Wide awake

2 a.m.

It was like clockwork, how my brain just knew it was 2 a.m. even when my eyes had been closed. I seethed with anger—at the clock, at my brain, at my happily snoring husband beside me.

This night in mid-October 2013 was the fourth in a row in which I awoke at 2 a.m. and was unable to fall back asleep. When 5 a.m. rolled around, I finally gave up and went to watch TV on the couch. When my husband found me there two hours later, he asked, “No sleep?”

“Nope,” I said, and began crying. “I’m starting to be afraid I’ll never sleep again.”

I’ve always been a lousy sleeper. A sneeze or a light in the hallway could wake me. I remember being 8 or 9 and distressed to realize that even my parents were asleep, while I lay awake. But until now, a few days of troubled sleep would eventually give way to normal nights.

What if I really never did have a full night’s sleep again? Could I die from this? Was I losing my mind? How little sleep could a person subsist on before it was dangerous? How would I get through the next day? The following week?

Night No. 5 was the same. I felt as if I had been awake the entire time, though a few active, bizarre dreams told me I must have gotten an hour or two at least.

By morning, I was a wreck. I made an appointment to see my doctor. By the time I could see him, I’d gone a week like this.

“It’s stress,” he told me.

“But I’m not really under much stress,” I argued. “Plus, I can fall asleep most nights. I just can’t stay asleep. Could it be my hormones? Shouldn’t you test for something?”

“It’s stress. Get some therapy. Take these,” he said, handing me a prescription for zolpidem (the generic form of Ambien) and standing to leave.

The Sleep Review reported recently that insomnia ranks second, after cold, as the most prevalent health complaint in the world. About 30 percent of Americans struggle with insomnia; the majority are women.

Sleep is not a luxury, either. It’s a necessity, as important as water or food. No one knows why we need it, but we absolutely do. According to Robert Stickgold in his October 2015 cover story about sleep in Scientific American, reduced sleep can lead to weight gain, impaired memory and brain function, increased risk of diabetes and hypertension, increased rates of depression and anxiety, and lowered immune response. Yet it’s among the least understood functions of the human body.

“There are only about 85 [sleep medicine fellowships] in the country,” says Dr. Michael Lucia, a pulmonary and sleep medicine specialist whose clinic, Sierra Pulmonary and Sleep Institute, is one of the only sleep clinics in the area. “Not nearly enough for the demand or need.”

Dazed and drowsy

Zolpidem and I became fast friends. On half a pill, I slept like a champion. But then my conscience, worried that I was becoming addicted, insisted that I try to sleep without it. When I did, sleeplessness inevitably returned.

Panic set in. How long could this continue? Would I be on sleep aids for the rest of my life? It seemed my body had forgotten how to sleep.

In a few months, I’d gained weight. My irritable bowel syndrome played havoc with my insides. My skin was sallow and pimpled. My eyelids were permanently swollen and red, and my eyes constantly teary. Friends and family loaned me relaxation CDs and books about sleep, recommending that I try certain teas or supplements. Melatonin and valerian and Advil PM and Benadryl and Sleepytime tea made no noticeable difference.

My ability to handle even minor challenges was diminishing, and the smallest offense—a stray cup, for example—threw me into a rage. One mid-January afternoon, when I found myself crying for no reason, I found a new primary care doctor to get to the bottom of this.

She saw me the next day—a lovely young doctor who was enormously sympathetic to my plight. She ordered a battery of tests, including a thyroid panel, celiac screening, hormone tests, and a test for vitamin D levels. She prescribed Zoloft for my depression and anxiety. And she referred me to Dr. Lucia’s sleep clinic.

The brain game

My appointment at Sierra Pulmonary and Sleep was weeks away. In the meantime, on the recommendation of my chiropractor, I made an appointment with Dr. Randall Gates, a chiropractic neurologist at Power Health Chiropractic.

“Functional neurologists look at stimulating parts of the brain that are not working correctly from a functional perspective, after we’ve eliminated other medical, neurological diagnoses,” Gates explains.

My two-hour consultation involved filling out approximately 10 pages’ worth of questions regarding my lifestyle and symptoms. Then, I was asked to perform a variety of tests to determine how the various parts of my brain responded to stimuli.

