Sleeping well without medication
Re: Tinnitus Overview / Sleep Tips / TSMB FAQ File
(8/6/03 1:36 pm)
SLEEPING WITH TINNITUS
Note: The following paper was submitted by a TSMB reader from another discussion forum who prefers to remain anonymous.
Sleeping With Tinnitus
[author's name withheld]
Intrusive tinnitus and sleep problems seem to go hand-in-hand. Whether the tinnitus is a mild ringing or a jet engine roar, the quietness of night seems to magnify the intrusiveness of T. Consequently, the incessant nature of T very often leads to problems in falling asleep and staying asleep.
This paper is an attempt to help those T sufferers who have sleep problems. It is by no means a literary work of art. Instead, it?s a collection of thoughts and ideas that I have written down based on my twenty-plus years of sleeping with T.
As a T counselor told me over 20 years ago, when it comes to sleep, seemingly small changes can make a big difference in one's sleep pattern. Thus, it is hoped that some of the ideas presented in this paper may make a positive difference in the reader's sleep pattern. In fact, if I can help even one reader sleep a little better, then this paper has been well worth the effort.
Who will this paper help?
The following people will benefit most:
1) New T sufferers who have trouble sleeping
2) T sufferers who have mild to moderate intrusive T.
I'm calling a person with a "mild" case of intrusive T someone who doesn't notice his T during the daytime, but hears it when he goes to bed. I'm calling a person with a "moderate" case of intrusive T someone who notices his T during the day, but can normally ignore it or block it out. This person can function during the day doing normal activities, but still has problems with sleep.
Note: For those T sufferers who have difficulty ignoring their T both during the daytime and at bed time, I would suggest seeing a doctor about getting the proper medications. These people will, hopefully, still find this paper of value. However, it is my opinion that most of these people will need some form of medication in order to restore their sleep pattern.
Author's Tinnitus History
I have had T for over twenty years. When I initially got T from swimming (yes, from swimming!), my T was in the form of a constant ringing, mostly in the left ear, but also some in the right. I was fortunate to be living near San Francisco, so I was able to get some T counseling from the SF Hearing & Speech Center. The Hearing & Speech Center was great at providing morale support and providing guidelines for living. However, regarding sleep, much was left to trial and error. Some of the suggestions made by my counselor are mentioned in this paper. Eventually, after a 4-6-month bout with sleep problems, I was able to return to a normal sleep pattern without the use of medication.
After 15 years of relatively stable T, I had a major flareup about five years ago. Again my sleep pattern was shattered and I had to resolve sleep problems that were much more serious than those of 15 years earlier. My T was much louder, more intrusive, and my anxiety level was much higher. In some ways, I felt as if I had to relearn how to sleep. After nine months of battling sleep problems, I took early retirement from my job. The elimination of work-related stress allowed me to regain a normal sleep pattern fairly quickly.
About 3 years ago I had another major flareup in my T. Being retired, a lot of stress had been eliminated so most of my sleep problems were related to the intrusiveness of my now-louder T. It was at this time that I discovered the existence of anti-anxiety medication. With the help of both an antidepressant and an anti-anxiety medication, I was able, once again, to re-establish a stable sleep pattern.
With the twenty-plus years of T and the major flareups of the past 5 years, I have gained a lot of experience in sleeping with T. This paper is my endeavor to use my experience to document the ideas and thoughts that have helped me to sleep.
Do I still have some problems with sleep? Yes, of course I do. However, my totally sleepless nights are rare (something that was very common years ago) and the number of "bad sleep" nights has been dramatically reduced. For the most part, I consider myself to have a fairly normal sleep pattern.
The Vicious Circle
Tinnitus -> Sleep Problems -> Anxiety -> Tinnitus -> Sleep Problems -> Anxiety -> Tinn...
Yes, Tinnitus–Sleep Problems–Anxiety is a vicious circle. Intrusive T can, by itself, cause sleep problems. The noise is never-ending, annoying, frustrating and can make falling asleep very difficult. In addition, the incessant nature of T can greatly increase anxiety. Just as noise pollution has been proven to affect people adversely (it's been proved that divorce rates are higher in noisier neighborhoods), T affects people adversely. I believe that the very sound of T induces anxiety.
