Sleep Restriction: New Thoughts on How It Works

Sleep restriction therapy helped me a lot. In fact, even without the other insomnia treatments usually offered with it, sleep restriction alone (enhanced by daily exercise) would probably have turned my chronic insomnia around.

Sleep researchers at Oxford recently proposed a new model of how the therapy works. If you haven’t yet tried sleep restriction, here’s why you’ll want to check it out.

Sleep restriction therapy involves postponing bedtime

Sleep restriction therapy helped me a lot. In fact, even without the other insomnia treatments usually offered with it, sleep restriction alone (enhanced by daily exercise) would probably have turned my chronic insomnia around.

Sleep researchers at Oxford recently proposed a new model of how the therapy works. If you haven’t yet tried sleep restriction, here’s why you’ll want to check it out.

Benefits of Sleep Restriction Therapy

Why would a person with insomnia even consider undergoing sleep restriction therapy (SRT), when what we want is to get more sleep and not less? Well, consider first the benefits. After 4 to 6 weeks of SRT, people typically

  • spend considerably less time in bed awake (a boon to sleep onset and sleep maintenance insomniacs alike)
  • fall asleep about a half hour sooner (particularly helpful for sleep onset insomniacs)

A few studies suggest that by the end of treatment, sleep timing is less variable than before treatment began. Total sleep time may be slightly longer, especially in the young and middle-aged.

If these benefits pale compared with what we really want (one to two hours more sleep, thank you very much!), consider next this new theory of how SRT works.

The Triple-R Model of Sleep Restriction Therapy

Chronic insomnia develops from a mix of physiological, psychological, and behavioral factors, and SRT, the Oxford researchers say, influences all of these factors at once. In effect, SRT walks us back to a time when sleep was less of a problem by doing three main things. It

  1. Restricts time spent awake in bed
  2. Regularizes the timing of sleep and wake
  3. Reconditions the association between bedroom factors and sleep

All together, the Triple-R process produces physiological and cognitive-behavioral alterations which in turn lead to better, healthier sleep.

This new model of SRT is theoretical, describing mechanisms the authors would like to see put to the test. It caught my attention because it pretty well describes what I saw happening when I went through SRT.

Restricting Time in Bed

The concept of restricting time in bed is foreign to many of us with insomnia. To get more sleep, it’s reasonable to think we need to spend more time in bed.

But the minute we find ourselves lying awake in bed for any length of time, we’re on a slippery slope. Lying awake in the darkness, our stamina low and our defenses down, we’re probably not fantasizing about a trip to Hawaii. We’re worrying instead about car payments or a mortgage, we’re obsessing over the latest political crisis. We’re anxious about sleeplessness itself and how it’s going to drag us down the next day.

Thoughts like these trigger physiological arousal—the heart beats faster, the body gets warmer—in turn feeding the mental anxiety, in turn arousing the body still more. Several nights like this can condition bodies and brains to associate the bed not with sleep but rather with wakefulness.

Then we’re cooked: Learned associations like this are hard to unlearn. I tried and failed for over 20 years.

Restricting Time Awake

When I considered sleep restriction, I assumed it would curtail the amount of time I slept. Some curtailment of sleep did occur during the first week of therapy, and that was rough.

But this early stage of SRT didn’t last long. Later the first week, the pressure to sleep increased to a point where by my prescribed bedtime I was falling asleep the minute my head touched the pillow and sleeping right through the night. With improved sleep efficiency, the sleep restriction protocol allowed me to increase my time in bed. So that by the end of therapy what I’d done was not decrease my total sleep time (in fact, I gained about half an hour) but rather decreased my time awake in bed.

What’s not to like about that?

Regularizing the Timing of Sleep and Wake

Regularity may sound boring but looking back, I think my insomnia was one of many signs my body actually craved it. And SRT delivered on that score. Starting from the first week of treatment I had to adhere to the same sleep schedule for one entire week. I made small adjustments on a weekly basis only, according to the protocol, adding time in bed as my sleep became more robust.

Why was regularity so important? Sleep and wake are controlled by two internal forces, the circadian pacemaker (the body clock) and the homeostatic pressure to sleep. Together, they dictate when we feel sleepy and when we feel alert. An erratic sleep schedule will tend to push these forces out of alignment, setting up the conditions for persistent insomnia.

A regular sleep schedule helps these forces remain in sync, in turn promoting better sleep. In myself, what I’ve observed is that regularity in almost everything I experience on a daily basis, including meals, exercise, light exposure, and even socializing, seems to benefit my sleep.

Reconditioning Myself for Sleep

Once sleep became more predictable, and once I was mainly sleeping when I was in bed (rather than lying in bed awake), my anxieties about sleep began to fade. Fear of sleeplessness wasn’t so quick to ambush me en route to the bedroom or when I glimpsed the clock at 2 a.m.

This last step in process — replacing my expectation that I’d be wakeful in bed with the expectation that I would sleep — came about gradually. During a couple of insomnia flare-ups, I needed to restrict my sleep again to keep my recovery on course.

But by the end of the first year post-SRT, my anxieties about sleep were pretty much a thing of the past. And that is truer now than it was 10 years ago. I’ve stuck with the habits I developed in SRT, and my sleep is much more robust as a result.

