Mindful

Joan Didion wrote in The White Album, “We tell ourselves stories in order to live.” As she suggested, we search for the hidden kernel of meaning in the shifting phantasmagoria that is our life so we can make sense of what is so often senseless—random gunfire that takes the life of an innocent child, an earthquake that kills thousands, a medical diagnosis that rocks us to our core.

But sometimes our stories become fixed, frozen, unchanging—even when change is both possible and desirable—especially the stories we tell ourselves about ourselves.

Here’s a story that until very recently I told myself about the insomnia that has plagued me for 30 years: “My body doesn’t know how to sleep. There’s obviously something very wrong with me. The only way I can fall asleep is to take a pill, and sometimes the only way to stay asleep is to take another pill. I hate how groggy the pills make me, but I am helpless and powerless to stop taking them. If I try, I’ll never sleep. I’ll be a complete wreck and fall apart and not be able to live up to my responsibilities. Sooner or later the lack of sleep will make me sick and die.”

This was the story I told myself night after night under cover of darkness, believing it to be the absolute, immutable truth, not a made-up tale spinning in my mind. In the morning I’d tell myself another story, depending on how many hours of sleep I’d had, usually ranging from three or four on a bad night to sixish on a good one. Soon after I awoke, I’d feel the rumblings of anxiety about the night ahead. I’d try to calculate: How many Xanax—an anti-anxiety benzodiazepine, my drug of choice—would I need? One? One and a half? Or could I get by with just a half? The panic would build throughout the day and peak as bedtime neared.

Like many stories of sleeplessness, mine began with a single incident. Though in childhood I’d had some anxiety about falling asleep, as an adult I was a pretty solid snoozer. That is, until I was 35 and a neurologist prescribed Inderal, a beta blocker, to treat my persistent migraines. The trouble was, beta blockers also lower heart rate and blood pressure—and my baseline for both was already low. Before long my usual vitality plummeted and I felt so weak and drained of energy that, without consciously deciding to, I began to keep myself awake at night, terrified that if I allowed myself to descend into sleep, I’d never wake up. That became an increasingly vicious cycle: sleep deprivation, exhaustion, insomnia, followed by even greater exhaustion—and mounting terror. I felt on the verge of collapse. But instead of grasping the whole picture, my internist prescribed sleeping pills. It wasn’t until I was rushed to the coronary care unit of my local hospital with a dangerously low heart rate that the problem got sorted out and I was taken off Inderal. But by then my story about not being able to sleep without pharmaceuticals had crystallized.

Still, I worried constantly about the long-term effects of the drugs on my mind and body, and took frequent stabs at rewriting my story. I’d try the latest, supposedly less harmful, wonder drug. When that didn’t work, the natural supplement and herbal sleep aid industry made a pile off of

me. I meditated, aerobicized, did tai chi, qigong, and yoga, consulted acupuncturists, shrinks, energy healers, and Reiki masters. There were even periods—weeks or even months at a time—when, miraculously, I slept unaided. But then I’d have a pressing deadline, an overseas trip, a big meeting and the story would return full-blown. Within a night or two, I was again the victim of my own dark and doom-filled narrative, abetted by my doctors. The prevailing wisdom was that it was better to take a pill and get some sleep than to spend the night tossing and turning. One physician even told me not to worry, I could take a little Xanax every night for the rest of my life, no harm in it.

I wanted to believe him.

• • •

According to the American Academy of Sleep Medicine, as many as 30-35% of adults complain of insomnia. The percentages spike to 40-60% in people over 60. Women are twice as likely as men to have trouble falling or staying asleep—the two sides of the insomnia coin. The disorder is diagnosed when: patients get less than 6.5 hours of sleep; it takes 30 minutes or more to fall asleep, and symptoms persist for at least one month; after six months the diagnosis is classified as chronic insomnia.

The Centers for Disease Control has labeled insufficient sleep a “public health epidemic,” and estimates that 50-70 million adults in the US suffer from a sleep or wakefulness disorder. Only a third of Americans (and almost no one I know personally) get the standard recommended eight hours of sleep a night. In a report issued in 2014, the CDC warned that people who get too little sleep are at risk for increased mortality, as well as chronic diseases such as cancer, diabetes, hypertension, heart disease, obesity, and depression. Sleep deprivation is also strongly linked to impaired immune function.

