Abigail Strubel, MA, LCSW, CASAC
Interminable Terminal Insomnia
When a clinician's bag of tricks is no match for her early morning waking
We can learn tremendously from patients’ treatment failures as well as successes, and it is very rare to read about failures that, by hook or crook, bloom into successes. Everyone prays for such an outcome!
Our guest blogger, Abigail Strubel, MA, LCSW, CASAC, provides a compelling personal account. You may remember her from her post on Complicated Grief and the Inner Clock, which has proved one of the most popular in our Chronotherapy series. Abigail is a Columbia-educated clinical social worker and certified alcohol and substance abuse counselor who uses light therapy to cope with her seasonal affective disorder, and also manages chronic insomnia through acupressure and good sleep hygiene. She has worked with formerly homeless adults, ex-offenders on parole, recovering heroin users, and other interesting populations. Her approach to wellness is a fusion of all compatible treatments, alternative or mainline, that contribute to healthy change. ―Michael Terman
ONE OF MY LEAST FAVORITE SYMPTOMS of seasonal affective disorder (SAD) ― not saying I enjoy the low mood, decreased energy, and impaired concentration ― is terminal insomnia.
Terminal insomnia is also known as “early morning waking.” It can take place anytime between 2 and 4 a.m., and it’s usually difficult to fall back asleep. It’s a well-known symptom of non-seasonal depression, but not so well known for SAD. If you’ve read any magazine story about SAD, you’ve no doubt gotten the impression that oversleeping is the problem ― but certainly not for me. Why should I be so different?
Dr. Terman thinks I may have a superfast circadian rhythm, making me a morning-type person, whereas most of the time SAD slows the inner clock, making it harder to wake up. That I become sensitive to the extended evening darkness in winter, whereas most SAD sufferers become sensitive to the extended morning darkness.
My SAD and terminal insomnia usually ensue right after the standard time begins in the autumn. This is not surprising, since exposure to light seems to affect mood and standard time restricts light exposure. Mood and sleep are both regulated, at least in part, by the neurotransmitter serotonin. Although using a light box every morning helped my other SAD symptoms, terminal insomnia persisted.
For years of winters I lived with limited sleep and the resultant fatigue and crankiness. I knew I didn’t want to use the kind of addictive sedatives that are frequently prescribed for insomnia. Most of the clients I’ve worked with ― ex-offenders on parole, recovering heroin users, homeless and formerly homeless individuals ― have faced mighty struggles with addiction. I also worried that I could become so dependent on medications that I wouldn’t ever be able to sleep naturally. So I worked on figuring out another solution.
One natural sleep aid I use every night of every season is melatonin. It’s a hormone that helps regulate the sleep cycle. Taking melatonin in the evening can sometimes help promote better sleep. Under the guidance of my doctor, I take the maximum dose year-round. Unfortunately, this means that when terminal insomnia strikes, I can’t increase the dose. Dr. Terman thinks that my melatonin regimen has not been fine-tuned to my problem with early morning waking: that taking a tiny dose of melatonin when I wake up in the middle of the night might help more. (I have yet to try this.)
The herb valerian has been used as a sleep and anxiety remedy for centuries. I had high hopes for it, but after two nights, my sleep was no better and my entire head felt like an aching, bruised peach. Headache and dizziness are common side effects of valerian, and I decided it wasn’t working for me.
The folk remedy of warm milk helps people sleep because milk is rich in calcium, a natural muscle relaxant. Imbibing any volume of fluids before bed can lead to waking scant hours later to eliminate, so I tried taking calcium supplements instead. No luck; I still woke up way too early.
BETTER SLEEP THROUGH ACCUPRESSURE
An especially painful option was something I dubbed “acutorture.” It’s an acupressure mat that I saw widely advertised several years ago as the ultimate answer to insomnia. You might have seen one: smaller than a yoga mat, but considerably thicker, it’s densely covered with plastic rounds studded with concentric circles of spikes. Lying on this modern-day bed of nails, it was promised, would lead to deep, blissful, uninterrupted sleep.
I was skeptical, but exhausted, so I ordered a mat. First I lay on it with a t-shirt on and thought, “This isn’t so bad.” It also wasn’t so effective; I woke up as if I’d never lain on it. So my next attempted use of it was undertaken shirtless.
I don’t have an especially high pain threshold. I admit this freely. And I admit that I hate every minute of lying on the acutorture mat, feeling thousands of points stabbing me. The advertising claimed that while lying on it, you experience “initial discomfort followed by a spreading, tingling sense of well-being. The pain will decrease as your body becomes inured to the stimulation.”
One hypothesis concerning the mat’s efficacy is that its infliction of minor pain stimulates the release of endorphins, natural chemicals that the body releases to dull the sensation of pain. Mildly sedating, endorphins can help with sleep. I didn’t notice any spreading tingling wellbeing or decrease in pain until I peeled myself off the mat and ended the torment. But: the mat helped. For years, when I used it, I slept better. Unfortunately, in the winter of 2013-2014, the mat stopped helping me sleep through the night.
I started seeing a new doctor who suggested another method of sleep regulation: trazodone.
Trazodone is a member of the class of antidepressants known as “tricyclics” based on their chemical structure. These medications have largely fallen out of use due to their side effects, which can include dry mouth, sedation, constipation, increased appetite/weight gain, and tremor.
Trazodone was never the most effective antidepressant in its class, but its side effect profile is relatively low, and although it’s quite sedating, it’s not at all addictive. The body doesn’t develop a tolerance to its effects, so once an effective dose is reached, it never needs to be increased. Nor does the body undergo withdrawal when it’s discontinued. So unlike other pharmaceutical sleep aids, I wouldn’t be dependent on the trazodone once standard time ended, and my sleep cycle returned to normal.
I was hesitant to take the trazodone, but desperate for better sleep. My doctor started me on a low dose, and gradually increased it until I was sleeping through the night and feeling refreshed during the day.
From December 2013 through April 2014 — until the onset of daylight savings time ― I remained on trazodone. Then I noticed I was feeling excessively sleepy in the morning. My doctor and I tapered the dose back down, and gradually I stopped taking it altogether. The terminal insomnia didn’t strike back, and I enjoyed good sleep through spring, summer, and early autumn.
The time change in November 2014 brought with it terminal insomnia again. For some reason it wasn’t as bad that year, so I took sporadic, lower doses of trazodone throughout the winter and slept reasonably, reliably well. When daylight savings ended, I packed up my light box and waited for my terminal insomnia to go away entirely. But it didn’t.
This was frustrating to a clinician who has educated many clients about good sleep hygiene and even published articles on the topic. I felt like a dermatologist with acne. I was practicing excellent sleep hygiene, but I couldn’t stay asleep. Night after night — morning after morning, really ― I bolted awake at 2:00 or 3:00 a.m. and for the life of me could not fall back asleep. I faced day after day with bloodshot eyes and irritability. The acutorture mat didn’t help, and the trazodone that had helped me in the winter left me sedated the next morning in the spring.
Fortunately, I was seeing an amazing psychotherapist, and she had an idea that I describe in my next installment.