For most of life's pursuits, the harder we work, the better we do. Sleep is an exception. "With sleep, the harder we try, the worse we do," says Duke University sleep psychologist Jack Edinger, PhD. "Good sleepers just go to bed. They don't get worked up about it, and sleep happens."
It sounds easy, says Edinger, but for the roughly 64 million insomniacs in the United States, pursuing 40 winks can be an anxiety-provoking, seemingly impossible task. According to Edinger, a psychologist who specializes in behavioral sleep medicine at Duke's Sleep Disorders Center, chronic insomnia patients tend to chase sleep by running in the opposite direction. They'll nap or sleep late on weekends to catch up—two habits that disrupt sleep routines—create pre-bed rituals that ramp up sleep anxiety, or fret about how their sleep debt will wreck the next day.
Using cognitive behavioral therapy (CBT) and other behavioral interventions, Edinger helps these patients quash such anxieties and regain their ability to sleep.
Experts in behavioral sleep medicine consider Edinger one of the field's most accomplished practitioners and prolific researchers, particularly on the assessment and treatment of insomnia.
"There's no one who is his peer in this area," says Richard R. Bootzin, PhD, a sleep psychologist at the University of Arizona.
Edinger sees between 100 and 200 patients each year at the Duke center, where he has been a faculty member in the department of psychiatry since 1980. Around 75 percent of his patients have chronic insomnia, and their treatment often begins with a night in the center's eight-bed sleep lab where physicians monitor how well and frequently they sleep.
His CBT sessions center on helping patients understand how much sleep they need—many of us actually need more or less than the eight hours most believe to be the gold standard. The goal is to make bedtime a mindless, stress-free activity. That means eliminating naps and other bad habits, such as consuming alcohol or tackling stressful work before bed, and setting regular bed and wake times. He also helps clients pinpoint habits that calm them before bed, such as watching low-stress, easy-to-switch-off television.
Edinger also sees patients with sleep apnea, a condition that increases risk for stroke, diabetes and other serious health problems. He helps them adjust to the CPAP (continuous positive airway pressure) device they must wear to bed. The machine, a blower unit connected by tubing to a nasal mask, can trigger panic and anxiety in patients, especially those with claustrophobia.
To help patients cope with the mask, he has them get used to it by first holding it to their faces for short periods, then taking naps with it on. Gradually, they can manage a full night's sleep.
Such behavioral interventions are an essential part of sleep treatment, says Duke psychiatrist Andrew D. Krystal, MD, who has worked with Edinger for 20 years.
And Edinger has a knack for helping patients who don't believe simply altering their routines can deliver the rest they need, Krystal adds. He's watched Edinger and his trainees tease great sleep out of challenging patients, including a therapy-resistant woman he recently sent to a one of Edinger's protégés. The patient came back to Krystal relieved and well rested.
"The light just completely went on for her," says Krystal.
Edinger's knack for sharing the secrets of good sleep may be due to the fact that he faithfully follows his own advice: He beds down at 8:30 p.m. each night and wakes at 4:30 a.m.
He needs the rest to fuel his busy, 60-hour workweeks. In addition to working at one of the nation's most respected sleep centers, Edinger is also the senior psychologist at the nearby Durham VA Medical Center, where he mostly sees veterans with trauma-related sleep problems, such as chronic nightmares.
Like insomniacs, veterans also work hard to sidestep their sleep troubles, Edinger says. Some try napping in the afternoon—when one is least likely to dream or have nightmares—which only results in later sleep loss, or they refuse to discuss their dreams in therapy. Many also have the wrong ideas about sleep: In this case, they believe their dreams are out of their hands, when they actually can be shaped, Edinger says.
"Dreams are learned phenomena," he says. "They are influenced by daytime behaviors and subject to manipulation."
Using a technique called imagery rehearsal therapy developed by sleep disorders specialist Barry Krakow, MD, Edinger has patients write the "script" of their recurring nightmares, then edit the story however they want. Once they've drafted new scripts, they rehearse them with Edinger at each session.
Over several months, the daytime script replaces or transforms the nightmare, Edinger says. He and his interns have seen dramatic improvement in the patients they've treated with the technique: One felt so confident he'd chased off his nightmares that he told Edinger they could follow up in one year.
"A year turned out to be one month after Sept. 11," says Edinger, a day that hit many veterans with post-traumatic stress disorder or combat-related nightmares particularly hard. "I was biting my nails wondering whether he'd fallen apart, and he was doing just fine. That drove home to me that this is a really powerful and effective treatment."
More rest for the weary?
Edinger's clinical work on nightmares and behavioral insomnia treatment has generated research in these areas as well, including studies on how home-and lab-based sleep measures for insomnia differ—lab measures aren't always as effective as one might think because some insomniacs sleep better without the distractions of their normal environment. Edinger is now working with researchers from Stanford and the University of Pittsburgh to find treatments for insomnia when it's paired with depression. While antidepressants often provide relief from depressive symptoms, studies show that insomnia usually remains, which only increases a patient's risk for depression relapse and suicide, Edinger says.
What he knows about sleep is also guiding him into a related area: fatigue. As part of a larger study on fibromyalgia patients, he's looking at whether CBT might lessen weariness in patients with the complex, controversial disorder.
It's the type of work Edinger does best, and that illustrates why he has consistently propelled sleep practice and research forward, says Allison Harvey, PhD, who runs the sleep center at the University of California, Berkeley.
"Jack takes on big questions and difficult questions," she says. "He doesn't try or need to have a clean picture."