Easing Worry and Anxiety about Sleep

Insomnia sufferers write to me often with complaints about sleep-related worry and anxiety.

“The more important the next day is to me, the harder it is for me to sleep,” Jessica says. “So I worry about not sleeping and then it turns into a self-fulfilling prophecy.”

Finding a solution to this problem can be tricky. It may require experimentation before you home in on a strategy that works.

Insomnia characterized by worry and anxiety about sleep can be alleviated using psychological and physiological strategiesInsomnia sufferers write to me often with complaints about sleep-related worry and anxiety.

“The more important the next day is to me, the harder it is for me to sleep,” Jessica says. “So I worry about not sleeping and then it turns into a self-fulfilling prophecy.”

“I finally had about 4 good nights after starting sleep restriction (about 11 days ago) but had a horrible night of anxiety last night,” Stacy says. “I was anxious about not being able to continue my good nights of sleeping. I find it hard to practice relaxation exercises when I’m that anxious.”

Achieving a relaxed state conducive to sleep can seem impossible with a mind that’s racing from one fraught thought to another. Likewise, the physiological changes that accompany worry and anxiety—the release of stress hormones, a faster heart rate, bodily warming, tensing muscles—are a better preparation for fight and flight than for relaxation and disengagement.

How to stop obsessing about sleep and sleeplessness is the main concern of many insomniacs, yet finding a solution can be tricky. It may require experimentation before you home in on a strategy that works.

Different Schools of Thought

Research backs a handful of approaches to managing the problem, but even among sleep experts there is no consensus as to which works best. It may depend on the nature of your insomnia and which approach you find more appealing.

Some experts promote a type of talk therapy–called “cognitive restructuring–as effective in reducing worry and anxiety related to sleep. The idea behind it is that sleep-related anxieties develop in part due to the misconceptions people have about sleep and catastrophic thinking about insomnia. Replacing these ways of thinking with attitudes that are more realistic and sleep-supportive should help.

Cognitive restructuring is normally presented as part of cognitive-behavioral therapy for insomnia (CBT-I). It usually involves work with a therapist, who helps you learn to talk yourself out of worries and anxieties about sleep and sleeplessness.

Mind/Body Approaches to Curbing Arousal

Other experts suggest that psychological treatments for sleep-related anxieties may not be as effective as treatments that simply help insomniacs learn to relax. Physiological hyperarousal is the main cause of poor sleep, they say, with sleep-related anxiety and worry developing as a result. Treatment should focus on tamping down arousal that gives rise to these sleep-related worries, enabling a stronger and more dependable relaxation response.

  • Relaxation training is recommended as helpful to sleep by the American Academy of Sleep Medicine. It may involve progressive muscle relaxation and/or autogenic training (guided visualization).
  • Mindfulness-based therapies enable people to become more accepting of unpleasant feelings and sensations and, in so doing, alleviate them. Mindfulness meditation has been shown in a handful of studies to help insomnia sufferers by cutting down on pre-sleep arousal, reducing wake time at night, and enhancing sleep quality.
  • Yoga has now been shown in several studies to help insomnia sufferers learn to manage stress and get more sleep. Not only does yoga practice effectively deactivate the stress system. Yoga postures, breathing, and meditation exercises also help people develop more resilience to stress.

Exercise, Anxiety, and Sleep

Still other experts advocate exercise as the best way to relieve the anxious arousal that sabotages sleep. There’s now solid evidence that regular exercise promotes sounder sleep and preliminary evidence that exercise is effective in reducing anxiety. A meta-analysis published in April shows that even a single bout of exercise has a small but significant anxiety-alleviating effect.

Strenuous exercise is the way I calm myself down in times of stress, especially when my old fear of sleeplessness threatens to stage a comeback. The minute I feel that happening, I push myself to work out longer and harder and, most of the time, it helps.

But which kinds of exercise will give you the most bang for the buck? University of Pennsylvania researchers, analyzing data from a huge survey of behaviors affecting health, have found that while walking is associated with better sleep compared with getting no exercise at all, aerobics, calisthenics, biking, gardening, golf, running, weight-lifting, yoga and Pilates are associated with even better sleep.

Consider these strategies if worry and anxiety are feeding your insomnia. Continuing to obsess about sleep and sleeplessness is surely worse than making a good-faith effort to try some of these practices out.

Insomnia Advice Can Miss the Mark

People sometimes offer advice when they hear about my insomnia. Their suggestions are not always helpful.

