Transitioning to Menopause? Don’t Give Up on Sound Sleep

I often hear sleep complaints from women approaching menopause. Hot flashes and mood swings are other common complaints. What can be done to improve sleep and reduce perimenopausal symptoms?

The key, say authors of a review paper published this year, is to use a variety of approaches based on individual women’s symptoms, history and needs.

Insomnia and hot flashes can be relieved with multi-pronged treatmentI often hear sleep complaints from women approaching menopause. Hot flashes and mood swings are other common complaints. What can be done to improve sleep and reduce perimenopausal symptoms?

The key, say authors of a review paper published this year, is to use a variety of approaches based on individual women’s symptoms, history and needs.

Sleep Problems in the Menopausal Transition

The transition to menopause begins 4 to 6 years before menstruation stops (the median age for menopause is 51 years). It’s a time of fluctuating reproductive hormone levels. Not all women suffer ill effects during this period but many do.

Sleep problems are one of the most common complaints, reported by up to 56% of women approaching menopause, say authors of the review, published in the journal Nature and Science of Sleep. In turn, trouble sleeping often compromises midlife women’s quality of life, mood and productivity.

There’s an uptick in sleep-disordered breathing (sleep apnea) among women transitioning to menopause. There’s also an uptick in insomnia. A study involving 982 perimenopausal women interviewed by phone found that 26% had symptoms qualifying them for a diagnosis of insomnia disorder as medically defined.

Not Just in Our Heads

Fluctuating levels of hormones—follicle-stimulating hormone, estradiol (an estrogen) and progesterone—likely play a role in insomnia that occurs during the menopausal transition. Hot flashes, too, which typically emerge as estrogen levels decline, are associated with poorer reported sleep quality and chronic insomnia.

As for objective evidence of menopausal sleep problems, results of population studies of midlife women involving polysomnography (PSG) are inconsistent. But in a recent study published in Psychoneuroendocrinology, investigators found “stark differences in PSG measures in women with, relative to women without, insomnia disorder developed in the menopausal transition.”

Women who developed insomnia during the menopausal transition

  • had poorer sleep efficiency
  • experienced more wakefulness after sleep onset
  • had shorter total sleep time, with 50% sleeping less than 6 hours
  • were more likely to have hot flashes, which predicted their number of awakenings per hour of sleep.

A Role for Depression and Stress

Symptoms of depression typically increase during the menopausal transition. Depression and insomnia are closely linked, with depression sometimes preceding insomnia and insomnia sometimes leading to depression. The results of one interesting study suggest that trouble falling asleep at the beginning of the night is associated with anxiety while nonrestorative sleep is linked to depression.

Chronic exposure to stress could be another factor in midlife women’s greater susceptibility to insomnia. And during the transition to menopause, traits associated with insomnia—increased tendency toward rumination, anxiety, generalized hyperarousal, stress reactivity, and neuroticism—are similar to tendencies predictive of hot flashes and other perimenopausal symptoms.

Treatments for Insomnia in the Menopausal Transition

Since insomnia in the menopausal transition is likely due to many factors, it’s challenging to treat. The reviewers recommend “flexible and individualized” treatments for insomnia depending on each woman’s current symptoms and history.

Hormone Therapy

Hormone therapy generally improves sleep quality in women who experience hot flashes during the transition. It may be a good option if, based on a woman’s history and health concerns, the overall potential benefits outweigh the risks. The reviewers note that abrupt discontinuation of hormone therapy is associated with hot flash relapse, which could in turn lead to insomnia.

Non-Hormonal Pharmacological Therapies

Sleeping pills, which are generally prescribed for short-term or intermittent use, are not a front-line treatment for insomnia in perimenopausal women. Taken nightly over time, many sleeping pills degrade sleep quality and have other negative effects. Following are the medications the reviewers suggest considering for perimenopausal women with insomnia and hot flashes:

