Sleep Dynamic Therapy

Archive for the ‘Insomnia’ Category

At the CPAPTALK.com forum, a question was raised about my frequent comments in my book, Sound Sleep, Sound Mind, about higher intelligence levels among insomnia patients. The following is the post I wrote on that issue:

Human Intelligence

Human intelligence, as everyone knows, is a complex dimension to measure, and I am no expert in measuring it. However, as a sleep doc, I’ve formed some fairly clear perceptions about patients with insomnia, who I believe often ‘suffer’ from a higher than average level of ‘intellectual’ intelligence, for lack of a better term.

TFI System

This insight emerged in my own thinking once I realized that most human behavior is coupled to a fairly prominent system of consciousness called the TFI System. (T = Thoughts; F = Feelings; and I = Images.) I write extensively about this system in my book, Sound Sleep, Sound Mind, because the balance within any individual’s TFI system predicts who is most likely to suffer insomnia, who is most likely to have difficulty adjusting to PAP therapy, and who has the capacity to engage in sufficient, self-generated cognitive restructuring (‘changing your mind’) to overcome or adapt to either of these difficulties (insomnia or PAP issues).

To simplify, before you eat, you THINK about the need or desire for food, FEEL hungry for food, or PICTURE (IMAGE) in your mind’s eye the sumptuous Caesar salad you crave. Each of these three activities represents the unique and overlapping components of the TFI System. If you spend time ‘observing yourself’ throughout the day, you will notice you spend at least some time with each component preceding, during or after various behaviors.

In unusually well-adjusted individuals, great awareness of all 3 components is the norm, leading to a balanced system in which the individual freely moves through all components at any given time as needed to adapt to and interact with their environment and the people in it. Having said that, you can no doubt imagine a hundred interpretations of what a ‘balanced system’ entails or feels like. Without wishing to be cryptic, however, let me just say that tasting the experience of a balanced TFI System is a much easier way to know it than someone trying to explain it to you.

Lacking Balance in the TFI System

It’s much easier to explain the opposite’a lack of balance, in which one component of the system tends to predominate or one component tends to be relatively absent. Most of us learn to keep our TFI systems out of balance, and we usually adopt this jaded system some time in childhood or adolescence. As the most classic and relevant example to our discussion, many insomniacs show a high intellect that arguably developed out of a desire (usually unplanned) to adopt an imbalanced system dominated by thoughts and lacking in emotion, which turns out to be a perfect setup for insomnia.

Let’s assume you are a smart person, and your intelligence is obvious to those around you as early as childhood. More importantly, let’s suppose you begin to notice in school or elsewhere that your mind is sharper or quicker than many others at certain intellectual tasks: solving math problems, remembering grammar rules, knowing more words, how to spell them and what they mean and so on. In a short time, you would receive a great deal of reinforcement (grades, praise, requests for advice/answers, etc.) buttressing the belief that your ‘thinking capacity’ is more advanced than others. Very soon, you will turn repeatedly to your powers of intellect to solve the problems you face. So far so good; this example describes a fair number of people who end up with graduate degrees in engineering, physics, medicine, other sciences and so on. In these individuals, ‘Thoughts’ are the predominant component of the TFI system and up to a point have served them well in society.

The question or problem arises at some point as to what happens to the other two components of the system: Feelings and Images. The answer for a lot of individuals is the person grows far too comfortable solving life’s problems with thoughts and conversely grows more uncomfortable attempting to manage emotions or mental imagery. Why so? Because the latter two components of the TFI system seem or feel chaotic; whereas, thoughts seem more controllable.

Over time, some individuals who go down the intellectual path will see a decay in their innate capacity to work effectively with feelings and mental imagery. In the single most classic example of this phenomenon, individuals no longer readily access their own emotions in direct fashion. Instead of ‘feeling their feelings,’ they ‘think about their feelings.’ If you describe this distinction to someone with a healthy and balanced TFI system, they immediately and fully understand the difference. If you make this point to an insomniac, they often need much more explanation (still more intellectual discussion) just to come close to understanding the distinction between ‘thinking about vs. feeling an emotion.’

