How many sleep disorders are caused by poor sleep habits (meaning, sleeping with the TV on, poor routines, etc.)?
This is a great question because it forces us to examine the discrepancies between what might be called the “conventional wisdom” or “mainstream media” attitude about sleep and sleep disorders and what sleep professionals know and treat every day in their sleep labs and clinics using the principles and practice of evidence-based sleep medicine.
Many articles are written every year in magazines, newspapers, or internet sites, and these pieces often provide short and superficial tips on how to investigate or treat sleep problems, yet time after time, we find evidence of journalistic “malpractice” in which the writer will leave the reader decidedly unsatisfied. To use your two examples, these articles might comment on why one should not watch television in the bedroom or how one needs to organize a sleep schedule to supposedly get more sleep. Clearly, such suggestions could be attempted by any number of insomniacs, yet the lack of context in these pieces not only diminishes the chances of helping a patient, but also worse sleep may result from these abbreviated instructions.
Let’s examine “watching television” in the bedroom. Does it cause sleep problems? Does it cause insomnia? Does it lead to greater sleep fragmentation? Not to make too fine of a point, but actually TV rarely “causes” these problems. Television obviously may aggravate existing sleep problems, but the main point to follow here is as follows: the individual who chose to view TV was already suffering from a sleep disorder and usually long before he or she decided to watch in bed.
So, why does someone choose to watch TV in a bedroom? The answers may be exhaustive and along many different fronts. I would like to focus on the emotional front. Primarily, television late at night is used to combat loneliness, social isolation, anxiety or fear, or some other cluster of worries and concerns that tax the individual’s current coping mechanisms. With a careful probe of the patient, one or more of these distressing emotional states almost invariably provide the clue to the clearest explanation for the inception of bedroom TV viewing. Thus, TV is the “treatment” for these emotions that disturb the mind. Are we declaring the individual suffers from a mental health disorder? No, but in most instances, this scenario reflects a mental health symptom for which the individual has been unable to develop more effective coping strategies. On the other hand, who is to say what “effective” means? At some point, TV viewing may simply evolve into a learned behavior that continues despite the resolution of the emotional distress that triggered the insomnia in the first place. Regardless, in my clinical experience it proves useful to look for the underlying cause of the behavior as well as to promote a change in the behavior, but I have found it more difficult to achieve the latter without addressing the former.
When I work with elderly patients who use TV as a soothing technique, recommending the removal of the TV from the bedroom or even hinting at turning it off would never be the first step in treatment. Asking otherwise of the patient would only aggravate the individual’s anxieties and fears and thus trigger a worse bout of insomnia. To address the heart of the problem we must engage individuals to discuss what exactly bothers them late in the evening such that they fear being alone with the thoughts, feelings, or images in their own minds. That discussion can lead to a deeper exploration of current emotional stressors, which the patient may in fact be experiencing much earlier in the daytime yet never addresses, which then carries over into the evening hours and eventually into the bedroom. Such an honest discussion will help the patient recognize the actual reason for choosing to watch TV late at night or keep the tube on all night.
Now the discussion can turn to alternatives, such as finding a station on the tube that might show nature pictures or other relaxing images, or moving from TV shows to soft music or even the purchase of an inexpensive white noise machine. In all instances, we would be attempting to move the patient towards a better option—less likely to aggravate insomnia or sleep fragmentation—while at the same time dealing with the actual circumstances that cause someone to feel he or she must hear or see the TV all night long.
Will there be patients you would encounter in a sleep clinic that would be receptive to turning off the TV? Probably a few, but more likely a patient who would appear to suffer from just this single cause of sleeplessness (a premise I remain skeptical of) would instead have found this topic discussed in the lay media, learns that TV makes sleep worse, and thus attempts to stop watching TV in the bedroom. Clearly this step shows potential to help in the short-run. Yet even though we have switched to a general population scenario, I would still question whether or not watching TV was the cause of the sleep problem? What if the individual ceases TV viewing but then consumes more alcoholic beverages in the evening near bedtime? Again, I would presume the underlying problem is loneliness, social isolation, anxiety or fear, or other worries and concerns. So, I will stick with the theory that TV may aggravate a sleep problem, but it is rarely the cause.
