Can a cadre of experts help this writer overcome her chronic insomnia? A nighttime drama in three acts.
I couldn’t sleep like a baby even when I was a baby. My mother says that when she rocked me, I would jerk myself awake. As an adult, I never looked forward to bedtime the way that other people did, and when I got stressed, sleeping was the first thing to go. Then, one night, I forgot how to do it entirely.
It happened when I moved from New York City to the bucolic New England countryside, just past a squash farm. How was I ever supposed to sleep in all that deafening quiet? It was a massive life upheaval, and sleep turned from challenging to impossible. The sun would come up and there I would be, wide awake under my charming homemade quilt. I tried to surrender to unconsciousness. I really did—but it felt like trying to drown myself in a bucket.
After doctors ruled out medical causes for my wakefulness (an overactive thyroid, for example), I experimented with acupuncture, yoga, herbs, Gregorian chants, earplugs, and a sleeping mask. What worked? Ambien. The hypnotic drug put me to sleep and more or less kept me asleep, and it felt like the best thing that had ever happened to me.
Ambien promotes the activity of gamma-aminobutyric acid (GABA), a neurotransmitter that reduces electrical impulses in the brain, and I’ve been taking it since my insomnia took hold, six years ago. From time to time, I’ve tried to get to the Land of Nod without those little pharmaceutical passports, but to no avail.
“Sleep can be a delicate process, and when insomnia sets in, it can easily become long-term,” says Gregg D. Jacobs, Ph.D., an insomnia specialist at the Sleep Disorders Center at the University of Massachusetts Medical School, in Worcester. “We develop thought patterns and behaviors surrounding the insomnia, and those patterns and behaviors help perpetuate it.” That is, sleeplessness creates anxiety, which causes us to think of our once cozy beds as torture racks, which makes us more anxious and sleepless. Then we try to manage the next-day exhaustion with caffeine (I’m guilty) or naps (I couldn’t nap at gunpoint), which ensures that it’s harder to sleep the next night and so on.
I hated the thought of being dependent on medication, and though I was sleeping, I often didn’t feel rested. Sometimes, after a really bad night, I would go to the ladies’ room for a second just so I could rest my head on the toilet-paper roll. I read a profile of Hillary Clinton that extolled her great talent for sleeping on command. I wondered what life would be like if I could sleep soundly. Maybe I could be the secretary of state.
The Sleep Clinic
In this, Year Six of my insomnia, I decide that I need a real intervention, so I book an appointment at the Sleep Disorders Institute, in New York City. I hope to spend a night hooked up to some wires, like the Six Million Dollar Woman, but no such luck. “A sleep study isn’t always the first line of treatment for someone with insomnia,” says Maha Ahmad, M.D., an associate director at the clinic. “First we want to look at your sleeping habits, then start you on a behavioral program.” I begin by keeping a diary (yawn) for two weeks, noting sleep and wake times and medication. For now I can keep taking the Ambien.
My sleep patterns are very consistent because they are artificially mediated by drugs: I am getting a respectable average of 7½ hours a night, with a few nighttime wake-ups. I find that my sleep gets choppier when I feel even mildly stressed. One night I decide not to watch the nail-biter TV show Breaking Bad before bed, only to have a dream about it that wakes me at 4 a.m. There is some evidence to suggest that my brain is working overtime. A 2004 University of Pittsburgh School of Medicine study that examined the brain’s metabolic activity determined that the brains of insomniacs are more active than those of normal sleepers.
When I bring my diary back to the clinic, Ahmad outlines my new behavioral plan. Over the years, I’ve read so much advice about “sleep hygiene” that I could recite most of the guidelines, well, in my sleep, but I’ve never implemented them. I’ve been arrogant enough to think that they couldn’t possibly help my uniquely Broken Brain. Now I agree to try them in the name of science.
- I will maintain strict sleep and wake-up times, even on weekends. My new schedule allows for seven hours, half an hour less than usual. This minor sleep restriction will supposedly harness the power of my homeostatic sleep drive, otherwise known as the natural urge to sleep.
