How a chronic insomniac found a radically simple cure for her sleepless nights
I was living in a co-op on the edge of Regent Park, next to a playground that was invaded by screeching junkies every night. Everything that year was miserable. My mother had been diagnosed with cancer and was receiving radiation and chemotherapy every day for a month. My dad and two brothers and I juggled our schedules to get her to Sunnybrook Hospital from north Scarborough. When I wasn’t scared I was despondent. Even as I tried to keep up my performance at work (I was an editor at Toronto Life at the time), I wasn’t sure if I wanted the job anymore. Then I got insomnia.
I didn’t sleep for the entire summer. That can’t be true, but it’s how I remember it. I constantly felt both heavy and weak. My muscles were sore and tense. My shoulders throbbed. Every step seemed to take gargantuan effort. I had chronic gut rot. A mental fog separated me from the rest of the world. There was a noticeable lag between someone speaking to me and my comprehension of their words. I was sure that every time I tried to participate in a conversation, I sounded like an idiot—I once broke down crying at work during a routine discussion about scheduling photo shoots.
My body was so, so tired, but when I lay down, my mind would not shut off. In medical terms, this is known as “hyperarousal”—my metabolism and body temperature were higher than normal, and cortisol raced through me, keeping me awake. I worried constantly about my mom, my job, my relationship, getting everything done, getting it done well, and oh yeah, global warming and world peace. I tossed and turned, had a snack, used the washroom, watched cats and raccoons slink through the streets. Digital clocks would mock me as they marked the crawling passage of time. I roamed the house, covering every eerie neon glow with sections of newspaper. I reread young adult novels (my comfort books of choice) and ran up a huge phone bill calling friends in other time zones. Once, I went to Fran’s 24-hour diner at 4 a.m., only to realize it isn’t a place to eat while sober. Most nights, I just didn’t know what to do. I lay in bed with my eyes open in the dark for endless hours over endless nights.
I gave up coffee, joined meditation groups and yoga classes and attempted innumerable visualization and breathing techniques. I tried natural remedies: melatonin and valerian and 5-HTP, which contains tryptophan, the amino acid in turkey that makes everyone—except me—sleepy. None of it helped, and more often than not I’d find myself in the kitchen in the middle of the night, nursing lonesome tumblers of red wine.
Although I felt alone in my predicament, I wasn’t. Insomnia is more common than alcoholism. According to Statistics Canada, there are 3.3 million insomniacs in Canada. One fellow sufferer told me she has struggled with sleep for over a decade, and doesn’t dare to drive her 16-year-old son to soccer practice. “I feel like I’m risking his life,” she says. Another takes three sleeping pills a night.
My mom’s cancer eventually went into remission, but my insomnia remained. My inability to sleep felt like a personal flaw, as if sleeping were one more thing I sucked at.
Finally, I saw a doctor. I visited the psychiatric department at Toronto Western, where a PhD student who seemed eager to use his new prescription pad encouraged me to try antidepressants. I was wary of messing with my brain chemistry, but in desperation I agreed to try a sleeping pill—a hypnotic called zopiclone, which goes by the brand name Imovane. In essence, zopiclone tranquilizes the central nervous system, paving the way for sleep. It leaves a deeply bitter taste in the mouth that lasts into the next day.
I’d lie in bed in the dark and wait and wait for sleep to arrive before giving up and popping the pill. Once I had, the drug would slice cleanly through my thoughts, plunging me into deep, black sleep within half an hour. Pills seemed like the easy way out of my misery, but hypnotics aren’t intended for chronic insomnia; when used over long periods of time they can cause a new set of problems, like tremors, seizures, delirium, heart palpitations and memory loss. They’re also addictive. I wasn’t curing my insomnia: I was burying it under a mountain of drugs.
Why we sleep is a mystery. Tissue restoration is one beneficial result, which is partly why lack of sleep causes pain and is implicated in fibromyalgia. Memory and thought organization seem to happen during REM sleep. Most people know REM as the dream stage, but dreams actually happen all night long; REM is usually the stage we’re in before we wake up, so those dreams are the easiest to remember. Beyond that, no one is quite sure what else is happening, or why it needs to happen while we’re unconscious in the dark. Evolutionary psychologists theorize that early humans spent the day avoiding predators and so used the night to rest. Physiologists prefer to think of sleep as an offshoot of our individual circadian cycles, which is how our waking and sleeping schedules coincide with the rise and fall of the sun.
The average adult sleeps seven and a half hours a night—less in the summer, when there’s more light, and more in the winter, when the sun sets earlier. Insomnia occurs when the circadian cycles and the sleep drive—the relationship between sunset and sleepiness—are misaligned. Psychiatrists diagnose chronic insomnia when that misalignment lasts longer than a month.
