The Insomnia Guide for Chronic Pain Patients
Serious insomnia-fighting advice from a veteran of the sleep wars
This detailed self-help article is humbly offered to people suffering from severe insomnia, in the hopes that my expertise and personal experience can be of some use to you. Before you place your hopes in any of my recommendations, however, please ensure that there is no medical cause for your insomnia first — they are common and hard-to-diagnose.1 But many severe cases of insomnia are essentially bad habits, and will respond to behavioural conditioning234 — and even if there is a medical cause for your insomnia, behavioural conditioning may still be your best defense.
Sleep is a reflex. You cannot “try” to sleep — you can only get out of its way. To the extent that insomnia is a bad habit, it’s largely that we are just interfering with the biological circumstances that would otherwise naturally trigger it. When you focus on sleep itself, it tends to turn its back on you like a cat.
Sleep is like a cat: it only comes to you if you ignore it.
Gillian Flynn, Gone Girl
How is insomnia relevant to pain and injury? Sleep deprivation is a major, common unsuspected factor in pain, and I have a extensive personal experience with that. Also, more obviously, pain is one of the most common causes of disrupted sleep (especially headaches, the most common of all pain problems).5 Pain and insomnia are trapped together in a dysfunctional relationship.
I am (mostly) recovered from extreme insomnia
I slept poorly from the age of twelve on, and I suffered through three major episodes of extreme insomnia as an adult. In 2005, I feel as though I nearly died from insomnia so savage that I slept as little as an hour a night for days at a time, over a period of many months. I was basically immune to pharmaceutical sleep aids that could have put a horse in a coma, and I had given every imaginable popular remedy a fair try.
If you have insomnia, you know all too well that people like to suggest insomnia cures even more than they like cold and flu remedies! I certainly believed that I had “tried everything.”
Fortunately, I hadn’t actually tried everything.
It’s amazing how much I was willing to suffer before I really took the challenge seriously. After a long struggle and an exhaustive personal investigation into the science of sleep and insomnia, I finally treated myself successfully. It was quite challenging, and my sleep is still far from perfect. But my average sleep quality is dramatically better than in the bad old days, and I have gone eighteen years without any more severe, routine insomnia.
Insomnia is a glamorous term for thoughts you forgot to have in the day.
Alain de Botton
Some consequences of sleep deprivation
Serious insomnia is nothing to mess around with. At my worst, I felt like I was made of glass, everything hurt, and I was seeing everything through a haze of mental distortions, exaggerated mental tangents, and minor hallucinations. From xkcd a popular geeky webcomic, here’s a strip about sleep deprivation that exactly describes how I felt in the summer of ‘05, and how any sleep-deprived person feels when they start to sink down to less than 3–5 hours per night. (Be sure to let your mouse cursor hover over the comic for an extra caption.)
“Still No Sleep”
Hallucinations are just the beginning: sleep deprivation can actually kill. Laboratory animals subjected to extreme sleep deprivation die relatively swiftly of unknown causes — exactly what goes wrong is not clear, but their body temperatures start to drop and then they suffer rapid and widespread physiological failure.6 This is a very curious thing about biology, that sleep is actually required for life, and in fact required for all life — virtually every living thing sleeps, if it has any kind of a brain of any kind.7
There is even a rare genetic disease, fatal familial insomnia (FFI), that causes such severe insomnia that victims die:
The main symptom of FFI … is the inability to sleep. First the ability to nap disappears, then the ability to get a full night’s sleep, until the patient cannot sleep at all. The syndrome usually strikes when the sufferer is in his or her 50s, ordinarily lasts about a year, and, as the name indicates, always ends in death.
“The Secrets of Sleep,” National Geographic Magazine, May 2010
Insomnia is not commonly fatal, of course, because there are all kinds of self-preservation mechanisms that kick in — as long as you don’t have a disease like FFI that absolutely eliminates sleep, you will never come anywhere close to losing enough of the stuff to kill you. But the fact that sleep is so basic strongly suggests that sleep-deprivation is a dangerous problem, even when it falls short of being actually lethal.8 And in fact there is a considerable amount of science confirming exactly this. Here in Vancouver, University of British Columbia psychologist Stanley Coren9 describes sleep deprivation studies in humans showing a number of ominous effects, and his book Sleep Thieves: An eye-opening exploration into the science and mysteries of sleep generally comes to the conclusion that everyone needs to take sleep deprivation much more seriously than we generally do. Here are several examples:
- Insomnia hurts. An internet survey of over 2,500 people with fibromyalgia (a chronic pain condition) showed that insomnia was one of the most commonly identified aggravating factors.10 There is good reason to believe that what makes fibromyalgics hurt probably predisposes healthier people in the direction of increased sensitivity as well. Another survey found the fairly spectacular statistic that 53% of chronic low back pain patients had insomnia, compared with only 3% in pain-free controls.11 Insomnia also saps your defenses against migraine headaches.12
- Insomnia makes you sick. It is strongly linked to metabolic syndrome (the term for a stew of factors associated with obesity, poor fitness, diabetes, and heart disease).13 A bout of insomnia is followed by periods of increased absenteeism from illness and disease… a vulnerability that can last for up to two years.14 A 2009 paper shows that people with even minor sleep problems (less than 7 hours per night) get almost three times as many head colds.15 and so on.
- Insomnia can wreck your mood. 40% of psychiatric mood disorders are preceded by insomnia, and insomnia sets in at the same time as another 20% of mood disorders.1617
- Insomnia impairs athletic performance, getting more sleep boosts it,18 and injury rates and recovery are probably affected too.19
This is just a sampling. For a complete discussion of how insomnia probably increases body pain of all kinds (and muscle pain in particular), see Insomnia Until it Hurts.
Sleep deprivation is serious. Take it seriously.
“Night owl” type insomnia (delayed sleep phase syndrome/disorder)
Delayed sleep phase syndrome (DSPS) is a sleep problem with a neurological cause and probably genetic roots.20 It is not a habit that can be broken. Like sleep apnea, it is relatively common — roughly 10% of insomnia cases are actually DSPS — but not nearly as well known. If you have a clear case of “night owl” insomnia, if you can’t get to sleep in the first place, you should read more about delayed sleep phase syndrome.
People with DSPS are not just night owls: they really are unable to fall asleep until later. Being a night owl is a lifestyle and a preference, probably also with some genetic basis, but it’s flexible. DSPD is not just a preference for staying up late and getting up late, and it’s not flexible. With DSPD, the body clock is not just delayed, it is also relatively carved in stone.
The lion and the lamb shall lie down together. But the lamb won’t get much sleep.
a very old joke (but a good one, which succinctly expresses the effect of stress on sleep)
Insomnia as a bad habit
Some insomnia is caused by sleep disorders such as DSPS, sleep apnea, or (seriously) narcolepsy.21 Or sleep loss may be caused by the pain of another medical condition, such as rheumatoid arthritis. But a great deal of insomnia is basically just a bad habit — a learned behaviour, which is usually aggravated into a crisis by emotional stresses22 or by other medical problems. This kind of insomnia is called “behavioural insomnia.”
I resisted this idea at first. Actually, I strongly resented it for a long time. It sounded like a dismissive “all in your head” diagnosis to me. I certainly did not feel like I had a bad habit. I felt like a victim of some terrible malfunction of my central nervous system.