Sleep problems can affect T levels. Many T sufferers experience increased loudness in their T when they don't sleep well. Sleep problems also affect anxiety. Poor sleep induces depression, negative thoughts and a resultant higher level of anxiety.
Anxiety is considered one of the major influences on T. Anxiety seems to make T sufferers more aware of their T and may actually increase the volume of their T. Anxiety also cause sleep problems. Even those without T find it more difficult to sleep when they have problems weighing on their minds.
So how do we break this vicious circle? It is hoped that the following paragraphs will aid in doing just that.
General Comments and Hints
- "No one has ever died from a lack of sleep". When I first got T twenty years ago, this was the first thing my T counselor told me. I was so relieved! He told me that your body ALWAYS gets as much sleep as it NEEDS. You may feel rotten, you may feel more tired than you have ever felt before, but you are not dying (it just feels that way!). So put this worry out of your mind.
- You can't MAKE yourself sleep; you can only LET yourself sleep. This may sound obvious, but it took me months to figure this out (I'm a slow learner!). The harder you try to sleep, the less successful you will be. So relax! Getting your mind and body relaxed is the key to falling asleep.
- Make your sleep environment as comfortable as possible. Remember that most people spend about one third of their life in bed so it's worth it to make it comfortable. Down pillows can be molded to suport your neck. Down comforters are light weight and are very warm. "Pillow top" mattresses add a bit of cushion to the mattress. If you are sensitive to light, block off any incoming light. Do anything that makes your sleep environment more comfortable and pleasurable.
- Don't listen to your T! I know that this is easier said than done, especially if T is new to you or you are experiencing a change in its volume or form. However, focusing on the sound of your T will impede sleep. (Note: I once read about a clever woman whose T sounded like cicadas. When she got into bed she pretended to be living in the country, listening to the natural sound of the cicadas. She found this very relaxing and was able to sleep. This is the only person whom I've read about who can listen to their T and still sleep.)
- One way to distract your mind from the T is to think about something else. Think about a beautiful place you have visited or a pleasant trip you have taken. Think about as many details as you can. Relive the experience in your mind. By taking this approach you accomplish several things. You take your mind off of the T, you calm your mind by reliving a pleasant experience, and you make the process of trying to fall asleep a pleasant one. The reason this approach works is based on the fact that your mind is "single-threaded", meaning that it can only process one thought at a time. If your mind is occupied thinking about a pleasant experience, it is not thinking about your T. Note: avoid thinking about overly stimulating experiences (e.g. sexually arousing thoughts); they may be pleasurable, but they won't help you to fall asleep!
- Establish a pre-bedtime routine. Whatever you like to do before getting into bed, it's a good idea to have a pre-bedtime routine. For example, you may like to eat a snack, read for 20 minutes, brush your teeth, do relaxation exercise, and say your prayers. Whatever your routine, the very act of following it prepares your mind and your body for sleep.
- The role of diet. Several foods increase the volume of T for some people. Caffeine, salt, sugar and alcohol are commonly cited examples of these. Obviously, you have to find out which foods, if any, affect your T and minimize your intake of these.
Some foods can make you sleepy. For me, spicy foods and foods made with soy sauce make me sleepy. Thus, if I need to get a good night's sleep, I will intentionally chose to eat a food that will aid in my sleep. So determine if there are certain foods that make you sleepy (without increasing your T) and take advantage of these.
- Clock watching. When you can't sleep, clock watching almost always induces additional anxiety. Thus, it may be a good idea to turn your clock at an angle such that you can read it when you focus on it, but not when you just glance at it. If you get up during the night, make it a habit not to glance at the clock on your way back to bed.
- Limiting fluid intake. If you frequently wake up during the night because you have to urinate, you may want to limit your intake of fluids during and after dinner.
