious enough to take any of these tests and end up learning something about your sleep, please take a moment to share it by leaving a comment. Thanks!

Paradoxical Insomnia: What It Is & How It’s Treated

Do you normally get just an hour or two of sleep? Are there nights when you don’t sleep at all?

You may have paradoxical insomnia. Despite its prevalence, the whys and wherefores remain largely unknown. But researchers have made a little headway in recent years, and here’s what they say now.

people with paradoxical insomnia report 1-2 hours of sleep but a sleep study isn't in agreementDo you normally get just an hour or two of sleep? Are there nights when you don’t sleep at all?

You may have paradoxical insomnia. An overnight sleep study would confirm the diagnosis. Despite your perception of getting very little sleep, your electroencephalogram (EEG)—the graphic record of your brain waves produced during an overnight sleep study—would indicate that you were actually sleeping a 6.5- to 8-hour night.

This sleep disorder seems to be fairly common. About 9 to 40 percent of the people diagnosed with insomnia are estimated to have it. Despite its prevalence, the whys and wherefores remain largely unknown. But researchers have made a little headway in recent years, and here’s what they say now.

Is There Really Anything Wrong?

Formerly called pseudoinsomnia and more recently sleep state misperception, the sleep of people with paradoxical insomnia looks similar to normal sleep in a conventional sleep study. In fact, the EEG of a person with paradoxical insomnia can look identical to the EEG of a normal sleeper. Doctors used to tell their patients that nothing was wrong.

But people with paradoxical insomnia do have grounds for complaint, and scientists are now a little closer to understanding why. In a 1997 study, Michael Bonnet and Donna Arand reported that compared with normal sleepers, people with paradoxical insomnia (1) were more confused, tense, depressed, and angry, and (2) had a significantly increased 24-hour metabolic rate. This is suggestive of hyperarousal, a characteristic of people with insomnia.

Subjective vs. Objective Insomnia

Paradoxical insomnia, also called subjective insomnia, differs from objective insomnia—the type that’s more familiar. Compared with paradoxical insomniacs, objective insomniacs

  • sleep significantly fewer hours, as recorded on the EEG
  • tend to be less inaccurate at estimating total sleep time
  • may have psychological and physiological symptoms that are more severe.

In a 2002 study, Andrew Krystal and colleagues presented an in-depth analysis of brain wave patterns that shed light on more differences. Compared with objective insomniacs, paradoxical insomniacs

  • had less delta wave activity during sleep (delta waves are the predominant waveform in deep sleep, the restorative stuff). The lower the delta activity, the greater the discrepancy between the total sleep time recorded on the EEG and the sleep time estimated by the patient.
  • experienced more alpha, beta, and sigma wave activity during sleep—brain waves commonly associated with arousal, perception, and thinking. This suggests that people with paradoxical insomnia are prone to perceiving and possibly even processing information when they sleep.

Overall, then, the sleep of people with paradoxical insomnia tends to be light and characterized by hypervigilance. Scientists are not sure if this sleep disorder is simply a way station en route to objective insomnia or a completely different kettle of fish.

Treatment of Paradoxical Insomnia

There is no standard treatment for people with paradoxical insomnia. Drug-free behavioral therapies such as sleep restriction and stimulus control may not help.

If physiological hyperarousal is the main problem for insomniacs in this group, one way to address it would be through physical training. Daily aerobic exercise—and possibly the daily practice of yoga, tai chi, or qi gong—would cut down on arousal and likely promote sounder sleep.

On the other hand, a team of Italian researchers thinks the problem is mainly perceptual. These patients “may have a sort of agnosia [a partial or total inability to recognize something by use of the senses] of their sleep,” they conclude.

Investigators at The University of Alabama treated four paradoxical insomnia patients with a kind of “sleep education.” After behavioral therapies failed to help, a specialist talked to each patient about sleep and sleep staging. Together, they looked at the patient’s EEG, watched a video of the patient sleeping, and noted differences between the recording of sleep and patient perceptions. After receiving the information, 2 of the 4 patients reported falling asleep much more quickly and sleeping a lot longer.

