Stay Healthy Over the Holidays Despite Insomnia

When my family gathers for a few days over the holidays, usually someone brings along a sore throat or a cough. Try though that unlucky person may to keep the germs from spreading, they almost inevitably do.

I catch colds fairly easily, and I’ve often wondered if insomnia has a part in that. A new study suggests that chronic insomnia does—at a minimum—increase our susceptibility to influenza. Here’s more about the study and precautions poor sleepers can take to stay healthy over the holidays.

Insomnia compromises immunityWhen my family gathers for a few days over the holidays, usually someone brings along a sore throat or a cough. Try though that unlucky person may to keep the germs from spreading, they almost inevitably do.

I catch colds fairly easily, and I’ve often wondered if insomnia has a part in that. A new study suggests that chronic insomnia does—at a minimum—increase our susceptibility to influenza. Here’s more about the study and precautions poor sleepers can take to stay healthy over the holidays.

Sleep and the Immune System

A robust immune system confers protection from colds and flu. In order to stay robust, the immune system needs ongoing attention, and it’s during sleep when the body’s metabolic resources are freed up to do this maintenance work. During sleep antibodies are created to fight invading viruses. Short sleepers develop fewer antibodies, past research has shown, and this puts them at higher risk for developing infections.

Insomnia Compromises Immunity

Chronic insomnia—trouble sleeping and daytime impairment—may also compromise the immune system, according to new research published in Behavioral Sleep Medicine. Participants in this study were 133 healthy college students, half meeting diagnostic criteria for insomnia and the other half experiencing no insomnia.

Via blood draws, the students’ influenza antibody levels were assessed twice: once before, and once 4 weeks after, they received flu shots (containing influenza vaccine). The expectation was that 4 weeks after receiving the flu shots, participants in the Insomnia group would have lower levels of influenza antibodies than participants in the No Insomnia group.

What the researchers found was telling. Both groups showed increases in antibody levels from pre- to postvaccine. But not only did the Insomnia group have lower antibody levels than the No Insomnia group 4 weeks after receiving the flu shots. The Insomnia group also had lower antibody levels to begin with.

Researchers can only speculate about why. But the result lends support to something I’ve thought (and sleep researchers have suspected) for a long while: chronic insomnia dysregulates the immune system, making insomniacs less able to fight off colds and flu.

Recipe for a Healthy Holiday Season

So if you’ve got persistent insomnia it’s wise to take extra precautions around the holidays. Here are suggestions for how to avoid colds and flu:

If you’re traveling: People with insomnia are said to sleep better away from home. Not me—I’m susceptible to sleep onset insomnia wherever I go. If you’re going away for the holidays, pack along all the accoutrements you need for a comfortable night’s sleep at home: ear plugs, eye mask, pillows, white noise machine, etc. I take a foam rubber futon for use in case the sleeping accommodations aren’t quite right.

Travel by plane: Airplanes are virus magnets. Pack along a couple face masks for use if nearby passengers are coughing or sneezing. Use antibacterial wipes on seatbelt buckles, tray tables, overhead air vents, and bathroom fixtures before touching them.

Avoid airborne viruses: Viruses are mostly spread through the air via coughing and sneezing and then inhaled. Steer clear of Uncle Dalbert if he has the bad manners to come down to Happy Hour hacking away. A hug for a sister who’s obviously contagious can wait for another day.

Hard surfaces that harbor viruses: Touching doorknobs, light switches, faucets and then absentmindedly touching your face is another way infection spreads. To lower your risk of infection, wash your hands with soap and water frequently (take along hand cream so your hands don’t dry out). Better yet, avoid use of your hands altogether. To open doors and turn on lights and faucets, use your arms instead. (It’s amazing what dexterous forearms and elbows I’ve developed since I set my mind to it.)

Pass on communal towels: Avoid sharing them—or give the sick one a towel of their own.

Passing dishes at the table: Leave the sick one out of the loop.

