Sleeplessness, sleep disturbances, insomnia and parasomnias

Sleepless in Pune. Sleeplessness, disturbed sleep, and shift work related sleep problems are interfering with our citizens recovery after a hard days (nights) work. Insomnias and parasomnias are common sleep problems. Once recognised these are treatable.

• Does it take you more than 30 minutes to fall asleep at night?
• Do you wake up too early or frequently at night and have difficulty going back to sleep?
• Do you feel groggy and lethargic when you wake up?
• Do you feel drowsy during the day?
• Do you depend on coffee to get through the day?

If you answer "yes" to any of the above questions; you have a sleep problem. You are not alone. 9-18% of adults suffer from treatable insomnia

What is insomnia?

The inability to fall asleep or remain asleep is insomnia (Latin for ‘no sleep’). In a broader sense insomnia is the inability to get the amount of sleep you need to wake up feeling refreshed.

How much sleep do you need?
As a rule of thumb an adult requires 7-9 hours of sleep. However individual needs differ. You can gauge how much sleep you require by monitoring your own response to different amounts of sleep. Are you productive, healthy and happy on 7 hours sleep or does it require 9 hours of sleep to make you feel good?

What are the effects of chronic insomnia?
Sleeping too little inhibits productivity, ability to remember & consolidate information (cognitive impairment). Chronic insomnia also has serious health consequences and can jeopardize your safety and those of people near you.

Treating insomnia

1. The first step to treating insomnia is to determine whether the insomnia is Primary i.e it is occurring independently from other disorders or Secondary i.e due to other associated medical conditions, (most importantly due to psychiatric disorders such as stress, depression, anxiety and panic disorder). The underlying condition needs to be addressed for the treatment to be effective.
   That is why our assessment includes a medical history, and a physical examination along with your sleep history and daily routine.
2. Behavioural therapy is part of any treatment for insomnia. This includes:
   
   • Stimulus Control Therapy
   • Cognitive therapy
   • Sleep Restriction Therapy
3. Medication most commonly used in treatment for sleep problems. It should be taken under medical supervision, after evaluation, and with appropriate sleep promoting practices.

Self medication and OTC drugs

Why you should avoid them
Medications which help induce and maintain sleep (sedatives and hypnotics) are prescription drugs the world over and for good reason. They can sometimes cause confusion, headaches, memory problems, daytime drowsiness leading to accidents at work and on the road, rebound insomnia when stopped suddenly after continued use. Many have drug interactions and some are addicting. You may develop tolerance and require larger doses.

Don’t let a pharmacist prescribe you a “safe” hypnotic. Consult a doctor who can treat your insomnia and the underlying cause. Follow your doctor’s instructions strictly about drug dosage, timing & duration and follow good sleep practices.

Alcohol and Sleep

Alcohol may help you to relax and thereby decrease the time taken to fall asleep, however sleep later in the night is fragmented and of poor quality. Continued use of alcohol can destroy normal sleep.

Shift work related sleep disorder

Shift work related sleep problems occur due to a lack of synchrony between the individual’s internal biological clock and the desired sleep-wake cycle. Frequently changing shifts, change from night or evening to daytime shifts are associated with greater sleep disorders.

The sleep disorder can vary from excessive sleepiness during the ‘wake’ period, to insomnia during the ‘sleep’ cycle. It is further aggravated by social commitments during weekends. The unsatisfactory quantity, quality and timing of sleep can cause marked distress and interference in daily functioning and living.

Parasomnias (sleep disturbing behaviours)

Nightmares

Repeated awakening from sleep with detailed and vivid recall of intensely frightening dreams. A major stressful life event precedes the onset in 60% of cases.

Sleep terrors

Repeated occasions of awakening from sleep beginning with a cry or scream and signs of extreme fright (sweating, rapid breathing, pounding heart) but with no recall of the content of dreams.

