Posted tagged ‘Shift work’

How to shift your bedtime/waking time to earlier

February 12, 2010

When I was using light therapy alone, I found that my 25 hour pattern shifted to 24 hours beautifully but that sooner or later, I would stay up too late and would end up stuck on falling asleep at 4 am or so again.  DSPS is a tough nut to crack.  This was in the days before I found darkness therapy, which has made my sleep/wake pattern rock solid, so here’s how I treated it at the time.

My preferred sleeping tablet when I need one is 20mg temazepam; many people find that 10mg is enough, but I need a higher dose.  While my GP advised me that I should be able to take it for up to a week, I found that taking it for a week straight caused rebound insomnia when I stopped, presumably because the ME/CFIDS makes me over-sensitive to medication.  I find that taking it for three consecutive nights is fine, so I work with that.  It’s entirely possible that I’d be fine with five nights, but I’ve never needed to try.

I would always recommend strongly that you discuss this with your GP.  They should be made aware of your sleeping problems anyway, even if you’re trying to solve them yourself, and sleeping tablets are fairly serious things, even the over-the-counter ones.  Discuss which sleeping tablets will best meet your needs, and if you’ve had a sleep problem for a while you’ve most likely tried several by now anyway.  Do tell them that you will only be using the tablets for a few nights in order to shift your sleep pattern, as otherwise they will be a lot more reluctant to let you have any meds.  I’ve managed to convinced a GP who’d never met me before to let me have four sleeping tablets for this purpose when it was an emergency (missed flight, unexpected night flight), and I doubt that he’d have let me have anything at all if I’d just wandered in to say that I was a bad sleeper and wanted some drugs please.

I’ve always been able to move my sleep back enough over three days using this method, but if I had needed to control a larger shift I would probably have done three days, waited a week, and then repeated the process.  My general lightbox treatment time is 45 minutes, but for this I would sometimes use a longer treatment time to help reinforce the circadian shift.  As far as I can recall, I used an ordinary alarm clock to make sure I got my light therapy at the right time the next morning, but dawn simulation would probably be even better.

Let’s assume that my bedtime is usually 1 am but has shifted to 4 am.

Day 0 – bed at 4 am, wake the next day at 12 pm.
Day 1 – sleeping tablet at 2.30 am for 3 am bedtime, bright lightbox at 11 am.
Day 2 – sleeping tablet at 1.30 am, lightbox at 10 am.
Day 3 – sleeping tablet at 12.30 am, lightbox at 9 am.
Day 4 – no sleeping tablet, lightbox at 9 am.

After that I would relax and use the lightbox whenever I woke up, instead of setting an alarm clock.  This method worked for me every time, including when I had to go on a night flight and deal with a 3 hour time difference to boot.

If you are using darkness therapy, you may not need the sleeping tablets at all.  Just put on the tinted glasses/switch over to orange lighting an hour earlier every evening.  The usual recommendation is to commence darkness therapy three hours before your desired bedtime, though some people find that they get sleepy too early if they do this.  Obviously getting sleepy too early is not a deterrent for DSPS sufferers!

For the above problem, I’d suggest starting the darkness therapy three or four hours before your current bedtime to begin with, and seeing what happened.  It may take a few nights to kick in fully.  Use the bright lightbox when you wake up.  You can wait until you wake up naturally, depending on how effective the darkness therapy is for you, or you can set an alarm so that you make yourself use the lightbox an hour earlier every day.  Since you’re not using sleeping tablets and therefore don’t need to worry about getting the process completed in a hurry, you can try shifting your sleep more slowly, even by 15 min a night.  Keep a diary of what you’re doing so that you don’t lose track.

If you have Non-24 Sleep-Wake Disorder, I’d suggest waiting until your circadian clock has shifted around to your ideal bedtime and waking time before trying anything, then hitting it with light therapy, darkness therapy and/or sleeping tablets to stabilise it there.  The sleeping tablets are a short-term measure, but the light and darkness therapies can be continued full-time and indeed should if you have a circadian rhythm disorder.

If your problem is jet lag or shift work, rather than a misbehaving body clock, you’ll have to experiment to find out what suits you best, and you may only need to use light/darkness therapies occasionally.  Sleeping tablets are best reserved for occasional use, so if you are going to be moving your sleep pattern every week or so, I wouldn’t advise them, and I would certainly suggest that you discuss this with your doctor.  Some companies give their night shift workers yellow safety goggles to wear when they go home in the daytime, so that the light on their journey won’t keep them awake.

