Insomnia, Nightmares Plague Post-September 11 World

Although the nation's flags are flying at full mast again, many Americans are still having a difficult time dealing with the aftereffects of Sept. 11th's attack. Angry, grieving, and losing sleep, the national disaster has literally become the stuff of many people's nightmares.

Studies show that people often have nightmares after catastrophes and this tragedy may affect more people than ever before. Plagued by nightmares and insomnia many Americans are finding it difficult to return to their usual routine. Our guest, Dr. Neil Kavey, is a Sleep Medicine Specialist and Director of the Sleep Disorder Center at Columbia Presbyterian Medical Center. Kavey will explain why this occurs and what sufferers can do about it.

Are more people suffering from insomnia and nightmares since the Sept. 11th attack?

We can only assume that this is happening based on word of mouth, but a study hasn't been done yet, so we don't know what the final effects Sept. 11th effect will have on sleep. But Sept.11th events have certainly made people hyper-aroused and hyper-alert, so the base line that they are functioning on has probably shifted. People are more scared, aroused and alert so they are probably having trouble sleeping. Mood also plays a factor in sleep patterns. Depression can cause people to have difficulty sleeping. And a feeling of depression seems to be sweeping the country as well. People get depressed from the images of innocent people being slaughtered, people jumping out of buildings etc…

Why does this effect sleep?

Sleep and its onset requires a certain level of relaxation. The balance between the alert mechanism and sleep mechanism has been thrown off-kilter by the bombings. The alert mechanism needs to wind down and remain down in order to enable people to fall and remain asleep. If people are anxious, fired up, and hyperalert then they will have a hard time beginning the sleep process and triggering the sleep mechanism. The waking mechanism won't let go because it's running on high octane. Right now there is so much force behind our waking mechanism that the sleep mechanism can't take hold. Then we see two different types of sleep problems emerging, difficulty falling asleep and difficulty staying asleep. Both are affected by the state of alertness. Depression undercuts our ability to sleep in a different way. The sad affect has a biochemical effect on the brain. Misery and grieving keep people awake.

What about nightmares?

Nightmares are very bad dreams. It's surprising how many dreams are bad dreams to begin with. The majority of dreams are bad anyway, because they involve conflict and problems. Most dreams aren't pleasant. And now everybody's problems have increased so their level of nightmares will also increase. These nightmares combined with the level of hyper-awareness will cause people to have a harder time staying asleep. If someone actually witnessed any of the events of Sept 11th irsthand then they might have a post-traumatic response involving terrible frightening nightmares because they are overwhelmed with stress. Those people will have nightmares during the time that they usually dream, but they will also start to have nightmares during the sleep period when it is not normal to dream because they are so overwhelmed with stress.

A lot also depends on the individual person's personality. Even a person who wasn't there firsthand might have severe symptoms. Proximity to the event and personality style will dictate what sort of sleep problems and nightmares a person will have. But this event has been so traumatic that people who normally distance themselves from things may not be able to escape the stress of this.

Is it normal to have trouble sleeping in response to the WTC attack?

Yes, this is a normal biological response to being threatened. We need to be more awake for our own survival when there is a danger lurking. It's nature's way o keeping us on our toes. On the other hand, we need to get our sleep in order to deal with this danger to function well when awake.

If these reactions are normal, when can a person expect these problems to subside?

People should understand that some degree of difficulty falling asleep and staying asleep is tolerable. People should not panic that they are getting imperfect sleep even if they have had perfect sleep for most of their lives. They should look more to how they are functioning during the day. They should ask themselves, "Am I functioning well?" If they are not functioning well, then they need to take steps to alleviate the problem.

Already some people are starting to sleep a little better, the immediate threat has passed. People are flying and taking the subway and beginning to be able to sleep better. As time passes and people feel less threatened, the incidence of sleep problems will decrease. But it is possible that we will see a greater incidence of insomnia over a very long period because we may be going to war, so people in general will have to maintain a state of hyper alertness over a long period of time. Many people will not be able to return to their prior level of calm for a while. This may make a lot of the population more vulnerable to insomnia, even people who never had sleep problems before. This is all normal considering the circumstances.

We've never been through something like this before. The Vietnam War body count was nightmarish to watch but it wasn't on our own turf.

What should someone do if their sleep problems are affecting their level of functioning?

They should try some self-treatment to maximize their chances of falling and staying asleep. They might need to put more effort into the sleep process than they have in the past. If the self-treatment tips (listed below) do not help then they should seek professional help. They should go see their doctor, who can go over their options with tem--prescribe a sleep aid, antidepressants, or recommend counseling.

