Sleep Restriction: New Thoughts on How It Works

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

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

Sleep restriction therapy involves postponing bedtime

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

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

Benefits of Sleep Restriction Therapy

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

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

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

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

The Triple-R Model of Sleep Restriction Therapy

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

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

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

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

Restricting Time in Bed

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

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

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

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

Restricting Time Awake

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

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

What’s not to like about that?

Regularizing the Timing of Sleep and Wake

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

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

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

Reconditioning Myself for Sleep

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

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

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

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

Anniversary Book Giveaway Marks Change in Blog

It’s time for a couple of announcements: The Savvy Insomniac came out four years ago today and we’re giving away 10 copies of the book to mark the occasion. Read on to find out how to get one yourself!

Announcement No. 2: I’ve been blogging weekly about insomnia for five years and now, starting in October, I’ll be posting once a month. I’m as committed as ever to offering news and perspective on issues related to sleep and insomnia. But other projects are calling and taking more time.

Here are the giveaway details. After that, a summary of popular blog topics you’ll hear more about in the future.

Still blogging about insomnia—now, once a month

It’s time for a couple of announcements: The Savvy Insomniac came out four years ago today and we’re giving away 10 copies of the book to mark the occasion. Read on to find out how to get one yourself!

Announcement No. 2: I’ve been blogging weekly about insomnia for five years and now, starting in October, I’ll be posting once a month. I’m as committed as ever to offering news and perspective on issues related to sleep and insomnia. But other projects are calling and taking more time.

Here are the giveaway details. After that, a summary of popular blog topics you’ll hear more about in the future.

Book Giveaway

First, heartfelt thanks to those of you who follow my blog. It’s one thing to visit a website now and then but quite another to sign up for news from a blogger who posts a 600- to 800-word story every week! Your interest in insomnia and insomnia treatments must be as deep and personal as mine.

For all the blogging I’ve done about sleep and insomnia, though, The Savvy Insomniac is the best and most comprehensive writing I’ve done on the subject. Anyone living in the US who hasn’t got a copy and wants one can use the contact form to let me know. The first 10 people who contact me with a question about sleep or insomnia (something you wonder about but haven’t found much information about) will get a copy of The Savvy Insomniac free of charge.

Don’t forget to include your mailing address. Overseas shipping rates are so exorbitant that I can’t ship books abroad. But inexpensive e-books continue to be available through Amazon and other online booksellers.

Here, now, are the blog topics most popular with Savvy Insomniac readers. Count on hearing more about them in the months ahead.

Insomnia Relief in the Form of a Pill

Sleeping pills don’t get great press these days, but they have great interest for Savvy Insomniac readers. Posts about Belsomra, the newest sleeping pill approved for the treatment of insomnia, consistently get the most views. Belsomra acts as a sedative by blocking transmission of orexin, a neurochemical that promotes arousal. Other orexin-blocking sleeping pills are in the works. I’ll write about them if and when they’re approved by the FDA.

Posts about sedating antidepressants are also popular. Since many sleeping pills have undesirable side effects, persistent insomnia is sometimes treated with low doses of a sedating antidepressant. Doxepin has been approved as Silenor for treatment of sleep maintenance insomnia. The others (trazodone, mirtazapine, amitriptyline) have not been sanctioned by the FDA as effective for insomnia. They do, however, have sedative properties.

Melatonin supplements are also of high interest to readers, especially in timed-release formulations. But melatonin is not a sleeping pill. Its usefulness lies in its ability to shift the timing of sleep. Melatonin is sometimes recommended to night owls whose daytime schedules make it necessary to go to sleep earlier than they would following their natural inclinations. It also helps lessen jet lag.

Insomnia: What’s Your Flavor?

Posts on the different types of insomnia are the next most visited category. Since the underlying causes of insomnia disorder remain unknown, insomnia is usually classified based on the symptoms people report.

Psychophysiologic (or psychophysiological) insomnia is the most common insomnia diagnosis given to those of us who report trouble sleeping at night and daytime impairments. Symptoms are both physiological (bodily tension and warmth, for example) and psychological (anxiety about sleep). Cognitive behavioral therapy (CBT) is now the first-line treatment for psychophysiologic insomnia.

