Sleep (Re)Training for Insomnia

What does falling asleep feel like? Good sleepers may never bother with the question. One minute they’re conscious and the next minute they’re out. But if you have chronic insomnia, falling asleep (or back to sleep) can feel like a tiresome slog.

Insomnia sufferers may actually lose touch with the feeling of falling asleep. So Sleep Technologist Michael Schwartz created a smartphone app to put people back in touch and increase their confidence and ease in falling asleep.

Insomnia sufferers relearn the feeling of falling asleepWhat does falling asleep feel like? Good sleepers may never bother with the question. One minute they’re conscious and the next minute they’re out. But if you have chronic insomnia, falling asleep (or back to sleep) can feel like a tiresome slog.

Insomnia sufferers may actually lose touch with the feeling of falling asleep, some have claimed. So Sleep Technologist Michael Schwartz created a smartphone app to put people back in touch and increase their confidence and ease in falling asleep.

Racing Thoughts and Brain Activity at Night

An independent study has found the smartphone app, called Sleep On Cue, to be accurate at detecting the start, or onset, of sleep. But let’s step back, for a moment, and imagine a typical insomniac night.

It’s after midnight and you’re obsessing about your deadlines tomorrow. Or you’re thinking about how to fight your way out from under all your student loans. The next thing you know the clock on your bedside table says it’s 2 a.m. In desperation, you stare at the clock face, willing time to stop. By 3 a.m. you’re still awake and hopping mad about it!

Maybe you have spent the last 4 hours with your entire brain spinning along in problem-solving mode. Chances are, though, that if on such a night you were undergoing a sleep study, your brain waves would tell a somewhat different story. Beta waves, fast wave activity commonly observed in people who are are thinking and solving problems, might be mixed in with alpha waves (slower waves linked to more relaxed states) and even slower theta waves, heralding the start of Stage 1 sleep.

Detecting the Lighter Stages of Sleep

But would it feel like you were actually sleeping? Research has shown that people woken up in Stage 1 sleep are often unaware that they’ve been asleep. In this liminal state, people can drift back and forth between sleep and wakefulness for quite some time before descending further into more sustained sleep, which is called Stage 2.

Stage 2 sleep is characterized by a predominance of theta waves and by features called sleep spindles and K complexes. Awoken in Stage 2 sleep, people are somewhat more likely to be able to sense that they were asleep.

But people with insomnia may not be as apt to report they were sleeping. Investigators have speculated that with all the nighttime baggage accompanying chronic insomnia—anxiety about sleep loss, lack of confidence in sleep ability, negative beliefs about sleep, increased beta wave activity during sleep—some insomniacs may simply lose touch with the feeling of falling asleep.

A Sleep Training Smartphone App

When a call went out for an inexpensive way to detect the start of sleep at home, Schwartz developed Sleep On Cue. A recent study comparing it to polysomnography (the test used in overnight sleep studies) found that Sleep On Cue was accurate at predicting the onset of Stage 2 sleep.

Why is this important? For one thing, the app (which costs $4.99) may prove to be useful in helping to administer intensive sleep retraining—an insomnia treatment developed in Australia—inexpensively in people’s homes.

But for readers of this blog, the immediate value of this app may lie in its potential to train or retrain insomnia sufferers to recognize what falling asleep feels like. This could alleviate some of the worry and anxiety about sleep and insomnia and thus make it easier to fall asleep and fall back to sleep.

Here’s How the App Works

Sleep On Cue works best, Schwartz says, if you conduct your training sessions when the pressure to sleep is high: late in the afternoon or early in the evening after a poor night’s sleep.

  1. Lie down and relax in bed, holding your smartphone in one hand. The phone will periodically emit a soft tone. Every time you hear the tone, give the phone a slight shake.
  2. When the app no longer detects movement, it assumes you’re asleep. Then, the phone vibrates to wake you up.
  3. The screen then displays this message: “Do you think you fell asleep?” Press “yes” or “no.”
  4. Next, you’re instructed to leave the bed for a few minutes. The phone will then vibrate to let you know when to return to bed for the next sleep trial. In this way, you begin to relearn what falling asleep feels like and gain confidence in your ability to do it.
  5. You decide when to end each training session. The screen then displays a graph with feedback about your sleep ability and your awareness of your sleep.

Here’s a link to the Sleep On Cue website. At $4.99, it’s not much of an investment and the payoff could be great.

If you’ve tried Sleep On Cue, did it improve your sleep and, if so, how?

Are Insomniacs Unreliable at Assessing Sleep?

