Sleep Anxiety: Tips on How to Cope With Insomnia Worsened By Worry

 There's one night in particular I remember most. It was my third night of zero sleep and the light was growing brighter in the living room — I had transitioned to the couch after tossing in bed for close to four hours. "Please," I pleaded aloud. "Please, just fall asleep." I was panicking, thinking I may never sleep again and that I'd end up in the hospital with delirium or drop dead from exhaustion on a city street. (Spoiler alert: neither happened.)

Insomnia can be an insidious, strange affliction, in that the more you care about its effects, the worse it gets. Though insomnia can be caused by a variety of issues, including physical and psychological factors, for many people a few sleepless nights can snowball into what's referred to as sleep anxiety — wherein your worry about falling asleep feeds the cycle of diminished sleep. This cycle can feel impossible to break, especially for those of us who are already prone to other forms of anxiety and obsessive thinking. Sufferers usually grow more and more anxious as the night draws closer. Reigning in the anxiety usually means rejiggering how your mind thinks about sleep.

First, a few facts about types of insomnia. It can be acute (short-term) or chronic (usually defined as at least three times a week for at least three months), as well as onset- (have trouble falling asleep) or maintenance-based (have trouble staying asleep). It can be primary, in that it has no outside causes, or secondary, wherein it's linked to periods of intense stress, mental illness, physical pain, sleep apnea, or a variety of other things. Speaking to a professional can be helpful in homing in on the root cause and can be especially important for those struggling with secondary insomnia caused by mental illness.

Arguably the most trusted and effective treatment for insomnia is cognitive behavioral therapy (CBT), a type of therapy that focuses on challenging disruptive, anxious thinking through behavioral changes and a realigned thought process.

CBT for insomnia (CBT-I) includes therapies that can seem counterintuitive. After I started researching the technique and working with Josuha Tal, Ph.D., a clinical psychologist who specializes in sleep and health psychology and CBT-I, I was surprised to learn that much of what I was doing to increase my chances of sleep on any given night was actually prolonging my insomnia.

A few counterintuitive tips:

STOP reading about the importance of sleep

Focusing too much on the importance of sleep is a big no-no. People with sleep anxiety know sleep is important — it's why we're anxious! All those studies and articles about the benefits of a full night's rest are meant for those who don't prioritize sleep, not those who are desperate for it and make time for it, but still aren't getting enough.

If you're in generally good physical and mental health, your body can handle bouts of sleeplessness, according to Tal. It may be a tad uncomfortable, but it's usually doable. Catastrophizing a sleepless night will only drag out the suffering.

Some experts suggest rewarding yourself, whether with a favorite food, a trip to the movies, whatever, the day after a bad night’s sleep. Disassociate a bad night’s sleep from having a bad day the next day. Don’t “lean in” to the tiredness. I was actually surprised at how well I was able to function after a poor night’s rest once I let go of how I was supposed to feel. Show your body and your brain that lost sleep is not as big a deal as you’d made it out to be.

In fact, a 2017 study found that believing yourself to be an insomniac (“insomnia identity”) was a better predictor of daytime impairment than actually sleeping poorly.

Think of sleep as a "flaky friend"

Tal introduced the metaphor of the "flaky friend" — they might come over if they're free tonight or they might not. And sure, you'll hang if they're in the neighborhood, but you're not going to send them any pleading texts; it wouldn’t help anyway. Reframing sleep as something that "if it happens, great, if not, no biggie," helps to readjust our relationship to sleep. Sleep is a natural process; it doesn't get better with effort in the same way blinking or swallowing don't get better with effort.

This can be especially hard for those of us with obsessive tendencies and a need for control. (Um, hello, sensorimotor OCD!) How we think about this issue has a direct effect on the issue, which can feel like a perpetually losing game. It's like if someone says, "don't think of a white elephant," it'll be the first image that pops into your head.

One of my main issues was “hypnic awareness” — being too aware of the moment you’re falling asleep, which then led to a hyperarousal state and feelings of, “I’ll notice this forever and never sleep again.” I tried to minimize my perception of it, which didn’t really work, and also meant I was still “trying” to do something. The best course of action, I found, was to notice it and then not care, because, really, our brains are weird and beautiful and highly evolved, and sometimes they get stuck on processes that should be automatic.

This framing is incredibly difficult but gets easier with time, especially when you count on a worst-case scenario—no sleep for 4, 5 nights or more in a row— and it doesn't materialize. Overcoming sleep anxiety can feel insurmountable, but is, at least in theory, deceptively simple. Trust in your body. Trust that it wants to — and will eventually — sleep.

Don't go to bed early after a bad night's sleep

"Going to be early after a bad night makes sense rationally. I lost sleep last night, I should get more sleep tonight to compensate," Tal says. "With sleep and insomnia, unfortunately, this usually backfires: increased time in bed leads to increased time awake in bed, and this process teaches the body to stay awake in bed rather than sleep." What to do instead? Go to bed at your regular time, do things you'd normally do, distract yourself, get tired!, then go to sleep. Equally as important: set an alarm for a normal wake time. Catching up on sleep is not as crucial as getting to a place where you're sleeping consistently every night.