  • Low-dose selective serotonin reuptake inhibitors—such as citalopram (Celexa) and escitalopram (Lexapro)—and low-dose serotonin norepinephrine reuptake inhibitors—such as duloxetine (Cymbalta) and venlafaxine (Effexor XR). Note that discontinuation of SSRIs is associated with hot flash relapse, which could lead to insomnia.
  • Gabapentin, shown to improve sleep quality in perimenopausal women with hot flashes and insomnia.
Non-Pharmacological Therapies
  • Cognitive behavioral therapy for insomnia (CBT-I) is the overall gold standard in drug-free treatments for insomnia. In a randomized clinical trial recently conducted on peri- and postmenopausal women experiencing at least 2 hot flashes daily, women who underwent CBT-I “had significantly greater reduction in insomnia symptoms and greater improvements in self-reported sleep quality” compared with controls. The improvements were maintained at 6 months after treatment.
  • Soy isoflavones—phytoestrogens found mainly in legumes and beans—have been shown in randomized controlled trials to reduce menopausal symptoms, including self-reported sleep disturbance. They’re available as dietary supplements.
  • High-intensity exercise and yoga are reported by the reviewers to be modestly beneficial in reducing menopausal symptoms and improving sleep.

Because many factors can combine to disrupt sleep in the period leading up to menopause—sleep disorders, mood disorders, medical conditions, and life stressors—no one-size-fits-all treatment will improve sleep and minimize menopausal symptoms. Instead, the reviewers recommend a multi-pronged approach to treatment based on individual women’s needs.

Insomnia: Are Primary Care Doctors Still Getting It Wrong?

It’s not always easy to find help for insomnia. Several people I interviewed for “The Savvy Insomniac” reported that their primary care doctors didn’t seem to take the complaint seriously or prescribed treatments that didn’t work.

I thought the situation must have changed since persistent insomnia is now known to be associated with health problems down the line. But a recent report on the Veterans Affairs (VA) health system shows that insomnia is still overlooked and undertreated by many primary care providers.

Here’s what you may find—and what you deserve—when you talk to your doctor about sleep.

Insomnia is not always treatable by primary care providersIt’s not always easy to find help for insomnia. Several people I interviewed for “The Savvy Insomniac” reported that their primary care doctors didn’t seem to take the complaint seriously or prescribed treatments that didn’t work.

I thought the situation must have changed since persistent insomnia is now known to be associated with health problems down the line. But a recent report on the Veterans Affairs (VA) health system shows that insomnia is still overlooked and undertreated by many primary care providers.

Here’s what you may find—and what you deserve—when you talk to your doctor about sleep.

Insomnia Addressed in Primary Care

Investigators surveyed 51 primary care providers (PCPs) in the VA system as to their perceptions and treatment of insomnia. About 80% of the respondents said they felt insomnia was as important as other health problems. Yet they tended to underestimate its prevalence and often failed to document its presence.

Other research has shown that the prevalence of poor sleep quality among veterans is extremely high: over 70% in veterans without mental illness and even higher in veterans with a mental health diagnosis. Yet most PCPs surveyed estimated that only 20% to 39% of their patients experienced insomnia symptoms. When insomnia emerged as a problem, only 53% said they regularly entered it into their patients’ medical records.

Insomnia Conceived Of as Secondary Problem

Scientists now have plenty of evidence that insomnia is a disorder in its own right—regardless of whether it occurs alone or together with another disorder. Yet many PCPs seemed to view it as merely a symptom or a condition secondary to another disorder.

All of the PCPs endorsed the belief that when insomnia occurs together with a health problem such as depression and PTSD, successful treatment of the depression or PTSD will eradicate the trouble sleeping. Current scientific evidence does not support this belief.

Insomnia Treated With Sleep Hygiene

The first-line insomnia treatment recommended by the American Academy of Sleep Medicine and other professional organizations is cognitive behavioral therapy for insomnia (CBT-I). CBT-I is available at VA facilities.

Even so, the insomnia treatment PCPs most often recommended to their patients was counseling on good sleep hygiene. But sleep hygiene doesn’t work as a stand-alone treatment for insomnia. What’s more, it may make the prospect of CBT-I less palatable, given that some CBT guidelines call for behavioral changes that resemble the rules of good sleep hygiene.

Still Getting It Wrong

It seems like primary care doctors are just as outdated in their conception and treatment of insomnia as they were 10 and 20 years ago. I’m not alone in voicing this concern. Here’s how Michael Grandner and Subhajit Chakravorty titled their commentary on the survey results: “Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed.”

There’s no ambiguity here.

Help You Deserve From Your Doctor

Your PCP may be responsive to your complaint of insomnia and current in his or her knowledge of how to diagnose and treat the condition. If so, well and good.

