https://www.washingtonpost.com/wellness/2021/12/16/how-to-fall-asleep/


Why it’s hard to fall asleep, and tips to make it easier

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Falling asleep is a complicated process that takes time, experts say. (The Washington Post illustration)

By Allyson ChiuToday at 8:00 a.m. EST

Sleep doesn’t always come easily to Rebecca Robbins. That might be surprising to people who know her, because Robbins is a sleep researcher, but “I am not immune to these things,” she said.

“It would be wonderful if we could just turn our brains off like a light switch or power our brains down like our cellphone,” said Robbins, an instructor in medicine at Harvard Medical School. “But unfortunately, it’s not that easy.”Tips for starting and getting the most out of therapy

Falling asleep, Robbins and other experts emphasize, is a complicated process that takes time. In fact, falling asleep right away may actually be a sign that you aren’t well rested, Robbins said. After the lights go off, experts say, it’s normal to take anywhere from 10 to about 30 minutes to fall asleep.

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And having occasional difficulty sleeping is to be expected. “If your standard is ‘I’m going to sleep great seven days a week,’ then you’re going to be really disappointed,” said Raj Dasgupta, a pulmonary and sleep specialist and spokesperson for the American Academy of Sleep Medicine (AASM).

Craig Canapari, director of the Yale Pediatric Sleep Center, agreed. “It is really important to have reasonable expectations about sleep and also realizing that you can only set the table for sleep,” he said. “You can invite it to come, but you can’t control when it happens.”

Experts’ go-to research-backed recommendations for addressing sleep difficulties are probably familiar to any person who has struggled with falling asleep: prioritize a healthy bedtime routine, keep a consistent sleep schedule and manage stress, among others.

“If you want to sleep better, you have to work at it,” Canapari said.

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What is the process of falling asleep?

A person’s sleep-wake cycle is largely influenced by the homeostatic sleep drive and circadian drive, experts said.

“What makes people sleep is when your circadian rhythm dips down for sleep and at the same time your homeostatic drive is really high to make you sleep,” Dasgupta said. “So, when you get that pairing, boom, you sleep.”

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The homeostatic sleep drive is similar to hunger, said Bhanu Kolla, an associate professor of psychiatry and psychology and a consultant at the Mayo Clinic’s Center for Sleep Medicine. The longer you go without sleep, the more the need for sleep will increase. “If you’re napping during the daytime, you start dissipating some of that drive, so you lose some of that drive to sleep,” Kolla said. “You’re borrowing from your nighttime sleep.”

Circadian rhythm, or the body’s internal clock, also influences wakefulness. For most people, their circadian drives move to “biological night” at around 9, 10, or 11 o’clock and can help with initiating sleep, Kolla said. But there are some people, particularly those in their teenage or early adult years, whose body clocks are set later.

Additionally, there is a phenomenon related to circadian rhythm that some call “second wind,” Canapari said. “There’s a burst of wakefulness at the end of the day,” he said, noting that anyone who’s stayed up past their usual bedtime bingeing a show might be familiar with this sensation. “All of a sudden they get into bed a little bit later than normal and they’re wide awake. They’re kind of pushing into that circadian second wind.”

The process of going from being awake to being asleep also involves changes in neurotransmitters in the brain, said Anne Marie Morse, director of child neurology and pediatric sleep medicine at Geisinger Janet Weis Children’s Hospital in Pennsylvania. Think of the brain as a “electrical circuit board” with neurotransmitters as “motivators of these circuits,” Morse said.

“We know that during the daytime there are very specific neurotransmitters like dopamine, serotonin, acetylcholine that really help in promoting wakefulness,” she said. “As we start transitioning into nighttime, some of those neurotransmitters or circuitry start to shut off in order to turn on the nighttime circuitry.” The nighttime neurotransmitters are more “inhibitory,” she said, and tell our brains that it’s the time to shut down, rest and restore.

What makes this process difficult for some people?

Some people are just predisposed to developing insomnia, Dasgupta said, whereas others’ sleep woes may be the result of underlying health conditions, an undiagnosed sleep disorder or certain medications.