Insomnia and the TFI System

And, therein lies the basis of my observations and theories. In my clinical and personal experience, people with balanced TFI systems rarely have trouble closing out the day at bedtime. Because they’ve spent much of the day processing a wide array of thoughts, feelings, and images, they fall asleep faster than you can say ‘lights out.’ But, for the individual with too much reliance on intellect, the lack of balance throughout the day means that emotional or imaginative residue probably lingers at bedtime and prevents the necessary closure that leads to the Land of Nod. In fact, among the majority of insomniacs, the single most common complaint is ‘I cannot turn off my mind,’ which means racing thoughts or other ruminations actively fuel the mind with too much alertness to permit sleep.

Returning now to the balance concept, the intellectually inclined individual has spent far too much time in life developing their ‘thinking smarts’ but now they pay for it with insomnia. Why would too much thinking lead to insomnia? Because thinking represents a very active component of consciousness within the TFI System, whereas feelings and imagery represent more receptive components.

When you fall asleep, can you guess which components are closer to the final point of wakefulness where sleep onset begins? The answer appears to be feelings as in feelings of comfort and sleepiness, followed by mental imagery as in little dreamlets that flash across your mental landscape just as you fall asleep.

In other words, active thinking is antithetical to sleep; but if you spend more of your day in the world of thought, there is no easy way to turn off the spigot of thoughts at bedtime. In my book, I describe at length how excess thinking in most insomniacs has actually become a ‘defense’ mechanism, which individuals use to avoid feelings and imagery. But, as I’ve just pointed out above, sleep does not follow from an active and ruminating mind; it follows from a receptive mind based on comfortable feelings and dreamy images.

Summing Up

Most insomniacs I’ve treated have a marked imbalance of the TFI System. The thinking system is so powerful it blocks most feelings and some images throughout the day. Eventually, it prevents the individual from fully processing the day’s experiences, because the system directs the person to think and self-talk about the day without processing deeper emotions or clearer images about the actual experiences during the day.

Finally, SDB patients with similar or other imbalances of the TFI System tend to have greater difficulty adjusting to PAP therapy, because the imbalance makes their personality somewhat more rigid. Their ability to ‘change their minds’ and adapt to the foreign nature of PAP therapy is less than it could be if their minds were more balanced.

In sum, in a large proportion of insomnia patients and some proportion of poorly adapting PAP therapy patients, I routinely see this highly intellectualized intellect, which in fact frequently correlates with a higher IQ. In my opinion, these patients ‘suffer’ a great deal from this lack of balance as they try to solve their sleep problems.

Today, at my talk at Sandia National Laboratories, the audience was interested in my opinion on the recent article on sleep duration in relationship to premature death from heart disease. As I’ve pointed out previously, these studies are incomplete works because they are looking at a sleep quantity model. Yet, the real insight is mostly likely explained by underlying physiological sleep disorders that causes one group to sleep too long (for example, classic sleep apnea patients with hypersomnia) and one group to sleep too short (for example, sleep breathing patients with a co-occurring problem of insomnia). Both types of patients have an underlying physical sleep disorder, but they look very different due to their pronounced differences in sleep duration. So, is sleep duration the important risk, or is it really the underlying physical sleep disorder? Parsimony suggests that sleep breathing problems provide the best reason to explain premature death rates.

This article describes the use of the imagery technique we pioneered for the treatment of chronic nightmares, but in this study it was used for insomnia. Although a strong proponent of imagery work for the treatment of insomnia, in my forthcoming book Sound Sleep, Sound Mind I detail how imagery actually represents that natural way in which an individual falls asleep. It’s not some special new miracle treatment. Rather, imagery is a natural part of the human mind’s capacity to function while awake and serves as a gateway to sleep. Thus, imagery is not needed for breathing and relaxation as cited in the article. Instead, just by tapping into the natural process of observing images in your mind, you are more likely to fall asleep. Why? Because you are jump starting the little dreamlets that emerge in your mind’s eye at bedtime, which are the very last stage of consciousness before you nod off. Nearly all insomniacs possess the ability to work on imagery, but the most important first step for them is to realize that imagery skills are something they already possess; they just need to reacquaint themselves with their use.

One month after the murderous rampage at Virginia Tech, should we expect a similar media frenzy to latch onto the community’s efforts at recovery? Obviously and regrettably not, as few journalists or media organizations know how or what to effectively broach when exploring the topic of recovery. Articles will appear here and there about various human interest stories, the availability of counseling, or with the media’s addiction to controversy, what the Scientologists are doing in Blacksburg. But, aside from rare instances when they cover in depth the work of an expert in the field of trauma recovery, most of what the mainstream media writes in this realm is useless.

