Your Complete Sleep Guide
Sleep problems are extremely common, even in normal times. Add in a fear about COVID-19, social unrest, an election cycle and severe structural issues like racism, economic problems and other life stressors and you’ve got yourself a recipe for insomnia.
What is insomnia?
Insomnia is persistent difficulty falling or staying asleep that interferes with your ability to do the things that make your life meaningful. Everyone has a bad night’s sleep from time to time, but it’s not considered “insomnia” unless the sleep difficulties show up 3 or more nights of the week, and persist for months.
Whether you meet the clinical criteria for “insomnia” or have just had a bad week of rest, you can use the following strategies to improve your sleep quality.
Associate your bed with sleep
If you have pets, you understand how quickly two things can become associated with one another. A dog can see you holding a leash, and immediately understand that he’ll be going for a walk. A cat can hear you get the treat bag out from across the house and know immediately she’ll be having a snack. That mental pairing-up of two things is called “association” and it’s one of the primary ways our brains learn what to instruct our bodies to do, and when. Ideally you should have a strong association between sleep and your bed: when your head hits the pillow, your brain should associate that sensation with being tired and falling asleep.
One major problem comes when we confuse our brains into thinking the bed isn’t associated with sleep. If you have a dog, you’ll know that if you randomly carry the leash around all week, the dog will no longer get excited about going for a walk when he sees it. And if you played a recording your cat’s treat bag rustling on loop, she’d eventually just ignore it.
When we watch TV, look at our phones, read, do crossword puzzles, get the laptop out and work, or hang out talking on the phone in bed, our brains can’t possibly associate the bed and the bedroom with sleep. As a result, when your brain hits the pillow, it doesn’t know what to do. Should it start dialing a phone number? Should it start analyzing that new project for work?
This is why so many sleep experts recommend you use the bed for sleeping, sex, and nothing else. Take the TV out of your bedroom, and do your reading, talking, working and browsing somewhere else, like on your couch in the living room or at least in a lounge chair.
Inevitably when I give this recommendation to patients, one will say “but I can’t sleep without the TV on!” To that I will say that if you feel you are getting excellent sleep all the time with your current strategies, you can stop reading this and get back to it, you rockstar. Otherwise, it is very, very unlikely that your brain is so unique that these universal principles of human learning don’t apply to you. I’ll go over more about the TV issue later, in the section “Yeah Buts.”
Stick to the Schedule
Just like it’s important for your brain to associate your bed with sleeping, your brain should also associate certain times of the day with being awake vs. being asleep. You may already have this type of time association with hunger and eating. If you’re like most people, you eat around the same time of day, every day. Lunch is always at 12:00pm, dinner is always at 6:30pm, and maybe you have a snack at 2:00pm. If the time your body associates with eating comes and goes, even if you’ve already consumed enough calories for the day, your body will let you know with a strong urge to eat.
The same thing can happen with sleep, if you stick to a schedule. The goal is that when your normal bedtime comes, your body is so used to falling asleep at that time, that it just naturally zonks you out. Avoid changing your bedtime or wake-up time, even if you want to sleep in on the weekends. If you sleep in, you may feel better temporarily, but ultimately your sleep schedule will end up out of whack, which is exactly what is causing the sleep deprivation that you are trying to make up for in the first place. If you’re always tired but you’re sticking to the same daily schedule, try increasing the amount of time you sleep by moving up your bedtime by 15 minutes at a time, until you feel rested when you wake up.
Good Sleep is Built During the Day
The quality of your sleep at night has a lot to do with your activities during the day. If you spend all day napping, it actually results in your brain doing an internal “calculation” that you don’t need to sleep anymore, resulting in impaired sleep at night (literally there is a part of your brain that tracks how much time you’ve spent awake and in bright light – it’s called the Suprachiasmatic Nucleus, in case you want to impress your friends with some trivia). To ensure your brain “calculates” that you should fall and stay asleep at night, you need to stay awake throughout the majority of the day, and get plenty of exposure to bright, natural (or natural-seeming) light. This means exercising, going on a walk in the morning, leaving your lights on during the day, and avoiding naps are all critical to building up enough sleepiness to get good rest at night.
Humans have a tendency to short-circuit our natural sleep rhythms by using substances to help us perk up. Coffee, tea, chocolate and sodas all contain caffeine, which helps us feel alert. However, caffeine absolutely can prevent good sleep at night. I recommend you stop eating or drinking anything containing caffeine no later than 2pm. If you take any medications that make you feel alert, like ADHD medications, take those early in the day as well. Nicotine, found in vape pens, cigarettes and smokeless tobacco, is also a stimulant and can impair sleep. I recommend quitting smoking to help with sleep and for a variety of other health benefits.