SRT is not a magic bullet, but by my lights it’s the most effective insomnia treatment available today. Anyone with chronic insomnia will want to check it out.

Anxiety About Sleep: Could Herbal Medicines Help?

“I have 5 years of anxiety about not being able to sleep to overcome,” began a query I received a month ago. “Once triggered, it is difficult to stop this downward spiral and sleep.”

Without a doubt, anxiety about sleep is one of the hardest aspects of insomnia to beat. Cognitive behavioral therapy for insomnia can help to reduce sleep-related anxiety, as can other adjunctive therapies. But here’s an alternative treatment that might lead to calmer nights: plant-based medicines found to be effective for anxiety.

Insomnia-driven sleep anxiety & herbal medicines“I have 5 years of anxiety about not being able to sleep to overcome,” began a query I received a month ago. “Once triggered, it is difficult to stop this downward spiral and sleep.”

Without a doubt, anxiety about sleep is one of the hardest aspects of insomnia to beat. Cognitive behavioral therapy for insomnia can help to reduce sleep-related anxiety, as can other adjunctive therapies. But here’s an alternative treatment that might lead to calmer nights: plant-based medicines found to be effective for anxiety.

Anxiety About Sleep: How It Develops

Anxiety about sleep is learned, and the learning is largely unconscious. The anxiety may develop during a stressful situation when you’re having trouble with sleep. You might be in a tight spot at work or in the midst of a contentious divorce. You might be worried about a new breast lump or how to make ends meet for the next 6 months.

Whatever the stress, it keeps you up at night and soon it extends to worry about sleep itself. What happens if you can’t get enough sleep? What if you’re too sleep deprived to meet the next work deadline? What negative effects will insomnia have on your long-term health?

Once anxiety becomes focused on sleep, it’s hard to root out. The triggers may remain unknown: a darkening sky, evening birdsong, the bed itself. A simple glance at the clock can set off alarms in your head. (“It’s already midnight and I’m still too wired to sleep!”) And feelings of anxiety — muscle tension, a rapid heartbeat, bodily warmth and perspiration — can sabotage sleep. If night after night this pattern is reinforced, no wonder it’s hard to break.

Herbal Remedies for Anxiety

Anxiety about sleep is situational, and therapies shown in clinical trials to lower sleep-related anxiety — cognitive behavioral therapy for insomnia (CBT-I), yoga, and mindful stress reduction — are probably the most reliable paths to relief. Exercise has stress-reducing effects as well. But GABA is the neurotransmitter most prominently associated with calming the brain, and plant-based medicines that act on the GABA system may be helpful, too.

A team of Australian researchers recently conducted a systematic review of plant-based medicines for anxiety including both clinical (human) and preclinical (in vitro and animal) studies. Following are herbal medicines the evidence shows are mostly likely to have anxiety-reducing effects.

Kava (Piper methysticum)

Kava, native to the South Pacific, is the hands-down winner when it comes to the amount of evidence amassed in support of its effectiveness as an herbal remedy for anxiety. “The number of positive findings from human studies of P. methysticum within randomised, well-controlled trials . . . supports its use as a treatment for various anxiety disorders and associated symptoms, demonstrating broad clinical utility,” the authors write.

The main active ingredients in kava are called kavalactones. Kava supplements contain specific concentrations of these kava extracts and are available in tablet form or as a tincture. See my earlier blog post for an in-depth treatment of kava’s effects on anxiety and sleep and possible adverse effects.

Valerian (Valeriana officinalis)

Valerian, native mainly to Europe, looks like the next most-promising herbal with anxiety-reducing properties. The root extract has been used as a sedative and anti-anxiety medicine for millennia. Tests on human subjects have found that valerian is particularly effective at reducing subjective feelings of anxiety that arise in stressful situations.

Two human studies suggest that valerian doesn’t negatively impact psychomotor and cognitive performance the way the benzodiazepines (medications often prescribed to reduce anxiety) tend to do. So regarding safety, valerian has a relatively clean bill of health.

Passion flower (Passiflora incarnata)

Passion flower, native to the Americas, has been used for millennia as an herbal remedy for anxiety and trouble sleeping. Investigators in 4 clinical trials studied its anxiety-reducing effects in patients who were about to undergo surgery. Results showed that passion flower significantly reduced anxiety in comparison with placebo. In fact, its effects were similar to those of anti-anxiety benzodiazepine medications, including, in one of the studies, reductions in blood pressure and heart rate.

Two more studies involving use of passion flower in people with anxiety disorders showed the herb’s anti-anxiety effects were similar to those produced by benzodiazepines.

Ashwagandha (Withania somnifera)

Ashwagandha, traditionally used in Indian Ayurvedic medicine, is a plant in the nightshade family. (It’s sometimes called Indian ginseng.) Ashwagandha powder, prepared from the root, leaves, or whole plant and taken orally, has been prescribed to reduce anxiety and improve sleep for centuries. Today it’s available as a dietary supplement in powder, capsule, and tablet forms.

In 5 clinical trials, ashwagandha was found to have at least one significant anti-anxiety, anti-stress benefit compared with control conditions. Another very recent clinical trial involving participants with chronic stress compared the use of 600 mg of ashwagandha extract daily to placebo capsules taken over 8 weeks. Significantly greater stress reduction occurred with the extract, as did decreases in salivary cortisol (a biomarker of stress and anxiety). See my earlier blog post for more information on ashwagandha’s effects on stress, anxiety, and sleep.