- A bedtime snack. Because I have been dealing with sleep problems for several years, I often experience a little bit of anxiety before going to bed. I have found that a snack tends to settle my stomach. Also, I often wake up during the night. If I am hungry, I find it very difficult to fall back to sleep. A bedtime snack usually eliminates the hunger. (Obviously, a bedtime snack is not good for the waistline so you will have to determine if it's of overall benefit to you)
- Try to maintain the same sleep schedule on the weekends as you do during the week. If you sleep in late on Saturday or Sunday mornings, it will be more difficult for you to get back on schedule Sunday night.
- The "Critical Instant". Time and again the following scenario has happened to me: I'm tired and sleepy and ready for bed. On the surface, my T seems normal, so I don't expect to have any problems falling asleep. I go through my normal bedtime routine and I get into bed. As I am in the midst of trying to fall asleep, I notice something in my T. Either it's slightly louder than I originally thought or perhaps there is a small change in it. For whatever reason, now I am thinking about my T. Worse yet, I keep it in my focus and am now beginning to get anxious about it. Well, there goes my chances for a good night's sleep!
So, what should I have done? In that "critical instant" that I first catch myself focusing on the T, I need to divert my thoughts. As suggested above, I starting thinking of a pleasurable experience. I purposely get my mind off of the T and keep it off. Then, instead of lying awake focusing on my T, I eventually drift off to sleep. By using this one diversionary tactic, I have saved myself from numerous "bad sleep" nights.
- When you wake up in the middle of the night and can't fall back to sleep. I tend to wake up at least once every night and often several times. Fortunately, I am used to this and, surprisingly, it doesn't affect how I feel in the morning too much because I normally don't have much trouble falling back to sleep. On occasion, however, I do have this problem. When this occurs, I use the following technique: I use the time to write "mental letters". These are letters that I compose to people who are significant in my life. I write these "mental letters" to friends, family members, co-workers, and even celebrities that I admire. Since these "letters" will probably never become reality (i.e. get written down on paper), I can be as open and honest as I care to be. For some reason, writing these "mental letters" relaxes me and helps me to fall back to sleep. A side benefit is that I find myself appreciating the people around me more.
General Approaches to Falling Asleep
- The most commonly used approach to sleeping is going to bed at a certain fixed time and getting up at a fixed time. If you don't fall sleep, you rest in bed. The theory is that whether you sleep or not, at least you get some "rest". This is a good approach if you get a good night's sleep each night. However, if you have difficulty in falling asleep as many T sufferers do, this approach can lead to a lot of tossing and turning and an inconsistent sleep pattern. Some nights you sleep well and other nights you get little or no sleep.
You can modify this approach. If you don't fall asleep in 25-30 minutes, you can get up and read or do some other relaxing activity. You return to bed when you get sleepy. The main problem with doing this is that the time you spend out of bed takes away from your "rest" time.
- In this approach you again go to sleep at a certain fixed time and get up at a fixed time. However, you adjust your sleep schedule. For example, let's say you sleep 8 hours per night, but your sleep pattern is not very consistent. You intentionally cut your sleep time to 7 1/2 hours per night. By doing this, you won't sleep as much each night, but, hopefully, you will eliminate the bad-sleep nights. If after a couple of weeks you still have trouble consistently falling asleep, you cut your sleep time down to 7 hours per night. You will keep cutting down your nightly sleep hours until you are able to fall asleep consistently. Once you reach a stable sleep pattern, you will probably feel a bit tired for a couple of weeks, but eventually your body will adjust to less sleep and you will feel "normal" again. (Using this approach, I was able to resolve my sleep problems 20 years ago without the use of any medication.) If you use this approach, try not to nap.
- Another approach is to go to bed only when you are sleepy. Note I said "sleepy" and if you aren't sleepy, read a book or do whatever relaxes you. If you get into bed and realize that you aren't sleepy, get up out of bed. If you use this approach, you will minimize the time that you "toss and minimize the time that you "toss and turn". However, it may mean that there will be less consistency in the amount of sleep that you get.
Note: the last two approaches are NOT mutually exclusive; that is, you can combine the two. In this case, you would cut back on your nightly sleep time AND you would go to sleep only when you are sleepy.