Winding Down
You probably already have some form of bedtime routine, but is it working for you or against you? A good wind-down routine should help you feel more relaxed, calm, and signal to your brain and body that it is time to sleep. Modern conveniences, like lights, TVs, phones and tablets all emit bright light that can make us feel more alert, impairing sleep. Consider the following routines:
Routine A: Ten minutes before bed, you brush your teeth while scrolling through Twitter. You realize you forgot to send an email earlier and while lying in bed, check your email and send the forgotten message. You then text your crush and desperately try not to check if she’s texted back while you mentally run through your checklist for a presentation tomorrow.
Routine B: Thirty minutes before bed you plug your phone in and turn off the TV. You do a few quick stretches and then hop in the shower, playing relaxing music while you wash. You get out of the shower, towel off, and get in bed. With the lights low, you do 3-5 minutes of meditation and then roll over to go to sleep.
Which one do you think promotes sleep? Which one is closer to what you’re currently doing?
I recommend you turn off all phones/tablets/TVs at least thirty minutes before bed, or an hour before if you have difficulty falling to sleep at night. If right now your “wind-down” routine includes watching TV, or looking at your phone in the dark in your bed, your routine is working against you, not for you.
An optimal wind-down routine should include something to help your body relax, and something to help calm any racing thoughts or worries in your mind. Meditating, taking a bath, praying, writing in a journal, working on a puzzle, listening to relaxing music or reading are all good options.
Keep in mind your brain does not have a sleep “switch”. It cannot just shut off and be ready for sleep. Your brain needs to go through an elaborate series of “wind-down” steps before it is relaxed enough to fall asleep. Make sure your bedtime routine allows for 30 minutes to an hour of relaxing, low-light, relaxation.
By the way, if you enjoy a cup of hot tea before bed, go for it! Just make sure it’s decaffeinated. If you enjoy the warm sensation of drinking something hot before bed, you can also try taking a bath or shower before bed. The brain naturally associates a drop in body temperature with sleeping, and you can mimic that drop it by warming your body internally or externally with a drink or bath, and then allowing your body temperature to drop naturally. For many people, this body temperature hack does wonders for falling asleep more easily.
How to Handle Difficulty Falling to Sleep
Once you’ve built up enough sleepiness through good sleep behaviors during the day and wound down with an ideal nighttime routine, you should have an easier time falling asleep. However, some people may still have trouble falling asleep. Pay attention to what seems to be keeping you awake. Are you thinking or worrying about the past or future? Is your mind racing with ideas or to-do list items? Are you replaying an embarrassing moment when you told your waiter “You too!” after he said “Enjoy your meal!” (been there!). If that’s the case, you need to double-down on your brain wind-down strategies before bed, and you may need to even meditate while in bed. Check out the section on meditations for a few ideas.
If you really can’t sleep and you’ve been lying in bed for 20 minutes, get back out of bed, return to your couch or chair, and do something relaxing until you become sleepy again. Be sure not to look at your phone, turn on the TV, or turn on any overhead lights. Listening to a book on tape, meditating, praying, or listening to relaxing music are all good options. You can repeat this strategy as many times as you need to. If you can’t sleep, get up and relax a while. Once you’re sleepy, return to bed. If you still can’t sleep or if you fall asleep but wake up, do it all again. Once your brain truly understands that the bed is only associated with sleep, and not with working, worrying or planning, you’ll be able to fall and stay asleep more readily. Remember, associating your bed with sleep is critical, and lying awake in bed worrying about how you’re not sleeping will just confuse your brain into thinking the bed is a place where you worry.
How to Handle Waking Up at night
What if you do finally fall asleep, just to wake up again? First, don’t panic, and do not look at your phone. If you have an alarm clock in your room, turn it around so that you can’t look at the clock. “Clock watching” when you wake up and calculating in your mind just how tired you’ll be when it’s time to get up will only make you feel anxious, which will make it harder to fall back to sleep. Instead, try meditating in your bed, praying, or simply closing your eyes and feeling the sensation of your weight in the bed. If you’re still awake after 20 minutes of doing that, get out of bed, go to your couch or lounge chair, and do one of your wind-down activities with as little light around as possible. When you feel sleepy again, go back to bed. You can do that as many times as you need to. Remember, associating your bed with sleep is critical, and lying awake in bed worrying about how you’re not sleeping will just confuse your brain into thinking the bed is a place where you worry.