A diagnosis of paradoxical insomnia may be made following a sleep study showing a large discrepancy between how much time a person reports sleeping and how much sleep is recorded on the polysomnogram (the test in the sleep lab). Treatment options vary and there’s no clear consensus on which works best.

Sleep Restriction for Insomnia Relief

Sleep restriction therapy comes in for a close third topic of interest to Savvy Insomniac readers. Offered as part of CBT-I or as a standalone therapy, sleep restriction has been found in research to improve several aspects of sleep.

Its appeal to readers of this blog may have to do with the sheer number of posts I’ve written on the topic (10) and the fact that it worked so well for me. Combined with daily exercise, sleep restriction helped me regularize my sleep and overcome my sleep anxiety. Invaluable gains, to me.

Seasonal Insomnia

Insomnia that varies seasonally is another topic that draws lots of readers. Environmental factors that occur in the spring and summer—too much light and too much heat—can easily interfere with falling and staying asleep.

Insomnia that starts in the fall and continues through the winter may be driven by other environmental factors. Lack of sunlight or other bright light is usually the culprit. Lack of vitamin D may be another factor. Expect to see an update on this topic coming fairly soon.

Don’t see a topic that interests you here? Use the contact form to ask a question about a topic that does interest you, and receive a free copy of The Savvy Insomniac.

And here’s a last request: please like and share blog posts you feel are helpful on Facebook, Twitter, and other social media. This will help The Savvy Insomniac blog remain discoverable to other insomnia sufferers looking for a better night’s rest.

Ebb Insomnia Therapy: The Silver Bullet We’ve Been Waiting For?

The company name has changed. So has the wearable part of this sleep-promoting medical device.

But the product launch at selected sleep centers is still set for the final months of 2017, with full production capacity expected next year. Here’s an update on a device that will add to research-based treatment options for people with insomnia.

Ebb Insomnia Therapy helps people fall asleep more quicklyThe company name has changed. So has the wearable part of this sleep-promoting medical device.

But the product launch at selected sleep centers is still set for the final months of 2017, with full production capacity expected next year. Here’s an update on a device that will add to research-based treatment options for people with insomnia.

What It Is

The Ebb Insomnia Therapy device was developed by Ebb Therapeutics (formerly Cerêve, Inc.). Worn at night, it consists of a soft headband (rather than the plastic cap envisioned last year) attached by a tube to a temperature regulator that sits on a bedside table. Fluid is continuously pumped through the part of the headband that rests against the forehead, cooling it down. Research has shown that by cooling the forehead, the device reduces metabolic activity in the front part of the brain and hastens the onset of sleep.

Excessive Brain Activity at Night

The bane of many insomnia sufferers at night is a mind that keeps going and going and doesn’t want to stop. Such thinking and other executive activities (planning, decision-making) are functions of the frontal cortex, or the front part of the brain, involving the metabolizing of glucose.

Functional brain imaging studies—movies of processes occurring in the brain—have shown that the brains of normal sleepers are mainly quiet at night. No activity is detected in the frontal areas. In contrast, imaging studies conducted by Ebb Therapeutics founder Eric Nofzinger have revealed a great deal of metabolic activity occurring at night in the brains of insomniacs, including activity in the frontal cortex. Published images show that at night, the brains of people with insomnia are “lit up like Christmas trees.”

Cooling the Brain

Why might cooling the brain help? For starters, our core body temperature tends to rise in the daytime and fall at night. Previous research has shown that we tend to fall asleep more readily when our core body temperature is on the downward part of the cycle.

Two early studies conducted on people with insomnia showed that cooling the forehead at night

  • reduced participants’ core body temperature, and
  • reduced metabolic activity in the brain, particularly in the frontal cortex.

When Nofzinger and colleagues conducted a third, larger study (randomized and placebo controlled), they found that wearing the device significantly reduced the amount of time it took insomnia sufferers to fall asleep.

Compared With Current Insomnia Treatments

Many medications for insomnia have unwanted side effects. Ebb Insomnia Therapy is reported to have no appreciable side effects and classified as low risk by the FDA. As for its effectiveness, only time will tell how well it stacks up against insomnia drugs such as Ambien and Belsomra. New insomnia treatments like Ebb are only required to perform significantly better than sham treatment or placebo pill to gain FDA approval.

