Insomnia Advice

Zzzzzzzzzzz

Photo by Priscilla Du Preez 🇨🇦 on Unsplash

For the past four years or so, I haven’t gotten a full night’s sleep. This sucks immensely. But I do have some hard-earned advice.

Acute Insomnia

If you have occasional insomnia—perhaps before a test, or when you had a fight with your spouse—it’s very useful to believe that lying down with your eyes closed gets much of the benefit of sleeping.

This statement isn’t precisely false. The Mythbusters, the patron saints of empiricism, tested something somewhat related: specifically, they made two people stay up for thirty hours and then do a crabbing-themed obstacle course. In the no-naps condition, those two people did about 30% as well as they did perfectly rested; if they took a twenty-minute nap every six hours, they did about 70% as well. The two participants didn’t have the subjective experience of sleeping in their twenty-minute naps; they just lay down and tried to nap, and it still helped.

This is not what you would call, like, bulletproof science, because the sample size was two people and it was made for a Discovery Channel TV show. But it is nevertheless very useful to repeat to yourself “the Mythbusters tested this and lying down with my eyes closed is almost as good as sleeping,” for several reasons.

First, if you lie down with your eyes closed, you might go to sleep, but if you get up and play video games, you definitely won’t. In particular, sometimes you sleep even if it doesn’t feel like you slept—that’s what’s happening when you close your eyes for ten minutes and feel like you’re awake the whole time, but when you check the time again an hour has mysteriously passed. So you shouldn’t assume that you didn’t sleep just because you didn’t have the subjective experience of sleeping.

Second, it keeps you from worrying about how you’re not going to go to sleep and you’re going to be tired tomorrow and screw up your test. For most of evolutionary history, when beings were afraid, it was because they needed to run from a lion or something. Fear of sleep deprivation fucking up your test scores is a strictly human affliction. So fear causes physical changes that make running from a lion easier: faster heart rate, faster breathing, more tense muscles, and a surge of restless energy. And because if you fall asleep around a lion you will definitely get eaten, anxiety makes it very difficult to sleep. You can try muscle relaxation, but that never works for me. I find it easier to convince myself that the current situation is fine, my goal is just to lie here with my eyes closed, and my test performance will be 70% of optimal even if I don’t sleep a wink.

Chronic Insomnia

There are two important things to know about chronic insomnia (i.e. insomnia more than three nights a week for more than three months with no medical cause).

First: you may have heard that all drugs for insomnia either are addictive and make your insomnia worse over time and summon walruses, or are melatonin.¹ This is a goddamn lie. A number of drugs (mostly antidepressants) cause sleepiness as a side effect, and they work reasonably well to treat insomnia for many people. Lobby your doctor politely for trazodone, mirtazepine, amitryptline, doxepin, or any drug you’ve previously taken that made you sleepy without too many other side effects. There are also a number of other sleeping drugs available, such as suvorexant or ramelteon, but I don’t have personal experience with them; do your own research.

Second: cognitive behavioral therapy for insomnia works. Not perfectly—I still struggle with insomnia after going through CBT-i. But it took me from five hours of sleep a night to six or seven, which is lifechanging. It’s difficult to find a provider who’s trained to provide CBT-i; most alleged CBT-i providers will just give you a handout about sleep hygiene. But it’s dead simple. You can do it on your own, if you have the willpower.²

The one caveat is that the weeks you’re doing CBT-i will be the most miserable you have ever experienced.

Here’s how to do it: For a week, track the amount of time you spend actually asleep (not “in bed”, asleep). Then, pick a consistent morning wakeup time. Add thirty minutes to your average amount of time asleep, and subtract that from your wakeup time (i.e. if you wake up at 7am, and you sleep for five hours and thirty minutes, you’d get 1 am).³

That’s your new bedtime.

You’re not allowed to go to sleep before your bedtime. You must get out of bed the second your alarm goes off in the morning. You may take one twenty-minute nap per day if it’s absolutely unendurable, but try not to do that, it makes it work less well.

During your sleep window, you may spend up to about twenty minutes trying to go to sleep. If you’re still not tired, get up and go to a different room. Do something interesting enough to distract you from worrying but that won’t get you excited; exciting things give you the Lions Problem. Playing Solitaire is good, or reading mediocre books. When you notice yourself getting sleepy, go immediately back to bed. Do not fall asleep on the couch. This is important.

Don’t do anything in your bed other than sleep and sex, if you’re feeling up for sex, which you won’t be.

After two weeks, observe whether you’re generally asleep more than about 85% of the time in your sleep window.⁴ If you are, you may move your bedtime fifteen minutes earlier. After that, any week in which you’re asleep more than 85% of the time in your allowed sleep period, you may move your bedtime another fifteen minutes earlier.

The idea is classical conditioning—like Pavlov’s dog that heard a bell whenever it was dinner time, and then started salivating whenever a bell was rung. If you’re insomniac, you’ve classically conditioned yourself that “bed” doesn’t mean “sleep,” it means “tossing and turning and worrying that you’re never going to go to sleep and staring at the clock.” You need to classically condition yourself that “bed” means “sleep.”

So you deliberately sleep deprive yourself until, the moment you go into bed, you pass out. As such, your brain breaks the “bed”/“anxious tossing” association and builds a “bed”/“immediately becoming unconscious the second your eyes are closed” association. That’s why it’s so important not to fall asleep on the couch—you’re wasting the precious, precious classical conditioning that you’ve worked so hard for on a place where you don’t want to sleep.

Everywhere else this is discussed downplays how miserable sleep restriction is. It’s awful. My CBT-i weeks were among the worst weeks of my life. But it really works. If you’re spending hours every night unable to sleep and you just want your life back, CBT-i can fix it. Everything I suffered was all worth it the first time I woke up in the morning and the sun had already risen.

But if you’re looking at this section going “why would anyone do this, on purpose,” I think the advice you need is the Mythbusters thing.

1. Read Lorien Psychiatry’s page about melatonin to learn about proper melatonin dosing; melatonin is usually dosed incorrectly.

2. Talk to a doctor if you have conditions that are seriously worsened by sleep deprivation, such as seizures or bipolar disorder.

3. If you sleep less than four hours a night, subtract four and a half hours instead; otherwise you risk hallucinating or other unpleasant side effects.

4. It’s fine to guess how long it takes you to fall asleep, this is a rule-of-thumb kind of thing.