When you’re out and about: Carry a small bottle of hand sanitizer in your pocket or purse and use it often, especially after handling money, signing for credit card purchases, and pumping gas.

A final suggestion: I have a brother who swears that daily nasal irrigation (with dilute salt water or a commercial sinus rinse) keeps him from coming down with colds. I don’t have enough discipline to incorporate this habit into my daily ablutions. But I use a sinus rinse when I’m bothered by allergies or feel a sinus infection coming on, and it helps.

Got any tips for staying healthy during flu season? Please share them in a comment below!

Insomnia: Are Primary Care Doctors Still Getting It Wrong?

It’s not always easy to find help for insomnia. Several people I interviewed for “The Savvy Insomniac” reported that their primary care doctors didn’t seem to take the complaint seriously or prescribed treatments that didn’t work.

I thought the situation must have changed since persistent insomnia is now known to be associated with health problems down the line. But a recent report on the Veterans Affairs (VA) health system shows that insomnia is still overlooked and undertreated by many primary care providers.

Here’s what you may find—and what you deserve—when you talk to your doctor about sleep.

Insomnia is not always treatable by primary care providersIt’s not always easy to find help for insomnia. Several people I interviewed for “The Savvy Insomniac” reported that their primary care doctors didn’t seem to take the complaint seriously or prescribed treatments that didn’t work.

I thought the situation must have changed since persistent insomnia is now known to be associated with health problems down the line. But a recent report on the Veterans Affairs (VA) health system shows that insomnia is still overlooked and undertreated by many primary care providers.

Here’s what you may find—and what you deserve—when you talk to your doctor about sleep.

Insomnia Addressed in Primary Care

Investigators surveyed 51 primary care providers (PCPs) in the VA system as to their perceptions and treatment of insomnia. About 80% of the respondents said they felt insomnia was as important as other health problems. Yet they tended to underestimate its prevalence and often failed to document its presence.

Other research has shown that the prevalence of poor sleep quality among veterans is extremely high: over 70% in veterans without mental illness and even higher in veterans with a mental health diagnosis. Yet most PCPs surveyed estimated that only 20% to 39% of their patients experienced insomnia symptoms. When insomnia emerged as a problem, only 53% said they regularly entered it into their patients’ medical records.

Insomnia Conceived Of as Secondary Problem

Scientists now have plenty of evidence that insomnia is a disorder in its own right—regardless of whether it occurs alone or together with another disorder. Yet many PCPs seemed to view it as merely a symptom or a condition secondary to another disorder.

All of the PCPs endorsed the belief that when insomnia occurs together with a health problem such as depression and PTSD, successful treatment of the depression or PTSD will eradicate the trouble sleeping. Current scientific evidence does not support this belief.

Insomnia Treated With Sleep Hygiene

The first-line insomnia treatment recommended by the American Academy of Sleep Medicine and other professional organizations is cognitive behavioral therapy for insomnia (CBT-I). CBT-I is available at VA facilities.

Even so, the insomnia treatment PCPs most often recommended to their patients was counseling on good sleep hygiene. But sleep hygiene doesn’t work as a stand-alone treatment for insomnia. What’s more, it may make the prospect of CBT-I less palatable, given that some CBT guidelines call for behavioral changes that resemble the rules of good sleep hygiene.

Still Getting It Wrong

It seems like primary care doctors are just as outdated in their conception and treatment of insomnia as they were 10 and 20 years ago. I’m not alone in voicing this concern. Here’s how Michael Grandner and Subhajit Chakravorty titled their commentary on the survey results: “Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed.”

There’s no ambiguity here.

Help You Deserve From Your Doctor

Your PCP may be responsive to your complaint of insomnia and current in his or her knowledge of how to diagnose and treat the condition. If so, well and good.

