Improving Sleep Quality. Evidence-based Strategies from a CBT Therapist.

Struggling to achieve restful sleep due to nighttime anxiety is a widespread issue, impacting up to a third of individuals in the UK.

This condition, known as insomnia, manifests through inadequate sleep or poor sleep quality, severely affecting our daily functioning.

Nighttime anxiety mirrors daytime anxiety, but it's often during the night's stillness that our worries become more pronounced. During the day, our hectic schedules distract us from these concerns, but they resurface at night, demanding our attention.

Sleep Anxiety, its symptoms and treatment

Anxiety manifests through a complex array of physiological and psychological symptoms, significantly impacting an individual's daily life and well-being. Key symptoms include a rapid heartbeat, sweating, accelerated breathing, restlessness, muscle tension, and unexpected surges of energy. These symptoms are not only distressing in their own right but also contribute to a debilitating cycle of sleep disturbances, exacerbating the individual's overall anxiety levels and further impairing their mental health.

A rapid heartbeat and sweating are often the body's immediate response to perceived threats or stressors, activating the "fight or flight" response. This physiological reaction, while beneficial in genuinely dangerous situations, can become problematic when triggered by unfounded anxieties, especially at night when our body simply needs to rest.

Accelerated breathing, or hyperventilation, can further compound these reactions, potentially leading to feelings of light-headedness or chest pain, which can be mistaken for more serious health issues, and thereby heightening anxiety. This symptom, in particular, can create a significant barrier to relaxation and sleep, as the body remains in a state of heightened alertness.

Restlessness and muscle tension are physical manifestations of the body's preparedness to respond to stress, often resulting in an inability to find a comfortable position for sleep or to relax muscles sufficiently to allow for the onset of sleep. The presence of these symptoms at night can significantly delay sleep onset or lead to fragmented sleep.

Unexpected energy surges, typically resulting from adrenaline release in response to anxiety, further disrupt the natural sleep cycle. These surges can leave individuals feeling paradoxically energised at night, despite experiencing fatigue and a need for sleep. This misalignment between the body's energy levels and the natural circadian rhythm can severely disrupt sleep patterns and contribute to insomnia.

The combination of these symptoms not only affects sleep quality and duration but also leads to a vicious cycle where the anticipation of sleep disturbances increases anxiety, which in turn exacerbates these physical symptoms. Over time, this cycle can become deeply entrenched, leading to chronic insomnia and requiring targeted interventions such as Cognitive Behavioral Therapy (CBT) to break the cycle and restore healthy sleep patterns.

Breaking the Cycle. How CBT Tackles the Feedback Loop of Sleep Anxiety

This cycle starts with poor sleep, resulting in fatigue and diminished energy throughout the day, further complicating sleep efforts despite exhaustion.

Worrying about sleep can significantly intensify existing sleep difficulties.

The interplay between anxiety and sleep disruption forms a challenging cycle that can exacerbate existing difficulties in achieving restful sleep. This cycle is rooted in a cognitive behavioural feedback loop where anxiety about not sleeping not only increases stress levels but also actively prevents the onset of sleep or the ability to stay asleep. This illustrates a fundamental concept in Cognitive Behavioural Therapy (CBT).

Our cognitive processes, including our thoughts and worries, have a profound impact on our behavioural outcomes, such as sleep quality.

A practical strategy to interrupt this cycle involves reframing worry thoughts about sleep that often arise during the night. Instead of engaging in mental debates with these anxieties, a simple cognitive shift can make a significant difference.

For example, replacing the distressing thought, "I’m never going to get to sleep, what if this lack of sleep never ends?" with a more balanced and realistic perspective like, "I’m not sleeping yet, but I usually manage to get some sleep during the night. I will fall asleep when my body is ready," can alleviate the pressure you put on yourself to fall asleep. This more accurate and positive appraisal helps reduce the self-imposed stress to sleep, subsequently making sleep more attainable.

