Sleepless in St. Louis

Do I have an Ambien habit? I am twenty years over the “short-term use” recommendation for these sleeping pills. I worry about running out before the refill date. I fantasize about having a stockpile against the day my doctor cuts me off. 

Ambien doesn’t even work well! I get sleepy, yes, but only for a few hours. Come morning, I don’t feel refreshed. Still, it’s infinitely better than the zombie feeling from no sleep. How ironic.  Now that I have no reason to set an alarm, I can’t sleep in. 

These days, I climb into bed around eleven. I read or do crosswords until my eyes get tired. The problem is that my brain is wide awake. I go through various sleeping techniques: the 4-7-8 breathing exercise (inhale to the count of four, hold for seven, then exhale to the count of eight); progressive muscle relaxation; listening to my iPod. Bill is already asleep. 

I give in and bite on an Ambien. I can sense my brain quieting. Then, blessed sleep. But, after a couple of hours, I wake up – or my bladder wakes me up – and it starts over. 

I wake at 1:30 or 3:00 or 4:45 or at all those times. Each time, I am faced with the decision – more Ambien? More often than I like, my hand grabs the bottle off the headboard. Even here I have to be careful. If I take too much, I feel hungover.

Yes, I have insomnia. Yes, I am a bit too fond of Ambien. But not until I read Unwinding Anxiety by psychiatrist Judson Brewer, MD, PhD, did I realize that my underlying issue is not insomnia. It’s anxiety about insomnia. 

Brewer has crafted a book that draws on brain science, psychiatry, clinical studies, personal history and spiritual practice to explain how anxiety underlies many self-sabotaging behaviors. As Brewer puts it: “[O]ne of the reasons so many people fail to see that they have anxiety is the way it hides in bad habits.” (I know about bad habits! My friends and I wrote a book called Guilty Pleasures.)

Before going into his anxiety-solving process – the unwinding part – Brewer posits that the line between “pesky habits” and “addiction” is more apparent than real. “Addiction isn’t limited to the use of chemicals such as nicotine, alcohol, and heroin.” 

Brewer defines addiction as “continued use despite adverse consequences.”  He argues that we can be addicted to anything (his italics) if we continue despite adverse consequences. Some of his examples: shopping, eating, pining for love, playing computer games, daydreaming, checking social media, and worrying (my italics.) According to Brewer, what’s different now is that modern technology has made emotional gratification so fast and so easy that we keep going back for one more hit. 

Brewer asks: “What if the root of addiction isn’t in the substances themselves, but in a deeper place? … Could anxiety be a habit, or even an addiction? Can we get addicted to worrying?”

Speaking for myself, hell yes! 

I still remember when I realized this. I had always thought of myself as calm, low-key, in control. So, it was memorable when, in 2006, after reading my essays, fellow doctor and writer Sue Beem observed, “You worry a lot, don’t you?” 

My immediate response was, “No, I don’t.” Then I started to pay attention. My mind was on constant surveillance for trouble. My joke that “I’m worried that I’m not worried” wasn’t all that funny. I was scanning 360 degrees at all times because it felt important to “see it coming,” whatever “it” meant. To this day, I’m hypervigilant. 

When my med school class started seeing patients, we worried about screwing up. A classmate dealt with her anxiety by repeatedly asking me the time – despite her own wristwatch. As a resident, my stomach growled every time I heard my name paged for a new admission. It took a while to connect the hunger response to the stress. I carried around packets of saltines meant for the patients. 

Last year, tennis friend Sherry made a date to come walking with me. I was thrilled. Then, my brain went to work. I wondered if she wanted to ask me to be on the Washington University YMCA board; if she wanted me to return to indoor tennis; if she wanted to talk about reconciling with an estranged family member. My concerns were unfounded. She just wanted to visit. 

Yeah, I still worry a lot. And I use Ambien, not so much because I don’t sleep but because I worry about not sleeping. 

Brewer points to brain studies that show how we develop brain chemical loops of repeated pleasurable, if temporary, rewards. I worry that I can’t sleep. I take an Ambien. I worry about being hooked on Ambien. I’m awake in the middle of the night. I take more Ambien. Rinse. Repeat. 

Interestingly, Brewer proposes using these same brain mechanisms to get out of the bad habits. But it’s not a magic bullet. There’s work involved, much of it spiritual. His smoking and obesity clinics (and apps) using these methods post impressive results. 

The first step is to become aware of what our bodies are sensing at the time we get anxious. This is not easy, as our brains tend to get ahead of us! We jump to worse case scenarios or dive straight to solutions. The best training for this kind of awareness is meditation. Just slowing our brains down through meditation lowers the emotional temperature. Once aware of our feelings, we can swap our current behaviors for something equally or more rewarding. We are establishing a different reward loop.   

So, how do I get out of my particular anxiety-about-sleep/Ambien loop? What is the pleasure to shoot for? What can make lying awake pleasurable? Agatha Christie!! I’m listening to Agatha Christie audiobooks from the library. I may be lying awake, but I am not worrying. I am keeping company with Hercule Poirot and Jane Marple. 

A better kind of reward would not depend on external objects. Brewer suggests we learn to be curious about ourselves, our feelings, our sensations. “Hmm, I wonder…” Every time we get anxious, we explore what that feels like: a journey into ourselves. I am working toward this, but I find it hard to focus on my own discomfort. 

At the same time that he is teaching about new thought patterns, Brewer promotes loving kindness or “metta meditation.” This spiritual practice of extending radical kindness to everyone, including ourselves, is the backdrop to all his programs. Like the emotive power of a movie musical score, kindness and forgiveness open our hearts to hope while we’re learning the new brain patterns. 

What’s ahead for me? I doubt that Agatha is a viable long-term solution. I might try marijuana edibles when they become legal. I want to check out Dr. Jud’s apps. Most of all, loving kindness for myself dispels hopelessness. I realize that dealing with sleeplessness is a work in progress. I am a work in progress. I have hope. 

Tell me: Is worry an issue for you?