Now at the one month mark—a critical milestone in trauma recovery—it is important to closely examine some aspects of recovery, including what is and isn’t normal and how to identify the risks that predict whether someone is heading in the wrong direction. First and foremost, from an economic and community perspective, it is useful to recognize that the vast majority of individuals directly impacted by the shootings (e.g. everyone on the campus or closely affiliated with the campus) need absolutely no interventions to recover from traumatic experiences. A large number of individuals probably need only to discuss their experiences with close friends and family members for a few days or weeks, and there are probably a sizeable number who probably need even less engagement and will do just fine.

Natural human resilience explains this process. It doesn’t mean that individuals are not scarred for life or that the imprint of the experience can be erased. Rather, it means that most humans have the ability to acknowledge terrible things, feel a wide range of distressing emotions, and then move on with their lives. Many in fact move up in a spiritual sense because the experience permits, encourages or forces them to take stock of their lives. Resilience should not be confused with callousness; resilience is the ability to engage a traumatic experience at a level that hurts but then move beyond that hurt to some form of reckoning—rational, emotional, or spiritual—that allows the individual to embrace the idea and feeling that “life goes on.”

How these resilient individuals negotiate this process takes various forms and steps, one of particular interest to the visual media is the desensitization caused by repeated exposure to the horrific images or assorted reminders of these images. This desensitization allows the person to dampen the emotional reaction to the trauma over the course of days or weeks. In this area, visual media are truly serving a valuable purpose for a very large number of survivors, although arguably most people would have recovered and coped fairly quickly with or without this added exposure.

Who then doesn’t recover quickly or recover to a reasonably healthy state? How do we identify and provide them the help they need? And, how do we match individuals with post-traumatic struggles with the best and most appropriate therapeutic interventions?

Sleep is a very useful marker to estimate when someone will recover fast, slowly, or poorly. Within days of traumatic events, most survivors describe unwanted sleeplessness, poor sleep quality, or nightmares, or a worsening of these symptoms if they already suffered from sleep disturbances. It is in fact logical to need less sleep or experience a lighter form of sleep (poor sleep quality), because adverse experiences raise a person’s threat level. A continuous threat assessment emerges after trauma, raising one’s level of alertness and vigilance to a state of hypervigilance. Consider how much more cautiously or safely you drive immediately after you suffer a very scary, near-miss with another car.

As your threat level rises, you want to reduce your vulnerability to future threats. The sensible thing is to avoid sleep, the most vulnerable state within the natural human life cycle. Sleep can be avoided in the extreme by not sleeping (insomnia), but one’s vulnerability can also be decreased by making sleep lighter (poor quality).

Nightmares play out in several ways in the recovery process. On the one hand, nightmares function acutely to remind you of events, thus insuring you keep your guard up; they also provide detailed information about what happened in ways that might stimulate you to reflect on all the circumstances surrounding the events and what you might do the next time to prevent something or respond in better ways. Nightmares also have direct therapeutic potential for some individuals by aiding their processing of emotional reactions to stressful events. It is extremely common for some survivors to report “instant replay” like dreams following traumatizing experiences, but typically in a matter of days or weeks, the nightmares change in ways that become less threatening than these original, disturbing replay images.

Research indicates that a metamorphosis occurs within the dream material. At first, the dreams resemble the actual trauma. Then, they change, becoming more symbolic or metaphorical about what occurred. During this transformation, emotions within dreams change in ways that suggest dreams are helping survivors feel more comfortable with and adapt more to their responses to the traumatizing events.

What’s remarkable about sleep symptoms is that the more and the longer you have them, the more likely you are to suffer a poor recovery or no recovery at all. In technical terms, a person with these symptoms almost always suffers from other post-traumatic stress symptoms; and, after the first month if they are still present, an acute stress disorder is diagnosed. When these stress symptoms including some of the sleep symptoms persist at three months, the individual may meet diagnostic criteria for post-traumatic stress disorder (PTSD).