What can a sufferer do about alleviating these problems?

1) The most important things to do is try to wind down, put a buffer between the horrors of the events and sleep--between the anxiety and tensions of the day and sleep. Everyone is so focused on the news and then they try to go to sleep right afterwards which is difficult to do. Instead they should try to set aside an hour to turn off the TV. Say goodbye to the day and tell yourself that it is more important that you get your sleep so you can function better, that everyone will be okay for a few hours while you sleep. Don't do work in bed. Don't read the newspaper. Read something that will help your alerting mechanism wind down to nothing so that the sleep mechanism can take over. Don't discuss the events of the day with your spouse and don't talk about life major events. Don't talk about the kids. Don't get into arguments. Read something relaxing, something that will take you away from the stress of the day and into another world--something mindless, a magazine maybe. Listen to music. Have sex, as long as it won't get you too riled up. Do anything to disengage from the day.

NOTE: This hour of relaxing should NOT take place in the bedroom, because you only want to associate the bedroom with sleep and not with anything stressful like terrorist attacks or the torture chamber of insomnia.

2) Be aware of those factors that can contribute to disturbed sleep, like alcohol or caffeine too close to bedtime.

Although alcohol does help people fall asleep it is a bad way to fall asleep becasue it wears off in the middle of the night and then people wake up and have trouble falling asleep again. Wine with dinner is a good way to wind down but drinking right before bed will cause fitful sleep. Also be careful of caffeine. Caffeine effects can last 8 hours so we tell people not to have caffeine after 2pm. The less caffeine igested the better, especially in the wake of the WTC attack. Even people who didn't previously have problems falling asleep when drinking caffeine at night may have a problem falling asleep because of the unusual circumstances and added stress. Because the baseline has been reset. Because the balance between the awake and sleep mechanisms have been upset.

3) Be wary of over-the-counter sleeping aids. You can take them, but be wary of them. They are mediocre in their effectiveness and give you a hangover during the day. People assume that they are safe to take because they are "over the counter," but they do have side effects. If you take them once in a while it's okay but if you find that you need to take them for a prolonged period of time (more than a couple of days) that's when it is time to turn to your physician for help. Stop trying to self-medicate and seek help. Your doctor can discuss your options with you, whether it is a good idea to prescribe something to help you sleep n a short-term basis--to help you through the crisis. They can also discuss the option of getting psychological help to deal with the stresses keeping you awake. Counseling can include relaxation techniques.

4) Don't nap during the day. Naps are wonderful when one is sleeping well, but when one is suffering from insomnia, naps tend to take the sleep pressure away from the night and trigger it during the day. So even if you are tired during the day you shouldn't nap. Fight the urge because it will only make your bouts with insomnia worse.

5) If you awaken during the night, try to go back to sleep but if that doesn't work get out of bed. Get out of the bedroom. Keep your awake time out of the bedroom so that you are conditioned to think of your bedroom as a place of sleep rather than as a torture chamber. Have a glass of milk, read that same relaxing book and then go back to bed.

6) DO NOT sleep later to compensate. Take the sleep loss for that night and get up at your usual time. It is more important to stay on a regular schedule. The tiredness from that night will help you to fall asleep the next night. You need to maintain your biological rhythm.

Of course there are exceptions to these rules but they are rare.

How much sleep do people really need?

Most people need 7 hours, and some need 8 to not be "sleep deprived." People can function on less sleep but they are functioning despite being sleep deprived. Lots of people need 9 hours, and those people wonder if something is wrong with them but there isn't.

Is it true that you need less sleep as your get older?

No, its true that you GET less sleep when you get older, but you need the same amount. The years take their toll on everybody. Older people have difficulty staying asleep.

What can a parent do if their child is having sleep problems?

Parents should be very loving, reassuring, and comforting. Spend a bit more time reading and relaxing with your child before bedtime. Read to them a little bit longer. You don't need to be rigid with the bedtime hour. It's okay if they go to bed a bit later, it's more important that they have a peaceful relaxed sleep. Keep in mind that the same stimuli and stress that keep adults awake are keeping the kids awake. If the child is having nightmares be reassuring. Let them know that things are okay, that it was just a nightmare, everyone is safe, daddy's here....etc. But it's important that the parents get enough sleep so that they can be patient, calm, and loving. So that they will be able to help the child to deal with their sleep problems and stresses.
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