Sleepwalking

Repeated episodes of rising from bed and walking about for several minutes. The child has a blank, staring face, is relatively unresponsive and can be awakened only with considerable difficulty. Upon awakening there is no memory of the event.

Bedwetting or Sleep enuresis

Associated with severe embarrassment, shame and guilt, leading to lifelong psychosocial impairment. More common in children but also seen in 1% of the adult population, properly administered behavioural therapy with judicious medication is effective.

Principles of good sleep practice

You don't need to follow all the points at one shot. Select two or three of them that appeal to you. The first point is essential.

• Set the alarm clock for a particular time and get up no matter how tired you are
• Establish routine times for retiring and waking
• Engage in quiet activities for about an hour or so before bedtime. Follow a relaxing bedtime routine and reduce ambient lighting 1 hour before bedtime
• Avoid engaging in stressful activities or unpleasant tasks near bedtime
• Avoid eating large meals and limit fluid intake immediately before bedtime
• Avoid caffeine for at least 6 hours before bedtime
• Exercise regularly but avoid exercising at least 3 hours before bedtime
• Make your environment right, i.e. your bedroom should be quiet, dark, and at a comfortable temperature.
• Use your bedroom only for sleep and sex, not for work or watching TV
• Avoid daytime naps

Anger management can save your life

Anger induced electrical changes in the heart

Anger management can save your life. Anger can place you at high risk for developing  electrical abnormalities in the heart tissue. These electrical abnormalities are strongly associated with subsequent heart attacks. The chances of surviving an out-of-hospital heart attack are not good. Anger control can save your life by reducing the risk of an out-of-hospital heart attack (Rashba, Lampert 2009).

Why we need the emotion of anger

Charles Darwin was the first to note the universality of anger and other facial expressions of emotion. He viewed this as evidence that emotional signals like anger have been stamped by evolution into the central nervous system. Anger has an essential survival function. Anger needs to be controlled or managed for it to be effective.

Anger management strategies

These are strategies to change your attitude to the expression of anger, as also immediate and long term behaviours to control anger.

Focus and mindset strategies

To control anger one needs to control the scripts that lead up to it

• He's being stupid again. Recognise how easy it is for the best among us to be wrong and make mistakes. Don’t expect life to go on as planned
• It's OK to blow my top once in a while. Talk things over before you reach the explosive stage. Think of how you will regret having been indiscrete and hurting someone. It could work to your disadvantage later. Don’t view an occasional outburst as good for letting off steam. Don’t bottle up your feelings - express them civilly.
• I'll show him who's boss. Remember that your aggression is likely to spark a chain reaction of aggression in others. Losing your temper is not the mark of a strong character who knows his/her mind
• That's my right. There is a difference between feeling indignation and losing your temper because you cannot have things your way. The former leaves room for negotiation, the latter only makes things worse

Strategies for immediate anger control

• Monitoring your feelings  is one of the key skills for anger control. Be aware of your body sensations, such as flushing, muscle tensing, and heart beat as you are getting angry. Take those feelings as a cue to stop and consider what to do next instead of shouting or lashing out.
• Force yourself to keep your voice down. Make a deliberate attempt to speak quietly and slowly
• Take 'time out'. Remove yourself physically by walking away from the place of argument
• Count to ten slowly so the impulse to retort will pass
• Look at your face in the mirror. Now you know why the others are laughing

What to do in the long run

Study your anger. Keep a diary of trigger incidents. Look for the pattern. Avoid precipitating situations as far as possible. Two situations that commonly precipitate anger.

1. Insecurity, which makes you unduly sensitive. Social cues interpreted as hostile may in fact be neutral or friendly
2. Frustration. Learn to accept what can’t be altered. Do your best – do not frustrate yourself over what is not in your control.