But your doctor may not be quite so on the ball when it comes to dealing with trouble sleeping. Don’t let that deter you from seeking help for insomnia elsewhere. A good doctor will:

  1. Respond to concerns about insomnia as attentively as he or she would to concerns about double vision or shortness of breath. Insomnia can be debilitating, and chronic insomnia can result in changes that compromise health and quality of life. A doctor who dismisses it as trivial or hands you the rules for good sleep hygiene before waving you out the door is not the right doctor.
  2. Ask questions about the duration, frequency, and severity of your problem, and possible underlying conditions. This type of inquiry is crucial to arriving at an accurate diagnosis and appropriate treatment. Doctors who don’t have the time or knowledge to ask these questions should refer you to someone who does.
  3. Discuss treatment options that are research based and individualized. CBT-I may require referral to a specialist, yet there may be no specialist certified in behavioral sleep medicine practicing in the area. Likewise, a prescription for sleeping pills is useless to a patient who has no intention of filling it. Treatment discussions should be dialogs, and doctors should encourage patient participation.

This is the kind of response we deserve when we bring up the topic of insomnia with PCPs.

But it may not be the kind of response we get. How has your doctor reacted when you’ve mentioned trouble sleeping? (If you found this post helpful, please like and share on social media. Thanks!)

Q&A: Can Poor Sleep Show in the Face?

Can chronic insomnia make you less attractive? speed up the aging of skin? cause irreversible damage to your face?

I heard these concerns as I interviewed insomniacs for my book. But recently I decided to check into them after receiving an email from a woman whose anxiety about her appearance was extreme:

Very worried middle-aged woman

Can chronic insomnia make you less attractive? speed up the aging of skin? cause irreversible damage to your face?

I heard these concerns as I interviewed insomniacs for my book. But recently I decided to check into them after receiving an email from a woman whose anxiety about her appearance was extreme:

 

Ever since it all started eight years ago, my drive has always been an extreme fear of the insomnia’s impact on my physical appearance—especially my face. I just cannot let go of the pain of seeing my face ruined by sleeplessness! . . . Frankly, I look 10 years older than my biological age.

I am so afraid that my face is scarred (it certainly looks that way) and that it cannot recover after all these destructive years!

When we look in the mirror and see drooping eyelids and dark circles under our eyes, do we imagine we look worse than we actually do?

Effects of Sleep Quality on the Skin

There haven’t been any studies comparing the skin of insomniacs with the skin of good sleepers.

But three years ago I blogged about a study involving 60 women, half reporting good quality sleep with a duration of 7–9 hours and the other half reporting poor quality sleep lasting 5 hours or less. (Symptoms of these poor quality sleepers come close to meeting the criteria for a diagnosis of insomnia disorder.)

First the researchers inspected participants’ skin. Then they tested the skin, exposing it to ultraviolet light and subjecting it to a tape-stripping procedure that caused skin barrier disruption. They then observed how long it took participants’ skin to recover from these challenges.

Study Results

Compared with the good sleepers’ skin, the poor sleepers’ skin:

  • Showed more signs of aging skin (e.g., fine lines, uneven pigmentation, flabbiness, and less elasticity)
  • Took significantly more time to recover from the UV light exposure, with redness remaining higher over a period of 3 days

The good sleepers’ skin recovered 30% more quickly than the poor sleepers’ skin.

The study results suggest that insomnia sufferers’ concerns about the health and appearance of our skin are probably valid.

Effects of Sleep Deprivation on the Skin

In another study researchers took photographs to compare the faces of healthy adults in two different situations: (1) when they were well rested and (2) under conditions of sleep deprivation. (Again, acute sleep deprivation is not the same thing as insomnia—and certainly not the same thing as chronic insomnia—but research suggests that insomniacs may suffer from mild sleep deprivation at least some of the time.)

Twenty-three participants, all healthy adults, were photographed in the afternoon after a normal 8-hour night of sleep and again after sleep deprivation (a 5-hour night of sleep followed by 31 hours of continuous wakefulness). The photos were then viewed in a randomized order and rated by 65 untrained observers.