Sleep Aids: Background noise generators
There are many different types of background noise generators. These are all used to help "mask" the sound of T. Some of them are mentioned below:
- Radio static. Tune a radio between stations to achieve a "static" sound. This is an inexpensive form of white noise. You can adjust the volume to appropriately mask your T.
- Fans. Fans can produce a steady background noise that can mask the sound of T. Obviously, the use of a fan on a cold Winter night may cause other problems.
- Sound-generating machines. There are a number of commercially available sound-generating machines.
- Sound Pillows. These can be purchased from HearUSA. These have a padded speaker imbedded in a pillow and the speaker can be connected to an external electronic device such as a CD player or radio. The choice of the masking sound is up to you. The speaker puts the sound next to your ear and it won?t disturb your sleeping partner. (see www.hearUSA.com)
- White Noise Generators (WNGs). Several models of WNGs are available from audiologists. They fit around the ear with a custom-made earpiece. WNGs are an integral part of Tinnitus Retraining Therapy (TRT).
So which one should you use? It's all a matter of personal choice and trial and error. Since T sounds vary from person to person, you have to choose what works best for you. Generally speaking, you should choose a device that produces a sound that closely mimicks the sound of your T, thus, masking it. Notes: if you do a lot of traveling, you may want to choose a device that is portable. Also note that a few T sufferers (including me) tend to notice their T MORE when background noise is present. If you are one of these people, background noise generators may not help you to sleep.
Sleep Aids: Medications
There are several types of medications that are prescribed to help T sufferers to sleep. Unfortunately, since each person's body is different, what works well for one person may not work well for another. Thus, to a great extent, the right drug(s) is a matter of trial and error.
- Sleeping Pills. Whether over-the-counter or prescribed (e.g. Ambien), I would not advocate their use for most T sufferers. Sleeping pills may induce sleep, but they don't promote the most restful form of sleep, REM (Rapid Eye Movement) sleep. This is one reason why people taking sleeping pills feel groggy and not fully rested in the morning. Note: any sleep, however, is probably better than no sleep!
- Anti-depressants. There are a number of anti-depressants prescribed to T sufferers. Elavil, Paxil, Pamelor and Trazedone are some examples. Since a prolonged lack of sleep very often causes depression, anti-depressants contain ingredients that induce sleep. All of the doctors I have seen for my sleep problems have recommended anti-depressants for sleep rather than sleeping pills.
- Anti-anxiety medications. Many people who suffer from the severe anxiety that commonly accompanies T are prescribed anti-anxiety medications. Xanax and Klonopin are examples of these. For these T sufferers, it's often their anxiety that keeps them from falling asleep. Anxiety symptoms may include increased heartbeat, shortness of breath, sweating, panic attacks, frequent urination and sometimes a "knot" in the stomach. Because these drugs reduce anxiety, they have the effect of inducing sleep.
Note try the deep breath techniques discussed elswhere
Personal note: when I had a major flareup in my T three years ago, I was prescribed Trazedone (an anti-depressant). The Trazedone did help me to sleep, but my sleep was still not consistent because of my anxiety. The additional prescription of Klonopin (an anti-anxiety medication) restored my sleep pattern in a matter of days.
Cautionary note: Benzodiazapenes (aka "benzos" such as Xanax and Klonopin are considered by many doctors to be "addictive". Some people on the TSMB disagree and do not consider them physically addictive. However, there may not be much disagreement that these drugs may generate an "emotional" or "psychological" dependency. Thus, anyone considering the use of these drugs must weigh the potential benefits against the potential risks.
Personal comment: sleep is SO important. I feel that it is the foundation for feeling healthy. Thus, I would rather get a good night's sleep every night with drugs than to have a poor sleep pattern and be drug-free. To me, living with a poor sleep pattern is not really "living"; it's more like "existing".
Sleep Aids: Relaxation Techniques
- Audiotapes. Audiotapes can be useful in reducing anxiety and promoting sleep. A variety of inexpensive tapes are available and cover such topics as improving sleep, overcoming anxiety, deep relaxation, and increasing self-confidence. Typically, these tapes run about 30 minutes and seem to help with relaxation and calming anxiety. I tried them and it was not unusual for me to fall asleep while listening to them.