Chamomile (Matricaria recutita)

Chamomile, a flowering plant in the daisy family, is plentiful throughout Europe and Asia. It’s been used for millennia, mainly as a tea, for its calming and sedative effects. In an 8-week clinical trial in patients with generalized anxiety disorder (GAD), participants taking 220 mg of chamomile 1 to 4 times daily showed significantly greater reductions in anxiety than controls. In another 8-week study involving patients with GAD taking a 500-mg capsule of chamomile 3 times a day, 58% of the participants showed significant reductions in anxiety.

In a strange twist, a study of the effects of chamomile in 34 patients with insomnia found that chamomile was effective at improving sleep and daytime stamina but did not reduce symptoms of anxiety.

Final Caveat

If you plan to try herbal medicine as an alternative treatment for anxiety about sleep, consult a naturopath or other health professional about the correct dose. At least do some research yourself.

And don’t expect momentary relief. Herbal medicines, said Jerome Sarris, an author of the Australian review paper whom I also interviewed for The Savvy Insomniac, “generally take longer to work, whereas some people just want that quick fix. I think they may have more of a role in long-term assistance.” So use herbal medicines as indicated and wait at least a few weeks to start looking for results.

New Technology May Help Insomniacs Sleep

I don’t often write about technology developed to improve sleep. I’m frankly skeptical that most products could help me any more than the daily exercise I do and the habits I changed after going through CBT for insomnia.

But a few items have caught my attention recently because they sound like they have genuine potential to help—two I’ve blogged about before and one brand new. See if you agree.

Trouble sleeping alleviated with new devices and an appI don’t often write about technology developed to improve sleep. I’m frankly skeptical that most products (e.g., sleep trackers) could help me any more than the daily exercise I do and the habits I changed after going through CBT for insomnia.

But a few items have caught my attention recently because they sound like they have genuine potential to help—two I’ve blogged about before and one brand new. See if you agree.

High-Tech Earplugs

QuietOn Sleep earplugs were designed specifically to block out noises such as snoring and the droning of plane engines.

Earplugs—these or any others—may not interest you if you’re a homebody and/or you share a bed with a quiet sleeper. But if your sleep is often disturbed by a snoring partner or unpleasant, droning noises, these earplugs could be a real boon.

How They Work

QuietOn earplugs contain a microphone that continually samples sound in the environment. They then create a phase-shifted sound that’s played through a speaker, cancelling the exterior noise out. The earplugs are battery powered and come with a carrying case that functions as a charger.

You might not imagine all this technology could fit inside a gadget so small. Apparently, it does. Twenty-one of these earplugs can fit on a single credit card. Encased in soft material, they fit inside the ear canal, neither big enough to hurt you nor small enough to pop out.

The one downside is the price. While limited numbers are available via an Indiegogo campaign at $149 a pair (2 pairs for $199), the full price after product launch will be $239.

A Brain-Calming Headband

At last Ebb Therapeutics has come out with its novel insomnia therapy device, a headband that cools—and so calms—busy brains at night. Here’s why it might improve your sleep.

The brains of normal sleepers are quiet during sleep but insomniac brains are not. In neuroimaging studies, scientists have found evidence of excessive metabolic activity occurring in our brains at night. Some of it occurs in the frontal cortex, located behind the forehead. By cooling the forehead, Ebb Insomnia Therapy reduces activity in the front part of the brain and in turn makes it easier to fall asleep.

How It Works

The headband has a special pad that rests against the forehead. This pad is continuously supplied with cooling fluid via a tube connecting the headband to a temperature regulator that sits on your bedside table.

The circulating fluid eventually evaporates and, after about three months, the temperature regulator alerts you to the fact that the fluid cartridge needs to be replaced. The replacement kit contains a forehead pad and a fluid cartridge.

How and Where to Get One

You need a prescription to get one; they’re not sold over the counter. However, Ebb Therapeutics, planning to market the devices widely, says they’re now available at sleep centers in these cities:

  • Atlanta, GA
  • Clayton, NC
  • Fargo, ND
  • Newark, DE
  • Pittsburgh, PA
  • Raleigh, NC
  • Rehobeth Beach, DE
  • St. Louis, MO
  • St. Petersburg, FL
  • Wilmington, DE
  • Wilson, NC

For a review of how this device may improve sleep and the tests that went into its development, see my earlier post on Ebb Insomnia Therapy. Contact the company directly to find out how much the device (and replacement kit) costs.

A Sleep Training Smartphone App

You might not think sleep could improve with training. Michael Schwartz thinks otherwise, based on years of work as a sleep technologist and sleep educator. He’s developed an inexpensive smartphone app called Sleep On Cue that can help people fall asleep and fall back to sleep more quickly.

The idea behind the app is this: Chronic insomnia often gives rise to anxiety about sleep, lack of confidence in sleep ability, negative beliefs about sleep, and increased brain activity at night. So it’s easy to lose touch with the feeling of falling asleep. The app essentially retrains you to recognize what falling asleep feels like, alleviating anxiety about sleep and restoring your confidence in your sleep ability.

