Section XVIII: Insomnia

Why Can't I Sleep?

Goals of the Exercise

1. Practice healthy sleep hygiene behaviors.

2. Use thought-stopping techniques to counter intrusive and disruptive thoughts.

3. Take psychotropic medications as prescribed.

4. Restore restful sleep.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Why Can't I Sleep?” activity is designed for use with veterans/service members whose insomnia is having a significant negative effective on their work/duty performance and/or quality of life. Establishing an effective sleep routine is essential to overcoming the sleep disturbances that are so common for many service members and veterans. Help the veteran/service member establish a routine that can be easily and reliably implemented. Keep in mind that this should also be applicable for the service member that is currently deployed. This exercise may also provide further insight into any additional problems that the veteran/service member may be dealing with such as nightmares, anxiety, or depression. Follow-up for this activity can include assignment of the other activity in this section, “Sleep Management”; referral for a sleep study to determine whether the veteran/service member suffers from sleep apnea if this has not been checked; coordination with his/her primary care physician (after obtaining necessary release of information) to ensure that insomnia is being considered in the veteran's/service member's general medical care; and bibliotherapy using books listed in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner.

EXERCISE XVIII.A Why Can't I Sleep?

Insomnia is a common problem in active duty military personnel and veterans dealing with mental or emotional problems related to military service. Some people believe that they need only four or five hours of sleep each night, when in fact most people need somewhere from seven to nine hours of sleep. Also, some people believe that they do not sleep at all. However, when observed by others they find out that they actually do get some sleep during the night, but it is typically interrupted/fragmented sleep. There are techniques you can use to reduce or eliminate your insomnia to gain more control over your sleep and improve your quality of life. This exercise will provide you with information on a number of techniques you can use.

1. The following strategies to counteract insomnia have worked for many people, and some of them are likely to be useful for you. Please read through this list and put a checkmark next to those that you are willing to use as part of your everyday routine.

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Engage in daily vigorous exercise, finishing no later than six hours before you go to bed.

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If you take prescribed medications, take them exactly as instructed. Tell your doctor you have insomnia so he or she can make sure none of your medications are keeping you awake; your doctor may also prescribe a sleep medication or recommend an over-the-counter medication, supplement, herbal tea, etc. NOTE: IT IS ALSO IMPORTANT TO TALK WITH YOUR DOCTOR ABOUT ANY OVER-THE-COUNTER MEDICATIONS YOU TAKE OR ARE CONSIDERING TAKING, both to make sure they aren't causing your insomnia and to be sure they don't have the potential for negative interactions with prescribed medications. You can also get information on medication interactions from your nearest Poison Control Center.

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Avoid caffeine for at least four hours before bedtime.

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Avoid nicotine for at least one hour before bedtime.

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Avoid large or spicy meals for at least three hours before bedtime.

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Avoid drinking alcohol to get to sleep—it may work for a short time, but once your body has processed the alcohol out of your bloodstream, your brain will become more active than usual in a rebound effect. Daily drinking for effect presents a high risk of alcohol dependence and other health problems anyway.

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Avoid emotional conversations with loved ones prior to bedtime. If a loved one brings up a subject that may lead to an emotional conversation, set a time the following day to talk about it. This is a good idea with emotional subjects anyway.

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Avoid activities that are mentally stimulating for at least an hour before bed—action films, high-energy music, etc. Reading something that you're interested in but does not cause strong feelings may help you get to sleep, or may make it harder. Try each way and check the results, then keep doing whichever is effective for you.

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Take a hot bath/shower 30 minutes before going to bed.

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Try wearing socks when you go to bed—this sounds strange, but it works for many people; having warm feet seems to make it easier to fall asleep.

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Go to bed and wake up at the same times each day (including weekends). Avoid taking naps during the day, even when you're tired.

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Don't watch television or play video games in bed.

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Write down disturbing thoughts, thoughts of things you need to do the next day, and any other thoughts that interfere with relaxation. This enables you to put them aside to deal with at an appropriate time. Keep a pen and paper near your bed to write down thoughts of this kind that come to you after you lie down without having to get up.

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Practice deep breathing 15 minutes before bedtime.

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If possible, make sure your bedroom is dark and quiet when you go to bed. If it helps you get to sleep to have relaxing music playing, make an exception for that.

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If you are familiar with the exercise titled “Safe and Peaceful Place Meditation,” practice it to get to sleep. If you haven't seen it, your therapist can give you the exercise to learn how it works.