It’s no wonder. In 2013, researchers at UC Berkeley found that sleep deprivation fires up the brain’s amygdala and insular cortex, regions associated with emotional processing. The resulting pattern mimics the abnormal neural activity seen in anxiety disorders. “These findings help us realize that those people who are anxious by nature [hello!] are the same people who will suffer the greatest harm from sleep deprivation,” said Matthew Walker, a professor of psychology and neuroscience at UC Berkeley and senior author of the paper, which was published in the Journal of Neuroscience.

Another 2013 study, published by the CDC’s National Center for Health Statistics, revealed that nearly nine million US adults take prescription sleep aids, called hypnotics—a number that is on the rise—with women leading the pack. And emergency room visits due to bad reactions to the drugs—especially zolpidem, the active ingredient in Ambien—are also on a steep uptick, having nearly doubled between 2005 and 2010.

The news just gets worse.

• • •

The day I returned home in the fall of 2014 after a trip to Italy, I found this email message from a close friend in my inbox: “You have to STOP taking Xanax NOW!!!”

My friend’s concern was prompted by a new study reported by French and Canadian researchers showing that benzodiazepine use is linked to higher rates of Alzheimer’s disease, and that the correlation increases with greater exposure to the drugs.

“The more the cumulative days of use, the higher the risk of later being diagnosed with dementia,” Antoine Pariente, a pharmacoepidemiologist at the University of Bordeaux and a coauthor of the study, told The New York Times. The researchers found that older adults who took daily doses for 91-180 days had an increased risk of 32%; those who popped benzos daily for more than 180 days had an increased risk of 84%. It didn’t seem to matter whether the number of days patients consumed the drugs took place over six months or five years.

“One physician even told me not to worry, I could take a little Xanax every night for the rest of my life, no harm in it. I wanted to believe him.”

These researchers were talking days, not years, and I’d been taking the stuff for the better part of 30 years—that’s 10,000 days, give or take. I completely freaked out.

What’s more, the risks are just as great for the newer generation of Z-drugs (zolpidem, eszopiclone, zaleplon—i.e., Ambien, Lunesta, and Sonata), as for older benzos like Halcion, Dalmane, and Restoril—and Xanax. In fact, researchers at three universities, including Harvard Medical School, have shown that about half the effectiveness of the Z-drugs is due to a placebo response, making their clinical use highly questionable.

And, I learned from watching UC Berkeley’s Matt Walker in a YouTube video called “The Mysteries of Sleep,” the sort of shuteye you get from taking hypnotics is really sedation, not true sleep—and lacks the essential benefits to the body and brain that occur during natural sleep cycles.

Obviously, I needed a new story—fast. But I knew it wouldn’t be easy.

“Often, when people try to go off these meds, they worry that their bodies won’t be able to sleep on their own and they won’t get as much rest as they need,” said James Lettenberger, a Washington, DC psychopharmacologist whom I consulted when I lived there. “It can definitely be done, but to be successful people need both a strong desire to stop taking the medication, and the belief that they can,” he told me over the phone.

I had the desire, but would I be able to change my belief system—my story—something I’d been unable to accomplish in the past?

• • •

Sick joke: Which is worse, the dementia you get from taking sleeping pills or the dementia you get from sleep deprivation?

At the same time I got wind of the bad news about sleeping pills and decided to taper off the Xanax, I came down with a nasty cold, which turned out to be a stroke of luck. I felt so rotten that all I wanted to do was sleep. And I did—soon, without pharmaceutical help.

I’m cured! I thought to myself. Free at last! The cold went away and still, I slept—about six, sometimes seven, hours. Oh, I’d wake up in the middle of the night, but more often than not I’d drift back. The ease with which this took place seemed like a blessing bestowed by a beneficent universe—especially the falling asleep part, my greatest challenge. A new story was emerging—a fragile chrysalis.

It didn’t occur to me that my turnaround had anything to do with the fact that it was taking place during the holidays. I had no deadlines and few obligations. Then January rolled around and with it, a pressing deadline. The old story came rushing back and took possession of my mind and body like some kind of spooky apparition. Each night became a battle royal between my desire to sleep unaided and the fear that I couldn’t, and the weeks of grace came to seem more like a blip than the start of a new story. Feeling defeated and defective, I reached for my stash of Xanax.

Though I was still determined to sleep drug-free, I cut myself some slack. Clearly, healing my sleep disorder was going to be a process, not a quick fix. And I needed help. I talked to an holistic doctor and an acupuncturist, who each suggested herbal remedies, while my more mainstream internist recommended trazodone, a tetracyclic antidepressant that has some side effects, but doesn’t seem to rot your brain like hypnotics do. These things helped some, as did my morning meditation and a soothing bedtime visualization recording made for me by a psychotherapist. Still, I continued to resort to hypnotics off and on, especially when I felt stressed.