You’ve heard it said before: insomniacs typically overestimate how long it takes to fall asleep and underestimate the amount of sleep we get. Time and again, sleep experts ask us to estimate our sleep time. Then they conduct overnight sleep studies with polysomnography (PSG) and find, on average, that we fall asleep faster and sleep longer than we think.

Are insomniacs just unreliable when it comes to estimating time? What else might account for this discrepancy? Should we be reassured that we’re probably sleeping more than we think?

Insomnia sufferers underestimate how long they sleepYou’ve heard it said before: insomniacs typically overestimate how long it takes to fall asleep and underestimate the amount of sleep we get. Time and again, sleep experts ask us to estimate our sleep time. Then they conduct overnight sleep studies with polysomnography (PSG) and find, on average, that we fall asleep faster and sleep longer than we think.

Are insomniacs just unreliable when it comes to estimating time? What else might account for this discrepancy? Should we be reassured that we’re probably sleeping more than we think?

Time Estimates in the Daytime

Normal sleepers are fairly accurate when it comes to assessing their sleep. Their estimates of sleep onset latency (the time it takes to fall asleep) and total sleep time are in sync with the results of PSG.

Overall normal sleepers are also quite accurate at estimating time during the day. They can reliably estimate various time intervals (5 seconds, 35 seconds, 19 minutes) and keep a steady beat in a finger tapping task.

So can insomnia sufferers. Research suggests that overall, we, too, are quite accurate at estimating time intervals and keeping a steady beat during the daytime. It’s not the perception of time per se that gets distorted in insomnia. Insomniacs’ unreliability in estimating the passage of time occurs only at the night.

“It Takes Me Over an Hour to Fall Asleep”

Most studies show that people with chronic insomnia tend to overestimate sleep onset latency. For example, after having a sleep study, you’re told you drifted off 25 minutes after closing your eyes but you could swear it took you at least twice as long to nod off. How to account for this discrepancy?

One thing to keep in mind is that Stage 1 sleep—the lightest sleep stage, when the faster, unsynchronized brain waves associated with wakefulness are slowing down into more synchronized alpha and theta rhythms—is easy to perceive as wakefulness. In fact, if you’re woken up during Stage 1 sleep, you may feel you were never sleeping at all.

Research has also shown that unlike good sleepers, insomniacs tend to have elevated levels of high-frequency brain activity in the period leading up to sleep. These faster brain waves are associated with pre-sleep cognitive arousal—with thinking, rumination, and worry. They’re also associated with low-level awareness of what’s going on in the environment—a flushing toilet, a flash of lightening, the smell of skunk wafting through the window.

Unsurprisingly, insomniacs have been shown to take twice as long as normal sleepers to descend into deep sleep. So we’re hovering longer in the lighter sleep stages. All these things could help explain why we perceive we’re taking longer to fall asleep than PSG says we are.

“I Don’t Get Much Sleep”

Not all insomniacs are created equal. When it comes to estimating total sleep time, some insomnia sufferers are relatively good at it. (And results of some studies suggest that some insomniacs actually overestimate their total sleep time.) These are the so-called objective insomniacs, whose estimates of sleep time match up pretty well with their assessments by PSG. The diagnosis for this type of insomnia is often psychophysiological insomnia.

People whose sleep studies indicate they’re consistently sleeping less than 5 hours a night are called “short sleepers.” Short sleep is associated with physiological hyperarousal and an elevated risk for related medical disorders, as well as persistent trouble sleeping. Of all the variants of insomnia, short sleep is thought to be the most severe.

All I Get Is 1 or 2 Hours”

Other insomniacs’ perceptions of sleep duration are wildly at odds with assessment by PSG. A person who complains of getting just 1 or 2 hours’ sleep a night and goes in for a sleep study is often found to be sleeping 6, 7, or even 8 hours a night. The diagnosis in this situation is paradoxical insomnia, a disorder affecting about 26 percent of people with chronic insomnia.

Because their sleep duration is normal and their sleep architecture (as assessed by PSG) largely intact, the thinking is that these insomniacs are getting most of the benefits that sound, sufficient sleep affords. This may be reassuring. But the jury’s still out on the underlying mechanisms at play. Multiple irregularities may contribute to the feeling of being awake when most of the brain is asleep.

The Upshot

Should we be relieved to know that most of us are getting at least a little more sleep than we think? It’s not a bad idea. Once I stopped caring about how much I was sleeping, my sleep improved. Whether or not this would be borne out in a sleep study, it feels like I fall asleep faster and sleep longer than I did before.

If you can swallow the idea that in this one place your perceptions might be a tad unreliable (believe me, I know how hard this can be!), you won’t regret it.