Q&A: Will Regular Rest Curb Sleep Anxiety?

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

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

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

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

 

 

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

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

Night-to-Night Sleep Variability

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

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

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

Insomnia and Sleep Variability

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

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

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

A Pattern of Good and Bad Nights?

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

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

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

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

Take the Bull by the Horns

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

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

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

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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Q&A: Start Sleep Restriction Right for Best Results

“I’m on Day 4 of SRT and it isn’t going well,” Jenny wrote recently. “I finally had an appointment with a sleep therapist last week. He talked to me about SRT and gave me a 7-hour sleep window, from 11 p.m. to 6 a.m. My usual bedtime is 9:30 so I had some apprehensions. But I started 4 days ago.

“Since then I haven’t slept more than 3 hours a night. It’s really hard for me to stay up till 11, and then when I get in bed I’m wide awake! In the morning I’m so tired I can hardly keep my eyes open! Is this normal? I’m afraid I may be a treatment failure. Any advice?”

Before sleep restriction, keep a sleep diary for a week to ensure successRecently I’ve heard from a handful of people starting out with sleep restriction therapy (SRT), a treatment for insomnia. All were in a similar predicament. Here’s what Jenny wrote:

 

 

 

 

 

 

I’m on Day 4 of SRT and it isn’t going well. I finally had an appointment with a sleep therapist last week. He talked to me about SRT and gave me a 7-hour sleep window, from 11 p.m. to 6 a.m. My usual bedtime is 9:30 so I had some apprehensions. But I started 4 days ago.

Since then I haven’t slept more than 3 hours a night. It’s really hard for me to stay up till 11, and then when I get in bed I’m wide awake! In the morning I’m so tired I can hardly keep my eyes open! Is this normal? I’m afraid I may be a treatment failure. Any advice?

First Few Weeks of Treatment

The first few weeks of SRT are not much fun. Your time in bed is cut short at night and naps are not allowed. It can be hard to figure out what to do during the extra hours you’re up. In the daytime you may feel sleep deprived: exhausted, cranky, off your game.

Is this normal?

Research suggests it’s not abnormal. Results of a study of 16 insomniacs in the UK showed that while their sleep was greatly improved following SRT, during the first few weeks of treatment, they were sleep deprived. Like Jane Fonda said: no pain, no gain!

The Week Before Restriction Begins

Jenny’s experience of the first few days of SRT is not so unusual. But nowhere in her email—or in the others I received—was there any mention of having kept a sleep diary* during the week before treatment. Also, all 4 I heard from were starting SRT with rather generous sleep windows: 6.5, 7, and even 8 hours in bed. Yet they didn’t say how those sleep windows were established.

Maybe sleep diaries were kept—and the writers just didn’t mention them. Or maybe a therapist determined, based on a clinical interview, that starting out with a generous sleep window was the best way to treat insomnia in that particular person. (See my blog on paradoxical insomnia for more on this.)

But I suspect that at least some who wrote had plunged right in to sleep restriction without filling out a sleep diary the week before and that their sleep windows were set arbitrarily. This can make the first week of sleep restriction even rockier than it needs to be—and might lead people to think the treatment is failing and quit.

How Much Do You Sleep?

To set your sleep window (time allowed in bed) at the start of SRT, you need to know how much sleep you’re getting from night to night. Maybe you have a pretty good idea of that already. In reality, though, most insomnia sufferers are not very good at estimating sleep duration.

Keeping a sleep diary during the week before treatment won’t necessarily make your estimate more accurate—but it might. By noting in the diary how many times you wake up each night, how long the wake-ups last, and the variability in your sleep from night to night, you might get a more realistic read on the average number of hours you sleep.

Look Before You Leap

Regardless of whether keeping the diary clues you in to anything you didn’t already know, the results are an indication of how much your time in bed should be restricted at the start of sleep restriction:

  • You discover you’re a 6-hour sleeper? Start SRT with a 6-hour sleep window.
  • You’re sleeping 5 hours 15 minutes a night? Start with a 5.25-hour sleep window.
  • There’s one exception: most sleep experts (but not all) recommend starting SRT with nothing less than a 5-hour sleep window. So 4-hour sleepers are usually advised to start with a 5-hour window.

