“Everything that upsets you is bad” – knowledge

SZ: Ms. Heidbreder, when was the last time you slept badly?

Anna Heidbreder: Definitely during a night shift in the clinic. Probably because I was stressed, because there was a lot to do.

Oh yes, the stress.

We call this Hyperarousal for people with difficulty falling asleep and staying asleep. You are in bed and want to go down, but you know you have to go back to work tomorrow, so you really need to fall asleep now. This creates a negative vortex. You already have an increased stress level that makes you feel hard to come down, and then it keeps increasing.

What do you do when you’re stuck in a vortex like this?

First of all, I try to remove all entertainment media from my bed and make nice thoughts about regulating myself down. It used to be said to count sheep, in the end I don’t do anything different: I let something monotonous go through my head that has little to do with my everyday life, for example a walk on the beach or across a green meadow. I then imagine how it smells and sounds there. Sometimes it works better, sometimes worse. Sometimes it is particularly difficult to fall asleep if you force yourself not to think about anything.

A vicious circle.

In this case, I advise my patient to stand up. We call this stimulus control: You shouldn’t lie awake in bed for long if you run the risk of the carousel of thought starting to spin.

One often reads that smartphones and tablets should be left out of bed. Is that correct?

There are always discussions among experts as to whether the light with a high blue component that is emitted by these devices is unfavorable for the release of the sleep hormone melatonin. One thing is certain: if you check your chats or e-mails shortly before going to bed, you will see the orders for the next day, things that have not been completed. So you might get into stress again.

So you’d better read a book in the traditional way?

Anything that shuts you down and brings the day to a close is allowed. Anything that upsets you is bad. Reading is also not always a good idea if you have trouble falling asleep after an exciting crime novel, for example.

Falling asleep badly sounds so banal, but the problem is immense: It is estimated that up to 45 percent of people worldwide suffer from sleep problems.

The awareness of this is growing steadily, everyone asks themselves, many are afraid that they will not perform well if they sleep too little. But you have to be careful not to pathologize yourself, so: What is normal, what is really sick? The research question is: Do these 45 percent really permanently meet the criteria for chronic insomnia? It is believed that only about ten percent of the population actually suffer from a chronic sleep disorder that really needs treatment and that has nothing to do with other underlying diseases. This puts the number into perspective.

What exactly are sleep disorders in your terms?

In sleep medicine we say sleep disorder first of all. Whether we mean sleep apnea syndrome, sleep-wake disorders or the difficulty falling asleep and staying asleep. The latter is a very common phenomenon, every one of us experiences such a sleep disorder at some point in life, with some it is a bit more extreme, often under special conditions, for example when an exam is pending or a life decision has to be made. That doesn’t always have to be negative. According to the definition, disorders of falling asleep and staying asleep are divided into acute insomnia, which occurs, for example, during certain life events such as the death of a relative, and chronic insomnia, when the symptoms persist on more than three days a week for more than three months you can no longer meet the tasks of the day.

Can difficulty falling asleep be a sign of a mental illness?

There is some research on this. Studies show, for example, that having trouble sleeping can be a symptom of depression. But we also know that people with chronic insomnia have an increased risk of developing depression. So the question is: what is hen, what is egg? Cardiovascular diseases are also linked to sleep problems – or the risk of developing diabetes.

Many people use valerian, melatonin, histamines, and the currently popular CBD oils. What is to be made of it?

The evidence for all of these over-the-counter drugs is very poor. As a sleep doctor, I have to take a critical look at this: I cannot recommend these drugs. With antihistamines in particular, we know that their aftereffects can damage alertness and concentration the next day.

But if I am convinced that it will help me?

Depending on what you’re buying, it can be said that the remedies might not hurt either. Valerian or sleeping teas, for example, are rather undramatic; they probably work via the placebo effect: You take something and relax – simply because you have taken something.

Which drugs from the pharmacy can you recommend?

