When you feel awake, but you’re really asleep

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Common beliefs about sleep which are misleading or incorrect

Congratulations on making so many changes to optimize your sleep! We know you have been paying attention to the data from your Knit camera and how it correlates with your daytime function and habits. Now that you have a better understanding of cause and effect, the time has come to STOP tracking your sleep. WHAT? That’s right, we said STOP tracking your sleep. A major step in reducing worry about sleep is recognizing that your sleep won’t always be perfect and learning to move on in the morning after a bad night.

As you have probably realized by now, the correlation between bad nights and bad days is not 1:1. We sometimes have a great day after a horrible night or a horrible day after a great night. Even when bad days and nights do track together, it turns out that there is usually an underlying cause for the disruption in both, typically stress or anxiety. As you have learned, stress and anxiety will cause our sleep to be lighter and more fragmented and can also cause us to feel poorly during the day. People often jump to the conclusion that they are feeling poorly during the day because they didn’t sleep the previous night, but typically they are actually feeling poorly because of stress or anxiety. Worrying about your sleep the previous night creates daytime anxiety that in and of itself makes you feel poorly. Letting go of that worry will help you feel better during the day. Learning to stop worrying about sleep is one of the most difficult concepts to grasp, but it can be done with practice.

Common Beliefs about Sleep that are Incorrect

A great place to start is by discussing some commonly held beliefs about sleep and showing you why these beliefs are incorrect or misleading. If you personally hold these beliefs, you are not alone! Many of these beliefs come from things we hear or read, but often the matter is more nuanced than it appears, which can lead to a person drawing incorrect conclusions about their own sleep.

Belief 1

I need to get 8 hours of sleep every night or I will feel poorly.

Why is this belief incorrect? It turns out it is the average amount of sleep that you get, not the exact amount on any given night, that most determine how you function. If you are typically getting enough sleep to be well rested, a bit less sleep for a night (or 2 or 3) doesn’t have much of an effect on your function. While it is true that a single night without any sleep (ie: total sleep deprivation) has clear harmful effects on human performance, a single night of reduced sleep in a well-rested individual (such as a night of 5 hours sleep in someone who typically gets 8 hours) does not have major adverse effects. You have worked hard to optimize your sleep habits to allow sufficient, good quality sleep overall, which means that you are now reasonably resilient to occasional nights where you do not obtain that same quality and quantity of sleep.

Additionally, that magical number of “8 hours” of sleep really refers more to time in bed, not time asleep. Studies of modern hunter-gatherer societies (who do not have access to artificial lighting or other technology) suggest that our ancestors actually only slept around 6-7.5 hours on average per night. They spent significantly longer than this in bed (typically 7-9 or more hours), but some of that time was time spent awake. It is interesting that the 7-9 hours seen in those studies corresponds to the current recommendation by the American Academy of Sleep Medicine that adults obtain 7-9 hours of sleep per night. You should, therefore, think of the 7-9 hour recommendation as a guideline for how long you should spend in bed resting each night, not how long you should actually be sleeping. Lastly, there is variability in the amount of sleep that individuals need. Some individuals seem to only need 6 hours in bed to be fully rested, others need 9 or more.

Conclusion: You do not need to get the exact same amount of sleep every night. Not everyone needs the exact same amount of sleep. As long as you are typically averaging enough sleep for your needs, you do not have to worry about a poor night of sleep here and there.

Belief 2

People with insomnia have worse sleep than people without insomnia.

Why is this belief incorrect? Recordings of the brainwaves of people with insomnia during sleep generally show that their sleep is actually normal and indistinguishable from the sleep of people without insomnia. Even when individuals do have objectively disrupted sleep at night, if they do not perceive their sleep as abnormal they will typically feel well during the day, far better than a person who had very little objective sleep disruption but believes their sleep was abnormal. (See Kenneth L. Lichstein. Insomnia identity, Behaviour Research and Therapy (2017). DOI: 10.1016/j.brat.2017.08.005). A major effect of Ambien and similar sleeping medications is that they create amnesia. This amnesia effect is why people can do things like eat or drive their car on Ambien and wake up the following day without memory of these nocturnal activities. With very short-term use, Ambien does reduce the time to sleep onset and total sleep time a little, but typically this objective improvement in sleep is small. Ambien has a far greater effect on subjective sleep, which is how the person who took the medication reports having slept. In other words, the primary effect of Ambien may simply be that it creates amnesia for how a person slept the preceding night, convincing the person who took it that they “slept well” regardless of how they actually slept. With practice, you can learn to stop fixating on how you slept on any given night and simply move on with your day.

Conclusion: The sleep of people with insomnia is typically no different than the sleep of people without insomnia, the difference is in their perception of the sleep. You can learn to change your perspective about your sleep.

Belief 3

When I am stressed about something, I know I will not sleep at all.

