Insomnia sufferers should do something quiet at night until they're sleepyLately I’ve been hearing from people who improved their sleep using sleep restriction or full-blown CBT for insomnia (CBT-I) and then experience a relapse. They have a few bad nights and fear they’ll never sleep well again. Here’s how one reader recently described her plight:

 

 

I realize that sometimes I will get scared when I have one or two bad nights once in a while. I’m afraid that insomnia will haunt me once again. Is this normal? What can I do?

Normal or Abnormal?

When cognitive behavioral therapies for chronic insomnia work—and they do improve sleep for 70 to 80 percent of the insomniacs who try them—it can feel like such an achievement. “At last,” you think, “I’ve got this monkey off my back!”

In reality, though, only a minority of the people who undergo CBT-I report that their insomnia is “cured.” The rest of us experience occasional insomnia relapses.

As anyone who’s read The Savvy Insomniac knows, I went through CBT-I with a group of 4 other insomnia sufferers. At the final group meeting, the therapist gave us a handout on how to maintain the gains made during treatment and what to do in case of relapse. Not only are occasional relapses not abnormal; for many of us, they’re probably inevitable.

All Is Not Lost

The first relapse can feel like such a downer and provoke lots of anxiety. “What? I restricted my sleep only to end up right back where I started, and maybe even worse?” It’s easy to appraise the situation this way: you’re short on sleep, fatigued, and out of sorts. Everything about it feels depressingly déjà vu.

But all is not lost. What occurs during CBT-I is a process some scientists liken to a rewiring of the brain. Neural pathways related to new thoughts and behaviors are established as sleep becomes more regular and the bed and the bedroom come to be associated with sleep.

Older pathways active during insomnia do not disappear. Rather, the new pathways—to continue speaking figuratively—are superimposed on the old. With every good night of sleep, neural connections along the new pathways are strengthened. You expect to sleep well at night and you do.

The older pathways and ways of thinking are still there, though, and due to stress or anything else disruptive to sleep, they may regain some influence. Insomnia returns, and you’re as anxious about it as you ever were. But there’s good news, too: once the newer pathways are established, they’re easier to return to.

I’ll attest to this from personal experience. Before I went through CBT-I (and sleep restriction therapy), my bouts of insomnia could drag on for weeks. Now when I experience insomnia and (in rare cases) my fear of sleeplessness returns, I’m able to return to better sleep and dispense with the anxiety in a few days. I do it pretty much by following instructions I received during CBT-I. Here’s how:

What To Do in Case of Relapse

  • Don’t go to bed unless you’re sleepy. If after 15 to 20 minutes you’re not asleep, get up, go to another room, and do something quiet until you’re sleepy again. Then return to bed. If this doesn’t help after a few days, try the next suggestion.
  • Restrict your sleep by an hour or more for a few days. Be strict about getting out of bed at a consistent wake time—even on weekends.
  • Once your sleep is solid again, extend your time in bed by half-hour increments every 2 nights until you return to your desired bedtime.
  • Be sure to get daily aerobic exercise throughout the process.

If you’ve experienced a relapse of insomnia, please take a minute to share how you got your sleep back on track.

Posted by Lois Maharg, The Savvy Insomniac

Lois Maharg has worked with language for many years. She taught ESL, coauthored two textbooks, and then became a reporter, writing about health, education, government, Latino affairs, and food. Her lifelong struggle with insomnia and interest in investigative reporting motivated her to write a book, The Savvy Insomniac: A Personal Journey through Science to Better Sleep. She now freelances as an editor and copy writer at On the Mark Editing.

17 Comments

  1. I’ve recently had a relapse which lasted 11 nights. This wasn’t my first relapse, but probably the longest so far. It was caused by taking medication for 3 nights in a row when staying with friends (I invariably don’t sleep at all well when sleeping anywhere else other than at home).

    As I’ve been practising sleep restriction therapy for over a year now, I found I didn’t panic too much, although it was certainly very tiring and annoying. By night 12 I was back to sleeping my normal/average number hours with a qood overall quality sleep.

    I wonder does medication affect other people in this way, or is it just me?

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    1. Hi Lesley

      I often have the same problem as you. When sleeping away from home, I still take sleeping pills although I’ve gone through CBT, and often it takes a couple of days or more to get back on track when coming home again. In my case I believe it is due to me thinking automatically that I wont be able to sleep without the pills again, even though I know from great experience that I will. Knowing is one thing, while breaking a very old and bad habit of negative thinking is a whole other story. I really hope it will get better with time!

      BTW Thank you so much for this great blog Lois! It has helped me a lot while going throug CBT 🙂 I’m actually considering creating something similar in danish, as we do not have anything comparable i Denmark.