But your doctor may not be quite so on the ball when it comes to dealing with trouble sleeping. Don’t let that deter you from seeking help for insomnia elsewhere. A good doctor will:

  1. Respond to concerns about insomnia as attentively as he or she would to concerns about double vision or shortness of breath. Insomnia can be debilitating, and chronic insomnia can result in changes that compromise health and quality of life. A doctor who dismisses it as trivial or hands you the rules for good sleep hygiene before waving you out the door is not the right doctor.
  2. Ask questions about the duration, frequency, and severity of your problem, and possible underlying conditions. This type of inquiry is crucial to arriving at an accurate diagnosis and appropriate treatment. Doctors who don’t have the time or knowledge to ask these questions should refer you to someone who does.
  3. Discuss treatment options that are research based and individualized. CBT-I may require referral to a specialist, yet there may be no specialist certified in behavioral sleep medicine practicing in the area. Likewise, a prescription for sleeping pills is useless to a patient who has no intention of filling it. Treatment discussions should be dialogs, and doctors should encourage patient participation.

This is the kind of response we deserve when we bring up the topic of insomnia with PCPs.

But it may not be the kind of response we get. How has your doctor reacted when you’ve mentioned trouble sleeping? (If you found this post helpful, please like and share on social media. Thanks!)

7 New Insomnia Genes: What’s in It for Us

A flurry of articles recently announced the discovery of seven new risk genes for insomnia. In an era when new genes are being identified for everything from infertility to schizophrenia, you might regard this discovery as simply the soup du jour.

Not me. Growing up when trouble sleeping was attributed to psychological factors, coffee, and alcohol, I was elated by this news. We stand to gain so much from knowing the genetic underpinnings of insomnia.

Causes of insomnia are closer to being figured outA flurry of articles recently announced the discovery of seven new risk genes for insomnia. In an era when new genes are being identified for everything from infertility to schizophrenia, you might regard this discovery as simply the soup du jour.

Not me. Growing up when trouble sleeping was attributed to psychological factors, coffee, and alcohol, I was elated by this news. We stand to gain so much from knowing the genetic underpinnings of insomnia.

A Biological Basis for Insomnia

The most immediate benefit of the discovery is that it affirms what scientists have suspected for years: there is a biological basis for insomnia. This is common knowledge among sleep researchers but not so well known among members of the public or even doctors. They may still blame insomnia on psychological factors and poor self-control and dismiss it as a complaint unworthy of attention or treatment.

“Insomnia is all too often dismissed as being ‘all in your head,’” said Eus Van Someren, a lead researcher on the project, quoted in a press release. “Our research brings a new perspective. Insomnia is also in the genes.”

Genes contain the information needed to make proteins, and proteins do most of the work in the cells in our bodies and brains. The identification of insomnia risk genes suggests that vulnerability to insomnia has a neurobiological basis. It is likely driven by an excess or deficit of key neurochemicals or abnormalities in the circuitry of the brain.

What the Discovery Doesn’t Mean

People sometimes confuse the idea of genetic risk with biological determinism—the belief that hereditary factors are the sole determinants of who we are and the health challenges we face. The assumption is that if constitutional factors predispose a certain disease or health condition, then nothing can be done to alter its course.

There are a small number of irreversible diseases caused by mutations in a single gene. If you’re born with a certain mutation in the HTT gene, for example, you inevitably develop Huntington disease. Nothing can be done to change this.

But most diseases and conditions—insomnia included—are complex. No single gene determines whether you get them or not. Multiple genetic factors likely come into play, increasing the odds of developing a disorder but not making it inevitable. Environmental, social, psychological, and behavioral factors may play as big a role in determining whether you develop insomnia or not.

It might be possible to inherit several insomnia risk genes but, thanks to a privileged set of circumstances, never experience trouble sleeping a day in your life. Likewise, despite being biologically predisposed to experience insomnia, you may be able to manage the disorder some or even most of the time with cognitive and behavioral techniques.

Benefits of Genetic Studies

Genetic studies such as this one will enable scientists to trace the pathways by which insomnia develops and identify the biological mechanisms involved. In turn, insomnia treatments can be developed that alter these particular systems, rather than being aimed at systems merely suspected of involvement. Drugs can be developed to target the root causes of insomnia rather than simply tranquilizing the brain.