Cognitive behavioral therapy for insomnia (CBT-I), currently the gold standard in insomnia treatments, requires effort and commitment to a rigorous, weeks-long therapeutic process. Ebb Insomnia Therapy is relatively effortless. All it involves is wearing a headband at night. Some insomnia sufferers may begin to benefit right away, according to the company website. Others may take time to adjust to the device and need to use it anywhere from 2 to 4 weeks before seeing sleep improvements.

Limitations

The device will not be sold over the counter. It requires a prescription from a licensed physician or a licensed nurse practitioner. Nor has Ebb Therapeutics said how much it will cost. The company has taken out several patents, though, so the device will not be cheap. In addition, a new fluid cartridge will need to be purchased every three months. The device and cartridges are not expected to be reimbursable by health insurance companies anytime in the near future.

It’s doubtful the device will solve the sleep problems of every insomniac. The studies show that Ebb Insomnia Therapy reduces the time it takes to fall asleep and users report, after 30 days, that it improves sleep quality. Nowhere is the company claiming the device cuts down on night-time wake-ups or increases total sleep time, two items on the wish list of many insomnia sufferers.

Even so, it may be the silver bullet that at least some insomniacs have been waiting for. Particularly if you feel your sleep problem is driven by a yammering brain that just won’t stop, Ebb Insomnia Therapy is certainly worth checking out.

Paradoxical Insomnia: A Second Look at Treatments

Paradoxical insomnia: a diagnosis given to people whose sleep studies show they sleep a normal amount but who perceive they sleep much, much less. When I wrote about it in 2015, the word was that cognitive behavioral therapy (CBT)—the gold standard in treatments for insomnia—might not be an effective treatment for it.

But a brief testimonial that recently appeared in American Family Physician argues otherwise. Here’s an update on this puzzling sleep disorder.

Paradoxical insomnia may respond to treatment with CBT & therapies lowering arousalParadoxical insomnia: a diagnosis given to people whose sleep studies show they sleep a normal amount but who perceive they sleep much, much less. When I wrote about it in 2015, the word was that cognitive behavioral therapy (CBT)—the gold standard in treatments for insomnia—might not be an effective treatment for it.

But a brief testimonial that recently appeared in American Family Physician argues otherwise. Here’s an update on this puzzling sleep disorder.

A Subjective-Objective Discrepancy

Time and again we hear that people with insomnia tend to underestimate sleep duration. Up to 50 percent of the time, the electroencephalograms (the graphic records of brain waves produced during overnight sleep studies) of insomnia sufferers reporting insufficient sleep look the same as those of normal sleepers, registering 7 or 8 hours of sleep.

But in people with paradoxical insomnia, the discrepancy between their sleep study results and their subjective assessment of their sleep is huge. The woman whose story appeared in American Family Physician perceived that she was routinely “awake all night.” Yet when she finally went in for an overnight sleep study, the record of her brain waves showed she’d slept a total of 7 hours and 18 minutes. She couldn’t believe it.

A Heavy Burden

You might think, since paradoxical insomniacs are getting a normal amount of sleep, that their insomnia symptoms would be less severe than those of “objective” insomniacs, whose sleep studies show they get less (sometimes considerably less) than 7 or 8 hours. Paradoxical insomnia may sound like “insomnia lite.”

Apparently it isn’t. Research has shown that paradoxical insomniacs tend to be more confused, tense, depressed, and angry than normal sleepers. They also have a higher metabolic rate, which suggests an overall higher level of arousal.

In-depth analyses of brain activity at night attest to this heightened arousal. Compared with objective insomniacs, paradoxical insomniacs experience more high-frequency activity, and less low-frequency activity, in the brain at night. Their sleep is light and vigilant.

Yet it’s often hard for people with paradoxical insomnia to convince others that anything is wrong. When the woman writing in American Family Physician complained about not having slept all night, her husband countered with insistence that she’d slept soundly the whole night. Her friends and colleagues were skeptical too, noting that she had a normal amount of energy and competence at work. She felt increasingly tormented—“not only because of the insomnia,” she wrote, “but also because of a loss of trust from my husband and friends. They said they wondered whether I was pretending just to get sympathy.”

What Could Be Wrong? What Can Be Done?

