Hugh Selsick cannot be absolutely certain, but he estimates that he has met more insomnia sufferers than any other person in Britain.
Yet, when he enters the waiting room for his insomnia clinic, he has no idea which one of the expectant faces is his patient. Most long-term insomniacs show none of the telltale physical signs of fatigue. Selsick places extraordinary importance on this initial meeting with a new patient. He knows that they may have been suffering from insomnia for decades, a period over which they have seen multiple family doctors, who have time and again given them the kind of advice you might give a fretful child: take a warm bath or a glass of milk before bed.
Others hold their heads in their hands, in shocked relief. Whatever the reaction, Selsick, who is soft-spoken, kind-eyed and bald as an acorn, said that, in that moment, a bond of trust is established that is stronger than any other he has known in his career as a psychiatric doctor.
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In this, our first meeting, I felt something of that emotional intimacy. Through shame, or a worry that he might think I was trying to jump the waiting list, I had not mentioned my own struggles with sleeplessness. His kind manner, and open acknowledgment of the pervasive awfulness of insomnia, was both comforting and thrilling. Today, Selsick and another consultant run the clinic with support from a GP who works one day a week and an associate specialist psychiatrist, who is supported by a trainee.
How is a central London clinic successfully treating an illness that, for decades, medicine has failed to adequately address? For decades doctors would treat the primary condition — diabetes, cardiovascular disease, respiratory problems — expecting that fixing this would help the patient to sleep. Selsick believes that only by treating insomnia as a psychiatric disorder, with degrees of severity that range from mild to chronic, can the health service begin to develop and prescribe appropriate treatments.
S elsick became an insomniac in , when he was 19 years old, staying on a kibbutz in the desert in Israel. With temperatures reaching 40C, desert-dwelling people typically sleep from 11pm through to 3am, at which point they start work while it is still cool enough.
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At lunchtime, when the heat is at its most ferocious, they take a siesta. One day on campus he saw an advert posted on a wall requesting volunteers for a sleep study. Selsick enrolled in the hope that he might discover what was happening to him. Each experiment lasted for four days, during which Selsick and the other volunteers would stay overnight at the sleep clinic, one monitor strapped to their head, another, to monitor core body temperature, inserted into their rectum.
Volunteers were kept to a specific diet. One week they would fast for 24 hours; the next eat three times their typical calorie intake. Then they were monitored to see what effect the food had on their sleep. Inspired by the professor who ran the course, Selsick began a postgraduate degree in physiology, based within the sleep clinic, where he studied the functions of REM sleep — a phase that occurs sporadically through the night, characterised by rapid eye movements — then carried out research on the impact of central heating on sleep patterns.
The ideal temperature in which to sleep is cooler than you might think: just 18C. This is one of the reasons why insomnia affects a disproportionate number of people in nursing homes, where round-the-clock heating makes it harder for the human body to cool down in readiness for sleep.
At this time, the use of psychotherapy to treat insomnia was still in a relatively early phase. Selsick estimates that it was before therapists began to undergo insomnia training, in order to apply research findings. When Selsick came to London in the late 90s as a trainee doctor at the Royal College of Psychiatrists, his own insomnia had passed.
Still, he was astonished to find a widespread lack of interest within psychiatry toward insomnia. She sent him a text message asking whether he would be interested in founding an insomnia clinic at the hospital. While staff across the health service were aware of the need, Selsick said, they knew that if they were to take insomnia referrals they would be inundated. He started small — one afternoon a week.
Then, a few months later, Selsick began to explore CBT. Not everyone was convinced by the new programme. Selsick believes that this association caused some GPs to not refer their insomniac patients. For those who make it through the door, Selsick provides an initial assessment in an attempt to find out what, of a constellation of different possibilities, is causing the sleeplessness. Like other sleep clinics, he screens for sleep apnoea and other respiratory problems. But this is merely the first step in the process.
Sometimes that diagnosis is narcolepsy, nocturnal epilepsy or sleepwalking — one of the scores of conditions that can lead to sleeplessness. In other cases it is, simply, psychiatric insomnia. W hen she was 13 years old, Zehavah Handler took a pen and scrawled a dot on her bedroom wall in north-west London.
