Help for Insomnia
What is the breathing connection?
Learning to control your breathing can make a big difference in both managing and preventing anxiety and insomnia. Controlled breathing is very calming. It’s a natural sedative. It enhances the autonomic nervous system’s parasympathetic state – the resting state. It’s a wonderful tool to have to calm your mind, calm your nervous system, calm your body and get off to sleep.
The Buteyko method of breathing retraining normalises both daytime and night-time breathing. A return to normal sleep patterns is observed in the vast majority of people who participate in a Buteyko workshop.
Breathing more than the body requires stimulates the sympathetic branch of the autonomic nervous system and places the body on alert mode. Insomnia sufferers typically exist in a permanent state of sympathetic stimulation and while this may go unnoticed during daylight hours, the resulting busy chattering mind limits the chances of a productive sleep.
A Buteyko breathing re-training workshop helps to normalise the breathing pattern, putting the body in a naturally calmer state for optimal sleep. The majority of participants are sleeping better and waking more refreshed within the first two or three sessions.
Insomnia and stress
Insomnia is very closely related to stress in that:
- Stress is one of the most powerful disrupters of sleep.
- Insomnia is one of the first signs of stress.
- Sleep research shows that many of the negative effects of sleep loss, may in reality, be due to the effects of stress.
Virtually all insomniacs have experienced stress-induced nights of insomnia:
- Major stressful life events are the most common causes of insomnia.
- Most people have a harder time sleeping on stressful days.
- Stress plays a primary role in the development of chronic insomnia. This happens because negative thoughts can set off negative emotions that then cause insomnia.
Stress speeds up your brain waves and makes your heart rate and breathing rate more active. Studies have revealed that stress disrupts sleep in two ways:
- Stress reduces deep sleep, which results in lighter, more restless sleep.
- Stress that occurs during the day raises stress hormone levels in the body, even at night.
Since we know that stress disrupts sleep, a lot of research has focused on the use of relaxation techniques for improving sleep. Dozens of scientific studies have shown that relaxation techniques (including breathing techniques) are effective in the treatment of insomnia.
These techniques are effective because they all elicit the ‘relaxation response’, which:
- reduces physiological activity (e.g. slower brain waves, decreased respiration rate and muscle tension)
- is the brain’s antidote to the stress response
The relaxation response improves sleep in 3 ways:
When elicited during the day, the relaxation response counters daily stress responses. This reduces the chance that stress hormones will be elevated at night.
When elicited at bedtime or after an awakening, the relaxation response helps to turn off dysfunctional sleep thoughts, quieten the brain, and relax the body. It helps to quieten the brain by producing a brain wave pattern that’s similar to Stage (1) sleep. Stage (1) sleep is the transition state between waking and sleeping.
During ‘Breathe Well Clinic’ workshops, participants will be instructed on how to elicit the relaxation response. The term ‘relaxation response’ was coined by the eminent American cardiologist Dr. Herbert Benson. If you would like information on how the relaxation response acts as an antidote to the ‘stress response’ and on the Benson technique for eliciting the relaxation response, you can find this in an article I had published in Irish Pharmacist in June 2014. For ease of access, I have pasted this article below.
Counteracting Stress with the Relaxation Response
by Dr. Alan Ruth
When we are under stress, our bodies respond with the fight-or-flight response, also known as the stress response. This response was critical to the survival of our cavemen ancestors when faced with a life or death encounter with a hungry sabre-toothed tiger. The stress response prepared the caveman’s body for action – to either fight or run away.
A primitive response
The primitive fight-or-flight response is still with us today and produces the same physiological changes in the body. Unlike our cavemen ancestors, we rarely face life-threatening situations. However, experts estimate that in modern society, most of us experience between 40 and 50 stress responses per day. The stressors that trigger the stress response nowadays are unlikely to be man-eating tigers. They are more likely to be difficulties at work, financial problems, being stuck in traffic, or a tight deadline that has to be met.
Whenever we are confronted by a threat, whether physical or psychological, real or imagined, the primitive brain (the hypothalamus) is activated to produce the stress response.
Unfortunately, psychological stress in modern times tends to be chronic rather than acute. When our stress mechanisms are chronically activated, the responses that were originally designed to protect us can become harmful, even lethal.