What the Observers Saw

You can probably guess what the results of the study were. Compared with well-rested faces, sleep-deprived faces were perceived as:

  • Less attractive
  • Less healthy
  • More tired

“Apparent tiredness was strongly related to looking less healthy and less attractive,” the researchers wrote. “The fact that untrained observers detected the effects of sleep loss in others” suggests that our sleep history gives rise to signs that can be noted by other people.

In other words, after several bad nights, the pasty complexion and dark circles we notice in the mirror are not just figments of our imagination. Others see them, too—and may judge us as less healthy and less attractive as a result. (Keep in mind, though, that the participants in this study were quite severely sleep deprived when the second round of photos was taken.)

What Can Be Done

If preserving your skin is important, then taking measures to improve your sleep might be one of the best preservatives. CBT for insomnia (or sleep restriction) is the No. 1 treatment for insomnia recommended by sleep experts. Find information about it by clicking “Blog” at the top of this page and typing CBT or sleep restriction in the site search box.

What about products that might help to preserve the skin? A dermatologist once recommended that I use CeraVe Moisturizing Cream. I like it well enough but have no way of knowing if it’s keeping my skin looking younger than it would otherwise be.

If you’ve found a skin product you like, please share it here

Find the Right Sleep Doctor for Insomnia

When people write in with lots of questions about insomnia, I’ll often recommend seeing a sleep specialist or a sleep therapist who can provide cognitive behavioral therapy for insomnia (CBT-I).

But finding sleep specialists and sleep therapists can be tricky. Here’s why you might want to consult one and how to locate the right provider.

Insomnia sufferers can get help from sleep specialists and CBT providersWhen people write in with lots of questions about insomnia, I’ll often recommend seeing a sleep specialist or a sleep therapist who can provide cognitive behavioral therapy for insomnia (CBT-I).

But finding sleep specialists and sleep therapists can be tricky. Here’s why you might want to consult one and how to locate the right provider.

Why a Sleep Specialist?

Many people turn first to a primary care provider for help with insomnia. Some PCPs may know enough about sleep disorders to diagnose your problem and give you the help you need.

But a 10-minute appointment may not be long enough for a doctor to correctly diagnose your sleep problem—let alone figure out the most appropriate treatment. Also, sometimes I hear complaints about how PCPs respond to people with insomnia. The complaints go something like this:

“He didn’t seem to have much sympathy for my situation.”

“All she wanted to do was prescribe another sleeping pill.”

In contrast, a sleep specialist

  • Will probably have more empathy for your problem. A doctor who completes a one-year fellowship in sleep medicine after a 3- or 4-year medical residency is likely to take insomnia complaints more seriously and show more compassion than doctors without this training.
  • Will spend enough time with you to make an accurate diagnosis. There’s no objective test for insomnia, so sleep doctors have to figure out what’s wrong based on clinical interviews alone. Just because you have insomnia symptoms does not mean the underlying problem is actually insomnia disorder, or that the insomnia is not occurring in conjunction with another health problem. A good sleep specialist may spend 45 or 50 minutes with you in order to arrive at an accurate diagnosis.
  • Has in-depth knowledge of (1) sleep and sleep disorders, (2) the clinic- and home-based tests used to diagnose sleep disorders (rarely used if the suspected diagnosis is insomnia), and (3) the array of treatments available—and is qualified to administer those treatments.
  • May or may not be a certified provider of CBT-I.

Find a Board-Certified Sleep Medicine Specialist

To make sure you’re going to get good care, you’ll want to consult a sleep medicine specialist who is board certified. This means that he or she has passed the certification examination administered by the American Board of Sleep Medicine.

Board-certified sleep specialists are often affiliated with sleep centers accredited by the American Academy of Sleep Medicine. Use this AASM locator tool to find an accredited sleep center (and a sleep specialist) near your home.

Help with Cognitive Behavioral Therapy for Insomnia

But say you’re reasonably certain that yours is a case of persistent insomnia uncomplicated by any other disorder. You might want to try CBT-I and be looking for someone to guide you through it. If so, your quest for help with sleep will follow a slightly different path.

There’s a branch of sleep medicine called behavioral sleep medicine. It addresses the learned behaviors and thought patterns that typically disrupt sleep, and changes that can be made to improve sleep. Providers certified in this field are the ones who can help you out.

