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Gregg D. Jacobs, Ph. D., is an insomnia specialist at the Sleep Disorders Center at the University of Massachusetts Medical School. As a senior scientist at Harvard’s Mind/Body Medical Institute and an assistant professor of psychiatry at Harvard Medical School, he spent almost twenty years treating and researching insomnia. More information on the studies supporting his program is available on his Web site, www.cbtforinsomnia.com.
|Preface: The New State of Sleep Science||p. xiii|
|Introduction: Conquer Insomnia and Change Your Life||p. xxix|
|You Can Say Good Night to Insomnia||p. 3|
|Some Basic Facts About Sleep and Insomnia||p. 12|
|Putting Sleeping Pills to Rest||p. 27|
|Conducting Your Own Insomnia Self-Assessment||p. 43|
|Changing Sleep Thoughts and Behaviors|
|Changing Your Thoughts About Sleep||p. 69|
|Establishing Sleep-Promoting Habits||p. 86|
|Lifestyle and Environmental Factors That Affect Sleep||p. 100|
|Managing Insomnia by Managing Stress|
|The Relaxation Response||p. 125|
|Learning to Think Away Your Stress||p. 148|
|Developing Stress-Reducing, Sleep-Enhancing Attitudes and Beliefs||p. 164|
|Managing Shift Work||p. 183|
|Managing Jet Lag||p. 187|
|Infants' and Children's Sleep||p. 191|
|Additional Relaxation Scripts||p. 197|
|Sources and Suggested Reading||p. 203|
|Table of Contents provided by Ingram. All Rights Reserved.|
You Can Say Good Night to Insomnia
Bedtime is approaching and Alan is dreading it. He knows what tonight will bring: the torment of another night of insomnia.
Each night has become agonizingly familiar. Exhausted, Alan gets into bed and turns out the lights to go to sleep, only to lie wide awake. The harder he tries to fall asleep, the more he tosses and turns and the more tense and frustrated he feels. With the realization that he can’t fall asleep comes a distressing wave of anxiety and stressful thoughts about sleep—"I’ve got to get some sleep or I’ll never function tomorrow!"—and the worries about the problems in his life: tomorrow’s meeting, Friday’s deadline, his company’s downsizing, his mother’s illness. All are made worse by the loneliness and darkness of the night.
Even when Alan finally falls asleep he cannot escape insomnia. After just a few hours, he wakes up and tosses and turns before falling back to sleep just as the sun rises.
When the alarm clock rings, Alan has to drag himself out of bed, angry and depressed in the knowledge that yet another day feeling wiped out, helpless, and desperate awaits him.
Insomnia has become Alan’s living nightmare.
• • •
Does Alan’s ordeal sound familiar? It does for most insomniacs, who live in an interminable state of anxiety concerning insomnia and its effects on their lives. Like Alan, they also feel hopeless, powerless, and trapped by their lack of control over sleep, and they dread what, for most people, is an enjoyable experience—going to bed.
And no wonder. The anger, exhaustion, and irritability caused by insomnia can handicap mood, productivity, coping skills, and family and social life, and deprive insomniacs of a sense of joy and well-being. They grow even more frustrated or depressed by family or friends who tell them "it’s all in your head" or "just relax," and may start to wonder whether they have a "psychological" problem. As a consequence, insomniacs feel embarrassed or even ashamed about their condition, which diminishes their self-esteem.
Doctors and Sleeping Pills
It is stressful enough to endure insomnia, but many doctors’ reactions to it can make it even worse. They frequently don’t ask about insomnia, overlook it, or simply ignore it. Why? Because insomnia is so ubiquitous that it is often dismissed by doctors as an unavoidable and normal part of life!
Doctors are not trained to diagnose or treat insomnia. Even though it is one of the most frequent health complaints today, doctors receive less than one hour of training on sleep problems during their entire medical education. This lack of training is compounded by the fact that, until recently, little federal funding has been allocated for insomnia research, which means that information about treating insomnia is not available to doctors in medical and scientific journals. (Fortunately, Congress and the National Institutes of Health have started to appropriate more money for sleep and insomnia research, as evidenced by the decision to fund my own research for four years.)
It is easy to understand why doctors are not comfortable treating insomnia. And when they are not comfortable treating something, they are inclined to avoid it. As Dr. William Dement, an international expert on sleep disorders and director of the Sleep Clinic at Stanford University School of Medicine, explains, "Most physicians dread the arrival of a chronic insomnia patient. If one asks a large group of doctors if any of them enjoy managing chronic insomnia, not a single hand will go up." It is no wonder that the vast majority of cases of insomnia go undiagnosed and untreated!
There is another reason insomniacs can’t turn to their doctor for help: medicine has not developed an effective treatment for insomnia. Until recently, the only medical treatments available were sleeping pills such as Halcion, Restoril, Dalmane, Xanax, Ativan, Klonopin, and many others. Sleeping pills, however, are no longer considered a safe or appropriate treatment for chronic insomnia because they can have serious side effects that far outweigh their benefits; are only moderately effective for insomnia and stop working over time; strengthen the belief that the cure for insomnia comes from external factors; and can lead to physical or psychological dependency, which can cause feelings of helplessness, loss of control, and lowered self-esteem.