“You have signs of functional abnormalities in your fear centers,” Gates explains. “And that’s causing you to not be able to sleep … We saw in you a decrease in the frontal lobe’s ability to shut off your stress response.”

In other words, I was under so much stress that my brain was stuck in fight-or-flight mode, with no shut-off switch. This kept my adrenal glands working overtime. No wonder I couldn’t sleep.

Gates recommended that I study the work of Stanford biologist Dr. Robert Sapolsky, author of Why Zebras Don’t Get Ulcers and focus of the documentary film Stress: Portrait of a Killer.

As the book and film explain, your brain’s stress response involves two hormones: adrenaline and glucocorticoids. They are critical to survival in times of stress—the zebra running from the lion, for example. When the zebra escapes and the danger passes, the stress response shuts down.

“But in today’s society, people don’t have an off button,” Sapolsky says in the film. “We turn on the exact same stress response thinking about the ozone layer, taxes coming up, mortality, 30-year mortgages… We’re not doing it for a real, physiological reason, and we’re doing it nonstop.”

Could this be the case for me? Could prolonged stress—about my writing business, my financial troubles, my 4-year-old daughter, and (now) my lack of sleep—actually be breaking my stress-response mechanism and keeping me awake?

Dr. Gates recommended a treatment plan that involved a series of brain exercises, access to relaxation facilities, tests for adrenal and thyroid issues, supplements, and a rigorous diet. But as encouraged as I was, and as much sense as this was starting to make, the plan was costly and not covered by my insurance. I’d keep looking elsewhere.

Natural remedies

I visited the Finley Center, a south Reno clinic for naturopathic medicine and acupuncture, to meet with Dr. Tara Finley, a Nevada-licensed oriental medicine doctor (OMD). In her work with patients, she will review labs and order new ones, and perform physical and nutrition exams. Her treatment plans typically involve nutritional programs, supplements and acupuncture. These, she explains, affect energy flow, which can have a significant physiological effect.

As part of my initial session, I received acupuncture. I’d always been afraid of acupuncture, but these needles were as fine as hairs. I never felt an actual needle prick. It was tremendously relaxing, like being covered with an electric blanket.

I felt tingly all afternoon. That night, I slept well.

Finley, too, suggested I take an adrenal stress test, for which I spit into a series of tubes and mailed them to a lab. When the results came back a few weeks later, they made sense—high adrenal function at night, when it was supposed to be tapering off, and low function in the morning, when my resources were depleted and I needed a boost of energy. Finley recommended an adrenal supplement.

After a few weeks of taking them, I didn’t notice much difference. I still had insomnia, and my insurance didn’t cover her services. I couldn’t afford to keep seeing her.

Sleep study

My appointment was not with Dr. Lucia but with a physician assistant who asked me a series of questions about my insomnia: Had I been told that I snored? Yes. Was I very tired in the morning, even if I’d slept? Yes. Did I ever wake up gasping for breath? No. Had anyone in my family ever been diagnosed with sleep apnea? Yes—my father, deviated septum.

My responses raised enough of an alert that she recommended a sleep study. Though I was convinced I didn’t have sleep apnea, I sort of hoped I did because it was a tangible, treatable thing, a reason for insomnia that doctors understood. Apnea patients could awake hundreds of times in the night, imperceptibly, when they stopped breathing. My adrenal stress test results meant nothing in the traditional medical community. Adrenal fatigue was not a diagnosis, and there was really nothing to be done for it. But apnea? That was a treatable problem.

A sleep study is a bizarre thing. I sat in a chair as a polite technician spent about 30 minutes gluing electrodes to my head, face and body. I was allowed to take a zolpidem, to overcome the lab insomnia I was sure to have, and I was fitted for a CPAP machine, should I have a breathing “episode” and require intervention that night.

I took my pill and slept restlessly. I was awakened at 5 a.m. The study was over. I’d never needed a CPAP. Electrodes and wires were removed, and I was out the door by 5:30, covered in glue.

