Q&A: Will Regular Rest Curb Sleep Anxiety?

“I have nights when I can’t sleep at all and other nights when I sleep a lot,” Philippa wrote last week. “If I don’t fall asleep straight away I find I often don’t sleep the whole night! Do you think sleep restriction would work for me?”

My answer to Philippa’s question is an unqualified “yes.” But first I want to look at sleep that’s inconsistent and unpredictable and how anxious it can make you feel.

Anxiety about sleep is treatable with CBT for insomniaMy sleep used to be erratic. Really, really erratic. The Sandman could come as early as 10 p.m. . . . but he might not show up till daybreak.

Occasionally I hear another insomnia sufferer voice a variation on the same complaint. Here’s what Philippa wrote last week:

 

 

I have nights when I can’t sleep at all and other nights when I sleep a lot. I don’t have a problem waking up at night and, if I do, I can go back to sleep. However, if I don’t fall asleep straight away I find I often don’t sleep the whole night! Do you think sleep restriction would work for me?

My answer to Philippa’s question is an unqualified yes. But before I talk about making sleep more regular, I want to look at sleep that’s inconsistent and unpredictable and how anxious it can make you feel.

Night-to-Night Sleep Variability

Actually, there’s not much talk about night-to-night variability in people’s sleep. We hear a lot about sleep need, but that’s always stated as an average, as in “most people need about 7 hours of sleep a night.”

But plenty of research shows there’s night-to-night variability in when, how long, and how well each person sleeps. Unsurprisingly, some people’s sleep is more variable than others’. According to a new paper published in Sleep Medicine Reviews, from night to night, your sleep is more likely to vary in duration, timing, or quality if

  • you’re young
  • you live alone
  • you’re a person of color
  • you’re a night owl
  • you’re overweight or obese
  • you have physical health conditions
  • you have bipolar or depressive symptoms
  • you’ve had lots of stressful life events
  • you have insomnia.

Insomnia and Sleep Variability

The word insomnia means “the condition of not being able to sleep.” Yet even if your insomnia is chronic, chances are you don’t sleep poorly every night. In fact, like Philippa, on some nights you probably sleep passably or even quite well. But good sleep is not dependable, and that’s a problem.

There may be certain situations you’ve identified that typically give rise to bad nights. For example, you may know your sleep will suffer after a bad day at work or if you have to give a speech the next day.

But the good and bad nights may not necessarily correspond to stressors you can put your finger on. And this lack of predictability can cause big-time anxiety. It certainly did for me.

A Pattern of Good and Bad Nights?

Is there an underlying pattern to insomniacs’ poor sleep and, if so, would discerning that pattern be reassuring? Maybe it would for some people with insomnia.

Researchers in Scotland looked at the sleep diaries of over 100 insomniacs and found a predictable pattern of good and bad nights in about two-thirds of the study participants. Most of these participants could count on a good night’s sleep after 1 to 3 bad nights.

It could be reassuring to know that a better night’s sleep is just a day or two away, the authors wrote. A predictable pattern of good and bad nights might alleviate some anxiety about sleep.

In a study conducted at the University of Pennsylvania, investigators concluded that insomniacs can expect a “better-than-average” night’s sleep within 3 days—but that “good” sleep may come only 1 night in 6. This doesn’t sound very predictable or reassuring to me.

Take the Bull by the Horns

It might be helpful to keep a sleep diary and see if you can identify a pattern of good and bad nights. Seeing method in the madness might allow you to dispense with some of the uncertainty that’s probably contributing to your anxiety about sleep at night (and driving your insomnia).

But getting rid of erratic sleep—and making sleep predictable—is a more effective approach to curtailing anxiety about sleep. Undergoing CBT for insomnia, which includes sleep restriction therapy, is a good way to do that, research shows. And both this blog and my book, The Savvy Insomniac, are a testimonial to what CBT for insomnia—combined with regular exercise—has done for my sleep.

I’ve written more about sleep restriction therapy because it’s the part of treatment that helped me the most. To read more about it, just click on “Blog” at the top of this page, type “sleep restriction” in the site search box, and start browsing.

Q&A: Panic About Insomnia Relapse

Lately 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’ve lost all the gains they made. 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?”

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.

An Insomnia Treatment of Her Own

A few weeks ago I got an email from Julie, who’d written to me about her insomnia before. Here’s how she began:

“I am happy to share with you, 5 months later, that I am sleeping peacefully and soundly! It didn’t happen overnight, but my improvement did happen because of the sleep restriction you recommended!”