I thought I had a “real” problem.
But it turns out I was just a guy with a bad habit, and the proof was in the results. Granted, it was a really bad habit — or several of them — but it really did come down to just learning how to sleep again. The cure was ultimately simple, and consisted of a simple 2-point plan:23
- sleep environment upgrading
- behavioural conditioning
The magic is in the behavioural conditioning, and it’s what most of the rest of this article is about. Step one just paves the way, and is mainly a determined application of common sense …
“Did you sleep well last night?”
“No, I made a few mistakes.”
Steven Wright, comedian
Sleep environment upgrading
All the behavioural condition in the world will be useless if you sleep in a bright, noisy, stuffy bedroom with a snoring spouse and a pesky cat. It is absolutely vital to have a sleep environment that is reasonably conducive to sleep, and it’s amazing how many things most insomniacs can do to improve their sleep environment.
Cover your windows with blackout curtains. Install sound-proofing eggshell foam. Find more comfortable earplugs. Get an air conditioner or a dehumidifier. Kick the dog out of bed. Get a squirt bottle and wage war on the cat until she learns that waking you up at 4:00 AM is going to get her nothing but soaking wet. Use a white noise machine or a fan. Buy the best mattress money can buy, get a deluxe pillow, and 900 thread count sheets. Fix the leaky tap. If your husband snores, get rid of him: separate bedrooms, separate lives, whatever it takes, even if it’s only until you learn to sleep again. Get rid of the phone too: permanently eliminate the possibility of it ever waking you up at 2:00 AM again.
Getting the idea?
Everyone’s circumstances are different, and the solutions will be unique, but stop at nothing to make your bedroom as sleep-friendly as humanly possible. And if you can’t do it — if there is something intrinsically sleep-hostile about your living space … move. Seriously. Why not? Remember what’s at stake here. People have transplanted themselves across oceans and continents for much less: jobs, boyfriends, and better scenery.Another sleep deprivation comic from xkcd. I think xkcd creator Randall Munroe knows all about this problem …
Sleep hygiene and stimulus control
Sleep is a complex human behaviour, and insomnia is a dysfunctional sleep behaviour — sleep behaviour that results in sleep that is at odds with what we want, usually not enough of it and at the wrong times. Either we start sleeping at the wrong time, and/or we can’t continue sleeping as long as we’d like, and/or we can’t sleep as deeply as we need to.
The sum of our sleep behaviours is called our “sleep hygiene.” Insomniacs usually have lousy sleep hygiene.
Sleep anthropologists — yes, that’s an actual field of sleep research, though admittedly a pretty small one — have taught us that “anything goes” with sleep. Sleep behaviour is quite variable and adaptable across cultures and situations, and we can learn and unlearn nearly any kind of sleep habit. And yet of course not all sleep hygiene actually works well. Just because we can learn to sleep in surprisingly sleep-hostile conditions doesn’t mean that it’s a good idea. That adaptability can work for or against us: it is easy to inadvertently teach ourselves sleeping habits with unpleasant long term consequences. It is less easy to deliberately teach ourselves better ones.
Without a doubt, we mostly suffer from civilization-induced insomnia. That is, we learn bad sleeping habits that are strongly associated with an electrical world. It’s easy to stay up. There’s stuff to do at night.
“Sleep hygiene” is the art of stimulus control and creating optimal circumstances for sleep. Do everything you can to avoid interfering with the natural impulse to sleep, and chief among those is simply getting too mentally engaged and aroused.
Many insomniacs will start protesting at this point: “But I try to go to sleep and I can’t!” Sure. But there are a thousand sneaky ways in which you tell and teach your brain not to go to sleep. There are several common themes, but let’s start with one of the worst and most common ways of training to become a champion insomniac …
Many insomniacs, when they have trouble falling sleep, get frustrated, get up, and do something stimulating. This is dangerous. Depending on the activity, this is a message to your brain. The message is, “1:00 AM is for checking my email. Reading a book. Watching a bit of boring telly. Having a snack.” Your ancestors didn’t have those options. Through most of our biological history, they literally couldn’t even put on a light!
It’s this simple: whatever you repeatedly do at 1:00 AM, that is exactly what your brain will think 1:00 AM is about! You are teaching your nervous system not to sleep, and like the miraculously adaptable thing that it is … it learns.
Learning to sleep again is something like training a dog: endless repetition, and positive reinforcement. Only instead of doggy biscuit rewards … your reward is sleep.
Sounds good, doesn’t it?
Behavioural conditioning is most familiar to us in the context of animal training. Unfortunately, this does not mean that we can easily “get it.” As any dog trainer will tell you, people really suck at training animals, and generally need far more training than the animals.24
People are no better at training themselves, probably even worse. We’re biased, emotionally messy, full of appetites and neuroses, a soup of stress hormones and a lifetime of habits already so well-established that they seem like a permanent part of the fabric of our lives. Saying that behavioural insomnia is just a bad habit is like saying that cancer is just a few bad cells. Habits are the most powerful forces in our lives. Learned adaptation is one of the basic organizing principles of our nervous systems. Going up against that is never going to be easy. But it can be done, just like professional animal trainers can get results that seem almost impossible to amateurs.
But behavioural conditioning itself is a skill that has be learned. It isn’t intuitive.
The total time in bed (TTIB) problem
Most insomniacs spread their sleep too thin: for instance, maybe you go to bed early because you’re exhausted, wake up a lot during the night because you’re an insomniac, and then of course you sleep in as much as possible to try to recover from the fragmented sleep. Your total time in bed may be 9, 10, even 11 or 12 hours sometimes.
The problem is that it is not actually possible for anyone — except cats — to consistently sleep solidly through such a long period. If you go to bed at ten and don’t get out of bed until nine the next morning, gaps in your sleep are inevitable!
This “total time in bed” is such a crucial concept that it should be acronymized: TTIB! Basically, as long as you have a high TTIB, good luck sleeping through the night.
An insomniac reader provided this good description of his experience of the TTIB problem:
I have often slept in a little to recover from a rough night, but going to bed at 10:00pm is actually not a good plan if I actually want to sleep past five or six … which I usually try to do. I have actually been going to sleep too early because I am anticipating trouble with sleep … I know I’ll have trouble, so I want more time to recover before the next day starts, so I start trying to sleep sooner. You can see how that might lead to sleep getting stretched thinner and thinner, where I’m actually causing the same problem I’m trying to solve.
Although there may be many things that wreck your sleep, TTIB is one of the most controllable and significant aggravating behavioral factors. And TTIB is usually most obviously aggravated by an inconsistent waking time. Many insomniacs get the idea of focusing on getting to bed at a consistent time, but rarely worry about wake time and semi-regularly stay in bed as long as possible trying to recover from the bad night of sleep. Unfortunately, this simply stretches out your TTIB and strongly reinforces the tendency to wake up in the night.
To have any hope of sleeping through the night, you have to have a consistent bedtime and a consistent waking time. Which brings us to sleep compression therapy.
Sleep compression therapy
Training for recovery from behavioural insomnia is usually most easily cured by restricting sleep to an inadequate, fixed period each night, and then gradually increasing it. It’ll be unpleasant at first … but you’ve got nothing to lose.