Cultivate a sense of perspective. Often the things we lose our temper over seem trivial in hindsight. What really matters to you in life? See things against that background. If its friendship, is it worth losing your friend by losing your temper? Take the perspective of other people. Get a sense of how you are being seen and of what other people might be thinking and feeling in the encounters that make you so angry
Understand people who make you angry. Ask yourself: ‘why do I always get angry with him/her?’ Why do you find them irritating? Enter into their experience – what does it feel like to be them? Others may not accept your point of view all the time. Understand the other person’s point of view. Don't be judgemental.
Relax. Incorporate a relaxation period in your routine – meditation, yoga, music; whatever works for you.
Get direct training in anger control. Many individuals are unhappy that they lose their temper easily. They are receptive to learning how to control it. In the heat of the moment, cool-headed responses such as walking away or counting to ten so the impulse to hit will pass are not automatic. Practice such alternatives in role-playing scenes. Try out friendly responses that preserve dignity while giving an alternative to shouting, hitting, and sulking.

Anger may signal a treatable underlying mood disorder. Treat it. Protect your heart

References

1. Eric J. Rashba . Anger Management May Save Your Life: New Insights Into Emotional Precipitants of Ventricular Arrhythmias. J. Am. Coll. Cardiol. 2009;53;779-781. doi:10.1016/j.jacc.2008.11.023
2. Rachel Lampert, Vladimir Shusterman, Matthew Burg, Craig McPherson, William Batsford, Anna Goldberg,  and Robert Soufer. Anger-Induced T-Wave Alternans Predicts Future Ventricular Arrhythmias in Patients With Implantable Cardioverter-Defibrillators. J Am Coll Cardiol, 2009; 53:774-778, doi:10.1016/j.jacc.2008.10.053

Academic stress in youth

Stressed youths relaxing

Academic stress is a significant aspect of youth. Youth is the developmental phase between puberty and working adulthood. It is a period of continuing student-hood. This is a distinctive feature of youth - it exists only for those who undergo post-secondary education. This is for the privileged few who do not join the workforce full-time after schooling.

Youth is a valuable time for serious experimentation. The young person is not fettered by long-term commitments. In contrast to adolescence, youth is a period of independence - the peer group is no longer a dominant influence. There is greater freedom to develop as an individual. The young person evolves a personal perspective on life and develops a sense of direction before tackling the duties of adulthood.

However this stage of life is by no means stress-free. By definition youth is associated with academics. Academic demands are perceived as significant stressors by youths (Rao 2000, Goff 2011). These demands include workload and time constraints (Jungbluth and colleagues 2011). On entering college the youth is suddenly exposed to an unsupervised life of parties, college events, projects, and an intense curriculum, all of which make demands on time.

Why do academic stressors acquire such significance in youth? Why do students who have done well in their 12th and got into good courses find it difficult to cope with the academics? Well, until high school the student has a limited syllabus. Students in good schools rely almost entirely on the notes dictated by their teachers. Also the exam system is designed so that most students can achieve high scores with minimal time spent on study. All this changes in college. When the youth enters college, he or she is confronted with the entire gamut of knowledge in a particular field. Without the skills to filter, assimilate and reproduce information in context the youth experiences stress.

There is also the problem of youths whose career path was chosen by their parents despite their protests or otherwise. These youth may find themselves completely out of their depth in a course for which they have little interest or aptitude.

Students cope with academic stressors using a combination of emotion-focused strategies like self-blame, or bunking, and problem-focused strategies like reading guide books, and cheating. Study skills training and the acquisition of good learning habits are essential life-skills for students. We have already shown that study skills are effective and can be successfully acquired.

Study skills training should be a part of every freshers curriculum.