“This woman is persistent,” I thought, and read on. I discovered that, while Julie’s first attempts at this insomnia treatment were strikeouts, rather than give up, she found ways to modify the sleep restriction protocol so it eventually worked.

Modifying sleep restriction for insomnia can lead to more satisfying sleepA few weeks ago I got an email from Julie, who’d written to me about her insomnia before. Here’s how she began:

“I am happy to share with you, 5 months later, that I am sleeping peacefully and soundly! It didn’t happen overnight, but my improvement did happen because of the sleep restriction you recommended!”

This woman is persistent, I thought, and read on. I discovered that, while Julie’s first attempts at this insomnia treatment were strikeouts, rather than give up, she found ways to modify the sleep restriction protocol so it eventually worked.

“I can now say that I’ve gone over a full month without any bad sleep,” she wrote, “and I’m now sleeping 7 plus hours a night!”

I decided to interview Julie, and here are excerpts from the conversation:

Insomnia Returns

Your insomnia started several months ago. What threw your sleep off track?

A health scare, which later turned out to be a false alarm. I didn’t sleep a wink that night, worrying about all the possibilities. . . . All it took [was] 4 bad nights to send me into the chronic insomnia pattern I experienced for the next 5 months: a few good nights followed by sleepless nights—up and down the roller-coaster.

You decided to try Sleep Restriction Therapy (SRT) for insomnia. What led to that decision?

I’d had an insomnia problem 14 years earlier that lasted for 2 years. It was caused by a bladder problem after the birth of my last baby. . . . I tried SRT but was unsuccessful with it because I needed to cure the bladder problem first.

I never expected to sleep poorly again after what I went through and solved 14 years ago. It was a total shock that the insomnia came back as horribly as before, only this time I couldn’t blame it on my bladder! I decided to take aggressive action. I purchased The Savvy Insomniac, and a book by Dr. Arthur Spielman. Everything I read encouraged me to try SRT again.

A Rocky Start

How much did you restrict your sleep at first, and how did you fare?

To begin SRT, I averaged my previous week’s sleep and came up with 4½ hours. I decided to stay up until 1 am and get up at 5:30. At first, I decided to stay in bed during those 4½ hours whether I was sleeping or not. My results were terrible! I alternated between zero sleep nights and 2 to 3 hours [of sleep]. Determined to force this to work, I started to get out of bed when I wasn’t sleeping. That didn’t work, either. I got an occasional 4-hour night but I was so sleep deprived [that] I didn’t feel comfortable driving at night, which was a deal-breaker for me.

You say that SRT called up lots of anxiety. Can you elaborate?

Being that regimented just threw me for a loop. I really dreaded the evenings. I would be up for hours after my family went to bed, waiting to fall asleep until the right time. For me, staying up later than the gang was . . . stressful. [And] looking at the clock, especially at bedtime, seemed to cause me stress.

Also, there was an 11-mile hike I was looking forward to in a month, and I put pressure on myself to be in good shape by then. Every day that I couldn’t . . . increase my time in bed, I would get discouraged and feel that going on the hike would be an impossibility. I also worried that health-wise it was not good to spend [such a] short time in bed for an extended period—and this was not looking to be a short-term project for me.

Rewriting the Rules

So you decided to make some changes. What were they?

The thing I discovered is I had to do [SRT] in a flexible way that worked with my environment and my personality. I decided to come up with a modified version of SRT, one I could stick with long-term.

First, I needed to be able to go to bed when my family did. . . . And I needed to start with 6 hours [rather than 4½].

I was not going to watch the clock strictly. I [would go] to bed at approximately 11:30 and get up at 5:30, but it worked best if I didn’t look at the clock.

Since even in normal times I usually had a few wake-ups an hour or 2 before it was time to get up, I vowed to get out of bed at one of these wake-ups, or at 5:30, whichever came first.

I did not put a time limit on how long I would keep up this routine, so there was no pressure to improve. I also vowed to make this a background project in my life—do my 6 hours in bed and go about the rest of my life.

How well did your modified protocol work?

I had one of my longest periods of good sleep . . . followed by some “off” nights. Then another record-long period of good nights, followed by 2 weeks of off-and-on.

Once I got past that, things improved at a quicker pace. I went a month with only 1 bad night, then a month with 3 bad nights, then, finally, a month with no bad nights. Two months into the project, I bumped up my time in bed by 15 minutes. Two weeks later, I added 15 minutes more. I’m now up to about 7½ hours’ sleep per night.