The idea of sleep compression therapy is pretty much identical to the logic behind the method used to train a cat not to be a fussy eater, which works like this:
Put a small dish of food out … for ten minutes only. If the cat doesn’t eat the food in that period of time, you take it away until the next meal time, by which time the cat is starting to feel a lot less choosy. After a few missed meals, even the fussiest of all possible cats is going to get hungry enough to eat whatever is in the bowl.
By compressing your TTIB into just a few hours, the message to the body is "this is all you’re getting, so make the best of it."
- Start with a 6-hour period, give or take: less than you need, but more than you are getting.
- Set the waking time you want to stick with. Count six hours backwards from that time to get your new bedtime. i.e. if you want to get up at 7:00am for the rest of your life, your new training bedtime is 1:00am.
- Start this on a weekend or when you have a day or even a week off from work. You don’t want to operate heavy machinery, or make important decisions, when you’re starting this process! You will almost certainly lose even more sleep than usual. You’ll lose sleep during your sleep period and have no opportunity to recover … until the next night.
- Do not nap at all or strictly limit napping. This is a significant challenge in itself. Do whatever you have to do. For the serious insomniac, a lot is at stake. All I can tell you is that it’s worth it.25
- Repeat for 3-14 days. Decide in advance how long to try the strategy, and stick to it. Basically, the worse your insomnia, the longer you need to really reinforce the “idea” that you’ve only got a few hours to sleep each night.
- At the end of the first phase, move your training bedtime 15-30 minutes earlier, and repeat for another 3-14 days. Increase your sleep in smaller increments for difficult cases.
The sleep “pressure” will accumulate enough so that you can hardly imagine not sleeping in the time available.
Sleep compression therapy is the beating heart of this article. The remaining sections are basically about how to make it better, how to troubleshoot it.
Valuable no matter what
One of the most common objections I’ve heard to sleep compression therapy is that it doesn’t matter if your insomnia has a medical or psychiatric cause, such as pain, or severe anxiety.
This is not true. It matters more.
It may not work as well … but the need is actually greater. The more difficulty you have sleeping for any reason, the more important it is to have good sleep hygiene.
Consider pain, for example. There is no question that it can wreck sleep! And no amount of improvement in sleep hygiene is going to magically make that pain go away — obviously. But there is only one thing worse than sleep-destroying chronic pain, and that is chronic pain plus crappy sleeping habits. The chronic pain patient who makes every effort to maximize their chances of sleeping is going to be better off, every time, than the chronic pain patient who does not.
No matter what is wrong with you, no matter what is disturbing your sleep, it is important to have sleep behaviour that is as good as possible under the circumstances.
Sleep isn’t an escape, it’s an act of rest.
Jock McKeen & Bennet Wong, founders of Haven
The importance of ritual and consistency
This is particularly important for insomniacs who have trouble falling asleep.
Spend some time and create a carefully planned and scheduled bedtime ritual of at least half an hour to repeat every night until you are cured, and frequently for the rest of your life.
The purpose of the ritual is to (a) wind down, and (b) learn to associate your bedtime with a series of predictable steps. It actually makes a difference whether you wash your face and then brush your teeth, or brush your teeth and then wash your face — it doesn’t matter which order you do it in, but it does matter that you always do it in the same order. The more consistent the ritual, the more quickly your brain can learn that face washing followed by teeth brushing equals bedtime.
The timing should be really consistent, too. The ritual should start at exactly the same time every time.
Morning rituals also work well for insomniacs who wake up too early, although not as well, for the obvious reason that the part we control — the ritual — comes after the part we wish we could control — the sleeping. Nevertheless, it’s just as important to teach your brain that waking time is well-defined.
What to do if you still can’t sleep
People who honestly stick to a basic sleep compression regimen rarely fail. When they fail, it is usually because they aren’t actually doing it — they are finding ways to “cheat.” However, some people have insomnia so severe that even a compressed sleep schedule does not work. I know this because I was one of those people! To make my sleep compression work, I had to up the ante. I needed to make myself even more exhausted.
If you need to up the ante, simply do whatever you have to do to be so exhausted that sleep is the only option. Just feeling tired doesn’t necessarily mean that you are exhausted enough to sleep, so don’t judge your sleep readiness only by how “tired” you are. Most insomniacs feel very tired, of course, but still can’t get to sleep. I have never been so tired in my life as I was during those long sleepless nights in 2005. A subjective feeling of tiredness is a poor measure. What you need is not just to "feel tired," but to actually "be exhausted." So you need to go to greater efforts to ensure that you are well and truly worn out: more fresh air, more exercise (more on this below), a shorter sleep cycle, no naps, etc ... anything you can think of to make yourself more truly exhausted at bedtime.
And remember that this is behavioural conditioning. Simply keep upping the deprivation ante until you reach the level where you can teach your body that your bedtime is the time when you fall asleep. Trust me, as long as there is no medical reason for your insomnia, there is a level of exhaustion at which even you will konk out!
How to fill those sleepless moments
Inevitably, there are going to be times when you find yourself awake when you don’t want to be, and one of the stickiest issues in insomnia management is what to do with those times. Even the most effective sleep compression regimen takes time to work. But trickier still is that being awake some during the night is probably perfectly normal, part of a healthy waking-up-at-an-ungodly-hour rhythm in human sleep. The science news:
We often worry about lying awake in the middle of the night — but it could be good for you. A growing body of evidence from both science and history suggests that the eight-hour sleep may be unnatural.
I agree that it is getting pretty clear that humans aren’t really built to sleep through the night (with the exception of my wife, apparently, who can sleep 10 hours without so much as rolling over). In fact, we probably have a natural wakeful period in the middle of the night in the same way that we are prone to naps in the afternoon — a sort of mirror image. They even tend to occur around the same section of the clock face: 2–4 PM and 2–4 AM.
So you want to respect the fact that being awake may be fine, while at the same time being quite careful that you’re not awake for the wrong reasons or for dysfunctionally long. The distinction between healthy and unhealthy wakeful patches can get pretty blurry and confusing, especially for the groggy, exasperated insomniac.
Blinded by insomnia recovery success
I’d actually known about this idea of a normal awake patch for several years. I first learned about it from a terrific radio documentary back in 2006. It probably didn’t really sink in because I was in the middle of my first major successful recovery from insomnia, and there just wasn’t much room in my head for another wrinkle. My recovery progressed more or less normally, even though I continued to wake up in the middle of the night. It wasn’t a failure to be up for a bit, as long as I could get back to sleep in a reasonable time. Which I did.
My intention at the time was to make it downright unappealing to be awake — to actively discourage it, to break any habit of being awake at that time. I thought the goal was to avoid “rewarding” my nervous system for being awake by doing anything pleasant. That was the advice in this tutorial for years, and it dovetailed well with sleep compression therapy.
But I never really followed my own advice!
I tried a few times. For instance, I tried just standing on the deck in midwinter, quite cold and uncomfortable, doing nothing until I couldn’t stand it any more and was desperate to get back into bed. But that kind of nonsense didn’t last long. Over a year or two, I “fought” wakefulness less with discomfort, and settled into the mild-mannered compromise that I’m still working with today: I don’t turn on any lights, and I don’t do any work or “engage” with the world at all; but I do make myself comfortable, and do something pleasant but mellow, like reading or listening to an audiobook. I’m usually quite content for 20-30 minutes, after which I can hardly imagine staying awake.
