Anxiety commonly shows itself in irritability. We react too quickly and too much to all manner of minor frustrations. We become upset by things which would not normally disturb us. We are more sensitive to noise, and are easily irritated by it. The noises at work which we had not previously noticed become a source of irritation; and at home the noise of the children brings us to distraction. We tolerate it as long as we can, then suddenly let go. We punish the child too severely, and then immediately regret it.

If someone finds fault with what we have done, we normally take the criticism in stride. But when we are anxious, we overreact to the situation; we flare up, we say what we should not say, and then regret it. The girl in the restaurant attends to us in the usual way, but because we are tensed up we feel that she is unbearably slow. The mannerisms and quirks of our friends and relatives, which we once enjoyed, now irritate us. There soon develops an atmosphere of tension in the home. Members of the family become cautious; they are restrained, and no longer laugh arid joke openly for fear of triggering off this unnatural irritability. The anxious one senses that the others are acting differently toward him, he becomes still more on edge, and the cloud of misunderstanding deepens.

A young woman in her early thirties, extremely tense and aggressive, came to consultation on account of her intense irritability with her two young children. These were her exact words: “With her like she is how could I be relaxed?” “It is not as if I am completely ignorant. I have had experience with doctors and that makes me a bit doubtful.”

For some years her husband had been under treatment for a peptic ulcer which I thought might easily be related to his wife’s irritability.

Her state was so severe that I arranged for her admission to a hospital, but she was so irritable and aggressive that she promptly left against advice. However, she returned to me some months later, just as irritable as ever, but determined to seek help. It took her several sessions to learn to do the relaxing mental exercises. She then underwent an extraordinary change in personality; she could smile and be pleasant in a way that had not seemed possible before. She learned to cope with the children and tolerate frustration without undue irritability.

*8\57\2*

Since hypnosis is not sleep, what is its relationship to sleep? I am going to illustrate this with the familiar experience of ‘highway hypnosis’. When a person is driving a long distance on a highway, his eyes are focused only on the highway; he cannot look at anything beyond the highway for more than a few seconds. His eyes and his attention have to come back to the highway all the time. His awareness of the surroundings becomes narrower and narrower. This affects the content of his thoughts, which also become narrower. Although he is in a fully awake state, his awareness is submaximal and is continuously constricting to a narrower span. During this period of extremely limited awareness, it is as if he is in a trance state. He is dissociated from the awareness of his surroundings. Highway hypnosis is very dangerous. Eventually, if he does not pull over and stop driving, he will most likely fall asleep and lose control of the car.

After driving a period of time on a highway, a person goes into highway hypnosis, and very often highway hypnosis leads to sleep. This raises the possibility of a continuum from the fully awake state through the hypnotic state to the sleeping state:

Awake → Hypnotic state → Asleep

With the invention of the EEG machine, we now know that hypnosis does not equate with sleep. Schwartz, Bickford, and Rasmussen in 1955 reported that hypnosis and the awake state have identical EEG patterns. But typical sleep patterns on the EEG can be brought about in hypnotized individuals by means of appropriate suggestions. Hence, although hypnosis and sleep are two different states, given the appropriate suggestions of heaviness, tiredness, and sleepiness, one can pass from the hypnotic state to the sleeping state easily.

David Foulkes, a US scientist, made a detailed study of the mental state of people falling asleep, and distinguished different phases. The first step is the loss of control over the flow of thought. Thoughts begin to wander and go their own way. In the sleep laboratory, if the subject is awakened and questioned just before the appearance of a sleep pattern on the EEG, he reports that he has lost his orientation in time and space and is no longer aware of the reality of life around him. It is as if he is in a dream state resembling that of REM stage sleep, and sometimes it is impossible to tell them apart. However, the EEG recording does not indicate any REM sleep and there is no rapid eye movement.

Well, what is the best way to cope with stress? Let us discuss this under the following ten categories:

The danger of destructive behaviour. Never make things worse than what the stress calls for. In other words, do not punch the bonnet of the car. Violent reactions to stress are uncalled for and are normally regretted afterwards. This is the number one rule. Stress itself is bad enough; there is no need to make it worse.

