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Sleep Problems / Insomnia

It is a rare New Yorker who reports that they get great sleep. But sleep problems can be caused by so many things, and in fact, are often the result of a combination of things. That’s why it’s so helpful to have a treatment provider who is a physician, a prescriber and also a therapist.

The First Step is to Learn More About Your Problems with Sleep

A thorough history starts the workup of all sleep problems. It’s important to know if insomnia is a lifelong problem or if it started recently? Do others in your family have the same issue? Are there any medical dietary substance related or lifestyle issues that might be contributing to or causing the problem? Is there a mental health issue such as anxiety, depression or racing thoughts that is causing the problem? I will also want to know what you have already tried to help you sleep. Have you tried Benadryl or Melatonin or CBD? Do you drink alcohol or smoke marijuana to help you sleep?

Is the problem that you can’t fall asleep? Can’t stay asleep? Wake up too frequently? Wake up too early and can’t get back to sleep? Each of these presentations is associated with different etiologies of sleep problems. When you do wake up at night do you lie awake and ruminate about the day’s stressors? Do you awake in a panic? Do you watch the clock and get more anxious about the fact that you are not sleeping?

Ruling Out and Addressing Medical Reasons for Poor Sleep

Sometimes insomnia is related to a medical problem that needs to be addressed. Many physiologic issues can contribute from sleep apnea to menopause. From restless legs or painful arthritis to frequent nighttime urination, the first step is to identify and address medical issues that may be contributing to your lack of sleep.

Behavioral or Lifestyle Contributors to Insomnia

Yes, I’m referring to that tempting brightly lit phone at your bedside. But I’m also referring to a host of other issues that may be contributing such as the number 1 cause of interrupted sleep, pets! Followed closely by children, roommates, noise, temperature, eating too late, eating too much, exercising too late, not exercising enough, working too late, not allowing enough time to unwind. Caffeine, Energy drinks and alcohol all can impair one’s ability to sleep. The list goes on and on. But fortunately, these can be easy fixes.

Psychiatric Reasons for Poor Sleep

Insomnia is a symptom of many mental health issues. As a result, if the underlying issue is treated sleep improves. Many people don’t know that depression actually causes a particular type of impairment in sleep. So does being manic or even hypomanic. People with social anxiety and generalized anxiety often can keep their worries at bay until they lie down and try to be quiet and then worries overcome them and prevent them from getting rest. And if you are suffering from Panic Disorder, it’s not uncommon to be awoken from sleep in a panic.

Psychological Contributors to Insomnia

Often what’s interfering with sleep is our beliefs about sleep itself. As the night progresses, we watch the clock and get increasingly worried that we won’t sleep. The more worried we are, the harder it becomes to sleep. This can become a vicious cycle. At other times, my clients have struggled with beliefs that interfere with sleep. We as a culture prize productivity and often devalue down time. So many of my ambitious high achieving clients feel they just haven’t accomplished enough in a day to allow themselves to wind down or to go to sleep. They feel they have to work late, but when they are finally done there are few hours left for sleep or they are too wound up to rest. And finally, many of my clients stay up late on purpose seeking some elusive “me time” but as a result aren’t getting enough sleep.

Why Seek Treatment for Sleep Problems

You know how little kids get when they don’t get enough sleep? They are cranky, moody, clumsy. Well we get the same way too. We just have learned to conceal it better. But lack of sleep causes emotional dysregulation and over reactivity. We cry easily and lose our patience, we snap at people and are too frustrated to problem solve. Being tired also causes cognitive impairments in executive function that are not unlike having ADHD. In fact, many kids diagnosed with ADHD actually no longer had those symptoms when they got enough sleep, and I’m sure the same is true of adults. Most menopausal women and new parents can attest that when you don’t sleep you feel forgetful and scatterbrained and generally less smart than you know you are. Also, when we can’t sleep we are more likely to engage in late night eating and drinking. Finally, your body makes essential neurotransmitters while you sleep. People with Bipolar disorder know that sleep deprivation alone is enough to precipitate a bout of mania or even psychotic symptoms. We need to sleep for our brains to function optimally.

Therapy for Sleep Problems and Insomnia

Sleep related treatment or psychotherapy can take many forms. It can be supportive, behavioral or cognitive. Often talking through the problems we are facing and making a plan to address them in the daylight hours helps prevent us from ruminating about life issues at night. Other times we need to learn proper sleep hygiene to change the behaviors and stimuli that are keeping us awake. When sleep hours have shifted and no longer coincide with the times of day that we are supposed to be sleeping, you may benefit from sleep training in which gradually the sleep period is shifted back. Yet other times we need to look at our values to see what it is that we are prioritizing over sleep and why. Finally, Cognitive therapy for insomnia or CBTi looks at how our thoughts about sleep and sleeplessness, worrying about not sleeping, and observing that we are not able to fall asleep may be exacerbating the issue.

Medications for Insomnia and Sleep Problems

When treating sleep problems, we want solutions that are safe and sustainable. It’s easy to throw a sleeping pill at the problem but if we don’t address the underlying problem that can be just a bandaid. What happens down the road? What will happen when you try to stop? What if you develop tolerance and the medication becomes habit forming such that now you can’t sleep without it?

The first step in treating sleep issues is to treat any underlying issue that may be interfering. If I suspect you may have sleep apnea or a sleep disorder I may refer you for sleep studies and discuss the results with you and your sleep clinic team to find answers. If pain or restless legs or urinary issues are playing a part, this also may require a collaboration with other physician providers. If there appears to be mania, hypomania, depression, anxiety or panic impairing your ability to sleep, then treating these as a root cause is essential.

That said, there is certainly a role for sleep medications and fortunately they come in many varieties. Some are over the counter and some are prescription. Some are habit forming while others are not. When you see a Psychiatrist with specialized training in the treatment of sleep disorders you will be advised of how to get relief in a way that is safe and sustainable for you. You will also have an ally in exploring other approaches you may be curious about such as THC, CBD or other herbal, “natural” or nutraceutical approaches, light therapy, meditation and other treatment approaches. As a source of evidence based scientific information about what helps with sleep and what doesn’t, I will help you find a plan that provides answers, relief and sustainable solutions.

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