In this chapter, I’ll look at two specific content areas of worry: sleep and health. Actually, the worries are about feared failures in these areas: worries about failing to sleep, or insomnia; and worries about disease when the worrier doesn’t seem to have a disease.
These worries often become closely tied with very specific responses, so I’ll describe the responses, explain how they make the problem worse, and offer some specific new responses that will help you unravel the problem. You can skip this chapter if you’re not bothered by either of these worries. You might still find it useful, though, for the way it describes how people’s behaviors change to fit in with the worries.
Jay was going through a stressful time. He had recently accepted a new position, a job he thought of as the chance of a lifetime. He accepted the job even though he had some concerns about juggling the new workload with his role as a new father. Work was actually going well for the first six months.
Then one night he had trouble sleeping. There was no obvious reason, but he woke up around 2 a.m. feeling anxious. His heart was beating faster than usual, and he felt apprehensive. He thought he had experienced an unpleasant dream, but couldn’t remember any details. He lay there for a while, trying to get back to sleep without success. He got up to use the bathroom, had a drink of cool water, checked his e-mail, and then returned to bed, hoping for sleep. He got none. He found himself resenting his wife for the peaceful sleep she seemed to be enjoying, and even the sound of her breathing seemed sufficient to keep him awake. Periodically, he’d look at the clock and calculate how much sleep he could get if he fell asleep right away. This aggravated him and made him less sleepy. Finally, around 5 a.m., he drifted off for a little while, but soon awoke to the sound of his son crying.
Jay went to work feeling a little tired, but the day passed without trouble. However, shortly before leaving the office, he found himself having the thought, I hope I don’t have trouble sleeping again tonight. The thought bothered him. He could feel his heart beat a little faster, and his breathing got short for a few moments. His thoughts turned to the question What if I can’t sleep tonight? and he envisioned himself mishandling work tasks because he was so sleep deprived.
Driving home, he found himself wondering what he could do to improve his chances for good sleep. He hit upon a few ideas: he’d have a mug of hot chocolate before bed; he’d skip watching his favorite crime show that night, which was sometimes kind of intense, and read something tame instead; and he’d go to bed early.
Jay worried about sleep throughout the evening, as if he were preparing for a physical challenge. He went to bed an hour earlier than usual, but it didn’t help him fall asleep earlier. He just lay there, feeling tense. Concerned, he got up and sat in the living room, watching a talk show and hoping to fall asleep. He fell asleep there, waking a couple of hours later with the TV still on and wondered if he should “risk” going back to the bedroom, or stay where he was. He tried going back to bed, but after a few minutes of anxiety there, he returned to the living room and slept until morning.
He felt apprehensive about going to work and had thoughts about not being alert enough to handle his responsibilities. He drank an extra cup of coffee and tried to get some reassurance from his wife. She pointed out, accurately, that he had gone with a lot less sleep during the first few weeks after the baby was born, but that fact didn’t really calm him. Before he left the house, Jay reviewed his schedule to see if there were any meetings or other activities he could cancel. He didn’t see any, but looking at his schedule reminded him of the end of the day, and he wondered again, What if I can’t sleep tonight?
Jay “got through” his workday without incident, but felt on edge, and he tried to think of more strategies to get better sleep. He stopped at the gym on the way home for a good workout, hoping to tire himself. He asked his wife to avoid any mention of negative topics, and hoped his son wouldn’t wake him early. He had a glass of warm milk that night, having read that chocolate might hamper sleep, and went to bed early, putting a hand towel over his eyes for extra darkness, and ear plugs in his ears for extra quiet. He tried not to think about waking up at 2 a.m. again. It took him longer than usual to fall asleep, but eventually he did.
Then he woke up at 2 a.m. and went downstairs to sleep on the sofa. Over the next few days, he started sleeping on the sofa instead of the bed, because he found it easier to drift into sleep there, watching TV and not focusing on trying to sleep. Whenever he went upstairs to go back to the bedroom, he worried about failing to fall asleep, and failed to fall asleep. He switched out the glass of warm milk for a glass of cold beer for about a week, until his wife persuaded him to go see his doctor. The doctor gave him a prescription for some sleeping tablets. He used those for a week or so, but didn’t like how groggy he felt in the morning, and since the doctor had cautioned him that the pills were only for short-term use, he discontinued taking them.
