Goodbye to Sleep Anxiety (and Fear of Dogs)

Meet Toby, our new dog. No, he doesn’t have a sleep problem. But Toby has a problem that seriously affects the quality of his and our lives: he’s terrified of dogs. We adopted him from a rescue shelter, unaware that the mere sight of a 5-pound Chihuahua would cause Toby to leap and bark as though he feared for his life. Toby’s fear of dogs reminds me of my own fear of sleeplessness, which I struggled with for decades. The problem seemed insurmountable . . . until I went through insomnia treatment and found a way out. If sleep anxiety is your problem too, read on.

Conquering sleep anxiety makes me think I can help Toby overcome his fear of dogs.Meet Toby, our new dog. No, he doesn’t have a sleep problem. But Toby has a problem that seriously affects the quality of his and our lives: he’s terrified of dogs. We adopted him from a rescue shelter, unaware that the mere sight of a 5-pound Chihuahua would cause Toby to leap and bark as though he feared for his life.

Toby’s fear of dogs reminds me of my own fear of sleeplessness, which I struggled with for decades. The problem seemed insurmountable . . . until I went through insomnia treatment and found a way out. If sleep anxiety is your problem too, read on.

Wondering Where the Fear Came From

How our muscular, 47-pound Labrador Retriever mix came to fear even dogs one-eighth his size is something we’ll never know. The shelter had little information about Toby other than that he may have spent some time on a farm.

We do speculate about his past. His fear of dogs might be a symptom of post-traumatic stress. Maybe he was once mauled by a pack of wild dogs (he has no visible marks of mistreatment). Or maybe he simply was not exposed to other dogs during that critical socialization period during puppyhood (the little bit of plaque on his teeth suggests he may now be approaching two years of age).

Regardless of what led to Toby’s fear of dogs, it’s now well entrenched. Yet our trainer says that with proper training we’ll be able to change Toby’s response to and behavior toward dogs.

How My Fear of Sleeplessness Developed

I know more about how my fear of sleeplessness developed (although, memory being as unreliable as it is, here, too, there’s speculation). I think my sleep anxiety must have started with the recognition that I was awake when others in the house/neighborhood/dorm were sleeping, that others seemed to fall asleep more easily and quickly than I did. In fact it was often when I felt exhausted and most craved sleep that I found myself tossing and turning in bed, awake till well after midnight even as a teenager (way before the advent of smart phones!).

Unpleasant symptoms followed those short nights: moodiness and unease during the daytime; at night, tension in the stomach, body warmth, and a racing feeling emanating from my chest down through my arms and legs. It’s no wonder I started worrying about sleeplessness at night: who likes those symptoms, anyway?

Sleep Onset Insomnia and Blaming Myself

Toby can’t see how useless and self-defeating his fear reaction toward dogs is or berate himself for his behavior.

But over the years my anxiety about sleep caused me to feel plenty of anger and disgust with myself. It was bad enough that I had sleep onset insomnia and could never predict when I’d finally fall asleep. But I knew the sensations accompanying my anxiety — the racing mind, the warmth, the tingling arms and legs — were only going to delay sleep further, yet I couldn’t stop myself from feeling them or worrying about how wasted I’d feel the next day.

I tried everything I knew of to solve the problem: relaxation exercises, yoga, tapes featuring sounds of nature, music purported to coax listeners into deep sleep. Those things might work for a week or two but soon I was back to the same old obsessive thinking about sleep. That I was unable to get a grip on the problem, unable to stop myself from prolonging my own wakefulness made me feel like I was engaging in willful self-sabotage. Just how ridiculous was I for doing that?

My fear of sleeplessness felt as entrenched as Toby’s fear of dogs. And it kept me feeling like an adolescent for many, many years. Why couldn’t I grow up and out of this phase and fall asleep like everyone else?

Changing Toby’s Behavior

Apparently changing dogs’ behavior can be accomplished through classical conditioning. Toby is very motivated by food, so we’re doing clicker training with him. Every time he looks at a dog, we click and give him a treat, click and treat, click and treat.