How the App Works

You conduct your sleep training sessions late in the afternoon or early in the evening after a poor night’s sleep. Lie in bed holding your smartphone. Via a simple call-and-response procedure involving soft tones and movement, the app detects when you’re falling asleep (although you may not).

To the question “Do you think you fell asleep?” you press “yes” or “no.” Then, you leave the bed a few minutes, awaiting the next sleep trial. When you decide to end your session, your phone displays a graph with feedback about your sleep ability and your awareness of your sleep. Gradually you get better at recognizing the feeling of falling asleep.

For details about the procedure and the testing behind it, see my earlier post about Sleep On Cue or go directly to the product website.

Sleep (Re)Training for Insomnia

What does falling asleep feel like? Good sleepers may never bother with the question. One minute they’re conscious and the next minute they’re out. But if you have chronic insomnia, falling asleep (or back to sleep) can feel like a tiresome slog.

Insomnia sufferers may actually lose touch with the feeling of falling asleep. So Sleep Technologist Michael Schwartz created a smartphone app to put people back in touch and increase their confidence and ease in falling asleep.

Insomnia sufferers relearn the feeling of falling asleepWhat does falling asleep feel like? Good sleepers may never bother with the question. One minute they’re conscious and the next minute they’re out. But if you have chronic insomnia, falling asleep (or back to sleep) can feel like a tiresome slog.

Insomnia sufferers may actually lose touch with the feeling of falling asleep, some have claimed. So Sleep Technologist Michael Schwartz created a smartphone app to put people back in touch and increase their confidence and ease in falling asleep.

Racing Thoughts and Brain Activity at Night

An independent study has found the smartphone app, called Sleep On Cue, to be accurate at detecting the start, or onset, of sleep. But let’s step back, for a moment, and imagine a typical insomniac night.

It’s after midnight and you’re obsessing about your deadlines tomorrow. Or you’re thinking about how to fight your way out from under all your student loans. The next thing you know the clock on your bedside table says it’s 2 a.m. In desperation, you stare at the clock face, willing time to stop. By 3 a.m. you’re still awake and hopping mad about it!

Maybe you have spent the last 4 hours with your entire brain spinning along in problem-solving mode. Chances are, though, that if on such a night you were undergoing a sleep study, your brain waves would tell a somewhat different story. Beta waves, fast wave activity commonly observed in people who are are thinking and solving problems, might be mixed in with alpha waves (slower waves linked to more relaxed states) and even slower theta waves, heralding the start of Stage 1 sleep.

Detecting the Lighter Stages of Sleep

But would it feel like you were actually sleeping? Research has shown that people woken up in Stage 1 sleep are often unaware that they’ve been asleep. In this liminal state, people can drift back and forth between sleep and wakefulness for quite some time before descending further into more sustained sleep, which is called Stage 2.

Stage 2 sleep is characterized by a predominance of theta waves and by features called sleep spindles and K complexes. Awoken in Stage 2 sleep, people are somewhat more likely to be able to sense that they were asleep.

But people with insomnia may not be as apt to report they were sleeping. Investigators have speculated that with all the nighttime baggage accompanying chronic insomnia—anxiety about sleep loss, lack of confidence in sleep ability, negative beliefs about sleep, increased beta wave activity during sleep—some insomniacs may simply lose touch with the feeling of falling asleep.

A Sleep Training Smartphone App

When a call went out for an inexpensive way to detect the start of sleep at home, Schwartz developed Sleep On Cue. A recent study comparing it to polysomnography (the test used in overnight sleep studies) found that Sleep On Cue was accurate at predicting the onset of Stage 2 sleep.

Why is this important? For one thing, the app (which costs $4.99) may prove to be useful in helping to administer intensive sleep retraining—an insomnia treatment developed in Australia—inexpensively in people’s homes.

But for readers of this blog, the immediate value of this app may lie in its potential to train or retrain insomnia sufferers to recognize what falling asleep feels like. This could alleviate some of the worry and anxiety about sleep and insomnia and thus make it easier to fall asleep and fall back to sleep.

Here’s How the App Works

Sleep On Cue works best, Schwartz says, if you conduct your training sessions when the pressure to sleep is high: late in the afternoon or early in the evening after a poor night’s sleep.

  1. Lie down and relax in bed, holding your smartphone in one hand. The phone will periodically emit a soft tone. Every time you hear the tone, give the phone a slight shake.
  2. When the app no longer detects movement, it assumes you’re asleep. Then, the phone vibrates to wake you up.
  3. The screen then displays this message: “Do you think you fell asleep?” Press “yes” or “no.”
  4. Next, you’re instructed to leave the bed for a few minutes. The phone will then vibrate to let you know when to return to bed for the next sleep trial. In this way, you begin to relearn what falling asleep feels like and gain confidence in your ability to do it.
  5. You decide when to end each training session. The screen then displays a graph with feedback about your sleep ability and your awareness of your sleep.

Here’s a link to the Sleep On Cue website. At $4.99, it’s not much of an investment and the payoff could be great.

If you’ve tried Sleep On Cue, did it improve your sleep and, if so, how?

9 Ways to Keep Worry From Sabotaging Sleep

These days people are worried about jobs, health care, the environment, the possibility of worldwide war. Uncertainty about the future, and fear of negative outcomes, may rob even reliable sleepers of sleep from time to time.