Why is this belief incorrect? Numerous studies have demonstrated that people in a state of hyperarousal (such as occurs with stress) will underestimate the amount of sleep they obtained on a given night. As stated above, recordings of the brainwaves of people with insomnia during sleep generally show that their sleep is actually normal and indistinguishable from the sleep of people without insomnia. Why then, does the person with insomnia feel like they didn’t sleep, or barely slept? The answer is that hyperarousal increases a person’s awareness of their thoughts and the surrounding environment during sleep, which makes it difficult for them to accurately determine whether or not they were asleep. When people with hyperarousal are awakened from sleep in research studies, they are much more likely to report having been awake than a person who is not experiencing hyperarousal. Even if a person’s sleep truly IS shorter than normal, remember that sleeping a bit less when under stress is actually supposed to be helpful, giving you more time to address the stressor during the day. During times of stress, we have increased alertness in both the night AND day, so, despite sleeping a bit less, we can still maintain our performance during the day. Remember that your brain may spend parts of the night planning for an upcoming stressful event, which might lead you to experience dreams related to planning or even dream fragments intermingled with thoughts resulting in a feeling that you barely slept. Telling yourself that you will not sleep on a given night will only serve to increase your level of hyperarousal, making you feel like you slept even less and feel poorly the following day.

Conclusion: When you feel like you will not sleep at all, or have not slept at all, try to reassure yourself that you will, in fact, get some sleep. When you wake up, remind yourself that you likely have gotten significantly more sleep than you were aware of. Also, reassure yourself that the hyperarousal associated with the stressor will help you to function the next day and will resolve once the stressor resolves.

Belief 4

Due to chronic sleep deprivation and/or poor sleep quality from insomnia, I am damaging my brain and body, predisposing myself to dementia, cardiovascular disease and numerous other health risks.

Why is this belief incorrect? It is true that chronically insufficient sleep CAN predispose to the worsened function of the brain and body. The type of insufficient sleep which causes this dysfunction, however, is from EXTERNAL causes of sleep restriction/disruption and is not the same as the subjective sleep insufficiency associated with insomnia. When people are working multiple jobs and only have a 4-hour sleep opportunity each night, or staying up late every night watching TV but still getting up early for work, they ARE compromising their cognitive and bodily function, especially if the sleep deprivation is occurring on a daily basis. When research subjects who are well rested in their daily lives are subjected to significant sleep deprivation in a research laboratory, their cognitive function declines. These situations of restricted sleep, however, are entirely different from insomnia and you cannot conclude from those studies that people with insomnia are predisposed to the same risks. Additionally, as we previously discussed, when you actually analyze the sleep of people with insomnia, it turns out they are not sleep deprived and typically are obtaining a normal quantity of sleep.

The same rule applies to experiments around sleep quality. If we artificially induce poor sleep quality in a research subject by waking them up from sleep too many times during the night for a prolonged period of time, we may see a reduction in daytime performance. If a person’s sleep quality is reduced by evening or nighttime blue light exposure, environmental noises (such as cars or trains), medications, caffeine, a shifting sleep schedule or other poor sleep habits, this can have health and cognitive consequences. Interruptions that occur between sleep cycles or at other normal arousals points during sleep, however, do not actually reduce sleep quality. The sleep disruption reported by people with insomnia typically occurs at these natural arousal points during sleep and the sleep structure is not actually different than in a person without insomnia.

Chronic stress and anxiety can take a toll on our brains and bodies and it is important to take appropriate measures to reduce the hyperarousal associated with chronic stress. Don’t assume, however, that the adverse health effects of stress and anxiety are mediated through sleep. There is no evidence that artificially deepening the sleep of someone under stress with sleeping medications has any benefit on their health. Studies show that using sleeping medications actually seems to cause worse overall health.

Conclusion: People with insomnia are unlikely to truly be sleep deprived, and there is a difference between sleep deprivation from an external source (such as excessive work hours) versus an internal source (anxiety). Chronic stress can cause health problems, but this effect is not mediated by sleep disruption. You have worked hard to optimize your sleep duration and environment so, at this point, your sleep is likely normal.

Belief 5

I sleep lightly and wake up during the night so this makes me a bad sleeper. Most other people I know are good sleepers and are therefore superior.

Why is this belief incorrect?

First of all, never assume that you know how other people are sleeping. Regardless of what your friend, colleague or neighbour may tell you about their sleep, you have now learned about all the commonplace American lifestyle habits which adversely affect sleep, so, chances are, that person is not sleeping nearly as well as they think they are. In fact, sleeping too deeply is typically a sign of a sleep or health problem, such as chronic sleep deprivation, obstructive sleep apnea or simply overall poor health. Don’t be envious of the person who falls asleep instantly in their seat on an aeroplane: that person is likely TOO sleepy.