Eventually, the trainer says, Toby will come to associate seeing dogs with the pleasurable experience of eating something tasty rather than the disagreeable thing he experienced before. It’s slow going, but we’re starting to see some changes and we’re only two months into the training.

Overcoming Sleep Anxiety

I went for decades believing I could never turn my fear of sleeplessness around. But it finally happened, and I attribute the change mostly to sleep restriction therapy, an insomnia treatment offered as part of cognitive behavioral therapy for insomnia.

You might think, since my problem involved anxious thinking about sleep, that cognitive therapy would be the way to go. In fact, as I underwent insomnia treatment, I was guided through “cognitive restructuring,” a cognitive approach to extinguishing negative thoughts and feelings about sleep through careful examination and reappraisal. Were my fears about sleeplessness realistic or distorted? If distortion was occurring, what might be an alternative, more balanced way of looking at the situation?

Apparently, this approach to decreasing sleep anxiety works for some people with insomnia. It did nothing for me. My fear of sleeplessness felt far too deeply rooted to be eradicated by simply reasoning with myself.

A Behavioral Approach to Fear Extinction

What it took to finally root out my fear was a behavioral approach similar to the one we’re using with Toby. By restricting my time in bed, sleep restriction therapy created the sleep pressure my brain apparently needed to fall asleep a lot more quickly. I started falling asleep pretty much on cue — a fabulous development! And when I began to see I could count on falling asleep with regularity, my fear of sleeplessness started to fade away.

The process took time, though, just as the process with Toby is going to take time. There were nights when the old anxieties returned to hijack my sleep. But with time the nights when fear ambushed me on the way to the bedroom were fewer and fewer.

Now my fear of sleeplessness is a thing of the past. With persistence and the right kind of insomnia treatment, yours can be made to disappear, too.

If you’ve struggled with sleep anxiety, what have you tried to decrease your anxiety, and has it worked?

CBT for Insomnia: Where to Find the Help You Need

Here’s a question that often comes my way: “I’d like to try cognitive behavioral therapy for insomnia [CBT-I], so where can I find a sleep therapist?”

The availability of CBT-I providers varies depending on where you live. Here’s where you’re likely to find help and where you’re not, and alternative ways to get the insomnia treatment you’re looking for.

Where to find a therapist who does CBT for insomniaHere’s a question that often comes my way: “I’d like to try cognitive behavioral therapy for insomnia [CBT-I], so where can I find a sleep therapist?”

The availability of CBT-I providers varies depending on where you live. Here’s where you’re likely to find help and where you’re not, and alternative ways to get the insomnia treatment you’re looking for.

Why CBT for Insomnia?

It’s the most effective insomnia treatment known at this time, improving sleep for 70 to 80 percent of the people who try it. CBT-I is more effective and long lasting than treatment with sleeping pills, and it’s effective for many people with chronic insomnia who also have other health problems such as depression, anxiety, or sleep apnea.

For more information on CBT-I, take a quick look at this blog post I wrote at the beginning of last year.

Where Can I Find Treatment?

It depends on where you live, say authors of a paper published last year in Behavioral Sleep Medicine. If you live in New York or California, insomnia therapy is likely close at hand. If you live in Hawaii, South Dakota, Wyoming, or New Hampshire, you’ll have no luck in finding a doctor, psychologist, or nurse practitioner trained in behavioral sleep medicine. Authors of the paper were unable to find a single provider practicing in those states.*

Here’s a chart showing the number of behavioral sleep medicine providers in the US by state:

No. of providers States
73–33 CA, NY, PA, IL, MA, TX
27–22 FL, OH, CO, MN, MI, WA
17–10 MD, NC, TN, AZ, MO, DC
9–6 CT, VA, WI, AL, OR, AR, SC, WV, IN, ME, NJ
5–3 AK, DE, GA, KS, LA, NE, RI, KY, NM, NV, OK, UT, MS
2–0 ID, ND, IA, MT, VT, HI, NH, SD, WY

 

Canada has 37 behavioral sleep medicine providers, but no other country outside the US has more than 7.

Do I Really Need a Sleep Therapist for CBT-I?

