To sleep? Perchance to sleep?

June 19, 2008 9:32 AM

Dear Type A personality, what helps you ward off insomnia?

One of my best friends has terrible insomnia. She's had it on and off her entire life, and recently it's been ON. Here are the facts:

On the plus side
1. She has a very healthy lifestyle: no drugs, very little alcohol, good eating habits, regular exercise.

On the con side
1. She just started a new job, which she loves, but it's a very high pressure job with real life or death consequences for the people she's helping, and she's very worried about doing well at it, making the right decisions, and making a good impression on her boss.

2. She has a tendency to knock herself down, especially when she can't get sleep. She sees having insomnia as a personal failing, which she knows is stupid, but it's a little voice she can't get rid of. Obviously that keeps her awake as well.

3. There's a good chance it's genetic, as her father (now deceased) had the same thing.

4. She takes Adovan occasionally for insomnia-related anxiety (I'm skeptical of this; I don't know if it's really indicated for that).

5. She's a Type A and also really not into the feel-good New Age stuff about mindfulness, meditation, yoga. Believe me, I've tried to bring this up with her.

Sigh. I personally think the major issue here is her crazy idea that insomnia some kind of moral failing, since she just starts hating on herself when she can't fall asleep and that exacerbates the issue. Obviously it would also be nice to get her to sleep in the first place.

Pharmacologically, I know some people take melatonin, and I've thought of recommending this to her, though I've never used it myself. Have any of you had luck with that?

So I guess there are a couple questions here: what do you do, in terms of drugs/sleep aids you take and things you do? How do you stop this cycle of late-night self hate?

Thanks! Looking forward to replies.

posted by MaddyRex to health & fitness (20 answers total)

Ativan, and many other benzodiazepines, are absolutely indicated for anxiety and occasional insomnia. I'm surprised she doesn't have Klonopin but meh. If she's only taking it 2-3 times a week tops then she'll probably be fine and not get addicted.

The main thing you could do to help is to STFU already. She doesn't need her friends criticizing her method of handling insomnia. You're only adding to the stress in her life.
posted by crazycanuck at 9:42 AM on June 19, 2008

Seroquel.
posted by sondrialiac at 9:51 AM on June 19, 2008

If this is adding to the cycle - e.g. she can't sleep, so she worries about not being able to sleep, so she can't sleep more frequently - perhaps she should see a doctor about trying some sleep meds.

While doctors say that you should beware becoming dependent on any drug, only regular ambien use really runs the risk of creating a dependency. If she's concerned about it though, she can try Rozerem, Sonata, or Lunesta, all of which have much shorter half-lives.

If she is changing her sleep cycle, it is vital to have a schedule that she sticks to, even if she can't sleep. E.g. she goes to bed every night at the same time. She should also remove all distractions from the bedroom or the bed area. If she's like me, she probably plays on her computer, watches movies and reads books in bed. This is really bed if you suffer from insomnia and it is important to stop doing any of those things in bed. Basically, she's trying to train her brain to let her fall asleep and having a regular time of doing it and not associating her bed with doing other stuff like, say, watching movies, is important.
posted by arnicae at 9:56 AM on June 19, 2008

Does she want help? I am a Type-A (A+, many days) personality, and I like my life. I don't understand the late-night self hate thing, are those in the words of your friend?

Not new-age or drugs, but it helps to be able to write everything down at the end of the day. Before I go to sleep, I make a list of what I need to do, personally & professionally, the next day. That gets it out of my head, and makes it more concrete.
posted by kellyblah at 9:59 AM on June 19, 2008

When I go through phases of this the most useful thing for me is to remove the time references from my environment. I check the clock, see that it's time to go to bed and then throw a sweatshirt over it or something. My biggest driver is not having enough time to get rested leading to failures when I need to be on the ball, it's an ugly cycle.
posted by iamabot at 10:00 AM on June 19, 2008

I have a brain that just won't shut up, and here's what usually helps me:

1. Regular bedtime.
2. Like kellyblah, I write a list of the major things I need to do the next day. I do that by the computer, not in bed.
3. Dark Time: No computer or other bright lights starting 1 hour before bedtime (at least). This means dimming the house lights, no TV, reading only by dim light. Books on tape are great.
4. Melatonin 1/2 hour before bedtime.
5. Read pleasant historical fiction and nothing else in bed. If I think of something business-related, I tell the voice recorder or jot it down, then immediately turn my attention back to the book. (Otherwise I lie awake thinking, "Don't forget that idea!")
6. If I'm still revving, cornsilk tea--it makes me high and mellow.
7. If I haven't fallen asleep within 1-2 hours, Ambien. This means my use is occasional (1x/week) and I haven't had any problems.

If she's having trouble with excessive self-criticism, I'd suggest cognitive therapy.
posted by PatoPata at 10:08 AM on June 19, 2008 [1 favorite]

kellyblah -- good question; I didn't really make that clear.

