Q&A: Panic About Insomnia Relapse

Lately I’ve been hearing from people who improved their sleep using sleep restriction or full-blown CBT for insomnia (CBT-I) and then experience a relapse. They have a few bad nights and fear they’ve lost all the gains they made. Here’s how one reader recently described her plight:

“I realize that sometimes I will get scared when I have one or two bad nights once in a while. I’m afraid that insomnia will haunt me once again. Is this normal? What can I do?”

Insomnia sufferers should do something quiet at night until they're sleepyLately I’ve been hearing from people who improved their sleep using sleep restriction or full-blown CBT for insomnia (CBT-I) and then experience a relapse. They have a few bad nights and fear they’ll never sleep well again. Here’s how one reader recently described her plight:

 

 

I realize that sometimes I will get scared when I have one or two bad nights once in a while. I’m afraid that insomnia will haunt me once again. Is this normal? What can I do?

Normal or Abnormal?

When cognitive behavioral therapies for chronic insomnia work—and they do improve sleep for 70 to 80 percent of the insomniacs who try them—it can feel like such an achievement. “At last,” you think, “I’ve got this monkey off my back!”

In reality, though, only a minority of the people who undergo CBT-I report that their insomnia is “cured.” The rest of us experience occasional insomnia relapses.

As anyone who’s read The Savvy Insomniac knows, I went through CBT-I with a group of 4 other insomnia sufferers. At the final group meeting, the therapist gave us a handout on how to maintain the gains made during treatment and what to do in case of relapse. Not only are occasional relapses not abnormal; for many of us, they’re probably inevitable.

All Is Not Lost

The first relapse can feel like such a downer and provoke lots of anxiety. “What? I restricted my sleep only to end up right back where I started, and maybe even worse?” It’s easy to appraise the situation this way: you’re short on sleep, fatigued, and out of sorts. Everything about it feels depressingly déjà vu.

But all is not lost. What occurs during CBT-I is a process some scientists liken to a rewiring of the brain. Neural pathways related to new thoughts and behaviors are established as sleep becomes more regular and the bed and the bedroom come to be associated with sleep.

Older pathways active during insomnia do not disappear. Rather, the new pathways—to continue speaking figuratively—are superimposed on the old. With every good night of sleep, neural connections along the new pathways are strengthened. You expect to sleep well at night and you do.

The older pathways and ways of thinking are still there, though, and due to stress or anything else disruptive to sleep, they may regain some influence. Insomnia returns, and you’re as anxious about it as you ever were. But there’s good news, too: once the newer pathways are established, they’re easier to return to.

I’ll attest to this from personal experience. Before I went through CBT-I (and sleep restriction therapy), my bouts of insomnia could drag on for weeks. Now when I experience insomnia and (in rare cases) my fear of sleeplessness returns, I’m able to return to better sleep and dispense with the anxiety in a few days. I do it pretty much by following instructions I received during CBT-I. Here’s how:

What To Do in Case of Relapse

  • Don’t go to bed unless you’re sleepy. If after 15 to 20 minutes you’re not asleep, get up, go to another room, and do something quiet until you’re sleepy again. Then return to bed. If this doesn’t help after a few days, try the next suggestion.
  • Restrict your sleep by an hour or more for a few days. Be strict about getting out of bed at a consistent wake time—even on weekends.
  • Once your sleep is solid again, extend your time in bed by half-hour increments every 2 nights until you return to your desired bedtime.
  • Be sure to get daily aerobic exercise throughout the process.

If you’ve experienced a relapse of insomnia, please take a minute to share how you got your sleep back on track.

Sleep Well Despite Poor Work Conditions

Stressors at work— demanding bosses, looming deadlines, performance reviews, and the like—can fuel insomnia. But low light and the timing of work can also affect sleep. Lack of exposure to sunlight on the job and night or shift work may reduce total sleep time and deprive you of energy in your waking hours.

But you may be able to manage these less-than-optimal work conditions in ways that improve both your sleep and your stamina.

working without natural light has a negative effect on sleep and staminaStressors at work— demanding bosses, looming deadlines, performance reviews, and the like—can fuel insomnia. But low light and the timing of work can also affect sleep. Lack of exposure to sunlight on the job and night or shift work may reduce total sleep time and deprive you of energy in your waking hours.

But you may be able to manage these less-than-optimal work conditions in ways that improve both your sleep and your stamina.

Working without Natural Light

Working without the benefit of sunlight during the daytime has a surprisingly negative effect on sleep, a new study in the Journal of Clinical Sleep Medicine shows. The goal of the study was to compare the vitality and sleep of employees that worked in windowless cubicles to those of subjects whose workstations were exposed to natural light.

Not only did the 22 workers in the windowless cubicles report less activity during the daytime and poorer quality sleep. On average, they also got 46 minutes less sleep than the 27 employees who worked near windows.

Out of Sync

The timing of your workday can also interfere with your sleep. Nearly 15 million full-time American workers labor on schedules that involve night, rotating or irregular shifts, which necessitates the resetting of the body clock.

Having to work when you’d normally be asleep and to sleep when you’d normally be awake causes changes in the activity of genes, a study recently published in the journal Proceedings of the National Academy of Sciences shows. Genes control the production of proteins, and to function optimally, protein production needs to coordinate with the natural cycle of activity and rest.

When the body clock is reset, as occurs in people who do night and shift work, the number of genes synched up to the body’s natural circadian rhythms falls rather dramatically, pushing digestive and other physiologic processes out of whack. Ten percent of shift workers are regularly diagnosed with “Shift Work Sleep Disorder”—they feel sleepy on the job and have insomnia when it’s time to sleep.

Night owls may choose to work the night shift and, given their delayed circadian rhythms, this schedule suits them to a “T.” Others fare poorly. The years when I worked a split shift were the years when my insomnia was at its worst.

What’s a Worker to Do?

If low light is a problem at work,

  • Invest in a light box and use it (for tips on how to use a light box, see my blog on winter insomnia)
  • Go outside or to sunlit parts of the building during breaks.
  • If you do work near windows, keep the blinds open and, if necessary, use anti-glare shades for computer screens.

If the timing of your workday is a problem,

  • Aim for consistency in your sleep schedule. It may be tempting to alter your sleep schedule on weekends to maximize time with family and friends. But having to readjust to your weekday schedule on Monday may leave you struggling to stay alert at work and tossing and turning in bed.
  • Manipulate your exposure to light. Bright light in the work environment will help to keep you alert and on your toes. But exposure to sunlight on your way home from work will tend to delay sleep further. If your goal is to get to sleep immediately after work, wear dark glasses on the way home.
  • Make judicious use of caffeine. Drinking coffee at the beginning of your shift should not interfere with getting to sleep when you get home. But the caffeine-sensitive will want to avoid caffeine later in the work shift. If sleepiness becomes a problem, the better strategy is to get up and move around.