The ability to respond to stress and the ability to relax are equally important in being able to function effectively in the modern world, while remaining healthy. In an ideal world, we would respond to challenges or difficult situations, fast and efficiently and then relax. Unfortunately, many people are better at getting ‘pumped up’ than at relaxing afterwards.
Physiology of the stress response
When a stressor is perceived, nerve impulses from the hypothalamus activate the sympathetic-adrenal-medullary system. This results in an increase in the secretion of adrenaline and noradrenalin from the adrenal medulla. These stress hormones mimic the action of the sympathetic branch of the autonomic nervous system and initiate a heightened pattern of physiological activities. The hypothalamus also releases corticotrophin-releasing factor (CRF). This stimulates the anterior pituitary to secrete adrenocorticotrophic hormone (ACTH). ACTH acts on the adrenal cortex causing it to release corticosteroids. Cortisol is the most important of the corticosteroids in relation to the physiology of the stress response.
The stress response involves the following physiological changes:
- Heart rate accelerates and blood pressure rises
- Glucose and fats are released from the liver
- Breathing becomes faster
- The muscles become tense in preparation for strenuous activity
- Blood coagulability increases
- Perspiration increases
- Saliva dries up and digestion ceases
- The pupils dilate and all the senses are heighted
- The bowel and bladder muscles may become loose
The relaxation response
The relaxation response is a physiological response that is the opposite of the stress response. It has been described as an antidote to stress. The term ‘relaxation response’ was coined by Dr. Herbert Benson, a Mind/Body Medicine Professor at Harvard Medical School.
Dr. Benson conducted a series of studies on practitioners of transcendental meditation and found that when practicing, they showed decreases in metabolism, heart rate, blood pressure, breathing rate, blood lactate, and muscle tension. In addition, normal waking brain wave patterns shifted to predominantly slower patterns. This series of physiological changes, which Benson named the ‘relaxation response’, occur when the mind and body become tranquil. The relaxation response is quite different to sleep and has been described as a wakeful hypometabolic state.
The relaxation response can occur naturally, for example, when lying on a sandy beach soaking up the sun. Normally, however, the relaxation response has to be brought about voluntarily and by intention. A large number of techniques can be used to elicit the response.
These include diaphragmatic breathing, meditation, yoga, repetitive prayer, autogenic training, progressive muscular relaxation, visual imagery, and qigong.
Regular elicitation of the relaxation response can help counteract the harmful effects of long-term daily stress and result in the alleviation of many stress-related disorders. Research has demonstrated that in people who have practised eliciting the relaxation response, the body is less responsive to stress hormones, even during the times of the day when they are not eliciting the response. Relaxation response-based approaches, generally used in conjunction with nutritional, exercise and stress management interventions, have been demonstrated to be effective in the treatment of hypertension, cardiac arrhythmias, insomnia, chronic pain, premenstrual syndrome, infertility, anxiety and mild or moderate depression.
The Benson technique
Based on his studies on practitioners of meditation, Dr. Benson developed a simple meditative technique to elicit the relaxation response. This consists of eight steps.
Step (1): Choose a focus word, phrase, prayer or image. It might be related to your religious belief. For example, a Roman Catholic might choose ‘Hail Mary, full of grace’, a Jew might select ‘Shalom’ or a Muslim might choose to focus on the word ‘Allah’. Alternatively, you may prefer a neutral word like love, peace or calm. You may also combine a clear visual image with the word. Whatever word, phrase or image allows you to focus your attention is a good choice.
Step (2): Sit quietly in a comfortable position. Sitting is recommended because if you lie down, you may fall asleep.
Step (3): Close your eyes.
Step (4): Relax the muscles throughout your body.
Step (5): Breath slow, quiet, and comfortable diaphragmatic breathes. A diaphragmatic breath is one in which you open your diaphragm as you inhale by letting your stomach expand, then letting your stomach move back as you exhale. (Although not mentioned by Dr. Benson, it is best to breathe in and out through the nose with the mouth closed).
Step (6): Assume a passive attitude and don’t worry about how well you’re doing. When your mind wanders, passively ignore the distracting thoughts and return to your focus.
Step (7): Continue for ten to twenty minutes.
Step (8): Practise the technique once or twice daily.
Published in Irish Pharmacist in June 2014
CBTi for insomnia
Another helpful approach to the treatment of insomnia that may be used in conjunction with the Buteyko Breathing Method is what’s referred to as CBTi (Cognitive Behavioural Therapy for insomnia). This being the case, below is an article I wrote titled ‘Cognitive Behavioural Therapy for Insomnia’. It was published in the journal Nursing in General Practice in 2014.