- Relaxation exercises. Several audio tapes and books advocate the use of physical exercises to relax the body and mind. Generally, the pattern is "tighten the muscle"; then "relax the muscle." You start at your feet, proceed to the mid-parts of your body, and then finish with your eyes and forehead. I found these exercises relaxing, but not particularly helpful in aiding sleep.
- Self-hypnosis. I took a six night course in self-hypnosis. One exercise I have found helpful was a relaxation exercise. Unlike the physical exercises mentioned above, these exercises are strictly mental. As with the physical exercises, you start with your feet and proceed upward. Basically, the script is mentally saying to yourself "my feet and ankles, I want you to relax" and a confirmation statement "my feet and ankles are relaxed". You then move up to your calves, then thighs, etc. On whatever part of the body I am focusing, I usually feel a slight tingling sensation. When done with the body, I then say "my mind I want you to relax". I picture my mind blanking out all thoughts. (It is at this point that I can introduce behavior modification suggestions if I desire) My final step is to say "after I leave this trance, I will sleep well, dream pleasant dreams, and will wake up refreshed". Sometimes as I am going through the relaxation steps I get so relaxed that I fall asleep.
Note: there are a number of different relaxation techniques such as cognitive therapy that I have not mentioned. They may be very helpful with relaxation. I have just not tried them myself.
Sleep Aids: Dealing with Anxiety and Panic
- Panic and panic attacks. I doubt that there is anyone who has had many sleepless nights because of T who has not experienced some form of panic or panic attack. Sometimes the panic is expressed by increased heartbeat and a "Why me?". A more severe panic attack may include increased heartbeat, shortness of breath, breaking out in a cold sweat, and an immediate impulse to jump out of bed and pace around. How can these panic situations be handled? Here are some ideas:
1) Try to catch yourself before the panic hits. With experience, you will know when panic is starting to set in, so try to catch yourself before it even starts.
2) If panic has already set in, remind yourself that:
a) Panic happens to all T sufferers at one time or another. You are not "different" or alone.
b) Panicking does not help
c) Panic can actually aggravate your T or prolong a "spike"
d) The best thing to do is calm down, relax, and think to yourself "I've been through this before" (most likely you have). "I will be okay".
- (for men only) Frequent urination. One of the symptoms of anxiety is frequent urination. Over the years many of the times that I had difficulty falling asleep my problem was the feeling of a "need to pee" only minutes after relieving myself. I discovered a technique to minimize this feeling. You will need a "lumbar roll". A lumbar roll is a foam pillow about two feet long and 5 inches in diameter. The foam is enclosed in a cloth cover. They are available from medical supply stores and some pharmacies. If you place the lumbar roll with one end inserted between your legs (assuming you sleep on your side) and the other end putting slight pressure on your crotch, the feeling of a "need to pee" will be greatly diminished. Notes: putting one end of the lumbar roll between your legs is also good for your back. The anti-anxiety medication Klonopin also addresses this sympton.
- A "knot" in the stomach. When I have severe anxiety, I have often felt a "knot" in my stomach just a few inches below my rib cage. The following technique does not always work, but it is worth a try. Roll up a towel so that it is about 9-10 inches long and about 5 inches in diameter. A couple of rubber bands can be used to hold it together. Place the towel against the knot in your stomach and hold it in place with your arm. Sometimes the slight pressure of the towel on the knot makes it feel better. Note: Klonopin also addresses this anxiety symptom.
Edited by: reph at: 6/4/05 6:14 pm
Re: Tinnitus Overview / Sleep Tips / TSMB FAQ File
Other Related Topics
Guidelines for living with T
"Live one day at a time." It's natural for a person with T to worry about the future. "What if my T gets worse?" is a common question that T sufferers brood about. The reality is that no one knows if their T will ever get worse so there is not much point in worrying about it. It's much healthier to try to live and appreciate each day.
"Live as normal a life as you possibly can. Do not develop the habit of saying 'No' out of fear of not knowing what will happen to your T." If you say No to this and No to that too often, you may be forfeiting much of your life, and this can be a very big price, indeed. Your self-confidence can erode and this can become as big a problem as having T.