Setting yourself up for success
Your bedroom should be a peaceful, dark, cool and quiet space that promotes sleep. Common things in the bedroom that sabotage sleep include lights from TVs, night lights, or bright street lights outside. Try turning off the TV, any night lights, and turn around your alarm clock if the display is bright. Other sleep interrupters include children, pets, noises, phone notifications, and needing to use the restroom. For the bright lights, you can try adding blackout curtains or using a face mask at night. For bothersome noises, like pets or neighbors, try using soft earplugs. Set your phone to “do not disturb” mode overnight, so any new messages, calls or notifications don’t make your phone screen light up. To avoid needing to use the restroom overnight, get plenty of hydration early in the day, and stop drinking most liquids around 8pm. If you always get up at least once at night to use the restroom, light your way with dim, red-tinted lights, rather than turning on any bright white overheads. Red lights are less stimulating than white lights, and can help you see without making you feel too alert.
Meditating
If you’re planning on skipping this section because you think meditating is nonsense, I strongly encourage you to continue reading. Some quick background on me: I was (and still am, to some degree) a highly anxious, perfectionistic worrier with insomnia. I never liked the idea of meditating because I felt that it was 1) nonsense, 2) for people who did goat yoga on farms for fun, and 3) would be a waste of my time. I was so, so, so wrong. Please learn from my mistake. At first, meditating was really scary and uncomfortable because I had spent a lifetime training my brain to think constantly about future plans, past problems, and to-do list items. But, as soon as I relaxed into meditating, it helped tremendously with my sleep problems (and anxiety!).
Meditating might sound silly, but its importance for sleep is now backed up by so much scientific evidence that it’s overwhelming. If you’re “just not a meditator” and are having sleep problems, this would be a good time to set aside your biases and give it a shot. The good news is its free and has no side effects, so if you try it for a few weeks and still don’t like it, you’ve lost exactly nothing.
My personal favorite meditation app, if you’re into that kind of thing, is Calm. I also have friends who swear by Headspace. If you’re low tech, you can find printable meditations online, or if you don’t want to pay for an app you can pull up YouTube and listen to free meditations there.
There are all different kinds of meditations, including those focused on managing thoughts, those focused on your physical sensations, those focused on the breath, and more. If you try a meditation and find it wasn’t your cup of tea, keep trying different types of meditations until you find one you like. There’s something out there for everyone.
Meditating is, at its core, just a way of detaching from all the chatter in your mind so that you can stop getting “wrapped up” in your thoughts. Our brains chatter at us all day to remind us of things, narrate our reactions, warn us about upcoming dangers, and generally help us process the world around us. Brains never stop chattering – it’s just what they do. Just like our skin protects our insides from our environment, and just like our liver filters out toxins and other junk from our bodies, our brains chatter. They are the chatter organ and it’s not reasonable to get them to completely stop chattering at us, just like we wouldn’t ask our livers to stop processing or our skin to stop protecting us. But brain chatter isn’t useful when it’s time to go to sleep. With meditation, we can get learn how to get less wrapped up in all the chatter. It’s like the difference between having the radio on in the car and listening to it intently, versus having the radio on in the car but at a low volume and not really listening. Meditation helps us “turn down the volume” on the chatter and not get wrapped up in whatever the brain is going on about.
Common “Yeah Buts” and How to Defeat Them
More often than not, when I give these same sleep recommendations to my patients, I get at least one “Yeah But”. “Yeah Buts” are things that we say that protect us from having to actually do the hard work of changing our habits. Below are some common “Yeah Buts” and how to get past them:
“Yeah, but I can’t sleep without the TV on.”
I know it seems like the TV helps some people sleep, but the truth is the TV is just a) acting as a cover for the brain chatter, or b) covering up other bothersome noises. Nine times out of ten, it’s option “a”: The TV is covering up our unpleasant brain chatter. The TV distracts us from our own thoughts so we don’t have to try to manage them ourselves, and thus it can seem like it’s helping us sleep. In reality, the TV is providing too much stimulation in the form of light and sound. If the TV seems to help you sleep and it’s uncomfortable being alone with your thoughts without it on, it’s your racing thoughts that are the problem. If you’re one of the few for whom the TV is simply covering up bothersome noises, you can try a noise machine at night, which won’t produce the lights or other variable noises. But I suspect you’ll have to do some serious meditating and really crank up your wind-down routine in order to effectively deal with the brain chatter before you can get high quality, restful sleep.
“Yeah, but I need alcohol/addictive sleep aids/other substances to sleep.”
