Sleep Tight: Advice for Insomniacs from Britain’s Sleep Guru
Dr. Hugh Selsick on what works, what to ignore, and how to wake up happier
It never fails: No matter how quickly I fall asleep at bedtime, my bladder wakes me at some ungodly hour, and I am doomed to lie there not sleeping — but fretting about not sleeping — until it’s almost time to wake up.
So I was eager to speak to Hugh Selsick, MD, one of the most sought-after insomnia specialists in Great Britain. Dr. Selsick, founder of that country’s first dedicated insomnia clinic and consultant in psychiatry and sleep medicine at University College London and Guy’s Hospitals, has treated thousands of sleep-deprived patients in the past decade. Not only does he see 1,200 new patients per year at the Royal London Hospital for Integrated Medicine, but 80 percent of those going through his cognitive-behavioral therapy program report major improvements in sleep — and nearly half claim to be completely cured.
What’s his secret? A former insomniac himself, Dr. Selsick says his own struggles with sleep led him to “really take patients coming in with insomnia seriously in a way that I think a lot of doctors don’t do.” Insomnia, he insists, is a serious disorder, one affecting approximately 10 percent of the adult population. Dr. Selsick spoke with TheCovey about how women can best battle insomnia and finally attain a good night’s sleep.
TheCovey: Many doctors consider insomnia a symptom of other disorders, but you consider it a disorder in its own right. What led you to this conclusion, and how does it influence your approach to treating insomnia?
Dr. Selsick: First, very simply, about 50 percent of patients who come here don’t have any other disorders, just pure insomnia. Very often, the mistake doctors have made is to assume that if you’re not sleeping, it’s because you’re stressed or worried about things or depressed. But large numbers of patients will say, “I’m not stressed, I’m not worried about anything, I have a good relationship — and I still can’t sleep.”
The second thing is that up until recently if there was insomnia with depression, it was always assumed that insomnia was a symptom of the depression — so treat the depression and the insomnia will get better. But if you look at longitudinal studies, very often insomnia is the primary condition and can precede the depression by many years. Insomnia is a serious psychiatric condition in its own right and has a significant effect on quality of life. You have to treat both aggressively as independent conditions at the same time.
TheCovey: Our readers are women over 40. Isn’t insomnia even more prevalent in this population? How do hormonal changes in midlife influence sleep?
Dr. Selsick: So they have two challenges: Insomnia is more prevalent in women in general, so they’re going to be a bit more at risk than their male counterparts, and hormonal changes around the time of menopause can have a significant impact on their sleep. Hot flashes can certainly lead to a lot of sleep disruption, but sleep gets worse at this time of life even in women who don’t have hot flashes.
TheCovey: What are the biggest myths regarding insomnia?
Dr. Selsick: So I think the first one that’s important to tackle is the myth that we are supposed to get a certain number of hours of sleep. If people aren’t getting the “mythical eight hours,” they get really anxious.
The second myth is that if one is not getting enough sleep, one should spend more time in bed to try to catch up. But this really just gives you more opportunity to be awake in bed, which makes insomnia worse. That’s why, counterintuitively, we actually ask our patients to spend less time in bed.
The other big myth about insomnia is that it’s not a serious condition, that it’s a lifestyle issue, and that sufferers would sleep better if they followed sleep hygiene advice, like avoiding caffeine in the evening, limiting alcohol consumption, or having a warm bath before bed. If those things were going to work, most insomniacs would have figured it out for themselves.
TheCovey: So if getting eight hours of sleep is not the holy grail when it comes to being well rested — how do you know how much sleep you actually need?
Dr. Selsick: The right amount of sleep for any individual is the amount that makes them feel well and alert, able to concentrate and function for most of the day, most of the days. It’s important to stress “most of the days,” because even good sleepers have bad days. The amount of sleep you needed 10 years ago may not be the amount you need now. As you get older, you need less sleep.
TheCovey: You say that rather than trying to sleep more, insomniacs should sleep less. You refer to this as sleep scheduling or sleep efficiency training. How does this work? Is this something that women can try on their own?