Julie’s right where she wants to be with her sleep. The way she got there–and the changes she made to SRT–wouldn’t be helpful for everyone. But my hat’s off to anyone who can take this insomnia treatment and tweak it in ways that work.

If you’ve managed a similar feat, please share your story here.

Insomnia: Holding Steady the Next Day

Will there ever be a morning-after pill prescribed for insomnia? Wouldn’t that be nice. Insomnia wouldn’t be half as bad if it weren’t so debilitating the next day. No fatigue to contend with, no brain fog, no low mood. White nights could even be enjoyable if we knew in the morning that we could resort to Plan B.

For now there’s no simple way to avoid insomnia symptoms that occur in the daytime. But there are ways to minimize their impact, whether the bad nights come often or just once in a while. Here are 6 habits I find useful and maybe you will, too.

Daytime affects of insomnia can be reduced by stretching and other activitiesWill there ever be a morning-after pill prescribed for insomnia? Wouldn’t that be nice. Insomnia wouldn’t be half as bad if it weren’t so debilitating the next day. No fatigue to contend with, no brain fog, no low mood. White nights could even be enjoyable if we knew in the morning that we could resort to Plan B.

For now there’s no simple way to avoid insomnia symptoms that occur in the daytime. But there are ways to minimize their impact, whether the bad nights come often or just once in a while. Here are 6 habits I find useful and maybe you will, too:

Eat a Healthy Breakfast

This might seem like a no-brainer, but with 18 percent of Americans older than age 2 regularly skipping breakfast, it’s worth a mention. Research suggests that eating a morning meal is beneficial in many ways: it lifts the mood and improves memory, and it makes you more active in the morning. Particularly when you’re feeling sluggish and sleep-deprived, a good breakfast is a must.

Make Judicious Use of Caffeine

It used to be that caffeinated beverages were on the “No Fly” list for people with insomnia. But expert opinion has changed. The thinking now is that while the caffeine-sensitive should avoid it within 8 hours of bedtime, it’s OK in moderation—and can even be helpful—as tolerated earlier in the day.

The trick is to discover what “as tolerated” means on days when you feel like drinking a whole pot of coffee. Caffeine has an average half-life of 5 to 6 hours (meaning that in 5 to 6 hours the amount of caffeine in the blood will have decreased by half). So most people can drink caffeinated beverages in the morning without fear of compromising sleep that night.

But many people experience a circadian slump somewhere in the middle of the afternoon. Particularly after a short night’s sleep, that’s when you really crave a pick-up. Is a 3 p.m. cappuccino going to set you up for another bad night?

Not necessarily, if you’re young or middle-aged. But it takes older adults longer to metabolize drugs. Keep this in mind as you decide when to drink that last cup of joe.

Drink Plenty of Water

Even mild dehydration can depress your mood, lower your ability to concentrate, and make tasks feel more difficult. It can also impair performance and short-term memory. So make a point of sipping often throughout the day. Keeping water on hand at your desk, or making frequent trips to the water cooler, could take the edge off a low mood and make it easier to accomplish what needs to be done.

Get Up and Move Around

Physical activity tends to elevate mood and alertness. New Zealand researchers found that subjects who reported higher levels of habitual physical activity also endorsed higher levels of interest, excitement, enthusiasm, and alertness—all qualities you may be short on if you’re short on sleep. Particularly if your work keeps you sedentary, make an effort to get up, move around a lot, and stretch at your desk. At lunchtime, take a walk.

Follow the Sun

Increasing your exposure to sunlight may also help to counteract symptoms of insomnia. Bright light tends to increase vitality and elevate mood. It’s also been shown to enhance alertness and cognitive performance. Even on cloudy days, daylight is 2 or 3 times brighter than normal office lighting. So make liberal use of it when you can. Particularly if you’re feeling sluggish, spend time outdoors or inside where there are plenty of windows.

Reorganize Your Day

You may not have much say in how you organize your day. Whatever tasks are on the schedule—make sales calls, teach a class, chair a meeting—you’ve just got to power through them, never mind that you’re exhausted when the day begins. But sometimes you can reset the agenda. After bad nights, juggle your tasks so you tackle the hard ones when you’re normally most alert and save the routine tasks for when you’re not.

Doing all these things may not have a big impact on your nights. But they may help you chart a steadier course during the day. That counts for something, don’t you think?

Q&A: Sleep Restriction: Tempted to Give Up

Jessica recently wrote with concerns about sleep restriction.