But for many insomnia sufferers, worry and anxiety about sleep itself—“It’s two o’clock and I haven’t slept a wink!”; “If I don’t get to sleep now I’ll get sick!”—is an equally powerful enemy of sleep.

Here’s more about worry and insomnia and how to keep them from spoiling the night.

Insomnia sufferers should incorporate a bath into their bedtime routineThese days people are worried about jobs, health care, the environment, the possibility of worldwide war. Uncertainty about the future, and fear of negative outcomes, may rob even reliable sleepers of sleep from time to time.

But for many insomnia sufferers, worry and anxiety about sleep itself—“It’s two o’clock and I haven’t slept a wink!”; “If I don’t get to sleep now I’ll get sick!”—is an equally powerful enemy of sleep.

Here’s more about worry and insomnia and how to keep them from spoiling the night.

Worrying Around the Clock

Worry and sleep don’t mix. Like anxiety, which is more intense, worry—or repetitive thinking about issues of concern—triggers the release of neurochemicals that prepare the body for action rather than for rest.

Some people are by nature inclined to worry day and night. Allison Harvey, in her cognitive model of insomnia (2002), hypothesized that round-the-clock worry about sleep led to arousal, resulting in the sleep problems experienced by insomniacs at night.

Worrying at Night

More recently, research has suggested that it’s worry in bed—rather than worry day and night, or trait-level worry—that is connected to trouble sleeping, and a new study published in Behavioral Sleep Medicine supports this conclusion. Researchers administered a series of questionnaires to 139 insomnia sufferers and had them complete sleep diaries every day for 10 days. Neither trait-level worry nor trait-level rumination (repetitive thinking about negative emotions) was shown to have a relationship with any aspect of sleep.

The researchers then conducted a similar study with another group of insomniacs. Sixty-four participants were asked to fill out two diaries: one at 6 a.m., to record the sleep-related worries experienced during the night, and the other at 7 p.m., to record sleep-related worry and stress experienced during the day.

The results? Nighttime sleep-related worry had a significant and negative effect on every aspect of sleep, including trouble falling asleep, being awake longer during the night, and sleeping less efficiently. In contrast, daytime sleep-related worry had a negative impact on sleep quality only.

“Cognitive activity during the day is relatively benign,” the study authors concluded, “but cognitive activity in bed plays an important role in development and persistence of sleep problems in insomnia.”

The Take-Away

Do your worrying during the daytime rather than at night!

Because that’s easier said than done, here are nine ways to check your worries—sleep-related or not—at the bedroom door.

  1. Write your worries down early in the evening. Preempt nighttime worrying by taking 10 or 15 minutes to write down the issues you’re worried about, whether or not they’re related to sleep. Beside each concern, write what action you’ve taken/you’re taking/you will take to deal with the problem. Some problems may be clearly outside your control (or feel that way), yet resolving to take some small action to manage the problem can afford relief.
  2. Share your worries with an empathic listener at dinner. Sharing your concerns with an empathic partner or friend over the evening meal can also help to preempt worry at night. And when it comes to figuring out how to deal with a problem, two heads are often better than one. Further, research suggests that regardless of who’s talking and who’s listening, interactions with friends and supportive family members help tone down stress.
  3. Create a pre-sleep routine. It’s important to end the day with a wind-down period (ideally, at least an hour) in the run-up to bedtime. Think of it as a time to indulge in self-care, incorporating activities that make you feel good—such as listening to slow jazz and bathing by candlelight. The aim is to create an end-of-day ritual that’s worry free. Doing the activities in the same sequence every night will establish a clear association between your wind-down routine and sleep.
  4. Train your attention on something outside yourself. Watch a movie or a sit-com. Read or listen to a novel with complex, interesting characters. Do a crossword puzzle or play a word game such as Scattergories (Pick a category: Food. Pick a letter of the alphabet: L. Think of all the foods that begin with the letter L.) If you can do so without disturbing others at home, play a musical instrument. Engaging your mind will free it from repetitive thinking and enable you to go to bed feeling more relaxed.
  5. Adjust your perspective with cognitive restructuring. Confront your worries head on by asking a series of questions to find out how realistic your repetitive thoughts about a worrisome situation really are. In the process you’ll often find your anxiety level going down. Click on cognitive restructuring to find out more.
  6. Do a low-key physical activity. Underlying worry and anxiety are neurochemicals that trigger the urge to fight or flee. Low-key physical activity, such as walking outside or around the house, enables you to work the stress out.
  7. Do a deep breathing exercise. Deep diaphragmatic breathing triggers the relaxation response, enabling the body to move out of fight-or-flight mode and into a relaxed and restful state. Sitting in a chair, slowly inhale to a count of 4, pause briefly, and exhale to a count of 4. Focus on your breathing. If you find your mind wandering, gently guide your attention back to your breathing. Repeat this cycle as many times as needed.
  8. Do progressive relaxation. Sitting or lying down, one by one, tense and release every group of muscles in your body. Start with the muscles in your toes and move upward through your trunk to your head. Then move downward through the arms to the fingers.
  9. Do a guided meditation. Allow someone else to lead you through meditations designed to quiet your mind and relax your body. Jon Kabat-Zinn, whose guided meditations are available on the internet, is a master at this.

Please share any strategies you’ve found to cut down on worry at night.