Some sleep specialists are certified in behavioral sleep medicine as well. (The credential is written CBSM, which stands for “Certified in Behavioral Sleep Medicine.”) MDs of all stripes are eligible to undergo training and become certified. So are psychologists (PhDs and PsyD’s), nurses, and some master’s-level health care professionals.

Unfortunately, certified CBT-I providers are still somewhat scarce. They tend to cluster in urban areas—which is also where most sleep centers are located.

Find a CBT-I Provider

But help is closer now than ever before. The Society of Behavioral Sleep Medicine has published a list of behavioral sleep medicine providers. The great thing about this list is that the providers are listed alphabetically by state (rather than by providers’ names). So click on this list of CBT-I providers, find your state (or a nearby state), and set up a consult.

It’s never too late!

If you’ve consulted a sleep specialist or a CBT-I therapist, how did you locate that person and were you satisfied with the help you got?

Insomnia and Napping: No One-Size-Fits-All Prescription

If you have insomnia, you’ve probably heard it’s best to avoid naps. Maybe you heard it from your doctor in a conversation about the rules of “good sleep hygiene,” or maybe you read it in a magazine. Is the advice to refrain from napping really sound advice and, if so, do you have to swear off napping completely to get a better night’s rest?

There are no one-size-fits-all answers to these questions, say researchers who recently reviewed the evidence behind the recommendation to avoid napping and other sleep-related do’s and don’ts. It depends on your age and situation.

Chronic insomniacs should avoid naps, but people whose sleep problems are less severe need not abstainIf you have insomnia, you’ve probably heard it’s best to avoid naps. Maybe you heard it from your doctor in a conversation about the rules of “good sleep hygiene,” or maybe you read it in a magazine. Is the advice to refrain from napping really sound advice and, if so, do you have to swear off napping completely to get a better night’s rest?

There are no one-size-fits-all answers to these questions, say researchers who recently reviewed the evidence behind the recommendation to avoid napping and other sleep-related do’s and don’ts. It depends on your age and situation.

Chronic Insomnia

If you’ve got chronic insomnia (trouble sleeping at least 3 times a week for at least 3 months accompanied by daytime impairments), then forgoing naps may improve your sleep. Research has shown that the pressure to sleep builds higher and higher during the daytime and is released at night during deep sleep. Napping during the daytime may result in the early discharge of some of the sleep pressure. This can make it harder for people with persistent insomnia to fall asleep and stay asleep at night.

Accordingly, if you go through cognitive-behavioral therapy (CBT) for insomnia, you’ll be asked to refrain from napping during treatment. The fact that CBT works as well as it does supports the idea that cutting out naps is a useful strategy for insomniacs who want to improve their sleep at night.

What should you do if you can’t survive without a nap? Sleep therapists may recommend the following:

  1. Keep the nap short—30 minutes or less—to avoid descending into deep sleep
  2. Refrain from naps in the evening, when the pressure to sleep is high.

Mild or Occasional Sleep Problems

If you’re basically healthy and your sleep problems are occasional or less severe, then it’s not so clear that cutting out naps will help. Nor is it evident, in insomnia associated with aging, that the benefits of napping don’t compare favorably next to the difficulties created when the nap is cut out.

Napping occurs more frequently as people age, so the subjects in most studies of napping in naturalistic settings have been older adults. The results have not been consistent from one study to the next. However, the majority have not identified a significant association between daytime napping and nighttime sleep in older adults. Nor did researchers who conducted a study involving healthy young and middle-aged nappers find such an association.

Adding a Nap

Researchers have also looked at how adding a nap into people’s daily schedules affects their sleep at night—mostly in middle-aged and older adults. Here, too, the results are mixed. In some studies, naps resulted in shorter, less efficient sleep at night; in other studies, the naps had absolutely no effect on nocturnal sleep.

Of note is the fact that no researchers have ever conducted a study to determine whether depriving habitual nappers of their naps actually improves their sleep at night.

So the recommendation not to nap that appears on the list of habits consistent with good sleep hygiene? Unless you have chronic insomnia, for now, take this recommendation with a grain of salt. There may be other more effective paths to reliably sounder sleep.

If you take naps, what effect do they have on your sleep at night?

Psychophysiologic Insomnia: What It Is & How to Cope

Psychophysiologic insomnia: This was my diagnosis when I finally decided to see a doctor about my sleep. I didn’t like the sound of it. “Psycho” came before “physiologic,” and to me the implication was that my trouble sleeping was mostly in my head.