First of all, no medication at all. I would turn around on the way to the pharmacy and instead think about what I can do for my personal sleep hygiene. For example, can I manage to switch off my everyday life in the evening, to switch off, not to drink alcohol?

A beer always makes you so tired.

Alcohol can convey the subjective feeling of being able to fall asleep faster, but the quality of sleep suffers: people snore more, and breathing pauses are often more pronounced after drinking alcohol. This in turn can lead to a poorer oxygen supply during sleep. The quality of sleep also suffers without snoring.

So no beer. So what?

Basically, it is good to end the day consciously with a kind of evening ritual, i.e. to deal with the thoughts of the day before going to bed, and also to write in a diary. In general, you should only go to bed when you are convinced that you can fall asleep. But be careful: You shouldn’t delay going to bed too long and nod off on the sofa. You have to keep your sleep pressure up until you are in bed.

You have to explain this to us: What is sleep pressure?

The concept of sleep pressure goes back to the 2-phase model of the pharmacologist Alexander Borberly. The model differentiates between circadian rhythms, in other words a kind of internal clock that regulates tiredness. In addition, there is the sleep pressure built up during the day, so we get more and more tired from being “awake”. We have no influence on the circadian rhythms, but when we nod off on the sofa in the evening it is of course difficult to be able to fall asleep again immediately in bed because the pressure has already been reduced a little.

We summarize: You can save yourself little pharmacy medication, as well as napping on the sofa. Then what can you recommend?

The drug of first choice for insomnia is cognitive behavioral therapy for insomnia. First of all, I like to explain to my patients what sleep is and how it works; also that it is normal to wake up at night.

Does this theory unit bring anything?

It’s about taking the pressure off. Many people go crazy when they hear that you have to sleep eight hours a night. Today we know that the length of sleep is overestimated. Many feel fit after just five hours and get through the day well. On the other hand, there are also people who need more sleep, which can also be within the framework of the normal.

What else?

It is important to know that it is quite normal for sleep to change over the course of life. The older you are, the more often you wake up at night. The proportion of deep sleep phases decreases with age, which is also normal. We’ll also talk about learning relaxation techniques and sleep rituals.

If all home remedies don’t help, when should you get medical advice?

If you can suddenly no longer sleep or suddenly need a lot of sleep, this should make you aware. In rare cases, organic diseases or sleep apnea syndrome are the cause. Even if you notice after three to four weeks of therapy that it won’t work, it will get worse, I just can’t calm down, it makes sense to talk to a doctor.

What do you do when you admit a patient to the outpatient department who complains of chronic sleep problems?

Here, too, we first question the patients in detail. It’s not just about sleep, but also about other diseases or drugs that could explain the problem. Sometimes we decide to examine someone in the sleep laboratory. You get wired up in detail and spend the night here with us. Many of my patients are then very worried that they will not be able to sleep in addition to the many devices. But people with severe insomnia in particular often feel relieved because someone is finally looking after them. These people sometimes sleep particularly well in the laboratory.

What exactly do you examine in the sleep laboratory?

Above all, we look for disorders that could explain to us why the patient’s sleep is disturbed, such as breathing disorders or sleep-related movement disorders. In addition, we check whether the person examined is really sleeping as badly as he or she perceives it to be. There is also the phenomenon that people have the feeling that they are not sleeping or that they are sleeping poorly, even though that is not the case. This is mostly due to the moments before going to sleep: From my clinical experience, I can say that many of my patients have a major problem simply being able to switch off.

Just relax. Sounds so easy.

We live, that’s not scientifically speaking, but my personal opinion, in a society of optimization. We always want to optimize a lot in our life, including sleep. Some even use their smartphones to measure how they slept. But as soon as you start to orientate yourself on scales, you will find deviations – and create additional stress, which certainly does not contribute to better sleep. So yes, even if it is not as easy as it sounds: just switch off.