There are alternatives to working with a doctor or therapist trained in behavioral sleep medicine. But working with a professional—someone with a clear grasp of the protocol who can lead you through it step by step, motivating you to continue if the going gets rough—is probably the best way to ensure success and maximize the gains you’re going to make.

“Having somebody who’s experienced with this telling me that, if I do this, there’s a good chance everything will turn around is very inspiring,” said a man I interviewed for my book, The Savvy Insomniac, after we finished a group course in CBT-I.

Find a professional trained to administer CBT-I by clicking on this provider directory.

What If I Can’t Get Insomnia Therapy Nearby?

Your next best bet is to take an online course in CBT-I. These interactive courses have been found to be as effective as the face-to-face coaching you’d receive from a sleep therapist, the only downside being that research shows people going through an online course are more likely to drop out. Check these programs out:

  • CBT for insomnia is a 5-week course developed by sleep specialist Gregg D. Jacobs at Harvard Medical School. The cost is $49.95.
  • SHUTi sells its 6-week course, developed by Canadian sleep specialist Charles Morin, for $149. The price includes access to the site for 26 weeks. The extended access might appeal to you if (1) you’re not ready to jump right into the course, (2) something unforeseen happens during therapy and you have to start all over again, or (3) you feel you might like to continue tracking your sleep after the course ends.
  • Sleepio, developed by UK sleep specialist Colin Espie, offers a 6-week course plus a year’s access to the website and a host of supplementary materials for the hefty price of $400. What you’d gain from a whole year’s access to the website isn’t clear to me. But you may be able to access Sleepio for free by agreeing to take part in a research study.

Couldn’t I Just Read a Book?

You could. Stephanie Silberman’s book, The Insomnia Workbook: A Comprehensive Guide to Getting the Sleep You Need, leads you step by step through everything you need to know to go through CBT-I using the book as your guide. But here’s a warning: while I know it’s possible to succeed in self-administering CBT-I using only a book as a guide (I did), I hear some people complain of failure. Make sure you succeed by starting out right:

  1. Read all you can about the CBT-I protocol before starting therapy. It’s important to understand the process before you begin.
  2. For 1 to 2 weeks before you start therapy, keep a sleep diary (download a sleep diary here), recording bed and rise times and relevant habitual activities.
  3. From the data you’ve gathered, calculate your average nightly total sleep time and set your initial sleep window accordingly. (But if you sleep less than 5 hours a night, set your sleep window at 5 hours.)

Stick closely to the protocol and hang tight. Your sleep should start to improve in a couple of weeks.

If you’ve found this blog post helpful, please like and share on social media. Thanks!

*To gather data, the authors consulted a directory of professionals certified in behavioral sleep medicine, BSM provider lists, and BSM listservs.

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!)

2017: Resolve to Improve Your Sleep

Do you have a persistent sleep problem? Make cognitive behavioral therapy for insomnia your No. 1 New Year’s resolution for 2017.

Here’s what you stand to gain, what may stand in the way, and where to find help.

CBT for insomnia should be your no. 1 resolution for the new yearDo you have a persistent sleep problem? Make cognitive behavioral therapy for insomnia your No. 1 New Year’s resolution for 2017.

Here’s what you stand to gain, what may stand in the way, and where to find help.

A Treatment That Improves Sleep

Cognitive behavioral therapy for insomnia is focused on boosting sleep drive and removing psychological barriers to sleep. It’s become the front-line treatment for chronic insomnia because it gets results. Most people who undergo therapy can expect to:

  • Improve sleep efficiency. In other words, you’ll cut the time it takes to fall asleep in half, and cut the number of nighttime awakenings—and their duration—in half.
  • Improve sleep quality. You’re likely to sleep more soundly and wake up feeling more refreshed in the morning.
  • Sleep moderately longer, especially if you’re young or middle aged.

So why hesitate?

The First (and Maybe Biggest) Barrier to “Yes”

If you’re like I was, the biggest barrier to trying cognitive behavioral therapy (CBT) for insomnia may be the belief that nothing can improve your sleep. This is actually a logical way of thinking if you’ve had insomnia for a long time. After years of trying to improve your sleep by means you’ve read about elsewhere—chamomile tea, talk therapy, relaxation exercises—and getting poor results, why would your expectations for CBT for insomnia be anything but low? Hope is hard to come by after years of insomnia and failed attempts to improve sleep.

