Insomnia versus Sleep Deprivation in new moms (yes, there is a difference between the two)

Here, finally, is my post on sleep (as a follow-up to my post “Some Postpartum Advice for New Moms-Part I”) ….or actually, insomnia.  Just what is insomnia?  Equally frustrating as explaining the difference between the baby blues and postpartum depression (PPD) is explaining the difference between having insomnia and not having the ability (or lack of opportunity/time) to sleep.  Insomnia is when you can’t sleep at night and can’t nap during the day no matter now exhausted you are.  I’m not talking about sleep deprivation, which is what ALL new parents experience in the first 3 months postpartum.  I’m not talking the lack of opportunity or time, either.  To be perfectly clear, a person with insomnia has difficulty falling asleep and/or difficulty staying asleep, even when the baby sleeps.  Insomnia is one of the most common symptoms of PPD. In fact, it has been shown that early severe fatigue predicts depressive symptoms at 1 month postpartum.  For me, insomnia was my very first symptom of PPD and I wholeheartedly believe that the constant sleep interruptions that started during my week-long stay in the hospital charted a course that was headed for PPD.

You need sleep to stay healthy and to be able to take care of your baby day in and day out.  I had it bad.  You’d think that sleep deprivation would cause exhaustion which would cause me to fall asleep readily and at first opportunity.  That couldn’t be further from the truth in my case.  I couldn’t fall asleep, even when the baby was sleeping.  I couldn’t nap during the day, even with someone taking care of the baby for a few hours.  When I told my doctor I couldn’t sleep at night, he instructed me not to take naps, to which I said “That’s not an issue because I can’t nap either…I can’t sleep at all.”

I encourage you to try one or more of the following to try to switch gears and condition your body out of this situation.  The key is to have the patience to stick it out for at least a couple of weeks.  I know with PPD it can be really hard to do, but please try your best.  Things don’t happen overnight.

1. If you can’t fall asleep within 30 minutes, stop trying to sleep.  The more I couldn’t fall asleep, the more I was unable to fall asleep.  This effect is referred to as conditioned insomnia where your mind doesn’t expect you to fall asleep, which in turn, keeps you from falling asleep. Lying there waiting to fall asleep but not succeeding will only eat at you and make you more and more frustrated.  It will do you no good.  The harder you try to sleep, the more anxiety you will experience, and that anxiety will keep you from falling sleep—a vicious cycle.  The key in those situations, it seems, is not to expect to fall asleep.  If you fall asleep, great.  Just relax and try to blank out your mind from any thoughts.  Sounds so easy, but is so hard to do.   So many people warned me that the last thing I should do is toss and turn in bed for more than half an hour at a time.  Instead, I should get out of bed and go into another room to watch TV or listen to some quiet music before trying to fall asleep again (this is to interrupt the conditioned insomnia).  Of course I didn’t heed their advice because I was stubborn.  In my mind, sleeping was the only thing I should be doing in the middle of the night.  Plus, I should be exhausted and able to fall asleep instantly.  But after 2 hours of tossing and turning, I was in a state of anguish beyond words.  Had I known at the time that PPD was behind this all, it never would’ve gotten this bad.
2. Avoid looking at the time.  Move your clock(s) out of the room, if necessary, as watching time go by will only serve to make you feel even more anxious about not being able to fall asleep.
3. Get a headphone noise canceller or white noise generator to use while getting your 5 hours of uninterrupted sleep.  This is, by the way, just if you have someone like your husband or relative staying with you and helping to care for the baby at night.  My husband had suggested getting me a headphone noise canceller or white noise generator in terms of helping me not to overreact to my daughter’s noises and his snoring (which I could hear even when he was in the den or living room downstairs).  I swear back then I could hear a pin drop, I was so attentive to every little sound that was made in the house!
4. Have your husband or whoever might be staying with you to give you a back/shoulder massage right before bed.  Ordinarily, a back/shoulder massage right before bed feels so good and is so relaxing, I would fall asleep immediately.  Needless to say, my husband’s massages when I was already sick with PPD didn’t help me one smidgeon.
5. Establish a bedtime ritual:  Much like trying to condition your baby to associate a bath, reading a book and/or humming a lullaby with going to bed, you should try to recondition your mind to associate drinking warm milk (if you’re not lactose intolerant) and eating something high in complex carbs that can promote drowsiness like bread, taking a hot soothing bubble bath or listening to relaxation music (the kind that would be played during a massage) with going to bed.  I never realized that the reason why so many people suggest warm milk to help you sleep is because it contains tryptophan, which increases serotonin, promoting sleep.
6. Avoid exercising within 2 hours of going to bed.  My doctor suggested exercise anytime during the day except for within 2 hours of your bedtime may burn off excess energy/reduce jitteriness and promote sleep.  I tried but couldn’t keep this up.
7. Avoid napping during the day.  My doctor suggested that I avoid napping during the day, as it may charge me up to the point and increase the likelihood that my body will feel less tired at the end of the day.
8. Do a wind-down routine.  My mother suggested I do a wind-down routine, similar as I would do for my daughter, every night before going to bed.  I should avoid exerting myself or watching stimulating television shows or read books that require too much thinking.  She gave me some information about Chinese relaxation techniques that have been used for centuries.  I tried that, but that night, I ended up having my first anxiety attack from failing to fall asleep after 3 hours of doing that relaxation exercise.  She also suggested I try breathing exercises and visualize positive things when I’m in bed, so as to facilitate sleep.  But try as I might, it was to no avail.  The harder I tried, the more I expected to be able to sleep, and the more agitated/panicked I felt that I would never fall asleep without medication for the rest of my life.  A friend told me that counting backwards in three’s helps her sleep.  I tried that too, but with no success.  It actually drove me crazier.
9. Reserve your bedroom for sleeping only.  There’s a reason behind the saying “Mothers know best.”  But nearly half the time, I dismiss my mother’s advice as “old wives’ tales.”  Well, when my mother advised me to reserve the bedroom for sleeping only and not do anything like read, watch TV or write in bed, I waved off her advice saying “Uh huh whatever you say, mom.”  Then, I read in “Postpartum Depression Demystified“ by Joyce Venis, RNC and Suzanne McCloskey (pg 41) that you should “Make your room your sleep sanctuary.  In other words, don’t watch TV, read, or play with your baby there.  Your bedroom should be only for sleep.” So, mom really does know best, after all.
10. Stay away from caffeine.  For me, caffeine wasn’t a factor, since I was totally caffeine free all of my pregnancy and continued to be caffeine free postpartum.
11. If within a week all the above suggestions fail–provided you don’t experience tremendous anxiety from not being able to fall asleep–then it’s time to see your doctor.  Don’t wait or you could you find yourself going down the same road I traveled—in other words, experiencing high anxiety and panic attacks from not being able to fall asleep.  Don’t wait.  You could go from bad to worse very quickly, and I wouldn’t want you to experience what I experienced (or worse).  Do see a doctor for an evaluation to help determine what is causing your insomnia.  Be honest about all your symptoms when talking to your doctor.  No question is a stupid question when you are a patient.  Doctors are paid to provide medical care, which includes consultation about your diagnosis and treatment.  Leaving out key details will only impede your recovery.  Also, do not let your doctor try to convince you that this is temporary and is experienced by all new mothers.  If you find that your doctor doesn’t know the difference between the blues and PPD, it’s time to find another doctor.  If you don’t know where to find a doctor that can help, reach out to your state PSI coordinator.