Jay’s experience with sleep worry is typical of what many people experience. They have a night of troubled or interrupted sleep, often for no apparent reason. They worry about it repeating. They try to head it off with a variety of tactics. These tactics treat sleep as if it were a struggle or an accomplishment. They actually make sleep more difficult, build worry about sleep. Worry about sleep is often a classic example of the Rule of Opposites. It so often leads people to respond in ways that make sleep more difficult even as they hope and wish for it to come easily.
Let’s start with some basics. What do we do to fall asleep?
Sleep is one of those activities that we allow to happen, rather than make happen. How do we do that? We create a space that’s quiet, comfortable, and dark, with no distractions or features that encourage waking activity. We show up and lie down, prepared to “let go” of daily concerns and activities, and we give that process a little time to occur.
“Trying to sleep” is a contradiction, because sleep is an activity that doesn’t respond well to effort. Think of one of your favorite meals. How likely are you, when served this meal, to scrutinize what you do with teeth and tongue? How likely are you to urge yourself to get more flavor and enjoyment from that meal, and judge how well you are doing at getting that flavor and enjoyment? Probably not so likely! Instead, you sit down at an appropriate place, with the appropriate utensils, have your beverage of choice, put the food in your mouth, and allow the experience to unfold. Even though it’s the same dish, it’s probably a slightly different experience each time, but you don’t score it like an Olympic event unless you’re a judge on Iron Chef.
Many of our daily activities are the type requiring effort, in which effort is rewarded. The more persistently I teach my dog to stay off the sofa, the better she’ll behave, at least as far as the sofa’s concerned. The more regular effort I put into my workout, the better my physique and muscle tone, and so on.
Sleep isn’t like that. The activity of sleep is more like simple relaxation, enjoying the flavor of your food, or having an orgasm. You arrange the right conditions, go through a few simple steps, and enjoy what comes your way. You don’t struggle to create the experience because struggle and enjoyment of these activities are mutually exclusive.
What are the right conditions? This is what sleep psychologists call “sleep hygiene.” It doesn’t mean having clean sheets, although that’s always a plus. It means creating a good environment, and routine, that’s conducive to sleep. This means reserving your bed and bedroom for sleep, also for sex, but nothing else. This may be a big adjustment for people who are “plugged in” 24/7.
No TV in the bedroom, get it out of there. Turn off your devices—your phone, your notebooks and other devices—and leave them in the living room. If you have to have something in your bedroom to divert you, one book is sufficient.
Take your clock and turn it to face the wall. When people are having trouble sleeping, they often check the time, then find themselves calculating how much sleep they can get if they fall asleep right away, as if sleep were some kind of timed exercise. That’s not conducive to sleep! Still wearing a wristwatch? Leave it on the bureau where you can’t reach or see it. And, if you’ve been using your phone for an alarm clock, it’ll probably be better to get yourself a traditional alarm clock. Even if you have your phone on mute, it probably still flashes and can get your attention that way.
Sleep is for letting go of the outside world, and it will help to structure your bedroom accordingly.
How about getting ready for sleep? Here are a couple of guidelines. Disconnect from the Internet and your cell phone for at least thirty minutes before going to bed. Do something a little more traditional and low key, like reading (no murder mysteries!) or watching TV in another room. Pick a program that’s not really engrossing or stimulating—talk shows are designed for this—and one that won’t interfere with your scheduled bedtime.
Let go of the evening snacks. If you’re sensitive to caffeine, limit any caffeinated beverages to early in the day. Go to bed at a time that will allow you to have the amount of sleep you think you need. Don’t go to bed extra early hoping to increase your chances of getting enough sleep. That will likely ensure extra time of tossing and turning.
It would probably be good to spend a few minutes with a simple relaxation exercise before going to bed, or right upon getting into bed, like the belly breathing and meditation exercises in chapter 10. As with any relaxation technique, the key is to simply go through the steps and allow whatever happens to happen. Maybe you’ll relax a little, maybe you’ll relax a lot. Just take what comes your way. Don’t strive to relax yourself!