Yes, she's both described the late-night self-hate thing as such and has described the "insomnia as a moral failing" as crazy. All the phrases noted here are her words, not mine. She called me at 3 am today and explicitly asked for my help with this. Believe me, I'm no Yenta.
posted by MaddyRex at 10:11 AM on June 19, 2008

Ok, with that update, yes, she needs to sort out that self hating thing, first. Until she does that, be it via talk therapy, CBT, or self-affirmations of some sort, the other stuff may not help much. Her insomnia isn't the issue, it is her perception of the insomnia. Once she gets right with that, then the regular bedtime, wind down, write down stuff may fix her up without drugs.

As for taking drugs in the meantime, benzos might help, seroquel may help, and trazodone may help as well.
posted by kellyblah at 10:24 AM on June 19, 2008

I tend to get very negative late at night, especially if I can't sleep. What has really helped was to change my attitude about what constitutes a night's sleep. If I get in bed 7 hours before I need to wake up, and I spend an hour just laying peacefully and then waking up every 2 hours, I still count it as a net positive. In other words, rather than tripping out on how much it sucks that I'm not sleeping, I give myself credit for getting rest. I've found that once I defuse the anxiety about not sleeping, I sleep a lot better overall.
posted by The Light Fantastic at 11:29 AM on June 19, 2008

I was on Seroquel a few months ago (in my case for bipolar stuff as well as sleep stuff). Its mechanism for inducing sleep is pretty much identical to cheap counter sleep-aids (histamine h1 receptor antagonism). The over the counter sleep aids also have the advantage of not interfering with your glucose metabolism, causing weight gain and increasing your risk of diabetes. It didn't do much for me in terms of sleep after the first couple of weeks of constant exhaustion. Interesting side effects, too. Taking powerful psychotropic medications for sleep is, in my opinion, an incredibly bad idea.

I also took temazepam (a benzodiazepine) for a couple of weeks, by the end of which I'd become completely tolerant to its effects. In my experience, medications for sleep don't tend to work very well.

The moral failing thing does make me wonder if she has insomnia or a circadian rhythm sleep disorder. I spent years thinking my inability to get to sleep and hence to wake up in the mornings was down to laziness, because that's what I was accused of constantly when I was a teenager. Maybe she's just a night owl (AKA delayed sleep phase syndrome) and her non-insomniac periods are times when she has this better controlled, or when circumstances allow more flexibility in sleep/wake times.
posted by xchmp at 11:40 AM on June 19, 2008

Ooh, I'm a type A - started a new job a few months ago. Am intimately familiar with what my street looks like at 2am in the morning, because I'm staring out my window wondering about the 45 things I have to do that are drowning me.

I have either a notepad or my laptop next to my bed. I find that when I can't sleep I'm usually worried about something undone, or forgetting something, and what I need to do is pop open my calendar and slot into my calendar either stuff I need to do, or slot in time to think about what I am going to do about something. For me it's about emptying my head. That takes anywhere from 20 minutes to an hour, just draining all of that out of my head....but afterwards while I don't feel I've solved the problems, I know I've slotted times for myself to deal with them.

I'm also usually pissed with myself for not 'living life well', so also slot in times to call family, or rend movie.

After that I usually turn on bbc world news on the radio, imagine I'm in a very safe, cozy cafe overhearing an interesting conversation going on, and usually then can fall asleep within 20 minutes.
posted by anitanita at 11:49 AM on June 19, 2008

This poster is describing me to a T. The only advice I can give your friend is to take her computer out of her bedroom. Believe me: it works.
posted by parmanparman at 12:23 PM on June 19, 2008

I have also suffered from this type of insomnia for most of my life. I have it (mostly) cracked with the help of a few sleep-aids:
1. Light-blocking drapes. Completely block off every chink of light, so you can't obsess over the "it's getting light and I'm still not asleep" moments. Plus it increases your melatonin levels, sleeping in a darkened room.
2. An MP3 player with a sleep-timer set to one hour, reading you a story at bedtime. Much less stimulating than reading a book yourself. A really good audiobook has the narrator doing different voices for different characters - so much fun! My favorites are lightweight-and-funny or familiar works of fiction. The Lord of the Rings, Terry Pratchett's discworld novels, Winnie The Pooh. The more you listen to them, the more you discover little bits that you missed previously and drift off to sleep thinking about those and not what a loser you are / what you should have said to your manager at the time.
3. When I don't seem to be drifting straight off, I use the Bach Flower essence, Rescue Remedy sleep spray, coupled with a lavender-water pillow spray. I was sceptical about this stuff at first, but it seems to work. The lavender water is a special treat - again, I was sceptical but it seems to work.
4. If all else fails (which it rarely does), a couple of Tylenol are probably less addictive and just as effective as the pharmaceutical sleep aids.
posted by Susurration at 1:11 PM on June 19, 2008

i think she should see a sleep specialist. there are tons of different remedies out there, but a sleep clinic can help set her up with the ones best suited to her type of insomnia.

most major medical centers have sleep specialists in their neurology departments. they interface with psychologists, psychiatrists, and respiratory therapists for patients with anxiety (like your friend), or apnea, or a neurological short-circuit, or whatever.