Cognitive Behavioural Therapy for Insomnia
“A ruffled mind makes a restless pillow.”
– Charlotte Brontë
Insomnia is defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as difficulty getting to sleep, staying asleep, or having non-restorative sleep, despite having adequate opportunity for sleep, together with associated impairment of daytime functioning, with symptoms being present for at least 4 weeks. When insomnia persists for longer than a month, it is considered chronic.
Chronic insomnia is a frequent problem encountered in general practice and GPs are often under pressure to prescribe hypnotic medication which frequently leads to long-term use. Chronic insomnia can have an adverse impact on quality of life, work productivity, and psychological health. It is also associated with an increased risk of accidents and increased use of healthcare services. It routinely leads to daytime fatigue, decreased energy, mood disturbances, and problems with cognitive functions. This can result in significant distress and functional impairments at home, at work, or in social activities. Impairment in daytime functioning is often the main reason individuals with insomnia seek treatment.
Prevalence of insomnia
According to the National Center for Sleep Disorders Research in the United States, about 30-40% of adults say they have some symptoms of insomnia within a given year, and about 10-15 percent of adults say they have chronic insomnia. More often, people suffer from chronic-intermittent insomnia, which means difficulty sleeping for a few nights, followed by a few nights of adequate sleep before the problem returns. The results of an Irish survey carried out in 2012 by TNS/MRBI, indicated that one-third of Irish adults have trouble sleeping. When asked about the reason for their sleep problems, 25 percent cited work stress as a primary factor and 9 percent attributed it to financial worries.
Age-specific rates for insomnia show a steady rise in prevalence across the lifespan, from 3-5 percent of those aged 18-25 years to 25-30 percent for those aged 65 and over. At all ages, women generally report higher rates of insomnia than men, particularly in the post-menopausal years.
The likelihood of insomnia developing is elevated among patients with long-term health conditions and those caring at home for a dependent relative or spouse.
Etiology of chronic insomnia
The Behavioural Model of Insomnia, which is often referred to as the ‘3 P model’, is the most widely cited theory in relation to the aetiology of chronic insomnia. Briefly, this model posits that 3 types of factors play a role in the development of chronic insomnia. These are: (1) predisposing factors (individual variants), (2) precipitating factors (stressors), and (3) perpetuating factors (maladaptive behaviours) that are intended to manage or compensate for insomnia but inadvertently exacerbate it).
Predisposing factors include a genetic predisposition to mental hyperarousal, anxiety, depression or insomnia, learned habits, some psychological coping styles, the inability to relax, and age. With regard to precipitating factors, acute insomnia (that may subsequently becomes chronic) may be caused by a series of stressful events, a medical or psychiatric illness, environmental disturbances, or particular drugs that cause sleep disturbances as a side effect. In relation to perpetuating factors, mental conditioning is the primary cause that perpetuates insomnia. Other perpetuating factors are a chronically stressed lifestyle; poor sleep hygiene, excessive use of caffeine, alcohol, tobacco, or certain psychiatric disorders.
A wide range of medications can interfere with deep (or slow wave) sleep or rapid eye movement (REM) sleep. These include calcium channel blockers, tricyclic antidepressants, beta blockers, anticonvulsants, antiarrhythmics, statins, bronchodilators, and monoamine oxidase inhibitors, to name but a few.
Most patients with insomnia are at increased risk for comorbid medical disorders. These include cardiovascular disease, obesity, chronic pain, neurologic disorders, gastrointestinal disorders, diabetes, and cancer. However, the most common comorbidity linked to insomnia is psychiatric illness, in particular, depression or anxiety. The conventional supposition that insomnia is secondary to psychiatric illness has been challenged by findings suggesting that insomnia more frequently precedes mood disorders and is likely to be a significant risk factor for them. Research suggests that patients with comorbid insomnia have similar dysfunctional sleep beliefs and maladaptive sleep hygiene practices as in those with what was, until recently, called primary insomnia. DSM-5 replaced ‘primary insomnia’ with the diagnosis ‘insomnia disorder’, so as to avoid the primary/secondary designation when this disorder co-occurs with other conditions.