I did that for years without thinking about it much, accepting my wakeful patches for the wrong reason, treating them like a minor, vestigial remnant of my insomnia that wasn’t worth fighting — rather than a natural, healthy part of my circadian rhythm that actually should be embraced, not resisted.
So now what? Why it may still make a lot of sense to stay mellow all night, even if you are awake
It may be healthy and normal to have a little early AM wakefulness … but it’s still problematic for insomniacs.
It is psychologically important for insomniacs not to indulge in much night-time activity. It would be foolish to turn on all the lights, pump up the volume, and catch up on household chores — not because it’s at odds with biology at that time of night, but because that would probably be part of a much bigger life problem (workaholism, overstimulation, anxiety) that tends to wreak havoc on sleep at all other times. It probably would be okay for non-insomniacs to get quite active for a spell during the night, just like it’s okay to have a hard two-hour nap after lunch (if you’ve got that in you). A healthy person can fall asleep after midnight romps.
But probably not someone with terrible insomnia! The insomniac has to be a little more careful — maybe a lot more careful — not to let a little natural alert period get out of hand.
I’m content to defy my natural biological rhythms a little by keeping things pretty low-key all night long, because it helps me keep my workaholic demons at bay. Plus it’s just practical to mostly go with the “sleep all night” cultural flow. My wife is never awake at that time, and it would be a bit problematic if I were to start making a habit of consistently getting up for a couple hours in the middle of the night. Not awful, just awkward. I suspect this is how most people will feel.
At the same time, it’s not necessary to aggressively fight that wakeful patch, however. There’s no need to deprive yourself of all comfort in an effort to drive yourself back to bed, as my tutorial has recommended for years. So my advice these days is to respect the fact that it’s probably normal and healthy to be awake a bit in the middle of the night. It has little to do with most insomnia, especially if you stay calm and just — quietly, calmly — go along with it.
Here’s a more step-by-step summary:
- Attempt to sleep in 20-30 minute blocks of time. If you can’t sleep, don’t lie in bed getting more frustrated, doing “sleep math” (calculating how much sleep you’re losing, how long it is until you have to get up for work, and so on). That creates a (really) negative association with bed. Simply remain calm, and get up.
- Address any immediate discomforts. Take care of yourself. Fix any problems you can fix. If you’re ravenous, have a snack. If it’s too cold, turn on the heat. If it’s too hot, open a window. And so on.
- Do something mellow. Minimize stimulation. Make yourself comfortable enough that you can doze off. Avoid anything associated with any anxieties that woke you up. This is not the time to deal with life problems (there might be rare exceptions26).
- After about 20 minutes, return to bed and try to sleep again. You’re trying to end the awake patch fairly quickly.
Repeat until asleep.
How long will it take?
Some improvements in sleep hygiene combined with sleep compression therapy alone will resolve behavioural insomnia for most people within 4-6 weeks. I had such a severe case that I took three times that long, and progress in the first month was sketchy — but it still worked. Eventually I removed the sleep compression restrictions and stopped using the rigid bedtime ritual, but I still return to these tactics regularly, whenever I suspect there’s a need to shore up my defenses — and now they always work quite quickly. In fact, it’s amazing how I start getting sleepy as soon I start to go through the steps of the bedtime ritual. Like a well-trained dog!
Sleep wreckers: other miscellaneous things that interfere with sleep that you may not know about
I’ll add to this section slowly over time. For now, it’s just three: backfiring exercise, backfiring creatine supplementation, and bright reading gadgets. There are surely many more! If you have a suggestion, please let me know.
“Get lots of exercise” is not an insomnia treatment for everyone
The no-brainer conventional wisdom is that exercise is good for sleep and helps insomnia: it “wears you out.” And that’s mostly true. The effects on non-insomniac sleepers are modest but confirmed,2728 and “exercise training is effective at decreasing sleep complaints and insomnia,” similar to the effects of hypnotic medications.29 So that’s nice. Most people should probably exercise regularly to treat insomnia.
But not everyone.
Our genes dictate much about how we sleep30 as well as practically everything about how we respond to exercise.31 And so, for some people, exercise can actually backfire. Working out too hard and too late is a fairly obvious hazard,3233 but it goes beyond that: some people struggle with this much more than others, for genetic and/or pathological reasons. The response to exercise may be positive overall — stimulating, invigorating — but bad for sleep. Or the response to exercise may have uncomfortable consequences — malaise, pain, greater overall sedentariness (from fatigue)3435 — that is also bad for sleep.
There are so many variables that can affect the effect of exercise on sleep that you should probably run your own experiment: keep a log! Pay attention to the variables until you know. Assuming you don’t already know. I am a semi-serious amateur athlete, and I’ve known for 20 years that I can kill a night of sleep by getting too sporty after 6pm (which really sucks), but if I walk for an hour midday it will improve my sleep. It’s not a subtle effect.
Creatine and insomnia
Late in 2012 I reversed a careless anti-creatine position. I reconsidered this supplement and publicly acknowledged that it is a safe and effective ergogenic aid, capable of reducing muscle fatigue at the gym. And then I tried it. And that went badly. I developed severe insomnia — and this was before I read that some people may have trouble sleeping when they take creatine. I can now add to that ancedotal evidence.
My own sleep troubles over the years are almost exclusively with “sleep maintenance” — I get to sleep just fine, but then I wake up. This creatine-powered insomnia was a mirror-image of that: I had a lot of trouble getting to sleep, but then I’d finally crash hard and even sleep in. This was all quite peculiar and unprecedented, and it didn’t take me long to get suspicious. Normal sleep was restored within 48 hours of stopping creatine. I performed pretty poorly at the gym during that 3-week period … probably because I was so fatigued!
So my creatine experiment was a bust, but that doesn’t mean creatine doesn’t work. My vulnerability to sleep problems is nothing new. Almost anything can wreck my sleep: a hangnail, a thrilling episode of Game of Thrones, a good idea, you name it. Creatine gets added to my list of sleep-wreckers, but I’m sure most people probably don’t have a problem with it.
Nevertheless, it seems to be well worth mentioning.
Is blue light evil? Lighting, gadget screens, and tenth-assed science
One ill-fated night of lost sleep that I will never forget was caused by a bad news notification on my iPhone. Just as I was supposed to start drifting off, I learned that PainScience.com was offline. This was back in the days when smartphone notifications were still a novelty, and I was still new to running an online business — so I wasn’t yet jaded and unflappable about downtime.37 Back then, downtime still freaked me out, and so I was awake for *hours* waiting for the website to come back to life. If only I hadn’t looked at my phone, I would have slept fine.
Obviously gadgets are a source of many potentially engaging or even stressful stimuli, best avoided when you’re trying to wind down. If you don’t put your phone down earlier to avoid the light, at least do it to avoid doomscrolling, or getting a troubling notification five minutes before you were wanted to be asleep.
I want you to read my articles. But possibly not at night. And with less blue.