one thing she can do before making an appointment is keeping a sleep diary for two weeks. (here's one she can print out.) it's basically a 24-hour chart where you mark your hours of sleep, waking, naps, caffeine, alcohol consumption and medication. i also mark exercise, and i found it helpful to divide it into quarter hours. she may also want to mark her anxiety level when she feels it.

this will help give the sleep specialist a good look at her specific type of insomnia (there are many kinds).

another good resource is the book say good night to insomnia. it's basically the same program every sleep specialist follows and is worth checking out.
posted by thinkingwoman at 1:18 PM on June 19, 2008 [1 favorite]

Xchmp, you seem to be implying that Seroquel is Benadryl but with horrible side effects. That is not the case.
posted by sondrialiac at 1:36 PM on June 19, 2008

sondrialiac: The mechanism by which benadryl and seroquel work their sedative effects is the same - histamine h1 antagonism. Seroquel affects a number of different receptors, but its dose-response curve is steeper for h1 antagonism than for dopamine and adrenergic receptors. So at low-ish doses, its sedative effect is much more prominent than its anti-psychotic effects. Typical doses for sleep problems range from 25mg to 150mg. An effective dose for acute psychosis (eg. effective dopamine antagonism) is typically up around 800mg.

At low doses it's fairly similar in effect and mechanism to the anti-histamine sedatives. Not identical, but similar. I'd be interested to see a study comparing the two. A quick search on pubmed doesn't seem to reveal any.

The side effects aren't necessarily horrible, but it's fairly well established that seroquel along with some of the other atypical antipsychotics often causes weight gain and can increase the risk of diabetes. At the doses usually used for sleep problems this may not be such a problem and other side-effects will be less likely. However, weird side-effects can and do happen - akathasia is no fun at all, for example.

I'm not a doctor or a pharmacologist, and I have no regrets about trying Seroquel out (I stopped because it paradoxically made my sleep problems worse), but as a well-informed patient I don't think anti-psychotics should be taken without some convincingly good reasons. The evidence for using them as sleep aids doesn't strike me as particularly convincing.
posted by xchmp at 2:21 PM on June 19, 2008

My sleep-deprived friend says a big thanks thinkingwoman & PatoPata for the thoughtful and detailed responses. And thanks everyone for taking the time to read my long post and for the great recommendations. She'll definitely check out Say Goodnight to Insomnia and try the sleep calendar, as well as the de-stress method of writing everything down pre-bedtime. After that, on to the sleep specialists.
posted by MaddyRex at 2:46 PM on June 19, 2008

She sounds like me and I've had great luck with Lunesta. Shuts the old brain right off so I can crash. Also, same bedtime every night, no TV in the bedroom, no computer one hour before bed, no eating or exercise about three hours before, but don't go to bed hungry.
posted by puddinghead at 3:20 PM on June 19, 2008

1. Sublingual melatonin. Much more effective (and quicker!) than the regular kind.

2. Warm-to-slightly-hot bath before bedtime.

3. No vigorous workouts after, say, 9:30-10:00 at night.

4. If you find yourself lying awake more than a half hour, get up and read something at least moderately challenging, something that demands that full focus and concentration in order to follow the material.
posted by jason's_planet at 12:05 PM on June 20, 2008

I know its late in the thread but I'm always ready to chime in on insomnia.

I'm really hard in myself about not sleeping too, and knowing that I have decided not to be hard on myself about taking what I need in order to sleep.

I take Ambien (after especially stressful days) or Xanax (on days of my usual low-grade anxiety) just about every night, except for rare periods of a week or more when for some mysterious reason, the stars are aligned and I can sleep with no pharmaceuticals. Someday, I expect the stars to align more consistently and to need pills less often. For now, I'm happy to sleep like a normal person for a while.

I've been warned repeatedly by doctors, counselors, and friends that these drugs are for short term use only, would lead to dangerous dependence if I took them longer than a few days, and I really should get myself on an antidepressant to get at "the root of the problem." Except for one thing: I'm not depressed. Just somehow the med-pharma complex has decided that some little white pills should be given out like candy, others like really expensive candy that you have to beg for.

In any case, the long and short of it is that taking Ambien or Xanax all these years (about 5 now) has not made me more or less able to sleep when I stop taking them. If I haven't been taking them and I decide for one more night not to take them, I don't sleep, and if I have been taking them and I decide to stop taking them, I don't sleep. All those shrinks/doctors/friends with all the advice just haven't experienced insomnia.

I have succeeded, during less stressful times in my life, in cutting my dosages of these drugs gradually until I could cut them out altogether. More evidence that they are no more addictive than any number of pills people take for chronic conditions.

Writing, hot baths, reading by candlelight or low light are all good supplements. A large cup of hot, foul-smelling Valerian tea has sometimes been enough to put me to sleep. I had a boyfriend once who would talk in an incredibly boring way about the history of marijuana legislation, and that put me to sleep a couple of times. Sleep is all about a sensation of inner contentment and security, and some of us have less of it than others.

I've thought about sleep clinics, but I think they mainly deal with sleep apnea. Let us know if your friend finds a good one. Hope this helps.
posted by vegsister at 2:25 PM on November 17, 2008