Time management problems for both waking and sleeping schedules are quite common in patients suffering from chronic insomnia. And, it could be stated almost categorically that insomnia patients’ perspectives on time worsen their insomnia in distinct ways. Remarkably, the insomniac often does not recognize or place much salience to his or her time obsessions during the day or night. Most importantly, most insomniacs do not connect time monitoring factors with their bouts of unwanted sleeplessness.
At night, the problem is most acute and apparent, because watching the clock is almost always associated with a conditioning process that teaches the insomniac to equate the bedroom with a place to monitor time instead of to sleep. This conditioning occurs in many other ways: the insomniac can lay in bed awake tossing and turning with racing thoughts, which teaches the insomniac the bed is a place to lay awake, toss and turn, and ruminate instead of sleep. Racing thoughts are the single most common self-described cause of this behavioral pattern and likely the most common cause of insomnia. However, time monitoring behavior is also extremely common, and among insomniacs it invariably worsens their sleeplessness.
When an insomniac is queried on the rationale for watching the clock, the answers usually revolve around feelings of control or comfort. The insomniac’s underlying premise is that when the precise time is known, time calculations can be made to determine how much longer it might take to fall asleep, how much time is left in the night to gain more sleep, and what adjustments might be needed to the alarm clock to accommodate potential changes in the night. Insomniacs do not immediately understand that this behavior teaches them to convert their bed and bedroom into a clock watching, time calculating environment instead of a sleeping environment.
Time monitoring behavior among insomnia patients produces this psychophysiological conditioning in contrast to a typical sleep apnea patient who might awaken multiple times per night, turn to look at the clock, and then roll over and fall right back asleep. Because the sleep apnea patient has no anxieties about the sleep initiation process, he or she re-initiates sleep as often as necessary during the night. Because insomnia patients, by definition, suffer some degree of anxiety about their capacity to sleep, at night after an awakening, their anxiety triggers the response to control the situation by clock watching. Over time (pun intended), the insomnia patient develops frustration about not sleeping, but may or may not appreciate that the obsession with time is fueling the frustration. Indeed, in our research with insomnia patients in a forthcoming paper we will be submitting for publication next year, we learned the frustration from watching the clock at night is one of the most important factors in predicting whether or not time monitoring is related to worse insomnia symptoms.
Teaching insomnia patients to stop clock watching is a straightforward step but not always one easily adopted by the patient. Mild to moderate levels of insomnia decrease rapidly when patients cease clock watching behavior. In more severe cases, the insomniac may have developed a very strong attachment to the clock, which is not readily abandoned. Moreover, in these severe cases, the patient may attempt to give up the actual watching of the clock, only to succumb to a host of environmental cues (e.g. change in outside light, dogs barking, traffic sounds, etc.) that trigger renewed mental calculations about time left in the night, which in turn fuels new frustrations. For these patients, more discussion and coaching are required to break the habit. In certain cases, individuals may refuse to follow these instructions; and in our experiences, these more vulnerable patients frequently end up on sleeping pills, because their anxieties about sleep are so omnipresent, they do not resonate with cognitive-behavioral strategies in general let alone the specific instruction to minimize or eliminate time monitoring behavior.
Although not a constant among insomnia patients, it is not uncommon to encounter an insomniac who obsesses about time while awake as well. Obviously, anyone who suffers from anxiety—and nearly all insomniacs show overt or covert signs of tension and anxiousness—is prone to worrying about things day or night. This worrying behavior may easily meld with concerns about completion of daily tasks, dealing with work deadlines, managing personal affairs, keeping scheduled appointments and so on, any of which could lead to paying too much attention to the clock.
In such circumstances, the insomniac is likely to benefit from psychotherapy to specifically address anxiety, worry, and waking time monitoring behavior. If the patient is capable of decreasing his or her daytime worries and also minimizes the exaggerated focus on time, two clear benefits may arise. First, diffusing the tension surrounding time may improve the patient’s daytime well-being. Second, learning to overcome the problem of time monitoring during the day may facilitate halting the behavior in the bedroom.
In sum, the patient does not necessarily need to smash an alarm clock to overcome time monitoring behavior. Nonetheless, some work is required in the realm of behavioral or cognitive-behavioral change for patients to accept the premise that clock watching is killing their sleep, after which they are more likely to follow the relevant instructions. More simply put, perhaps the patient will learn the value of “killing” time in the bedroom to achieve a good night’s sleep.