Gearing up to try yet another insomnia treatment can reawaken hope. But it also opens up the possibility of failing again. Just how comfortable is that? Besides, undertaking CBT for insomnia involves going through a process—and that process may not sound particularly quick or easy. It can be hard to silence these objections and commit yourself to another insomnia treatment.

A Second Possible Barrier: Fear of Sleeplessness

The prospect going through sleep restriction (the part of CBT for insomnia that involves curtailing your time in bed and observing prescribed bed and rise times) may make you uneasy. Sleep restriction was a red flag for me.

What if, during my allotted time in bed, I never fell asleep at all? This was scary to contemplate. As described in Chapter 8 of The Savvy Insomniac, my sleep anxiety was sky high when I went through treatment and drove me to do some pretty strange things.

No doubt my fear of sleeplessness made the first few days of treatment harder. But the gains I made were quick in coming. By the fourth night of treatment, I was falling asleep at my designated bedtime and sleeping right through the night—a pattern that was touch and go for a while but has held up very well over time. My sleep anxiety is now a thing of the past.

Take some advice from a lifelong insomnia sufferer who dithered around for 11 years longer than she should have before finally taking the plunge: just do it.

Finding a Sleep Coach

CBT for insomnia is typically administered by a trained sleep therapist over the course of 6 to 8 weeks. This is still the preferred form of treatment for the many insomniacs who like the idea of face-to-face coaching (and have insurance covering treatment or can afford to pay for it themselves).

Here’s how to find a sleep therapist certified in behavioral sleep medicine:

Some behavioral sleep medicine professionals offer a condensed form of CBT-I called brief behavioral treatment for insomnia (BBTI). Therapy takes place over 4 weeks (rather than 6 to 8) and involves two face-to-face meetings with the therapist and two follow-up phone calls. Read more about it in this blog post about BBTI.

CBT for Insomnia Online

What if you live in the hinterlands and there are no behavioral sleep medicine therapists nearby? With access to the internet, you’re still in business. Three interactive online programs—SHUTi, Sleepio, and CBT for Insomnia—are excellent resources for insomniacs in far-flung locales and those on a limited budget:

  • The SHUTi program ($135 for 16 weeks of access and $156 for 20 weeks of access) was recently shown in a clinical trial to get results equivalent to those obtained in standard face-to-face CBT-I.
  • A clinical trial of the Sleepio program ($300 for 12 months of access) is under way right now.
  • The CBT for Insomnia program is a 5-session program created by Dr. Gregg Jacobs, author of Say Goodnight to Insomnia, for the nominal cost of $44.95.

Insomnia sufferers, suspend your disbelief and try this out. I can’t promise it will relieve your insomnia—but the odds are greatly in your favor.

Good night, and good luck.

What doubts do/did you have about CBT for insomnia?

Sleep Tracking? No. Now It’s Sleep Training

You can train to run a marathon. You can train yourself to recognize Chopin. But can you train yourself to sleep (or train yourself not to have insomnia)?

Michael Schwartz, creator of the Sleep On Cue iPhone app, says yes.

Insomnia sufferers may learn how to sleep with this iPhone appYou can train to run a marathon. You can train yourself to recognize Chopin. But can you train yourself to sleep (or train yourself not to have insomnia)?

Michael Schwartz, creator of the Sleep On Cue iPhone app, says yes.

Sleep training “appears to work via conditioning,” Schwartz said in a recent email exchange. “People ‘learn’ the act of falling asleep. I have found it to be helpful for those who struggle to fall asleep initially and/or struggle to return to sleep during the night.”

But why do insomniacs need to learn to sleep when for most people sleep is effortless?

Intensive Sleep Retraining

The idea of sleep training is based on intensive sleep retraining (ISR), an insomnia treatment originally developed by sleep researchers in Australia. It grew out of sleep studies showing that many insomniacs fall asleep more quickly and sleep longer than we think we do.

Schwartz has observed this phenomenon firsthand in his work as a registered sleep technologist in the United States.