But should our concern go deeper? Is it about the light? What about the whole blue-light panic? Do our screens blast us with circadian-rhythm wrecking rays?
Reading backlit devices like iPads before bed might hurt sleep.38 Although the science is barely there (details below), we might as well minimize and mitigate. These days we can make most screens less blue, which allegedly prevents harmful interference with our circadian rhythms (and maybe reduces eye strain too). All platforms have jumped on this bandwagon and added features like “Night Shift” (Apple) and “Night Light” (Android, Windows). Long before they were baked into our operating systems, indie software developers made apps like f.lux39 (Apple, Windows) or Lux (Android), and those are still available (as of 2021), with more flexibility and features, for whatever that’s worth.
Surely there’s a good reason for those features…
Or is just just more over-hyped hand-wringing about the perils of modern living? Which is a weirdly popular hobby in a world where we live three times longer (and better) than our primal ancestors.
It also makes sense to be somewhat cautious with turning on lights during the night: light may be a strong message to your brain, and the message probably ain’t “go to sleep.” Turn on only the dimmest lights for short periods, avoid blue lights in particular, and consider having a couple of lights just for night time use: low wattage bulbs with a warm hue.
The science of light and sleep
My lighting advice is based on complex, conflicting, and extremely incomplete science. However, just minimizing light intensity and blueness at night is easy advice to follow, safe and free, and may also reduce eye strain or just be more aesthetically pleasing.
I have some of these around the house for (very) warm light at night. I don’t care if it’s evidence-based. I do it because it makes my home look more like a “lair,” & there’s still a bit of “goth” in me, leftover from my ridiculous youth. 🧛🏻♂️
The first ever direct efficacy trial of the iPhone’s Night Shift feature, which makes the screen much more yellow and less blue at night, made headlines in mid-2021.40 Every cynic who saw those headlines rolled their eyes, said “I told you so!” … and stopped thinking about it.
But genuine critical thinkers rarely close a subject, of course. Skepticism isn’t (just) cynicism.
It was an important study, the right kind of study — testing the effect of the feature on how well people actually sleep. (There’s a bunch of other relevant research, but it’s all indirect evidence.) But it also had flaws and limitations, as all studies do, and so it was hardly the last word.41
Just two months later, a second study of this kind was published — which did not make headlines — showing the opposite.42 They were more serious with their measurements — polysomnography for the win! — and they *did* detect a meaningful effect on “slow-wave-sleep and -activity in the first night quarter.” This study *also* had flaws and limitations, of course, but it doesn’t even really matter: the point is not what this or that study said, but just that there aren’t enough studies yet.
Tentative conclusions and advice about night light sources
And as for optimism? It’s probably broadly true that our circadian rhythms are indeed light-regulated. It has always been *plausible* that filtering out some parts of the spectrum at night is helpful — and it remains plausible, because it simply hasn’t been tested adequately. Despite the headlines in October. Those headlines amplified one small portion of imperfect data.
We don’t consider anything proven with one study… and we don’t consider it disproven with one study either. Different and better studies could easily find different results — and one already has.
So apply the cautionary principle. It’s worth minimizing blue/intense light before bed, because it’s easy, it might help, and it certainly won’t do any harm to live a little more like we did before The Age of Screens.
Using medications to prevent minor aches and pains from interfering with sleep
If any kind of chronic/serious pain is interfering with your sleep, obviously you should do whatever you can to diagnose and treat that problem in the most appropriate way possible. However, many insomniacs have relatively minor, annoying aches and pains that have no obvious explanation or treatment, and they get in the habit of popping pills to try to prevent the pain from interfering with sleep. It’s a bad, dangerous habit.
And yet the pills can be useful. It’s just very important to use them strategically and minimally. To do that right, you need to understand them. The types and risks and benefits of common pain-killers are bewildering. Here’s a very carefully prepared summary of all of them:
Over-the-counter (OTC) pain medications are fairly safe and somewhat effective in moderation and work in different ways, so do experiment, but do it cautiously. There are four kinds: acetaminophen/paracetamol (Tylenol, Panadol), plus three non-steroidal anti-inflammatories (NSAIDs): aspirin (Bayer, Bufferin), ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn). Don’t take any of them chronically — risks go up over time, and they can even backfire and cause rebound headaches. They are all probably equally effective for acute injuries (Hung), but benefits vary with people and issues (chronic pain, headaches, arthritis, etc), and relief is usually minor at best.
Acetaminophen is good for both fever and pain, and is one of the safest of all drugs at recommended dosages, but it may not work well for musculoskeletal pain (at all?), overdose can badly hurt livers, and it might harm fetuses. The NSAIDs all reduce inflammation as well as pain and fever, but at any dose they can cause heart attacks and strokes and they are “gut burners” (they irritate the GI tract, even taken with food). Aspirin may be best for joint and muscle pain, but it’s the most gut-burning of them all. Voltaren is an ointment NSAID, effective for superficial pain and safer (Derry). Athletes, puh-lease don’t take “Vitamin I” to prevent soreness — it doesn’t work! Worse, it may impair tendon and bone healing.For more information, see The Science of Pain-Killers.
The trick is to experiment cautiously over time, and only use them occasionally when the pain is worst and the need for sleep is greatest: they may genuinely help in that situation.
Anti-depressants for insomnia are probably ineffective
Biology is insanely complex, and psychology is even worse, and so there are probably some people out there somewhere who have slept better thanks to their anti-depressants. But on average? Quite unlikely. This old idea that anti-depressants can treat insomnia is almost certainly wrong for most patients. We have some good evidence of absence, and also a rather tragic absence of evidence.43 You’d think that after decades of people routinely getting these prescriptions for insomnia, they might be based on more actual data, but unfortunately that is not the case.
Chronic widespread pain (fibromyalgia) is firmly linked to a lack of restorative sleep, and the antidepressant amitriptyline consistently appears in pain treatment guidelines for this reason. However, that is not based on robust evidence either… and the evidence for amitriptyline as a direct insomnia treatment is almost perfectly AWOL. Everitt et al.:
There was no evidence for amitriptyline (despite common use in clinical practice) or for long-term antidepressant use for insomnia. High-quality trials of antidepressants for insomnia are needed.
And then there’s the side effects. Bear in mind that so-called anti-depressants actually cause depression in many patients — half of them in one study44 — maybe because of all the other common and unpleasant side effects? 😬 Caveat emptor! These drugs may have their place, and it is not my place to say what that place is, but I am confident it isn’t insomnia treatment.
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About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:
- Anxiety & Chronic Pain — A self-help guide for people who worry and hurt
- From National Geographic Magazine, “The Secrets of Sleep,” a superb feature article on sleep, which is entirely available online. Reading it, I thought, Wow, when traditional media is good, it’s still really good — NGM produces amazing content.
- Sleep thieves: an eye-opening exploration into the science and mysteries of sleep (book), by Stanley Coren. Amazon.com ❐ UBC scientist Stanley Coren takes the reader on an entertaining tour of the weird world of sleep ... and then sets about proving that almost all of us are sleep-deprived, and paying for it with our health. Because of this book, I believe that sleep-deprivation is probably a factor in most cases of chronic pain. Stanley Coren is an entertaining writer, a skilled science popularizer from my own stomping grounds (Vancouver). Although he is better known for his books about the intelligence of dogs, this book about sleep is just as much fun, and of particular interest to anyone who has ever suffered from insomnia or other sleep disorders. It’s definitely not a self-help guide for insomniacs (see The Insomnia Guide for Chronic Pain Patients for that), just a really interesting tour of sleep science in general.
