Organized Chaos - Volume 9
To Sleep, Perchance to Dream
by James Claiborn, Ph.D.
Many people with OCD have concerns or problems with sleep. In this article I will describe some of the more common problems and what can be done to help manage them. I will begin by explaining some things about sleep to help put problems in perspective.
Although we spend about 1/3 of our lives asleep, most people, including many health care professionals, don’t know much about what is going on. Sleep actually consists of different states that are referred to as stages, and the brain is involved in different kinds of activity during these different stages. The stages are broken into a few larger categories. Stage 1 sleep is the lightest stage, and when individuals are in this stage they can be easily awoken. They may claim they were not asleep. Stage 2 is a little deeper, and if awoken the person will ordinarily agree s/he was asleep.
Stages 3 and 4 are often lumped together and sometimes referred to as delta sleep because of the characteristic brain waves produced. This type of sleep is the deepest, which means it is the one most difficult from which to wake someone. Delta sleep is also the sleep that seems most important in terms of feeling rested or restored, and if someone doesn’t get it s/he is likely to have lots of physical complaints. Some sleep problems, sleep walking and night terrors (not to be confused with nightmares), occur in delta sleep. Sleep stages 1-4 are sometimes lumped together and called non-REM sleep.
The fifth stage of sleep is called REM (Rapid Eye Movement) sleep. It is called this because during this stage of sleep the person’s eyes are typically moving about rapidly as if the person were looking around. REM sleep is the sleep where almost all dreaming takes place, and this includes nightmares or anxiety dreams. During REM sleep there is a general loss of muscle tone, and people can’t move. This is a good thing since apparently if we could move we would do the things we are dreaming about.
If we look at a good sleeper and keep track of what stages s/he experiences at what times during a night’s sleep, there is a regular pattern. This pattern includes getting delta sleep mostly in the first 1/3 of the night and having episodes of REM sleep at about 90 minute intervals. The episodes of REM start out being brief, but as the night goes on they get longer. By the end of a night’s sleep most of the time will be spent in REM sleep.
Both OCD and depression are often associated with sleep problems. One problem, insomnia, is common in the general population; but it is very common in depression and OCD. Often people with OCD find themselves obsessing when they go to bed or are unable to get to bed at a reasonable time because they have compulsions that need to be completed before they will allow themselves to go to sleep. There are also some differences in the pattern of sleep that may be associated with problems like depression. As an example, REM sleep seems to start too early in people with depression. This was also believed to happen in people with OCD. More recent research has not supported this. Older antidepressant drugs delay the start of REM, which seemed like a good thing.
SSRIs have a complex effect on patterns of sleep and may lead to REM-like sleep occurring much of the night along with frequent awakening. This frequent awakening and some reduction of the depth of sleep may account for many people reporting very vivid dreams when taking SSRIs. These same medications may also be associated with increased bed wetting. Because SSRIs disrupt sleep and produce awakenings, they are linked to complaints of being excessively sleepy during the day as well as complaints of insomnia.
Another concern is that dreams are about obsessions, include engaging in compulsions, or both. Sometimes these dreams are distressing enough to be called nightmares. People with OCD may also have panic attacks that wake them up. Most people assume this is connected with nightmares, but nocturnal panic attacks do not seem to occur in REM sleep. Instead they are associated with the transition from one stage of sleep to another. Many people who have panic attacks in the daytime will have panic attacks that wake them up. Nightmares or anxiety dreams are common especially in people with anxiety disorders, including OCD and PTSD. Sometimes people develop secondary sleep problems because they are trying to avoid nightmares. They may avoid going to sleep or use other methods to try to prevent them.
People with insomnia often worry about the effects of not getting enough sleep. While there are some adverse effects of not getting enough sleep, the worst is being sleepy; and these effects are generally quite manageable.
The good news is that there are some good treatment options for the more common sleep problems. Insomnia responds well to a cognitive behavioral approach; and longterm effects are often superior to the results of taking medications to help sleep. We can understand insomnia as a problem with habits related to sleep and with the thinking about sleeping or not sleeping. Then we can look at developing new habits that will facilitate better sleep. As a CBT therapist, I often tell people to keep records. In the case of sleep problems this means a sleep log. You can make up a simple one that records when you go to bed, how long it takes to fall asleep, how many times you wake up, when you wake up for the day, when you get out of bed, and other details that seem important such as use of sleep aids, alcohol, etc.