In fact, I used to feel impatient with–and occasionally hurt by—comments that to my ears sounded judgmental or attitudes toward insomnia that I felt were just plain wrong. The comments were well meaning, but that didn’t make them easier to tolerate. Here are a few that put me off and what I think about them now.

Advice about insomnia can hurt rather than helpPeople sometimes offer advice when they hear about my insomnia. Their suggestions are not always helpful.

In fact, I used to feel impatient with–and occasionally hurt by—comments that to my ears sounded judgmental or attitudes toward insomnia that I felt were just plain wrong. The comments were well meaning, but that didn’t make them easier to tolerate. Here are a few that put me off and what I think about them now.

There must be a part of you that doesn’t want to sleep.

No doubt this suggestion was meant to be insightful, but I found it exasperating. The idea that there might be a twin self lurking inside me that wanted to stay awake (to do what? force myself to read when my eyes could barely focus? play another round of Internet solitaire?)—just how crazy did that make me sound?

Normal sleepers may assume that people who have insomnia actually want to remain awake because of a belief that sleep can be regulated voluntarily. This belief is fairly common, and some people do seem to have quite a bit of control over their sleep. I once knew a woman who could will herself to take a 10-minute cat nap whenever and wherever she pleased. And what about the lucky ones that drop right off in their seats even before the plane is finished boarding?

Sleep is more complicated for people with insomnia. Yes, there are habits and attitudes we can adopt to avoid sleep problems and we should do this. Yet wanting sleep is not always enough to make it happen–any more than a person with asthma can breathe easily on command.

Something has to be causing your sleep problem. Maybe it’s time you went to a therapist to figure it out.

The suggestion that insomnia was a symptom of a larger psychological problem was dismaying. I doubted very much that an unresolved internal conflict was driving my insomnia–that, despite my years of psychotherapy, a dark secret buried in my unconscious was keeping me awake. Or that I was actually deriving some benefit from insomnia (the sympathy of friends, for example) and this was keeping it alive.

A general practitioner actually made the above suggestion to me not 10 years ago. Obviously he hadn’t read Harvard sleep scientist Gregg D. Jacobs’ book, Say Goodnight to Insomnia, in which Jacobs writes, “There is not one scientific study demonstrating that psychotherapy is effective in treating chronic insomnia.”

Theories about the psychological origins of insomnia were predominant for most of the twentieth century, though, so it’s not so surprising that people—even some doctors—put stock in them still. These days, people who study chronic insomnia say the disorder develops due to many factors: biological, situational, behavioral, and attitudinal. As for the suggestion that a therapist could help me “figure it out,” well, all the world’s sleep scientists haven’t been able definitively to do that yet. So a lone psychologist would surely come up short.

Have you tried melatonin/valerian/yoga/warm milk?

It still surprises me when people offer suggestions like these as though they were novel ideas. I know people are only trying to be helpful and that it’s curmudgeonly of me to complain. But anyone who hasn’t heard of these insomnia remedies has never been on the Internet or read a magazine!

These sleep aids remain popular because sometimes they work: Night owls, for example, can use melatonin successfully to shift their sleep to an earlier hour. Valerian taken nightly has been shown in some studies to improve sleep. The daily practice of yoga reduces arousal and builds resilience to stress, which will have a positive effect on sleep. Milk contains the sleep-friendly amino acid tryptophan. Combined with a complex carbohydrate, it makes a good bedtime snack.

But a person with chronic insomnia has probably been there and done that, not to mention experimenting with a raft of other sleep aids. Sometimes I think we could do with a few more expressions of sympathy and a little less “helpful” advice.

What suggestions have people made about your sleep problem that annoyed you?

Insomniacs Weigh In on Mindful Stress Reduction

A lot of people with insomnia say the main barrier to sleep is an unquiet mind. The minute they lie down, the mind starts racing over the events of the day or sprints ahead to the next day, chewing over problems and unable to stop.

If you could put a lid on the chatter and improve your sleep by dedicating 20 minutes a day to meditation, focused breathing, and simple yoga poses, would you do it?

Here’s what you could expect to gain, in the words of those who are doing it.

Insomnia is less bothersome if you practice meditation, focused breathing and yogaA lot of people with insomnia say the main barrier to sleep is an unquiet mind. The minute they lie down, the mind starts racing over the events of the day or sprints ahead to the next day, chewing over problems and unable to stop.