- Sleepyhead: The Neuroscience of a Good Night’s Rest (book), by Henry Nicholls. A useful and fascinating tour of sleep disorders from the perspective of a narcoleptic science journalist. This interview with the author is a fine introduction to the book. Narcolepsy is not just about falling asleep when you shouldn’t, but about lousy overall regulation of sleep: narcoleptics usually can’t sleep when they want to any more than they can stay awake when they need to. It is one of several overlapping disorders that screw with the neurology and endocrinology of sleep regulation and circadian rhythms. As Nicholls learned this for himself, he was inspired to write about all of the many underestimated medical causes of messed up sleep, creating a book that should be read by anyone who has ever slept badly. It’s thorough, funny, erudite and reassuringly free of crank theories. He does a particularly good job of putting sleep science in historical context, explaining how we discovered what little we know. Some of the stories of pioneering sleep research are both amazing and surprisingly recent.
- “While You Were Out” an audio recording from Ideas (CBC Radio One). Why we spend a third of our lives cut off from the world is still a mystery! An excellent two-part, two-hour radio documentary by Jeff Warren about sleep science, with excellent discussions of dream interpretations, a really exciting section about lucid dreaming, and some surprising insights into the anthopology of sleep and “natural” sleep rhythms. (To obtain audio, please contact me privately (see email link at top of page), as CBC has not made this show publicly available and obviously I cannot legally post it for distribution. I don’t technically have the right to give it away either ...)
- From Radio Lab, a whole show about sleep from 2007, brilliant as always.
- Sleepio.com is basically the online version of the classic insomnia self-help guide, Overcoming Insomnia and Sleep Problems: A Self-Help Guide Using Cognitive Behavioural Techniques (now out of print and no e-book version). It probably actually works.45 The site also has a good library of articles about insomnia.
What’s new in this article?
Thirteen updates have been logged for this article since publication (2007). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets PainScience.com apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.
I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
Jan 19, 2023 — Science update. Short new section about the use of anti-depressants for insomnia.
2021 — Completely rebooted all content about light, blue light, screens, and gadgets features like Night Shift and Night Light. New science, all new commentary.
2018 — Added a footnote about the surprising prevalence and relevance of narcolepsy.
2018 — Added point and citations about the effect of sleep deprivation on athletic performance and injury rates.
2017 — New section, “‘Get lots of exercise’ is not an insomnia treatment for everyone.”
2017 — New section about delayed sleep phase syndrome.
2016 — Science update: evidence for CBT for insomnia is now quite strong, see Trauer.
2015 — Added section “Using medications to prevent minor aches and pains from interfering with sleep.”
2015 — Added section about lighting and gadgets.
2013 — Rewrote section, “How to fill those sleepless moments.” The section now deals with the likelihood that it is actually healthy and normal to be awake for a little bit in the middle of the night. A small thing, but the section pretty much had to be completely revised.
2011 — Added a small but imortant point about the trouble with hot baths.
2010 — Added this quote: “Sleep isn’t an escape, it’s an act of rest.” (McKeen)
2010 — Added two interesting references and the XKCD comic strip about sleep deprivation.
2007 — Publication.
- Sometimes insomnia is a symptom of another condition or a side-effect of a medication; a few kinds of insomnia have biological origins that will defy any attempt at self-help, such as delayed sleep phase disorder or narcolepsy (which, counter-intuitively, actually does cause insomnia as well as sleeping at odd times). A bit more on these below.
- Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004;164(17):1888–1896. PubMed 15451764 ❐ PainSci Bibliography 55914 ❐
From the abstract: “These findings suggest that young and middle-age patients with sleep-onset insomnia can derive significantly greater benefit from cognitive-behavioral insomnia therapy (CBT) than pharmacotherapy and that CBT should be considered a first-line intervention for chronic insomnia. Increased recognition of the efficacy of CBT and more widespread recommendations for its use could improve the quality of life of a large numbers of patients with insomnia.”
- Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian RE. Does cognitive-behavioral insomnia therapy alter dysfunctional beliefs about sleep? Sleep. 2001;24(5):591–599. PubMed 11480656 ❐
From the abstract: “[Cognitive-behavioral insomnia therapy] is effective for reducing dysfunctional beliefs about sleep and such changes are associated with other positive outcomes in insomnia treatment.”
- Trauer JM, Qian MY, Doyle JS, Rajaratnam SM, Cunnington D. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015 Aug;163(3):191–204. PubMed 26054060 ❐ From the abstract: “cognitive behavioral therapy for insomnia (CBT-i) is now commonly recommended as first-line treatment for chronic insomnia.”
- Ohayon MM. Relationship between chronic painful physical condition and insomnia. J Psychiatr Res. 2005 Mar;39(2):151–9. PubMed 15589563 ❐
Is chronic pain (regardless of the condition, and lasting more than six months) a major cause of sleep disturbances? This was a large study with more than 18,000 participants, deemed representative of a population of 206 million people. The short, obvious answer appears to be yes. The conclusions of the study were: “CPPC is associated with a worsening of insomnia on several aspects: a greater number of insomnia symptoms, more severe daytime consequences and more chronic insomnia situation. CPPC plays a major role on insomnia. Its place as major contributive factor for insomnia is as much important as mood disorders.”
Science may produce an explanation for this over the next few years, and some very interesting clues have already emerged. For instance, in 2007 the radio show Radio Lab did a whole show about sleep, quite brilliantly reporting this tidbit that I’d never heard before: that sleep deprivation may do its dirty work by (somehow) interfering with protein folding (starting about minute 29, transcription a bit imprecise because of the complex mix of sound bytes):
Dr. Allan Pack, a “rabid biologist,” has been looking at sleep at the cellular level, and one of the things he’s found over and over and over — shown in mice, shown in rats, shown in fruit flies — is that certain cells in all those different types of animals, when they are sleep-deprived … what happens is that you don’t get proteins properly folded.
Excuse me? Proteins properly folded? This is a phenomenon called the unfolded protein response. But what on earth does that mean? Why do you need proteins to “properly fold”? Well, you’re made of proteins. Proteins are the essence of you. If your proteins are misshapen, if they’re not folded properly, if they don’t have the right three-dimensional structure, and as a result they start accumulating inside the cell, then these unfolded proteins can start to aggregate together and form clumps inside the cell and essentially clog it up and it’s really quite toxic. Clumpiness equals tiredness!
But when you get sleep, a group of cleaner-uppers have gone through your cells and removed the misshapen proteins so that, in effect, sleep is the best housemaid you’ve ever had, in the hotel of you.
- Coren S. Sleep thieves: an eye-opening exploration into the science and mysteries of sleep. Simon & Schuster; 1997. Stanley Coren discusses this sort of thing in considerable detail in his book. Very interesting stuff!
