This Brain Goes to 11—And Won’t Shut Up!
Shelby Harris, Psy.D., C.BSM is Director of the Behavioral Sleep Medicine Program at the Sleep-Wake Disorders Center at Montefiore Medical Center and Assistant Professor of Neurology as well as Psychiatry at the Albert Einstein College of Medicine. A graduate of Brown University, Dr. Harris received her doctorate in clinical psychology from Ferkauf Graduate School of Psychology, Yeshiva University.
As a licensed psychologist, Dr. Harris specializes in behavioral sleep medicine and CBT for anxiety and depression. She has published and presented research on the neuropsychological effects of insomnia in older adults as well as behavioral treatments for insomnia, parasomnias, narcolepsy and excessive daytime sleepiness. Dr. Harris is also a consultant for the New York Times "Consults Blog."
Question: Why can’t people with insomnia get to sleep despite having large sleep debts?
Shelby Harris: Well, the actual function of the brain, not so sure yet. There’s a lot of different theories about it, but when you talk about psychologically in your brain, a lot of people with insomnia, though not all, report that they can’t turn their minds off. So, it’s not every patient that I see, but I’d say a good 70% to 80% of the patients when they go to bed it’s like a stereo is playing at an 11 or 12 and they can’t turn it down, at all. So it makes it very hard for their body to down regulate to be able to go to bed at night. And in those patients they tend to then be more awake at nights, they’ll toss and turn, they’ll think more, they get frustrated. And when that starts to happen, you really don’t sleep even more because you’re making your body tense and your mind is getting more and more active.
And you said, “sleep debt” so, in general, there are patients with insomnia who – many patients with insomnia will actually over report the lack of sleep that they are getting. They are still having insomnia, but it’s seems worse to them than actually it is. So, if they say they’re sleep deprived, they haven’t slept at all in three days; if we actually take them into a lab, most of the time we actually do see they’re sleeping on and off here and there. There might be little episodes of micro-sleeps or naps during the day, but they’re actually getting a little bit of sleep.
And we’ve looked at sleep diaries of patients with insomnia, and they’ll say that they don’t sleep for one or two days. And the body actually has a natural function, after about the third day to start catching up and you get a little bit more sleep the third night. And that’s usually what I tell my patients. When they start worrying about not sleeping, I’ll say, “Say the mantra to myself; if I don’t sleep tonight, I’ll likely sleep tomorrow, and if not tomorrow then definitely the third” because our body has a way of naturally catching up.
Question: How can we treat insomnia?
Shelby Harris: So there’s a few different ways that we treat insomnia. The first thing that we always do is we look at the cause. So, more times than not, but not every time, it can be linked to a medical problem, such as menopause, cancer, chronic pain, it can be linked to anxiety and depression. Those are the more common causes. There are some patients who just have insomnia and they’ve had it since they were a kid and we don’t quite know why. So when we look at the cause, we definitely want to treat whatever else is going on, but insomnia often because it becomes its own diagnosis and that requires its own treatment. So if somebody has chronic pain, we want to manage the pain, but we still want to treat the insomnia separately. So what we’ll tend to do in our sleep lab is we’ll do a thorough evaluation and we usually have myself, who is a Psychologist and a Sleep Behavioral Sleep Specialist, I treat the patients first. So we try not using medications initially, and we use something called **** behavioral therapy for insomnia. This changes behaviors people do in bed, none of the tossing and turning. I’ll work on patient’s thoughts about sleep, “So I must get eight hours of sleep tonight or I won’t sleep tomorrow.” That sometimes – or “I won’t function tomorrow.” That sometimes makes it very difficult for you to sleep at night. We’ll work on relaxation strategies and also changing the times you go to bed will actually make them sleep a little bit less for a few nights so their body’s natural sleep drive starts to kick in. That is very effective in about 60% to 70% of patients who do it, four to eight sessions, not even every week; it works for 60% to 70% of patients. The rates are just a good as all the medication that are out there, and the rates are actually better in the long term.
The other option we have are medication treatments. So you’ll have the treatments such as Ambien, Lunesta, Sonata, and we’ll also have Rozerem and for some patients we use Benzodiazopine/Clonazepam. Things like that to help with anxiety. Those are another option that we’ll use. Sometimes we’ll use them in combination with behavioral, sometimes alone. It really depends upon the patient.
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