If you start with a too-small sleep window, you’ll wind up very sleep deprived. But if your sleep window is too generous (as I suspect may have been the case for Jenny and the others who wrote in), you’re likely to continue with the same broken sleep pattern you’ve known from before. This could sour you on sleep restriction even before you’re off the ground.

So keep a sleep diary for a week before starting SRT and set your sleep window accordingly. It’s the quickest path to success.

* Download this sleep diary from the National Sleep Foundation and make several copies for use during SRT.

What was your experience like during the first week of sleep restriction therapy?

Sleep Restriction: What You Need to Succeed

My video and blog on Sleep Restriction Therapy get lots of comments, and certain questions about SRT come up again and again. Here I’ll review the concepts behind this treatment for insomnia and offer pointers on how to succeed.

Sleep restriction guidelines should be carefully followed for sounder slumberMy video and blog on Sleep Restriction Therapy get lots of comments, and certain questions about SRT come up again and again. Here I’ll review the concepts behind this treatment for insomnia and offer pointers on how to succeed.

Why Restrict Sleep?

If you struggle with insomnia, chances are your sleep is not very efficient. You may toss and turn a long time before actually falling asleep, or awaken several times at night. You may wake up at 3 a.m. and not be able to get back to sleep.

Researchers have found that restricting sleep—or, more accurately, restricting time in bed—leads to increases in sleep efficiency, quality, and even length. Efficient sleep tends to be deeper and more satisfying. You wake up feeling more refreshed in the morning.

Right now you may not be sleeping very well. But if you build up sufficient sleep drive, the urge to sleep becomes so powerful that you can’t resist. The goal of sleep restriction is to enable a daily build-up of sleep drive that puts you to sleep more quickly and keeps you asleep longer—night after night.

Here’s How to Get Results

Have realistic expectations. Sleep restriction is not an overnight fix for insomnia. In fact your sleep may get worse before it gets better, and you may feel logy in the daytime, especially during the first week of therapy. (Don’t worry: this may actually speed the process up.) It’s realistic to expect to see signs that your sleep is improving within a few weeks.

Begin by keeping a sleep diary. Diving into sleep restriction without first gathering information about the length and timing of your sleep is a mistake. Sleep ability varies from person to person, and you can’t know how much to restrict your time in bed without first getting a clear picture of how much you’re actually sleeping. Download this sleep diary from the American Academy of Sleep Medicine, and make copies so you can maintain the diary throughout therapy.

Keep the diary for a week before starting treatment. Write down when you go to bed and get up in the morning, and how much of that time you’re actually sleeping. At the end of the week, calculate the average amount of time you sleep each night (disregarding for the moment how much time you spend in bed).

Make a list of quiet activities you can do at night once therapy begins. Passive activities like watching TV are not as helpful in the early stages as activities with a bit of movement—folding clothes, sorting through old photos, rearranging bookshelves. For more ideas, click here.

Establish your initial sleep schedule and stick with it. If you find you sleep an average of 5 ½ hours a night, in Week 1 restrict your time in bed to 5 ½ hours. Decide on a wake-up time and set your alarm for that time every day. Then count backwards 5 ½ hours to set your bedtime. Your sleep schedule could be from 12:30 a.m. to 6 a.m., or it could be from 10:30 p.m. to 4 a.m. Whichever one you choose, stick with it, staying up until your chosen bedtime and getting out of bed when the alarm rings. If you drift off early or if you oversleep your alarm, this will lessen the accumulation of sleep drive and retard your progress.

Avoid looking at the clock at night. Clock-watching tends to arouse anxiety in people with insomnia. Once your bedtime arrives, turn all clocks to the wall. If you can’t sleep, go to another room and do something quiet until you feel sleepy. But don’t look at the clock! In the morning when you’re filling out your sleep diary, estimate the time you were awake.

Calculate your sleep efficiency at the end of the week and set your sleep schedule for the following week. (See this blog for how make the calculation and reset the sleep schedule.) Continue the process for as many weeks as it takes to establish a solid sleep pattern and maintain a sleep efficiency of at least 85%.

