Action 3

I need to get good uninterrupted sleep. Sleep disturbance strongly increases negative moods and decreases positive emotions. Similarly, high levels of emotional arousal can disturb sleep. Sleep deprivation can induce neurochemical changes similar to depression and impairs my quality of life.

Useful Information

Sleep disturbance is the most frequent non-wound or non-injury related concern reported by deployed service members during post-deployment. Sleep disturbances, nightmares, fear of sleeping are part of a normal and typical response to trauma. Rates of sleep disruption usually decline within 1-3 months post trauma. If sleep disturbances persist, then the individual should seek professional help as in the case of insomnia, trauma-related nightmares, sleep apnea and narcolepsy. Sleep disturbance often precede the onset of depression and Post Traumatic Stress Disorder (PTSD).

Sleep has a protective effect on the brain. Most people need 7 to 8 hours of sleep each night. It may take 3 to 6 months to readjust one’s sleep pattern (for example, shifting from a 4 hour sleep pattern while deployed to a 7 to 8 hour sleep pattern during post-deployment or after experiencing a traumatic event). Sleep disturbance can contribute to mood and behavior problems. The following steps enumerate ways to break this “vicious cycle” between sleep disturbance and mood and behavior difficulties.

How To: Improve Sleep Behavior

  1. Determine your individualized Sleep Efficiency score by keeping a sleep diary for 7 to 14 days. Record the times you went to sleep and woke up for a week or two. Also jot down any times you were aware of waking up in the middle of the night. Your Sleep Efficiency Score (SE) reflects the Total Sleep Time (TST) and the Total Time in Bed (TIB). SE=TST/TIB X 100
  2. Maintain a regular sleep schedule. Establish a regular time for going to bed and getting up in the morning. Have a routine wake up time, 7 days a week. A regular wake-up time in the morning will help set your “biological clock” and lead to regular sleep onset. Limit time spent in bed prior to sleep.
  3. Have a comfortable sleep environment. Make sure your bed is comfortable and that your room is quiet and set at a comfortable temperature. Turn off all lights (television, computers.) Use eye shades, if necessary.
  4. Use your bed only for sleep and sex. Do not use the bed for eating or watching TV.
  5. Have a simple relaxing wind down 30 to 60 minutes routine before you go to bed. Outside of the bed, do something relaxing in the half-hour before bedtime. For example, listen to soothing music, read, or do some form of relaxation exercises (meditation, yoga).
  6. Do not use alcohol or non-prescription drugs to help you fall asleep. A small amount of alcohol can promote the onset of sleep, but as alcohol is metabolized sleep becomes disturbed and more difficult. Thus, alcohol is a poor sleep aid. Sleep medications are effective only temporarily, losing their effectiveness in about 2 to 4 weeks when taken regularly. Over time, sleeping pills can make sleep problems worse. When sleeping pills have been used for a long period, withdrawal from the medication can lead to an insomnia rebound. There are however, some prescription medications such as Prazosin® that have been found to reduce nightmare intensity and frequency, in addition to improving total sleep quality without causing excessive sedation. Such medications should only be taken with a doctor’s supervision.
  7. Things to avoid before bedtime.
    • Avoid caffeine 4-6 hours before bedtime. Caffeine disturbs sleep. Caffeine is found in coffee, tea, soda, chocolate and many over the counter medications such as Excedrin. Caffeine and also tobacco increase heart rate and respiration rates that interfere with sleep.
    • Avoid nicotine before bedtime and during the night since it is a stimulant.
    • Avoid drinking fluids and high energy drinks before bedtime, so that sleep is not disturbed by the need to use the bathroom.
    • Avoid eating a large meal before bedtime. However, a light soothing snack facilitates sleep. A glass of warm milk or a bowl of cereal can promote sleep.
    • Avoid taking a hot bath shortly before bedtime since it tends to increase alertness. However, spending 20 minutes in a tub of hot water an hour prior to bedtime can promote sleep by lowering body temperature that aids sleep onset.
    • Avoid vigorous exercise within 2 hours before bedtime which elevates nervous system activity and interferes with sleep onset. However, maintaining a regular exercise schedule will enhance general well-being and foster sleep.
  8. Do not nap during the day. Save the need to fulfill the body’s sleep requirements to your night time sleep activity. If you do nap, be sure to schedule naps before 3:00 P.M. Go to sleep at bedtime when sleepy.
  9. Do not watch the clock as you try to fall asleep. Watching the clock and obsessing about the time will just make it more difficult to sleep. Position clocks out of sight, as clock watching can create anxiety about lack of sleep.
  10. If you are unable to fall asleep (in some 20 minutes) do not remain in bed. Get up and move to another room and stay up and read or try another quiet activity until you are sleepy again. The goal is to associate the bed with falling asleep quickly.
  11. Do not have worry time in bed. If worrying or ruminating are interfering with your sleep, designate a “worry chair” that is not too comfortable in another room and use that chair as the location for worrying and ruminating. Plan time earlier in the day to review and deal with any problems. Worrying in bed can interfere with sleep onset and cause you to have shallow sleep. Tell yourself that you will postpone thinking or worrying about anything until the next day. While you are in the “worry chair” you can write down your thoughts and feelings about what is bothering you and you can talk them over with a friend the next day.
  12. Do not try too hard to fall asleep. You will frustrate yourself, leading to a paradoxical effect and work yourself into an anxious state of mind. Instead, tell yourself, It is okay if I get only a few hours of sleep tonight. I can catch up the next few nights. This change in expectation will free you up to relax. The harder you try to go to sleep, the harder it will be to induce sleep.
  13. Do not go to bed mad. Instead, generate a “gratitude” list of things for which you are grateful. Use positive images to recall these events (See Action #30).
  14. Use a variety of coping strategies like meditation, mindfulness skills and pleasant imagery to relax. The positive image can be a place you would like to go on a vacation, or something relaxing you have done in the past. See if you can “switch mental channels” and tune into pleasant relaxing scenes (See Action #41).
  15. If you cannot fall asleep, just lie in bed and try to rest. Tell yourself that “it is okay to just rest.” Give up the struggle to go to sleep. Let a restful state set in which may induce sleep.
  16. Avoid “chasing” sleep. If these sleep hygiene and stimulus control procedures do not work, then try consolidating and restricting your sleep patterns. Sleep restriction is accomplished by establishing a fixed wake up time and then limit the time in bed as determined from your Sleep Diary. If you need to wake up at 7 A.M. and you average 5 hours of sleep you would have to go to bed at 2 A.M. As this sleep time improves to 90% of the five hours, you can go to bed earlier in increments of 15 minutes. Such sleep management procedures are usually effective.
  17. Include your partner as a collaborator in implementing this sleep plan.
  18. Establish a bedtime ritual with your partner (if you have one), whenever possible. Go to bed at the same time so that you can share intimacy, “pillow talk” and a satisfying sexual, love-making relationship that contributes to sound sleep.