Ralph Downey, a sleep specialist at Loma Linda Sleep Center, conducts therapy sessions for people with paradoxical insomnia in a sleep lab. Each time a patient falls asleep, she’s awakened and asked whether she thinks she’s asleep or awake. After repeated awakenings, the patient develops the ability to recognize the bodily cues that accompany sleep. Her perception of sleep becomes much closer to that recorded on her EEG.

Michael Schwartz, whose SleepQ app I reviewed last fall, believes that the same thing can be accomplished with a smart phone and an app costing just $4.99.

If you found this information helpful and/or interesting, please like and share on social media sites. Thank you!

 

Q & A: When Sleep Apnea Looks Like Insomnia

Keisha was wondering whether to have a sleep study.

“I asked my doctor to give me something for my insomnia,” she wrote, “but he wants me to have a sleep study first. He thinks I might have sleep apnea. I don’t think I do. I don’t snore (as far as I know). I wake up a lot at night but I’m not short of breath or gasping for air.

“Besides, how could I get any sleep at all with those wires attached to my head! You say sleep studies aren’t helpful for people with insomnia. So what’s your opinion here? Should I have a sleep study or will it just be a waste of my time?”

insomnia and daytime sleepiness may actually be sleep apneaKeisha, a 37-year-old graphic designer, wrote to Ask The Savvy Insomniac recently with a question about having a sleep study.

I asked my doctor to give me something for my insomnia, she wrote, but he wants me to have a sleep study first. He thinks I might have sleep apnea. I don’t think I do. I don’t snore (as far as I know). I wake up a lot at night but I’m not short of breath or gasping for air.

Besides, how could I get any sleep at all with those wires attached to my head! You say sleep studies aren’t helpful for people with insomnia. So what’s your opinion here? Should I have a sleep study or will it just be a waste of my time?

When Is a Sleep Study Useful?

Keisha is right: I’ve blogged about sleep studies before because I’m skeptical about their value for people with simple insomnia. As conducted and scored today, they do very little to help insomniacs other than rule sleep apnea and other sleep disorders out.

But if a doctor suspects you have sleep apnea, it’s important to verify that objectively. A sleep study is then in order, at a sleep clinic or with one of the newer devices for use at home.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a serious problem. During sleep, the tongue falls back against the throat, collapsing the upper airway. This keeps you from breathing, deprives you of oxygen, and increases your level of carbon dioxide until you wake up enough to start breathing again.

OSA compromises the sleep you get, leaving you sleepy and prone to mistakes and accidents. It also leads to serious health problems. Repeated episodes of apnea stress the heart, increasing your susceptibility to hypertension, heart attacks, and other cardiovascular diseases. It’s also associated with weight gain, type 2 diabetes, inflammation, asthma, and acid reflux.

In short, it’s nothing to fool around with.

Often Looks Like Insomnia

But here’s the problem: In most cases, people with OSA are not aware of these repeated awakenings because they occur beneath the level of consciousness. Convincing support for this assertion came in a review of medical records published in the December 2014 issue of Mayo Clinic Proceedings. Take a look at some numbers here:

  • Of 1210 insomnia patients presenting at a sleep clinic in Albuquerque, New Mexico over a period of 8 years, about three-quarters (899) were using sleep aids regularly or occasionally. The majority of these—710—were using prescription sleeping pills. The rest were using over-the-counter sleep aids.
  • None of the 899 medication users reported improved sleep. So they, as well as the others, whose sleep had failed to improve following drug-free insomnia treatments, were seeking further assistance.
  • All of the patients were verbally screened for OSA. Then 942 underwent sleep studies.
  • About 91 percent tested positive for moderate to severe OSA. Yet a screening tool used by many primary care physicians to ascertain the likelihood of sleep-disordered breathing failed to detect it in 32 percent.
  • What’s more, the patients taking prescription sleeping pills were least likely to report symptoms of apnea and the most likely to report severe insomnia and other health problems.