Most important, sleeping pills don’t cure insomnia, because they don’t treat the causes of insomnia. Consequently, if you rely on sleeping pills, your sleep may improve while you take the pills, but as soon as you stop, your insomnia will return, thereby sustaining the cycle of insomnia and sleeping pills.
Given everything we know about the drawbacks to sleeping pills, why do so many doctors still prescribe them? Partly because when doctors are busy and don’t know what to do about insomnia, sleeping pills are a fast and easy solution. Another reason is the pervasive influence of drug companies, which sponsor scientific conferences, advertise in medical journals, send sales personnel to doctors’ offices, supply free samples of sleep medications, and fund research studies that pay part of doctors’ salaries. Therefore, doctors may be subtly influenced to prescribe the sleeping pills that the drug companies manufacture.
Doctors also prescribe sleeping pills because of the predominant attitude in medicine today that drugs are the best treatment for health problems. This drug-oriented approach, which focuses on treating the body, has worked well for acute and infectious illnesses.
However, it has been largely ineffective in the treatment of today’s chronic health problems such as stroke, heart disease, arthritis, cancer, insomnia, chronic pain, and mental illness, in which emotional, behavioral, and lifestyle factors play a prominent role.
Psychotherapy and Over-the-Counter Sleep Aids
Not surprisingly, 85 percent of insomniacs never seek medical help. Insomnia has become an epidemic affecting desperate, silent sufferers who, believing that their doctors can’t help them or will prescribe habit-forming prescription sleeping pills, have been left to fend for themselves, typically spending years battling the problem futilely and suffering needlessly.
You may be one of the many insomniacs who have turned to expensive, time-consuming psychotherapy in your belief, or perhaps your doctor’s, that insomnia is caused by "psychological problems." Not only does this belief induce feelings of helplessness and diminished self-esteem; there also is no scientific proof that psychotherapy is effective for insomnia, in large part because the majority of insomniacs do not have a psychiatric problem such as anxiety or depression. This is why trying to treat insomnia as a problem caused by psychiatric factors is destined to fail and only contributes to the stigma of insomnia being a "psychiatric" problem.
Millions of other insomniacs have turned to a slew of new over-the-counter nighttime sleep aids such as Tylenol PM, Excedrin PM, and Anacin PM, whose manufacturers have capitalized on this epidemic. These products, cloaked in the brand names of trusted medicines, avoid the stigma associated with prescription sleeping pills. Consequently, they are one of the fastest-growing classes of health care products today, with sales soaring to over $100 million in 1992. Yet, in truth, there is no scientific evidence that these medications are any more effective than a sugar pill!
Like prescription sleeping pills, over-the-counter sleeping aids can have unwanted side effects, lose effectiveness over time, and bolster the belief that the cure for insomnia comes from something external, which can foster psychological dependency and feelings of helplessness. Most important, these sleep aids don’t cure insomnia because they don’t treat the causes. Therefore, if you stop taking over-the-counter sleep aids, your insomnia will return.
Insomniacs spent an additional $200 million annually on one recent self-help craze for insomnia: melatonin. Health fads are nothing new, but rarely does one strike with the force of "melatonin madness," which hit its peak in 1995. Advertised at drugstores with signs proclaiming we have melatonin and extolled by the media and national magazines and books as the cure-all for insomnia, melatonin has also been trumpeted as a cure for heart disease, diabetes, depression, and aging. Demand for melatonin was so high that for almost a year vendors had a hard time keeping it in stock.
As we will see, however, the exaggerated claims about melatonin’s benefits for insomniacs go far beyond established scientific evidence. It turns out that these claims are based on only a few selected studies, one of which was conducted by a scientist who owns a company that sells melatonin. What insomniacs do not know is that there are just as many studies showing that melatonin has no consistent beneficial effect on insomnia. Consequently, the public has been given an unbalanced picture about the present state of knowledge concerning melatonin, knowledge that is woefully incomplete. Therefore, if you are using melatonin, you are assuming unknown risks.
Why are insomniacs willing to spend money on melatonin and gamble their health on unproven claims about its effects on sleep? Probably because melatonin is available over the counter, is inexpensive, is promoted as "natural" (lead is also natural, yet can be dangerous), and because the lure of a fast and easy panacea for insomnia is irresistible.
Although melatonin may ultimately prove to be effective for some insomniacs, you are risking your health by using it. You are also relying on something external, which only leads to dependency. And because melatonin, like all drugs, does not treat the causes of insomnia, your insomnia will return if you stop taking it.
A Breakthrough in the Treatment of Insomnia
The only true hope for insomnia sufferers is the development of a safe, natural, and effective drug-free treatment that addresses the causes of insomnia. This program has not existed—until now.
