I have a full toolbox of techniques for handling anxiety during the day, but nighttime is a little trickier. If you’ve had the same experience, you’re not just imagining things.
A Live Science article by Louise Bond examines this issue. According to Clinical Psychologist Charissa Chamorro, PhD, at night our brains have fewer distractions, leaving us more vulnerable to worries that creep in. This makes sense as we can redirect our attention during the day to activities that are not available when we’re in bed.
Darkness can be unsettling enough, but researchers feel that the circadian rhythmn is also involved in the accentuation of nighttime fear.
And you don’t need to be suffering from horrible anxiety for this to be the case. Research (Li et al., 2015, Int J Psychophysiol) showed that even among women without anxiety, fear was enhanced at nighttime, and not simply because of darkness, suggesting the involvement of the circadian rhythm. At the same time, as diurnal beings, humans naturally evolved to have stronger fear responses at night. This is partly due to the fact that we don’t see well in the absence of light and therefore are more vulnerable to nighttime predators.
Furthermore, while there is a natural ebb and flow of cortisol throughout the circadian cycle with cortisol levels peaking in the morning and being lowest at midnight, when anxiety keeps cortisol levels high during the day, that affects nighttime hormone release and therefore your ability to rest (Hirotsu et al., 2015, Sleep Sci).
To make matters worse, once your sleep is disrupted, worrying about your inability to get a good night’s sleep can result in being unable to sleep, and a vicious cycle develops.
Establishing calming practices during the day can have a positive effect on nighttime anxiety.
You’ve probably heard the suggestions for improving sleep: turning the lights down in the evening, avoiding electronics (or using blue-light blockers), keeping your bedroom cool and dark, using a sound machine to mask noises, avoiding stressful or polarizing conversations in the evening, and the like.
To that I would add that what you do during the day itself can affect what kind of sleep you have at night. Meditation, practicing mindfulness, doing deep breathing exercises all put us into a calmer state. If you wake up in the middle of the night with a racing mind, having practiced and become adept at self-grounding techniques in daytime can help you soothe yourself at night.
While the roots of our anxiety may be complex, for those of us for whom it’s built up over time, so too will it take time to establish behaviors to help control it. Sometimes we need support of a therapist or medication, sometimes we can manage on our own, but setting aside time every day for even a short calming practice can help you improve management of anxiety no matter when it appears.
I, like so many people, keep a lot of tension in my neck and shoulders. Some days it feels as though my neck is made of steel, but not in a good way.
The reality is that I don’t even realize how tight those muscles are until I lie down and try to relax.
So I have made a meditation of this for bedtime. Instead of focusing on the sensation of my breath, the focus is on releasing the tension in my neck and upper shoulders.
It may sound like I would not be able to squeeze an entire meditation session out of this, but oh, I can.
Complete release takes focus!
Lying down on my back I inhale, and then with the exhale, I focus on my neck and relax it, releasing the rest of my body along with it. With the following exhale, I do that again. That’s because while I may think that the initial release took care of the tension, there is still tightness there and I really have to work on it mentally to release that.
It’s as though my neck muscles are springs that I can stretch, releasing tension through the exhale, but once I let go (inhale) the “memory” in my muscles tightens them up again.
It helps to imagine my body melting, as if I’m being drawn downward into the Earth.
I can keep going like this, feeling my chin inch slightly towards my chest as the tension releases. Melting into the mattress. The more I release, the more subtle the sensation, yet very satisfying. The more I relax, the more deeply I breathe and everything lets go.
The awareness of what is going on in my body helps so much, but the tension is tenacious. This is not surprising, given how much mental weight my neck and shoulders bear. So it is a dance between releasing and returning to release again. Little by little until I eventually fall asleep.
Another stressful night left me wide awake at 3am again. Not fun when you’ve got a long day of work ahead of you.
I went to my tried-and-true tactic: several guided meditations which usually work to take the place of the worries swirling in my noggin. But this time it wasn’t enough. The voices were soothing but I wasn’t close to falling asleep.
So I came up with a simple impromptu meditation that kinda-sorta breaks the mindfulness “rules”.
So many numbers out there for me to count while I’m not sleeping…
I’ve been taught that one can count the breaths to help deal with the chattering “Monkey Mind”, and this can be done in various ways. For example, count each inhale as one and each exhale as two, repeating with the next inhale as one and exhale as two, and so on, never progressing further.
Or counting each breath cycle up to 10 (or any other preset number) and then start again at one. If your focus is lost at any point, start at one again, working your way back to 10, restarting at one if your mind wanders off again.
These types of counting techniques aren’t meant to get you anywhere. The number you reach doesn’t matter. What matters is that you make the breath counts your point of focus, giving the Monkey Mind something to do and keeping anxious thoughts at bay.