Spend less time in bed

Sleep restriction is a critical component of CBT-I, according to Tal. "Instead of spending all that time in bed not sleeping, sleep restriction reduces the amount of time in bed to the amount of time you are actually sleeping. So for example, if you are sleeping only 6 hours but you are in bed for 9, sleep restriction would tell you to be in bed for only 6 hours," he says. Initially, this will increase anxiety around sleep, but according to Tal, by the 2nd or 3rd night most people pass out the minute their head hits the pillow. [Ed note: it took me until the 5th night.] You add on time in bed incrementally, as you begin to sleep more. The goal is two-fold: ramp up sleep drive ("our natured nature to sleep," per Tal) and decouple the bed from feelings of anxiety and restlessness.

That last bit is important because the more your body starts to associate the bed as the place where you DON'T sleep versus one where you do, the more entrenched your insomnia becomes. At one point, my own bed, which I'd loved for so long, began to feel like a cruel medieval torture chamber. Tal strongly recommends that insomnia sufferers not undertake sleep restriction on their own, especially if they have a psychological illness or other medical conditions. The good news is that CBT-I is a short-term treatment that offers results fairly quickly, often within 5-8 weeks, though it doesn’t work for everyone.

Another element of sleep restriction: if you're aren't able to fall asleep after about 20-30 minutes, get out of bed, do a relaxing, not-too-stimulating activity (for me, word search puzzles were the perfect balance of involved but not too tricky), and only get back in after you're feeling sleepy, not just after a specific amount of time has passed. (Ideally, you should be estimating the 20-30 minutes, as it’s best to keep any visible clocks out of the bedroom during treatment.)

This was the trickiest part of insomnia treatment for me. I found that if I wasn’t asleep within a few minutes, I would catastrophize and assume I wouldn’t sleep at all that night — a self-fulfilling prophecy. If I was awake but feeling sleepy, I stayed in bed and the sleep eventually came. I only got up if I was fully awake.

The first few nights of sleep restriction can be terrible; you likely won't sleep much (see opening paragraph). Tal refers to these nights as the "death rattle" of insomnia. "When you make a negative association and you try to break it, sometimes your body will increase the conditioned response as an attempt to get it to continue before it gets better," he says. It’s almost certain though, that eventually, you will sleep. Your body's eventual response to sleep restriction is two fold and strangely contradictory: you start to both naturally crave sleep as well as understand that a perfect night’s sleep is not as absolutely essential as you had thought.

Have a bedtime routine if you’d like, but don’t freak out if it’s different each night

A routine “establishes a positive conditioning for sleep,” says Tal. “When you start your routine, your body gets the "hint" and starts to initiate the mechanisms for sleep.”

It was important for me, however, to realize that I’m someone who might be unmoored by obsessing over the ritual of what I do each night. During treatment, I liked to take a shower, have a warm glass of milk with honey and do some type of relaxing activity. Early on I found that if I didn't do something exactly as I'd done it the night before, I would grow anxious over my ability to fall asleep that night. And then boom, no sleep. Instead, I now keep the overall framework of a nighttime routine but have let go of the specifics. One night, I may watch 20 minutes of a TV show, another I might read 10 pages of a book. I've done this so my brain doesn't associate the particular ordering of activities with sleep. For me, the ritual was about relaxation, not rigidity.

Accept that this is your now (not your forever)

Acceptance therapy — a type of psychotherapy that allows you to sit with and process uncomfortable feelings — can be particularly useful for insomnia. "The more pressure you put on yourself to sleep, the more you won't sleep. So one strategy is to accept the sleeplessness and insomnia in order to reduce the anxiety to facilitate sleep," Tal says. "It is sort of ‘reverse psychology,’ the more you don't care, the more likely you will sleep."

For me, this sometimes meant repeating the following to myself when I was in bed and couldn't sleep: "This is my current reality. It won't always be this way, but this is how it is right now, and that's okay." Thank your brain for trying to keep you safe with its anxious thinking, Tal suggests. Don't treat those thoughts as a sign of any kind of "brokeness." My anger at my own brain was one of the hardest things to overcome.

"By ‘thanking your brain,’ it brings perspective to the anxiety and reduces the activation caused by it," Tal says. "It also externalizes the anxiety as caused by ‘my brain’ instead of ‘myself,’ making it less of something that will last forever."

Sometimes, though, the mantra I created became too effortful (see the “flaky friend” entry), so to speak, in that there was clearly an underlying agenda of “please sleep” attached. In those instances, it was best to just simply let go as best I could and do nothing.

Acceptance therapy extends to acceptance of relapses. In fact, Tal explicitly says that he wants each of his patients to experience a bad night after treatment starts working, to know that they can handle it. Getting over chronic insomnia and sleep anxiety can take time, and it’s reasonable to feel discouraged.

But it's not your indefinite reality, it's only your now, and you will surely sleep again.

A few resources that were an immense help to me: sleep physician Daniel Erichsen’s The Sleep Coach School videos, insomnia coach Martin Reed’s forums, and the site Insomnia Free.

 

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