Avoid napping during the day. When you sleep during the day, it often leads to less sleep at night, and you want to get back into the automatic habit of sleeping comfortably at night. So, even though it might seem like a good way to compensate for lost sleep, it probably just leads to more lost sleep. Get on a regular bedtime schedule and stick to it.
How soon will you or I fall asleep tonight? We just don’t know exactly. The main point is to create the right conditions for sleep and allow whatever happens to happen.
Worry about sleep usually takes the form of this thought: What if I don’t get enough sleep? The overwhelming majority of times, the answer to this question is that you will get sleepy. It’s a self-correcting problem! It’s not like the problem of, for example, dehydration. If I don’t get enough water, I have to specifically correct that deficit; my body will not generate water on its own, and I have to find it and ingest it. When I get sleepy, my body will induce sleep. My main task with respect to sleep is to stay out of my own way and allow sleep to occur, rather than to make it occur.
Your best response to worries about troubled sleep will include handling worry about sleep separately from handling sleep. Handle worries about sleep the same way you handle any other comment from Uncle Argument. Treat it as worry, don’t get fooled into taking the content very seriously, and humor the worries. Handle the activity of sleep in accordance with the sleep hygiene suggestions above.
What to do if you find it hard to fall asleep? Don’t lie there for hours, trying to fall asleep. Give it a reasonable amount of time, perhaps half an hour. If you’re unable to fall asleep within that time, I suggest you get up and engage in a brief period of activity.
What kind of activity? If you have a history of being able to relax yourself to sleep, perhaps with a book, then do that. But if you have a history of trying to relax yourself and failing, then don’t do that again. Instead, take twenty minutes and work on some uncomfortable, boring chore, like scrubbing a floor or a bathtub. You just had the cleaning lady in today? Doesn’t matter! The point of this task isn’t to spruce up your place, it’s to make sleep more inviting. If you get up and watch a TV show you like, or start a good book, it’s likely to postpone sleep because you’re doing something that’s more interesting than sleep. Do a task that’s less interesting for twenty minutes or so, then go back to bed. If you’re still up in twenty or thirty minutes, repeat the process as needed.
Sometimes people fall into an unfortunate pattern of waking at the same time each night. It’s usually a particularly unwanted time, like 2 a.m. This seems to occur because, after it happens once or twice, the person starts to worry—What if I wake up at 2 a.m. again?—and sure enough, like a self-fulfilling prophecy, they do. They get caught up in a vicious cycle of anticipatory worry about early wakening, followed by early wakening, followed by more worry, and on and on and on.
This is a classic example of chronic worry, in which worry about the possibility and uncertainty of early wakening leads to precisely the outcome you don’t want. Here’s a remedy I’ve found useful. It’s not for the faint-hearted, because it has that classic aspect of medicine—helpful medicines always taste bad—but don’t let that dissuade you.
When I work with clients who have this problem of habitual waking at 2 a.m., I usually suggest they set their alarm clock for 2. Then quickly, before they storm out of my office, I explain that it’s the doubt and uncertainty about whether or not they will wake at 2 a.m. that feeds and breeds all the worry that actually wakes them, and creates the habitual early wakening. When they set the alarm in this manner, they no longer have any doubt about it. They’re going to wake at 2 a.m.
This changes the problem. Before, they worried about whether or not they would wake up at 2 a.m. Now they know they will, and when they do, they can decide how to respond. Maybe they’ll respond the same way they do every other time they wake early, but this is not what usually happens, and if it does, they’re no worse off than before. What often does happen is that the person wakes in response to the alarm; wonders why the alarm has gone off; remembers that I asked them to set it that way; has a few choice thoughts for me, then turns it off and goes back to sleep. Sometimes people even find they wake a few minutes before the alarm, turn it off, and go back to sleep.
Even with this explanation, people often think it’s a pretty weird idea, setting an alarm clock for 2 a.m. because they don’t want to wake up at 2 a.m. And I guess it is. But this is a counterintuitive problem, and it requires a counterintuitive solution. When you need a counterintuitive solution, you can always turn to the Rule of Opposites. Setting the alarm for 2 a.m. is a pure application of the Rule of Opposites.