If you’re experiencing sleeplessness at least three days a week for three months or more and it’s affecting your daytime functioning, those symptoms meet the clinical diagnosis of chronic insomnia and it’s important to seek help from a health-care provider or sleep specialist. Sleep problems have been pervasive during the coronavirus pandemic, which has also been responsible for increased mental health challenges, including stress, anxiety and depression.

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In many cases, however, sleep issues can be the result of behaviors that interfere with the body’s natural processes of falling asleep. Exposure to bright lights at night or around bedtime, for example, can delay your body clock, while stress and anxiety can activate the body’s “fight or flight” response and increase the number of neurotransmitters that make you feel more alert.

Oftentimes, “sleep difficulties are an artifact of your day,” Robbins said. In a world where technology has exposed us to more information than ever and people are so busy, when bedtime rolls around “you haven’t really been able to process everything or think deeply about problems or issues,” Robbins said. “So, sometimes those things can surface close to sleep, which is, of course, the worst time for them to be surfacing.”

Racing thoughts, a form of cognitive hyper-arousal, are one of the main barriers to falling asleep, said Michael Smith, a behavioral sleep medicine expert at Johns Hopkins.

And feeling frustrated about not being able to sleep can also make drifting off more difficult, Morse said. People may develop “a relationship with their bed as a place that their brain now looks at as, ‘This a place I stay awake. This is the place I worry. This is the place that keeps me from falling asleep,’” she said.

In some cases, this frustration can lead to bad habits, such as spending too much time in bed or drinking alcohol, which may worsen insomnia, Dasgupta said.

While recognizing that sleep is critical, Kolla cautioned against overthinking. “The more you try to pay attention to it and optimize, the more difficult sometimes it tends to get.”

What should I do if I can’t sleep?

Most experts recommend a change in behavior. Cognitive behavioral therapy for insomnia is widely considered by experts to be the front-line, gold-standard treatment for chronic insomnia.

First, assess what you’re doing before you go to sleep, Morse said, and ask some key questions: What is your routine? Are you engaging in mostly stimulating and exciting activities rather than focusing on relaxation? What and when are you eating and drinking?

Dasgupta recommends having a sleep schedule with consistent bed times and wake times, including on holidays and weekends. Beyond creating a dark, quiet and cool environment conducive to sleep, give yourself time to prepare for bed. That means unplugging from screens and using the time to wind down with relaxing activities, such as taking a warm bath or shower, reading (preferably a boring book) or practicing meditation and mindfulness.

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For those with racing thoughts, Smith recommends trying different relaxation exercises to help initiate sleep, such as abdominal breathingprogressive muscle relaxation or imagining scenes you might find pleasant or relaxing.

It may also be beneficial to set aside time earlier in the day to address those thoughts. “Creating a space to deal with anxiety that’s not in your bed is helpful,” said Canapari, who often encourages his younger patients to write in a “worry journal.”

Avoid eating heavy meals right before bed or drinking caffeinated beverages. Although alcohol might help you fall asleep quicker, “the second half of the night’s sleep is extremely disrupted because you have metabolized all that alcohol,” Kolla said.

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If you’re struggling to fall asleep, get out of bed. “You don’t want to pair your bed and bedroom with being awake and worrying, because then that becomes a habit in and of itself,” Smith said.

Once you’re out of bed, keep the lights low and “do anything that’s mind-numbingly boring,” Robbins said. When you feel tired, get back into bed, but be aware that it might take a few tries.

Experts generally recommend behavioral approaches instead of relying solely on prescription medications or over-the-counter sleep aids, such as melatonin. “You can’t medicate yourself out of poor sleep hygiene,” Canapari said. “You can take all the melatonin in the world, but if your eyes are glued to your screen until five seconds before you expect to fall asleep, it’s not going to work.”

It’s important, however, to be realistic and patientabout progress. Try to stick with a regimen for at least a month and see if you can gain even 15 more minutes of sleep, Morse said. “Small steps are big wins.”

One bad night of sleep also isn’t the end of the world, experts said. “You can optimize things all you want, but once in a while, everybody’s going to have a bad night,” Canapari said.

“Just read a book, do something relaxing, drink a cup of tea and then try to go to sleep when you feel tired. You’re going to be okay the next day.”

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