I’m on Day 6 of sleep restriction and I don’t think it’s working. The first 3 nights were miserable. I kept looking at the clock and thinking, just 4 more hours to sleep, just 3 more, just 2 . . . I had so much anxiety I hardly slept at all!

Am I just going to have to resign myself to insomnia for the rest of my life? Honestly I’m on the verge of giving up.

coffee-in-bedJessica recently wrote to Ask The Savvy Insomniac with concerns about sleep restriction.

I’m on Day 6 of sleep restriction and I don’t think it’s working. The first 3 nights were miserable. I kept looking at the clock and thinking, just 4 more hours to sleep, just 3 more, just 2 . . . I had so much anxiety I hardly slept at all!

But on the 4th night I passed out and overslept my alarm in the morning. I FELT GREAT. And I’m like, sleep restriction rocks! But . . . the next night was terrible. I barely got 2 hours, and the same thing happened again last night. Today I feel so bad I called in to work—something I never do unless I’m sick.

Now I’m wondering if it’s worth the punishment.  Am I just going to have to resign myself to insomnia for the rest of my life? Honestly I’m on the verge of giving up.

An Erratic Sleep Pattern

I can so relate to Jessica’s plight. The sleep pattern she describes was mine for several decades. Terrible sleep for 3 to 5 nights in a row, followed by a night where I conked out so completely I could sleep through ear-splitting thunder.

Mornings after super long nights felt great. But nothing is comforting about this kind of sleep pattern. Lurching from one bad night to the next, never knowing when I was finally going to pop off a good one, raised my anxiety sky high. I wanted good sleep to be regular. I wanted it to be dependable.

With Restriction, a Payoff

My first week of sleep restriction was pretty close to hell. Like Jessica, I had 3 really bad nights before I was sleepy enough to fall asleep at the bedtime I’d chosen. But sleep restriction also required getting up at a fixed time every morning. This rule contradicted one of the most ingrained notions I had about my sleep, namely, that on the rare nights when I could sleep, I’d better let myself sleep as long as possible—because I never knew when I’d get another chance.

So when the alarm rang at 5 a.m., the temptation was simply to roll over and go back to sleep. It felt like the middle of the night. It felt like I needed more sleep. Why deny myself something my body evidently needed?

By that time I was far enough along in my research to understand the theory behind sleep restriction; I understood the forces driving my insomnia well enough to know that letting myself sleep late was probably a road to nowhere. So I mustered up my willpower and hauled myself out of bed and into the day–and the next day, and the next.

Wasted is how I felt after those short nights, and definitely lame in the head. But I held fast to my sleep window, recalculating my time in bed at the end of each week. And in time my sleep became deeper, longer and more dependable. Amazing gifts for a guerrilla sleeper like me.

Rest for Success

Not every insomniac will benefit from sleep restriction. But research suggests many can. Set yourself up to be one of them by

  • choosing to go through treatment at a time when you’re not too busy with other things.
  • avoiding clocks after bedtime. Looking at the clock creates anxiety, and that’s something you want to avoid.
  • setting appropriate bed and wake times and observing them to the letter.

What problems have you encountered during sleep restriction?

Insomnia at Night, Running on Empty All Day

People usually think of insomnia as a problem of the night, but it’s more than that. Poor sleep puts a damper on the day and affects our performance on the job.

This week is Sleep Awareness Week. To call attention to the fact that the effects of chronic insomnia are 24/7, I’m posting my final book trailer, where I discuss the daytime symptoms of insomnia and offer a few tips for coping after bad nights.

People usually think of insomnia as a problem of the night, but it’s more than that. Poor sleep puts a damper on the day, as Kim, a nurse I interviewed, explains: “Generally, I experience insomnia just about every night. The older I get, the more I pay for it the next day. I am groggy and grumpy and I can’t think straight. But I’m usually OK until the afternoon and then it’s pure hell. I get really sleepy about 2 p.m. and have to just keep on working until I get things done.”

Not only do our bad nights leave us feeling lousy the next day. They also affect our performance on the job. A review of the occupational effects of insomnia found that insomnia symptoms

  • increase the risk of accidents in the workplace
  • reduce productivity on the job, and
  • inhibit career advancement.

This week is Sleep Awareness Week. To call attention to the fact that the effects of chronic insomnia are 24/7, I’m posting my final book trailer, where I discuss the daytime symptoms of insomnia and offer a few tips for coping after bad nights. Take a listen and see if you relate!

Insomnia at Night, Running on Empty All Day