If your problem is instead Advanced Sleep Phase Syndrome, then use bright light therapy in the evenings instead to keep you awake for longer.  I have absolutely no idea how darkness therapy would factor in here, but if you’re using it for other purposes (e.g. sounder sleep), I would imagine you would want to be careful not to start it too early in the evening, and remember that darkness therapy alone is unlikely to shift your body clock in the desired fashion.  Light therapy will be the key here.

For any of these problems, dawn simulation alone is unlikely to be enough to shift your body clock, at least in my experience, but may be very helpful in sticking to a good pattern once you have one in place.  I recently went back to dawn simulation, and while I had already stabilised my body clock using light therapy and darkness therapy by now, I think it may be adding a little extra help, and my partner is certainly finding that the dawn simulation makes it much easier to get up in the mornings.

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Sleep hygiene

January 26, 2010

Google this and read a few articles on it.  This one by the ME specialist and researcher Dr Sarah Myhill* is particularly useful, though I’m not convinced that we should all be going to bed at half-past nine (Dr Myhill does admit that she’s a natural “lark” herself).  Note the areas you’re not doing well in and think about how you might be able to improve them, even if it’s just partially.  The main thing I had to stop doing was staying on the internet too late, it’s a big sleep-killer.  It’s important to keep yourself in a steady routine as far as possible, including regular mealtimes, if you have any problems with circadian rhythms.

For those of you who aren’t in the mood for hunting around for different articles, here are some sleep hygiene tips.