Here's a personal example of what I am talking about. When I first got T, I was not sleeping well. I had a 3-night business trip coming up. I told my T counselor "I'm afraid of going on this trip because I don't know what will happen to my T and I don't know how much sleep I'll get." His response was "Go!" So, yes, I went. I got about 5 hours total sleep in the three nights. Yes, it was hard. Yes, I was dog tired! But I never regretted going. I learned that I could handle a very tough situation and I learned the value of saying "Yes" to life.
The importance of managing stress
If you'll remember, the three parts of the "vicious circle" were tinnitus, sleep problems and anxiety. Unfortunately, stress can have a direct impact on each of these. Stress is the number one aggravator of T. Stress can cause difficulty in sleeping, even for non-T sufferers. And stress obviously has an impact on anxiety. Thus, whatever you can do to manage your stress, do it!
Personal example of the impact of stress: When I had a major flareup in my T five years ago, I fought sleep problems for nine months. Even with medication, there were periods when I would lose an entire night's sleep every third night. There was one work week when I slept only two nights. After nine months, I decided to take early retirement from my job. Believe it or not, from the very day I announced my retirement, my sleep pattern was restored. The absence of work-related stress resolved my sleep problems, even with the T. The surprising thing was that I had thought that I had had a pretty good handle on my job. I didn?t have any idea that work-related stress was having such an impact on me. Thus, even subconscious stress can affect sleep.
The importance of finding the right doctor
The TSMB is fraught with stories related to uncaring doctors and doctors who just don't listen to their patients. So, if this is your situation, find another doctor! In the personal example of stress cited above, if I had had the right doctor, I believe he would have worked with me to find the right combination of medications. He would have worked with me to help me re-establish a suitable sleep pattern. As it was, my doctor at the time didn't seem to care about my sleep problems. He actually seem to act as if losing a night?s sleep every third night was normal! Consequently, as I previously stated, I had to take early retirement from my job. I honestly feel that if he had treated me properly, this wouldn't have been necessary. (fortunately, this doctor has retired and now I have a great doctor)
Reducing your use of medications
No one wants to be dependent upon drugs, particularly drugs that have addictive qualities. Thus, once you have established a consistent sleep pattern, you may have a desire to cut down on the dosage of your drugs. This can be a bit unnerving since you don't want to jeopardize your sleep pattern. Here's one approach that has helped me. Let's say you want to try taking half a pill instead of your normal dose of a whole pill. At bed time, take half of the pill and put the other half on your nightstand along with a glass of water. Give yourself 20-30 minutes to fall asleep. If you are not asleep in 20-30 minutes, take the other half of the pill. The knowledge that the half pill is there if you need it will give you a more comforting feeling. If you continue to use this approach, each time cutting down on the dosage of medication, you will eventually find the minimum dosage needed to maintain your sleep pattern. Note: inexpensive pill cutters are available at most drug stores.
How to not listen to your T (a "far out" technique)
Note: I don't suspect that there will be many people who can use this technique successfully. In fact, I don't know how I ever learned it myself; it just happened. It is probably most useful for those with bilateral T (in both ears). In any case, here's the technique:
(this can only be attempted when it's quiet, like at bed time)
1) While lying in bed, intentionally focus on the T in your right ear. Envision the noise emanating from your right ear.
2) Now divert your attention to the T in your left ear. Envision the noise emanating from your left ear.
3) Now imagine the "space" in between noise. Somewhere in this space there may be a spot where either:
a) the noises from each ear neutralize each other and it is "quiet" there or
b) the noises balance each other out.
4) If you can focus your mind on either of these spots (whichever one you can find), it will become easier to sleep. In fact, you can even learn to do your thinking in this spot! It's almost as if your brain has found a refuge from the noise of your T.
A) At first, finding this "spot" will require conscious effort. With time, however, your brain will go to this spot automatically, without any conscious effort.
B) Please don't get upset if you can't use this technique! When you eventually habituate to your T, you may discover that your brain is doing something similar to what I have described.