“It seems [that insomniacs] who are taking a traditional hypnotic . . . tend to overestimate sleep time,” he says. “Then if the insomniac begins a tapering of the medication, it swings to an underestimation of sleep time.”

Unlearning and Relearning Sleep

The question of why so many insomniacs tend to underestimate sleep time has not been definitively answered. ISR proponents suggest that insomniacs’ trouble sleeping is conditioned, resulting from poor sleep habits, worry about sleep loss, and negative beliefs about sleep. Eventually we lose touch with what falling asleep actually feels like.

So the goal of treatment is to retrain insomnia sufferers in the experience of falling asleep. Proponents claim that sufficient practice (within the prescribed protocol) will make our perceptions more accurate (i.e., more in sync with objective sleep tests, which indicate we’re sleeping longer) and restore confidence in our ability to sleep.

The Challenge and the Payoff

The ISR treatment as originally prescribed is short but onerous. You spend 25 nearly sleepless hours in a sleep lab. Every 30 minutes, you get a chance to fall asleep (and if you fall asleep, you’re woken up). At the end of the 25-hour period, you’ve had lots of practice falling asleep . . . and you’re very sleep deprived.

But after the initial 25 hours the benefits of ISR are immediate. With loads of sleep pressure built up by the next night and instructions on how to proceed, insomniacs who undergo ISR have experienced improved sleep starting at Day 2. The gains continue, research has shown, for at least 6 months.

A Sleep Training App

An insomnia treatment that involves wiring patients up in a sleep lab and round-the-clock supervision by sleep technicians is very expensive (which may be the reason nobody’s doing ISR in the United States). So when a call came out to get ISR out of the lab and make it available to insomniacs at home, Schwartz went to work.

“After reading the ‘call to action’ article by the notable insomnia researchers, I began thinking about how to detect sleep onset without expensive amplified EEG recording,” Schwartz said. He came up with several ideas before landing on the idea of an iPhone app.

“My ‘ah-ha’ was to realize that a call (tone) and response (slight movement) with a smartphone might be the ticket,” Schwartz said, “and it seems to work well.” Here’s how:

  • You lie down in bed holding your iPhone. Each time the phone emits a tone, you shake it slightly.
  • If the app doesn’t detect a shake, it assumes you’re asleep and vibrates to wake you up.
  • A message then comes on the screen: “Do you think you fell asleep?” You press yes or no.
  • You’re then instructed to leave the bed for a few minutes. The phone vibrates again to indicate when to return to the bed for the next sleep trial.
  • You decide when to end each training session. The screen then displays a graph with information about your sleep ability and your awareness of your sleep.

Modified ISR

The Sleep On Cue protocol is very similar to the ISR protocol, allowing for repeated, short sleep onset opportunities with sleep–wake estimation and confirmation. But Schwartz felt he needed to make ISR more palatable for home users.

“So I decided to reduce each sleep trial time slightly after each successful sleep attempt, as well as to prompt the user to leave the bed for just a couple minutes between sleep trials,” he said. “These two features allow more sleep trials in a shorter amount of time.

“I suggest . . . that sleep training should be done around bedtime for a couple of hours following any poor night of sleep. So maybe 10 sleep trials. Put the phone down and go to sleep when done, review the summary graph in the morning.”

Testimonials on the Sleep On Cue website suggest the app has been helpful for users, including users coming off sleeping pills. According to Schwartz, tests verifying the accuracy and clinical effectiveness of a modified version of the app are under way in Australia right now.

“The best user of my app is someone who is committed to sleep training,” he said, “who can grasp the idea of ISR and how it can help.”

If you try this app, let us know how you fare.

Are Sleep Restriction and Exercise a Good Mix?

When people ask what insomnia treatment helped me the most, I mention sleep restriction therapy (SRT) and exercise.

But I’d never seen SRT and exercise paired as equal partners in a therapeutic intervention for insomnia until last week. Trolling the Internet, I came across a study conducted in China to determine whether adding an individualized exercise program to SRT would result in better outcomes than SRT alone. The investigators came up with interesting results.