  • Your bed should be blissfully comfortable.  Opinions on exactly what your bed should be like seem to vary, so read up on this if you’re in any doubt, but you probably know what you prefer.  Do remember not to let your mattress get too elderly.
  • Reserve your bed for sleep and sex, so that your brain doesn’t associate it with wakefulness.  If there are good reasons why that’s not possible, for instance due to having ME/CFIDS, do think about how the process of association works and consider workarounds, such as switching to the sofa for part of the day, or even a spare bed.
  • Generally think about relaxing pre-bedtime routines and how you think about sleep.  Routines can make a surprising difference, and it helps to have a daytime mindset and a bedtime mindset.
  • Meditation, visualisation and the like can be very helpful, especially if your mind goes whizzing round in the evenings.  There are lots of different ways you can do this, so keep looking if the first method you find merely irritates you.  I quite like a Zen meditation technique where you repeatedly count to ten, one number with each breath.  Usually I just drift off while daydreaming.
  • It’s well-known that caffeine will keep you awake, but few people know that alcohol and nicotine do as as well.  If this applies, you can either change your habits in a big way, or at least remember not to drink/smoke after lunchtime for special occasions, such as when you will have to be up for an early morning appointment or anticipate that something will disrupt your sleep (e.g. travelling on an overnight bus).
  • Try to reserve energising activities for earlier in the day.  This can be tricky for natural night owls who feel at their most creative in the evening, or people who only really come to a few hours after they finish work, but it’s worth thinking about if you want to improve your sleep.  Knowing your natural tendencies is a big part of the battle.
  • Strenuous exercise is best reserved for earlier in the day, say up to mid-afternoon.
  • Computers are lethal for keeping you awake in the evening.  This is partly because they engage your mind, and partly because they emit a lot of blue light which suppresses the sleep hormone, melatonin (keep reading to find out more about this).  Either stay off the computer altogether, or use an orange screen filter, preferably combined with keeping to less energising activities (playing computer solitaire is fine, writing a blog post about something that really excites you is likely to lead to “how did it get to 5 am?” syndrome).
  • Televisions pose similar problems to computer screens, both in terms of blue light and getting your brain involved.  I manage as long as I wear my orange glasses to block the blue light, and generally keep to something relatively soporific if it’s just before bed.  This is the time for watching an episode of a not-terribly-exciting TV series, not for starting a two hour horror film.
  • Know your bladder!  Some people find that they go to the toilet all night if they so much sip a little water in the evening, in which case set yourself a time after which you won’t drink anything, or at least restrict fluids.  Other people are fine whatever they do, and these folks are good candidates for calming herbal teas, such as chamomile or lemon balm (melissa).  I recommend Dr Stuart’s Valerian Plus, which has a goodly amount of valerian in it, along with passiflora and hops which are both useful for sleep, but it doesn’t taste too bad for a valerian tea, probably because it has lots of linden blossom (lime flowers), which tastes beautiful as well as being calming.  If you find chamomile effective but don’t like the taste, there are some good chamomile blends out there, such as Twinings Chamomile & Limeflower.
  • Warm baths help for some people.  You can add Epsom salts (magnesium sulphate), which are meant to relax the muscles, or a few drops of a calming essential oil such as lavender.  If you go for the aromatherapy option, don’t get too hung up on which oils are prescribed for insomnia, as reaction to smell is intensely personal and you just want whatever makes you feel relaxed.  Check whether the oil is listed as sedating (neroli is wonderful, although pricey so buy it diluted for this) or stimulating (rosemary is definitely not a bedtime oil).
  • You can also utilise aromatherapy by putting a single drop of a calming oil on a tissue and keeping it near your pillow.  I don’t recommend oil burners which use candles for obvious safety reasons; if you want to use an electric oil burner, plug it into a timer so that it won’t be on all night.  Another pleasant use for aromatherapy is to buy or make up an oil blend with calming essential oils, such as Roman chamomile and bergamot, and either apply it to yourself or, better still, get your partner (if you have one) to give you a gentle massage.
  • Some people are kept awake by chilly feet.  If this is the case, there’s the obvious sock option and the marginally less obvious hot water bottle or microwaveable rice bag option.
  • Warm bed, cool room, seems to be the advice I’m finding on most sites.  Probably worth following, and fresh air is always good, but as ever, go for what makes you most comfortable, don’t follow something you don’t get on with just because a website suggested it.
  • If you’re kept awake by worries or other thoughts, and you are either single or have a very deep-sleeping partner, you can try keeping a notepad by the bed for writing down anything that is keeping your mind on the hamster wheel.  Use a dim light for doing this, preferably one that is yellow, orange or red (see the articles on darkness therapy).
  • If you can’t get to sleep, or wake up in the night and can’t get to sleep, give it 20 minutes (this is the usual recommendations; many people would consider 20 minutes fantastically fast to get to sleep, so it may need to be longer for you), and if you still can’t sleep, go and do something relaxing in another room, such as reading or listening to soft music.  Again, use yellow/orange/red light if possible, and dim light at the very least.
  • And this applies for getting up to use the toilet in the night too.  It only takes a short exposure to white/blue light to suppress melatonin levels, unfortunately.  Don’t forget to take the hallway light levels into consideration either.
  • If your child insists on a nightlight, or you need one for navigating hallways, find something that’s yellow/orange/amber/red.  It is ludicrous how many nightlights are just the right kind of bluish white that will keep you awake.
  • On that subject, speak to your doctor if you’re being kept awake by your urinary tract or digestive system.  It is not normal to need to urinate several times during the night, or to be kept awake by gas, and it may be a sign of Overactive Bladder Syndrome, Irritable Bowel Syndrome or a food intolerance (e.g. gluten), amongst other possibilities.
  • Ditto for pain: I don’t care if you dislike painkillers, any pain that is disrupting your sleep is serious enough to warrant being discussed with a doctor.  You may need to take medication or alter the medication you’re taking already, and you may also be able to find a non-drug solution.  Remember that poor sleep increases daytime pain levels, so it’s a vicious circle very much worth breaking.
  • While I’m marching people off to their doctors, remember that how you sleep reflects your mental health as well.  If you’re up half the night every night worrying, you may have an anxiety disorder, for instance.  Just because you may been experiencing it for as long as you can remember doesn’t mean that it’s healthy!
  • Find out what sort of sleep is normal for your age group, rather than following myths.  It is perfectly normal for teenagers to be on a late schedule, though this should improve by 20 or so.  It is not the case that you need less sleep when you’re elderly, however, although many elderly people do sleep less due to, say, pain from arthritis, or other similar problems which – you’ve guessed it – should be discussed with a doctor.
  • If an external factor is disrupting your sleep, don’t just assume that everyone has to put up with this, as there may be a solution for it.  Darkness therapy is useful for shift workers and new parents, for instance.  New curtains, if yours are letting the light in, may be unaffordable, but clip-in blackout linings are cheap and very effective.
  • If your partner snores, consider the following: earplugs, a white noise generator/tinnitus relaxer (some can be plugged into a pillow), separate bedrooms.  If you haven’t done this already, march them off to the doctor to be checked for sleep apnoea, a very common and rather dangerous condition.  This may mean that you end up having to listen to their CPAP machine instead of their snores, but at least they’ll be a lot healthier.

* Please note that Dr Myhill is now being viewed with caution.  See the Links page for more information.