Is Your Sleep Tracker Stressing You Out?

What Is Orthosomnia?

Interviewer: Sleep. It seems like something that's really basic, so easy a baby could do it. But in the modern era, sleep has become something to optimize. And for some people, that optimizing turns into a problem in and of itself. And back in 2017, a group of sleep researchers gave that pattern a name: orthosomnia, a preoccupation with sleeping correctly that can end up making sleep actually worse.

We are here with clinical psychologist Dr. Kelly Baron, PhD, MPH, who is a professor in the Department of Family Medicine and Public Health at University of Utah Health, and leads the behavioral sleep medicine program here. She coined the term, and she recently worked with a research team over in Norway on the first validated tool for measuring it.

Dr. Baron, let's start with the pattern itself. Take me back to that clinic. What were you seeing in patients that made you feel this is something new, this is something different, we need a new word?

When Sleep Tracking Becomes Sleep Anxiety

Dr. Baron: So this is going back to the 2010s, the mid-2010s, as Fitbit was getting more popular and other devices like the Jawbone, if anybody remembers that one. And the devices were really crude. They were really based on movement, and they weren't very good at measuring sleep.

But on the other side, as a psychologist, I was super excited to see people interested to learn about their sleep and measure it and try to make it better. I thought that was engaging and exciting.

But we were noticing in our clinical populations that people were coming in and misusing the devices in a way that we hadn't anticipated. And this is things like people were saying, "I can't function if I don't get seven hours." And actually, devices overall tend to overestimate sleep a little bit.

On the other hand, at that time, they were really measuring quiet wakefulness as well. And so people were deciding their entire day based on what the device said, which wasn't very accurate.

We were also noticing that they would encourage perhaps negative behaviors. When somebody has insomnia, what we don't want them to do is lie in bed more and toss and turn. And it was encouraging some behaviors like that and just general sleep anxiety.

And so we kind of started talking about it in our team and just saying, "Wait, there's somebody else, and there's somebody else." So we put it together in a case report. And as we talked about it, more and more, we were having patients bringing these devices and making decisions based on their sleep and their health in a way that the data didn't support.

Now, the devices have gotten much better, but we still do see it from time to time. And so we named it orthosomnia because there is a disorder called orthorexia, which is preoccupation with right or clean eating, you might say. And so we were observing some similar patterns in sleep, that people were really trying to hack or optimize their sleep.

And we noticed there was an element of perfectionism or someone trying to perform their top . . . to be at 100 out of 100 every single day. And that meant to them getting that seven hours of sleep every night.

Anybody knows that sleep is not something that you can get 100% every single night. Maybe you had dinner too late, or you had something wake you up in the night. There are things that are uncontrollable.

Obviously, having a good sleep pattern, having some wind-down time, and things like that, you can have better sleep, but you can't have perfection in sleep. We're humans, and there are so many things that affect it. And people were getting stressed about it because they were getting a number on their device.

Orthosomnia Is a Behavior Pattern, Not a Diagnosis

Interviewer: Yeah, and then they would come and talk to you about a problem that might not actually be there. Is that my understanding?

Dr. Baron: I think that their expectations were too high, I would say, to really hack the perfect night of sleep. It's hard because there's no thermometer to see how somebody feels. And if they feel like they're not getting enough sleep, how they feel is what matters.

But on the other hand, there is a limit to how much a person can sleep or how perfect your sleep could be. You can't manufacture a perfect night of sleep.

Interviewer: Now, to be clear, just for anyone listening or reading along, this is not a diagnosis, correct? This is just kind of a description of a behavior.

Dr. Baron: Exactly. This is not a diagnosis. And we're trying to understand now how to measure the behavior. We think it's really a combination of perfectionism and sleep anxiety. And the problem with that is the more anxious you are about the sleep, the worse your sleep is. And the more that you try to overcontrol your sleep, also, that's usually not a good outcome.

Sleep Anxiety and Perfectionism Can Fuel Orthosomnia

Interviewer: So why don't you tell me a little bit about what this new research actually measures?

Dr. Baron: In this group, we conducted a process of selecting items for a scale and then testing out that scale. So, basically, to look at what are the characteristics of somebody who you might think has this condition? And then also asking people to answer the survey to see which items hang together and how similar or different is it than insomnia.

There is some overlap with insomnia, which is trouble sleeping, difficulty falling asleep, staying asleep, waking up too early. And there can be people who have difficulty sleeping who also have anxiety about using their wearable device, but it's probably not a cut-and-dry, black-and-white thing.

There's probably a range of how anxious the data makes somebody feel or how much they're overly believing their device versus somebody who is less anxious about their sleep or less intense about how they use their wearable device.

And I would say, too, the caveat is that I find this to be pretty rare. Out of my time in working with patients, I would say that I see it from time to time, and I see people come in and worry about every little awakening that's on their graph or that sort of thing.

But more than anything, I see people who ask me, "Which device should I get?" or, "What does this data mean?" I get that a lot when they shove their phone in front of me.