Lying on the bed, she could just pick out the mark in the milky glow of her nightlight. There, as the house settled around her, she would challenge herself to stare at the dot for as long as possible without blinking. The game became a ritual and, eventually, became the only way, she believed, that she could fall asleep — although it was often 4am before she finally drifted off. In adulthood Handler, now 40 and a mother of four, still suffered from insomnia. She would wake at 7am to drop her children off at school, then lie down on the carpet of her bedroom.
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There she would watch the ceiling till mid-afternoon, her heart palpitating with exhaustion, when she would leave for the school pickup. After feeding and bathing the children, Handler would retire to her own bed. When she began to experience memory loss and irritability, Handler visited her GP. She spent the first night in a nest of wires, like an android recharging its batteries, lying awake worried about whether or not the machines would know that she was just pretending to be asleep.
Nevertheless, the results came back clear: she had no breathing issues, no twitching muscles. Selsick concluded that Handler was one of his many patients for whom insomnia is not a symptom of some other disorder, but the disorder itself. The programme takes place in a small room in the bowels of the hospital.
Handler remembers that none of her fellow patients talked and few made eye contact, paralysed by the secret shame of the insomniac.
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How much will we have to reveal of ourselves? To figure out how much sleep they need, each attendee is told to start a sleep diary, recording what time they go to bed, what time they get up, how long it took to fall asleep and how many times they wake during the night. Next Selsick undoes the idea that a person should have a set bedtime. Typically, insomniacs will go to bed earlier or stay in bed longer in order to increase their sleep opportunity. Instead, patients are told to set a hard-and-fast time to wake up. There must never be any lie-ins, and never any naps chewing gum, Selsick says, keeps napping at bay.
The theory is that if you get up at the same time every morning, you begin to feel sleepy at the same time every night, and, over the weeks, your bedtime will naturally become consistent.
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If they need to be up for work at 7am, this means they are forbidden from entering the bedroom till 1am. This behavioural technique is termed sleep efficiency, and despite its disarming simplicity, patients report astonishing results. But despite my scepticism, the results were immediate. Selsick worked to break the negative associations Handler had with her bedroom. When insomniacs go to bed they often feel afraid of having to lie there frustrated and increasingly irritated. After a while the simple act of going to bed begins to wake an insomniac up.
The bedroom becomes a trigger toward alertness, even fear. To counter this, Selsick urges patients to leave the bedroom after just 15 minutes if they are not yet asleep. All activity apart from sex and sleep is barred from the bedroom. Patients are even told to change their clothes in another room. I would make all my phone calls there, work on my laptop there, eat and watch TV in bed. All gone. I say goodbye to my room at about 7. But after about five weeks, the negative psychological association of the bedroom with wakefulness has been broken, and replaced with new, positive connections.
S tudies show that CBT is the most effective long-term treatment for insomnia. But in order for it to be effective, it requires the patient to establish and maintain a stable routine. These patients want not a timetable to which they must stick, but a pill they can swallow. Surprisingly perhaps, for a doctor who strongly advocates the use of CBT in treating insomnia, Selsick believes that sleeping pills should be far more widely prescribed in the UK. Much of this anxiety is focused on the addictive qualities of benzodiazepines.
In cognitive behavior therapy CBT , sleep doctors often start with your wakeup time, then count backward about six to seven hours. A a. Spend the first 20 minutes finishing up any must-dos walking the dog, firing off a few last emails and the next 20 minutes on sleep hygiene showering, brushing teeth, pajamas. For the final 20 minutes, do something relaxing like meditation, gentle yoga, or reading a book. Then lights out. In fact, caffeine has a half-life of eight to 10 hours meaning that eight hours after your last grande latte, half of the caffeine is still in your system , so drinking too much too late in the day may inadvertently be arresting your sleep.
Here are other surprising ways caffeine affects your health. Breus says a big part of insomnia rehab is coaching patients to reframe negative or incorrect perceptions of sleep. He recommends counting backward from by 3s to bring on drowsiness. This may be better than automatically jumping out of bed the minute you find yourself awake, which only arouses you more. Check out these other techniques that help you fall back asleep when you wake up in the middle of the night. But what you do next is key to ultimately falling back asleep. Stay away from anything too stimulating, like checking email or social media, which can be bad insomnia causes, says Carney.
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