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This is the fifth installment of “The Sleep Suite,” a six-part series of posts on sleep, aging, and wellness. Each will include practical takeaways intended to optimize your physical and psychological health.
We’ve got lots to worry about. A stubborn pandemic, accompanying spikes in unemployment; revelations of deep and systemic sociopolitical ills; racism; senseless and inhumane public killings. For the sake of my sleep and yours, I’ll stop there.
Our psychological and emotional demands have undoubtedly increased, which may partially explain upticks in reported nightmares, daytime fatigue, and insomnia symptoms.
Cognitive processes—including the inability to “shut off” repetitive thinking, worry, and rumination—play large roles in maintaining insomnia. Most models of insomnia acknowledge their contributions.
Thinking vs. worrying vs. ruminating
A perpetuating risk factor in these models, repetitive thinking colors many disorders, including depression, anxiety, and insomnia. But thinking, worrying, and ruminating sometimes get conflated and used interchangeably. These words have different meanings and capture discrete constructs that may exert independent or dynamic effects on sleep and functioning.
Thinking generally works for us, not against us. It involves collecting “data,” analyzing, and reflecting upon it to clarify and inform action. Thinking aids problem-solving and if done effectively, eliminates or reduces our challenges.
Worrying may start as problem-solving but morph into a loop of anticipated future disasters at worst and unrealistic outcomes at best. It feels at once "wiring but tiring" and usually involves distorted thinking — like catastrophizing. It works against us. While worrying and ruminating share a repetitive thought process, their forms and functions differ.
Ruminating makes attributions for current states (i.e. mood, symptoms) using the past; worrying fixates on predicting the future, negative consequences of those current states.
Worry, rumination, and sleep
People with or predisposed to chronic insomnia may worry and ruminate about things generally, sleep specifically, or both.
In insomnia, ruminative content may focus on why certain symptoms and events happen (e.g. daytime fatigue) and rely on past events to explain them (i.e. previous night’s sleep). Worry, instead, may focus on how the current state (e.g. anxiety) may prohibit future events— such as good sleep later — leading to future distress interfering with future functioning. In both cases, ruminative and worrisome thoughts can perpetuate dysphoria and anxiety that fuel repetitive thinking and increase the arousal associated with prolonged wakefulness and sleep disturbance.
Don’t worry (or ruminate); try these tools
Comprehensive, evidence-based Cognitive Behavioral Therapy for Insomnia (CBT-I) can target and interrupt the behavioral and cognitive patterns that maintain insomnia. Some of these tools can help, too:
1. Scheduled “worry” time. After a days’ worth of distractions, many people can experience worry and rumination antithetical to sleep around bedtime. But 30 minutes of daily scheduled “worry” time may help to reduce insomnia symptoms. It works like this:
- Using a calendar, schedule your 15-30-minute worry period for the same time each day, in the morning or afternoon.
- During that protected time, write down all of the worries you can think of, big or small. Consider making two columns: one for the worries, the other for steps. Don’t pressure yourself to “solve” anything. Instead, focus on listing one small step toward reducing that worry, even if the worry feels large and amorphous (e.g. worry: “I am a bad friend”; potential step: send friend a text).
- Set intentions at the start and end of each period, kindly encouraging yourself not to attend to these worries outside of it. Also gently remind yourself to release them until the next-scheduled worry period using self-soothing and reinforcement in the meantime.
- At the end of each week, note the themes and patterns in your worries. Usually, the same ones get replayed.
- Rinse and repeat, modifying scheduling as needed.
With sustained practice, like a muscle that strengthens with weight training, you’ll notice increases in your cognitive “strength” to restrict, contain, and control worry.
2. Turning your clock around. Clock-watching can perpetuate insomnia symptoms. Experimental studies among “good” sleepers and those with insomnia alike found that those assigned to a clock monitoring condition (vs. not), reported more pre-sleep worry and longer sleep onset latency (SOL). Findings suggest that clock monitoring may trigger pre-sleep worry and in fueling it, maintain insomnia symptoms.
Practical management strategies include:
- Turning your clock around;
- Placing a piece of tape over less mobile clocks, like those beneath or on televisions, and/or;
- Leaving your phone or other device across the room or in an adjacent one. This reduces anxious monitoring and may promote a more regular wake-up time, because when your alarm sounds, you’ll have to get out of bed to turn it off.
3. Relaxation and mindfulness. Multi-component CBT-I includes relaxation training to help manage the physiological and cognitive features of insomnia. I prefer Lichstein’s (2000) version which combines adopting a relaxed attitude, diaphragmatic breathing, and progressive muscle relaxation with repeated autogenic phrases (“I am at peace, my arms and legs are heavy and warm”). Experiment and find a relaxation exercise you like.
Practicing mindfulness-based approaches can also help tether us to the present and limit our preoccupation with the past or future, thereby reducing rumination and worry, respectively.
But, just as you wouldn’t practice CPR for the first time on someone choking, don’t practice relaxation when you feel extremely activated. Instead, first try during more emotionally “neutral” times so you master the technique and can use it effectively when needed. After that, use it at bedtime, or if you have difficulty falling or returning to sleep.
Of course, should your sleep issues cause significant distress and impairment, consult with your healthcare provider or a behavioral sleep medicine specialist. Hope and effective treatments exist.
