Resolving your patients’ sleep complaints is good. Teaching them to use sleep to flourish is even better.
The Gardens of Versailles are among the most beautiful in all of Europe. Impeccably maintained, there is rarely a leaf out of place or a weed to be found. But after visiting the gardens, one mostly remembers the flowers, shrubs, trees, ponds, and statues. Weeding is not enough to grow a beautiful garden.
In much the same way, alleviating symptoms is not enough to maximize sleep-related quality of life. Because of the 24-hour nature of our field, sleep specialists have the opportunity not only to alleviate negative symptoms (such as reducing the apnea-hypopnea index) but also to increase positive experiences and dramatically enhance quality of life in our patients.
Positive psychology is the domain of psychology that focuses on helping individuals develop and maintain sustainable well-being. From a positive psychology perspective, characteristics of this “good life” include positive emotion, engagement, relationships, meaning, achievement, and more.1 In other areas of medicine, positive psychology interventions have demonstrated promising, if preliminary, results.
Unfortunately, with the notable exception of mindfulness training, sleep scientists have only begun to explore the beneficial effects of positive psychology interventions on sleep outcomes. A correlational study found the trait gratitude to be associated with self-reported sleep quality.2 Although the study design precluded causal inference, gratitude was found to enhance sleep quality via changes in pre-sleep cognitions. Despite the lag in clinical research exploring positive psychology and sleep, behavioral sleep specialists have had success incorporating positive psychology interventions into routine sleep medicine care for decades. Not only are these interventions highly patient-centered and very low risk, but clinical experience also suggests they improve sleep-related quality of life.
For the patient-centered sleep clinician, the emerging science of positive psychology provides helpful insights and useful tools to improve sleep patient care. This article will introduce this fascinating subject and provide 3 practical interventions that you can start using today.
Sleep Loss Impairs Formation of Positive Memories—But Not Negative Ones
One of the earliest experiments exploring sleep and positive affect was conducted at Harvard College.3 In this study, healthy undergraduates were randomized to 36 hours of self-administered sleep deprivation or 2 nights of normal sleep prior to a memory encoding session. During the memory exercise, participants were asked to memorize a list of words that surreptitiously included positive, negative, and neutral words. Following 2 nights of subsequent sleep, participants returned for an unexpected recognition task. Impressively, the sleep-deprived group recalled 40% fewer words compared to the normal sleep controls. Even more striking, the sleep-deprived group recalled 59% fewer positive words than controls, which accounted for most of the overall differences between groups. Conversely, the difference between groups in recall of negative words was not statistically significant.
In other words, not getting enough sleep diminished students’ ability to recall the positive, but the ability to recall the negative was sustained.3 Perhaps it is no wonder that irritability or rumination seems worse after a poor night’s sleep. Sleep-deprived brains are unable to recall what is good but appear well able to retain what is bad.
Decreased Slow Wave Sleep Reduces Positive Affect
More recently, sleep researchers at Johns Hopkins University School of Medicine have conducted an impressive and tightly controlled laboratory experiment to examine the impact of sleep disruption on the positive affect system.4 Among healthy volunteers and compared to both sleep deprivation and normal sleep controls, experimental sleep fragmentation resulted in decreased slow wave N3 sleep after night one and diminished positive affect after night two. Further, decreases in slow wave sleep were found to mediate between-group differences in positive affect.4 These results suggest that sleep fragmentation (that is, an experimental model of simulated insomnia), above and beyond sleep loss, results in diminished positive affect, and that slow wave sleep is a key physiologic mechanism.
3 Interventions to Increase Positive Affect
In my own practice, I routinely employ behavioral activation, mindfulness, and gratitude, as well as other positive psychology interventions, regardless of presenting complaint (see Table). The reason for this approach, which I call “Positive Sleep,” is my unwavering focus on quality of life as a key patient-centered outcome. (For more on maximizing quality of life, see my article “How to Provide Better Patient Care via Powerful Listening.”5) Positive psychology and behavioral skills are highly transferrable and, in my experience, directly related to patient satisfaction, long-term adherence, and enhanced quality of life. Indeed, sleep medicine and other trainees regularly report that learning a strengths-based, positive psychology approach to patient care made a dramatic impact on their approach to treating sleep disorders.
Summary and What to Do Next
This is an exciting time to practice sleep medicine—the need for our services has never been greater. But the sleep medicine landscape is changing. Multiple stakeholders including patients, providers, and regulatory agencies are increasingly interested in improved quality of life as a core, measurable outcome.
To achieve lofty results, weeding is not enough. You also must plant flowers to grow a beautiful garden. To improve quality of life in your patients, build on their strengths and focus on positive affect. You will be amazed with the results.
Emerson M. Wickwire, PhD, is director of the Insomnia Program and associate professor of Psychiatry and Medicine at the University of Maryland School of Medicine.
1. Seligman MEP. Flourish: A Visionary New Understanding of Happiness and Well-being. New York: Simon and Schuster; 2011.
2. Wood AM, Joseph S, Lloyd J, Atkins S. Gratitude influences sleep through the mechanism of pre-sleep cognitions. J Psychosom Res. 2009;66(1):43-8.
3. Walker MP, Stickgold R. Sleep, memory, and plasticity. Annu Rev Psychol. 2006;57:139-66.
4. Finan PH, Quartana PJ, Smith MT. The effects of sleep continuity disruption on positive mood and sleep architecture in healthy adults. Sleep. 2015;38(11):1735-42.
5. Wickwire EM. How to provide better patient care via powerful listening. Sleep Review. 2016;17(7):28-29.