References

1. Jungbluth C, Macfarlane IM, Veach PM, Leroy BS.Why is Everyone So Anxious?: An Exploration of Stress and Anxiety in Genetic Counseling Graduate Students. J Genet Couns. 2011 Jan 25. [Epub ahead of print]. PubMed
2. Goff AM. Stressors, academic performance, and learned resourcefulness in baccalaureate nursing students. Int J Nurs Educ Scholarsh. 2011;8(1):Article1. Epub 2011 Jan 24.
3. Rao K; Moudud S; Subbakrishna DK. Appraisal of stress and coping behaviour in college students . Journal of Indian Academy of Applied Psychology. 2000 Jan- Jul; 26(1-2):5-13

Manage exam stress: what Pune’s students need to do

Exams at St Germain's

Pune students need to differentiate true exam stress or test anxiety from rational test anxiety that occurs due to a lack of adequate preparation. Both conditions need to be addressed differently. True test anxiety is diagnosed when the student panics, "blanks out", or overreacts despite the following (Hanoski 2008):

• there is enough time for studying
• study strategies are adequate
• attendance is regular
• class material is understood

Managing rational test anxiety

(Morgan et al, 1986)
When there is adequate time for preparation effective learning habits minimise rational test anxiety.

Effective learning habits

We begin at this stage if the student comes to the clinic 6-8 weeks before the exams. Acquiring effective study skills is essential for all students.

• Plan and stick to a study schedule. This simple yet crucial first step is often neglected.
• Spend at least half the study time in elaborative rehearsal, thinking about what is being rehearsed and relating it to other things that are known or being learnt
• Organise the study material to form retrieval cues or reminders for recall
• Get feedback on how well things have been learnt and remembered
• Review before the exam in the same way things were learnt in the first place. Focus the review on the type of exam.
• Over learn the material. Go back and re-learn it after a few days.

Prior to the exam

 (University of Illinois)

These techniques are applied 1-2 weeks prior to the exam

• Avoid "cramming" for a test
• Combine all the information presented throughout the year. Work on mastering the main concepts.
• Anticipate questions that may be asked and try to answer them by integrating ideas from lectures, notes, texts, and supplementary readings
• Select important portions that can be covered well if you are unable to cover all the material given throughout the term, 
• Set a goal of presenting knowledge of this information on the test.

True (Classic) Test Anxiety

True or classic test anxiety occurs despite effort to study and requires further measures. Again these measures vary as per the phase of the examination.

Pre-test

These measures can be instituted at any time prior to the exam and should become routine for all students.

Adopt a health-promoting lifestyle

Behavioural measures

• Assertiveness - claim space and environment for study, study materials, access to experts
• Time management - especially with a view to program adequate study hours by identifying periods in which time is spent on distractions
• Recreation and social activities - essential for maintaining concentration, and motivation. Should be programmed daily in small quantities

Physical measures

• Nutrition - don’t skip meals. Eat plenty of fruit and coloured vegetables
• Exercise - the amount can be varied. Incorporate some stretching exercises and some aerobics like skipping or same place jogging.
• Relaxation - use a muscle relaxation technique or any form of meditation that doesn't take more than a few minutes
• Sleep hygiene - for adequate, predictable and refreshing sleep

Cognitive and emotional measures

• Cognitive restructuring - see the exam as a means not an end. Keep in mind the ultimate goal you are working towards. This goal may differ from those of your parents and school. Aptitude testing, career guidance and counselling help match your expectations and capabilities with that of your family and school.
• Stress inoculation - take regular mock exams under the same conditions as the actual test
• Anxiety management techniques

Attention to practical aspects of the exam

• Find out where the test is scheduled to take place and how long it will take to get there
• Look at the buildingso that it feels more familiar.
• Know the rules as to what can be taken into the exam room etc [28].

The Day of the Test

• Begin the day with a moderate breakfast, avoid coffee
• Do something relaxing the hour before the test
• Plan to arrive at the test location early
• Avoid classmates who generate anxiety

During the Test

There are basic test taking strategies and specific anxiety management techniques that the student needs to learn (Hinton and Casey 2006).
Before answering

• Review the entire test and then read the directions twice.
• Think of the test as an opportunity to show what you know then begin to organise time efficiently.

