Insomnia, Sleep Disturbance and Tinnitus

Dr Ross Dineen of Dineen and Westcott Audiology

Sleeping problems or insomnia are very common in our society at any given time. Up to one third of adults have difficulty sleeping, and up to one fifth have serious difficulty sleeping. Having a disturbed sleep is a common reaction to a crisis. Insomnia is not a life-threatening problem, but if you are having disturbed sleep you will know just how disruptive it can be.

True insomnia is properly defined as poor sleep accompanied by daytime fatigue. This includes being physically tired, having difficulty concentrating, and feeling depressed, irritable or lethargic. It is these daytime components of insomnia that are the problem. About half the people who have a distressing level of tinnitus initially report some sleep problems. People will often claim that their tinnitus causes the sleep problems. Interestingly researchers have found no correlation between the physical dimensions of persons' tinnitus, such as its loudness or the pitch of the sounds and the presence of sleep disturbance but other factors that occur in conjunction with the tinnitus.

The need for sleep varies a lot between different people and tends to decline with increasing age. Around two-thirds of adults sleep 7-8 hours per night, a fifth less that 6 hours and one tenth more than 9 hours. Complete insomnia is a very rare condition. Some insomnia sufferers complain that they "didn't get a wink of sleep" but research has shown that most have "micro sleeps", very brief periods of sleep during periods of wakefulness which are so brief that they go unnoticed. One bad night's sleep, even as little as two hours, doesn't really effect your performance the next day although you may feel irritable, hostile, fatigued, or unhappy. Short sleep for a week makes some people pathologically tired, but even these cumulative effects disappear after one night's good sleep. So the real issue is not how much time you spend asleep but how you feel during the day.

The initial sleep problems of some insomnia sufferers are triggered by an easily identified problem like a painful illness, a period of extreme stress or an increased awareness of tinnitus. But after the initial cause has faded in significance, the sleep problems can remain because they have become a part of your life. The act of going to bed can become a source of anxiety, as you worry about having yet another sleepless night. Often it is the worrying about whether or not you will be able to sleep tonight, the anticipatory anxiety that leads to a long-term sleeping problem.

Sleep researchers agree that insomnia is not an illness itself, but a symptom of underlying problems. There are five groups of factors which have been shown to contribute to insomnia, these are:

  • Biological factors health problems such as arthritis, angina, migraines, asthma etc., which cause physical pain
  • Psychological factors, such as emotional crisis and stress.
  • Use of drugs including alcohol and sleeping medication.
  • Disturbing environments and bad habits, any aspect of the environment that impinges on your ability to get to sleep, e.g. Intrusive lighting, an uncomfortable bed, or disturbing noise, should be changed. With tinnitus, using other sound such as the radio on softly, or tapes of environmental sounds, to stop you focusing on the tinnitus can be very helpful.
  • Conditioning, the more you associate being in bed with struggling to sleep the harder it becomes to relax there. Only go to bed when you are sleepy.

Specialists in treating sleep disorders highlight two further points:

  • No one with sleep disturbance experiences one of these factors in isolation. Significant sleep problems always involve the interaction of several of these possible causes.
  • Successful resolution of a sleep disorder requires careful defining of all the causes applying to that person, so that all of them are addressed. Even if your tinnitus is clearly the main factor contributing to your sleep problems there are almost certainly some of the other factors involved as well. If you want to solve your sleep problem you need to try and identify all of its possible causes and do something constructive about them.

Suggestions for managing your sleep better

  • Learn to relax physically. Attend a regular relaxation class, or use a self-help relaxation tape. Research has indicated that all the relaxation techniques such as yoga, meditation, biofeedback, progressive relaxation work equally well, so experiment and find the ones that suit you.
  • Try to have a regular bedtime. Don't go to bed if you don't feel sleepy. Do something quiet and relaxing until you do.
  • If you are not going off to sleep easily, don't worry about it. Try and focus your mind on something pleasant and relaxing. Do a simple relaxation exercise, like the progressive relaxation, so that you've got something to focus on other than your worries and/or your tinnitus.
  • If you are not asleep after half an hour, get up. Don't lie there tossing and turning and getting upset. Get up go into another room and do something quiet and relaxing until you feel drowsy and then go back to bed. The same applies if you wake during the night. It is better to spend an hour in the lounge room reading or listening to music, than an hour tossing in bed.
  • Reduce alcohol, smoking, chocolate, coffee, tea, and caffeinated soft drinks. People vary quite appreciably in their sensitivity to these substances. It is a good idea to reduce your consumption of them, especially in the late afternoon and evening.
  • Keep fit with regular exercise. Regular exercise helps you cope better with stress and helps reduce fatigue that can actually make sleeping difficult or disturbed.
  • Don't eat heavy meals just before bedtime. Carbohydrate-rich meals such as pasta for a main course or cake for dessert can have a calming or sedating effect, but you must give yourself time to digest them before bed and of course moderate the alcohol intake.
  • Reserve your bed for sleep. Don't take your worries to bed. Don't have important discussions and arguments in bed. Don't read disturbing books or watch horror movies in bed. Plan these activities for other times and places. Sex is OK as long as it leaves you feeling relaxed.
  • Experiment with low intensity background sounds in the bedroom. One of the problem areas with tinnitus is that it can become highlighted when you go to bed, as everything is so quiet and there is nothing to distract you from listening to, or focusing on, your tinnitus. The more you listen to your tinnitus the louder it seems to become. Listening to soft music when you go to bed can help - most clock radios have a snooze button which switches if off after up to one hour. Tape recordings of pleasant monotonous environmental sounds, such as rain on the roof, or ocean surf can stop you focusing on your tinnitus.
  • Get up at the same time every day. Some experts claim that this is more important than going to bed at the same time each day. Don't sleep in, even if you don't feel great for the rest of the day. You will only waste your sleep needs and upset your biological rhythms.
  • Do not nap during the day. If you have had a bad night's sleep, try to keep physically active rather than napping. This will help you sleep better the next night.
  • Manage your daytime stress. Regular practice of relaxation techniques is very important. Setting aside time each day for you, to focus on your needs, is an important part of effective stress management.
  • Get medical advice. If you think there are any medical problems that are contributing to your sleep disturbance seek medical advice. Don't let unresolved worries about your health ferment in the back of your mind, get advice and assistance. If sleep problems persist, don't put up with them; seek professional help for the sleep difficulties.