My results came in four weeks later. I was low on vitamin D and needed a supplement. I had mild apnea when sleeping on my back—not severe enough for CPAP, but nightly Flonase was recommended. And I had what the PA explained was a “really weird sleep cycle.”

“Most people get about three or four cycles of REM sleep a night, and they’re usually a couple hours,” she told me. “You had only two cycles, and one was only 15 minutes long.”

Yes! Finally! Someone else had seen it too! It wasn’t in my head! But what does one do about that?

“I’m not sure, unfortunately,” she told me, handing me some brochures on sleep hygiene and suggesting I keep a sleep diary. “I think you’re a candidate for long-term sleep-aid use.”

Insomniac diaries

So it was late March, and I still knew very little about why I was awake. Except for vitamin D and the Flonase, things were status quo.

I focused on this sleep hygiene thing everyone kept talking about. I stopped looking at any screens in the bedroom at night, kept consistent sleep and wake-up times, got up early each morning to walk, stopped drinking caffeine after 11 a.m., limited wine to two glasses and maintained a cool, dark bedroom. I began placing a pillow over my eyes and ears when I slept—a sort of sensory deprivation.

I decided that minimizing my stress was the key to everything. I enrolled in a Sunday morning yoga class. We started a monthly budget to pay down debt. And I kept telling myself that it wasn’t as bad as I felt it was.

“All insomniacs underestimate their sleep,” Dr. Lucia says. “They say things like, ’I didn’t sleep for two nights.’ That’s physiologically almost impossible. You are getting more sleep than you realize.”

The other problem, Lucia points out, is the misperception that we need eight hours of sleep each night. Some may only need seven or less. It’s about setting realistic goals.

It’s in my conversation with Dr. Lucia, in preparation for this article, when I learn about what the American Academy of Sleep Medicine now recommends for the treatment of insomnia: cognitive behavioral therapy for insomnia (CBTi).

CBTi is a structured program aimed at changing sleep habits and thinking that perpetuate sleep problems. It is a relatively new area of specialization, and Nevada only has one fellowship-trained and certified specialist in CBTi, Dr. Ruth Gentry, who set up shop in south Reno two years ago.

During the first session, Gentry will do a full sleep evaluation seeking medical causes (such as apnea) and behaviors that could be contributing to sleep problems. The following sessions address techniques for quieting the mind or reframing thoughts that could be delaying sleep. Gentry also typically recommends a “sleep efficiency schedule.”

“A lot of times people will do things they think are helpful for sleep but aren’t. For example, they’ll spend 10 hours in bed hoping to sleep six of them. … Sleep efficiency therapy is reducing the time in bed and making that time what they actually need for sleep,” Gentry says. “There’s a lot of mental force we put on sleep, and that just makes it worse, so the cognitive part is reframing the way people look at sleep in their thinking.”

She uses a Chinese finger trap to illustrate the problem—the more she pulls and forces her finger out, the tighter the trap. “The more you tell yourself, ’I have to sleep!’ the more your body stresses out and you respond by not sleeping. Once you let go and see it’s not working, you’ll get out of the sleep trap. But you have to shift your approach to sleep.”

Typically CBTi can be completed within four sessions, and the effects are long lasting. And while she is not professionally able to make recommendations regarding medication, she emphasizes that she can work in accordance with a doctor, if patients desire, to taper those medications down over time.

“A lot of times, their sleep gets better with CBTi, and they build confidence, and when you’re confident, your sleep is better,” Gentry says.

CBTi from a certified practitioner isn’t cheap, but Gentry accepts most insurance plans, and the Affordable Care Act’s provisions for mental health care mean that behavioral therapy is now accessible and usually covered. Additionally, there are online CBTi programs and a self-help books that may be an effective, affordable way to start.

I plan to pursue CBTi, and in the meantime I’m reminding myself that this too shall pass.

“Nobody’s going to die of insomnia,” Dr. Lucia says. “If you have a few nights where you feel like you’ve only slept a few hours, you’re still functional.”

And this is a first-world problem, a uniquely American one, says Lucia.

“This American lifestyle of making more, of having new stuff, drives us to give up sleep. We’ve all been guilty. … Patients are mostly responsible for their own sleep problems. They perpetuate them. And the answer is not a pill.”