Remedies for Insomnia
If medication seems to contribute to insomnia, simply changing the time of day you take it may be enough to help. If not then I suggest some rules to follow.
- Go to bed when sleepy (not tired, as that is different). A regular bedtime is nice but not critical.
- Get up at the same time every morning. This means holidays, weekends or after nights with limited sleep are included.
- When in bed only engage in activities that begin with S. Thus sex, sleep and snoring are OK. Eating, arguing, tossing and turning, obsessing, reading, watching TV do not begin with S and are not good things to do in bed.
- After going to bed or at any time during the night if you are awake for longer than 15-20 minutes (estimated), get up, get out of bed, go to another place and engage in a quiet activity. Do not smoke or engage in vigorous activity. Do not return to bed until sleepy. Lying in bed trying to go to sleep is about the best way I know to make sure you will stay awake.
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Manage aspects of your life to promote
good sleep.
- Exercise regularly, but do so several hours before you expect to go to sleep.
- Avoid stimulants such as caffeine later in the day. Also avoid alcohol because although it may seem to help you fall asleep, it actually interferes with normal sleep.
- Do not eat a big meal just before bed, but a small snack may be helpful.
- A comfortable routine before bed may be helpful, but people with OCD need to be aware of a tendency to develop rituals around going to bed that in the long term contribute to problems.
- Avoid naps or attempts to make up for perceived lost sleep.
- Manage your sleep environment in ways that facilitate sleep. For most of us, this means a quite, dark and reasonably cool room will work best. You may need to arrange things such as clocks so they are not visible.
- If you worry a lot about the effects of not getting to sleep or not getting enough sleep, you can either do exposure to this fear or use some cognitive restructuring methods.
Remedies for Nocturnal Panic Attacks
Since people who have panic attacks that wake them up almost always also have daytime panic attacks, the best approach is a treatment that works for both. Medications, often including the same ones used for OCD, can be effective for panic; but, ironically, in some people actually lead to the development of panic attacks. Panic disorder has some similarity to OCD in that it can be understood as a catastrophic reaction to normal sensations, and OCD is understood as a catastrophic reaction to normal thoughts. CBT works well for panic and OCD and involves many of the same elements such as planned exposure. A CBT therapist would be able to help with panic as well as OCD, or if you are using a self-help approach the same sort of ideas apply. When daytime panic attacks are controlled, nocturnal panic typically subsides.
Treating Nightmares
Strange as it may sound nightmares may also be thought of as a habit problem. The most effective treatment for nightmares is to develop a script for the dream with a different ending. You can choose to make it come out any way you like. You can include things that are impossible in life since the world of dreams allows for magic. When you have the new script you can rehearse it before bed each night. Despite the fact that nightmares are associated with anxiety disorders, they can be changed without having to do exposure to the upsetting images.
Dealing with Excessive Daytime Sleepiness
As I mentioned earlier excessive daytime sleepiness produced by SSRIs is most likely to be the result of disrupted sleep. This means that if you can do the things suggested for insomnia you may experience some improvement in the night’s sleep and be more awake in the daytime. You can also look at the time of day you take medication as sometimes this helps. In general, if it makes you sleepy, take it before bed; if it keeps you awake, take it in the morning. For more difficult problems with excessive daytime sleepiness you may want to do a little more investigation into the cause. You might also have common health problems, including sleep apnea. If the daytime sleepiness is associated with medications taken for OCD, you can discuss possible changes with your prescribing professional. This can include adding other medications, specifically, ones designed to help you stay awake and even an antidepressant called Trazodone. This medication is often used to help people sleep and may reduce the SSRI-produced disruption in sleep so that you will be awake in the daytime. Many of the things discussed in this article such as methods for dealing with nightmares and insomnia as well as a sample sleep log are included in “The Habit Change Workbook” that I wrote with Cherry Pedrick.
Dr. Claiborn is in private practice in South Portland, Maine, and regularly answers questions on the OCD-List on Yahoo.