My insomnia felt physical, accompanied as it was by bodily warmth, muscle tension, and a jittery feeling inside. I was anxious about sleep, too, and my thoughts weren’t exactly upbeat. But surely putting the psycho before the physiologic was putting the cart before the horse?

Psychophysiologic insomnia is a sleep problem involving physical and mental factorsPsychophysiologic insomnia: This was my diagnosis when I finally decided to see a doctor about my sleep. I didn’t like the sound of it. “Psycho” came before “physiologic,” and to me the implication was that my trouble sleeping was mostly in my head.

My insomnia felt physical, accompanied by bodily warmth, muscle tension, and a jittery feeling inside. I was anxious about sleep, too, and my thoughts weren’t exactly upbeat. But surely putting the psycho before the physiologic was putting the cart before the horse?

Don’t let the terminology put you off the way I did. Psychophysiologic insomnia (I’ll call it PPI) is a problem in which constitutional vulnerabilities, situational factors, habits, and dysfunctional thinking are so intertwined that it’s hard to sort them out. Here’s a brief description and recommendations on how to manage it.

A Diagnosis Based on Symptoms

No objective test can reliably distinguish between normal sleepers and people with PPI. So the diagnosis is made based on symptoms alone. In PPI as in other types of insomnia, the wakefulness may occur at the beginning, in the middle, or at the end of the night. But people with PPI also:

  • have a lot of anxiety about sleep
  • are prone to intrusive thoughts and involuntary rumination
  • feel physically wound up
  • fall asleep at unusual times and places
  • experience daytime impairments such as fatigue, moodiness, and trouble thinking

Polysomnography (PSG)—the test administered overnight in a sleep lab—is not usually recommended because it doesn’t discriminate well between people with PPI and normal sleepers. But PSG results show that overall, people with PPI sleep less, and spend more time in lighter stages of sleep, than people who sleep well. (In contrast, the PSG results of people with paradoxical insomnia look normal, even though sufferers may feel like they’re getting 1 or 2 hours of sleep at best.)

How PPI Develops

Often it begins in adolescence or early adulthood, showing up as light sleep or periodic episodes of poor sleep.* Some people are naturally more susceptible than others. This may be true, sleep expert Peter Hauri has written, because of “an inherent, mild defect in the sleep-wake system, i.e., either excessive strength of the reticular activating system [the arousal system] or a weakness in the inhibitory, sleep-inducing circuits. Because the sleep-wake balance in such patients might lean toward wakefulness, such people would be suffering from an occasional, neurologically based poor night of sleep long before developing serious insomnia.”

Stressful situations lead to more extended bouts of poor sleep. Sooner or later, concern about sleep sets in. This is when insomnia starts to get “serious,” to use Hauri’s word. Looking for ways to reestablish better sleep, people change their habits—trying harder to sleep, going to bed early, taking naps—in ways that actually make sleep worse. The bed and the bedroom come to be associated with not sleep but rather with wakefulness and worry about sleep.

Thus begins the vicious cycle where long stretches of wakefulness in bed, accompanied by feelings of tension, begin to condition arousal of the brain, in turn fueling more bodily arousal. What began as light sleep or an occasional stress-related bout of insomnia has become a chronic affair.

Management Options

Once the PPI train pulls away from the station, it’s hard to get off. For decades I tried every trick in the book—sleeping on the couch, watching nature programs, listening to white noise, scenting my pillows, rhythmic breathing, drinking tea made from Chinese herbs. Nothing worked for long or without cost.

The good news is that PPI, unlike some other types of insomnia, responds well to treatment with cognitive behavioral therapy for insomnia (CBT-I). (While the name might suggest that it’s similar to conventional talk therapy, CBT-I is mainly focused on helping people modify habits.) For me, sleep restriction therapy, a treatment offered as part of CBT-I, was especially useful. Sleep restriction led to an awareness that my sleep could be reliable if I timed it right.

Equally important, though, for people whose insomnia feels physical (like mine) is finding a way to tamp the physiological arousal down. What works best for me is daily aerobic exercise. Research also suggests that mind-body therapies such as yoga, tai chi, and mindfulness meditation are helpful in this regard.