How To: Deal with Nightmares

It is not unusual for individuals to have nightmares. As many as 25% of individuals have a nightmare at least once a month. Nightmares often follow trauma exposure and victimization experiences. The content of trauma-related nightmares tend to change over time, shifting from memories and reminders that were directly related to the trauma to more generally anxious dreams along the themes of loss of control, guilt, shame, abandonment and the like. Remind yourself that nightmares are “night time spoilers.” Remember that all bad dreams are normal and common among those who have experienced stressful events. Nightmares can be disruptive, but they cannot hurt you and you can gain control over nightmares.

A procedure that has helped individuals with nightmares is called imagery retraining. The individual who experiences repetitive nightmares is asked to rescript his/her nightmare. Imagery Retraining has individuals write down their nightmares and then asks them to change them in any way they wish, and then to write out their new dream. By changing the ending, or by inserting protective features, or by transforming features of the dream, or distancing oneself as if watching it on a television, the dreamer is able to develop mastery over the nightmare. Individuals are encouraged to practice the new dream at least twice a day for 10 minutes each time. (See Action #37 for other examples of “writing cures”).

Maintaining Healthy Sleep and Daily Rhythms during COVID-19

The Pitt Sleep and Circadian Science group, Marissa Bowman, MA, and Jessica Hamilton, Ph.D. developed these evidence-based infographics to help synthesize key information for maintaining healthy sleep and daily rhythms during COVID:

Action 4