Other Discoveries and Implications

  • The insomnia risk genes are known to be associated with disorders that often occur with insomnia: restless legs syndrome, anxiety disorders, depression, and type 2 diabetes. Likewise, insomnia was found to have a shared genetic background with neuroticism and poor sense of well-being, traits that often occur in people with insomnia.
  • Some genetic variants associated with insomnia in women were different from the variants associated with insomnia in men, so the biological mechanisms driving insomnia may in some cases be different. If this is true, insomnia treatments prescribed for women may in some cases need to be different from those prescribed for men.

Every new genetic study brings us closer to the time when trouble sleeping will be treated based on the cause of the insomnia rather than its symptoms. Surely that’s something to celebrate!

15 Tips for Better Sleep in the Summer

I love warm weather and long summer days. Birds singing, trees leafed out, garden thriving. Me, outside in shorts and a tee-shirt, able to appreciate the natural beauty till almost 10 p.m. What’s not to like?

Insomnia, in a word. On long, hot days I’m just not sleepy at my usual bedtime. I’m up later and later till—oops—I’m in the insomnia trap again.

You’d think I’d know by now: heat and light may boost my spirits but, in too big a dose, they’re a bane to sleep. So now it’s time to knuckle down and observe the rules for better sleep in the summer. Here they are:

Manage insomnia in the summer by cooling off & darkening the house
Here I am planting coleus in the iris bed.

I love warm weather and long summer days. Birds singing, trees leafed out, garden thriving. Me, outside in shorts and a tee-shirt, able to appreciate the natural beauty till almost 10 p.m. What’s not to like?

Insomnia, in a word. On long, hot days I’m just not sleepy at my usual bedtime. I’m up later and later till—oops—I’m in the insomnia trap again.

You’d think I’d know by now: heat and light may boost my spirits but, in too big a dose, they’re a bane to sleep. So now it’s time to knuckle down and observe the rules for better sleep in the summer. Here they are:

Reduce Exposure to Late Evening Light

I love the late evening light but it does not love me. One effect of light on sleep—especially light containing lots of blue light, such as sunlight and the light from devices with screens—is that it blocks release of the hormone melatonin. Melatonin secretion typically starts some two hours before bedtime. Exposure to daylight late in the evening may delay secretion, altering circadian rhythms and keeping us awake later than usual. If you’re light sensitive and looking for insomnia relief,

  1. Wear dark glasses if you’re out for an evening stroll.
  2. Don’t wait until the sun sets to darken your windows. Lower shades and close drapes by 8:30 p.m.
  3. Start your pre-sleep routine at the same time as usual—even if it’s still light outside.
  4. An hour or two before bedtime, get off computers, tablets and and smart phones. Blue-blocker glasses and apps that filter out blue wavelengths are supposed to make light less harmful at night. But I installed f.lux software on my computer and I still think looking at the screen after 9:30 or so has a negative effect on my sleep.

Reduce Exposure to Early Morning Light

Especially if you live at the eastern edge of a time zone, your problem may have to do with the early sunrise at this time of year. Sunlight may start streaming in the bedroom window and wake you up as early as 4:30 a.m. What a lousy start to a summer day! If early awakening is a problem and you’re after insomnia relief,

  1. Invest in a lightweight, light blocking eye mask.
  2. Install light blocking window treatments on bedroom windows and keep them drawn at night.
  3. Consider sleeping in a room with fewer windows around the time of the summer solstice.

