For people who struggle with initiating and maintaining sleep—oftentimes for decades—insomnia becomes central to their lives, even their identity.
A well-recognized clinical phenomenon in the world of behavioral sleep medicine, insomnia identity describes the conviction that one has insomnia, independent of actual sleep patterns.
So, clinically, like a mentor of mine once remarked, when you stop thinking and talking about your sleep—or identifying as an insomniac— you know you’ve done some good, solid work.
The work? Typically, cognitive behavioral therapy for insomnia (CBT-I).
Considered the gold standard treatment for chronic insomnia, CBT-I claims high clinical effectiveness and efficacy, with many patients experiencing durable symptom remission. It uses talk therapy—usually over four to eight visits—to examine unhelpful thoughts, emotions, and behaviors maintaining insomnia and comprises five core treatment components: 1) sleep education, 2) relaxation training, 3) stimulus control, 4) time in bed compression/restriction, and 5) cognitive therapy.
But for patients who have experienced longstanding symptoms and then no longer experience them after treatment, remission can, admittedly, feel disorienting—even anxiety-provoking. Some of my own patients have analogized it to feeling naked, or leaving the house without their phone.
Clinical Management
So, how can you learn to manage this tragicomedy of anxiety secondary to remitted insomnia? A few practical thoughts:
1. Validate your feelings. Feeling felt, feeling understood, feeling seen—sometimes these serve as the best interventions for tricky feelings. What does this mean practically? Reflecting, not repairing. That could sound like saying some version of this to yourself:
“I’m used to having trouble sleeping and don’t anymore. It feels disorienting and anxiety-provoking. That makes sense and it’s OK.”
Simply hearing “that makes sense”—from yourself or another person— offers a balm to the nervous system and preempts upregulating symptoms. Don’t believe me? Try remembering how your body and brain felt after someone offered those words in response to your suffering, pain, or strife. The phrase is like the Swiss Army knife of mental health.
2. Get paradoxical. Try not to think about a white polar bear. Seriously, don’t. Stop!
(You’re probably thinking about a white polar bear.)
Our funny little exercise demonstrates how thought suppression usually increases the frequency of undesired thoughts or behaviors.
Similarly, the common preoccupation with avoiding recurring symptoms among people in remission from insomnia can increase the odds of recurrence. Paradoxically, when we allow ourselves to experience rebound symptoms—and work to decatastrophize them—we can reduce the likelihood and severity of a recurrence. This application of paradoxical intention (PI) empowers you to radically own, acknowledge, and permit the possibility of your symptoms returning, thereby reducing or eliminating the performance anxiety associated with avoiding them.
Through exposure, PI minimizes sleep performance anxiety, diverts attention from sleep effort, and promotes expectation management— freeing you of both having to manage insomnia AND the (potential) disappointment of re-experiencing symptoms. Paradoxical intention may look and sound like this:
- “’I’m going to allow myself to experience symptoms if they arise.”
- “I’m going to release the expectation of full remission.”
- “Adopt a mindset of not expecting anything.”
The more you try to do one thing (allow symptoms), the more the opposite may happen (maintained remission).
3. Use psychoeducation. Cognitive therapy assumes thoughts (i.e., how we process information), feelings, and behaviors have synergistic and reciprocal relationships. In other words: How we think influences what we feel and do; what we do can influence how we feel and think, too.
Conflating insomnia symptoms with a relapse illustrates a common cognitive fallacy people in recovery can commit. And as a form of catastrophizing, this confusion can perpetuate insomnia via psychophysiological arousal—the disorder’s signature because telling yourself you’re experiencing a relapse (vs. having symptoms) sounds much, much scarier and feels more activating.
An elegant and effective intervention uses psychoeducation to differentiate symptoms from relapse. This typically sounds like: “I can have symptoms without experiencing a relapse.”
…and then clearly defining the terms: “I can experience symptoms—or features of a disorder—without having a relapse, which describes a full-blown return of the clinical syndrome prior to undergoing treatment. Symptoms don’t mean relapse.”
Empowering yourself to understand and label the difference interrupts inflammatory cognitive processes implicated in maintaining insomnia.
4. Reframe. But as any good cognitive therapist knows, teaching patients to consider and sit with the worst-case scenario has its own unique therapeutic benefits. Reframing a relapse as an opportunity to refine and sharpen newly acquired CBT-I skills leverages the benefits of both cognitive and exposure-based techniques. My recommended script sounds like some version of this:
“Experiencing relapse does not undo the skills I’ve learned. If anything, it sharpens them. Even if I do experience a relapse, I now have the skills and support to navigate it. And it’s never going to be harder than the first time. I may experience symptoms again, and that’s frustrating but manageable.”
Translating these scripts into your own coping statements, preferably through writing, usually enhances the therapeutic potency of these interventions
Conclusion
For those who have experienced longstanding symptoms of insomnia, remission can have associations with secondary anxiety. Anticipating these feelings as well as creating a thorough discharge and relapse prevention plan using validation, paradoxical intention, psychoeducation, and reframing can help to manage and prevent symptoms of both.
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.
A version of this post also appears on MedCircle.
To find a therapist, please visit the Psychology Today Therapy Directory.