Two Signs of Orthosomnia

Interviewer: So I read a little bit about the questionnaire, and it sounded like there were two dimensions that this questionnaire really landed on: interference and rigidity. Do you mind explaining to me what they are and how they're different?

Interference

Dr. Baron: So interference would really fall into the category of functional impairment. Because they are preoccupied with, let's say, getting enough sleep, they might need to leave a social event early, or they might they might be more irritable with their family. And so that's one element of how the device use could be problematic.

Rigidity

The rigidity is something that, I think, as a clinician, we're more aware of. And that's really when somebody has just such a strongly held belief, like, "If I don't sleep X, then I can't function in the day."

That sort of rigid sleep belief about how much one should sleep or that sort of thing doesn't allow for the shades of gray that happen with sleep. And also, it creates anxiety for that person, because if they feel like they need that to function, then they're going to want it more and have more emphasis on getting that.

Who Can Develop Orthosomnia?

Interviewer: When you look at someone who maybe scores high on this tool or just is exhibiting a bunch of these behaviors, what kind of person is the person who this is happening to?

Dr. Baron: The research on these characteristics is really in its infancy. So I would say that we don't really know. My own experience is that it happens to men and women and people of every age. I've seen every age come in stressing about their device, and most likely people who have a sleep concern. So people who have insomnia or trouble sleeping, they're clinging onto this data because they don't feel right and they're trying to feel better, is the most logical explanation.

But I think there's also the element of the sleep hacking or competitiveness. There's that element as well. And that person could be like that for many different types of data in their life. There's somebody who's demanding of themselves, and they want every advantage or every possible boost to perform what they feel like they have to do to be their best.

Healthy Sleep Habits vs. Sleep Anxiety

Interviewer: One of the things I want to better understand is where is the line? You and I, we've talked about sleep quite a few times over the years, and I've worked really hard to get my sleep habits better. But what separates a healthy bedtime routine, that sleep hygiene, from orthosomnia?

Dr. Baron: Basically, the question I ask my patients is, "Is this device making you feel better or making you feel worse?" Do you feel motivated and say, "Oh, tomorrow night I'm going to work toward that bedtime that I'm aiming for," or does it make you feel bad about your sleep and discouraged or anxious to see that number? And some people say, "You know what? I took a break for two weeks, and I felt better, and I didn't need that data."

Sleep Trackers Can Be Motivating

Interviewer: What does it feel like? How do people describe sleep anxiety and maybe orthosomnia?

Dr. Baron: In my clinical experience, they come in just saying that they look at the data and it makes them feel stressed or worried, discouraged, or it makes them feel like they missed the mark in some way, versus feeling like a challenge.

Overall, I don't want people to ever get the impression that I'm anti-device. Actually, I love sleep technology, and I think it's very engaging for a lot of people, that they really like it.

For my device, I know that . . . and I've worn all of them. I know that if I don't go to bed before 10:30, then I never have even a chance at getting the seven hours of sleep that I would like to get. And so, for me, it's motivating because I can see, "Oh, last night I was closer to that goal." Also, it's a pretty picture to see the stage of the sleep and that sort of thing.

Consumer Sleep Technology Is Becoming More Accurate

A really cool thing is that . . . I think some of the companies have heard this information, and they have changed how they present data to consumers.

For example, Apple changed the word . . . instead of saying light sleep, it says core sleep, which I think is really helpful because people are coming in saying, "I'm really worried that I have so much light sleep." And the funny thing about that is half your night should be light sleep. That is the most prevalent stage of sleep, Stage 2. They're like, "I need more REM," but REM should be like 25%, 30%. You don't need more REM.

And we're not worried about the stages of sleep. There are even some medications that suppress REM sleep, and that's normal. So that's not a disorder, but they're concerned about it.

And so by changing some of the way things are just displayed, for example, what goes into a sleep score, all the companies now, or most of them, are giving some background about why the score is what it is.

In fact, Apple first got some feedback that they were too positive to people because they didn't want to stress them out about sleep. But previously, like Fitbit, it just gave a number. I'm pretty sure I never got an A-plus, which is really difficult for me because I'm a good student.

You Don’t Need a Sleep Tracker to Improve Your Sleep

Interviewer: Yeah. So I do want to ask a little bit more. I guess what is the benefit of a sleep tracker then? You had mentioned that there was a recent study, a consensus study from the World Sleep Society.

Dr. Baron: There was recently a consensus panel that resulted in a publication that we put out with some standards, and just some description about how consumer sleep trackers work and the types of sensors, but also some recommendations for healthy people who are just interested in their sleep or people with sleep disorders or use in medical records and things like that. And this is an ongoing process. We're working on different consumer toolkits and clinicians' toolkits as well.

And so I think the number one thing that I would say is that you don't need a tracker to improve your sleep. You can improve your sleep even keeping track of your sleep on paper and pencil. It's about how you feel and the pattern of behavior. You don't need a device to do that.