- I will use the bed only for sleeping (and sex). This is called “stimulus control,” which sounds like something out of a psychology experiment because it is. Stimulus control is how Pavlov trained his dogs to salivate every time a bell rang. The theory is that I’ve come to associate my bed with wakefulness, an idea that is reinforced every time I get into it only to watch TV or surf the Internet. Consistency is key: If Pavlov had alternated bell ringing with tap dancing and mooing, the dogs would never have known when to drool. If I can’t sleep after 20 minutes, I should get out of bed until I feel sleepy again.
- I will get a little exercise every day, even if it’s just a 20-minute walk, ideally five to six hours before bed. It’s easier to fall and stay asleep when your core body temperature is on the decline; exercising will elevate my core body temperature for several hours, then it should be on a downswing by bedtime.
- At least an hour before I turn in, I will dim the lights and put aside the laptop. When I’m exposed to light, my brain thinks that it’s daytime, and a tiny region of brain cells called the suprachiasmatic nucleus suppresses the release of the sleep hormone melatonin. I can read by indirect light—say, a floor lamp placed next to the couch. It’s also fine to watch TV, because I’ll be farther from the light source than I would be with a computer. (And during the day I should get as much light exposure as possible.)
- Thirty minutes before bed, I will eat a light snack. Cheese and crackers is a good choice because it contains protein, complex carbohydrates, and tryptophan, which boosts the calming neurotransmitter serotonin.
- Surprise: If I need a little caffeine to power through the days on my restricted sleep schedule, then I can have it, says the doc, just not after midafternoon or so.
- I will lull myself to sleep with guided visual imagery, imagining myself in a relaxing place—preferably one I’ve actually been to (say, the beach) so that my imagination can incorporate all five senses. I need a scenario that engages me without generating too much activity in my brain. That’s why the favorite-vacation technique may be more effective than a method like counting backward from 100 by twos or naming everything I can think of that starts with a G.
- I don’t have to give up the medication right away. The plan is to get my behaviors in place first, then gradually wean off the pills.
Starting that night, I adopt the plan with religious zeal, and it makes me weirdly anxious because I’m obsessed with doing it perfectly. Which is how I wind up taking my nightly bath in the dark, trying to read by flashlight. (I fear that the bathroom light is bright enough to stimulate my suprachiasmatic nucleus.) I call Rubin Naiman, Ph.D., a clinical assistant professor of medicine at the University of Arizona’s Center for Integrative Medicine, in Tucson, and the author of The Yoga of Sleep ($20, amazon.com), to tell him that this relaxation stuff is harshing my mellow. He explains that I need an attitude adjustment. “First,” he tells me, “you have to have faith that it’s possible to sleep again.”
Self-efficacy—the belief in one’s ability to achieve a goal—is a crucial part of making any big health change. Yet my self-efficacy is getting mowed down by the panicked thought I’ll never fix this. To defeat this kind of internal sabotage, Jacobs recommends cognitive behavioral therapy (his five-week program can be found at cbtforinsomnia.com), which includes reframing one’s assumptions about sleep. For instance, the frenzied I’ll never be able to function tomorrow should be replaced with I have had bad nights before, and I’ve managed. I am skeptical about insisting to myself that I will be fine tomorrow, just fine. Yet I try it one night at 3 a.m. and find that I do feel slightly less gritty-eyed the next day.
I don’t want to just reframe my thoughts, though. I want to rewire my brain so that I can stop its nightly racing. I decide to try neurofeedback, in which the brain’s electrical signals are monitored and then fed back via a computer screen or audio tones. The idea is that when you can see what’s happening under your mental dashboard, you can learn to control it.
I visit Les Fehmi, Ph.D., the director of the Princeton Biofeedback Center, in Princeton, New Jersey, and a coauthor of The Open-Focus Brain ($19, amazon.com). Fehmi was one of the first researchers to study biofeedback in the 1960s, when he discovered that subjects could learn to produce the slow, synchronized alpha waves that come with relaxation through what he calls open-focus exercises. “We spend most of our lives in narrow focus,” says Fehmi. “It’s a tense, survival-oriented mode—think of what a lion experiences when he scans the horizon for prey. His brain becomes more electrically active. His heart rate and blood pressure go up as he gets ready to attack. But that physiological stress response isn’t meant to be sustained over the long term.”