There is also natural variation in the population in how sleepy or alert an individual tends to be during the day and night. You can think of the variation in sleep as being similar to natural variation we see in height or personality, and we now know many of the genes involved in determining our sleep characteristics. Some of these genes result in increased susceptibility to sleep disruption from stressors, such as sleeping lighter/less after an argument with a spouse or the night before a trip. Naturally lighter sleepers might have an evolutionary advantage in terms of being less likely to roll over and smother their baby, or more easily aroused if there was an invader or environmental threat at night. Naturally deeper sleepers might be a bit more resilient to the adverse health effects of chronic hyperarousal and might have had an advantage under periods of prolonged stress. Having an assortment of sleep depths (and sleep timing, which is also variable within a population), would have served to protect a tribe of people living together. The theory that natural variation in sleep patterns results in at least one person in a tribe being awake at all times was actually shown to be true in a 2017 study of the Hadza hunter-gatherer society in Tanzania. That study found that over 20 days and nights of monitoring, there were only 18 non-consecutive minutes where everyone in the tribe was simultaneously asleep. This means that at least one person in the tribe was awake 99.8% of the time.

Conclusion: Just because you are a lighter sleeper doesn’t mean you are a BAD sleeper. You can actually consider your lighter sleep a superpower, enabling you to be more aware of your environment while you sleep. Your sleep is likely healthier than that of your overly sleepy neighbour.

Belief 6

If I sleep poorly during the night I should spend extra time in bed the next morning or nap the next day to catch up on sleep.

Why is this belief incorrect? Varying your schedule by sleeping in will only worsen your sleep problems in the long run by weakening your body’s circadian rhythm. In addition, if you nap the following day your sleep drive will be weakened that night, making it harder for you to fall asleep and leading to more anxiety about sleep.

Conclusion: Even if you have a particularly poor night of sleep you should stick to your regular schedule to avoid further deterioration in sleep.

Belief 7

My sleep problems are caused by a chemical imbalance (such as menopause, medications, inflammation, psychiatric disease) and therefore I cannot do anything about them.

Why is this belief incorrect? Hormonal changes, medications, psychiatric and medical conditions CAN cause measurable changes in sleep. Nevertheless, the techniques you have learned in through our program are helping to improve sleep quality even when there is a clear underlying cause of the sleep disruption which cannot fully be corrected. Cognitive behavioural therapy for insomnia (a program similar to what you have done with us) has been shown to be effective in patients with obstructive sleep apnea, depression, anxiety, PTSD, chronic pain, perimenopausal symptoms and other health issues which might be contributing to poor sleep. There will always be causes of sleep disruption which are out of your control: a sick child may wake you up; you may have to stay up late doing work; the weather may change overnight so your room heats up; you yourself may be ill, etc.; but if you are optimizing your sleep the majority of the time, you should be more resilient to these disruptions. If you have a condition which will reduce your sleep quality for a prolonged period of time, you can still do your best to ensure that your sleep quality is otherwise optimal.

Conclusion: Yes, there may be factors outside of your control which disrupt your sleep. Optimizing the factors that you CAN control will still help to improve your sleep quality.

Belief 8

Taking a sleeping pill will help me sleep better at night.

Why is this belief incorrect? Sleeping pills do not create normal sleep. Some of them may increase the duration of time during which you are unresponsive to your environment, but this is not the same thing as normal sleep. Most people do not actually take sleeping pills to help them sleep at night, they take the pills because they think that the improved sleep created by the pills at night will help them to function better during the day. There is no scientific evidence that sleeping medications improve daytime function and many of them have daytime hangover effects which worsen function. The American Academy of Sleep Medicine, American Medical Association and numerous other national medical associations ALL recommend behavioural therapy for insomnia as the treatment of choice.

Conclusion: Behavioral therapy for insomnia such as what you have been doing IS the best way to improve your sleep. Sleeping pills do not induce natural sleep and do not help people feel/function better during the day.

Belief 9

I happen to be sleeping better right now when my insomnia returns, I have no idea what to do.

Why is this belief incorrect? Relapses of insomnia are normal and expected. As you have already learned, any time you are in a state of hyperarousal your sleep will feel lighter and more fragmented. With practice, you will learn to accept these hyperaroused nights when they occur and not let them worry you. Until you get to this point, however, reassure yourself that you DO know what to do. Recognize the underlying stressor and work to resolve it or reduce your anxiety relating to that stressor. Get back on a regular sleep schedule and constrict your time in bed slightly. Reassure yourself that this too shall pass and that your sleep can and will improve again, then let go of the worry about your sleep. Reimplement the rest of the techniques you have learned through this program.

Conclusion: Relapses of insomnia will happen and you have the tools to deal with them when they occur.

Next Steps for Your Sleep

From this point forward, turn OFF the Knit Sleep Assistant App and work on letting go of thinking about your sleep. Take a deep breath and say the following Mantra every morning: I may or may not have slept last night but at least I rested my body. Today is a new day; the sun is rising and I am letting go of the night.

To help yourself stop worrying about sleep, embrace the following concepts:

• Have realistic expectations of sleep
  
• Recognize that your sleep disruption and daytime dysfunction might have a common cause (ie: stress/anxiety, lack of exercise, etc.)
  
• View the night as a time to rest and/or sleep, not JUST sleep
  
• Practice selective amnesia for how you slept the previous night
  
• Avoid blaming sleep disruption for all your problems
  
• Don’t cancel commitments due to lack of sleep