Dr. Selsick: We work from our patients’ sleep diaries to see how long they are currently sleeping on average. Say you’re getting up at seven in the morning: That’s the time you should set your alarm for, seven days a week. If you are only sleeping for six hours: 7 AM minus 6 hours takes you to 1 AM. That’s your new bedtime. We gradually extend bedtime until the time in bed actually matches patients’ time asleep.
If you want to try this at home, try pushing your bedtime later by 15 minutes per week until you are falling asleep quickly and sleeping through the night. Reducing time in bed works really well for people who have fragmented sleep. By going to bed later, they are taking all those bits of wakefulness they have during the night and getting them out of the way before they get to bed. Compressing time in bed increases your sleep drive. What people will often find is that things like pain, the need to go to the bathroom, or hot flashes are less likely to wake them if the pressure to sleep is higher. And even if they do wake up, they are able to get back to sleep much more quickly.
TheCovey: Cognitive-Behavioral Therapy (CBT) has been gaining traction in the treatment of insomnia. Can you tell me how — and why — this kind of therapy works for those struggling with sleeplessness?
Dr. Selsick: The vast majority of our patients come through the CBT program. We use behavioral techniques to optimize sleep habits. This means making sure patients get up at the same time every morning regardless of how they slept or what time they got in bed, making sure they don’t nap during the day (any nap during the day will in effect be stealing that sleep from night) and making sure they don’t do anything in bed other than sleep.
Good sleepers usually go to bed because they’re feeling sleepy. And what good sleepers do in bed is sleep, so the act of going to bed actually makes them sleepy. Whereas people with insomnia spend a lot of time in bed awake, feeling frustrated, anxious, and uncomfortable. For them, the bed is associated with wakefulness. We want to change that association. You aren’t allowed to do anything in your bedroom other than sleep and sex. You’re not allowed to work, talk on the phone, watch TV, meditate, pray, exercise, iron clothes — nothing other than sleep or sex.
If you go to bed and don’t fall asleep in about 15 minutes, instead of lying in bed feeling frustrated, get out of bed and out of the bedroom, and read or listen to a podcast or do something you find relaxing. Only go back to bed when you are battling to keep your eyes open. That might happen after two minutes or after two hours or sometimes it might not happen at all. This treatment has side effects: People feel a bit worse before they get better, but that’s part of the process.
The point of doing this is to assure that if you are awake you are not awake in the bedroom.
Then we do things like teach[ing] them relaxation techniques to help them fall asleep. We look at ways to have a wind-down period before going to bed: We have patients take stock of the day and write a list of what they have to do the next day, so they feel a sense of control.
We tackle some of their anxieties about sleep itself — which is often what perpetuates insomnia — by giving them simple techniques to use if their head is busy when they go to bed. One is to think the word “the” in their head — largely because it’s a completely neutral word. It seems to be a very effective and simple way of quieting the mind and stopping worrisome thoughts from really getting a hold of you. This is the cognitive part.
TheCovey: What advice can you offer for those who can’t make it to your clinic?
Dr. Selsick: Studies have shown that if you learn CBT from a book or pamphlet or PDF, and do it, it works. Very little of the therapy happens in the room, it happens when you take the techniques home. Our job as therapists is to convince people to do the techniques long enough for them to work.
Simple things to do first: Set an alarm for the same time every day, seven times a week, regardless of what time you’ve gone to bed, and don’t nap. Try the simple way of doing sleep scheduling, progressively pushing your bedtime 15 minutes later each week until you find that when you go to bed you fall asleep within 15 minutes and don’t spend more than 15 minutes awake during the night. And remember, the bed is just for sleeping.
TheCovey: What about “natural” sleep supplements, like melatonin, valerian, or the increasingly touted CBD oil? Do they help?
Dr. Selsick: In the UK, melatonin is a prescription drug, classified as a sleeping medication, and can be effective. It’s very mild, and we think it’s generally safe. (In the US, where it’s classified as a supplement, quality control is not going to be as tight, so some brands may be better than others, and quality may vary from tablet to tablet.) There is very scant research on CBD oil, so we can’t really say from a scientific perspective whether it works or not. To be honest, there isn’t much evidence that any food or supplements are effective in promoting sleep. If those things worked, I wouldn’t have a job.