The rule of exaggeration. Albert Ellis called this ‘catastrophization’. We all magnify stress and this is a normal psychological reaction. This is useful as we want to examine the details of the stress so as to resolve it. However, catastrophization is dangerous, as it blows things out of perspective. A small incident becomes a big incident, and our reaction is consequently out of proportion to what is called for.

Inability to sleep. Insomnia is useful in stressful situations, as it allows us to stay awake and search for a solution to resolve the situation. However, insomnia is useless if we just stay awake, feeling all distressed and sorry for ourselves, wishing the stress would go away. This kind of insomnia is not constructive, and perhaps some mild sleeping pills may help. If you are awake at night because of stress, tell yourself this is only useful if your thinking is constructively helping you sort out the issue so that you eventually resolve it. Sometimes, when it is quiet and you are all alone, thoughts and intuition may come which may help you to tackle the challenge better. Of course, good sleep hygiene demands that you do all the thinking in another room and leave your bed for sleep and sex. The best way is, once you are in bed, to dissociate yourself from the stress you are experiencing. Practice self-relaxation, and be confident that you will sleep. Let tomorrow look after tomorrow.

Change irrational thoughts to rational ones. Along the lines of the rational emotive theory developed by Albert Ellis, some of our irrational thoughts are: ‘I must be loved and approved by every person in my life, I must achieve at all times, and it is the end of the world if things are not how I expect them to be’. We have to reconstruct a more logical and rational way of thinking. Cars break down everyday, although it is inconvenient, and this is an everyday ordinary stress. A car has to break down now and then; even a Rolls Royce has its hiccup.

Correct appropriate action. This is not easy, but, if you keep your head cool and follow the logical steps to resolve or minimize the impact of the stress in question, you will turn distress into success and become proud of how you handled yourself under stress. This is why astronauts need to practice all possible mishaps and emergencies, so that when they are under stress they know exactly what are the logical steps to take to avoid catastrophy and they can handle emergencies with ‘military precision’.

How? Look at the alternatives, use your imagination, spend all your time in constructive activity, use your head, solve the problem. If your boss misunderstands you, do not feel distressed. Use your magnifying glass and examine why. Explain to him, assert yourself, or change your behaviour so that the same misunderstanding will never happen again. If the car breaks down, use your head, not your fist. Use your magnifying glass to examine what is wrong with the car, and take appropriate action. If the car cannot be fixed, just bad luck, call a tow truck, and arrange alternative transportation.

A comfortable room and surroundings are beneficial to a good night’s sleep. Noise from the street, or noise from your snoring partner, may be disturbing. Bright light or an uncomfortable bed may distract you from concentrating on falling asleep. A bedroom that is too warm or too cold is not suitable.

Some beds nowadays are not specifically designed for the purpose of sleep. Someone has told me that he gets seasick when he sleeps in a water bed. On the ether hand, some people are so used to water beds that they can no longer sleep in an ordinary bed when they take a holiday.

Bed manufacturing is a huge industry, as everyone needs a bed. Ideally, beds are designed to give good support to the spine and the body during sleep. A firm bed is essential. As discussed earlier, when the sleeper enters REM sleep, the whole body is paralysed. If the bed is very soft and sagging in the middle, during REM sleep the spine will conform to the curve of the sagging bed. In the morning there will be muscle pain because the muscles have been stretched in an abnormal posture for about 25 per cent of the time spent in sleep. For people who have back problems, a soft comfortable bed is not ideal.

The bed should be restricted to two basic forms of activity. Sleep, and the familiar reproductive activity starting also with the letter ‘s’. However, some people use the bed for other activities, such as reading, watching television, drinking, thinking, and planning. All these activities have the tendency to distract you from sleep, and may let you form a habit of thinking about your past and planning your future in bed. This generates unnecessary tension and anxiety, which obviously leads to insomnia. From now on, remember, the bed is reserved purely for the enjoyment of the two activities starting with ‘s’: sleep and sex, or sex and sleep, and nothing else. A bedside TV set or a reading lamp are not recommended in the bedroom of the problem sleeper.

