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?

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.

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?