The Missing ZZZZs

Solving the Problem of Poor Sleep

All day our bodies buzz along, chasing errands and kids, dashing from home to work and back again. Our brains burn down to-do lists and fly through appointment calendars. By the end of the day, our tuckered-out bodies and brains need some rest and time for repair. And so, we fall asleep. Or not.

Insomnia, though it strikes many of us at some point in our lives, can be difficult to quantitatively define, because each person has a unique sleep pattern and sleep need. Duke sleep expert Andrew Krystal, MD, takes a practical approach. “If a person has trouble falling asleep or staying asleep, and her quality of life during the day is impaired as a result, then we consider that insomnia,” he says. “You are the best judge of whether or not you have insomnia.”

Many people who suffer from insomnia develop the problem during a period of stress, illness, or injury. Say, for example, you came down with bronchitis and missed two weeks of work. While you were sick you woke up frequently in the night with chest pain and anxiety about your health and your job. Then, after many days of fitful daytime naps, your lungs healed -- but your sleep was still broken. Krystal says that often a stressful event will cause our behavior to shift in a way that interferes with restful sleep.

If you visited the Sleep Disorders Center at Duke, one of the first tactics to treat your insomnia might be a behavioral therapy that Krystal calls sleep restriction therapy. “We work to maximize the time between when the person wakes up and when she next attempts to sleep,” says Krystal. This is because our bodies have what’s called a sleep drive, which builds up while we’re awake and is discharged whenever we sleep. “Napping during the day takes away from the sleep drive,” he says, “so the longer period of time between periods of sleep, the more likely you are to be sleepy and to stay asleep.”

Duke’s sleep center is one of the few in the country that uses such targeted behavioral therapies to address insomnia. These therapies are not “sleep hygiene”—the oftentried checklist of dos and don’ts to help improve sleeping (do set a fixed bedtime; don’t exercise vigorously within two hours of that bedtime). Behavioral therapy, says Krystal, can help undo deep-seated barriers to restful sleep that have developed over time. “We’re similar to Pavlov’s dog,” he says. “After enough experiences of frustration and anxiety in a sleepless bed, we will begin to feel that frustration and anxiety just by climbing into bed.”

For people who don’t improve with behavioral therapy alone, medications might also be needed. Some physicians are hesitant about prescribing sleep medications, says Krystal, because “many of us were trained in an era where there was not a lot of data -- and therefore a lot of anxiety -- about the side effects and potential addictiveness of these drugs. Now we have data to show that there are medications that are effective and largely safe, but a lot of doctors aren’t aware of that data. My recommendation to people who aren’t sleeping well is to see your doctor. And if he or she doesn’t treat you, see another doctor.”

What's Keeping You Up: Other causes of sleeplessness

Sleep Medicines and Misbehaving: Could It Happen to You?

The spate of stories of reckless driving, eating, drinking, and other bad behaviors undertaken while under the influence of a sleep medication make many people wary about taking these drugs. Krystal says that because sleep medicines often have an amnesia effect, it’s possible that the people in these reports were actually awake during their troubled episodes. “The important thing to remember about these stories is that sleep medications will not cause these sorts of problems in most people,” he says, adding that the question of using medications is a matter of balancing risk and benefit. “The improvement in your function and health may be worth the low risk of side effects. It’s something an individual decides based on his or her situation.”