Scientists can’t explain exactly what the problem is. One hypothesis holds that paradoxical insomnia has something to do with sleep quality, and that treatments that train paradoxical insomniacs to perceive sleep when they’re objectively determined to be asleep may help. (See my other post about paradoxical insomnia here.) But adjusting people’s perceptions may not necessarily resolve all their insomnia symptoms or improve their long-term health.

Other researchers have proposed that paradoxical insomnia occurs due to heightened brain activity during sleep, a condition which is accurately perceived by those who experience it but will require more sophisticated measures to assess scientifically. If it’s true that in paradoxical insomnia the main barrier to satisfying sleep is excessive brain activity and vigilance at night, then therapies designed to lower arousal levels—exercise, yoga, meditation—may help.

How About CBT for Insomnia?

Some experts have expressed doubts about whether CBT for insomnia (CBT-I) has the potential to work as well for paradoxical insomnia as it does for the more common psychophysiologic insomnia. The main value of CBT-I is its ability to help people fall asleep more quickly and decrease nighttime wake-ups. At least when their sleep is assessed objectively, paradoxical insomniacs don’t usually have these particular problems.

But CBT-I also helps to dispel negative beliefs and excessive worry about sleep, which can make any type of insomnia worse. It was an effective insomnia treatment for the woman writing in American Family Physician. “After receiving cognitive behavior therapy,” she wrote, “I began to feel much better and now am able to sleep well most of the time.”

So if it feels like you’re hardly sleeping at all, consult a sleep doctor or a sleep therapist for a proper diagnosis and help in improving your sleep. There may be more insomnia treatment options than you think.

If you feel you’ve benefited from reading this post, please like and share on social media. Thanks!

7 New Insomnia Genes: What’s in It for Us

A flurry of articles recently announced the discovery of seven new risk genes for insomnia. In an era when new genes are being identified for everything from infertility to schizophrenia, you might regard this discovery as simply the soup du jour.

Not me. Growing up when trouble sleeping was attributed to psychological factors, coffee, and alcohol, I was elated by this news. We stand to gain so much from knowing the genetic underpinnings of insomnia.

Causes of insomnia are closer to being figured outA flurry of articles recently announced the discovery of seven new risk genes for insomnia. In an era when new genes are being identified for everything from infertility to schizophrenia, you might regard this discovery as simply the soup du jour.

Not me. Growing up when trouble sleeping was attributed to psychological factors, coffee, and alcohol, I was elated by this news. We stand to gain so much from knowing the genetic underpinnings of insomnia.

A Biological Basis for Insomnia

The most immediate benefit of the discovery is that it affirms what scientists have suspected for years: there is a biological basis for insomnia. This is common knowledge among sleep researchers but not so well known among members of the public or even doctors. They may still blame insomnia on psychological factors and poor self-control and dismiss it as a complaint unworthy of attention or treatment.

“Insomnia is all too often dismissed as being ‘all in your head,’” said Eus Van Someren, a lead researcher on the project, quoted in a press release. “Our research brings a new perspective. Insomnia is also in the genes.”

Genes contain the information needed to make proteins, and proteins do most of the work in the cells in our bodies and brains. The identification of insomnia risk genes suggests that vulnerability to insomnia has a neurobiological basis. It is likely driven by an excess or deficit of key neurochemicals or abnormalities in the circuitry of the brain.

What the Discovery Doesn’t Mean

People sometimes confuse the idea of genetic risk with biological determinism—the belief that hereditary factors are the sole determinants of who we are and the health challenges we face. The assumption is that if constitutional factors predispose a certain disease or health condition, then nothing can be done to alter its course.

There are a small number of irreversible diseases caused by mutations in a single gene. If you’re born with a certain mutation in the HTT gene, for example, you inevitably develop Huntington disease. Nothing can be done to change this.

But most diseases and conditions—insomnia included—are complex. No single gene determines whether you get them or not. Multiple genetic factors likely come into play, increasing the odds of developing a disorder but not making it inevitable. Environmental, social, psychological, and behavioral factors may play as big a role in determining whether you develop insomnia or not.