11+ Nighttime Activities for Sleep Restriction

Here’s a complaint I often hear from insomniacs going through sleep restriction therapy: it’s hard to stay awake until bedtime. A related frustration comes with suddenly having extra time on your hands.

“I don’t know what to do with myself till 2:30 in the morning!” an insomnia sufferer groused to me.

Here are variations on 11 activities aimed at keeping you awake until the clock says it’s time to head to bed.

Sleep restriction less difficult with enjoyable activities that keep you awakeHere’s a complaint I often hear from insomniacs going through sleep restriction therapy: it’s hard to stay awake until bedtime. A related frustration comes with suddenly having extra time on your hands.

“I don’t know what to do with myself till 2:30 in the morning!” an insomnia sufferer groused to me.

Here are variations on 11 activities aimed at keeping you awake until the clock says it’s time to head to bed.

A Trivial Topic? Think Again

Sleep restriction therapy involves first restricting your time in bed to just the number of hours you’re actually sleeping. Then you gradually add time in bed until you find your ideal sleep window. Normally, this means starting therapy with a later-than-usual bedtime, an earlier-than-usual rise time, or both.

If you’re new to sleep restriction, planning what to do in the run-up to a later bedtime may seem unnecessary.

“I’ll read,” you say, “I’ll watch TV, I’ll catch up with friends on Facebook. I’ll do what I always do at night, only I’ll stay up longer.”

Sticking to the familiar may not work and here’s why:

The first week you’re restricting your sleep you’ll probably feel somewhat sleep deprived. If even mild sleep deprivation is involved, passive activities like watching TV and reading can lead to nodding off well before the prescribed bedtime. This interferes with establishing a regular sleep schedule, which is one thing you’re trying to accomplish. The more you stick to your prescribed bed and wake times, the quicker the therapy will take effect.

Devices with screens (computers, iPads, iPhones) emit blue light, which blocks secretion of the sleep-friendly hormone melatonin. It’s helpful to install an app called f.lux or wear blue-blocker glasses if you use devices at night. Even so, being wedded to the screen in the hour leading up to bedtime is not a good idea, especially for people with sleep onset insomnia (people whose insomnia occurs at the beginning of the night).

Other Constraints on Nighttime Activities

Evening activities have to be quiet unless you live alone. Playing the saxophone may be fun for you but obviously not for other members of the household.

Evening activities can’t require a lot of physical or mental stamina. By then you’re usually low in the tank.

A walk outside might have appeal. But depending on who you are and where you live, it may not be safe to leave home after dark.

The Special Challenge of Sleep Anxiety

What to do in the run-up to bedtime can be especially challenging for sleep onset insomniacs, whose anxiety about sleep tends to escalate the later it gets. Clock watching adds to (or is a part of) that sleep-related anxiety. When undergoing sleep restriction there’s no getting around use of the clock for information about when it’s OK to go to bed.

Waiting until anxiety sets in to decide what to do can be risky. A glass of wine? A sleeping pill? You’re off the rails before you’ve even begun. Why add stress to the sleep restriction process by waiting too long to decide what you’re going to do in the extra time you’re up?

Take it from one who’s been there twice and who, knowing what she knows now, would do it somewhat differently. In the week before you start restricting your sleep (as you’re collecting information about your sleep and recording it in your sleep diary), come up with a list of activities you’re going to do when restriction begins, acquiring any supplies you’ll need in advance. Ideally, these activities should (a) be somewhat enjoyable (or at least tolerable), (b) offer mild mental stimulation, and/or (c) involve some movement.

This list of activities is hardly comprehensive. But maybe it will motivate you to come up with other activities that would suit you as well or better.

  1. Do (or Take Up) an Art or Craft:

  • Needlework (quilting, knitting, crocheting, embroidery).
  • Jewelry or beadwork.
  • Woodworking or leatherworking
  • Calligraphy.
  • Origami.
  • Sewing. Lay out a pattern and cut the fabric.
  • Any artistic activity, such as sketching or watercolor painting, as long as it doesn’t require much clean up.
  1. Make Lists:

  • To-do lists and grocery lists.
  • Travel checklists for different kinds of trips (road trips, air travel [overseas and domestic], business trips, camping.) Printed out before each trip, they make packing a lot easier.
  • Gift lists. Avoid panic during the holidays and at birthdays and other special occasions.
  • A bucket list. Think of everything you’d like to see and do while you’re still able to do it.
  1. Organize or Reorganize:

  • Your tool bench.
  • Your jewelry box(es).
  • Your music. If you have CDs, tapes, albums, or sheet music, arrange them by style, period, composer, or instrument.
  • Your herbs and spices. Group them as powders, whole spices, and herbs, or arrange them alphabetically.
  • The garage or the basement.
  1. Sort and Discard:

  • Books. Do one shelf at a time, separating them into keepers, throw-aways, and give-aways.
  • Clothing in closets and drawers.
  • Old photos. Put the ones you want to keep into albums or photo boxes.
  1. Redecorate:

  • Your walls. Take down wall art and replace it with other paintings, photos, prints, or posters.
  • Your shelves. Replace pottery and art objects with others.
  1. Bake Cookies or a Coffeecake.