Fehmi has created a series of exercises designed to give the brain a break. They use “objectless imagery,” which allows you to achieve the Zen-like goal of thinking about nothing. (For instance: Imagine the space between your eyes.) The goal is to cultivate a loose, diffuse kind of attention; to me, it feels like a jacked-up form of meditation. First Fehmi hooks me up for an electroencephalogram (EEG) and has me do the exercises. When I produce alpha waves, I’m rewarded with a flashing light and a beeping sound. Over the course of several sessions, we repeat these exercises, and I find that they make me feel calmer. It’s as if my mental furniture has been pushed up against the walls, leaving a clear, bright space.
Fehmi gives me a CD and asks me to do a half-hour exercise at least once a day. Sometimes when I’m listening, I can feel myself drifting into what might be stage-one sleep, the kind where you think you’re awake but you see random images, like a floating shoe, drifting across your consciousness. I’m experiencing other sleep gains. I nod off a few times, though it doesn’t last; inevitably I jolt myself awake and think, I need a pill. Also, I am knocked over by a taxicab (I’m fine! Not even a bruise), but that night I fall right to sleep (with Ambien)—not bad, considering that a couple of weeks earlier I had been kept awake by the thought of a TV show. I have reduced the Ambien to half a tablet, but I can’t kick it entirely.
It’s progress, sure. But it doesn’t feel like enough. However, Michael Breus, Ph.D., a clinical psychologist based in Scottsdale, Arizona, a fellow of the American Academy of Sleep Medicine, and the author of The Sleep Doctor’s Diet Plan ($26, amazon.com), tells me not to lose heart. “If you’ve been battling this problem for six years, you’re probably not going to clear it up in six weeks,” he says. “And incremental change is still change. We lose sight of that.”
It’s possible that I’m just a bum sleeper. There is evidence that troubled sleep has a genetic component. A new study from Université Laval, in Quebec City, has determined that people who have at least one insomniac family member are 67 percent more likely to be insomniacs themselves. (My mother takes an over-the-counter sleep aid nightly.) Researchers aren’t sure whether the mechanism is physiological or psychological. It’s probably worth noting that several of the insomnia specialists whom I have spoken to concur that if small doses of Ambien are doing the job, maybe I shouldn’t worry so much about ditching it. “Think of a problem like high blood pressure,” says Breus. “If that condition runs in your family, then you can and should make lifestyle changes to manage it. But that still might not be enough to keep you off medication.”
I’m eight weeks into my sleep project, and all this effort is making me tired. So I jump at the chance to go to the Mohonk Mountain House resort, in New Paltz, New York, for its Attainable Sleep spa treatment. I don’t expect fancy bath salts to do what modern medicine couldn’t; I just want to be rolled in fluffy towels.The treatment is a 90-minute massage-and-soak that includes essential oils said to have aromatherapeutic properties: bergamot (an antidepressant), lavender (to relax the muscles), and clary sage (to sedate). This is all pretty delightful, especially when the massage therapist stimulates a point under the ball of each foot, which I later learn is the solar plexus point, noted among acupressure practitioners for its calming capabilities. The pressure makes me feel not just relaxed but dazed, like a sunning reptile. My self-efficacy upticks slightly. After the treatment, I violate sleep-hygiene protocol with a big steak and two glasses of wine. Then I go to my room to lie down.
Reader, I fall asleep. And I stay asleep.
I’m not sure why. Maybe it’s because massage activates the body’s parasympathetic nervous system, which is responsible for “rest and digest” activities in times of relaxation. Maybe it’s the mountain air. Maybe it’s because I didn’t believe that it would work and so I quit thinking about it. Maybe it’s because I felt treated instead of instructed, which let me stop beating myself up. And maybe it was just the 800th thing that I had tried.
There’s such a Peter Pan aspect to solving sleep mysteries. (Think lovely thoughts and you can fly!) “Your ability to sleep never really gets destroyed,” says Naiman. “The most important thing is that you have hope. I have hope for you, but I can’t just tell you that, because hope doesn’t translate through words. It translates through experience.” And though I can’t fix my insomnia by moving to a spa (and I haven’t thrown out my meds), it’s heartening to know that I’m less broken than I thought.