Sleep restriction therapy and exercise are an effective combinationWhen people ask what insomnia treatment helped me the most, I mention sleep restriction therapy (SRT) and exercise.

But I’d never seen SRT and exercise paired as equal partners in a therapeutic intervention for insomnia until last week. Trolling the Internet, I came across a study conducted in China to determine whether adding an individualized exercise program to SRT would result in better outcomes than SRT alone. The investigators came up with interesting results.

Getting Beyond “No” to “Yes”

For some readers neither SRT nor regular exercise will have much appeal.

Sleep restriction may sound difficult if you feel you don’t get enough sleep. Nobody wants to experience sleep deprivation. And sleep deprived is probably how you’re going to feel in the first week or two of therapy. Most people’s sleep eventually improves (and continues to improve following treatment), but the fact remains that in the first few weeks, SRT is not a picnic.

Many insomniacs are likewise turned off at the thought of exercise or physical training.

“Usually when I propose physical training to my patients,” sleep investigator Michael Bonnet told me in an interview, “they don’t like the idea. They’re resistant to the idea of exercise, and this may have contributed to their sleep problem in the first place.”

And just how realistic is it to think that people experiencing mild sleep deprivation will be motivated to step up their level of physical activity? Research has shown that exercise improves sleep, but it’s also shown that poor sleep makes people less willing to exercise. How could an insomnia treatment be set up to avoid these potential snags?

Sleep Restriction, Slightly Modified

The team from China, whose study appeared in Neuropsychiatric Disease and Treatment in October 2015, did so by using a slightly modified version of SRT and offering intensive one-on-one support for the exercise.

Usually people begin SRT by keeping a sleep diary and restricting their time in bed to their average total sleep time (but usually not less than 5 hours a night). In this study, all 71 participants began with a sleep window equal to their average total sleep time plus half an hour. So a person averaging 5 hours of sleep a night began SRT with a 5.5-hour sleep window.

The rest of the 4-week treatment went by the book. Participants used data from their sleep diaries to calculate sleep efficiency at the end of each week and adjusted their sleep windows accordingly.

An Individualized Fitness Plan

In addition to SRT, half of the participants attended weekly help sessions with a fitness counselor. The first week’s session consisted of creating an individualized fitness plan. It included

  • an assessment of the participant’s fitness and information about the benefits of 30 minutes of moderate-intensity exercise at least 5 days a week;
  • setting personal goals and drawing up a plan to do the exercise of their choice; and
  • a prescription for how and when the exercise would be carried out, and a calendar for recording each exercise session and noting weekly follow-up visits with the counselor.

At the follow-up visits the counselor reviewed each participant’s progress, provided support, made adjustments as needed, and encouraged adherence to the fitness plan.

A Better Outcome

After 4 weeks of SRT, the sleep of both groups had improved: participants were falling asleep more quickly, experiencing fewer middle-of-the-night wake-ups, and sleeping 20 to 30 minutes longer every night. They were also more alert during the daytime.

But the sleep efficiency of the exercisers improved significantly more than that of the non-exercisers (20% vs 13%). In other words, the exercisers were spending less time awake in bed.

Also, the exercisers reported significantly less sleepiness and fatigue during the daytime. This might be a direct effect of the increased physical activity during the daytime. But the authors suggest it might also be a sign of improved sleep quality.

These results don’t surprise me. If I hadn’t kept up my workouts on the elliptical trainer during SRT, getting past wakefulness to sleep would have been harder. I’m almost certain my sleep wouldn’t have improved as quickly as it did.

If you’re considering SRT, consider stepping up physical activity as well. It can only help.

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It Might Not Be Insomnia After All

People come here looking for solutions to sleep problems. Some read about sleep restriction, a drug-free insomnia treatment, and decide to try it on their own. It’s not rocket science: insomnia sufferers who follow the guidelines often improve their sleep. It’s empowering to succeed.

But self-treatment is not the right approach for everyone. Sometimes insomnia is complicated by another disorder, or what looks like insomnia is actually something else. In both cases, the best thing to do is to have yourself evaluated by a sleep specialist ASAP.