The paradox of trying too hard to sleep

Another critical aspect of overcoming sleep difficulties is to recognise the paradox of trying too hard to sleep. Contrary to those who sleep well, individuals struggling with insomnia often find themselves overly focused on how and when they will fall asleep. This heightened alertness about the need to sleep paradoxically makes it more challenging to achieve restful sleep.

Good sleepers tend to adopt a more passive approach to sleep, exerting less effort and experiencing less pressure to fall asleep, which, in turn, facilitates easier and more natural sleep.

By embracing this absence of effort and reducing the pressure on oneself to sleep, falling asleep becomes a more effortless process, offering a path out of the cycle of anxiety and sleep disruption.

CBT addresses these issues by helping individuals identify and challenge unhelpful thought patterns related to sleep.

Through techniques such as cognitive restructuring, individuals learn to question the validity and helpfulness of their fears (e.g., "How likely is it that I will have a panic attack if I don't sleep well tonight?"), and to replace them with more balanced and realistic thoughts (e.g., "Even if I'm tired tomorrow, I have managed to function effectively on less sleep before").

Additionally, CBT for insomnia (CBT-I) employs behavioural strategies to break the cycle of sleep anxiety. Techniques such as stimulus control therapy and sleep hygiene education are used to create a more conducive environment for sleep and to establish a stable sleep routine.

Relaxation techniques and mindfulness exercises may also be incorporated to reduce physical tension and mental chatter, further alleviating anxiety's impact on sleep.

By addressing both the cognitive and behavioural components of sleep anxiety, CBT provides a comprehensive approach to dismantling the feedback loop of anxiety and sleeplessness. This empowers us to regain control over our sleep patterns and to reduce the overall impact of anxiety on our lives.

Cognitive Behavioural Therapy (CBT), a well-supported method, is recommended for breaking these cycles by challenging the beliefs behind our thoughts and decoupling our emotional responses from them.

Lisa Johnston, an Online CBT therapist specialising in anxiety disorders, offers several recommendations to improve sleep quality and mitigate nighttime anxiety. Emphasising quality sleep over quantity, she suggests actively reevaluating pre-sleep worries.

Nighttime magnifies fears, making problems seem insurmountable. Writing down these thoughts can help, either by postponing their analysis to the morning or reinterpreting them in a less distressing light before bedtime.

Questions to help reframe worrying thoughts include evaluating the evidence supporting these thoughts, distinguishing facts from assumptions, considering advice you'd give a friend, assessing judgments based on feelings versus facts, estimating the severity of outcomes, and assessing your coping abilities.

Once you have come up with a more realistic perspective on a problem, it then helps to think through more practical things you can do to help those more positive outcomes to be more likely to happen. 

To help you reframe your worry thoughts, you could ask yourself;

• What evidence do I have for this thought? 

• Am I confusing a thoughts with a fact?

• What advice would I give to a friend or loved one who had a similar worry?

• Are my judgements based on how I feel rather than facts?

• Am I overestimating how awful if would/could be?

• Am I underestimating my ability to cope?

• How likely is it that this will still be import in the morning? Next week? In three years time?

  
  

If these self-help strategies are challenging, consulting with a CBT therapist can be highly beneficial. My Therapist Online (MTO) connects you with expert CBT therapists skilled in managing anxiety and sleep issues, offering personalised matches for your unique needs.

Read on for some other sleep tips to try.

Increase daytime activity - earlier in the day.

Increasing daytime physical activity can enhance sleep quality, although it's advisable to avoid late-day exercise due to its short-term stimulating effects on adrenaline levels

Set a regular wake time and stick to it, even at the weekends.

Establishing a consistent wake-up time is a powerful strategy to synchronise your internal body clock, enhancing your ability to both fall asleep and remain asleep throughout the night.

It's crucial to resist the temptation to compensate for a restless night by sleeping in. Succumbing to prolonged sleep, even for just a few days, can shift your body's natural rhythm, leading you to feel tired later in the evening and consequently wake up later in the morning.

By maintaining a steady wake-up schedule, you reinforce your body's sleep-wake cycle, promoting healthier sleep patterns and overall well-being.