Cool Your Bedroom Down in Advance

People with insomnia may have greater temperature sensitivity than good sleepers, or less ability to recognize what a comfortable ambient sleeping temperature is. Summer heat may be the cause of your trouble sleeping now—I know it’s a factor for me. If it feels too hot to sleep,

  1. Keep shades and drapes drawn during the daytime to block out heat from the sun.
  2. If you have air conditioning and want to save on energy during the daytime, turn the thermostat down a degree or two about a half hour before bedtime.
  3. In the absence of air conditioning, use a window fan. But don’t wait till bedtime to turn it on. Keep tabs on the temperature outside and, when it starts to drop, turn on the fan.
  4. If A/C and fans don’t do the trick, try sleeping on a lower level of the house.

Cool Yourself Down

People tend to fall asleep more easily when their core body temperature is falling, which normally it does at night. But research suggests that compared with good sleepers, people with insomnia may have more trouble downregulating internal temperature. If this is true, then especially in the summertime, it’s important to take measures to cool your body down before you go to bed. Research has shown that when done late in the afternoon or early in the evening,

  1. Exercise heats your body up, triggering an internal cooling mechanism that may later help you fall asleep.
  2. You can achieve the same delayed cooling effect by indulging in a warm shower, bath or sauna early in the evening.

But if at 11 p.m. you return to a hot house expecting to take a quick shower and hop into bed, it’s time for emergency measures:

  1. Turn on the A/C and/or fans full blast and take a cool shower.
  2. Place a cool, wet washcloth on your forehead when you finally turn in.

If you have trouble sleeping in the summer, what do you think is the cause of the problem?

9 Ways to Keep Worry From Sabotaging Sleep

These days people are worried about jobs, health care, the environment, the possibility of worldwide war. Uncertainty about the future, and fear of negative outcomes, may rob even reliable sleepers of sleep from time to time.

But for many insomnia sufferers, worry and anxiety about sleep itself—“It’s two o’clock and I haven’t slept a wink!”; “If I don’t get to sleep now I’ll get sick!”—is an equally powerful enemy of sleep.

Here’s more about worry and insomnia and how to keep them from spoiling the night.

Insomnia sufferers should incorporate a bath into their bedtime routineThese days people are worried about jobs, health care, the environment, the possibility of worldwide war. Uncertainty about the future, and fear of negative outcomes, may rob even reliable sleepers of sleep from time to time.

But for many insomnia sufferers, worry and anxiety about sleep itself—“It’s two o’clock and I haven’t slept a wink!”; “If I don’t get to sleep now I’ll get sick!”—is an equally powerful enemy of sleep.

Here’s more about worry and insomnia and how to keep them from spoiling the night.

Worrying Around the Clock

Worry and sleep don’t mix. Like anxiety, which is more intense, worry—or repetitive thinking about issues of concern—triggers the release of neurochemicals that prepare the body for action rather than for rest.

Some people are by nature inclined to worry day and night. Allison Harvey, in her cognitive model of insomnia (2002), hypothesized that round-the-clock worry about sleep led to arousal, resulting in the sleep problems experienced by insomniacs at night.

Worrying at Night

More recently, research has suggested that it’s worry in bed—rather than worry day and night, or trait-level worry—that is connected to trouble sleeping, and a new study published in Behavioral Sleep Medicine supports this conclusion. Researchers administered a series of questionnaires to 139 insomnia sufferers and had them complete sleep diaries every day for 10 days. Neither trait-level worry nor trait-level rumination (repetitive thinking about negative emotions) was shown to have a relationship with any aspect of sleep.

The researchers then conducted a similar study with another group of insomniacs. Sixty-four participants were asked to fill out two diaries: one at 6 a.m., to record the sleep-related worries experienced during the night, and the other at 7 p.m., to record sleep-related worry and stress experienced during the day.

The results? Nighttime sleep-related worry had a significant and negative effect on every aspect of sleep, including trouble falling asleep, being awake longer during the night, and sleeping less efficiently. In contrast, daytime sleep-related worry had a negative impact on sleep quality only.

“Cognitive activity during the day is relatively benign,” the study authors concluded, “but cognitive activity in bed plays an important role in development and persistence of sleep problems in insomnia.”

The Take-Away

Do your worrying during the daytime rather than at night!