One of the main causes of insomnia is forcing natural circadian rhythms to submit to our preferred schedules. This happens first in adolescence, when the surge of hormones into the body morphs teenagers into nocturnal creatures. Adolescent insomnia can evolve into a life of poor sleep. In the middle of life, the biggest obstacle to sleep is often work: shift work, juggling work with domestic life, and the pressure to always be on. It seems obvious that pinging email alerts throughout the night prevent good, deep sleep, but sleep clinic patients are often surprised, or defensive, when told to turn the smart phone off at bedtime. True insomniacs often gain weight, develop mood disorders and flirt with alcoholism. My weight didn’t change, but I was definitely moody and I downed more 3 a.m. scotch than I care to admit.
In Greek mythology, Hypnos, the god of sleep, uses the poppy to induce slumber. The flower and its parts are among the oldest insomnia cures. Other remedies have ranged from the addictive to the downright farcical—W. C. Fields, a notorious insomniac who dubbed sleep “the most beautiful experience in life, except drink,” couldn’t sleep unless he was lying under a beach umbrella sprinkled by a garden hose. In the 1960s, pharmaceutical companies began releasing benzodiazepines, like Valium, to calm the nerves and help induce sleep. The sedatives Restoril and Ativan are sometimes prescribed to new insomniacs whose condition seems incident-related (such as the bereaved), but they’re meant to be used for six weeks or less, since they’re known to be extremely addictive. In the 1980s, doctors began prescribing zopiclone for insomnia, and initially they claimed it was less addictive than benzodiazepines.
What my psychiatrist didn’t tell me was that the zopiclone wouldn’t work forever. At first, the pills transformed me into Frankenstein: slow, dumb and mechanical. Eventually I developed a tolerance. If I popped a zopiclone now, it wouldn’t even induce an afternoon nap.
One day last February, while desperately Googling variations on “sleep Toronto insomnia clinic,” I came across the website for the sleep and mood disorder program in the psychology department at Ryerson University. The psychologist Colleen Carney founded the program three years ago, after a decade researching sleep and depression at the Centre for Addiction and Mental Health in Toronto and at universities in the U.S. Intrigued, I picked up Quiet Your Mind and Get to Sleep, a 2009 self-help book Carney co-wrote with another sleep specialist, Rachel Manber. The book describes a process that was familiar to me: a patient visits the doctor, complaining of sleep problems. The doctor prescribes a sleeping pill. The patient comes back in a month, unable to sleep without the pill and unhappy with how the pill makes him or her feel. The doctor prescribes an antidepressant.
Carney’s research calls into question much of what we’ve come to accept about sleep treatment. Most psychologists view insomnia as a symptom of another problem (usually depression) and assume the insomnia will disappear with antidepressants. Carney believes that antidepressants don’t correct insomnia and sometimes aggravate it. It’s a controversial idea that’s gaining ground: recent books by psychologists, psychiatrists and journalists have criticized the frequency with which antidepressants are prescribed and questioned whether such drugs even work. Instead of prescribing drugs, Carney treats insomnia with cognitive behavioural therapy, or CBT. Blending elements of talk therapy and behavioural modification, CBT has been used to treat mood disorders for decades, but it was only recently accepted as a legitimate treatment for insomnia. The cognitive part involves identifying and analyzing false assumptions—for insomniacs, that might mean accepting the idea that you can survive on less than eight hours of sleep. The behavioural element requires the insomniac to make seemingly minor but ultimately profound changes to her lifestyle, like getting out of bed after 20 minutes of sleeplessness to avoid the association of bedtime with an active mind. The key: whatever other issues a patient is facing, insomnia is a unique problem that must be treated on its own.
Medical treatments for sleep are still uncharted territory in Ontario. There aren’t any OHIP-funded clinics or doctors who offer CBT for insomnia. Some private clinics do offer it for about $100 an hour (most cases take four or five hour-long sessions to treat), like MedSleep, which has seven locations across Canada and treats about 2,000 insomnia patients a year. Carney’s method is slowly moving toward mainstream acceptance: last year, she received a $150,000 grant from the Ministry of Research and Innovation to train therapists in CBT for insomnia. Five of her current master’s and PhD students will be trained by 2015. Carney is also campaigning to train nurses in CBT techniques.
