By Michael Tompkins, PhD
Beck Institute Faculty
Oliver is a 63-year-old electrical engineer who retired just
a few months before the pandemic hit. Although Oliver lived alone, he had
filled his life with interesting friends from around the world. Oliver was an
avid birder and had planned to spend his retirement years traveling with fellow
birders and photographing and building his catalog of bird sightings. The
Covid-19 pandemic changed everything. Although Oliver suffered with
intermittent insomnia over the years, these episodes typically resolved within
a few weeks because he was able to maintain his sleep habits and daily routines.
This time, however, Oliver’s insomnia lingered as the pandemic disrupted these habits
and routines. Week after week, Oliver’s sleep difficulties worsened.
Two body systems influence our sleep: the sleep-wake homeostasis and the circadian biological clock. Cognitive Behavior Therapy for Insomnia (CBT-I) includes interventions that target these two systems in order to re-regulate the sleep system. We made four changes that influenced these systems and corrected Oliver’s insomnia:
Established a consistent rise time
The pandemic affected the consistency of Oliver’s out-of-bed times, which weakened his circadian biological clock. As a lifelong birder, Oliver arose early most mornings to bird with friends or to sit on his deck and photograph birds in the back garden. Due to the pandemic, Oliver was no longer getting up at the same time. Over several weeks, we slowly worked Oliver back to a consistent rise time and scheduled pleasant, interesting activities in the morning to counter his tendency to linger in bed.
Optimized homeostatic sleep drive
Oliver’s response to the pandemic influenced his homeostatic sleep drive. The homeostatic sleep drive is like a balloon that fills when we’re awake and active. The balloon gets bigger and bigger over the course of the day, achieving an optimal level of “fullness” after about 16-18 hours of wakefulness. A full sleep-drive balloon facilitates our ability to fall asleep quickly, stay asleep, and produce good quality sleep.
Because of the pandemic, Oliver was often bored or lonely and would nap during the day. These naps released air from his sleep drive balloon, making it more difficult for Oliver to fall and stay asleep at night. He agreed to stop the naps and we brainstormed activities to counter sleepiness, boredom, and loneliness. He agreed to wear a mask and stroll around his neighborhood photographing birds and to send the best photos to his friend when he returned home. If it was raining, Oliver agreed to do a few jumping jacks in front of the French doors to increase his alertness and fend off drowsiness. Oliver agreed that if he was very drowsy and planned to drive long distances, he could take a brief nap (15 to 30 minutes), approximately seven to nine hours after rise time, because it was not likely to disturb nocturnal sleep.
Decrease conditioned arousal
The pandemic influenced Oliver’s sleep in ways that he was not even aware. When people lie awake in bed night after night, their bedroom becomes associated with feeling awake, alert, frustrated, and anxious, rather than feeling relaxed and sleepy. This is conditioned arousal. In order for sleep to come while in the bedroom, it’s important to break this conditioned alertness.
Oliver agreed to go to bed only when sleepy, increasing the likelihood that he would fall asleep quickly. He also agreed that if he was awake after 20 minutes, either at the beginning or in the middle of the night, to get out of bed and return to bed only when sleepy again. Oliver and I designed his waiting-for-sleep place, which was a comfortable chair with a reading light and warm comforter. He placed several birding books on the end table, along with a radio to play comforting music.
Established consistent social rhythms
The pandemic had influenced Oliver’s social rhythms, which in turn influenced his circadian biological clock. He no longer ate his meals at the same time each day, nor did he meet with friends for dinner out as often as before. He often slept in, rather than getting up to bird in the mornings. These activities were important to Oliver and helped him feel happy and connected. As Oliver’s sleep-wake cycle became more consistent, he agreed to eat at consistent times. He also agreed to share a meal with a friend via Zoom once each week and to go on brief, socially-distanced hikes twice each week with friends. These social visits not only countered his boredom, but greatly lifted his mood.
After four appointments, Oliver was sleeping much better, and he now had the energy to engage in more pleasant activities, engage with friends, and reconnect with his family, in spite of the limitations of Covid-19. I helped Oliver with all of these over the course of a few more meetings. I still hear from Oliver. Usually it’s a text of a photo of a recent bird sighting and a brief message, “Still sleeping great in the pandemic.”
Dr. Tompkins will be teaching a CBT for Insomnia Webinar on February 26 from 9:45 AM – 5:00 PM Eastern Time. The webinar offers clinicians a concrete framework for implementing sleep education, sleep hygiene and sleep restriction interventions, cognitive restructuring of sleep worry, and implementing relapse prevention.