If this sounds like the type of insomnia you’ve got, check into CBT-I and physical training. There’s nothing to lose and much to gain.

How do you manage your insomnia? Has your strategy worked?

* Lee-Chiong T. Sleep Medicine: Essentials and Review. New York: Oxford University Press; 2008: 84.

Easing Worry and Anxiety about Sleep

Insomnia sufferers write to me often with complaints about sleep-related worry and anxiety.

“The more important the next day is to me, the harder it is for me to sleep,” Jessica says. “So I worry about not sleeping and then it turns into a self-fulfilling prophecy.”

Finding a solution to this problem can be tricky. It may require experimentation before you home in on a strategy that works.

Insomnia characterized by worry and anxiety about sleep can be alleviated using psychological and physiological strategiesInsomnia sufferers write to me often with complaints about sleep-related worry and anxiety.

“The more important the next day is to me, the harder it is for me to sleep,” Jessica says. “So I worry about not sleeping and then it turns into a self-fulfilling prophecy.”

“I finally had about 4 good nights after starting sleep restriction (about 11 days ago) but had a horrible night of anxiety last night,” Stacy says. “I was anxious about not being able to continue my good nights of sleeping. I find it hard to practice relaxation exercises when I’m that anxious.”

Achieving a relaxed state conducive to sleep can seem impossible with a mind that’s racing from one fraught thought to another. Likewise, the physiological changes that accompany worry and anxiety—the release of stress hormones, a faster heart rate, bodily warming, tensing muscles—are a better preparation for fight and flight than for relaxation and disengagement.

How to stop obsessing about sleep and sleeplessness is the main concern of many insomniacs, yet finding a solution can be tricky. It may require experimentation before you home in on a strategy that works.

Different Schools of Thought

Research backs a handful of approaches to managing the problem, but even among sleep experts there is no consensus as to which works best. It may depend on the nature of your insomnia and which approach you find more appealing.

Some experts promote a type of talk therapy–called “cognitive restructuring–as effective in reducing worry and anxiety related to sleep. The idea behind it is that sleep-related anxieties develop in part due to the misconceptions people have about sleep and catastrophic thinking about insomnia. Replacing these ways of thinking with attitudes that are more realistic and sleep-supportive should help.

Cognitive restructuring is normally presented as part of cognitive-behavioral therapy for insomnia (CBT-I). It usually involves work with a therapist, who helps you learn to talk yourself out of worries and anxieties about sleep and sleeplessness.

Mind/Body Approaches to Curbing Arousal

Other experts suggest that psychological treatments for sleep-related anxieties may not be as effective as treatments that simply help insomniacs learn to relax. Physiological hyperarousal is the main cause of poor sleep, they say, with sleep-related anxiety and worry developing as a result. Treatment should focus on tamping down arousal that gives rise to these sleep-related worries, enabling a stronger and more dependable relaxation response.

  • Relaxation training is recommended as helpful to sleep by the American Academy of Sleep Medicine. It may involve progressive muscle relaxation and/or autogenic training (guided visualization).
  • Mindfulness-based therapies enable people to become more accepting of unpleasant feelings and sensations and, in so doing, alleviate them. Mindfulness meditation has been shown in a handful of studies to help insomnia sufferers by cutting down on pre-sleep arousal, reducing wake time at night, and enhancing sleep quality.
  • Yoga has now been shown in several studies to help insomnia sufferers learn to manage stress and get more sleep. Not only does yoga practice effectively deactivate the stress system. Yoga postures, breathing, and meditation exercises also help people develop more resilience to stress.

Exercise, Anxiety, and Sleep

Still other experts advocate exercise as the best way to relieve the anxious arousal that sabotages sleep. There’s now solid evidence that regular exercise promotes sounder sleep and preliminary evidence that exercise is effective in reducing anxiety. A meta-analysis published in April shows that even a single bout of exercise has a small but significant anxiety-alleviating effect.

Strenuous exercise is the way I calm myself down in times of stress, especially when my old fear of sleeplessness threatens to stage a comeback. The minute I feel that happening, I push myself to work out longer and harder and, most of the time, it helps.

But which kinds of exercise will give you the most bang for the buck? University of Pennsylvania researchers, analyzing data from a huge survey of behaviors affecting health, have found that while walking is associated with better sleep compared with getting no exercise at all, aerobics, calisthenics, biking, gardening, golf, running, weight-lifting, yoga and Pilates are associated with even better sleep.