But for this particular 3am waking, I decided to try something else: count breaths without a stopping point. Instead of observing the breath without changing it, as is usually done during other mindfulness meditation practices, I counted during the exhale, consciously extending the breath as I thought the number. And as I focused on my breath, I kept track of the ascending numbers. This required a touch more concentration and yet was simple and boring enough to not excite my mind.
Somewhere in the 70s and 80s the numbers started jumbling in my head and I repeated several, not being sure exactly where I was. By the 90s, my monkey brain was muttering. I remember getting to 100 and going past it, but my memory is foggy. Consciousness faded in the one hundred teens, I think.
As far as back-to-sleep methods go, this was not a quick fix, but I was too awake to try anything else. I counted for a good 20-30 minutes. I manipulated the breath, so as I mentioned, this practice didn’t follow the mindfulness meditation “rules”, although it did offer me meditation practice in lieu of spinning my worry wheels.
But in the wee hours of the morning when nothing else seemed to be working, it got me to where I needed to be: asleep.
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When the going gets tough, I’ve found counting to be one of the most effective last-ditch back-to-sleep methods, for me preferable to getting out of bed and going out to the couch to read or something. If nothing else, I get in some effective meditation practice. Additionally, this was not a night with a totally hyperactive Monkey Mind. My monkey was awake for distractible.
Note that as I was doing this, I lay on my side, bolster between my knees, white noise playing through my earbuds (yes, I’ve taken to sleeping with earbuds in!). I was in “sleep position” and keeping still, so the only “moving parts” were my brain and the expansion and contraction of my chest and belly.
The last time I was researching the link between cancer and sleep, noting the myriad benefits gained from solid nighttime rest, I was surprised to see mention of melatonin’s role in decreasing the risk of cancer.
For anyone who might not be familiar with it, melatonin (a tryptophan derivative) is a naturally-occuring hormone secreted by the pineal gland that signals when it’s time to sleep and wake. It’s mediated by light levels, with the amount of melatonin in your body increasing as the sun goes down. You’ve probably seen melatonin on the vitamin shelves at your local store, as in recent years it’s been popularized as a non-addictive sleep aid. What I hadn’t realized was that its effect on cancer cells has become an active area of study.
I dug into the PubMed database to find there was quite a bit on this topic. However, note that not all the journals in which these results were published were familiar to me, so I cannot vouch for the rigor of the peer review, however, there was a general consensus that melatonin showed promise.
Melatonin shows a lot of promise as a cancer fighting hormone.
It’s well-established that women who work night shifts experience disruption of their circadian cycle and have an increased risk of breast cancer risk, purported to result from extra circulating estrogen (Cohen et al., 1978, Lancet). Researchers are now linking that disruption with a decrease in melatonin production.
Amin et al. (2019, J Cell Biochem) describe the action of melatonin as it relates to cancer: “Melatonin via its receptors and various second messenger pathways decrease[s] cell duplication and increase[s] cell differentiation.” Since cancer tumors are composed of a proliferation of poorly differentiated cells, this means that the action of melatonin works against the process by which cancer develops and progresses.
Amin et al. continue by noting that melatonin “regulates estrogen-dependent pathways (by nonreceptor-dependent means) and reduces the production of oxidants; as a result, melatonin inhibits cell toxicity and mutations….Melatonin interrupts estrogen-dependent cell signaling and also causes reduced estrogen-stimulated cells in breast cancer. [It] is a mammary tumor inhibitor…[as relates to the] development, progression, and metastasis of breast cancer via a number of molecular mechanisms.”
A randomized, double-blind, placebo-controlled research study showed that melatonin has a neuroprotective effect that can counteract the effects of chemotherapy on “cognitive function, sleep quality and depressive symptoms” (Palmer et al., 2020, PLOS One). These are significant side effects that have a profound impact on the patient’s quality of life, and anything that may relieve these will improve the entire treatment experience.
Griffin & Marignol (2018, Int J Radiat Biol) noted that melatonin administered to subjects before they were exposed to ionizing radiation resulted in the breast cancer cells being more sensitized to the radiation therapy, rendering it more effective. And melatonin seemed to reduce the radiation-induced side effects exhibited by both human and rodent subjects.
No matter how many drug treatments are available for cancer, they do no good if the cancer cells develop a resistance to them. In a study published this year, Sang et al. (2021, Cancer Lett) found that melatonin increased the effectivess of drug lapatinib in HER2 receptor-positive breast cancer cells that were originally resistant to the drug, suggesting that melatonin could be a promising adjuvant therapy for treating advanced HER2+ tumors.
So, melatonin may reduce breast cancer risk, make existing treatments more effective and help protect patients against negative effects of these therapies. Does that mean you should run out and gobble melatonin every night?