Because that’s easier said than done, here are nine ways to check your worries—sleep-related or not—at the bedroom door.

  1. Write your worries down early in the evening. Preempt nighttime worrying by taking 10 or 15 minutes to write down the issues you’re worried about, whether or not they’re related to sleep. Beside each concern, write what action you’ve taken/you’re taking/you will take to deal with the problem. Some problems may be clearly outside your control (or feel that way), yet resolving to take some small action to manage the problem can afford relief.
  2. Share your worries with an empathic listener at dinner. Sharing your concerns with an empathic partner or friend over the evening meal can also help to preempt worry at night. And when it comes to figuring out how to deal with a problem, two heads are often better than one. Further, research suggests that regardless of who’s talking and who’s listening, interactions with friends and supportive family members help tone down stress.
  3. Create a pre-sleep routine. It’s important to end the day with a wind-down period (ideally, at least an hour) in the run-up to bedtime. Think of it as a time to indulge in self-care, incorporating activities that make you feel good—such as listening to slow jazz and bathing by candlelight. The aim is to create an end-of-day ritual that’s worry free. Doing the activities in the same sequence every night will establish a clear association between your wind-down routine and sleep.
  4. Train your attention on something outside yourself. Watch a movie or a sit-com. Read or listen to a novel with complex, interesting characters. Do a crossword puzzle or play a word game such as Scattergories (Pick a category: Food. Pick a letter of the alphabet: L. Think of all the foods that begin with the letter L.) If you can do so without disturbing others at home, play a musical instrument. Engaging your mind will free it from repetitive thinking and enable you to go to bed feeling more relaxed.
  5. Adjust your perspective with cognitive restructuring. Confront your worries head on by asking a series of questions to find out how realistic your repetitive thoughts about a worrisome situation really are. In the process you’ll often find your anxiety level going down. Click on cognitive restructuring to find out more.
  6. Do a low-key physical activity. Underlying worry and anxiety are neurochemicals that trigger the urge to fight or flee. Low-key physical activity, such as walking outside or around the house, enables you to work the stress out.
  7. Do a deep breathing exercise. Deep diaphragmatic breathing triggers the relaxation response, enabling the body to move out of fight-or-flight mode and into a relaxed and restful state. Sitting in a chair, slowly inhale to a count of 4, pause briefly, and exhale to a count of 4. Focus on your breathing. If you find your mind wandering, gently guide your attention back to your breathing. Repeat this cycle as many times as needed.
  8. Do progressive relaxation. Sitting or lying down, one by one, tense and release every group of muscles in your body. Start with the muscles in your toes and move upward through your trunk to your head. Then move downward through the arms to the fingers.
  9. Do a guided meditation. Allow someone else to lead you through meditations designed to quiet your mind and relax your body. Jon Kabat-Zinn, whose guided meditations are available on the internet, is a master at this.

Please share any strategies you’ve found to cut down on worry at night.

Q&A: Can’t Sleep Due to Temperature Sensitivity

A reader named Gunjan recently asked a question about trouble sleeping due to temperature changes at night. Here it is, lightly edited:

“It seems my body is very sensitive to temperature while I am sleeping. Many times it has happened that I went to bed at an optimal temperature. But as soon as my body sleeps, I wake up feeling too cold. Then I go to bed after switching off the fan or covering myself with the bed sheet but then I can’t sleep because I’m too hot. This is quite frustrating. . . . Does anybody . . . have any help to offer?”

Insomnia sufferers may have increased temperature sensitivity at nightA reader named Gunjan recently asked a question about trouble sleeping due to temperature changes at night. Here it is, lightly edited:

“It seems my body is very sensitive to temperature while I am sleeping. Many times it has happened that I went to bed at an optimal temperature. But as soon as my body sleeps, I wake up feeling too cold. Then I go to bed after switching off the fan or covering myself with the bed sheet but then I can’t sleep because I’m too hot. This is quite frustrating. . . . Does anybody . . . have any help to offer?”