It was obvious I needed more help.

• • •

For the past several years, the gold standard, non-pharmaceutical treatment for insomnia has been Cognitive Behavioral Therapy for Insomnia—or CBTI, which in numerous studies has been shown to be more effective than sleeping pills. In fact, CBTI is now recommended as the number one treatment for chronic insomnia by the National Institutes of Health.

The program is based on a simple concept: Insomnia is caused by learned thoughts and behaviors that can be unlearned or changed. In other words, it deals directly with the story.

So why did it take me so long to check it out? Delusion, perhaps. Another story I told myself, about how I should be able to conquer my insomnia on my own.

Although there are sleep clinics that offer CBTI in the San Francisco Bay Area where I live, I decided to try an online program that’s available to anyone, anywhere. For $44.85, I signed up at cbtiforinsomnia.com and got the five-week program, plus a few extras, including evaluation of my weekly sleep diary by Dr. Gregg Jacobs, an insomnia specialist at the University of Massachussetts Memorial Medical Center.

The basic drill, week by week, is this: 1) education about the stages and functions of sleep; 2) sleep scheduling and stimulus control (i.e., don’t spend too much time in bed awake, and only sleep or have sex there); 3) cognitive restructuring and medication reduction techniques (!); 4) daytime relaxation techniques and stress-reducing attitudes and beliefs; 5) bedtime relaxation techniques and lifestyle practices for improving sleep.

Photograph by Nicky Willcock/Millennium Images, UK
Photograph by Nicky Willcock/Millennium Images, UK

In case I thought I was special, I learned that the themes in my personal narrative were among the 10 most common negative thoughts about sleep, and were addressed head-on. For example, a corrective to I will never fall asleep is My brain wants to obtain my core sleep (5.5 hours—and I most likely will). An antidote to the I will not be able to function tomorrow belief is Sleep loss does not always have a significant impact on my functioning.

All first-rate stuff. I began relying less on the pills and sleeping more or less the way I imagined normal people do. In fact, I thought I was doing brilliantly until I got this email from Dr. Jacobs after submitting my sleep diary. “Your time allotted for sleep (lights out to arising time) was 8.5 hours on many nights. Because you averaged 6.5 hours of sleep, your time allotted for sleep goal should not be more than 7.5 hours from lights out to arising time. Therefore, you need to reduce time allotted for sleep by 1 hour on many nights. This is the most crucial goal for improving your sleep and you did not meet this goal for the past two weeks of this five-week program. If you do not meet this goal this week, you are unlikely to experience significant improvement in your sleep from this program.”

Really? So I read in bed more than half an hour on several nights and lingered a bit in the mornings; is this a crime? Did Dr. J. (or his canned bot) have to be such a scold? Couldn’t he at least comment on how well I was doing, how much less medication I was taking—also noted in my diary? The program was certainly valuable in helping me to reframe my story, but I could have done with a bit more friendly reinforcement.

A newer approach that shows great promise, but is still in the developmental stages, is Mindfulness-Based Therapy for Insomnia—or MBTI. Although both mindfulness meditation and Mindfulness-Based Stress Reduction (MBSR) have been shown to improve sleep quality in adults, MBTI integrates specific behavioral strategies from CBTI with mindfulness meditation practice.

“Insomnia is a disorder of cognitive and physiological hyperarousal, which mindfulness addresses but CBTI doesn’t deal with directly,” said Jason Ong, a psychologist at Rush University Medical Center. This inspired him to combine the strengths of each approach into one program. What’s more, he told me over the phone, MBSR lacks targeted cognitive and sleep hygiene techniques that are key to CBTI. Ergo, Ong recently conducted a randomized controlled trial comparing MBTI to MBSR in patients struggling with chronic insomnia, and found that MBTI showed significantly greater—and longer lasting—benefits in reducing insomnia.

A lot of acronyms, I know. But in a funny way, by practicing mindfulness meditation daily (well, almost) in tandem with CBTI, I have (loosely) been practicing my own version of MBTI.

• • •

“Letting go into sleep is no longer the dark herald of death, imprinted in me so many years ago.”

And, yes, I sleep. Drug-free now for months, I sleep. Not always as many hours as I’d like, sometimes fitfully, yet I sleep. On nights when I’m having trouble, my little herbal cocktail—melatonin and the L’s, tryptophan and glycine—help. On other nights I need to talk myself down, like a parent to an anxious child, placing my hand over my heart and reminding myself that my body does indeed know how to sleep. And when I have a really lousy night, I don’t panic the way I used to. For the most part, sleep has become what it’s designed to be—rest and recuperation for body and brain—and I would add, spirit. Letting go into sleep is no longer (in my most fearful imaginings) the dark herald of death, imprinted in me so many years ago.

