In a recent post, we discussed connecting points between sleep hygiene and CBT-I for the treatment of insomnia. Now, I want to turn a sharp focus on one of the most aggravating and perpetuating symptoms that may arise among chronic insomnia patients: “Losing Sleep Over Losing Sleep” or LSOLS, through which the individual becomes so obsessed with the recurrent experience of not sleeping, he or she ruminates excessively about the poor prospects for ever sleeping again. This thought pattern literally leads to worse insomnia; and in the most ominous cases, the individual actually believes sleep will never return after which severe psychiatric distress emerges, including suicidal ideation.
As a sleep specialist, I see many of these cases every year, and they present along a continuum wherein the mild form of LSOSL causes and aggravates insomnia, but the individual’s coping mechanisms are strong enough to limit distress to varying degrees of frustration without more intense or decompensating emotional reactions. In moderate cases, individuals descend toward a panicky situation, but instead of going over the edge, they use what appear to be common sense solutions (at the time) by ingesting more alcohol near bedtime or during the night, or they find extra doses of sleep aids, prescription or over-the-counter, for urgent relief. When moderate cases present to the center, these patients are troubled by the whole experience, recognize their current remedies must only be temporary, and are quite receptive to various CBT-I solutions to resolve the problem.
In these moderate cases, a very straightforward discussion about time spent worrying about not sleeping is time spent promulgating more sleepless nights. In nearly all such cases, the anxiety response experienced by these patients derives from some other problems or vexing situations in their lives. However, due to a personality quirk, their coping style leads them down a path to focus narrowly on not sleeping instead of recognizing the deeper psychological issues afflicting them. When we talk about the more severe cases below and in Part II, you will see how and why this deeper explanation of the problem is so relevant. In the moderate cases, the individual may admit rather quickly to the unresolved conflict in his or her life. Regardless, moving forward with a discussion about stimulus control (get out of bed when not sleeping because you cannot force yourself to sleep) or sleep restriction (limiting hours in bed to promote greater sleep pressure and usually greater sleep continuity) will typically engage those patients with a moderate problem, and they will consider these simple albeit challenging behavioral steps.
Moderate cases respond well, but it would not be unusual for them to have already become dependent on hypnotics or other sedating psychotropic medications. Thus, working with such individuals still requires a fair amount of attention, because they are often unwilling to go without some of the medication for a short or extended period of time until the CBT-I steps prove efficacious. Clearly, the faster the treatment works (self-efficacy), the sooner the patient would consider tapering off the hypnotics. In these situations, it is interesting that patients with a moderate degree of LSOSL astutely recognize medications actually caused part of the problem, because the ineffectiveness of the drugs coincided with the development of the LSOSL.
Severe cases of LSOSL are a completely different magnitude of difficulty and often end up in emergency rooms, where patients seek strong sedating medication and usually need extended observation or hospitalization. Those patients who do not put together a plan for seeking care may develop suicidal tendencies, which lead them to ingest massive quantities of alcohol or other sedating medications and thus may be transported to a hospital after a 911 intervention. Some of these cases involve patients who unequivocally deny any suicidal intent in their actions; rather, they simply thought, in the moment, the most rational way to treat sleeplessness was to self-medicate as much as necessary to “knock themselves out.”
Some severe cases make it to a sleep medical center. On presentation, their most obvious problems are obsessions with not sleeping and an undue focus on time. The latter problem is a form of the time monitoring behavior we have discussed previously, but in these circumstances, you cannot treat patients with instructions to stop looking at the clock or to stop obsessing about quantity of sleep or any other time-related metric.
The deeper problem with these patients is the very strong emotional attachment these individuals have fixed to their inability to sleep or the time obsession centered around lost sleep. These points are not meant to discount these emotional responses. To the contrary, these emotional reactions almost invariably reflect a much deeper problem in the individual’s life. In other words, you do not just develop severe LSOSL out of the blue and suddenly find yourself not sleeping at all. In these cases many other issues and emotions are driving the individual to the brink. However, as the patient’s distress levels steadily increase toward dangerous levels, at some point it becomes obvious insomnia is also part of the equation. Remarkably, the individual may not realize beforehand that his or her distress levels are on the rise. That is, the first indication of the problem may actually feel like insomnia is coming out of the blue, and then LSOLS takes over and runs its course along the continuum until it becomes so severe, the patient begins to decompensate, after which self-medicating behavior or professional treatment is sought.
Regrettably, then, most individuals do not suddenly gain insight and comment, “Oh, I must be having severe insomnia because I am so upset about what happened at work or in a relationship or with a personal health issue.” In other cases, the patient’s pre-existing mental health condition such as anxiety, depression, or PTSD is clearly worsening and exacerbating insomnia. Regardless of how this person travels down what for him or her may in fact be an inexorable path, sooner than later, most of these individuals shift all their attention onto the severity of the insomnia, which then triggers great anxiety about not sleeping, which finally turns into severe LSOSL. Remember, among the patients with milder forms of LSOLS there is no danger, because inherent or learned coping skills are sufficient to solve the problem or get the right kind of treatment. But, in the severe cases, individual do not possess the self-reflective tools to figure things out or find the right kind of help, albeit calling 911 or landing in an emergency room are very sensible steps in a crisis.
In Part II, we will look at a couple of specific cases of severe LSOLS, speculate on the relationships between LSOLS and suicidal thinking and the indications for hospitalizations, and finally discuss how sleep breathing treatment can prove an urgent life-saver in some of these cases.