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      1. Hello Signe,

        Thanks for your apt description of the automatic thinking that can arise in conjunction with taking sleeping pills. These learned associations are very hard to break. You may have more success as time goes on.

        You’re welcome for the blog. It took a long time to get much notice on the web. But now I get quite a few visitors every day. Good luck with starting a similar blog in Danish! I’m sure insomniacs in Denmark would be grateful to have it.

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    2. Hi Lesley,

      It’s great that you can go through a bad spell lasting 11 nights without too much panic. There is probably a relationship between the length of time you’ve practiced scheduling your sleep and your ability to manage insomnia relapses. Thanks for calling attention to that.

      About medication, the older I get, the more I notice unpleasant side effects. I haven’t noticed that they prolong the occasional insomnia relapses that I have. But it’s certainly possible that they might—depending on the sleeping pill—and of course they could for the reason Signe mentions in her post.

      What I don’t like is the out-of-sorts feeling I sometimes experience the day after taking a sleeping pill. So I use them more sparingly now than ever. I’m still glad to have them, though, especially for nights away from home.

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  2. Harvard Medical School, and a number of others in the US and elsewhere, have reported that benzodiazapram Rx’s, frequently used for insomnia by MDs seeking a quick fix, if used in sufficiently high doses for a sufficient long time, can lead to early-onset Alzheimer’s and dementia for those 60 or above. I am 60 and tapering off Klonopin (now at 2.75mg/pm from 4.00mg/pm tapered over the past 3 months, but I am suffering from benzo insomnia rebound, which clients should be aware of). Get off gradually, but best, Don’t Start).

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    1. Hi Gerard,

      Yes, it is good to be reminded that many sleeping pills, especially in high doses and when taken nightly over time, can be harmful to health. Congratulations on your decision to taper off Klonopin, even in the face of the rebound insomnia you’re experiencing. I wish you success.

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  3. Hello Lois,

    And thank you very much for this post!
    Every year at the same time(between the end of April and the end of June..i don’t know why?), my sleep becomes very capricious…I don’t sleep when i go to bed…and, inexorably, i have to start again a new “sleep restriction”. Like you said, it feels “depressingly déjà vu”…I feel pretty jaded because it’s difficult !
    So i will respect your recommendations 😉

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    1. Hello Sheppard,

      I’m glad you’ve written in. Looking at reader comments, questions I’m asked, and blog post traffic, I see that—like you—many people start to experience insomnia with the approach of summer.

      Seeing this pattern repeat year after year, I’m pretty sure that for people who live in the northern hemisphere it must have to do with the days lengthening as they do at this time of year. Right now, we’re exposed to a lot more daylight in the evening than at other times of the year. Exposure to sunlight or any bright light can block secretion of melatonin and this might interfere with getting to sleep at your normal bedtime.

      So in addition to following the protocol I’ve suggested in this blog post, you might find that restricting your exposure to light in the evening helps. I’ve written some blog posts about this, which I’ll provide links to. But, in a nutshell, try these things: wear sunglasses if you spend time outside in the evening; lower shades and close curtains before it gets dark outside; keep inside lighting low in the run-up to bedtime.

      https://thesavvyinsomniac.com/cant-sleep-in-the-summer-heres-what-to-do/

      https://thesavvyinsomniac.com/q-a-how-to-beat-summertime-insomnia/

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  4. Thanks Lois.

    You’re right, I think my sleep problem is related to the light!

    When the days begin to lengthen, my insomnia reappear.It’s automatic!
    I very rarely wear sunglasses…so, I must change this habit.Now, I’ll wear sunglasses when I’ll get out of work.I will keep you informed.

    Have a nice day

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  5. Hi Lois,
    My insomnia started this spring with a lot of stress at work followed by a period of BPPV, which really scared me and disrupted my sleep completely. I started my sleep restriction therapy 3 weeks ago and it has been working out fairly well so far. My doctor gave me a “mild” version to follow, and now I’m sleeping on an average 6-7 hours. I still feel really anxious before going to sleep though, and I’m never sure what the night’s going to be like. About once or twice a week I can not sleep at all and feel like I’m lying awake all night (although I’m probably drowsing off a bit now and then). It takes so little to get me “off track”. A comment from my husband, the kids being too energetic, a bad thought… How long did it take you to start trusting your sleep after you went through sleep restriction therapy? Is it normal to still have these sleepless nights? How long did it take for you before you felt that these relapses came less often? It seems to me I will never go a week without a night of really bad sleep. Especially these nights seem to occur after a really good day, which makes me really depressed, since I can’t enjoy the good days. My doctor told me bad nights were to be expected in the beginning of SRT, but I would have expected them to wear off by now. I’m so frustrated and feel like I’m in a constant state of worry, almost unable to think about anything else.

    Thanks for a great blog!