Many studies are first run on animal subjects, but to truly determine whether a treatment will be effective for cancer patients, it must be tested on humans.
No! As tempting as it sounds, that’s not an advisable course of action. Many more studies still have to be run to evaluate the exact mechanisms by which melatonin acts on physiological processes. Some of the results in the cited studies were based on small sample sizes; good for proof of concept, but following up with larger scale studies is critical. Some studies were run on animal models which are not the best human analogues. In addition, there’s little direction regarding proper therapeutic dosages. Establishing those will take additional research.
Keep in mind: a naturally-occurring hormone like melatonin likely has a “sweet spot” in terms of dosing, and determining the ideal amount may be tricky. Just because you can buy melatonin gummies in 10mg doses does not mean you should be taking that much.
Furthermore, melatonin may elicit negative side effects in some people, including headaches, nightmares and nausea. Side effects tend to be short-lived with short-term usage but there’s still not enough information available about long-term safety, so taking it for longer periods of time is strongly discouraged.
Note also, the articles I’ve mentioned above were selected because they describe recent research, although some of these are review articles that espouse the authors’ opinion, backed up by research selected for the purpose. If you’d like to read the above studies yourself and the links I’ve posted do not provide you full access, please consult your local university library for copies (copyright laws prohibit me from providing access to pay-only articles, regrettably).
Finally, it may be that some of melatonin’s benefits might be its undoing. Reiter et al. (2017, Int J Mol Sci) note that melatonin is inexpensive and readily available, and therefore there might not be the same level of interest in researching and developing it for cancer use as there might be with a novel drug with the potential to be more lucrative.
Where does this leave us?
I would urge you to: 1) Ask your oncologist about what they would recommend, given the research that’s coming out. They are still your best source for information. FranticShanti.com is only a blog and can be used as food-for-thought but definitely not for determining your course of treatment. 2) Learn how to read scientific studies. There are free courses on educational site such as Coursera.com that explain research design and interpretation in layperson terms. They can offer instruction on reading research with a critical eye. 3) Keep an eye on emerging research. Databases such as PubMed are excellent sources for health research. Even if you’re not well-versed in research design, you can look up articles to bring to your next visit with a health provider. 4) Do not take megadoses of melatonin! There is still so much we have to learn about this hormone as it relates to cancer, and self-medicating with melatonin in the hopes that “maybe it’ll help” is dangerous. Again, your oncologist remains your best source of information.
Promising drugs aside, get your sleep!
I do encourage you to respect your circadian rhythm by establishing good sleep hygiene practices to improve the conditions for your body to create and release its own melatonin. Proper and adequate sleep will always benefit you!
And so we get back to the idea that launched this post: sleep remains the ultimate good.
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It bears repeating: ALWAYS ask your cancer team about starting any new medication or supplement, regardless of how well-supported it is by research.
Some time back I posted sleep researcher Dr. Matt Kelly’s TED Talk on sleep, which I highly recommend. Now, the American Academy of Sleep Medicine (AASM) has issued a position paper which states unequivocally that “sleep is essential to health”.
As noted in the position paper, “Healthy sleep is important for cognitive functioning, mood, mental health, and cardiovascular, cerebrovascular, and metabolic health.” Anyone who has suffered through the daylight savings time change – that would be most of us – can tell you that even missing out on a single hour of sleep can leave you feeling off for a few days.
Sleeplessness is too often an occurence for too many of us.
And many of us have likely had the experience of sacrificing sleep for school or work projects, adjusting to newborns, or other similar temporary situations, not to mention the occasional middle-of-the-night stress session.
But sleep disruption on a chronic scale has far-reaching repercussions, and has been “associated with an increased risk of mortality and contributes to both the individual risk and societal burden associated with several medical epidemics, including cardiovascular disease, diabetes, obesity, and cancer.”
In particular, shift work has been associated with an increased risk of cancer, due to the persistent disruption of the body’s biological clock, as reported in a recent CDC blog post based on reviews by the National Toxicology Program and the International Agency for Research on Cancer. Data came from both breast and prostate cancer surveys. [The CDC post does outline what shift workers can do to protect themselves.]
While the studies may be confusing, good sleep hygiene is always important.
According to the AASM position paper, the consensus among different sleep-related organizations is that adults require at least 7 hours of sleep regularly, with the range being 7-9 hours. While this seems straightforward, one meta-analysis (Lu et al., 2017, Biomed Res Int) of 10 studies suggested that sleeping excessive amounts (over 9 hours) was linked to an increased risk of estrogen-positive (but not estrogen-negative) breast cancer for women. At the same time, Xiao et al. (2016, Sleep Med) found that short sleep duration was associated with triple-negative (but not estrogen-positive) breast cancer in black women as compared to white women, suggesting racial disparities in the data, so further research is needed.