Focusing exercise

• Take a deep breath. Look straight ahead at something inanimate (the wall, a picture, the clock)
• Focus the mind on the positive thought 'I CAN DO this exam' while breathing out.

Do the easiest parts first

• For essay questions start by constructing an outline.
• For short-answer questions answer exactly what is asked.
• If there is difficulty with an item involving a written response show some knowledge.
• If proper terminology evades you show what you know with your own words.
• For multiple choice questions read all the options first, then eliminate the most obvious. If unsure of the correct response rely on first impressions, then move on quickly. Be careful of qualifying words such as "only," "always," or "most."

Stick to time

• Do not rush through the test.
• Wear a watch and check it frequently
• If it appears you will be unable to finish the entire test, concentrate on parts you can answer well.

Recheck your answers only if you have extra time - and only if you are not anxious.

Anxiety management techniques

Learn a few of these techniques and stick to the ones that suit you. Use them whenever you panic while studying or during the exam. If problems persist despite using these techniques there are safe and effective medications that can be used just prior to the exam.
Thought-stopping

• Anxiety produces negative thoughts ('I can't answer anything', 'I'm going to panic' etc).
• Halt the spiralling thoughts by mentally shouting 'STOP!' Or picture a road STOP sign, or traffic lights on red.
• Once the thoughts are stopped continue planning, or practise a relaxation technique.

Mild pain

• Pain effectively overrides all other thoughts and impulses.
• Lightly press your fingernails into your palm
• Place an elastic band around your wrist and snap it lightly

Use a mantra

• A mantra is a self-repeated word or phrase.
• Repeatedly say 'calm' or 'relax' your breath

Distraction

• Distract attention from anxious thoughts and keep your mind busy
• Look out of the window, count the number of people with spectacles
• Count the number of desks in each row
• Make words out of another word or title

Bridging objects

• Carry something having positive associations with another person or place
• Touching the bridging object is comforting
• Allow a few minutes to think about the person

Self-talk

• In exam anxiety or panic there are often negative messages, 'I can't do this' 'I'm going to fail' 'I'm useless'. Consciously replace these with pre-rehearsed positive, encouraging thoughts:
• 'This is just anxiety, it can't harm me',
• 'Relax, concentrate, it's will be OK',
• 'I'm getting there, nearly over'.

After the Test

• Whatever the result of the test, follow through on a promised reward - and enjoy it!
• Try not to dwell on all the mistakes.
• Do not immediately begin studying for the next test. Do something relaxing for a while! (University of Illinois 2007).

Exam stress in students requires active management. State boards are taking exam anxiety and its adverse fallout seriously. The Central Board of Secondary Education (CBSE) has brought out a handbook, Knowing Children Better, offering information and advice on handling exam stress. When problems persist students and parents should not hesitate to seek psychiatric help (Malhotra 2007).

References

1. Geetanjali Kumar. Knowing Children better. CBSE. New Delhi. 2005.
2. Hanoski TD. Test anxiety: what it is and how to cope with it. http://www.ualberta.ca/~uscs/counselling_links.htm Accessed 27-Jul-08.
3. Hinton A, Casey M. Managing Exam Anxiety and Panic-A guide for students. 18-Sep-2006. http://www.brookes.ac.uk/. Accessed 27-Jul-08.
4. Malhotra S. Dealing with exam stress amongst students: Challenge for psychiatrists. Abstracts of 59th Annual National Conference of Indian Psychiatric Society. Indian J Psychiatry 2007;49:1-60. Available from: http://www.indianjpsychiatry.org/text.asp?2007/49/5/1/33280
5. Morgan CT, King RA, Weisz JR, Schopler J. Introduction to psychology. 7th Edition. New York. McGraw-Hill Book Company, 1986
6. University of Illinois. Test Anxiety. 2007. http://www.counselingcenter.uiuc.edu/. Accessed 27-Jul-08.