Fear can be a powerful disincentive to change. It was one of several factors that kept me from undergoing cognitive-behavioral therapy for insomnia (CBT-I) for over a decade.
Not that I wasn’t eager to trade in my bad nights for better nights. I’d struggled with bouts of sleeplessness since my teens. Stress at work or anticipation of a challenging day ahead could keep me wound up until 2 or 3 in the morning, and occasionally all night. A few bad nights could usher in a cycle of insomnia lasting three or four weeks.
But knowing in advance what CBT-I would entail — restricting my sleep every night — was a deal-breaker for me. Subject myself to a series of short nights that were sure to make my daytime symptoms worse? Prolong my exhaustion, my bad mood, and my trouble thinking, on the slim chance that sleep restriction would turn my problem around?
The prospect was not just distasteful. It was also scary. What if during my sleep period the Sandman never showed up? The fear of it tied my stomach in knots. While CBT-I might help others, it was not for me.
But I laid my apprehensions aside and decided to try it as part of my research for a book about insomnia. CBT-I was every bit as difficult as I’d anticipated. Restricting my time in bed turned me into a zombie the first few days. I shuffled along with mush for brains, forgetting where I put my keys and barely able to compose a paragraph. Which made me cross: why such punishment to achieve something that should be effortless?
But it was at night when the sleep issue came to a head, forcing me to confront my fear of sleeplessness face to face. How else to explain the freak show those early nights of treatment became? No matter that I had to march myself around the house to stay awake until 12:30, my designated bedtime. As I was heading to the bedroom, fear ambushed me in the doorway. I panicked at the thought of not sleeping and how rotten I’d feel the next day. I was much too aroused to fall asleep.
Treatment protocol required that I avoid the bedroom until I felt sleepy, so I turned away and sat down to read until I felt myself drifting off again. But when I went to the bedroom to lie down, fear seized me again, and then a third time, and a fourth. I got up, I lay down. Lay down, got up. How long would the torture last?
I battled my fears for three nights and slogged through three miserable days. If I hadn’t been determined to see the thing through for the sake of my research, I might easily have given up. But at 12:30 on the fourth night I collapsed and slept until the alarm woke me at 5:15. I’d been shot cleanly through the goalposts without a moment’s wakefulness.
That was the beginning of the end of my protracted bouts of insomnia. I still had miles to go: adding time in bed as sleep became more solid, tweaking bed and wake times, modifying my bedtime routine. But staying the course with CBT-I eventually led to sounder, more regular sleep. It didn’t “cure” my insomnia; I’m still susceptible to stress-related sleep disturbance. But now it takes a bigger challenge to throw my sleep off course, and when it goes off course I can right the ship in days rather than weeks.
CBT-I was also an exposure therapy for me, routing my fear of sleeplessness. Before treatment, the mere sight of the sun setting or the thought of a bad night ahead could make my stomach clench.
But no longer. By forcing me to confront my fear while priming me to sleep by means of sleep restriction, it effectively extinguished that fear. As the days went by, I found myself sleepier and sleepier at bedtime and often fell asleep within minutes of lying down. I was less fatigued and my thoughts were clearer during the day. As bedtime approached, I began to expect that I would sleep. Eventually my fear of sleeplessness all but faded away: a great boon after having lived with the fear for so many years.
But CBT-I as I experienced it was not a gentle or systematic desensitization. It was scary to contemplate and scarier still to follow through with. During an interview in September 2011, I told sleep investigator Michael Perlis that it was like staring at a big spider in front of my nose.
Perlis, associate professor of psychology and director of the Behavioral Sleep Medicine Program at the University of Pennsylvania, acknowledged my point. “I never said that sleep restriction was kind and gentle, and you’re right to say that it’s not systematic. There are other forms of therapy that are implosive,” he said, “where they throw you in a bin with snakes” in an attempt to change a response or behavior very quickly. The mechanism that enables CBT-I to work as effectively as it does — a dose of sleep restriction sufficient to enable the rapid and overwhelming buildup of sleep drive — would be lost if therapy were administered in attenuated doses. An already disagreeable treatment would only be further drawn out.
But as Perlis and I were discussing why the response rate to CBT-I is only 70 to 80 percent*, I returned to the scare factor. Not everyone with chronic insomnia develops fear of sleeplessness. I wondered aloud if the insomniacs who do — whose fear would tend to manifest as trouble getting to sleep at the beginning of the night, or “sleep onset insomnia” — might be more likely than others to drop out of therapy.
CBT-I works equally well for all three subtypes of insomnia patients, Perlis replied: people with sleep-onset insomnia, people prone to middle-of-the-night awakenings, and those who awaken too early. But if a study were done to ascertain who across the subtypes tended to suffer the most during treatment and drop out, Perlis thought I might be right. “It’s all the onset folks, because [with sleep restriction] you’ve just done the meanest thing you can do.” Not only have you set them up to experience sleep deprivation; you’ve also forced them to face down a monster in their bed.
My fear of sleeplessness is water over the dam. But the thought of having to face it was part of what kept me from trying CBT-I many years before I did, and I regret it. Those years would no doubt have been better without the tormenting bouts of insomnia I experienced so often and at such great length.
My concern is now for others like me, who, struggling with fear of sleeplessness, shy away from CBT-I or get overwhelmed early in treatment and drop out. As the sleep community looks for ways to deliver therapy to more patients, addressing the anxieties of this group of insomniacs early on might make a difference. Talking about fear of sleeplessness when presenting CBT-I as an option, or at the start of sleep restriction, might encourage more sleep onset insomniacs to try it and stick with it long enough to reap the benefits.
Reference
Morin, C.M., et al. (1999). Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep, 22(8), 1134-1156.