Additional Suggestions

Here are some of the things we did to help my daughter sleep through the night, which may be helpful to you:

1. If you are breastfeeding without any difficulties, you may want to consider having the baby sleep in your room in a co-sleeper so you can pull the baby into bed with you for nighttime feedings without ever having to get up.
2. If you aren’t breastfeeding, it would help to prepare bottles of pumped milk or formula in advance and have your husband take turns with you in terms of nighttime feedings.
3. By 3 months if you haven’t done so already, have the baby sleep in her crib in her own room so you will not constantly be disrupted, especially if the baby tends to make a lot of noise while sleeping.  My daughter started sleeping in her own room at 6 weeks because her noises kept us from sleeping during the night, which I know contributed toward my insomnia and PPD.  I had every intention of keeping her in our room through the 2^nd month.  Avoid setting this expectation, as it will only let you down harder if you are unable to follow through.  The fewer expectations you have and the more open-minded/flexible you are, the better off you will be.
4. Keep a clear distinction between night and day as bed time and awake time, respectively.  Keep the room completely dark and quiet at night and bright during the day, with constant noise and hustle and bustle of activity (even when the baby naps during the day).  Doing this consistently can contribute toward your baby’s sleeping through the night earlier.  Every baby is different, I realize.  Fortunately, our daughter was sleeping through the night within 2 months.
5. Establish a bedtime ritual for your baby, like reading a book or humming a lullaby so she associates bedtime with them.  My daughter used to hum and then drift off to sleep.  So she clearly associated humming with sleeping.  In fact, at four years old, I can still tell when she’s tired because she would all of a sudden start humming/singing to herself.
6. At 3 months, you may want to start trying to avoid immediately going to your baby when she cries during the night or as you put them to bed.  It’s tough to not immediately go to your baby when they cry.  A minute can feel like an eternity when you hear your baby crying.  At first, you may want to give it 5 minutes before going to her.  If you can’t last 5 minutes, try 3 minutes at first and work your way to 5 minutes.  And then over time, stretch the interval to 10-15 minutes before going into her room, calming her down and letting her cry another 10-15 minutes.  To calm her, you can try humming a lullaby or talking to her, avoiding picking her up, and then walking out of the room.  Repeat this until she falls asleep on her own.  Pick her up and comfort her (or feed her if necessary) only when all else fails.  Keep this up…it will work.

 We found that for 1-2 weeks at a time while she was teething, and even after she learned how to go back to sleep, she would wake up every night at around 2:30 AM crying.  She needed our comfort during that time to fall back asleep.  So we’d pick her up, hold her while sitting in the rocking chair, and sometimes hum her back to sleep.  After about 5-10 minutes, we’d put her back in her crib whether she was asleep or not.  At first, we feared she had regressed.  But it was only temporary.  You may find this will happen to your baby while they are sick, teething or have an ear infection.  A baby who is teething and/or has a fever and/or is not feeling well should be comforted immediately.

 By 4 months, in order to teach her to fall asleep in her crib while she is still awake, begin putting your baby to bed at night while she is still awake.  If your baby will only fall asleep if you rock, nurse and/or hum a lullaby, she will come to depend on being rocked, nursed and hummed to in order to fall asleep, so that when she wakes up in the middle of the night, she won’t know how to fall back asleep without your intervention.

Stay tuned for my next post that continues on this topic, specifically in relation to awareness of the importance of sleep and setting up a support network before you have your baby as being the key to prevention of insomnia (and PPD).