In other words, it’s easy to mistake OSA for insomnia, and primary care physicians may do the same. You’re then treated for insomnia when you should be treated for apnea, compromising your quality of life and increasing your vulnerability to heart and other serious health problems down the line.

The Take-Away

Occasionally I hear from people like Keisha who doubt that a sleep study could tell them anything they don’t already know. There’s a chance they could be right. On the other hand, this is one instance when what you don’t know could end up hurting you a lot. And now, with much less expensive home testing devices available, there’s less reason for concern about cost.

If your insomnia takes the form of waking up several times at night and if, after being interviewed by your doctor, he or she suspects you might have OSA, bite the bullet and have the test. Insomnia is no picnic, but untreated apnea is worse.

Sleep Studies: Do You Really Need One?

If you haven’t had a sleep study, you may wonder if spending the night at a sleep clinic might help the doctor understand your problem and how to fix it. Polysomnography, or PSG, is the test conducted at the clinic. New guidelines from the American Board of Internal Medicine (ABIM) clarify when PSG is useful in cases of chronic insomnia and when it isn’t. Here’s a summary and explanation of the guidelines.

Sleep studies are useful when insomnia is complicated by another disorderWhen I ask people with persistent insomnia if they’ve had a sleep study, the common responses I get are these:

  • “I had one and all I learned from it was that I don’t have sleep apnea.”
  • “I want one, but my doctor won’t write the prescription.”

If you haven’t had a sleep study, you may wonder if spending the night at a sleep clinic might help the doctor understand your problem and how to fix it. Polysomnography, or PSG, is the test conducted at the clinic. New guidelines from the American Board of Internal Medicine (ABIM) clarify when PSG is useful in cases of chronic insomnia and when it isn’t. Here’s a summary and explanation of the guidelines.

When a Sleep Study Is in Order

PSG is good at detecting sleep apnea, sleep-related movement disorders, and violent or harmful behavior that might be occurring at night. If a doctor suspects that your insomnia is associated with any of these disorders, you’ll likely be going in for a sleep study.

Occasionally a person with insomnia reports such an unusual assortment of symptoms that, even after taking an extensive patient history, the doctor can’t figure out what’s going on. Here, too, PSG may help. The doctor may also prescribe a sleep study if you’ve undergone treatment for insomnia (with or without drugs) but your sleep has failed to improve.

When Sleep Studies Won’t Help

But neither the ABIM nor the American Academy of Sleep Medicine recommends sleep studies for other insomnia patients. Here are some of the reasons.

1.  PSG cannot do much except confirm the symptoms you report to the doctor during a clinical interview.

  • Let’s say you wake up several times at night and have trouble falling back to sleep. PSG may confirm that you experience these wake-ups but will not shed light on why.
  • Or maybe your problem is that it usually takes you a long time to fall asleep. Upwards of $2,000 is a lot to spend on a procedure that merely corroborates what you already know.

2.  PSG does a poor job of discriminating between normal sleepers and people with insomnia. In fact, up to 50 percent of the time, the brain activity of insomniacs looks identical to that of normal sleepers.

3.  In some insomniacs, there is abnormal brain activity occurring at night—activity typically associated with being awake. But standard PSG will not show evidence of this wake-like activity. As a measure of what’s going on in the brain at night, PSG is not finely tuned.

4.  Finally and importantly, in most cases of persistent insomnia, PSG will not suggest a course of treatment that differs from treatment that would be prescribed based on a thorough clinical interview.

  • If your complaint is that you’re a light sleeper and wake up frequently at night, the doctor will probably prescribe cognitive-behavioral therapy for insomnia (CBT-I) or some other behavioral treatment before considering medication. PSG might corroborate your symptoms but would not alter the diagnosis or the treatment.
  • Or let’s say your main complaint is that your thoughts keep you too wound up at night to fall asleep easily. The doctor isn’t going to need for you to undergo a sleep study in order to diagnose and treat the problem.