A clock is bad for someone who is conscious of the number of hours they feel is necessary to sleep each night. A common experience for most people who wake up in the middle of the night is to look at the clock by their beds. Some will exclaim, ‘My goodness, it is now one in the morning. This is it, I will be unable to sleep again and will stay awake for the rest of the night’. The worry of what time it is in the middle of the night can give rise to tension and anxiety. Of course, this tension and anxiety will prevent the person from falling asleep again. Then when they look at the clock again after a while, they will panic and say to themselves, ‘It is now two, and there is only a few hours before morning’.

There is a self-fulfilling prophecy for some people. They believe that, once they wake up in the middle of the night, they will not sleep again. Their tension increases as they mark the hours through the night. This tension is in fact reducing their chances of sleep. So, as the night approaches, they already predict that they are going to wake up in the middle of the night and will not be able to fall asleep again. The night comes and they wake up in the middle of the night and immediately look at the clock to find out what time it is. Each time they look at the clock, they generate more anxiety within, which prevents them from sleeping. Each time they fail to sleep, they are convinced once more of their own prediction.

Anxiety is cumulative and their confidence to sleep is reduced with succeeding nights that they fail to sleep. Looking at the clock and marking the hours of the night is to be avoided completely, as this generates tension and reduces the confidence to sleep.

I always tell my patients who have sleeping problems to put their clocks either under the bed or in a drawer, so that they will have no way of looking at the clock when they wake up during the night. It has been discovered in sleep laboratories that it is perfectly normal and healthy to wake up in the middle of the night. A normal sleep pattern always consists of a few awakenings at night. The older we are, the more frequent we wake up in the night. However, it is common that we do not always remember these awakenings, and we fall back into sleep. Next time when you wake up in the middle of the night, tell yourself it is perfectly normal and healthy to do so. Do not bother to find out what time it is or try to work out how much time you have slept or how long it will be before daybreak. I know it is very tempting to look at the clock, but once you get used to putting the clock away you will surely sleep much better. Just lie back, do nothing, practise self-relaxation, and you will fall back into sleep.

*36/23/5*

There are many causes of insomnia. The following are some of the more common causes:

(1) Pseudo-insomnia

This is probably the most common cause in the normal population. These people believe they cannot sleep because of one or more of the above mentioned reasons. Their confidence to sleep is gone, and they become worried as the evening approaches since they predict they will not sleep. Because they experience insomnia in bed, some develop a phobia about their beds, as they can sleep anywhere and at any time except in bed. They may be quite happy sleeping on a sofa or in front of the television, but when they are in their beds at night they are wide awake and feel distressed.

(2) Biological clock related insomnia

We all have a biological clock within us. Sometimes we have to reset out biological clock abruptly; for instance, because of jet lag or a change in shift duties, and the clock is thrown out of phase. The biological clock governs a number of biological functions in the body; the most important is the sleep pattern. The other functions are body temperature, hormonal balance, metabolic rate, urine output, stomach and bowel activity, and so on. Each biological function follows the biological clock differently, and any sudden changes to the clock throw them out of phase with each other. Besides not being able to sleep, we feel below par and are unable to function normally.

(3) Situational insomnia

This is normally transient and is precipitated by some situation that a person is experiencing. Anxiety, stress, and worry of what is going to happen are typical causes of insomnia. Stress is a common cause of insomnia.

(4) Physical illness

It is a fairly common practice for the sister in charge of a hospital ward to ask the resident doctor to prescribe sleeping pills for the patients just in case they cannot sleep. This is a much more common practice in nursing homes. There are two reasons why sleeping pills are prescribed in hospital. The first is that it is reasonable not to be able to sleep in hospital. You are sick and in a totally new bed in a new environment with a new routine. On top of all this there is the additional stress of your own physical illness and not knowing its outcome. The second reason is that if some patients are not sleeping they may interfere with the other patients and, in the end, no one gets any sleep. This is especially true in nursing homes. In this instance sleeping pills are given for the benefit of the patients who would normally sleep but who are being disturbed by those who cannot.

(5) Pain

We all experience pain at some stage in our lives, whether it is toothache, headache, stomach-ache, or whatever. The pain we feel drags us down, we feel awful, our whole routine is ruined. Chronic pain is even worse, as there is no escape; the pain is with the sufferer all the time. People who suffer from chronic pain may find sleep the only escape, but if they have insomnia there is no escape at all.

