How to Deal with Insomnia

It is 4 o'clock in the morning, and Los Angeles is asleep—except for Robin, who is painting, and Diane, who is listening to National Public Radio, and Joan, who is reading a trashy novel. They're not alone—more than half of women ages 30 to 60 have trouble sleeping through the night, according to a National Sleep Foundation survey.

We think of insomnia as the inability to fall asleep, but two other forms of the ailment tend to plague women: With maintenance insomnia, sufferers wake up in the middle of the night and have trouble getting back to sleep; with terminal insomnia, they wake up at 4 or 5 o'clock and are too alert to doze off again. Once up, she starts to worry about how long she'll be awake, or all the things she failed to do during the daylight hours. The more distressed she gets, the less likely she is to fall asleep again.

Certain people are predisposed to developing insomnia, according to Oneil Bains, MD, director of the insomnia program at Seattle's Virginia Mason Medical Center, and some of the reasons are beyond our control—a woman's genetically determined "sleep drive", for example, and her personality. Life changes can also trigger insomnia, and we can't do much about those, either. But the third element in the slumber trifecta is the way we think about sleep, and that's where free will comes into play.

Most insomniacs worsen their condition by worrying about it. Then again, it's hard not to. The 11th commandment in this culture might as well be "Thou must have eight hours of sleep"—we fear anything less means not being as fresh, alert, or productive as our well-rested colleagues.

Letting go of that 11th commandment is the first step toward relief. "Most people with insomnia don't need eight hours," Bains says. When they stop fighting with themselves and settle for less, they feel better.

Robin, for example—an artist and graphic designer in her 50s—has been waking up at 4 a.m. for most of her adult life and happily uses the time to paint, read or answer e-mails from her students. She is admittedly an extreme example, since she gets along fine on five or six hours a night, but the important thing about Robin is her attitude. She has defined her sleep habits in a positive way, says Bains. "And if they don't impact how she functions during the day, then as a doctor, I wouldn't worry about her."

Diane, on the other hand, was a wreck when she started waking up in the middle of the night five years ago. Dog-tired by day, "I was up almost every night, anxious and worried, my mind racing," says the 52-year-old who works at a charitable foundation. She would get upset simply because she was awake, which only perpetuated the insomnia. One night, looking for something productive to do, she turned on National Public Radio. "I forgot what I was worrying about, and eventually it lulled me back to sleep." Diane never considered getting medical help because she was concerned about becoming dependent on sleep medication. "I figured," she says, "that it was better to be addicted to NPR." She now refers to herself as a once-in-a-blue-moon insomniac.

Without intending to, she taught herself to relax at the sound of NPR. "I listen to the station all day," she says, "but if I turn it on in the middle of the night, I fall right back to sleep."

Joan, a clinical psychologist who just hit 50, also stumbled on a remedy. Between work and family, she often gets only six hours in bed; if a barking dog or a wobbly hormone jolts her out of a dream, she's in danger of serious sleep deprivation. She used to read literary novels during her bouts of insomnia, but they required too much effort, "so i just moved down the food chain," she says, until she got hooked on romance novels. She still doesn't get the optimal amount of rest, but she stopped feeling so frantic about it—and sometimes the books help her get back to sleep more quickly. Between that and the occasional sleep-in on a weekend morning, she's no longer exhausted the way she was when all she did at night was worry.

For the many insomniacs who need more than NPR or a good bodice ripper, the classic approach is behavioral modification. Experts prescribe an arsenal of lifestyle adjustments that help patients practice what's known as good sleep hygiene. One strategy is taking time during the day to write down everything that needs to get done, in order to prevent panicked list-making in the middle of the night. Another is to avoid stimulating conversation, books or television shows before bedtime. Bains also tells patients not to turn on the light or to look at the clock when insomnia strikes (light can trigger the brain's wake-up chemicals, and the time on the clock fosters anxiety as the patient calculates just how little sleep she's had).

If gentle modifications don't work, Bains and other sleep experts practice various forms of tough love. in the neurology department of New York City's New York-Presbyterian Hospital, Anne Remmes, MD, deprives a patient of sleep until she's so tired that her sleep drive overcomes her tendency to wake up. If a woman says she goes to bed at midnight and wakes up at 7 a.m. but gets only five hours of sleep because she's lying awake for two hours, Remmes has her stay up until 2 a.m. for three or four nights while keeping the alarm set for 7. The goal is to get the same five hours of sleep—without interruption. Once the woman can do that, Remmes lets her go to bed 15 minutes earlier. Three more nights of good sleep and Remmes gives her another 15 minutes, until the patient can sleep for seven hours straight, or until she feels rested the next day.

"It's a very strict program," Remmes says, "and nobody likes to do it," but results usually last forever, as long as patients maintain good sleep hygiene. The program works, she says, because most insomniacs underestimate the amount of time they sleep. The woman who reports getting only five hours probably gets six, or has a weekly catch-up night when she passes out for eight or ten hours. Limiting herself to five hours and then gradually extending the time is going to boost her sleep drive, and her nocturnal self-esteem. As little as two weeks of decent sleep can make a dramatic change in her state of mind, according to Bains. "Confidence is a powerful thing," he says, when it comes to falling asleep.

Sometimess the best solution is medication. Gynecologist Judith Reichman, MD, author of the book Slow Your Clock Down: The Complete Guide to a Healthy, Younger You , may prescribe hormone replacement therapy for newly menopausal patients who are suffering from significant sleep problems; she reevaluates the women after three and five years, when, she says, about 80 percent of troublesome symptoms go away. If endorsing HTR is a controversial position these days, Reichman points out that much of medicine involves choosing the lesser of two evils. A woman how hasn't slept well in three years is probably going to have health problems, including impaired immunity and depression.

In many cases, insomnia experts prefer the strategic use of short-acting prescription sleep drugs (see "Snooze Control" ) in conjuction with behavioral changes. Sonata, which lasts about three hours, and Ambien, which lasts about six hours, can be especially helpful for women who have trouble falling or staying asleep, because they won't feel groggy in the morning. But Bains points out that both drugs are for short-term use only, generally no more than a couple of weeks. For ongoing sleep troubles, he suggests addressing behavioral factors rather than continuing to take medication.

In the meantime, happy insomniacs suggest trying a little imagination before reaching for drugs. Some nocturnal habits may not need to be cured. And for anyone who can manage to keep her eyes open and her demons at bay, those wakeful hours are precious—"the gift," says Robin, "of extra time."

Snooze Control
Sleeping pills do not have a great rep. But when all else fails, isn't there some dreamy little thing you can pop for a good night of slumber? Here's how the nocturnal drugs and natural remedies stack up, along with their risks and side effects.