2. If you haven't done so, ask your primary care doctor to help you get to a specialist to check for a condition called sleep apnea. If you have sleep apnea, it disrupts your breathing up to several times per hour while you sleep, and each time this happens you become partly awake until your breathing is back to normal. Even though people with sleep apnea don't usually remember these interruptions and may think they slept through the night, apnea results in not feeling rested even after a full night's sleep. If you do have sleep apnea, there are effective treatments you can discuss with your doctor. Do you know whether you have sleep apnea?_____ If not, when will you talk with your primary care physician about insomnia and possible sleep apnea?_____

3. Keep a journal, and use it to write about any situations that are stressful and interfere with your sleep (don't do this writing during the last two hours before bedtime.) Many people find that putting their thoughts and emotions down on paper helps in letting go of negative emotions and getting rid of tension. As part of your journal, make a point each day of writing about stressful events that day, which methods you know to help you get to sleep, how you slept the night before, and any dreams you remember. This can give you useful information when you want to see how your sleep management program is working over time. Do you already keep a journal?_____ If so, have you been keeping track of sleep, dreams, and/or how rested you feel?_____

If you haven't kept a journal before, when in your daily routine will you take time to write about your day in a journal?_____

Be sure to bring this handout back to your next session with your therapist, and be prepared to discuss your thoughts and feelings about the exercise, including which of these methods you are trying out and which have either worked or failed to work so far.

Sleep Management

Goals of the Exercise

1. Eliminate nighttime sleep interruptions.

2. Eliminate mental and physical side effects caused by sleep deprivation.

3. Verbalize an understanding that poor sleep hygiene habits contribute to insomnia.

4. Take psychotropic medications as prescribed.

5. Restore restful sleep.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Sleep Management” activity is designed for use with veterans/service members suffering from insomnia as a follow-up to the other activity in this section, “Why Can't I Sleep?” This activity builds on “Why Can't I Sleep?” which introduced the concept of sleep hygiene and a number of techniques to reduce or eliminate sleep disturbances. This activity will guide the veteran/service member in developing a more comprehensive and proactive sleep management plan. Follow-up for this activity could include a referral for a sleep study to determine whether the veteran/service member suffers from sleep apnea if this has not been checked, coordination with his/her primary care physician (after obtaining necessary release of information) to ensure that insomnia is being considered in the veteran's/service member's general medical care, and bibliotherapy using books listed in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner.

EXERCISE XVIII.B Sleep Management

Insomnia is frustrating and stressful. It interferes with being able to perform at your best during the day and can weaken your immune system, making you more vulnerable to common illnesses such as colds and influenza. You may have already done the exercise titled “Why Can't I Sleep?” This exercise will guide you in creating a more effective sleep management program for yourself and provide you with information on a number of techniques you can use.

1. Have you worked through the “Why Can't I Sleep?” exercise, and if so, which of the techniques in that exercise are working most effectively for you?

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2. If there are still some techniques from “Why Can't I Sleep?” How many are there and when will you try some or all of them?

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For some people it works to try each new one for a week, keeping track of the results in a journal it recommends you use for that purpose.

3. The goal of this exercise is to take the strategies that work for you and combine them in a plan to manage your sleep as effectively as you can. Most people don't think about this, but we normally have management plans, even if we don't call them by that name, for other important things in our lives. For example, if you almost always eat three meals each day, at about the same times each day, that's a basic nutrition management plan—more so if you have particular kinds of food at different meals or on different days. In a similar way, we use management plans to pay bills, clean our homes, go to classes, and do homework if we're in school.

4. The easiest way to see these plans can be on a chart or grid that matches actions or other events with the times and places where they happen. Depending on the kind of plan, the chart may cover any time period from a day to several years. For a sleep management plan, we'll use a chart that covers one day, since it works best to follow the same sleep management routine every day, including weekends.

5. Following is a sample sleep management chart filled in with actions that work for some people—please ask your therapist for blank copies to fill in with your own plan. When you've done that, start following it, and keep talking about it with your therapist in your future sessions.

Time Action or Event How Long
05:30 Wake up—write notes on how I slept and any dreams I remember 5 min.
05:35 Personal hygiene—brush teeth, shave, etc. 20 min.
05:55 Dress in PT gear 5 min.
06:00 Go running/work out at gym 45 min.
06:45 Shower, get dressed for the day 30 min.
07:15 Breakfast 30 min.
07:45 Go to work—normal work day routine/weekend day activities 4 hrs.
11:45 Go to lunch 1 hr.
12:45 Back to work/weekend day activities—no caffeine from 15:00 on 4 hrs.
16:45 Leave work/break in weekend day—evening meal 1 hr.
17:45 Evening activities—social, recreational, educational, chores, etc. No nicotine from 18:30 on; avoid watching TV or playing video games in bed 3 hrs.
20:45 Prep for sleep—no more mentally/emotionally stimulating activity. Write in journal, personal hygiene, take meds, etc.—possibly try a new sleep management technique I haven't tried before 45 min.
21:30 Lights out—use meditation, visualization, etc. that I've found work for me to get to sleep 8 hrs.