Self-help treatments for insomnia will not work for other sleep disordersI’m a take-charge person when it comes to managing chronic health problems, especially when solutions proposed by doctors are unsatisfactory. I hunt for solutions myself, reading a lot and sometimes coming up with a fix.

People come to my blog looking for solutions to their sleep problems. Some read about sleep restriction, a drug-free insomnia treatment, and decide to try it on their own. It’s not rocket science: insomnia sufferers who follow the guidelines often improve their sleep. It’s empowering to succeed.

But self-treatment is not the right approach for everyone. Sometimes insomnia is complicated by another disorder, or what looks like insomnia is actually something else. In both cases, the best thing to do is to have yourself evaluated by a sleep specialist ASAP.

Up Late at Night

Chris wrote in with questions about sleep restriction several months ago:

I recently started sleep restriction therapy about 3 days ago, and I’m not too tired during the day even though I barely slept the last two nights. Is this normal? I set my bed time at 3:30 a.m. and force myself to get up at 9:30 a.m. even if I haven’t slept too well. Should I restrict my time even more if I’m not too tired? Additionally, I find that I have anxiety when I am in bed sometimes. Do you think I should get out of bed if I am anxious?

Chris knows he experiences insomnia, but the symptoms he reports aren’t the classic symptoms of people with insomnia disorder.

  • He’s “not too tired during the day” even though he “barely slept the last two nights”; many insomniacs during the first week of sleep restriction report feeling tired and out of sorts.
  • He’s set his sleep window at 3:30 to 9:30; a more normal sleep window would be from 12 to 6. Maybe Chris works the evening shift and can’t get to bed until 3:30. But if this is his sleep window of choice, then maybe he has a circadian rhythm disorder—in which case sleep restriction would not be an appropriate treatment.
  • He’s anxious when he’s awake in bed; many insomniacs are, too. But Chris’s anxiety could also be an indication of something else.

Chris’s situation sounds complicated and as though in starting sleep restriction he may be on the wrong track. My response to Chris and others like him is to suggest seeing a sleep specialist for an accurate diagnosis and guidance in managing the problem.

Sleepy in the Afternoon

Shelley contacted me via Ask The Savvy Insomniac. “Could sleep restriction help me?” was the subject line of her email.

I’ve had insomnia for 5 years now. Getting to sleep is no problem. But I wake up several times at night. It’s a drag. The alarm rings in the morning and it never feels like the night was long enough. I manage OK in the morning but after lunch I’m like the walking dead. Coffee doesn’t help. I fall asleep during meetings all the time and people notice. It’s embarrassing.

Nighttime wake-ups are a common symptom of chronic insomnia. But Shelley’s inability to stay awake during afternoon meetings gives pause.

It might seem logical that a person with insomnia would feel sleepy during the daytime, and some insomniacs report that they do. Other words that describe the feeling are tired, fatigued, and exhausted.

But the actual inclination to nod off involuntarily during the daytime is not as common in people with insomnia as it is in people with other sleep problems: sleep apnea, for example, and narcolepsy. It might sound counterintuitive, but a majority of insomniacs given opportunities to sleep during the day are no more likely to do so, say sleep experts, than people who sleep well at night. In fact, some studies show it takes insomniacs longer than normal sleepers to fall asleep during the daytime.

If Shelley has sleep apnea or narcolepsy, sleep restriction will do more harm than good. She needs to consult a sleep specialist and get a diagnosis before starting any type of treatment.

The Take-Away

What looks like insomnia may not actually be insomnia disorder. Before you plunge into sleep restriction or any other insomnia treatment, see a doctor for a diagnosis or do lots of reading to make sure that what you’ve got is insomnia and not something else.

Q&A: Sleep Efficiently for a Better Night’s Rest

A reader—I’ll call her Chantal—wrote in June with questions about insomnia and sleep restriction. A few weeks ago I heard from her again:

I’m now in week 6 of sleep restriction and I have to say my sleep is getting better. I mostly sleep for 5.5 hours a night. When I started it was 3.

But the last couple of nights, I’ve woken up in the middle of the night and had trouble falling back to sleep. I have no idea why I’m waking up. Do you have any tips for staying asleep?

