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Non-Restorative Sleep In Chronic Fatigue Syndrome

Non-restorative sleep in chronic fatigue syndrome, despite sufficient or extended total sleep time, is one of the major clinical diagnostic criteria.

There is preliminary evidence that alteration in sleep stage transitions and sleep instability, and other physiological mechanisms such as heart rate variability and altered cortisol profiles, may be implicated in the sleep difficulties of this population.

The Meta Cognitive Model of Insomnia

In a paper entitled ‘Improving Sleep Through Mindfulness And Acceptance: The Metacognitive Model of Insomia’ the authors propose that:

increasing awareness of the mental and physical states that are present when experiencing insomnia symptoms, and then learning how to shift mental processes, can promote an adaptive stance to one’s response to these symptoms. These metacognitive processes are characterized by balanced appraisals, cognitive flexibility, equanimity, and re-commitment to values and are posited to reduce sleep-related arousal, leading to remission from insomnia.

What is Metacognition?

An awareness or knowledge of one’s own cognitive process. This has also been referred to as “thinking about thinking” or a meta-level governing of thoughts and beliefs.

In distinguishing metacognitions from cognitions, we conceptualise two levels of sleep-related cognitive arousal. Primary arousal consists of the cognitive activity directly related to the inability to sleep. This includes the thoughts that interfere with sleep and the beliefs about daytime consequences of poor or insufficient sleep. Secondary arousal consists of how one relates to thoughts about sleep. This includes the emotional valence one assigns to those thoughts, the degree of attachment one has to them, and the meaning of those thoughts in relation to one’s values (interpretive value). Therefore, secondary cognitive arousal tends to amplify the negative emotional valence and/or create a bias in the attention to and perception of sleeprelated thoughts at the primary level. For example, the thought, “I need eight hours of sleep to function well the next day” can create primary arousal when the individual is lying in bed unable to sleep. A rigid attachment to this thought interferes with serious consideration of alternative beliefs and can amplify the valence, or degree of negative affect, associated with the thought, thereby creating secondary arousal. The degree to which one accepts thoughts as facts determines the valence these thoughts generate. Without the flexibility to allow competing thoughts to be considered (e.g., “I can find other ways to cope if I get less than 8 hours”), secondary arousal becomes a mechanism by which insomnia is perpetuated.

Metacognitive Shifting

Metcognitive shifting involves changing the “relationship with” as opposed to the “content of” cognitions. Instead of changing a thought or behavior, greater awareness promotes a metacognitive shift towards a more objective, non-judging stance.

Balance: As applied to insomnia, a balanced stance involves managing the attraction and aversion to sleep. In assessing patients with insomnia, many will report a tendency to seek sleep, meaning there is an imbalance in thoughts and behaviors related to sleep, such as striving to go to sleep or “clinging” to the bed in hopes of getting more sleep

Flexibility: Flexibility in stance is also an important component, consisting of openness, a willingness to adopt a beginner’s mind, and acceptance of a wide range of cognitive and emotional phenomena.

Safety behaviors (Harvey (2002) are specific routines or rituals that must be done in order to fall asleep or to limit the consequences of poor sleep. Examples of these safety behaviors include avoidance of social functions and, increasing time in bed in an effort to avoid the fear of not sleeping or the consequences of not sleeping. Safety behaviors reflect unwillingness to accept sleeplessness and its consequences. Ironically, attempts to control sleep have the paradoxical effect of perpetuating sleeplessness.

Equanimity: With equanimity, one is adopting a stance of non-attachment to sleep outcomes, which facilitates improved emotion regulation in the face of insufficient sleep and fatigue. This stance refers to actively letting go of the desire to get sleep or the expectation of meeting certain sleep needs. It also refers to letting go of the strong belief in contingencies between sleep and daytime functioning, such as the need to get eight hours of sleep in order to function well during the daytime. People with insomnia are often driven towards sleep-seeking behaviors because of messages from the media emphasizing the consequences of sleep debt. This belief can increase sleep effort or increase time spent in bed when sleep goals are not achieved.

Commitment to values: Individuals experiencing chronic insomnia may lose sight of some of their life values as their focus becomes more directed towards control of sleeplessness. Awareness of values can be a reference for developing values-consistent goals, and for determining if individual actions are consistent with values. Once values are identified, therapists can help a patient realize the cost of a behavior (e.g., canceling a social engagement because of poor sleep the previous night) in terms of a linked value (e,g, staying connected with people).

A Similar Model – The IAA Model  (Intention, Attention, Attitude)

Shapiro and colleagues (2006) followed with the IAA model of mindfulness in which intention, attention, and attitude (IAA) are seen as an interwoven processes that can lead to “re-perceiving” experiences. Segal and colleagues (2002) introduced the concept of decentering as the ability to “step outside of one’s immediate experience, thereby changing the very nature of that experience” and is seen as a similar process to re-perceiving in Shapiro’s model (2006). These metacognitive models promote a shift in mental processes (second order) rather than a direct change of the mental contents or behaviors (first order). This shift in perspective (stance) enhances self-regulation and promotes an adaptive response (action), rather than maladaptive stress reactivity (reaction).

You may like to read out article ‘Self-compassion: A way to improve resilience‘ that ties in with some of the above concepts.