Insomnia and Thermosensitivity

Insomnia may have something to do with compromised thermoregulation, but the issue has not been fully investigated, say authors of a paper on sleep and thermosensitivity. Evidence shows that older adults may have an impaired ability to recognize the most comfortable temperature for sleep, and this may relate to abnormalities in the area of the brain that evaluates comfort. Not much else is known.

But I’m never surprised when people complain of trouble sleeping related to temperature sensitivity. I have the problem myself. I’ve gone to bed in very hot and very cold situations and lain awake for a good chunk of the night. Like Gunjan, I regularly have to make small temperature-related adjustments in the middle of the night. Now, with some nights warm and others cool, is the season when it’s trickiest to get it right.

Temperature Changes at Night

Core body temperature varies by about 1.5 degrees Fahrenheit over the course of the 24-hour day. From a temperature high in the evening, it descends and reaches its low point some 1 to 3 hours before normal wake-up time. If you keep the bedroom windows open at night (a cool bedroom is good for sleep), the room temperature will likely drop as well. The combination of internal and environmental temperatures falling could easily explain why you might wake up feeling cold at night.

Covering yourself with a blanket or a bed sheet is the obvious way to make yourself comfortable enough to get back to sleep. But what if, like Gunjan, you then feel too hot?

Covering up can create a closed system where, once the skin temperature has risen enough to dilate the blood vessels close to the skin, the body heat then released has no place to go. It’s similar to the situation created by an electric blanket. The blanket continues to add heat to the body, increasing skin and core body temperatures. The heat the body would normally throw off is then trapped underneath the blanket. You wake up feeling too hot to sleep.

Here are two ways to keep from overheating at night:

  • Use sheets and blankets made of a breathable fabric such as cotton. Fabrics like polyester are more likely to trap heat rather than allow for its release.
  • When you cover up, see if keeping your feet outside the covers helps. You lose lots of heat through your extremities, so keeping them uncovered, or partially covered, may make you comfortable enough to sleep through the night.

Help for Sleep Onset Insomnia

It’s easier to go to sleep when core body temperature is falling, and people who have problems falling asleep—sleep onset insomnia—may have trouble cooling down at night.

Ideally, the temperature in the bedroom should be a little lower than is comfortable during the day. But there are also ways to facilitate internal heat loss. Activities that increase skin temperature eventually help to cool you down. Warming the skin dilates blood vessels close to the skin. This enables the release of body heat and a lowering of core body temperature to occur for a few hours after the activity ends, in turn facilitating sleep.

Early in the evening these activities may trigger processes that help you fall asleep:

  • Take a hot shower or bath
  • Spend time in a sauna
  • Do a resistance workout or aerobic exercise

As you’re winding down on cooler nights, mild heating of the hands and feet may dilate the blood vessels enough to facilitate heat loss, lowering your core body temperature and inducing sleep. But this is a losing strategy on the warmer nights. Lightly clad and barefoot is the way you want to be.

If you’re sensitive to temperature changes at night, what have you found that helps?

Sleep Tracking? No. Now It’s Sleep Training

You can train to run a marathon. You can train yourself to recognize Chopin. But can you train yourself to sleep (or train yourself not to have insomnia)?

Michael Schwartz, creator of the Sleep On Cue iPhone app, says yes.

Insomnia sufferers may learn how to sleep with this iPhone appYou can train to run a marathon. You can train yourself to recognize Chopin. But can you train yourself to sleep (or train yourself not to have insomnia)?

Michael Schwartz, creator of the Sleep On Cue iPhone app, says yes.

Sleep training “appears to work via conditioning,” Schwartz said in a recent email exchange. “People ‘learn’ the act of falling asleep. I have found it to be helpful for those who struggle to fall asleep initially and/or struggle to return to sleep during the night.”

But why do insomniacs need to learn to sleep when for most people sleep is effortless?