Sleep duration and mortality risk
Many studies have indicated that sleep duration is associated with mortality and that the relationship can be depicted by an inverted U shaped curve with the lowest risk being found with individuals who report sleep durations of 7 to 8 hours. However, a review published in June 2013 concluded that it was premature to conclude that a robust association exists between reported sleep duration and mortality. This review examined 42 prospective studies of sleep duration and mortality. A separate prospective study, also published in 2013, reported that among men, difficulty falling asleep and non-restorative sleep were both associated with a higher risk of mortality, especially mortality related to cardiovascular disease.
Insomnia management in general practice
A study on GPs’ management strategies for patients with insomnia, reported in the February 2014 issue of the British Journal of General Practice found that GPs look for signs of depression and anxiety in patients, and if present, treat these first. ‘Sleep hygiene’ advice was provided by 88 percent of the GPs, but often seemed insufficient and they felt under pressure to prescribe. The study found that benzodiazepines and Z drugs are prescribed, often reluctantly, for short periods, because of known problems with dependence and tolerance. Many of the GPs were found to prescribe low-dose amitriptyline for insomnia although it is not licensed for this indication.
The GPs reported a lack of knowledge in relation to psychological therapies such as cognitive behavioural therapy (CBT) in the management of insomnia. Also, patients were rarely offered CBT-I despite the very strong evidence for its effectiveness.
Identifying chronic insomnia in general practice
Chronic insomnia is often unrecognised and untreated. It tends not to resolve by itself and many people endure it for years without effective help. Routinely asking patients about their sleep and any problems they have with it, is a good way to identify sleep problems in their early stages. Patients may be reluctant to report insomnia for a variety of reasons e.g. the notion that the doctor or practice nurse would not attribute importance to it or that they would merely be prescribed sleeping pills.
In trying to identify insomnia, try to make sure that the sleep difficulty is in fact insomnia and not another condition presenting as insomnia. Similar sleep complaints can occur with medications, a medical condition or another sleep disorder (e.g. sleep apnoea, periodic limb movement disorder, or restless legs syndrome). Insomnia is usually accompanied by fatigue, not sleepiness. Patients who are sleepy are more likely to have a sleep disorder other than insomnia.
Nurse administered CBT-I in general practice
A few studies have demonstrated promising results for nurse administered CBT-I in general practice. In a 2013 study published in the Journal of Sleep Research, a research team from Uppsala University sought to investigate whether CBT-I delivered by nurses and social workers can improve sleep in general practice patients. Sixty-six primary care patients were randomised to a small group given CBT-I, over five biweekly sessions, or to a waiting list control group. CBT-I was delivered using standardised manuals, by nurses and social workers, who had no specific previous training in CBT-I, but had attended a 2-day workshop on insomnia management. The main findings were that, post-treatment, patients in the CBT-I group had significantly reduced insomnia severity, sleep latency and wakefulness during the night, relative to waiting list controls. Almost half of the CBT-I group evidenced a clinically-relevant improvement in sleep versus just 6% of the waiting list control group.
CBT- i: an effective first line therapy
CBT-I is an effective treatment for chronic insomnia, but it remains underutilised. Lack of appropriately trained CBT-I providers is a major reason. More than three decades of research support its utility in treating chronic insomnia, with several meta-analyses showing both short term and long term efficacy. In 2008, the American Academy of Sleep Medicine published practice guidelines for the treatment of chronic insomnia that confirmed CBT-I as a first line therapy for chronic insomnia.
CBT-I is directed at changing sleep habits and scheduling factors, as well as misconceptions about sleep and insomnia. It targets maladaptive behaviour and thoughts that may have developed during insomnia or have contributed to its development. The main techniques used are: stimulus control, sleep hygiene, sleep restriction therapy, cognitive restructuring and reducing sleep interfering mental arousal.
- Stimulus control involves the therapist looking at the client’s sleep habits and pinpointing different actions that may be prohibiting sleep e.g. spending time in their bedroom when unable to sleep, instead of leaving the bedroom after 15-20 minutes and not returning until they are ready to sleep. Stimulus control involves viewing the bedroom as being reserved for sleep, sex, and undressing/dressing only. It also involves removing all stimuli from the bedroom that are potentially sleep-incompatible (e.g. watching television, reading, and using computers). For the poor sleeper, the bedroom triggers associations with being awake and mental arousal.
