TCPR: You wrote an excellent book on non-pharmacological approaches to insomnia, and I’d like to go over some of the techniques you suggested. What are some practical techniques that psychiatrists can use in the context of short visits with patients?
Dr. Breus: The first thing is to give patients some sort of a sleep hygiene worksheet. This is pretty standard advice, and most clinicians have these around and give them out, but, in all honesty, many of them are not particularly effective, because they tend not to be realistic. If I told every one of my patients that they could never drink caffeine again and that they had to go to bed at 9 o’clock in a perfectly darkened room and that they could never drink a glass of wine in the evening, I wouldn’t have very many patients left.
TCPR: So describe your more realistic approach to sleep hygiene.
Dr. Breus: I begin talking about nicotine. I tell my patients who smoke that they should not try to stop smoking and fix their sleep at the same time, because it doesn’t work. People who are undergoing smoking cessation are miserable – they have headaches, they are nauseous and they don’t sleep. If you smoke and you have problems sleeping, pick one or the other to work on.
TCPR: In addition to limiting nicotine intake, most standard sleep hygiene sheets discourage caffeine use.
Dr. Breus:I tell patients to taper their caffeine throughout the day. If you can get yourself under about 200 or 250 mg of caffeine, that is pretty good. The National Sleep Foundation uses that as a recommendation. Don’t ever tell somebody to go cold turkey off caffeine because it is a nightmare.
TCPR: Give us some benchmarks for what 200 or 250 mg of caffeine translates to.
Dr. Breus: If you have a regular brewed cup of coffee at your home, depending upon the bean that you choose, you could have anywhere from 110 to 180 mg of caffeine in one cup. A bottle of cola contains 60-65 mg of caffeine. The National Sleep Foundation web site has a handy caffeine calculator (http://www.sleepfoundation.org/atf/cf/%7BF6BF2668-A1B4-4FE8-8D1AA5D39340D9CB%7D/caffeine.pdf). I tell people to start with their highest caffeine content beverage in the morning and to taper down throughout the day. By 2 in the afternoon, patients should switch to fruit juice or water. Chocolate doesn’t have enough caffeine in it to worry about.
TCPR: What about the effects of alcohol on sleep?
Dr. Breus: When you fall asleep after drinking alcohol, you may fall asleep quickly and go right into stage I and stage II sleep, but you get less deep sleep and it affects your ability to get into REM sleep. So I advise people to do the “one-to-one.” This means drinking one 8-ounce glass of water for every one alcoholic beverage. The reason for this is three-fold. Number one, it helps flush out your system. Number two, it slows down the amount of alcohol you drink. And finally, it helps prevent dehydration, which is one of the causes of hangover. The other thing I tell patients is that usually when you are drinking, you are staying out past your bedtime, and so you are giving yourself a double whammy – ingesting something that affects your sleep, and also depriving yourself of sleep.
TCPR: Aside from all these things to avoid, what can patients do in order to improve sleep?
Dr. Breus: Exercise is the single best way to increase the overall quality of your sleep. So encouraging patients to get onto a regular exercise program is crucial.
TCPR: Should they avoid exercising at night?
Dr. Breus: We used to believe that night exercise causes too much autonomic arousal, but the data are very inconsistent. Many patients feel relaxed after exercise and sleep fine.
TCPR: What about the importance of the bedroom environment?
Dr. Breus: I work with my patients in helping them to do an “extreme bedroom makeover.” For example, one of the first things I do is advise patients to decrease the wattage of their bedside lamp bulbs to around 45 watts. I also recommend the use of book lights (especially for the bed partner) and night lights for hallways and bathrooms. Turning on a bathroom light in the middle of the night can initiate the waking process prematurely by decreasing melatonin levels, and obviously we want to avoid that. There are many other bedroom tips for patients, many of which sound obvious, but I’m often surprised by how helpful they can be for sleep. This includes very specific advice about sheets and thread-count issues, pillows, mattresses, the effect of odors, the effect of clutter, etc. [Ed. note: I found Chapter 4 of Dr. Breus book chock-full of practical tips and highly recommend it.]
TCPR: What do you tell patients about sleep restriction techniques?
Dr. Breus: Sleep restriction means reducing time in bed to sleep time only. I tell patients, “I want you to stay in bed only during times that you are asleep. So if you get in bed at 10 o’clock, but you don’t really fall asleep until 12, don’t go to bed until 12:30. If you wake up at 6 and you don’t usually get out of bed until 7, then start getting out of bed at 6. Try to restrict the time in bed to almost less time than you are actually sleeping. So if generally you sleep about five hours because you have insomnia, I only want you in bed for five hours. Also, don’t take any naps throughout the day.” I have patients continue this regimen for seven days in a row. If they are successful, by the end of that period, they are exhausted, and they fall asleep easily.
TCPR: Do you recommend any other behavioral techniques?
Dr. Breus: I also use “stimulus control,” which is an old tried and true Skinner idea – don’t do anything except sleep or have sex when you are in the bed. And the reason for that, of course, is that we don’t want people to associate a poor night’s rest with the bedroom. That said, I certainly don’t insist that patients do nothing other than sleep or sex in the bedroom, since that’s unrealistic. So I might say, “If you want to read in bed, fine. But use a book light as opposed to a bedside table lamp so you don’t have direct light towards your eyes, which would be telling your brain that it is daytime.” As far as the television is concerned, I would say about a third of my patients cannot fall asleep unless the T.V. is on. The reason is that they haven’t had any time throughout the entire day to just sit down quietly with no stimulation, and so when it is finally quiet, they can’t turn their brain off. They watch 20 or 30 minutes of boring T.V. and they can drop off. There is nothing wrong with that. I just advise them to get a T.V. timer so that it shuts off in the middle of the night.
TCPR: How is cognitive behavior therapy (CBT) related to these behavioral approaches?
Dr. Breus: CBT is different because it focuses on changing the way patients think about sleep. Patients might have catastrophic thoughts such as, “Oh my God, I am never going to get a good night’s sleep. I am going to die ten years earlier because of it.” This is very rigid thinking, and a therapist will say, “Let us look at the data that proves to you that that is not true. Now how can we think about this a little bit differently so hopefully we can change some of those thoughts or patterns?”
TCPR: What about relaxation exercises and meditation?
Dr. Breus: Generally speaking, I like to start off with classical Jacobsonian muscle relaxation. I created a meditation/relaxation CD and it is extremely self-explanatory. It basically says, get in bed, get into a dark quiet place, and I start with deep breathing exercises and I move from the deep breathing exercises on to progressive tension and relaxation of the muscles going from the head all the way down to the feet. [Ed. note: Dr. Breus maintains a website, www.soundsleepsolutions.com, which sells various products but also has some useful free resources for patients and clinicians. In addition, he has made a Sleep Hygiene Sheet available to TCPR readers as a free download from our website at www.TheCarlatReport.com.