Insomnia sufferers can improve their sleep by spending less time in bedA reader—I’ll call her Chantal—wrote in June with questions about insomnia and sleep restriction. A few weeks ago I heard from her again:

I’m now in week 6 of sleep restriction and I have to say my sleep is getting better. I mostly sleep for 5.5 hours a night. When I started it was 3.

My sleep window starts between 11 and 12 and ends at 6. I was having trouble staying awake until midnight, and by allowing myself to go to bed at 11 (or soon after that) I can fall asleep faster.

But the last couple of nights, I’ve woken up in the middle of the night and had trouble falling back to sleep. I have no idea why I’m waking up. Do you have any tips for staying asleep?

Chantal’s sleep has improved a lot with sleep restriction therapy. She’s nearly doubled her sleep time, going from 3 to 5.5 hours of sleep a night. But now her sleep is interrupted with wake-ups. If she wants to stay asleep at night, she needs to improve her sleep efficiency. Regardless of whether you’re going through sleep restriction therapy, it’s helpful to understand this concept if you want to improve your sleep.

Why Sleep Restriction?

Sleep restriction therapy is an insomnia treatment that consolidates sleep by first limiting time in bed to the actual amount of time a person is sleeping. (That chunk of time is sometimes called the sleep window.) Most insomnia sufferers experience sleep deprivation in the first week or two. But studies show that fairly soon this leads to deeper, more efficient sleep. In the process you gradually enlarge your sleep window until you’re sleeping efficiently and as much as you can.

Sleep Efficiency—What It Is and Why It Matters

Sleep efficiency refers to the percent of time you’re actually sleeping when you’re lying in bed at night. The sleep of good sleepers is highly efficient (i.e., they’re asleep 90% or 95% of the time they’re in bed). They drop off quickly and sleep soundly through the night.

If you have insomnia, your sleep is probably inefficient, interrupted by patches of wakefulness. You may only be sleeping 70% or 75% of the time you’re in bed.

Restricting time in bed will help you (1) fall asleep faster and (2) cut down on sleeplessness in the middle of the night. In other words, your sleep will become more efficient—and efficient sleep is typically sounder and more refreshing.

Calculating Sleep Efficiency

If you go through sleep restriction therapy, you’ll calculate your sleep efficiency at the end of each week. Here’s how to make the calculation:

  • Sleep Efficiency (SE) equals Total Sleep Time (TST) divided by prescribed Time in Bed (TIB) multiplied by 100.
  • The formula looks simpler using abbreviations and symbols: SE = TST ÷ TIB X 100.

Increased sleep efficiency is good in and of itself. But during sleep restriction, your sleep efficiency is also used to establish your sleep window for the following week:

  • A high sleep efficiency suggests it’s time to enlarge your sleep window.
  • A low sleep efficiency (anything less than 80%) suggests a need to tighten up your sleep window until your sleep is solid again.

Reducing Wake-Ups at Night

Chantal says she’s averaging 5.5 hours of sleep a night but that she’s now having wake-ups. The problem may lie in her variable bedtime (between 11 p.m. and midnight) and the amount of time she’s spending in bed. It’s easy to see if we do the math:

If on most nights she goes to bed at 11 p.m. and gets up at 6 a.m. (for a total of 7 hours in bed), her sleep efficiency may be low: 5.5 ÷ 7 X 100 = 78.6%. Inefficient sleep is characterized by patches of sleeplessness.

In contrast, if on most nights Chantal restricts her time in bed to 6 hours (as would occur if she delayed her bedtime until midnight and got up at 6 a.m., or set her sleep window from 11:30 p.m. to 5:30 a.m.), her sleep efficiency will probably be high: 5.5 ÷ 6 X 100 = 91.7%. She can increase her time in bed by 15 or 20 minutes the following week.

Tightening up her sleep window now may enable Chantal to maintain consolidated sleep as she gradually increases her time in bed.

Bottom Line

If you’re going through sleep restriction, don’t make the mistake of enlarging your sleep window too fast too soon. At the end of each week, calculate your sleep efficiency and adjust your time in bed accordingly. Slow and steady wins this race.

For those who simply want to cut down on middle-of-the-night wake-ups, try spending less time in bed.