Her sleep and mood disorders lab at Ryerson, where she is performing clinical trials, occupies one hallway of fluorescent-lit rooms in a four-storey building on Bond Street. On my first visit, I filled out a questionnaire before being fitted with an Actiwatch, an innocuous all-black wristband that resembles a sports watch but can sense both tiny and sweeping movements and, via constant, minute calculations, allow a clinician to assess the length and depth of sleep. Astronauts wear them to help study their sleep-wake cycles in space, which lends a certain cool factor, and there are now various commercial versions for the home insomniac (one of which, the WakeMate, lets users monitor their results via iPhone). For 10 days, the Actiwatch would use my body movements to record exactly how many minutes I spent awake and asleep. I was told to input my fatigue levels on a scale of zero to 10 at 10 a.m., 3 p.m. and 7 p.m. daily. As advised in Quiet Your Mind, I had been keeping a log of my bedtime, wake time and nighttime awakenings, which I was to continue to do for the next week and a half.
Then came the therapy part. Carney and I discussed my sleep beliefs and habits. She challenged my language—when I said I had “lost” my ability to sleep when my mom was sick, she looked at my log and pointed out that I hadn’t lost it at all, since I was sleeping for hours every night.
CBT for insomnia emphasizes stimulus control. Carney forbids her patients from watching TV, using a computer or even reading in bed—the goal is to eliminate anything that would encourage the brain to associate bed with alertness (sex is allowed, unless the patient finds it especially “activating,” says Carney). The first thing my boyfriend Steve and I bought when moving into our house last summer was $1,000 worth of blackout blinds (my old condo had been so flooded with ambient city light we could see each other’s faces all night long). Wearing earplugs makes me feel claustrophobic, so I run a humidifier for white noise (largely to drown out my bellowing neighbours, who could use some marital counselling). Carney approved.
Next, she set out to increase my so-called sleep drive—which would be done by restricting the window of time in which I slept. Carney’s treatment isn’t just about quantity; it’s about quality, and frequent awakenings meant I was spending more time in light sleep than in restful slow-wave sleep.
What would seem like common-sense coping methods, such as going to bed early, sleeping in on the weekend or catching a quick afternoon nap, are murder on an insomniac’s sleep drive. “Physiologically, these things have sort of the opposite effect on insomnia,” says Carney. In a non-insomniac, the body’s response to one night of poor sleep is to produce excellent, deep, restorative sleep the following night. But for insomniacs, a habit of naps and sleeping in tells the sleep drive that compensatory sleep isn’t needed, which then leads to a pattern of light sleep and multiple awakenings. By making patients genuinely sleepy, therapists hope to highlight how insomnia is different from fatigue, since the latter can have various non-sleep-related causes, from anemia to computer-screen eye strain. The physiological goal is to build up the sleep drive for nighttime, exhausting the patient enough to short-circuit hyperarousal.
To try and achieve seven and a half consecutive hours, I was told I could stay in bed only for half an hour more than my average. That meant eight hours a night. To give my sleep drive a nudge, I was told not to go to bed any earlier than 11 p.m. It could be later if I wanted, but no matter what, I had to have my “feet on the floor” at 7 a.m. every day, including weekends. This seemed like a reasonable schedule. Still, Carney was sure I’d be exhausted, since I would probably still wake up during the night, meaning I wouldn’t truly get those seven and a half hours, at least not right away. “You’ll hate me by the middle of the week,” she said confidently.
It’s much easier to take a pill every night than to commit to waking up at 7 on Saturday mornings, but I tried hard to do as I was told. I dutifully swung my feet onto the floor as soon as my alarm went off. I filled out my sleep logs (without lying about how much beer I consumed during the week of my birthday) and rated my fatigue when the Actiwatch beeped. Before bed, I puttered, watched movies or simply sat on the couch holding my eyes open, determined not to lie down until 11. Once, around 10:30 p.m., I ran upstairs for a minute, and Steve took it as a cue to turn off the downstairs lights. “What are you doing?!” I shrieked. “Turn the lights on right now!” I then gave him a lecture on being supportive. By the time I was done, it was officially time to go to bed.
Carney’s patients often complain about the pressure to go to bed at the same time as a partner. I’m jealous of Steve’s easy slip into nighttime slumber. He regularly gets eight, or even nine, solid hours. He used to set his alarm for 7:45 a.m., since his workday starts at 9:30 and his office is just a 10-minute bike ride from our house. I work at home and had gotten into the habit of lying around in bed trying to sleep a bit longer while Steve took a shower, and not kicking off my workday until after he’d left. My mornings were sludgy and anxious.