Try not to problem solve in bed

Nighttime is not a good place to work through your worries or find solutions for problems. If you have done a paper exercise as above, it may have come up there. Or you can tell yourself, this is just a worry thought, if it is important enough, you will remember it and address it in the morning. Alternatively, keep a pen and paper by your bed and put your ‘to do's’ onto there to be addressed the following day.

Create some wind-down time

Creating a dedicated wind-down period before bed can help transition your body and mind into sleep mode. This process involves deliberately setting aside time to relax and decompress from the day's stresses and activities, ideally starting an hour before you plan to go to sleep. Engaging in a nightly wind-down routine signals to your body that it's time to slow down and prepare for rest, which can significantly improve the quality of your sleep.

To effectively create this transition, consider turning off stimulating devices such as televisions, computers, and smartphones. The blue light emitted by screens can interfere with your body's natural production of melatonin, the hormone responsible for regulating sleep-wake cycles. By reducing exposure to blue light in the evening, you can help enhance your body's readiness for sleep.

In place of screen time, we recommend engaging in activities that promote relaxation and calmness. Progressive muscle relaxation, a technique involving the tensing and then relaxing of different muscle groups, can be particularly effective in releasing physical tension and fostering a state of deep relaxation. This practice not only soothes the body but also calms the mind, making it easier to fall asleep.

Listening to soothing music or ambient sounds can also create a tranquil environment conducive to sleep. The right kind of music can lower heart rate and blood pressure, reduce anxiety, and ease you into a more relaxed state.

Reading a book is another excellent way to wind down before bed. It allows your mind to shift focus from the day's worries to the narrative or information in the book, facilitating mental relaxation. Try to opt for light reading material that doesn't overstimulate the mind or evoke strong emotional responses.

A warm bath can be a luxurious and effective part of your wind-down routine. The warmth of the water helps to relax muscles and induce a feeling of sleepiness as your body cools down afterward. Adding elements such as Epsom salts or essential oils can enhance the relaxation benefits and create a spa-like atmosphere in your own home.

Incorporating these relaxation activities into your nightly routine can help signal to your body that it's time to wind down, aiding the transition into sleep mode and contributing to a more restful night's sleep.

Don’t dine after nine.

Eating your evening meal earlier ensures that you're not retiring for the night with a full stomach, which can lead to discomfort and disrupt your sleep. Digesting food requires energy, and the process can keep your body awake, making it harder to fall asleep and stay asleep. Moreover, lying down after a heavy meal increases the likelihood of experiencing acid reflux or indigestion, further impeding your ability to rest comfortably.

It's also worth noting that while some foods may hinder sleep. Caffeine, nicotine, and spicy foods, for example, can stimulate the body and mind, making it more difficult to fall asleep. Similarly, high-fat or heavy meals can lead to discomfort and prolonged digestion times, further disrupting sleep.

By paying attention to both the timing and content of your evening meals, you can create a conducive environment for restful sleep, ensuring you wake up feeling refreshed and rejuvenated.

Only use your bedroom for sleep.

To enhance your sleep quality, it's crucial to create a strong association between your bedroom and sleep. This strategy is grounded in the principles of sleep hygiene, which suggest that our environments can significantly influence our sleep patterns.

By reserving your bedroom exclusively for sleep (and intimacy), you reinforce the mental association that the bedroom is a place of rest, which can help cue your body to wind down and prepare for sleep upon entering the space.

Eating in the bedroom can also impact sleep quality. Not only does it risk associating the space with wakefulness and activity, but lying down soon after eating can lead to discomfort, indigestion, or acid reflux, further hindering the ability to fall asleep comfortably.

Similarly, working from your bed can blur the boundaries between work and relaxation, elevating stress levels and making it more difficult to unwind at night. The stress and mental engagement required for work activities can keep the mind active and alert, counteracting the relaxation needed for sleep.