Sometimes people experience the flip side of this problem. When they wake at the desired time in the morning, they lay in bed a while, trying to get a little more sleep. Instead of sleeping, though, they often juggle worrisome thoughts about their day as they lay there. Sometimes people even set their alarm a little earlier than they need, so they can build in an extra period of snoozing. The “snooze alarm” feature on some clocks encourages this practice.
Perhaps the best advice I can offer you about these “top of the morning” worries is this: don’t take it lying down! You’re at a big disadvantage as you lay there on your back, worrying, without anything else to do.
You’ll be better off getting out of bed once you recognize that you are awake. Lying in bed, contemplating the bad things that might happen today, is not the way to start your day! Instead, get out of bed and start your morning routine—showering, having breakfast, letting the dog out. Get your day started, and postpone, for a short period, your contemplation of the day ahead.
After you’ve finished a portion of your morning routine, about fifteen minutes’ worth, then sit down in a chair and take a few minutes to review the upcoming day. You’ll be better able to view the day when you’re fully awake and sitting up. If you “need” to worry in the morning, this is a better time and place to do it. If you have a strong habit of waking and worrying in bed, it might be a good alternative to schedule a worry appointment (chapter 10) as part of your morning routine.
Worry about possible disease and illness can be an especially challenging form of chronic worry.
Someone with “illness anxiety,” as it’s called by professionals, or someone who just has some tendencies in this regard, is going to experience lots of thoughts and concerns about the possibility that he has a disease. Sometimes this worry leads people to seek out much more medical attention than would otherwise seem necessary or desirable. Sometimes it leads people to do the opposite of that, to avoid ordinary medical checkups and procedures that would otherwise make good sense. We’ll look at both responses here.
People who experience illness anxiety usually find themselves focused on some really serious and dread diseases, like cancer, Alzheimer’s, AIDS, multiple sclerosis, heart ailments, and so on. You know what you’re supposed to do if you detect a sign or symptom of some potential ailment, right? You go see the doctor and get it checked out! That makes sense.
The doctor should listen to your concern, examine the relevant parts of your body to evaluate it, and perhaps run some tests—blood work, X-rays, or other scans of relevant areas. In some cases, a consultation with a specialist may be part of the evaluation. The doctor’s aim will be to clarify, to her satisfaction, whether or not an ailment exists; if so, to identify a course of treatment; and see any necessary treatment through to its successful conclusion.
But here’s where it gets so tricky for people with chronic worry about the subject of a possible illness. If you have this kind of chronic worry, you arrive at the doctor’s office with two goals in mind. First, you want the doctor’s professional opinion as to whether or not you have a disease. If the doctor says you do have a disease, you want the doctor’s recommendation for treatment. If the doctor says you don’t have a disease, you want to be 100 percent confident that the doctor is correct—and that’s a problem.
No matter how healthy you may be, no matter how skilled, thorough, kind, and persuasive the doctor may be, you won’t get the 100 percent certainty that you crave. Even if you feel that way during the visit, by the time you get home you’ll probably start doubting all over again. This is the problem of trying to prove that something doesn’t exist. It can’t be done.
A person who worries a lot about her health may develop a concern about, say, having a dangerous heart condition, or stomach cancer. She’ll notice physical sensations that seem to indicate that she has that disease—her heart occasionally changes speed or skips a beat, or her stomach produces sensations that she doesn’t expect—and she’ll consult a doctor about it.
She hopes to be able to prove that she doesn’t have a disease and listens very closely to the words the doctor uses. If the doctor says, “I don’t see any sign of this disease,” she’s unhappy with that, because it leaves open the possibility of the disease appearing in the future, maybe as soon as she leaves the office.
What she’d like the doctor to say is something more like, “You don’t have this disease now, and I guarantee you will never get it in the future.” That would sound good to her. But, it wouldn’t be long before she’d start wondering, and get back to worrying. How can the doctor be so sure?