Carney sees a lot of opposites-attract pairings between extreme morning people and strict night owls. “The morning person always takes the moral high ground,” says Carney. “They’re like, ‘You’re being lazy by not getting up in the morning.’ Or, ‘You need to stop messing around down there and come to bed.’ They always seem to get their way.” In serious cases, when partners need drastically different bedtimes, or separate bedrooms, Carney has helped couples find a way to maintain intimacy while separating it from bedtime and sleeping—perhaps advising the night person to try cuddling when the morning person is bedding down, then leave the bed and resist the urge to return until he or she is truly sleepy. For the first day or two that I was trying Carney’s program, Steve grumbled. He’d head up to bed alone or woo me with his sleepy embrace in the morning. Soon, though, he accepted his fate, getting up at 7 a.m. with me and heading out for early morning runs before work.
I was amazed at how quickly my sleep drive was affected. By day four of the program, I was so intensely sleepy that one afternoon I dozed off while reading—and I’ve been incapable of a good nap for years. On day five, I fell asleep mid-afternoon again. After that, I started going for an afternoon walk to get away from my tempting bed and couch. And oh, my bed was tempting. I had dragged Steve on a shopping expedition, coming home with a not-too-hard, not-too-soft pillow-top mattress that is literally the stuff dreams are made of. One CBT tactic is to break the associations that lead to a hyperaroused mindset: a new bed, a new wall colour, or simply reorganizing the furniture can often help insomniacs reimagine a space they’d learned to associate with anxiety rather than rest.
When I returned to Ryerson 10 days after starting the experiment, I was falling asleep within 10 minutes of turning off my bedside light. I’d had only two longish middle-of-the-night awakenings during that time, and those were both less than three hours, far less time than I’d been staring at the ceiling before. I felt less fatigued in general, including on the days after those awakenings—it seemed that a lot of my fatigue was caused by the anxiety around sleep, and not the lack of sleep itself. This was in mid-April. I haven’t taken a zopiclone since.
Solid nights of sleep are bliss. There are other signs that my problem is in remission. My hyperarousal has disappeared: I’m not a blazing, sweaty furnace during sleep anymore. If I do end up awake for an hour or two for any reason, I feel confident the result will just be a deep slumber the next night. I’m a human Pavlov’s dog—at 10:45 p.m., I will be yawning through whatever concert or late movie I’m trying to take in, and my brain will stir just before 7 a.m., without fail. More than once I’ve left a party while my friends are still mixing cocktails because I just can’t keep my eyes open. (I feel like a loser, but often when I stop and explain that I’m trying to cure my insomnia, people will ask me to let them know if it works.)
Bedtime is no longer a minefield of worry and preparation (what book do I want to read at 4 a.m.? What snack will I have?). But I must admit I miss late nights and spontaneity. And the yoga class at 8:30 a.m. on Saturday that at first felt novel and healthy now makes me feel like a square.
I’ll also admit that I’ve slept in a few weekend mornings, but it’s hardly enjoyable, since there’s always a voice in my head nagging me about my precious sleep drive.
The year my mom was sick, Johnny Depp was on the cover of Vanity Fair, after receiving an Oscar nomination for the first Pirates of the Caribbean movie. He talked about how travelling and having young children were wrecking his sleep, offering up a quote that’s stuck in my mind ever since. “It’s amazing when you get to a certain age, and you talk about sleep in the same way you spoke about inebriates 20 or 25 years before,” he said. “ ‘Man, I got eight hours last night—it was fantastic.’ ” Everyone has a sleep story, and I’ve heard them all now: new parents who give fresh meaning to the phrase “running on empty”; couples who lie down together, both attached to Darth Vader–like sleep apnea machines; and people with freaky conditions like sleep paralysis, who wake up unable to move because their bodies are still frozen in REM sleep.
Not long ago, I met a marketing manager in her mid-30s who has fought insomnia for 12 years. She showed me her big bag of pills—she’s tried every med and supplement that exists, attended sessions of individual and group therapy, and gone through periods when she considered quitting her job because she was so exhausted. She, too, found that zopiclone led to Frankenstein brain and is trying to go drug-free. Her approach involves a lot of meditation and acupressure, and, if she’s being good, no booze. Oh, and a regular bedtime, of course. “It seems to be working, but it’s kind of like my life’s a bummer,” she says. “I’m not supposed to consume gluten. I’m not supposed to eat sugar. I’m supposed to go to bed at the same time, wake up at the same time. If it’s been a rough day, I need to meditate for 30 to 40 minutes. I just don’t know if it’s something I can do for the rest of my life.”
“Will I always have to live like this?” I ask Carney. “No, but maybe,” she says with a shrug. Really, it depends on me, and whether I like lazy mornings more than I hate sleepless nights, and how well I am able to drag myself out of bed at 7 a.m. after staying out until 3 the night before. Every one of us has to make choices in life, and right now, I choose sleep.