This same line of reasoning applies to people who operate with erratic schedules or poor routines. When they engage in counterproductive sleep behaviors within the hour before bedtime, such as working on tax returns, drinking espresso, or arguing with the spouse or kids, there is no question each activity could aggravate if not cause insomnia. But again, let’s explore the emotional and usually rational explanation for the behavior in the first place. Why did you need to work on the tax return at midnight instead of waiting until the next day? Why were you drinking espresso before bedtime? What prompted you to spark an argument so late at night? When you tackle these questions you rarely come up empty handed and almost always discover something more meaningful besides the simplistic explanation of “bad habits” or “poor routines.”
Take the example of caffeine late in the afternoon or early in the evening or even late at night. Do you really want to instruct someone to cease this behavior when you discover it is directly related to driving home safely from work or a social event?
What about late night confrontations with family—what’s really happening? In most instances, the individual has been holding back emotional reactions to something throughout the day, and then later in the evening as fatigue sets in this individual can no longer maintain a “defense mechanism” to thwart the outburst. So, the real problem is not at night; the real dilemma builds throughout the day because the individual has not learned how to work with his or her emotional tension hour by hour as it emerges, which is a much healthier coping style. Telling someone to stop arguing at bedtime makes practical sense, but it may not make emotional sense to someone who pays no heed to his or her feelings until a point of explosiveness is reached. Thus, the behavior of arguing at bedtime is not the real cause of insomnia. For all we know, had the individual not released the emotional tension at or near bedtime, nightmares of the unresolved conflicts might have fractured the sleep period anyway. So, the real issue cannot simply be ascribed to the seemingly irrational behavior of lashing out in the evening; the real problem is the inability to understand how to cope day in day out.
Last, the same holds for working late into the night. If we do not know the pressures or deadlines facing the individual, then again we may be aiming at the wrong target. The real problem is what occurs during the day or what will occur the next day that prevents the person from completing the task far removed from sleep period.
There are always exceptions to this more complex view of “poor sleep hygiene.” I have encountered many people whose sleep improved dramatically by removing a lousy mattress and investing in a brand new and higher quality one. I’ve seen similarly large improvements linked to finding the right bedroom temperature, installing an advanced air filtration system, or even just inserting quality earplugs. Other strategies may also prove relevant. Teaching a patient the value of napping for a shorter period of time and earlier in the day can make a big difference if the individual conscientiously implements the strategy. Selecting the right type of reading material for bedtime consumption can lead to healthy drowsiness in less than 30 minutes. A little sunshine in the morning and a long walk late in the day often help to maintain a healthy sleep-wake schedule.
In contrast, the opposite of all these steps could and does lead to some sleep problems in many susceptible individuals. Bad mattresses, excessive napping tendencies, over-stimulating suspense novels, a noxious bedroom environment, and failing to spend time outdoors to get fresh air, sunshine, and exercise can all produce or aggravate sleep problems, especially among those people who unknowingly are already suffering from a more specific sleep condition such as a diagnosable case of insomnia, leg jerks, or sleep apnea. As such, these poor habits, routines, or circumstances can tip the scales toward a more complex set of symptomatic sleep complaints. Indeed, in my experience in a sleep medical clinic, it is much more common to find “poor sleep hygiene” among patients with actual sleep disorders. In turn, I am regularly surprised by and impressed with how treatment of the core components of these disorders leads to spontaneous resolution of some of these sleep hygiene problems.
Bottom line, teaching any patient with sleep disorders the value of correcting bad habits and poor routines may serve as one component of their care, but targeting the deeper cause of these behaviors often yields more lasting results for a patient susceptible to or currently suffering from a chronic sleep disorder.