It might be possible to inherit several insomnia risk genes but, thanks to a privileged set of circumstances, never experience trouble sleeping a day in your life. Likewise, despite being biologically predisposed to experience insomnia, you may be able to manage the disorder some or even most of the time with cognitive and behavioral techniques.

Benefits of Genetic Studies

Genetic studies such as this one will enable scientists to trace the pathways by which insomnia develops and identify the biological mechanisms involved. In turn, insomnia treatments can be developed that alter these particular systems, rather than being aimed at systems merely suspected of involvement. Drugs can be developed to target the root causes of insomnia rather than simply tranquilizing the brain.

Other Discoveries and Implications

  • The insomnia risk genes are known to be associated with disorders that often occur with insomnia: restless legs syndrome, anxiety disorders, depression, and type 2 diabetes. Likewise, insomnia was found to have a shared genetic background with neuroticism and poor sense of well-being, traits that often occur in people with insomnia.
  • Some genetic variants associated with insomnia in women were different from the variants associated with insomnia in men, so the biological mechanisms driving insomnia may in some cases be different. If this is true, insomnia treatments prescribed for women may in some cases need to be different from those prescribed for men.

Every new genetic study brings us closer to the time when trouble sleeping will be treated based on the cause of the insomnia rather than its symptoms. Surely that’s something to celebrate!

Why Are Insomniacs Prone to Hyperarousal?

My insomniac nights are rare these days—but I had one last week. Nearing bedtime, it felt like a train was running through my body with the horn at full blast.

The mechanisms underlying hyperarousal are still unknown. But according to a study recently published in the journal PNAS, it may be linked to fragmented REM sleep and unresolved emotional distress. Here’s more:

hyperarousal is a common daytime symptom of insomniaMy insomniac nights are rare these days—but I had one last week. Nearing bedtime, it felt like a train was running through my body with the horn at full blast.

Earlier that evening I’d returned to a place where I had a humiliating experience a few years ago. Being at that place made it feel like the incident was happening again. The emotions it recalled were so powerful that at midnight I was still too aroused to fall asleep. I had a bad night and woke up to what I call an “insomniac day”: the feeling of being depressed and anxious at the same time.

Insomnia is often described as a problem of “hyperarousal,” and when I look for signs of hyperarousal in myself, this sort of situation comes to mind. It starts with a powerful emotion (like humiliation or excitement) and with what I’ve come to feel is an impaired ability to calm down. I have coping strategies that work pretty well in the daytime. But if something triggers strong emotion in the evening, I’m sunk.

The mechanisms underlying hyperarousal are still unknown. But according to a study recently published in the journal PNAS, it may be linked to fragmented REM sleep and unresolved emotional distress. Here’s more:

Sleep Helps Regulate Emotion

Sound sleep helps stabilize emotional memories in long-term memory. It also reduces their emotional charge. Being robbed at gunpoint just 2 blocks from your house is a frightening experience. But if you sleep well that night, the next day, although you’ll recall the robbery clearly, the fear accompanying it will be less distressing than it was the day before.

Rapid eye movement (REM) sleep, associated with dreaming, plays an important part in this process. Intact REM sleep enables us to regulate negative emotion and wake up in a better frame of mind. But when REM sleep is fragmented, as often occurs in insomnia, less resolution of emotional memories can occur. In this study, scientists looked for relationships between fragmented REM sleep, slow-resolving emotional distress, hyperarousal, and insomnia.

Shame and Other Self-Conscious Emotions

In the past, scientists investigating REM sleep’s role in emotion regulation have looked at its effects on basic emotions like fear and anger. But the authors of this study claim that people more often need help with problems involving self-conscious emotions such as pride, guilt, embarrassment, humiliation, and shame.

In this study, they focus on shame because “it may interfere the most with healthy psychological functioning. . . . By obstructing effective coping mechanisms, shame often hinders therapeutic progress, to the point that it may even lead to a negative therapeutic outcome.”

A Two-Part Study

Thirty-two people participated in the first part of the study, 16 with insomnia disorder and 16 with normal sleep. They spent two nights in a sleep lab undergoing polysomnography, a test that records brain waves. They also filled out a questionnaire about the frequency and content of their dreams.

Participants whose brain waves indicated more frequent arousals and who experienced increased eye movement during REM sleep (i.e., the insomnia sufferers) experienced more thought-like (rather than dream-like) mental activity at night. Investigators concluded that a higher “nocturnal mentation” score could be used as a stand-in for the experience of restless REM sleep.