Consider these strategies if worry and anxiety are feeding your insomnia. Continuing to obsess about sleep and sleeplessness is surely worse than making a good-faith effort to try some of these practices out.

The Insomnia/Perfectionism Connection

Do you hold yourself to high (sometimes impossibly high) standards? Do you tend to be self-critical and cringe at making mistakes? Is it even difficult sometimes to take pleasure in your own hard-won achievements?

These are signs of perfectionism, and perfectionists are more susceptible to insomnia than people who can shrug off their mistakes.

Perfectionism may or may not be a predisposing factor to insomniaDo you hold yourself to high (sometimes impossibly high) standards? Do you tend to be self-critical and cringe at making mistakes? Is it even difficult sometimes to take pleasure in your own hard-won achievements?

These are signs of perfectionism, and perfectionists are more susceptible to insomnia than people who can shrug off their mistakes.

The theory that perfectionism and other personality traits (such as neuroticism and internalization of negative feelings) are the main drivers of insomnia has not withstood the test of time. But the evidence for an association between perfectionism and insomnia remains fairly strong. Even so, a team of Swiss researchers has found that when they take stress, poor coping strategies, and poor emotion regulation into account, perfectionism’s role in explaining insomnia all but disappears. There’s a message here for those of us who want to improve our sleep.

Where Perfectionism Comes From

Like many personality traits, perfectionism appears to have both environmental and genetic components. “It is likely that a perfectionistic orientation develops over time, and family history may contribute to the development of perfectionism,” wrote Cal State University researchers David R. Hubbard and Gail E. Walton, who in 2012 reported interviewing 36 students about perfectionism and the motivation to achieve. Two aspects of experience differentiated the perfectionists from their nonperfectionist peers:

  1. The perfectionists felt pressure from their families to succeed.
  2. Their parents were overly critical of their mistakes when they were growing up.

But inherited genetic material may also make people more inclined to perfectionism. When researchers at Michigan State administered a series of tests to 292 young female adults in the Michigan State University Twin Registry, they found that both anxiety and maladaptive perfectionism (concern about mistakes and doubts about actions) were moderately heritable—on par with the heritability of general intelligence. A second twin study found that identical twins were more alike than fraternal twins in how much they idolized skinny celebrities—another sign of perfectionism.

A Relationship Between Perfectionism and Sleep

Chronic insomnia is attributable to a mix of factors: physiological and psychological, environmental and behavioral, inherited and learned. The dysfunctional processes underlying perfectionism (manifesting as doubts about abilities, concern about mistakes, and so forth) might be similar to those that underlie trouble sleeping, the Swiss researchers reasoned. So they gave a battery of pencil-and-paper tests to 346 college students to see what relationships would emerge.

Statistical analyses showed that perfectionistic traits were associated with trouble sleeping and the same daytime complaints of people with persistent insomnia: tiredness, reduced concentration, and low mood. But when perceived stress, poor coping strategies, low emotion regulation, and low mental toughness were factored into the equation, perfectionism’s contribution to sleep disturbance was nil. In other words, the researchers conclude, “It is not perfectionism per se, but rather the underlying psychological mechanisms that best explain the association between perfectionism and poor sleep.”

Why Is This Important?

Let’s assume you have insomnia. A therapist you’re working with thinks the problem is personality-related and sets out to address it by helping you modify your perfectionistic tendencies.

Changing personality traits originating in childhood and/or predisposed at birth is a real challenge. It might not be impossible to free yourself from a harsh inner critic that developed under the watchful eyes of Mom and Dad, yet the effort it would take—several months (if not years) of psychotherapy—would be great and the results, uncertain. As for improving your sleep, well, good luck there. Psychotherapy has never been found to be an effective treatment for insomnia.

Targeting the psychological mechanisms underlying chronic insomnia directly would be a faster, more effective approach to improving sleep, the researchers conclude, particularly in insomnia sufferers with perfectionistic tendencies. Cognitive-behavioral therapy for insomnia (CBT-I) does this. Its cognitive restructuring component is aimed at dismantling the mental and emotional underpinnings of persistent insomnia. So CBT-I is a better treatment option than psychotherapy if your goal is better, sounder sleep.