Racing Thoughts & Sleep
Having the proper 'head space' when going to bed is essential for achieving good quality sleep. Some of the most common issues we encounter are racing thoughts and restlessness when trying to go to bed. Sometimes physical issues with the body can be the main problem and other times it is primarily psychosocial.
Physical Factors
Disruptive physical ailments that make sleeping hard can cause a person to dread going to sleep. We call this "secondary insomnia." For instance, if there is disruptive back pain or overactive bladder, they may make sleeping so unpleasant that going into the bed causes fear. It is important to get a good understanding of the quality of such a person's sleep.
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The most common patient story is that poor sleep quality was the first issue to develop, and then difficulty falling asleep followed it. However, many times people don't realize how disruptive and poor their quality of sleep is and never mention it. At Sleep Doc LA, we believe it is vitally important to collect objective data regarding sleep quality, including to detect difficult to recognize issues such as sleep apnea that could be driving the insomnia. Furthermore, we believe that the best therapy is one that treats both the physical and the psychosocial issues at the same time.
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Because of our unique home-based program, we can often identify environmental issues that can be negatively contributing to sleep. Many times our patients will overlook the climate, the mattress quality, neglect to mention the nearby train tracks and sometimes, perhaps most importantly, we help identify that the sleep partner has disruptive snoring and gasping, keeping an entire household from achieving adequate rest.
Psychosocial Factors
This is by far the fastest growing cause of insomnia today. Easily accessible, immersive technological distractions from tablets, large HD screens, virtual reality headsets combined with emotionally charged and ubiquitous messaging means that the human mind is constantly engaging with external influences and rarely has an opportunity to process daily thoughts in peace. Most people don't realize how important it is to have a daily monologue, to come to terms with emotionally impactful events, organize and prioritize and mentally grapple with challenges. As a consequence, the only moments that we are alone with our thoughts in silence are at night, once the lights are turned off and our heads hit the pillow. We experience this as the waking of our subconscious mind with nagging and intrusive thoughts and ideas, some of which seem random and irrelevant, and others that have immense value and have gone neglected.
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Certain types of distraction like falling asleep with the phone or TV are a form of self hypnosis that in the short term can facilitate the transition to sleep, but in the long term is a cycle of dependency of aides to distract us from the necessary process of quiet reflection. It often starts with the TV and escalates to ever increasing medications for the purposes of "knocking us out" each and every night. Such overstimulation has been associated with the development of conditions such as ADD and Bipolar Disorder, two conditions that have been growing rapidly among the public.
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The most simple therapy for this is scheduling periods of zero distraction during the day. Timing ten minutes without interruption may seem easy, but for longtime sufferers, it can be incredibly painful and sometimes nearly impossible. Ritualistic daily activities that force healthy quiet can be beneficial and include: journaling, maintaining a diary, meditation, yoga, prayer, exercise without loud music or a reflective shower before bedtime. Many of these techniques have been referred to as "mindfulness" therapies and there are some apps that can even assist you with this (though choose cautiously).
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Patients with true anxiety disorders that cannot be managed with mindfulness techniques may require medication, especially for short term stressors or therapy resistant conditions. Identifying and helping to manage anxiety is a big part of what makes Sleep Doc LA uniquely effective.
Not Feeling Tired at Night
There are two main systems in the brain that help us to feel naturally tired at night. The first one is based on activity: the more active you are during the day, the more your brain is demanding rest at night. The second one is based on light: as you perceive bright light in the AM and weaning light in the PM, your natural biological (Circadian) rhythm helps you to feel sleepy at a normal bedtime. That Circadian rhythm is what helps you to lock into a new time-zone within a short period, after a long flight to a far away land.
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You can tell that based on these two main factors, if you have been very inactive or you have had minimal natural light exposure, especially during the key times of the day (dusk & dawn), you might not feel very tired when it comes to bedtime. A classic example would be someone with an office desk job working in a windowless cubicle all day. Such a situation may benefit from an artificial light box in the AM and prescribed walks to ensure an adequate level of cardiovascular activity. Some young people who stay up late and wake-up late behave as if they are in the wrong time zone, and carefully timed phototherapy and melatonin can help bring those people back into cycle (such as for business obligations). Sleep Doc LA utilizes research grade Actigraphy, which is a device that studies sleep-wake cycles, daytime activity levels, nighttime sleep quality and light exposure to discover causes of lack of nighttime sleepiness. Late napping can also be an unrealized contributor which can sometimes go unnoticed by the patient, but cannot escape careful collection of objective data. This is a far superior method of analysis than a patient's subjective journal of their sleep.
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Substances ingested can contribute to lack of sleepiness at night. Coffee or energy drinks have lingering effects that make their use in the afternoon harmful to good sleep. Prescription substances taken with poor timing such as Adderall, Prozac, albuterol or steroids can make starting sleep challenging. Finally illicit substances including methamphetamines and cocaine are notorious for wreaking havoc on sleep.
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Medical conditions should be carefully screened as they can cause severe sleep onset insomnia. Such conditions include hyperthyroidism, pheochromocytoma and Cushing's Syndrome. With Sleep Doc LA, we take time to review medications, labs and order appropriate testing as we are physician directed and understand the complexities involved with making the right diagnosis.
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Finally, when we create mental associations with our home sleeping area (the bedroom) that are not sleep, it can be hard to feel tired. People who do work or consume media in bed may not realize that such mentally stimulating activities have created powerful non-sleep associations with the sleep environment. This is especially true if the behavior is stressful work or emotionally impactful media consumption. As much as we are convinced that such behaviors won't negatively influence our developed, intelligent, conscious mind, we require a tranquil subconscious to fall asleep and enter unconsciousness. The subconscious thrives on routines and one' nighttime routine primes the brain to prepare for sleep. Training the mind to make sleep associations with the bedroom is a process referred to as Cognitive Behavioral Therapy for Insomnia (CBT-I) which is considered the most effective therapy for sleep onset insomnia that exists today. This is an important piece of the treatment plan at Sleep Doc LA no matter what the primary cause for insomnia is.