If you could put a lid on the chatter and improve your sleep by dedicating 20 minutes a day to meditation, focused breathing, and simple yoga poses, would you do it?

This is the commitment a group of insomnia sufferers made after participating in an 8-week study comparing the effects of mindfulness-based stress reduction (MBSR) to treatment with the sleeping pill eszopiclone (Lunesta). The MBSR and the Lunesta groups experienced similar improvements in their sleep. But the MBSR group reported a lot more treatment satisfaction. Five months later, 9 participants gathered at the University of Minnesota in focus groups to discuss the effects of MBSR on their sleep and waking hours. Here are some of their comments.

Improved Sleep

Mine [my sleep] was almost immediately, positively impacted . . . I didn’t sleep longer, but I slept better. So I woke up more refreshed even though I wasn’t sleeping more, and that happened for me very quickly.

Sleep quality improved with MBSR practice. Specifically, people reported (1) getting to sleep more quickly, (2) having shorter nighttime awakenings and fewer early-morning wake-ups, and (3) waking up feeling more rested and refreshed.

Benefits of the Body Scan

The body scan is a guided meditation that several people in the group found was especially effective in halting mental chatter and helping them relax. (The body scan involves focusing your attention on body parts one by one, starting, for example, with the left big toe. With acceptance rather than judgment, you’re to notice any sensations you’re experiencing there, and continue doing the same thing through the rest of the body.)

The body scan helped keep my mind from racing, so that I could just decompress and fall asleep.

If I wake up in the middle of the night it [the body scan] seems to help me relax and get back to sleep. And a lot of times I’m back to sleep before I get past the left leg.

Better Sleep Habits

While undergoing the MBSR training, participants also learned the rules of good sleep hygiene: avoid caffeine late in the day, get up at the same time every morning, and so forth (you know the drill!).

MBSR helped in

making it a priority to do the things that we all know we are supposed to do, but we don’t necessarily do. Like not watching TV in bed, not eating chocolate at 7 o’clock at night.

Overall, MBSR training made it easier to shy away from behaviors that interfered with sleep and adopt habits that were helpful.

Benefits Beyond Sleep

Sleep wasn’t the only that improved with training in MBSR. People also reported feeling better emotionally and physically in the daytime.

I feel as though instead of getting worked up about things throughout the day and then having it be difficult to come down to relax and sleep, I feel that when I started doing the body scan [in the morning] I was at a stable emotional level throughout the day.

The yoga component of the training was helpful in increasing physical flexibility and reducing aches and pains.

It’s low impact and I don’t get stiff like I used to sitting working long hours.

Use It or Lose It

Like many techniques and skills, though, MBSR requires ongoing practice. One group member couldn’t do her customary meditation while on vacation and backslid as a result:

I noticed that the benefits left me. . . . I came back home and here was the chatter all back again. ‘I shouldn’t have said that. Shouldn’t have done that.’. . . It was all back. And . . . I couldn’t go to sleep. And when I do the meditation that chatter goes away. . . . I lay down at night and I’m not chattery.

The Take-Away

A maintenance routine of 20 minutes a day does not sound like a big investment if the potential gains are as great as these comments would suggest. As alternative treatments for insomnia go, this one is not so demanding.

But the initial 8-week training requires a bigger time commitment. To learn MBSR techniques, group members participated in a 2½-hour class every week and a daylong silent retreat. They were also asked to do 40 minutes of home practice 6 days a week. This is the standard MBSR training program recommended by Full Catastrophe Living author Jon Kabat-Zinn.

But a 20-minute maintenance regimen that can be done at home with no special equipment and no special clothes? Especially if mental chatter and/or conditioned arousal keep you from sleeping at night, MBSR is worth a serious look.

Yoga for Seniors with Insomnia: Thumbs Up

Once on a whale-watching cruise, when the ship was rocking from side to side and I was clinging to the gunwale for dear life, I watched an 81-year old woman walk down the center of the boat with nothing to steady herself. The secret to her amazing sense of balance, she said, was 60 minutes of yoga practice every day.

A growing body of research shows that yoga also has a place among alternative treatments for insomnia. A new study of the effects of yoga on the sleep and functioning of older adults suggests how and why.

Yoga increases deep sleep and improves sleep quality in older adultsOnce on a whale-watching cruise, when the ship was rocking from side to side and I was clinging to the gunwale for dear life, I watched an 81-year old woman walk down the center of the boat with nothing to steady herself. The secret to her amazing sense of balance, she said, was 60 minutes of yoga practice every day.