  2. Do Light Housework:

  • Dust furniture.
  • Fold or iron clothes.
  1. Prepare for the Day Ahead:

  • Set the breakfast table.
  • Pack lunches.
  • Do prep work for the evening meal.
  1. Do Things You Enjoyed in the Past:

  • Play Solitaire.
  • Do a thousand-piece jigsaw puzzle.
  • Get out a telescope, look at the stars, and identify constellations.
  • Gather every small thing you’ve collected outdoors—flowers, nuts, leaves, shells, stones, feathers, pine cones—and look at them under a microscope.

The following two categories of activities may be too passive for some people but could work if combined:

  1. Look at Publications with Images:

  • Art books.
  • Coffee table books.
  • Catalogs.
  • Family albums.
  • Cookbooks. Use a post-it note to mark every recipe you want to try out.
  1. Using Headphones, Listen to:

  • Music.
  • Books on CD.
  • A podcast. (But avoid looking at screens.)

Before you start to restrict your sleep, make a list of activities you’re going to do in the run-up to bedtime. And who knows? You might even enjoy some of that extra time awake.

If you’ve gone through sleep restriction, what activity did you find was most helpful in keeping you awake till bedtime?

Sleep Hygiene May Keep You From Backsliding

Observing the rules of good sleep hygiene may not work as a standalone treatment for insomnia. But now that I’ve learned to manage my insomnia, I follow most of the rules because they help me maintain sounder, more regular sleep.

Some are especially helpful in preventing backsliding. They may help you, too.

Observing sleep hygiene can hold insomnia at bayObserving the rules of good sleep hygiene may not work as a standalone treatment for insomnia. But now that I’ve learned to manage my insomnia, I follow most of the rules because they help me maintain sounder, more regular sleep.

Some are especially helpful in preventing backsliding. They may help you, too.

Maintain a regular sleep routine.*

After sleeping when I could and all I could for decades, I finally faced the music: consistent bed and rise times were actually helpful to my sleep. Of the two, I think a consistent rise time is the more important. Getting up at the same time every day helps keep circadian rhythms synchronized and allows time enough for sleep pressure to build until it puts you to sleep and keeps you asleep at night.

But life isn’t as regular as clockwork. By the end of the week you may be feeling sleep deprived. To catch up on lost sleep, sleeping half an hour or even an hour later than usual on weekends may not throw your sleep off track.

But when I’m short on sleep, getting extra sleep at the beginning of the night (i.e., going to bed earlier than normal) works better than allowing myself to sleep late. That way, I catch up on lost sleep but avoid setting myself up for Sunday night insomnia.

Don’t watch TV or read in bed.*

If watching TV in the bedroom or reading in bed reliably puts you to sleep, you may want to ignore this rule. In an earlier blog post, I mentioned one sleep expert who finds that reading in bed is exactly the kind of soporific he needs to fall asleep.

For other insomniacs (I was one) engaging in wakeful activities in the bedroom does not reliably put us to sleep. On the contrary, activities such as reading or studying in bed lead to more wakefulness at night. Then anxiety about sleep starts creeping in.

“It’s midnight and I’m still not sleeping,” you may find yourself thinking. “It’s 1 a.m. . . . it’s 2.” If night after night things continue in this vein, simply being in bed starts to cause anxiety about sleep. But anxiety is not compatible with sleep. Insomnia, which may have begun as an occasional thing, becomes a permanent state of affairs.

It’s hard to unlearn this association between the bed and wakefulness and reprogram your brain to expect sleep. At a very minimum, it involves moving every activity except sleep (and sex)—reading, TV watching, grading papers—outside the bedroom, and leaving the bedroom if you find you can’t sleep.

Kicking and screaming, I finally managed to do it: learn to go to bed expecting to sleep rather than lying anxiously awake. And now that I’ve done it, I’m loath to go back. I follow this rule in both letter and spirit, using my bed only for sleep and sex. Period.

Exercise to promote good quality sleep.**

I was never quite a couch potato. I knew a sedentary lifestyle wasn’t healthy, so I jogged, hiked, or rode my bicycle the recommended 3 times a week.

It was when I started to keep a sleep diary that I noticed a correspondence between aerobic exercise and my sleep. After days when I exercised, I fell asleep more quickly and had good quality sleep.

Thirty minutes of vigorous exercise every afternoon hasn’t exactly turned me into a jock. But now I find a daily dose of exercise is something I crave. And when I can’t have it, I get fidgety and sometimes a little bit cross. I don’t fall asleep as easily or sleep as soundly that night.

So I build swimming or working out on the elliptical trainer into my days as regularly as I do my meals. It’s a small price to pay for holding insomnia at bay.

Establish a regular relaxing bedtime routine.**

You may feel exhausted, but going straight to bed after a long, hard day can be a setup for insomnia. It was and is for me. So no matter how late I’m out or how absorbing my daytime activities are, I always make time for a wind-down ritual at the end of the day. Beyond incorporating the necessities (bathing, brushing teeth), a bedtime routine should be calming (no surfing the internet) and enjoyable (no washing the dishes).

Reading a novel works for me. Not only does it divert my attention away from the events of the day. Now that it’s habitual it also cues sleep. Suddenly I’m yawning and nodding over my book. After a few failed attempts to return to reading, it’s time to head to bed. I’m out in a flash.

