Are you sabotaging your sleep in your quest to improve it?
Many new tools are becoming available to monitor your sleep or help you achieve better sleep: wearable watches and bands; "nearable" devices that you can place on your bed or nightstand; and apps that work by monitoring biometric data, noise and movement. They can remind you to start winding down, or generate a report on your night's slumber.
But some sleep specialists caution that these apps and devices may provide inaccurate data and can even exacerbate symptoms of insomnia. Fiddling with your phone in bed, after all, is bad sleep hygiene. And for some, worrying about sleep goals can make bedtime anxiety even worse.
There's a name for an unhealthy obsession with achieving perfect sleep: orthosomnia. It was coined by researchers from Rush University Medical School and Northwestern University's Feinberg School of Medicine in a 2017 case study published in the Journal of Clinical Sleep Medicine.
Kelly Baron, one of the paper's authors and the director of the University of Utah's behavioral sleep medicine program, said that sleep trackers can be helpful in identifying patterns. She herself tracks her bedtime with a Fitbit. But she said she had noticed a trend of patients complaining based on unverified scores, even for things like the amount of deep sleep, which varies by individual.
"People were putting a lot of stock in what it was telling them," she said. "Like, 'I'm afraid I'm not getting enough deep sleep. There's something wrong with me.'"
As gadgets proliferate, so do concerns
The flood of data and buzzwords can easily become confusing: sleep debt percentages, heart rate dips, sleep rhythms, graphs of sleep disruption and comparisons to other users.
Dr. Seema Khosla, medical director of the North Dakota Centre for Sleep and chairwoman of the technology committee of the American Academy of Sleep Medicine, said she and other clinicians had scrambled to stay abreast of all the devices and apps on the market. She appreciates the greater awareness the new sleep tech promotes, but is wary of the pitfalls of inaccurate data and increased worrying.
"We want to partner with our patients to improve their sleep," she said. "This means that we need to understand sleep technology — including its limitations — without dismissing this potentially valuable resource."
In the case study on orthosomnia, researchers found that patients had been spending excessive time in bed to try to increase their sleep numbers, which may have made their insomnia worse. And they found it difficult to convince patients to stop relying on their sleep trackers, even if the numbers had been flawed.
Researchers say that trackers can overestimate the amount of sleep that you get, particularly if they focus on tracking movement. If you are lying awake in bed, the tracker might think that you're asleep. While devices that track heart rate or breathing give a more complete picture, they are still only generating estimates.
One cautionary tale from the case study: A woman came in reporting that she had an average sleep efficiency of only 60%, according to her tracker. She was given medication for restless leg syndrome, tested negative for disordered breathing, and underwent a formal sleep study. But after being told that she had slept deeply in the lab, she was not reassured.
"Then why does my Fitbit say I am sleeping poorly?" she asked.
Fitbit and other companies say the threat of anxiety is overblown
The makers of tracking devices and apps defend their use and accuracy. Conor Heneghan, a research director for Fitbit, said that few people experience extreme sleep anxiety.
He said tracking sleep can drive home the importance of a consistent bedtime and wake time. It also can underscore the effects that factors like alcohol and exercise can have on sleep patterns.
"What we're trying to do is give people a tool to understand their own sleep health," he said.
He said that the bands can provide reliable estimates based on algorithms that the company had developed using machine learning in sleep laboratories. The trackers can also recognize the heart rate and movement patterns associated with various stages of sleep, he said.
A company-supported study in 2017 compared the sleep data of 60 people, using both Fitbits and medical-grade monitoring equipment in a sleep laboratory. It found that the data matched 70% of the time, he said. Heneghan said that when two human analysts are asked to score the same sleep study, they typically match about 90% of the time.
Users of devices like Apple's smart watch have noticed something similar, with different apps giving different scores on the same night. Apple says that its watch tracks heart rate and motion data. The app makers are responsible for the algorithms that interpret them. "Each experience is unique to that app," the company said.
Dr. Eugene Spiritus, chief executive of SleepWatch, an app that pairs with the Apple Watch, said that his company's focus was on getting users to pay attention to their behavior and change it. If you sleep poorly, the app will send a prompt asking what might have gone wrong. A late meal? Too much coffee? Too much to drink? Skipped the gym?
"Can some people become obsessed with this and have anxiety?" he said. "Sure. But there are many, many people telling us it helps them."
Roy Raymann, vice president of sleep science and scientific affairs at SleepScore Labs, said the company had focused on its apps and a "nearable" device because some people had found it uncomfortable to sleep with a gadget on their wrists. The products monitor breathing and movement using radio and sonar waves, and offer a "smart alarm" feature that avoids waking the user from deep sleep, which can feel more jarring.
He noted that there had been some discussion within the industry about the need to standardise accuracy ratings.
But no matter how accurate a sleep tracker is, he said, it is only a tracker. It cannot by itself improve sleep. He made an analogy to a bathroom scale: "If you stand on it every day, it will not make you lose weight."
The Food and Drug Administration does not regulate sleep trackers because they are low-risk devices that only make general claims about improving health and well-being rather than diagnosing or treating particular conditions.
Falling asleep, the old-fashioned way
Health experts say that getting enough sleep on a regular basis is crucial: It can help you think clearly, avoid colds and other illnesses, and maintain a healthy weight, among other benefits. Chronic insomnia has been linked to an increased risk of dying prematurely, having heart attacks, and developing hypertension, Type 2 diabetes, depression and anxiety.
While sleep needs vary by individual, the National Sleep Foundation recommends that adults up to age 64 get seven to nine hours a night; younger people need much more.
Khosla said that she had seen patients with trackers neglect the basics of sleep hygiene, like following a regular schedule and avoiding screens before bedtime.
"People will shell out 200 bucks for some sleep device, but we're not willing to just shut off our phones and go to bed," she said.
Sleep trackers have a low-tech predecessor: sleep diaries. Both can be helpful to reduce anxiety by reducing "catastrophic thinking," such as the notion that the day will definitely be ruined if you're only running on, say, six hours of sleep. Khosla said she counselled patients to let go of the unrealistic notion that they must strive for "perfect" sleep.
Hawley Montgomery-Downs, a professor of psychology at West Virginia University who has researched the limitations of sleep-tracking devices, believes the best way to assess your sleep quantity and quality is based on how your body feels.
She recommended avoiding sleep trackers altogether. Her advice? Find a week when you don't have to get up at a certain time — on vacation, perhaps — and turn off your alarm. You'll sleep a lot at first, but within a few days, she said, your body will adjust and let you know when to go to bed and wake, and how much nightly sleep you truly need.
"Trust that," she said, "instead of the device."
Written by: Karen Zraick and Sarah Mervosh
Photographs by: Dan Koeck
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