Last night Wichita State University fell to top-seeded Louisville in a valiantly fought Final Four semi-final NCAA men’s basketball tournament game in Atlanta.  As my blog followers know, I’m a Kansas Jayhawk first and foremost, but I grew up in Wichita and have strong ties to WSU.  My heart aches for the Wichita State Shockers, as it did last week when Kansas lost to Michigan.

Intermediate- to low-seeded teams are a rarity in the Final Four, and ninth-seeded WSU truly exceeded the expectations of many.  Few anticipated the Shockers to make it much past the second or third round of the tournament.  But as Wichita State continued to shock the nation with win after high-profile win, something beautiful started to germinate and grow in my native Wheat Country:  hope, hope that those wins will continue, all the way up to the end.  Could it be that this young mid-major squad, whose name sportscasters and game announcers can’t even pronounce properly (“Wishlata?”  “Stalkers?”  Seriously???), might possibly wrestle the national title from the vaunted blue bloods of college basketball?

The Merriam-Webster definition of hope:  “desire accompanied by expectation of or belief in fulfillment.”

Though the championship is now not to be this year for Wichita State, Shocker fans did not lose much by daring to hope.  Hope implies a transition from non-expectation to expectation.  Hope is also rooted in reality, arising from a personal interpretation of what is experienced, such as upsetting the top-seeded team in your tournament region.  Despite the inevitably profound disappointment when your team loses after having battled to within an arm’s length of the national title, there still lingers the warm feeling of what has been achieved, against all odds, and what therefore can be further achieved in the future.  The new expectation then morphs into a different belief system, and it is this new set of beliefs that generates optimism, a hopeful confidence that continues to build and grow as the years go by.

Nowhere in the realm of sleep medicine is one’s individual system of belief more important–and more responsible for great success or abject failure–than in the management of insomnia.  If you’ve had difficulties falling and staying asleep in your bed for years, you can gradually become conditioned to not sleep well there.  There is no longer the expectation that you will sleep well there due to years of experience to the contrary, so you begin to feeling you’re losing hope that you’ll sleep well again.

Therein lies the cognitive paradox pertaining to insomnia.  We all know that sleep is a necessary and required biological function, and that sleep must be achieved eventually and inevitably, because we must sleep no matter how bad our insomnia; as such, logically there is every reason to expect to sleep, every reason to hope.  However, previous experience sleeping badly enforces the idea that we won’t be able to sleep reliably well again, and this misconception is reinforced every time we try unsucessfully to achieve asleep–such as by counting sheep, listening to relaxation tapes, or what have you–and the resulting fear and frustration keep the hope from surfacing.

In a clinical scenario, a longstanding insomnia patient may respond to the physician’s suggestion, for example, with the knee-jerk exclamation, “But I’ve already tried that!”  I’ve heard that response once or twice in my career, sometimes loudly, even angrily.  But the thought process that generates that frustrated claim can be self-defeating.  First of all, by the time insomniacs feel compelled to visit me in my clinic, they’ve usually already been through a variety of physician-recommended or self-employed treatments or management programs.  Second, by the time they make it through my doors they usually have developed multiple specific reasons to have the insomnia.  Third, whatever was tried earlier probably wasn’t tried in the same context of what is being suggested now.  Finally, often what is “tried” in the first place is tried with the additional burden of performance anxiety:  that feeling of “this had better work,” which only compounds the frustration when what is tried doesn’t result in the achievement of sleep.  Despite all of this, however, hope exists:  were it not for hope, these folks would never have bothered to make an appointment.

My job in this situation is that of both doctor and coach.  Hope is based on reality and fueled by knowledge.  Therefore, for my chronic insomnia patients, the first thing I do after collecting a history and performing a physical examination is sit and discuss at length why I think the insomnia is happening.  I make a list and outline all the probable reasons why the problem has started and continued.  I’ve found this helps them understand the reasons why subsequent recommendations are made, and why I believe that real improvements can actually be achieved, no matter how stubborn or prolonged the insomnia has been.

I believe that even the most hardcore insomniacs can use hope to their advantage.  I suggest that insomniacs choosing to visit a sleep specialist go in with an open mind, a willingness to absorb thoughtfully made recommendations and employ them with an expectation that they may well be helpful, though not necessarily immediately.  It’s hope that brings them to the clinic in the first place, so I recommend making the most of what they already have in them and allow themselves the willingness to believe that the sleep can get better.  If doctor and patient listen to each other openly, it just might.