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Getting Back To Sleep

Ian Paterson, Vice President, Tinnitus Association of Victoria

Sleep continues to be a major problem for many people with tinnitus. The most common problem is that they wake during the night and then cannot get back to sleep, often blaming the tinnitus for initially waking them and then preventing them from getting back to sleep. Although tinnitus can cause a person to wake from sleep, there are many other more obvious factors that can cause this, such as irregular hours, having something on your mind, poor sleep habits etc. To understand what is happening when we are awakened from sleep and how to get back to sleep, we must understand our bio-clock or 'circadian rhythm'.

Humans, like all other animals, are biologically programmed to follow a 24 hour cycle that is linked to sunlight and darkness. This rhythm regulates natural chemicals that rise and fall within our bodies throughout the 24 hour period governing periods of alertness and sleep, as well as those states between the two.

Although humans have a circadian rhythm that dictates that we will be more alert during the day, and more likely to sleep during the hours of darkness, we all have minor variations that manifest themselves in some people being more a 'morning person' or a 'night owl' etc. These minor variations are not important. However, what is important is maintaining a regular routine in our 24 period. If you regularly go to bed at 10.00 p.m. each night, but decide to stay up until 3.00 a.m. for the next few nights, you are disturbing your natural rhythm and it is highly likely that you would not function at peak performance for the following few days. Part of any sleep management program dictates that you should go to bed when you are tired and get up at about the same time each day. This maintains your circadian rhythm.

Part of our circadian rhythm is that we have a wave cycle happening throughout the day and night that allows our body to have periods of less intense alertness during the day, and periods of deeper rest during the night. Without this natural cycle occurring, we would be like a motor that is running on full throttle all the time and would soon 'burn-out'. At night this cycle continues, causing us to go from periods of rest to actually falling asleep. These cycles happen approximately every 90 to 120 minutes and can be likened to waves that form in the ocean, they arrive on the beach at more or less regular intervals, and, when the wave of deep rest arrives, we are more likely to fall asleep.

When some people wake during the night, they make a conscious effort to fall back to sleep immediately.

When this does not happen, frustration and anxiety sets in and the more they try to get back to sleep, the more likely they are to toss and turn all night and NOT go back to sleep. The waves of deep rest that will lead to sleep will happen regularly throughout the night in the same way as waves reaching the beach.

Surfboard riders can paddle as fast as they like between waves, but they will not go anywhere until a wave appears. In the same way, if you wake and your wave of deep rest is not upon you, you are better to physically and mentally relax, clear the mind and wait until the next wave of deep rest occurs at which time you will most likely go to sleep.

If you can relate to waking during the night and having trouble getting back to sleep, recognise that your wave of deep rest may not be upon you yet. If you have been awake for 40 minutes or so and are experiencing anxiety in trying to sleep, get out of bed and do something that will occupy your mind for half an hour, such as writing a list of things to do tomorrow, writing a letter or doing a crossword. These activities will stop your 'sleep anxiety' and allow you to return to your bed ready for sleep.

Foods that influence your ability to sleep

Eating heavy meals just before bedtime or eating late in the evening are likely to prevent you being able to get off to sleep quickly, this is well known, however there are also foods that you should avoid late in the day as they contain tyramine, an amino acid that increases the release of a brain stimulant and thus will likely influence your ability to relax and drift off to sleep, these foods are:

bacon, sugar, spinach, tomatoes, potatoes, ham, cheese and chocolate.

Conversly there are foods that are rich in trypophan, an amino acid that promotes sleep. These foods are

bananas, turkey, tuna, milk, whole grains, figs, dates and nuts