The expectation that I will sleep has made all the difference. So has realizing that, like many people who struggle with insomnia, I had swallowed some pretty basic myths. For starters, the notion that we need eight hours of shuteye every night: Recent studies involving over a million people found that those who sleep seven hours live longer than people who sleep eight or more. Even more surprising, sleeping five hours a night is associated with longer life expectancy than sleeping nine hours. And seven (some studies suggest that the range is between 6.5 and 7.5) hours per night appears to be the sweet spot. The same number holds true for preserving memory. A landmark study of 15,000 female nurses conducted at Brigham and Women’s Hospital in Massachussetts found that women who slept an average of seven hours each night had significantly stronger cognitive skills later in life than those who slept less than five hours or more than nine.

Perhaps the most liberating of the debunked myths is the discovery that the belief we hold so dear—namely, that we should sleep undisturbed in eight-hour chunks—is a relatively recent development in human evolution. In 2001 Roger Ekirch, a history professor at Virginia Tech, published a paper revealing a wealth of historical evidence showing that for millenia—until there was artificial light—humans slept in two segments, usually referred to as the first and second sleep. The time between the two chunks was often devoted to prayer, meditation, quiet reflection—and it was also notably the hour when many babies were conceived. Ekirch’s hypothesis, based on 16 years of research, was backed by an experiment conducted by psychiatrist Thomas Wehr, a prominent scientist at the National Institute of Mental Health. In Wehr’s study, subjects were plunged into darkness 14 hours a day for one month. After adapting to the new schedule, they typically slept for four hours, then awoke for one or two hours before falling into a second fourish-hour snooze.

In his new book on the subject, Waking Up to the Dark, author Clark Strand writes: “Recently, as a result of Wehr’s study and others like it, some sleep specialists have reported that the best treatment for the Hour of the Wolf [Strand’s term for middle-of-the-night agita] is to tell patients that nightly waking is natural and, consequently, that they shouldn’t struggle against it. A doctor told me that once he explained this to them, many of his patients simply went to bed earlier each night and never asked him for sleep medications again.”

A glowing new spin on a damaging old story.

Just like the bright new spin on my own story, which continues to unfold.


Sleep Reminders

Here are a few mindfulness principles that you can explore, and recall, if you need help getting to sleep or falling back asleep. These tips are compiled by Jason Ong, Ph.D., a psychologist at Rush University Medical Center who works with Mindfulness-Based Therapy for Insomnia.

Beginner’s mind
Remember: Each night is a new night. Be open and try something different! What you have been doing to this point is probably not working well.

Non-striving
Sleep is a process that cannot be forced but instead, should be allowed to unfold. Putting more effort into sleeping longer or better is counterproductive.

Letting go
Attachment to sleep or your ideal sleep needs usually leads to worry about the consequences of sleeplessness. This is counterproductive and inconsistent with the natural process of letting go of the day to allow sleep to come.

Non-judging
It is easy to automatically judge the state of being awake as negative and aversive, especially if you do not sleep well for several nights. However, this negative energy can interfere with the process of sleep. One’s relationship to sleep can be a fruitful subject of meditation.

Acceptance
Recognizing and accepting your current state is an important first step in choosing how to respond. If you can accept that you are not in a state of sleepiness and sleep is not likely to come soon, why not get out of bed? Many people who have trouble sleeping avoid getting out of bed. Unfortunately, spending long periods of time awake in bed might condition you to being awake in bed.

Trust
Trust your sleep system and let it work for you! Trust that your mind and body can self regulate and self correct for sleep loss. Knowing that short consolidated sleep often feels more satisfying than longer fragmented sleep can help you develop trust in your sleep system. Also, sleep debt can promote good sleep as long as it is not associated with increased effort to sleep.

Patience
Be patient! It’s unlikely that both the quality and quantity of your sleep will be optimal right away.

This article originally appeared in the December 2015 issue of Mindful magazine.
Barbara Graham

Barbara Graham is an author, essayist, journalist and playwright. Barbara is the author/editor of the New York Times bestselling Eye of My Heart: 27 Women Writers Reveal the Hidden Pleasures and Perils of Being a Grandmother, and author of Women Who Run with the Poodles: Myths and Tips for Honoring Your Mood Swings, and most recently Camp Paradox.

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