The Bottom Line

Sleep studies are an indispensable tool for people suspected of having sleep apnea and many other sleep disorders. But as conducted now, they’re of no help to insomnia sufferers unless your insomnia is related to another health problem.

If you’ve had a sleep study, what did you learn from it?

 

How Much Sleep Is Enough?

Getting 8 hours’ sleep a night is as healthful as eating 9 servings of fruit and vegetables and getting daily exercise—or so we’re told. In truth there’s no way to determine how much sleep any one of us really needs.

But the 8-hour recommendation is based on something, which is why we hear it so much. For those concerned about getting too little sleep, here are 3 ways to find out how much you’re actually getting.

Regarding sleep need, sleep quality may matter more than sleep durationGetting 8 hours’ sleep a night is as healthful as eating 9 servings of fruit and vegetables and getting daily exercise—or so we’re told. In truth there’s no way to determine how much sleep any one of us really needs.

But the 8-hour recommendation is based on something, which is why we hear it so much. Recent studies show “a strong association between nightly sleep duration and mortality risk,” Michael Grandner and colleagues say in a paper on sleep duration and health. Overall, people who report sleeping 7-8 hours a night live longer than people who report sleeping 9-10 hours and those who report sleeping 6 hours or less.

The same is true of the relationship between sleep duration and cardiovascular disease (and related conditions such as hypertension and diabetes). Short and long sleepers tend to be more vulnerable to these ailments than people who sleep 7-8 hours a night. Of interest to those of us with insomnia, short sleepers (who sleep 6 hours a night or less) with poor quality sleep have a much higher risk of developing cardiovascular disease.

Counting the Hours

If you’re concerned you’re not sleeping enough, consider the possibility that you may be sleeping more than you think. About 5 percent of insomniacs have “paradoxical insomnia.” Usually pretty energetic during the day, they feel like they sleep just a few hours a night. Yet polysomnography (PSG)—the test performed in a sleep lab—shows 7 or 8 hours of sleep-like activity going on in most of the brain. (I’ll explain this phenomenon in another blog.)

Many of us perceive the lightest sleep stage as waking. Up to 50 percent of the time, the brainwave patterns of insomniacs who undergo sleep studies look exactly the same as those of normal sleepers. So our perception of sleep does not always jibe with sleep as measured by PSG. And the while PSG cannot assess sleep quality, its assessment of sleep duration is important. People whose polysomnograms show they get considerably less than 7-8 hours’ sleep a night are the ones most vulnerable to cardiovascular disease and early death.

Objective Sleep Measures

Here are 3 ways to find out how much you sleep.

  • A sleep study. There are lots of downsides to going this route. It requires a doctor’s prescription, costs a lot, and is just a one-shot deal. Insomniacs’ sleep tends to vary a lot from night to night, and a sleep study is not going to provide information about your sleep duration over time, which is really what you want.
  • Actigraphy. This involves wearing a wristwatch-type device to bed for several nights. The actigraph assesses your sleep-wake patterns based on bodily movement. It’s fairly reliable most of the time. It also requires a doctor’s prescription.
  • Sleep-monitoring devices available without prescription. I’ve written about the Beddit, and a Google search will acquaint you with several others. These devices are relatively inexpensive, but none of them have been tested on insomniacs. They may not be sensitive enough to assess the nuances of insomniac sleep. (Coincidentally, just a few days after this blog post went out, Dr. Christopher Winter, who tested several sleep tracking devices on himself, posted a review of his findings in Huffington Post. It’s definitely worth reading if you’re considering buying one for yourself.)

Me personally? I know I’m a short sleeper but I’m not so concerned with racking up the hours. Health and longevity depend on several factors. Regarding sleep, I’m convinced that quality, and not quantity, matters more.

If you’ve undergone a sleep study or tried monitoring your sleep in some other way, what did you find out? Were you sleeping more—or less—than you thought?