In my clinical and research experience, I have found that once sleep symptoms of any type persist beyond 4 to 6 weeks, the chances are much higher that the trauma survivor’s recovery will go slower and less smoothly unless proper treatment is provided. Proper treatment would not mean treating just these sleep symptoms, because most survivors who report sleep problems one month later would also report other types of post-trauma stress indicators such as: memories of the trauma while awake, easily startled, restless or jumpy feelings, emotional numbness, difficulties with memory and concentration, irritability, increased pessimism, feelings of isolation, and behavioral avoidance in which survivors distance themselves from circumstances, locations, or discussions that might trigger memories of the traumatic experiences. Undoubtedly, these other symptoms are also useful markers in recognizing individuals who are more susceptible to a slow or poor recovery.

Sleep symptoms are particularly vexing because sleep deprivation due to insomnia, compromised sleep quality, or nightmares worsens all other symptoms by triggering chronic, daytime fatigue or sleepiness that robs survivors of the energy they need to cope effectively and move toward a health recovery. In our work, we find that sleep treatments spark a lot of curiosity among trauma survivors. It’s not to say that sleep treatment is the best approach or that it should be the first approach. Rather, as physicians, we must recognize the “opening” the patient offers and use that to initiate treatment with the hope of expanding services as needed to maximize recovery.

Trauma survivors can hear instructions about how to tackle sleep problems or how to use their dreams to help them recover; whereas, they may be less inclined in the early going to discuss the actual traumatic events. This reluctance also manifests as a disconcerting paradox in the mental health community. On the one hand, many researchers have developed state-of-the-art programs that dramatically increase rates of recovery from traumatizing events; and these treatments require that the person “re-live” some of their experiences to either become desensitized to them or to work successfully through their emotional responses (usually both goals are achieved). These techniques are known as exposure therapy, and in the space of weekly sessions, given for about 2 to 4 months, they will often reduce PTSD symptoms to negligible levels or yield an outright cure.

The paradox is that a large proportion of community-based mental health professionals outside of academic centers are often unaware of these advanced yet now standardized techniques, have never received training to provide such therapies, or have their own reluctance about using them. Ironically, this reluctance mirrors that of those survivors who are skeptical, weary, or nervous about being “exposed” to exposure therapy. Survivors and therapists alike have concerns about the “reexperiencing” model and imagine it could just as easily worsen stress levels. However, exposure therapy is conducted in a controlled environment in which traumatic memories are divided up into much smaller units to make the process more digestible. The key element occurs when individuals allow themselves to reexperience the distressing emotions, and they do so by permitting themselves to feel feelings in their bodies instead of overanalyzing their feelings in their minds. In the simplest terms, trauma survivors who are recovering slowly or poorly often fear fear, so they engage in activities to avoid having to feel fear. Through exposure therapy, the fear is reexperienced, preferably in graduated doses over several weeks of work, and the individual gradually realizes they no longer have to fight with their traumatic memories or the distressing emotions triggered by these images.

Remarkably, it is this key part of the process that seems to generate reluctance among many therapists, even among those who have received training or education on exposure therapy. They apparently fear that the patient’s reaction to the therapy will lead the patient to feel overwhelmed, even though the technique when properly administered frequently leads the survivor to much healthier, richer, and controllable forms of emotional expression.

In our practice of sleep medicine, we are not trained and do not offer exposure therapy. Instead, we see many trauma survivors in research and clinical practice eager to start treatment by focusing on their insomnia, poor sleep quality and nightmares. In my new book, Sound Sleep, Sound Mind (October, Wiley & Sons), I detail a number of techniques to solve these problems, and the book was written with many of my most complex patients in mind, particularly trauma survivors who report some of the most severe sleep disturbances. In future posts, I’ll be discussing these techniques, and our website www.sleepdynamictherapy.com will also provide practical, interactive programs to lead you through many of the steps.

In this recent letter to the editor in the Annals of Clinical Psychiatry, we respond to Dr. Rosenberg’s critique, which outlines some of the weaknesses in medications for the treatment of sleep maintenance insomnia (middle of the night awakenings). As we continue to find in our research and clinical work, most of these patients suffer awakenings due to sleep-disordered breathing. Therefore, testing these patients with overnight sleep studies in the sleep lab often yields valuable insights into the patient’s underlying sleep fragmentation and may lead to dramatic treatment gains, if the insomniac chooses to treat the sleep breathing condition.