- U.S. Department of Health and Human Services. Perceived Insufficient Rest or Sleep Among Adults — United States, 2008. Morbidity & Mortality Weekly Report. 2009 Oct 30;58(42):1175–1179. PainSci Bibliography 55373 ❐
This report by the U.S. Department of Health and Human Services’s presents evidence that sleep-deprivation is common and serious: about 30% of American adults are getting less than 7 hours per night (and of course many of those are getting much less), and at least 10% of people have gotten “insufficient rest or sleep on all days during the preceding 30 days.” That’s one in ten people getting inadequate rest every night for 30 days in a row!
Consider: if 1 in 10 people have gotten inadequate rest every night for 30 days … how many got inadequate rest for 29 days? 28? 27? The report concludes:
The importance of chronic sleep insufficiency is under-recognized as a public health problem, despite being associated with numerous physical and mental health problems, injury, loss of productivity, and mortality. … Health-care providers should consider adding an assessment of chronic rest or sleep insufficiency to routine office visits so they can make needed interventions or referrals to sleep specialists.
I have long believed that this was an almost completely neglected consideration in chronic pain care.
- Best known for his work on dog intelligence, but also a sleep expert.
- Bennett RM, Jones J, Turk DC, Russell IJ, Matallana L. An internet survey of 2,596 people with fibromyalgia. BMC Musculoskelet Disord. 2007;8:27.
- Tang NK, Wright KJ, Salkovskis PM. Prevalence and correlates of clinical insomnia co-occurring with chronic back pain. J Sleep Res. 2007;16(1):85–95. Although of course it may be low back pain that is keeping these people awake, in fact my clinical experience suggests that this is by no means the case: chronic low back pain patients are often poor sleepers, and insomnia may routinely precede episodes of pain!
- Alstadhaug K, Salvesen R, Bekkelund S. Insomnia and circadian variation of attacks in episodic migraine. Headache. 2007 Sep;47(8):1184–8. PubMed 17883523 ❐
- Koren D, Dumin M, Gozal D. Role of sleep quality in the metabolic syndrome. Diabetes Metab Syndr Obes. 2016;9:281–310. PubMed 27601926 ❐ PainSci Bibliography 53564 ❐
- Akerstedt T, Kecklund G, Alfredsson L, Selen J. Predicting long-term sickness absence from sleep and fatigue. J Sleep Res. 2007;16(4):341–345.
This is a statistical analysis of insomnia’s relationship to absences from work caused by illness. They identified a clear connection and concluded that “disturbed sleep and fatigue are predictors of long-term absence [from work due to sickness] and it is suggested that impaired sleep may be part of a chain of causation, considering its effects on fatigue.”
- Cohen S, Doyle WJ, Alper CM, Janicki-Deverts D, Turner RB. Sleep Habits and Susceptibility to the Common Cold. Arch Intern Med. 2009 Jan 12;169(1):62–67. PubMed 19139325 ❐ PainSci Bibliography 56092 ❐ For a good summary of this research, see Sleepless Nights Equal More Colds In U.S. Study.
- Ohayon MM, Roth T. Place of chronic insomnia in the course of depressive and anxiety disorders. J Psychiatr Res. 2003;37(1):9–15.
- Neckelmann D, Mykletun A, Dahl AA. Chronic insomnia as a risk factor for developing anxiety and depression. Sleep. 2007;30(7):873–880.
The results of this large and well-conducted survey are “consistent with insomnia being a risk factor for the development of anxiety disorders.”
- Bonnar D, Bartel K, Kakoschke N, Lang C. Sleep Interventions Designed to Improve Athletic Performance and Recovery: A Systematic Review of Current Approaches. Sports Med. 2018 Jan. PubMed 29352373 ❐ Just getting more sleep at night “had the most beneficial effects” on athletic performance, compared to napping, sleep hygiene, and post-exercise recovery strategies for young athletes.
- Watson AM. Sleep and Athletic Performance. Curr Sports Med Rep. 2017;16(6):413–418. PubMed 29135639 ❐
- Hamet P, Tremblay J. Genetics of the sleep-wake cycle and its disorders. Metabolism. 2006 Oct;55(10 Suppl 2):S7–12. PubMed 16979429 ❐
“Circadian clock genes (Clock, Per) were first isolated in Drosophila, and their homologous counterparts have been found in mammals. Some of the circadian master genes have been shown to influence sleeping behavior. For instance, a point mutation in a human clock gene (Per2) was shown to produce the rare advanced sleep phase syndrome, whereas a functional polymorphism in Per3 is associated with the more frequent delayed sleep phase syndrome.”
Narcolepsy is a disease of dysfunctional sleep, not only the famous drowsiness at awkward times, but also wakefulness when you’d rather be asleep. Much like sleep apnea, it tends to interfere with deep sleep. Henry Nicholls in Sleepyhead (p. 199):
It turns out that insomniacs and narcoleptics have far more in common than meets the eye. People with insomnia have difficulty initiating or maintaining sleep (despite ample opportunity to do so). Those with narcolepsy almost never have a problem getting to sleep, but they can have tremendous difficulty maintaining it.
Narcolepsy is also surprisingly common, and more people have milder narcolepsy that is much harder to recognize for what it is than the more recognizable severe form of the disease. Emmanuel Mignot regarding Nicholls’ book:
Nicholls H. Sleepyhead: The Neuroscience of a Good Night’s Rest. First U.S. edition ed. Basic Books; 2018.
Too often, the hallmarks of the condition are mistreated as depression, epilepsy or simply ‘conversion disorder’ — physical symptoms thought to express repressed anxiety.
- It’s been well-established by scientific research that insomnia is strongly linked to stress. For instance, see Knutson: Bad sleeps — quantity and quality, probably especially if caused by stress — are associated with elevated blood pressure, according to a side project of the big CARDIA study of coronary artery disease. They used wrist gadgets to monitor sleep and blood pressure in more than 500 adults in their 30s and 40s. The authors say the sleep-BP link is supported by previous research and “laboratory evidence of increased sympathetic nervous activity as a likely mechanism underlying the increase in BP after sleep loss.”
- Waters WF, Hurry MJ, Binks PG, et al. Behavioral and hypnotic treatments for insomnia subtypes. Behav Sleep Med. 2003;1(2):81–101.
From the text: “There are good theoretical and empirical reasons to believe that SHE [sleep hygiene education] improves sleep.” In other words, reading this will put you to sleep!
- Recently I heard a woman on the street outside my apartment angrily yell at her dog, “Come here right now, dammit!” Yeah, that’s gonna work …
- I chose to carefully restrict napping rather than eliminating it altogether, because I felt it was a necessary compromise in my circumstances. I couldn’t take time off. A 20-minute nap helped me get through the second half of the day, without sabotaging the whole project. My sleep debt was so large that tiny naps really didn’t put a dent in it, and I was still able to sleep through the compressed night. Do what you need to make it work for you, but respect the principle: if you nap too much, obviously it undermines your chances of sleeping at night.
- Once in a blue moon I have chosen to deal with some life problem that is bothering me especially badly, and can be addressed relatively easily. If there’s an easy win, and you’ll feel heaps better, go for it. But beware — this is definitely a slippery slope. Try to keep any such efforts tightly contained and get back to being mellow ASAP!