Based on ten years of research and clinical practice that I have conducted at Harvard Medical School, the groundbreaking program presented in this book is the only drug-free program scientifically proven to conquer insomnia. The results are extraordinary: 100 percent of insomnia patients report improved sleep and 75 percent become normal sleepers as a result of this program; improved sleep is seen to be maintained or even enhanced at long-term follow-up; and insomniacs fall asleep faster using this program than using sleeping pills.
The program is also natural, easy to learn, and practical. It has no side effects, yields results that last, optimizes empowerment and self-control by demonstrating that the cure for insomnia resides within you, enhances mind-body control, and improves health and well-being.
Why This Program Is Different
My insomnia program achieves its remarkable results because it is based on a simple yet powerful concept: insomnia can only be treated by addressing all the underlying causes. In most instances, the causes of insomnia are thoughts and behaviors (habits) that are learned and can be unlearned. Some examples include:
• Attitudes and beliefs about sleep
• Negative, stressful thoughts about insomnia
• Feelings of loss of control over sleep
• Inadequate exercise or exposure to sunlight
• Going to bed too early or sleeping too late
• Trying to control sleep rather than letting it occur naturally
• Negative responses to stress
• Lying awake in bed, frustrated and tense
The following story, about one of my patients, illustrates the idea that insomnia is caused by thoughts and behaviors. Does her experience sound familiar?
Carol was a forty-seven-year-old nurse whose insomnia began after the death of a close friend. After experiencing sleeplessness for a few weeks, she started to worry about it, which only made it harder for her to sleep. Carol also began "trying" to fall asleep, which backfired and made her more wide awake, tense, and frustrated.
After a month of sleepless nights, Carol began to expect that she wouldn’t sleep, which caused her to fear going to bed. Although Carol had exercised for years, she became so fatigued from insomnia that she stopped exercising. She also began to try to catch up on sleep by spending more time in bed and sleeping late on weekends, all of which seemed to make her sleep worse.
Carol became so desperate that she began drinking a glass of wine or taking a sleeping pill to fall sleep, both of which disturbed the quality of her sleep and made her feel guilty and out of control. Her preoccupation with sleep, coupled with the stress of diminished performance at work, only compounded her insomnia. It wasn’t long before Carol began to wonder if something was wrong with her mind and whether she should visit a psychiatrist.
By the time Carol came to see me, she was sleeping less than five hours per night and had been experiencing insomnia for several years. As a result, she always felt exhausted and irritable and was becoming depressed. She perceived her bed as the "enemy" and wondered whether she would ever sleep well again.
Carol then entered my Insomnia Program at Deaconess Hospital. After just a few days in the program, her sleep started to improve. After six weeks, she eliminated sleeping pills, fell asleep easily, and stayed asleep. As a result, she was able to sleep over eight hours per night, awakened refreshed, and "loved her bed again." She also felt more empowered, more confident, and had more control over her mind and body. Even Carol’s husband remarked that she was like a new person!
• • •
Larry was another patient who came to my program suffering from insomnia. He was a fifty-year-old attorney whose insomnia began during law school. Although Larry could fall asleep easily, he frequently awoke during the night and would lie awake for hours. When Larry came to see me, he had been experiencing insomnia for more than five years and was sleeping about four hours per night, leaving him feeling wiped out, frustrated, and desperate.
After two weeks in my program, Larry slept through the night for the first time in years. By the time he completed the program, he was sleeping nearly seven hours per night and was able to fall asleep again easily if he woke up. Larry was calmer, more energetic, and more productive during the day and also felt more control over his emotions and health.
Carol and Larry achieved their remarkable success by learning a variety of nondrug techniques:
• Viewing insomnia as a learned problem that can be unlearned
• Changing negative, stressful thoughts about sleep
• Managing stress more effectively
• Eliciting the relaxation response, an inborn biological response that allowed them to voluntarily produce the brain-wave patterns that induce sleep
• Using the power and biology of positive beliefs about sleep
• Strengthening the brain’s sleep rhythm by reducing excessive time in bed and getting out of bed at the same time every day
• Receiving exposure to bright sunlight and exercising at specific times of the day
• Unlearning the habit of trying to sleep
• Using naps to boost mood and performance
• Developing a sense of control over sleep
Carol’s and Larry’s cases illustrate that insomnia can be conquered only by addressing all the underlying causes, which, in most cases, are thoughts and behaviors. Sleeping pills and psychotherapy don’t effectively treat insomnia because they don’t treat the thoughts and behaviors that cause insomnia; they reinforce dependency on external solutions, which minimizes self-control and empowerment.
You, too, can improve your sleep and your life the way Carol and Larry did. The rest of this book will show you how.
Excerpted from Say Good Night to Insomnia by Gregg D. Jacobs.
Copyright 1998 by Gregg D. Jacobs.
Published in 1999 by Henry Holt and Company.
All rights reserved. This work is protected under copyright laws and reproduction is strictly prohibited. Permission to reproduce the material in any manner or medium must be secured from the Publisher.