- Sleep hygiene refers to various behavioural and environmental recommendations that promote healthy sleep. These include: (a) minimising the amount of light, noise, and temperature change in the bedroom, (b) limiting the quantity of stimulants consumed during the day, especially close to bedtime, (c) avoiding vigorous exercise during the two hours before bedtime, (d) avoiding eating large meals close to bedtime, and (e) regulating one’s sleep-wake schedule. Sleep hygiene education is most effective when tailored to an analysis of a patient’s sleep/wake behaviours.
- Sleep restriction therapy limits the amount of time spent in bed to increase the biological need for sleep at night. This process usually starts by restricting the time spent in bed to the amount of time estimated that one should spend sleeping. For example, a person stays in bed for about 9 hours but only sleeps for about 6, will initially restrict time in bed to 6 hours. This initially causes mild sleep deprivation but the sleepiness it creates trains the body to fall asleep more quickly. As sleep becomes more consolidated, the length of time in bed can be gradually titrated upwards in 15 minute increments.
- Cognitive restructuring involves using the cognitive aspect of CBT-I to reduce mental arousal by helping patients shift from ‘trying hard to sleep’ to ‘allowing sleep to happen.’ In using cognitive restructuring clients identify, challenge and replace dysfunctional sleep related thoughts with more functional sleep related thoughts. Examples of typical dysfunctional sleep related thoughts are: “I will have an awful day if I don’t sleep well” or “I should fall asleep quickly.”
- Reducing sleep interfering mental arousal involves the use of a variety of relaxation techniques to reduce sympathetic nervous system activity and enhance parasympathetic activity. Relaxation techniques include breathing exercises, progressive muscular relaxation, guided imagery, mindfulness meditation and self-hypnosis. The technique(s) used should be matched to the patient, depending on their preference(s).
Self help CBT-I resources for patients
In Ireland, professionals trained in CBT-I, are very few in number. Fortunately, there is sufficient evidence to indicate that self help bibliotherapy and web based CBT-I programmes are effective. Some patients will manage well with bibliotherapy and/or a web based programme, while others may need more personal treatment and guidance.
If you would like to be able to suggest bibliotherapy to a patient, I would recommend the following book: ‘Say Good Night to Insomnia’ (2009 edition) by Dr. Gregg D. Jacobs. This book instructs readers on how to follow a 6 week CBT-I programme developed at Harvard Medical School.
If you would like to be able to suggest an online CBT-I programme, I would recommend ‘Go! to Sleep’. This is a 6 week online CBT-I programme developed by experts at the world-renowned Cleveland Clinic. The cost is 40 U.S. dollars and more information may be accessed via the following link: www.clevelandclinicwellness.com
Cunnington, D et al (2013) Insomnia: Prevalence, Consequences and Effective Treatment, Medical Journal of Australia, 119 (8): 36-40
Davidson, J R (2012) Treating Chronic Insomnia in Primary Care – Early Recognition and Management, Insomnia Rounds, Canadian Sleep Society, Vol 1, Issue 3
Davidson, J R (2013) Sink into Sleep: A Step by Step Workbook for Reversing Insomnia, New York, DemosHealth
Espie C A et al (2007) Randomised Clinical Effectiveness Trial of Nurse Administered Small Group Cognitive Behaviour Therapy for Persistent Insomnia in General Practice, SLEEP, 30 (5), 574-584
Everitt, H et al (2014) GPs’ Management Strategies for Patients with Insomnia: A Survey and Qualitative Interview Study, British Journal of General Practice, Vol 64, 619, e112-e119
Idzikowski, C (2013) Sound Asleep: The Expert Guide to Sleeping Well, London, Watkins Publishing
Jacobs, G D (2009) Say Good Night to Insomnia, New York, St. Martin’s Press
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Morin, C M (2012) Insomnia: Prevalence, Burden and Consequences, Insomnia Rounds, Canadian Sleep Society, Vol 1
Morin, C M & Espie, C A (2012) The Oxford Handbook of Sleep and Sleep Disorders, Oxford, Oxford University Press
Perlis, M L (2008) Cognitive Behavioural Treatment of Insomnia: A Session by Session Guide, New York, Springer
Reading, P (2013) ABC of Sleep Medicine, Oxford, Wiley-Blackwell/BMJ Books
Redeker, N & McEnany, G P (2011) Sleep Disorders and Sleep Promotion in Nursing Practice, New York, Springer Publishing Company