6) Drug-withdrawal insomnia

It is now recognized that the modern sleeping pill is effective for about two weeks only. These pills supress REM sleep. When the pills are stopped, the sleeper experiences a rebound of excessive REM sleep. This means the sleeper will have an excessive number of dreams and sometimes nightmares. This will be experienced as disruptive sleep and insomnia. The person who experiences drug-withdrawal insomnia believes that his innate ability to sleep is lost, for once he stops taking the pills he cannot sleep anymore. In fact, of course, he has not lost his ability to sleep. It is just that the symptom of drug withdrawal is insomnia. When the drug-withdrawal insomnia has passed, the normal sleeping pattern returns. It is important to distinguish drug-withdrawal insomnia from insomnia resulting from unresolved stress. It is a common experience for a patient to see his doctor and say, ‘I ran out of sleeping pills two nights ago and I cannot sleep at all. I guess I do not know how to sleep anymore. Please prescribe me another 50 tablets’. This should of course be rephrased as, ‘I ran out of sleeping pills, and I cannot sleep because I am addicted to them, but once the withdrawal effect passes I will be sleeping again’. Ideally sleeping pills should not be stopped suddenly, but rather the dosage reduced gradually and finally stopped.

7) Excessive daytime sleepiness or EDS

This includes narcolepsy and sleep apnoea. Narcolepsy is abnormal sleep attacks and sleep apnoea is frequent waking at night because of an inability to breathe. Sufferers fall asleep easily in the daytime and most of them do not have the distress of not sleeping at night; hence their chief complaint is normally not insomnia.

(8) Mental illness

Insomnia is a common symptom of mental illness, but frequently there are many other symptoms at the same time. This book is not written for sufferers of mental illnesses, as they always need the care of professionals. People with these conditions should not stop their medications, as very often the medications provide the only effective treatment.

*30/23/5*

‘Apnoea’ means not breathing. Sleep apnoea is the inability to breathe whilst asleep. The frequent attacks of sleep apnoea disturb sleep profoundly. Because sufferers do not have enough sleep at night, they feel tired all day and have no energy to do anything. They are unable to concentrate at work, and lose interest in sex and other things they enjoyed before. This is another common cause of excessive daytime sleepiness, and is now studied extensively in sleep laboratories. As a result, this condition is now believed to be more common than was previously believed. It is estimated that over 1 per cent of the adult population is suffering from sleep apnoea.

Sleep apnoea becomes more frequent as we grow older. The typical sufferer is a man over forty years of age who is grossly overweight and has high blood pressure. His sleeping partner invariably complains that he is snoring every night. A keen observer may be able to report that the sufferer snores very heavily, then wakes himself up, takes a few deep breaths, and falls back into snoring again. This may happen many times throughout the night. In fact people suffering from sleep apnoea do not have any real sleep. They keep waking up throughout the night However, in the morning, they may not remember that they have been waking up frequently, but somehow have the feeling that they have not slept. They also fall asleep very easily in the daytime, at the most inappropriate times. Many road accidents involve people who have sleep apnoea.

This condition is caused by obesity; in particular, the accumulation of fat around the throat. During sleep, air is sucked into the lungs, creating negative pressure around the surroundings of the throat and the tongue, which leads to a reduction in the diameter of the throat. This reduces air flow into the lungs. In normal people this reduction in the diameter of the throat is minimal, and may create only a snoring sound. Snoring results from the vibration of the palate, which is the roof of the mouth, as air is blowing across it. The flute and other woodwind instruments work on the same principle. In some obese people the air passage is narrowed far more than in normal people because of the accumulation of fat around the throat. This causes an even greater reduction in the flow of air to the lungs and results in obstructive sleep apnoea.

The condition is made even more severe during REM sleep. In REM sleep the muscles of the body are almost paralysed. Hence the muscles in the throat become flaccid and the diameter of the opening is further reduced. Because there is a reduced air flow into the lungs the person is virtually suffocating; this subsequently reduces the amount of oxygen circulating in the brain.