If you’re a clock watcher at night, hide the clock.*

Viewing clocks at night makes me anxious. It’s another learned association, one I’ve never managed to break. So ever since going through sleep restriction (where I had to watch the clock, which drove my sleep anxiety sky high) at night I simply turn my clocks to the wall.

Observing these rules of sleep hygiene may not cure your insomnia. But once you’ve found a way to manage your sleep, it may keep your sleep more regular.

What change of habit has helped your sleep the most?

*American Sleep Association

**National Sleep Foundation

Q&A: Anxious About Sleep? Get Relief

Anxiety about sleep is a problem for some insomnia sufferers. Fear of sleeplessness is the main thing keeping them awake at night.

Here’s how sleep anxiety develops and how to tone it down.

Relieve fear of sleeplessness with cognitive and behavioral therapies.This week a woman (I’ll call her Gina) wrote to Ask The Savvy Insomniac with questions about sleep anxiety and sleep restriction.

 

 

 

 

I have had chronic insomnia since September. I honestly didn’t have any major life event that caused it. Just a few bad nights of sleep—and the anxiety started setting in. The worst part of it for me is that as soon as it nears “bedtime” my heart starts racing and I feel extremely anxious.

I am doing sleep restriction therapy (I’ve been averaging 5 hours per night) but I’ve had a few “slips” along the way. I tend to drift off to sleep on the couch (for about 5 or 10 minutes). How long does this take? I’ve been doing it for over a week and I haven’t seen any great improvements. I’m losing hope.

Anxiety About Sleep: How It Develops

Anxiety about sleep can develop during a stressful life event when sleep is difficult. It can also develop following several nights of bad sleep, regardless of what triggered them.

Being unable to sleep when you want to sleep is frustrating. Frustration may give rise to symptoms of physiological arousal: increased heart rate, blood pressure, respiratory rate, and body temperature. If you’re prone to developing chronic insomnia you may be particularly sensitive to what’s going on inside your body. Merely noticing signs of arousal at a time when the brain and body are supposed to be shutting down can cause anxiety.

It’s important to note when and where these unpleasant sensations are occurring. They’re not happening as you drive your 3-year-old to daycare or participate in a staff meeting. They’re happening at night when you’re in bed in the bedroom—where you’re supposed to be asleep.

After a few bad nights you may also begin to notice unpleasant symptoms during the daytime: lethargy, low mood, trouble thinking. Consciously or unconsciously, you might start to connect these these symptoms to your struggle for sleep at night. This, too, can give rise to anxiety or exacerbate existing anxiety.

Activities and projects may claim your attention during the daytime. But when nighttime rolls around and your physical and mental stamina are at low ebb, boom! The mere thought of going to bed makes you anxious, ramping up physiological arousal and increasing your anxiety still further.

Forget about sleep when you finally go to bed. Your odds of an easy send-off are nil.

If You’re Anxious About Sleep

Keep these things in mind. Sleep-related anxiety:

  • Is learned. It doesn’t just materialize out of nowhere but is rather conditioned through a process similar to the one described above (and likely predisposed by constitutional factors as yet unknown).
  • Is not your fault. Conditioned learning takes place at an unconscious level; you are not aware that it is occurring. So don’t play the blame game—it hurts rather than helps.
  • Can be unlearned. That’s where we’re heading now.

Some insomniacs who are anxious about their sleep respond to treatment with cognitive therapies. Cognitive restructuring, offered as part of cognitive behavioral therapy for insomnia (CBT-I), may help by dismantling some of the attitudes and beliefs that keep sleep anxiety alive. Other insomniacs have found that mindfulness meditation helps to alleviate sleep anxiety. Acceptance and commitment therapy is worth checking into as well.

Stimulus Control Therapy

For me personally, the two behavioral strategies I learned during CBT-I had the biggest impact on my sleep anxiety. By regularizing and solidifying my sleep, they helped to make fear of sleeplessness a thing of the past.

You’ve heard advice to the sleepless that counsels avoiding the bed except for sleep and sex? Well, this rather parsimonious view of how to use the bed has grown out of studies showing that stimulus control therapy (SCT) for insomnia works. The protocol is simple:

  1. Go to bed only when sleepy.
  2. Use the bed only for sleeping (and sex). Do not read, watch TV, eat, or do anything else in bed.
  3. If within 15 minutes you’re unable to sleep (estimate the 15 minutes; do not watch the clock), move to another room. Do a quiet activity—reading, knitting, watching TV—until you feel really sleepy. Then return to bed. The goal is to break the association between the bed and wakefulness and instead learn to associate the bed with falling asleep quickly.
  4. Repeat the above instruction as often as necessary.
  5. Get up at the same time every morning regardless of how much or how little you’ve slept.
  6. Do not take naps.

Sleep Restriction Therapy

The aim of sleep restriction therapy (SRT)—the treatment Gina is undergoing—is to restrict your time in bed so that most of your time there is spent sleeping rather than lying awake and worrying about sleep. The SRT process is somewhat involved and I’ve blogged about it elsewhere. Find out more by typing “sleep restriction” in the site search box above.

In response to Gina’s concerns about sleep restriction: avoid drifting off too early by engaging in evening activities that are not completely sedentary. And don’t lose hope because you’re failing to see improvements right away. It may take two or even three weeks before you notice appreciable benefits.

Take it from one who’s been there and done that: it’s worth the wait.