If you’re regularly relying on a substance to force yourself to fall asleep, it’s going to be a long road to being able to fall asleep without it, but worth it in the end. Alcohol in particular, even in small amounts, can make us feel tired and help us initially fall to sleep. The problem is, it then disrupts sleep quality to such an extreme extent that the sleep we get even with only one drink in us is extremely poor. If you’re using a substance to fall asleep, try cutting back slowly over time. If you’re taking a habit-forming sleep medication like a benzodiazepine (Xanax, Ambien, etc.) work with your physician to slowly lower your dose over time while committing fully to all the rules in this guide. You’ll be able to break free from the substance dependency with time, and the freedom of that, plus the improved sleep quality, will substantially improve your quality of life.
“Yeah, but I’ve tried everything and it didn’t work.”
As my friend Dr. Janssen would say, “Did you though? Did you really?” The problem with trying sleep advice is that we usually take bits and pieces of the advice, and try it intermittently for a few days. When that doesn’t work miracles, we conclude that it’s us who must be broken, or the advice was bad to begin with. Sleep improvement can take weeks or even months. The brain needs to literally re-grow new pathways as you train it to fall and stay asleep in a certain place at a certain time. That doesn’t happen overnight (hah!) and it certainly doesn’t happen when you just pick and choose which sleep recommendations to follow. If you follow the full program for several weeks and still have serious problems sleeping, then you might want to see a sleep psychologist and/or go to the sleep physician to rule out any underlying neurological problems or genetic sleep disorders.
Getting More Help
evidence-based treatment
If you have done absolutely everything you can think of to get better sleep, including the tips included in this guide, it may be time to get professional help. You might think that heading to your primary care physician is the first step, and you can certainly do that. However, did you know that the first-line treatment for insomnia is actually talk therapy, using an evidence-based therapy called Cognitive Behavioral Therapy for Insomnia (CBT-I)? In many cases, CBT-I alone alleviates insomnia without the need for medications in a matter of a few weeks. If your therapist and your physician work together, you can also try medications to help you sleep.
Learn more about finding and choosing a therapist here.
Medications
Taking medications for sleep seems like a good idea. They’re usually not expensive, they can work quickly, and they immediately solve the problem of needing to fall asleep. The problem is that depending on the medication, they can be habit-forming, which means over time you come to rely on them to be able to sleep. Then, you can build up a dependency on them, meaning that without them, you cannot sleep at all. Finally, they become less effective as your brain and body get used to the substance. You might need more and more until finally, they stop working completely. At that point you both desperately need them to sleep but they don’t work anymore. That’s a pickle. Rather than falling into that trap, avoid the urge to seek the easy solution and use the above strategies to build quality sleep naturally.
melatonin
Some sleep medications do exist that don’t have the above problems. One is melatonin, which is a natural substance produced in the pineal gland in the brain that helps your brain know when it is day and when it is night. Melatonin helps your brain keep track of the day/night cycle and encourages you to be asleep during the night and awake during the day. Melatonin can be taken safely as an over-the-counter option by most people.
The thing about melatonin you should know is that it doesn’t work instantly, like some other sleep drugs. Rather, it kicks off a cascade of internal events in your brain that eventually results in sleepiness. Remember, melatonin is a substance that keeps track of day/night cycles. So, it’s important to take melatonin at the time when the sun would naturally be going down, not when you want to go to sleep. Between 7-8pm is often a good time for most people to take melatonin. If you take it too late at night (at 2am when you can’t sleep, for instance) it can really throw off your sleep cycle. Melatonin should only be given to adults. A “dose” of melatonin starts at about 3mg and can go up to 10mg. Any more than that and you can have unhelpful side effects that can impair sleep or, at the extreme, cause an overdose. The general advice is to start “low and slow” and build up to the dose you feel comfortable at, not to exceed 10mg unless directed by a physician.
Antidepressants
Some antidepressants can cause drowsiness, and if you are prescribed one and also have difficulty sleeping, your physician may direct you to take it before bed. Additionally, because sleep problems can be a symptom of depression, treating depression can help alleviate sleep difficulties.
Conclusion
Sleep problems are extremely common, but the good news is they are also extremely treatable. If you’ve had enough with feeling exhausted all day and staring at your ceiling at night, take the above strategies and use as many as you can, overhauling your entire night routine and redecorating your bedroom, if need be. If that doesn’t work, know that there’s still lots of hope and seek out a sleep psychologist for CBT-I. Once your sleep is great, you’ll find your mood, productivity, and health improve too. Good night!
Be Well,