- Kredlow MA, Capozzoli MC, Hearon BA, Calkins AW, Otto MW. The effects of physical activity on sleep: a meta-analytic review. J Behav Med. 2015 Jun;38(3):427–49. PubMed 25596964 ❐
The first review of the effects of physical activity on sleep (not insomnia) in over a decade, based on 66 studies, finding small to moderate effects for regular and acute exercise (acute exercise meaning “exercise you’re not used to”). The best benefits were from regular exercise on sleep quality and how long it takes to fall asleep in the first place, and from acute exercise on waking up after falling asleep. The intensity of the exercise did not seem to be much of a factor.
- Jurado-Fasoli L, De-la-O A, Molina-Hidalgo C, et al. Exercise training improves sleep quality: A randomized controlled trial. Eur J Clin Invest. 2020 Mar;50(3):e13202. PubMed 31989592 ❐
- Passos GS, Poyares DL, Santana MG, Tufik S, Mello MT. Is exercise an alternative treatment for chronic insomnia? Clinics (Sao Paulo). 2012;67(6):653–60. PubMed 22760906 ❐ PainSci Bibliography 53536 ❐
- von Schantz M. Phenotypic effects of genetic variability in human clock genes on circadian and sleep parameters. J Genet. 2008 Dec;87(5):513–9. PubMed 19147940 ❐ “Recent findings have shown that the variable number tandem polymorphism in PER3, previously linked to diurnal preference, has profound effects on sleep homeostasis and cognitive performance following sleep loss, confirming the close association between the processes of circadian rhythms and sleep at the genetic level.”
- Bretcontreras.com [Internet]. Krieger J, Contreras B. Individual Differences: The Most Important Consideration for Your Fitness Results that Science Doesn’t Tell You; 2017 February 6 [cited 19 Jul 7]. PainSci Bibliography 53546 ❐
Fascinating, readable tour of the many surprising (genetic) differences in the how people respond to the same diet and exercise.
- Altun I, Cınar N, Dede C. The contributing factors to poor sleep experiences in according to the university students: A cross-sectional study. J Res Med Sci. 2012 Jun;17(6):557–61. PubMed 23626634 ❐ PainSci Bibliography 53539 ❐
About 54% of 256 Turkish university students — a very active and probably night-owlish population — felt that “strenuous physical exercise” caused “poor sleep experiences.” No surprise there.
- Gupta L, Morgan K, Gilchrist S. Does Elite Sport Degrade Sleep Quality? A Systematic Review. Sports Med. 2016 Nov. PubMed 27900583 ❐ “…athletes show a high overall prevalence of insomnia symptoms characterised by longer sleep latencies, greater sleep fragmentation, non-restorative sleep, and excessive daytime fatigue.”
- Di Blasio A, Ripari P, Bucci I, et al. Walking training in postmenopause: effects on both spontaneous physical activity and training-induced body adaptations. Menopause. 2012 Jan;19(1):23–32. PubMed 21993080 ❐
In this experiment, 34 women participated in a 13-week brisk walking program. Some of them experience an increase in “spontaneous physical activity,” while others saw a decrease.
- Nijs J, Kosek E, Van Oosterwijck J, Meeus M. Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise? Pain Physician. 2012 Jul;15(3 Suppl):ES205–13. PubMed 22786458 ❐
Exercise is great medicine for many chronic pain conditions, but there is an important “but”: it’s unclear if it’s a bandaid or if it actually “has positive effects on the processes involved in chronic pain (e.g. central pain modulation).” This narrative review concludes that it’s complicated and it depends, and some patients definitely have a “dysfunctional response” to exercise, and thus “exercise therapy should be individually tailored with emphasis on prevention of symptom flares.”
- First of all, a lot of the supplements industry is Big Pharma these days: pharmaceutical companies have bought up many profitable supplement brands.
- But there are still massive profits for many companies that remain independent from the traditional pharmaceutical corporations — so massive that corruption is inevitable. Many people still habitually think of these manufacturers as scrappy little underdogs, but they’ve been raking in serious dough for a long time now. How much? Many tens of billions at least.
- Extremely limited regulation, basically nonexistent quality control. These companies can put basically whatever they want in the bottle. Massive profits + no regulation = a horrifying and now well-documented pattern of contaminated, adulterated, and ineffective products.
Running a website takes nerves of steel, which I didn’t know when I started. I had to learn, slowly and painfully, to remain calm when the technology was glitching out of my control.
- Chang AM, Aeschbach D, Duffy JF, Czeisler CA. Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proceedings of the National Academy of Sciences of the United States of America. 2015 Jan;112(4):1232–7. PubMed 25535358 ❐ PainSci Bibliography 54150 ❐ A dozen people were studied for 14 days, half reading regular books and half reading backlit e-books each evening. Blood tests, brain waves, and other measures showed that the e-book readers were less sleepy, took longer to fall asleep, shifted their circadian rhythm later, were less alert the next morning, and produced much less melatonin (the time-to-go-to-sleep hormone).
Reading a light-emitting eBook in the hours before bedtime likely has unintended biological consequences that may adversely impact performance, health, and safety.
So that really sucks! E-books are one of the best things about The Future. They are the main reason I’ve bought any mobile device for almost a decade. They’ve changed my life as much as any technology ever has — like earning a living from selling them, for instance — but perhaps in worse ways than I realized.
But perspective! In this study, only a half dozen study subjects read e-books for four hours each evening. That’s a lot of reading.
- To my amusement, f.lux has a research page that once struck me as impressive, but is now painfully out of date — time marches on. To be fair, that business is likely nearly dead from competition from the built-in blue light filter features. I can’t really blame the developer for dropping that ball.
- Duraccio KM, Zaugg KK, Blackburn RC, Jensen CD. Does iPhone night shift mitigate negative effects of smartphone use on sleep outcomes in emerging adults? Sleep Health. 2021 Aug;7(4):478–484. PubMed 33867308 ❐
The most important of those flaws was probably that they used a “sample of convenience,” healthy university students, a population that sleeps so much better than people twice their age that they might as well be a different species for this purpose. Many variables and potential confounding factors were not controlled here. And there’s another big one that stands out…
They used an easy, sloppy way of measuring sleep: smart watches. This has genuine advantages and disadvantages, but there’s just no way it can ever be considered definitive data on sleep quality.
- Schmid SR, Höhn C, Bothe K, et al. How Smart Is It to Go to Bed with the Phone? The Impact of Short-Wavelength Light and Affective States on Sleep and Circadian Rhythms. Clocks Sleep. 2021 Oct;3(4):558–580. PubMed 34842631 ❐ PainSci Bibliography 52168 ❐
- Everitt H, Baldwin DS, Stuart B, et al. Antidepressants for insomnia in adults. Cochrane Database Syst Rev. 2018 May;5(5):CD010753. PubMed 29761479 ❐ PainSci Bibliography 51418 ❐
- Anagha K, Shihabudheen P, Uvais NA. Side Effect Profiles of Selective Serotonin Reuptake Inhibitors: A Cross-Sectional Study in a Naturalistic Setting. Prim Care Companion CNS Disord. 2021 Jul;23(4). PubMed 34324797 ❐
- Espie CA, Kyle SD, Williams C, et al. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. Sleep. 2012 Jun;35(6):769–81. PubMed 22654196 ❐ PainSci Bibliography 52354 ❐