Wellness@Work: Better understanding your sleep/wake behavior
Most people describe insomnia as problems with getting to sleep, staying asleep, and/or waking up too early. Almost always, the answer is not taking a sedative, but rather changing their behavior.
By William A. Broughton, M.D.
Mastin Internal Medicine
In 35-plus years of practicing sleep medicine, I mostly see patients with obstructive sleep apnea. However, a significant number of people are referred for what they describe as insomnia.
By the time they see me, multiple doctor visits and various sedatives have failed to improve their condition. A question that is rarely asked by doctors is, “What do you mean by 'insomnia’?”
Most people then describe problems with getting to sleep, staying asleep and/or awakening too early. Almost always, the answer is not a sedative, but a change in their behavior, and almost all of these complaints are sleep-scheduling difficulties. A detailed assessment of their sleep/wake behavior is essential.
The most common problems are:
"Can’t get to sleep” (delayed sleep-phase)
For most people, sleep is a daily occurrence that happens at the same time each day (a circadian pattern, i.e., about a day). A regular sleep schedule entrains the brain and body to a stable pattern influenced by darkness and light. This leads to routine times of sleep and awakening.
When people adopt a late time of sleep onset and the resultant late-day awakening, they can inadvertently retrain their brain to adopt that pattern. Subsequently, when they try to go to bed at an earlier time, their body is not ready for sleep.
It is common for teenagers to stay up late on the weekends and sleep late on Saturday and Sunday. Then, they are unable to get to sleep and wake up easily throughout the early week. Things start to get better by week’s end, but then the weekend comes, and they restart the behavior. This is sometimes called “social jet lag” and leads to daytime sleepiness during the week.
Disabled and elderly persons can also adopt such behavior because they no longer have to arise early for work. This is not usually perceived as a problem unless the late bedtime is a source of worry.
The fix for this is not sedatives, but the adoption of strict time of arising. Assigning a desired time of awakening and sticking to it (regardless of the resulting temporary sleepiness) will produce an earlier bedtime in a week or two.
“I wake up too early”
Often, my older patients will tell me that they awaken at 4 a.m. when the house is still asleep, and they cannot get back to sleep. My question is always, “When do you get in bed and go to sleep?” The answer is often, “around 7 p.m.”
In these cases, their circadian time of sleepiness has advanced, and they are ready for sleep too early (advanced sleep-phase). The fix is simply staying awake a bit longer and allowing the sleep phase to delay a bit. I will admit that is easier said than done, but it works!
Shift-work sleep disorder
The idea of businesses running 24 hours a day began in 1772. The plan was not designed for workers’ well-being, but for monetary reasons. Now, there are critical services like the power grid and hospitals that require such schedules. If these workers could live on their work schedule every day, they would adapt to it readily.
The problems come from rotating day and night shifts, and from people who exclusively work night shifts trying to sleep on a “day-worker schedule” when they are off. This change in sleep is often necessary for errands and for getting family time. These shift-work difficulties are usually best addressed by a sleep physician. Behavioral changes are sometimes not enough.
Sleep scheduling problems constitute the majority of what is perceived as insomnia. Examining how you live and work can be helpful in knowing how to best optimize what sleep you get. Remember, no matter what your perception, if you are getting too little sleep for you, sleepiness will intrude on your day. If you are remaining alert during the day, your sleep duration is probably OK.
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