What do you do when you find yourself once again worrying about the possibility that you have a dreaded disease and that the doctor, for whatever reason, failed to find it? If you’re like most people with this concern, you respond to the doubt by engaging in a variety of anti-worry behaviors, just like the bull charges the red cape. You go back to that doctor to explain your situation again. You might have the thought that you left out an important detail the first time, or that you simply didn’t emphasize it enough; or that the doctor overlooked it for some reason; or maybe even that the lab mislabeled your blood sample and you got someone else’s report. So you go back and repeat the visit, asking the doctor to check again. You go to other doctors for other tests and opinions. You search the Internet. You ask friends and family for reassurance. But no matter how hard and thoroughly you try, there’s Uncle Argument tapping you on the shoulder—“What if… ?”
It might seem to you as though this subject, a possible fatal illness, is too important to settle for less than 100 percent certainty. The fact is that no matter how important the subject seems, you can’t have 100 percent certainty that a problem doesn’t exist. The harder you try to attain it, the more painfully aware you will be that you’re still not sure.
If this is your situation, you’re not unsure because you failed to investigate your concern sufficiently. You’re unsure because no one can be as sure as you wish. You’ve already attained your first goal, getting the doctor’s opinion about your health. You’re stuck trying to achieve your second goal—being 100 percent sure—and you’re not going to achieve that goal.
You’re not focused on this problem because undiagnosed disease is the biggest threat to your survival. It’s not. There are any number of ordinary daily activities that carry more likelihood of death than undiagnosed disease, and you probably don’t pay them much mind at all. You’re stuck on this problem because it makes you feel so uncomfortable. It’s discomfort, not danger. When you treat it like danger, the problem seems to spiral further out of control.
What can you do? The problem is that you’re going to the doctor hoping to get a new opinion—from yourself. You’re hoping to come home, thoroughly convinced and satisfied that you are healthy, without the disease that you feared, and that this certainty in your new opinion will last the rest of your life. But the only reason to go to the doctor is to get an opinion from the doctor, not to change your opinion or thoughts. You go there wanting to find out if the doctor thinks you have a disease. Make it your goal to get an opinion from the doctor, knowing that you will likely continue to have worrisome thoughts about disease before, during, and after your appointment. Don’t go there for certainty, just go for the doctor’s opinion.
Some people get stuck on this worry because they repeatedly have physical symptoms as well as worry. Anxiety is not all in your head. You will also experience it in your body. Some of the classic physical symptoms of anxiety include feeling lightheaded or dizzy; changes in your apparent heart rhythm or speed; muscular tightness in your chest, shoulders, back and neck; digestive distress; and more. Even though these are common symptoms of anxiety, some people who experience them have a lot of trouble accepting and believing that they can have physical symptoms that are just part of anxiety and not part of a physical disease.
People who worry about potential illnesses and find it hard to let go of those concerns frequently get angry at themselves. “I do it to myself!” they often say, and blame themselves for their troubles.
If you have worries about illness, and physical symptoms of anxiety as well, it’s true that no one else is doing this to you. The worries and physical symptoms occur within your body and mind without outside cause, but this isn’t really the same thing as you doing it to yourself. These worries and physical symptoms are natural, involuntary activity within your mind and body, part of the process by which we routinely scan and watch for signs of trouble.
If you have worries like these, you’ve got overzealous watch dogs! They bark when there’s a prowler, and that’s good. But they also bark when kids run across your lawn, or when the mailman leaves your mail. It’s too much of a good thing! But they are dogs, after all, and it’s probably unhelpful to expect that they only bark when there’s an actual threat and never bark when there isn’t. They’re not doing it to bother you; they’re doing it because that’s their nature.
In the same way, it’s within all of us to watch for signs of possible trouble and seek to head it off. That’s a part of our nature, and sometimes we get more of it than we might wish. That’s a problem. But it’s not your fault.
Other people will respond to chronic worry about possible illness in a very different fashion. They avoid doctor visits like the plague. People who get caught up in this pattern go for years without seeing a doctor. They avoid annual physicals as well as the usual recommended milestones, like colonoscopies at certain intervals after age fifty, a shingles vaccination at age sixty, and so on. The necessity of a medical visit, perhaps for a chest X-ray required by a new employer, or for an actual medical emergency, often becomes a crisis for people with this kind of worry. If you’re someone with this kind of experience, your worries take a different form compared to people who constantly seek out medical evaluations.
Why does illness anxiety lead people to avoid doctors? There are several reasons.