Intensive Sleep Retraining

The idea of sleep training is based on intensive sleep retraining (ISR), an insomnia treatment originally developed by sleep researchers in Australia. It grew out of sleep studies showing that many insomniacs fall asleep more quickly and sleep longer than we think we do.

Schwartz has observed this phenomenon firsthand in his work as a registered sleep technologist in the United States.

“It seems [that insomniacs] who are taking a traditional hypnotic . . . tend to overestimate sleep time,” he says. “Then if the insomniac begins a tapering of the medication, it swings to an underestimation of sleep time.”

Unlearning and Relearning Sleep

The question of why so many insomniacs tend to underestimate sleep time has not been definitively answered. ISR proponents suggest that insomniacs’ trouble sleeping is conditioned, resulting from poor sleep habits, worry about sleep loss, and negative beliefs about sleep. Eventually we lose touch with what falling asleep actually feels like.

So the goal of treatment is to retrain insomnia sufferers in the experience of falling asleep. Proponents claim that sufficient practice (within the prescribed protocol) will make our perceptions more accurate (i.e., more in sync with objective sleep tests, which indicate we’re sleeping longer) and restore confidence in our ability to sleep.

The Challenge and the Payoff

The ISR treatment as originally prescribed is short but onerous. You spend 25 nearly sleepless hours in a sleep lab. Every 30 minutes, you get a chance to fall asleep (and if you fall asleep, you’re woken up). At the end of the 25-hour period, you’ve had lots of practice falling asleep . . . and you’re very sleep deprived.

But after the initial 25 hours the benefits of ISR are immediate. With loads of sleep pressure built up by the next night and instructions on how to proceed, insomniacs who undergo ISR have experienced improved sleep starting at Day 2. The gains continue, research has shown, for at least 6 months.

A Sleep Training App

An insomnia treatment that involves wiring patients up in a sleep lab and round-the-clock supervision by sleep technicians is very expensive (which may be the reason nobody’s doing ISR in the United States). So when a call came out to get ISR out of the lab and make it available to insomniacs at home, Schwartz went to work.

“After reading the ‘call to action’ article by the notable insomnia researchers, I began thinking about how to detect sleep onset without expensive amplified EEG recording,” Schwartz said. He came up with several ideas before landing on the idea of an iPhone app.

“My ‘ah-ha’ was to realize that a call (tone) and response (slight movement) with a smartphone might be the ticket,” Schwartz said, “and it seems to work well.” Here’s how:

  • You lie down in bed holding your iPhone. Each time the phone emits a tone, you shake it slightly.
  • If the app doesn’t detect a shake, it assumes you’re asleep and vibrates to wake you up.
  • A message then comes on the screen: “Do you think you fell asleep?” You press yes or no.
  • You’re then instructed to leave the bed for a few minutes. The phone vibrates again to indicate when to return to the bed for the next sleep trial.
  • You decide when to end each training session. The screen then displays a graph with information about your sleep ability and your awareness of your sleep.

Modified ISR

The Sleep On Cue protocol is very similar to the ISR protocol, allowing for repeated, short sleep onset opportunities with sleep–wake estimation and confirmation. But Schwartz felt he needed to make ISR more palatable for home users.

“So I decided to reduce each sleep trial time slightly after each successful sleep attempt, as well as to prompt the user to leave the bed for just a couple minutes between sleep trials,” he said. “These two features allow more sleep trials in a shorter amount of time.

“I suggest . . . that sleep training should be done around bedtime for a couple of hours following any poor night of sleep. So maybe 10 sleep trials. Put the phone down and go to sleep when done, review the summary graph in the morning.”

Testimonials on the Sleep On Cue website suggest the app has been helpful for users, including users coming off sleeping pills. According to Schwartz, tests verifying the accuracy and clinical effectiveness of a modified version of the app are under way in Australia right now.

“The best user of my app is someone who is committed to sleep training,” he said, “who can grasp the idea of ISR and how it can help.”

If you try this app, let us know how you fare.

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!