Once you’ve found your ideal sleep schedule, observe that schedule night after night. Most important is getting up at the same time every morning (and resisting the urge to nap). This will prime you for sleep when bedtime rolls around and stabilize the sleep you get.

For more detailed guidance with sleep restriction therapy, see chapter 8 of THE SAVVY INSOMNIAC.

Q & A: Be Your Own Sleep Scientist

“What good is keeping a sleep diary,” Lawrence wrote to Ask The Savvy Insomniac recently, “when all it’s going to do is confirm what I already know?”

It might seem pointless—and like a whole lot of bother—to keep a sleep diary when you’ve lived many years with insomnia and know its shape and contour like the back of your hands. But I think it’s a valuable investigative tool.

sleep scientistWhat good is keeping a sleep diary, Lawrence wrote to Ask The Savvy Insomniac recently, when all it’s going to do is confirm what I already know? Insomnia is my problem—I’m lucky if I get 5 hours a night. Exactly how am I going to benefit if I find out that Monday night I slept 4 hours and 45 minutes and Tuesday I slept 6 minutes less? A colossal waste of time that I can see. Besides, clock watching tends to make my insomnia worse.

It might seem pointless—and like a whole lot of bother—to keep a sleep diary when you’ve lived many years with insomnia and know its shape and contour like the back of your hands.

But I think it’s a valuable investigative tool. Not only can keeping a sleep diary give you a more realistic picture of how much and how soundly you sleep. It can also help you zero in on habits that may be interfering with—or helping—your sleep. You can then adjust your habits accordingly.

How a Sleep Diary Works

The American Academy of Sleep Medicine has a good sleep diary that you can download here. The task is to keep the diary for two weeks, noting every day when you do the following:

  • Go to bed (Don’t look at the clock after going to bed)
  • Sleep (Estimate the time you fall asleep), including time spent napping
  • Take medicine
  • Drink beverages with caffeine
  • Drink alcohol
  • Exercise.

You might also want to note how well rested you feel each morning.

Results

Tracking these variables over a two-week period may reveal quite a lot. In addition to discovering what your average total sleep time is (which may or may not be surprising), you might find that drinking a second cup of coffee at noon is OK, but a second cup at 2 p.m. tends to keep you up too late. Or you might discover that exercise helps you sleep more soundly. I did.

Now to be really scientific about this, you’d have to test these variables one at a time. One week, keep a sleep diary and vary the amount or timing of the caffeine you drink. The next week, vary the amount or timing of the alcohol. And so forth.

But for me personally, since I’m mostly a creature of habit, the amount and timing of the things I do doesn’t vary all that much from one day to the next. It’s the activities and habits that DO vary that may afford insight into how to avoid insomnia and improve your sleep.

Getting scientific about things can sometimes help.

Have you ever tried keeping a sleep diary? What, if anything, did you learn?

Sleep Restriction in a Nutshell

In last week’s blog I explained the rationale behind sleep restriction as a treatment for insomnia. (Here’s a link to that blog post.) Now I’ll offer a quick and dirty description of how it works.

sleep-restrictionIn last week’s blog I explained the rationale behind sleep restriction as a treatment for insomnia. (Here’s a link to that blog post.) Today I’ll offer a quick and dirty description of how it works.

The first order of business is to keep a sleep diary, recording every morning how many hours you slept the night before. After one week, calculate the average number of hours you’re sleeping. This becomes the number of hours you’re allowed to be in bed during the first week of sleep restriction. (Many sleep therapists suggest starting with no fewer than 5 hours in bed.)

Start Restricting Your Time in Bed

Decide on a wake-up time, and count backward to determine your bedtime. Stay up until then every night, doing whatever it takes to stay awake. Get up at the same time every morning.

At the end of the first week of sleep restriction, calculate your “sleep efficiency” (percent of time in bed actually spent sleeping). Divide the total number of hours you slept during the week by the total number of hours you were in bed, and multiply by 100. If your sleep efficiency is above 85 percent (some therapists recommend that your sleep efficiency be at least 90 percent), then add 15 minutes to your time in bed during the second week.