One common pattern is that people worry not about the potential effects of a disease, but rather about the shock and anxiety they think they’ll feel if a doctor tells them of one. If you have this type of chronic worry, your chief concern is an imagined, hypothetical moment when the doctor examines you, or reads your lab report, looks up at you with a heavy sigh, and says, “I have bad news.”
People with this form of illness anxiety imagine this scenario frequently, and the thought of hearing bad news scares them so much they think they have to avoid that possibility at all costs. It’s similar to the anticipatory fear a person with panic disorder feels when they imagine getting into a situation they associate with panic attacks, perhaps an airplane or crowded elevator.
A routine part of most doctor visits is a blood pressure reading. Some people hate and fear this to such an extent that it leads them to avoid the doctor. Maybe they have a pattern, called “white coat syndrome,” in which their blood pressure goes up when it’s time for the reading, and they have such an anticipatory reaction to this that they get caught up in a vicious cycle. They imagine the nurse saying something like, “Oh my God, your blood pressure is through the roof!” and causing a scene, while their blood pressure continues to mount.
People who experience anticipatory worry about the blood pressure reading, the doctor’s feedback, or any other aspect of the office visit sometimes find it intolerable to wait their turn in the waiting room, because that’s prime time for anticipatory “what if” thoughts to arise. Just like the fearful flier who gets to the gate only to turn back, sometimes people get as far as the waiting room only to leave in response to heightened anticipatory fears.
If you recognize yourself in the above descriptions, and see that chronic worry about health and illness is having a negative effect on your life, then the fact that the apparent content of the worry is about health and illness becomes much less important. Think back to chapter 6, in which we diagrammed the typical worry sentence. The content of the worry sentence is revealed to be of very little importance when we consider the meaning of the “what if” clause that precedes it. Do you remember what the “what if” part means?
It means “let’s pretend.” Whatever follows that pretend clause—cancer or the common cold—it’s still pretend! You’re still multiplying by zero!
That’s what you end up with when “what if” thoughts get you to pretend, even about topics that would be very important outside of pretending.
It’s very common for people who struggle with chronic worry about illness to try to deny and hide it when they visit the doctor. Do you do this? Some of this is motivated by a desire to not be hampered by this problem—you probably don’t want to “give in to it.” Some of it is from embarrassment. It’s also often motivated by a concern that, if you acknowledge to the doctor that you have some trouble with worry, all your medical concerns and complaints will be dismissed as simply “anxiety related.”
These are understandable concerns. However, to the extent that they lead you to disguise or deny your troubles with worry, they probably make your situation more difficult rather than better. If you have chronic worry about illness, you really have two problems to bring to the doctor: the symptoms you want to investigate, and your burning desire to prove, beyond a shadow of doubt, that you are not ill. If you only acknowledge the symptoms, without acknowledging how your quest for certainty complicates your life, then both you and the doctor may get diverted into unproductive areas.
Some physicians, seeing that the patient is not entirely satisfied with the diagnosis of good health, will suggest test after test and specialist after specialist, either not noticing that chronic worry is part of the issue or preferring to avoid dealing with it. You can waste a lot of time and money this way! You will also probably be disappointed to find that no amount of tests and consultations will give you the perfect reassurance you seek. In fact, the more tests you have, the more opportunities for worry will come your way.
Your internal process of worry continues to go forward whether you acknowledge it or not. If worry about possible illness is part of your lot in life, hiding that from your physician may well make the doctor-patient relationship seem more adversarial and less helpful. However, if you can acknowledge and discuss with your physician the way worry influences your thinking about your health, you may find it easier to arrive at a more satisfying working relationship with that doctor.
Some physicians probably don’t want any part of this and would prefer to have obedient, cooperative patients who accept their recommendations and don’t worry about it. If you happen to have such a physician, you may well need to change doctors and find one who is more open to working around the way worry influences your medical treatment.
Worries about sleep and health follow the general pattern of all chronic worry, and may also lead to the creation of strong habits that increase and maintain your worry. This chapter identified some characteristic behaviors that people adopt hoping to get the worry under their control, behaviors which ultimately make the worry more persistent and severe rather than less. Identifying such behaviors, and reversing them, is an important part of changing your relationship with chronic worry.