Confusing? Yes, this is clearly an area that calls for more study. Some clarification came recently from the publication of the “Million Woman Study”. This was an extensive prospective multi-year study of women in the UK that, you guessed it, found no association between breast cancer and sleep of any duration (Wong et al., 2021, Sleep). Nonetheless, the authors did note some shortcomings of the study, so this question is likely to be revisited.
Take home message? Conflicting studies aside, everyone would agree that good sleep hygiene (see CDC recommendations) is important no matter what your cancer risk. With our lives running 24/7 and sleep schedules constantly being disrupted, we should take a clue from the animals who settle down as the evening begins, like clockwork. We might have advanced as a civilization, but we can’t get past the reality that when it’s dark out, it’s time to hit the sack.
With everything that’s going on right now, it would not be surprising if you were having trouble sleeping.
I myself have an internal alarm that wakes me up around 3am, giving frightening thoughts a chance to land hard punches. It’s far easier to keep negative emotions at bay during the daylight hours, but our defenses are down when we’re groggy. Before I know it, I’m already on that hamster wheel, getting nowhere and working up an anxious sweat in the process.
Ok, nighttime. Wanna go?
There’s a lot to worry about in the time of COVID-19. Take your pick of stressors: finances, physical health, relationships, emotions. At night, our brain wants to fix everything that we’re hit with during the day, but obviously, that’s not the time for it. Few things are as critical for dealing with stress as a good night’s sleep, which you won’t get if you’re trying to calculate how many months’-worth of rent you have left.
The mistake we make is trying to let go of things completely. When “danger is imminent”, as in, the worst-case scenario is a distinct possibility, it’s unrealistic to pretend it’s not. I promise you, as a former cancer patient, I had terrors breathing down my neck. I could not simply “let go” of them. They were life-changing and oh-so real. But with a little effort I could loosen their grip on me.
Your concerns need some respect. So instead of trying to avoid them, try gently putting them aside. You know they’re still there, they know they’re still there, but you’re not butting heads. This may take some mental calisthenics.
Even the tiger needs some shut-eye.
Ask yourself, “Can I do anything productive right now?” If the answer is no (hint: unless the house is on fire or there’s a tiger loose in your bedroom, the answer is no), then create a mental shelf for your anxious thoughts. You can build one for yourself, right there lying in bed, no hammering required.
Find yourself a jar with a secure lid. I know you have one somewhere in your mind. Scoop your thoughts in there, screw the lid on tightly and place the imaginary jar on that imaginary shelf. This may take several tries — unpleasant thoughts are slippery — but that’s okay. Make sure the shelf is across the room from you. The jar will still be there in the morning when you wake, thoughts swirling inside. But in the darkness, you’ll have some space between them and yourself.
As you lie in your bed, take a deep breath, feel the weight of your body on your mattress, feel the softness of your sheets on your skin. Look at the shelf, way over there. Way, way over there, and you safe in your bed. Allow yourself to relax.
That’s what you need most in the wee hours of the morning. So rest easy now. Tackle the problems tomorrow.
I hold sleep as one of the most critical elements of self-care in our lives. Get enough sleep and the whole world looks brighter. But ignore the call of the mattress and dire consequences await.
This is especially true for me, as I slog through the ever-changing side effects of my current anti-cancer therapy (Tamoxifen). The amount and quality of sleep I get sets the tone of my day and determines my resilience to work and life stress. In addition, sufficient sleep has a significant positive effect on my cognitive functioning, which took a hit from cancer treatment.
But this is not limited to my personal experience. The more we learn about the science of sleep, the more we understand how our electronics-driven lifestyles disrupt sleep patterns and affect us as a society.
Dr. Matt Walker (UC Berkeley) is a strong proponent of sleep, and for good reason. He outlines in his TED talk (19:19) below some of the latest research on the repercussions of not getting enough shut-eye, and it’s not pretty. As a cancer survivor, I find this information particularly sobering. While I’ve written about the downside of placing superhuman expectations on ourselves, having THIS kind of superpower, getting sufficient sleep, is literally life-preserving.
Let’s start with “testicles”…
Dr. Walker’s two main suggestions for good sleep? (14:16 in the video) 1) Keeping a regular sleep schedule, retiring and rising at the same time regardless of day of the week. 2) Keeping your bedroom temperature at about 65°F (no mean feat without A/C in the summer months!).
For many of us, improving the amount and quality of our sleep will take concerted planning and possibly sacrifices. We live in a 24-hour-a-day world and sometimes we try to keep up with that ’round-the-clock pace; ultimately, however, we pay the price for it. There should be no question that sleep is critical to our well-being and it’s time that we give it the priority that it deserves.
Frantic Shanti 