 

A growing body of research shows that yoga also has a place among alternative treatments for insomnia.

One goal of yoga, said Jonathan Halpern, lead author of a new study exploring the sleep benefits of yoga in older adults, is to put a stop to the fluctuations of the mind. “As primary insomnia is very often related to stress, anxiety and uncontrolled thoughts and emotions,” Halpern told me, “you can appreciate how reducing the fluctuations of the mind even to some extent would have a positive effect on insomnia.”

Yoga in this study also led to improvements in several areas of daytime functioning, including stamina and mood.

Highlights of the Study

Sixty-seven subjects ages 60 and above completed the study. Those who received training in yoga attended 12 weeks of classes twice a week and did daily practice at home. Treatment included practice in yoga postures and three types of meditative exercises. Subjects who stuck with the protocol made significant gains:

  • In contrast to the control subjects, who received no treatment, the yoga subjects reported longer, more efficient sleep and improved sleep quality.
  • Those who practiced yoga at least 25 minutes daily also experienced 11.5 percent more deep sleep. This is an impressive result. As humans age, we get less deep sleep, when the secretion of growth hormone and the synthesis of brain proteins occur. Any activity that promotes deep sleep is likely to make sleep feel sounder and more restorative.
  • Yoga subjects also experienced improved daytime functioning: they reported managing better physically and socially, and feeling less depression, fatigue and stress.

“Daytime functioning is a general measure,” Halpern said, “but it probably results from the fact that people slept better at night, were less tired during the day and therefore could perform better physically, mentally and emotionally. Not at all rocket science,” he added. (For more on how yoga improves stress tolerance, click here.)

So if you’re older and open to alternative treatments for insomnia, yoga is worth checking out.

If you’ve tried yoga, what health benefits did you notice it had for you?

Too Aroused for Sleep? Try Yoga

Sat Bir Khalsa, a professor and researcher at Harvard Medical School, thinks that among alternative treatments for insomnia, yoga may also be a viable solution for people who feel too aroused to sleep.

I attended Khalsa’s presentation at a conference a while back. Here’s the gist of what he said.

Insomnia sufferers may want to try yoga to prepare for sleepAn acquaintance of mine said she’s often “just too wound up, too hyped up” to sleep.

I know the feeling. It‘s like my body’s stuck in overdrive, and I can’t find the brakes. The best solution for me is physical exercise.

But Sat Bir Khalsa, a professor and researcher at Harvard Medical School, thinks that among alternative treatments for insomnia, yoga may also be a viable solution for people who feel too aroused to sleep. I attended Khalsa’s presentation at a conference a while back, and later I contacted him for more information.

“Yoga works on inducing the relaxation response,” Khalsa said, producing “a reduction in stress system activation. Yoga and meditation practice also changes the perception of stress … creating a positive change in stress tolerance.”

Sounds good to me. But is there proof?

A small number of studies attest to the benefits of yoga as a strategy for managing insomnia, and some of them are randomized controlled trials (RCTs). In RCTs, the results of subjects who undergo a treatment are compared to the results of control subjects who do not, a protocol considered by scientists to meet the highest standard of proof.

  • An RCT conducted in an Indian home for the aged produced spectacular results: subjects who practiced an hour of yoga six days a week for six months increased their total sleep time by a whopping 60 minutes a night! They also reported greater ease in falling asleep and feeling more rested in the morning.*
  • In an RCT published last year, postmenopausal women in Brazil experienced a significant reduction of insomnia symptoms and increased stress resistance following four months of yoga practice.**
  • Khalsa’s RCT, which he discussed at the conference, showed that the sleep of subjects who practiced 45 minutes of yoga before bedtime every day for eight weeks improved substantially more than the sleep of control subjects, who received information about sleep hygiene. Yoga subjects reported increases in total sleep time that were two and three times as great as the increases made by controls. (Again, we’re talking in the neighborhood of 60 minutes’ more sleep a night.)

Yoga may achieve its calming effects in a paradoxical way, Khalsa told me, by increasing levels of the stress hormone cortisol while at the same time improving stress tolerance. The overall effect is to decrease feelings of arousal.

This is why insomniacs – particularly those who tend to feel wound up at night – may want to try it out.

*   Influence of Yoga & Ayurveda on self-rated sleep

** Yoga decreases insomnia in postmenopausal women