For example, if during the first week you restrict yourself to 5 ½ hours in bed and your sleep efficiency is 90 percent, during the second week of sleep restriction, you increase your time in bed to 5 ¾ hours. If at the end of the second week your sleep efficiency is still above 85 percent, add 15 more minutes for a total of 6 hours in bed. And so on from week to week, until you find the maximum time you can spend in bed without your sleep efficiency falling below 85 (or 90) percent. This is your ideal sleep time, and, once you’ve found it, you stick with it.

The Hard Part

It’s not easy complying with such a rigid schedule, especially during the first week. I found it increasingly hard to keep myself awake until midnight, the bedtime I’d set. Passive activities like reading and watching movies led to nodding off early. So I switched to activities like folding clothes, rearranging cupboards, and walking around the house.

Also, it was harder and harder to pull myself out of bed when the alarm rang at 5 a.m. For three days I walked around like a zombie, forgetting appointments and misplacing glasses and keys.

But by the end of the first week, I was falling asleep the minute my head hit the pillow and sleeping right through the night—a major coup for me.

Sleep restriction is just one among a handful of treatments you may undergo as part of cognitive-behavioral therapy (CBT) for insomnia. Three online programs offering CBT are CBT for Insomnia, Sleepio, and SHUTi. Check into one of these if you’re leery of trying sleep restriction on your own.

Does sleep restriction sound like something you would try? Why or why not?

Sounder Sleep with Regular Exercise

For several years, I jogged, rode a bicycle or worked out at a gym three days a week. This physical activity was both a duty and a pleasure. It kept me healthy, and often it made me feel good. But it didn’t seem to affect my sleep one way or the other.

A new survey suggests that exercise generally tends to improve sleep.

Exercise-and-sleepFor several years, I jogged, rode a bicycle or worked out at a gym three days a week. This physical activity was both a duty and a pleasure. It kept me healthy, and often it made me feel good. But it didn’t seem to affect my sleep one way or the other.

A new survey suggests that exercise generally tends to improve sleep. Data from the National Sleep Foundation 2013 poll released on Monday show that

  • Exercise correlates with better sleep quality. About 83 percent of the survey respondents who got vigorous exercise reported their sleep quality to be “very good” or “fairly good,” as well as 76 to 77 percent of the respondents whose exercise was light to moderate. Only 56 percent of the non-exercisers reported good sleep quality.
  • Exercise helps you fall asleep faster. Non-exercisers reported taking nearly twice as long to get to sleep as those who exercised vigorously.
  • Exercise cuts down on feelings of sleepiness during the day. Nearly twice as many non-exercisers (24 percent) as exercisers (12 to 15 percent) experienced excessive daytime sleepiness.

Walking the Walk

Everyone knows we should get more exercise (just like we should eat more fruit and vegetables and pass on dessert). But finding the motivation to actually do the exercise is another matter. It can also be hard to find the time. After a day’s work, fixing dinner, playing with Junior and then getting him to bed, when can you fit it in?

The motivation issue can be tough to contend with, especially if you’re not convinced there’s a relationship between physical activity and your sleep, which is how I felt.

Keeping a Sleep Diary

Then about five years ago a sleep therapist suggested keeping a sleep diary for a couple weeks. I did, recording daily the time it took to fall asleep, the number of times I woke up, how long I slept and the amount of exercise I got.

The diary revealed a clear pattern. Overall, I slept better and longer, and fell asleep more easily, on nights following afternoon workouts on the elliptical trainer. There it was in black and white—the facts spoke for themselves.

This motivated me to start exercising every day, and it’s clear now that daily exercise really helps my sleep. So one way of tackling the motivation issue may be to keep a sleep diary for a few weeks to see if there is in fact a relationship between exercise and your sleep.

Finding time to exercise may be a harder problem to solve. I’ll consider this in a separate blog but, for now, the National Sleep Foundation poll concludes that “exercise, or physical activity in general, is generally good for sleep, regardless of the time of day the activity is performed.”

National Sleep Foundation – 2013 Exercise and Sleep Poll