Ensure you have a good pillow and supportive mattress 

Ensuring you have a good pillow and supportive mattress is foundational to achieving quality sleep. The right mattress and pillow can significantly affect your sleep comfort, spinal alignment, and overall sleep health. A supportive mattress helps distribute your body weight evenly, relieving pressure points and reducing the likelihood of waking up with aches and pains. Meanwhile, a pillow that correctly aligns your head and neck with your spine is crucial for preventing neck and shoulder discomfort.

Personal Comfort and Sleep Environment

Beyond support, the overall comfort of your mattress and pillow can affect your sleep temperature, which is critical for uninterrupted sleep. Some materials, such as memory foam, can retain heat, while others, like latex or gel-infused foams, are designed to be more breathable and regulate temperature more effectively.

Creating an optimal sleep environment goes beyond just the mattress and pillow. Consider the bedding materials, bedroom temperature, and any other factors that contribute to your comfort and relaxation. Every detail of your sleep setup can contribute to deeper, more restorative sleep, enabling you to wake up feeling refreshed and ready to tackle the day.

Turn tech off or onto blue light blocking mode

The blue light from our phone is stimulating to the brain and can suppress melatonin release (melatonin helps you sleep). Ideally, it is best to try to not look at your phone or other screens an hour or two before you go to bed. However, if that feels like a habit you are not keen to change, then you can use a blue light blocking mode such as “Night Shift” on iPhones or wear blue light blocking glasses, and turn the brightness on your screen right down. 

The 20 minute rule

Don’t toss and turn for more than 20minutes. Get out of bed, try not to put too many lights on as this will wake you up even more. Go to the loo, have some water and focus on a low stimulus activity for 5-10 minutes or so before re-setting and returning to bed. 

Make sure your room is quiet and dark

You can block out unwanted noise by wearing earplugs, putting on a fan or play a white noise (designed to screen out the sleep-disruptive sounds). 

Keep your bedroom cool

Generally speaking temperatures much above 24 degrees Celsius cause unwanted wake-ups from sleep. 

Pulling it all together for improved sleep

Navigating the complexities of nighttime anxiety and its profound impact on sleep is a journey that many find challenging.

The intricate dance between our daytime worries magnifying in the stillness of the night and the physiological symptoms that keep us in a heightened state of alertness creates a cycle that can feel impossible to break.

However, understanding the cognitive behavioural feedback loop at the heart of sleep anxiety, and employing targeted strategies like Cognitive Behavioural Therapy (CBT), offers a beacon of hope. My Therapist Online (MTO) stands at the forefront of providing access to sleep expert therapists who specialise in these exact challenges, offering personalised support to those in need.

The key to reclaiming restful nights lies in acknowledging our thought patterns, engaging in behaviours that promote relaxation, and creating environments conducive to sleep. From reframing our worries to embracing the paradox of not trying too hard to sleep, the strategies discussed offer practical steps towards achieving better sleep. It's about more than just avoiding caffeine or ensuring a dark room; it's a holistic approach that addresses the mind, body, and environment.

Employing techniques such as CBT, adjusting our sleep hygiene habits, and making our bedroom a sanctuary for sleep can dramatically transform our sleep quality. By understanding the role of anxiety in sleep disturbances and adopting these evidence-based strategies, we empower ourselves to break the cycle of sleepless nights. It's not merely about finding temporary relief but about making long-lasting changes that foster a healthier relationship with sleep.

Remember, while these self-help strategies can be highly effective, consulting with a sleep expert therapist through My Therapist Online can provide tailored advice and support suited to your unique situation. With many sleep expert therapists available, MTO is dedicated to helping you navigate the complexities of sleep-related issues, bringing you closer to achieving the restorative sleep essential for our well-being. Achieving a good night's sleep is not just a dream, but a reachable reality for those willing to embrace change and seek the support MTO offers.

Lisa Johnston

CBT Therapist

Director of My Therapist Online

If you or someone you know is struggling with anxiety during the night which is affecting their sleep, My Therapist Online can match you with an online Cognitive Behavioural Therapist equipped with the skills to help you tackle the anxiety. 

Please visit www.MyTherapistOnline.co.uk for further information or get in touch with me at hello@mytherapistonline.co.uk

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