For Part 2, about 1,200 participants in the Netherlands Sleep Registry filled out a battery of questionnaires concerning nocturnal mentation, the duration of emotional distress after a shameful experience, insomnia severity, hyperarousal, and a host of related phenomena.

Hyperarousal Linked to Slow-Dissolving Distress

The researchers analyzed their data using sophisticated statistical techniques and here’s what they concluded:

  • The overnight resolution of distress from shame (and likely other negative emotions) is compromised in people with insomnia
  • This deficit may result from a build-up of unprocessed emotion and contribute to hyperarousal
  • This deficit seems in part to develop due to restless REM sleep (with frequent arousals and high-density eye movements) and thought-like nocturnal mentation.

If all this is true, then insomnia treatments need to target restless REM sleep. No treatment available now has been specifically shown to do that. Still, given that cognitive behavioral therapy for insomnia (CBT-I) has been shown to help people with insomnia and depression, another disorder characterized by irregularities in REM sleep, it might be the best treatment on offer now.

Sleep Better with Fewer Bathroom Calls

Nothing ruins the night more than an overactive bladder. If you’re lucky you’ll fall right back to sleep when you return to bed. But getting back in the groove is not always easy. Sometimes your mind latches onto a problem and you lie awake for hours.

Here’s how to reduce the urge to go at night and get a better night’s rest.

Reducing bathroom calls at night will improve your sleepNothing ruins the night more than an overactive bladder. If you’re lucky you’ll fall right back to sleep when you return to bed. But getting back in the groove is not always easy.

“I wake up at 3 to go to the bathroom,” Becky, an acquaintance, told me recently. “Immediately I say to myself, ‘Here we go, I need to go the bathroom really quick and try not to wake too much and try not to think about anything and get right back into bed.’ But of course that doesn’t usually happen. Then I start to have a lot of anxieties—tension I can feel in my body, and a general feeling of stress. My mind starts racing and I’m not able to quiet it enough so that I can fall back to sleep.” Often that’s the end of her night.

Nocturia

The need to void at least once a night is common among seniors. Three-quarters of adults aged 65 and older say having to use the bathroom is the most frequent reason they wake up at night. But nocturia is not just a problem for seniors. Forty percent of younger adults attribute most of their nighttime awakenings to it, as do 58 percent of adults in middle age.

Statistics show that nocturia interferes with getting a good night’s sleep. It’s a risk factor for both insomnia (75% increased risk) and reduced sleep quality (71% increased risk). It’s associated with shorter sleep duration, poorer sleep efficiency, and greater daytime dysfunction as well.

Also, in a telling measure of just how big an impact it has, people with overactive bladders are less likely to benefit from insomnia treatments such as CBT-I (cognitive behavioral therapy for insomnia) and BBTI (brief behavioral treatment of insomnia). Consequently, say the authors of an analysis recently published in the journal Sleep, nocturia should be treated before or during the behavioral treatment of insomnia.

Cut down on nightly bathroom calls by changing what you consume and what you do:

  1. Keep yourself hydrated during the daytime but avoid drinking fluids after dinner (especially alcohol and beverages containing caffeine).
  2. Don’t eat foods high in liquid—soup and fruit, for example—for dinner.
  3. Avoid heavily salted foods later in the day. These foods cause your body to store extra fluid and increase urine production at night.
  4. If you are on diuretic medications (water pills), take them earlier in the day.
  5. If your bathroom trips at night are caused by swelling in the ankles and legs, elevate your legs during the daytime and wear compression hose.
  6. Do pelvic floor exercises. Squeeze the muscles that control the flow of urine and hold for a count of 10. Repeat 4 or 5 times. As your muscle control improves, increase the length of time you hold the muscles and the number of repetitions you do.
  7. If none of these strategies work, talk with your doctor about the possibility of taking a medication to reduce bladder spasms and the urge to go at night. Desmopressin and imipramine are two medicines that may help.
  8. Talk to the doctor about the advisability of surgery. Surgical options that relieve the urge to go at night include a device implanted under the skin near the tailbone and procedures for reducing enlarged prostates.