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    1. Hi Anna,

      Congratulations on taking yourself in hand and daring to try sleep restriction to improve your sleep. It took me a decade before I was willing to try it—and then it was only because I was writing a book about insomnia and I felt I had to try literally every treatment on the planet!

      As to how long it took me to start trusting my sleep, I’ll begin by saying that because I was determined to do everything “by the book,” I started sleep restriction with a sleep window of just 4 hours and 45 minutes. Before starting treatment, I’d kept a sleep diary for 2 weeks and that, I found, was my average total sleep time for the night. (I document all this in Chapter 8 of my book, The Savvy Insomniac.)

      Because I had such a narrow sleep window, it wasn’t long before I felt my sleep starting to stabilize. By the end of 2 weeks, I was definitely hopeful that the process was going to work for me.

      But my progress wasn’t linear. Some nights were better than others, and once in a while (although less a less frequently) my old fear of sleeplessness would return. That was dismaying. It felt like I was back to square one.

      But I wasn’t. As long as I continued to follow the sleep restriction protocol, my sleep became more and more dependable. I began to trust that even on nights when I wasn’t falling asleep right away, sleep would eventually come. And most of the time—unless I was really stressed out about something—sleep DID come.

      But . . . the situation you describe, being unable to sleep after a really good day, suggests to me that perhaps your sleep window is a bit too large. Here are a couple of blog posts you might be interested in reading:

      https://thesavvyinsomniac.com/insomnia-finding-method-in-the-madness/

      https://thesavvyinsomniac.com/qa-start-sleep-restriction-right-for-best-results/

      If you want your sleep to start feeling more solid, and gain confidence that, when bedtime rolls around, you WILL sleep, my suggestion would be to tighten up your sleep window just a little bit more.

      Best of luck in continuing the process and coming to a place where your frustration and worry are the exception rather than the rule.

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  6. hi lois,
    I am going through a relapse at the moment. It’s been a week and my sleep is around 4.5-5 hours sleep a night, I saw a naturopath yesterday and was told to take Magnesium glycinate or Magnesium L-threonate 3 times a day after meals. Last night i slept 6 hours I am not sure if it’s the magnesium or the SRT that helped me last night. I am going to bed at 10pm and waking up at 4.30am at the moment. Do you think magnesium would really have any effect on sleep? Can I combine the Magnesium and SRT for good effect?

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    1. Hi Moe,

      I’m sorry to hear you’re going through a relapse. But it’s good you’re still looking for help.

      I briefly looked through the Pubmed database for studies about the effects of magnesium on insomnia. There are a few whose results look somewhat promising. Here’s the URL for the most recent study I found, conducted on older adults with insomnia:

      http://www.ncbi.nlm.nih.gov/pubmed/23853635

      Magnesium is important to many bodily functions and might help your sleep. But as with so many supplements, it could take a while—as in weeks—to start noticing any gains. One good thing is that magnesium supplements are unlikely to have any adverse effects.

      If I were you I’d take the advice of this naturopath and see if the magnesium supplements help.

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  7. Thanks for your advise lois. I had all the magnesium deficiency symptoms and the naturopath diagnosed me with magnesium deficiency (muscle spasms/cramps/ eye twitching, insomnia, anxiety/ depression, hair losss and acid reflux to mention a few. But i never knew these were caused by magnesium deficiency

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  8. Hi Lois
    Im doing SRT at the moment, after keeping a sleep log for 2 weeks my average is 4.5 hours a night. Whats really frustrating is i always wake up between 2-3am. And not being able to go back to sleep. My sleep window is from 10.30pm-4.30am. Can you please tell me why am i always waking up around 3am? Is there anything i can do to get my sleep to normalise?

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    1. Hello Moe,

      We’ve been back and forth about this several times now. I’m sorry you’re still not getting the sleep you feel you need. I’d like to be able to make a helpful suggestion. But you’ve tried the things I’ve suggested and apparently they haven’t worked out. I’m not a doctor, so I’m simply not qualified to take our discussion any further.

      You need to consult a sleep specialist with years of clinical experience and a commitment to helping people with insomnia that isn’t responsive to commonly prescribed treatments.

      That said, if you’re continuing to wake up as early as 2 or 3 every morning, I’m wondering if your sleep problem isn’t somehow tied to depression. Insomnia and depression are closely related, and waking up too early is the type of insomnia people with depression often have. This could be something to pursue with a doctor if you haven’t pursued it already.

      Anyway, I wish you luck in finding the help you need.

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  9. Thanks for the quick reply lois. I have made my sleep window 5 hours and my slerp seems to be a bit better. On the 1st night i woke up aound 3.45am and last night I woke up around 4.00am, then i was falling asleep again but the alarm went off at 4.30am. I will try to see if the 5 hour sleep window is going to help

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