But some people find it engaging. It's interesting. It's another way of understanding your health. So I think it can be good.

But the data really have shown that, in any sort of study, first of all, the trackers themselves do not improve your sleep. It takes more intervention. You have to do something active. You can't just buy something and wear it and then feel better, generally. At least for sleep, you can't do it. It's not magic. You have to change your behavior.

And the devices, in general, aren't providing any sort of therapy, like cognitive behavioral techniques or anything like that. Maybe someday they will.

And then in studies where they have paired the tracker with the cognitive behavioral therapy for insomnia, like the online CBT-I program Sleepio, people could connect their Jawbone or Fitbit or Apple to that program. And those people who did, they engaged with the program a little more. So perhaps they're engaging, but it doesn't change their outcome. Their outcome is the same.

I think overall the devices are becoming more accurate, and part of it is because they have more sensors, better algorithms, and they're pretty close to a sleep study now, whether it's 10 or 15 minutes.

They're obviously going to be more accurate the healthier you are. So if you have a chronic condition, pain, or a neurologic condition like Parkinson's, or if you're sleeping at weird hours, if you're sleeping in the daytime, it's not going to be as good with those atypical sleep patterns. It won't be as good at picking those up. But overall, for generally normal folks, they're pretty accurate now.

And the innovation now is that there are several devices that are now FDA-cleared to show risk for sleep apnea. The important thing to know about, though, is these sleep apnea alarms are really focused on moderate or severe sleep apnea, meaning that if you get a notification, it means that it's likely that you have moderate or severe sleep apnea. But if you don't get one, you still could have it.

They're really biased to pick up the more severe cases, just so they're not giving people too many alarms or scaring them when they don't need to. So just so you know, if it doesn't say you have sleep apnea, it doesn't mean that you don't. But if it does, then you really most likely do.

When Sleep Concerns Need Professional Evaluation

Interviewer: So for someone who is maybe experiencing sleep anxiety, you mentioned cognitive behavioral therapy. Is there anything else that could maybe help calm that down?

Dr. Baron: So the first thing is I would discuss with your clinician, with your primary care provider, or discuss it with your spouse who sees your sleep pattern as well, really to understand, "Are you having a sleep problem? Are you having trouble falling asleep, staying asleep, waking up too early? Do you have the signs of sleep apnea? Are you having trouble staying awake during the day ? Is there a clinical problem there?" That can help guide you whether or not you need to see a sleep clinician to see what's going on with your sleep.

Or are you anxious about whether or not you're getting the right amount of sleep or the right kinds of sleep? That might require some education: understanding how much sleep you should be getting for your age, is there a deficit, or is there anything that you do need to address about your sleep.

An interesting thing about the trackers is that they generally will show you sleep a little bit less than you think you're sleeping. So if you think you're sleeping eight hours, it might show seven because you don't sleep every second that you're in bed.

And so, in general, they're like 15% less than what the person perceives of their sleep, and that's normal. Very few people have eight hours of sleep in adulthood. A lot of that research was based on self-report: how much you feel like you're sleeping. And when you measure it with a device, it's going to be a little bit less than that, and that's normal.

Talking about the stages or awakenings, how much is it normal to be awake in the night, or how many awakenings, or how long are they, that's also a sign to discuss.

I've had people come in and say, "I wake up three or four times a night for a few minutes." And that's normal, especially as the older you get, the more you have to get up and use the bathroom or have aches and pains.

It's really only a problem if you're having difficulty returning to sleep, or if you're feeling fatigued, or feel like it's affecting your daytime functioning, or if you think you might have sleep apnea, you have snoring or pause in your breathing. So awakenings could mean a lot of things, or they could just be a normal part of sleep.

The other recommendation for people who do have sleep anxiety or orthosomnia is that they should really think about their sleep over a one- or two-week period rather than thinking about it night to night. You really can't try to have the best sleep possible every single night, but you can try to have a good sleep pattern and think about it over time versus just night to night.

There are going to be some disruptions here and there. But it is about the pattern over weeks or months versus night to night and trying to fix that one night or get yourself back to sleep. If you get woken up by your dog running around in the night, then you have the next night that you can recover and keep going.

And then the other thing is to use your context as well. Sleep isn't just about the minutes you get per night, but it's also about how you feel during the day and how the people around you perceive you. So if they're noticing that you're more irritable with them or that sort of thing, that can be some of the context as well versus the specific number of minutes of sleep per night.

Taking a Break From Your Sleep Tracker Can Help

Interviewer: Now, for someone who is listening or reading along and recognizes themselves or maybe someone they care about in this kind of orthosomnia, sleep anxiety cycle, what do you want them to know?

Dr. Baron: I would want them to know that tracking your sleep can be interesting, it can be motivating, but sometimes it can create anxiety, negative feelings, competitiveness.

And so they really have to ask themselves, "Is this something that's making me feel motivated and feel engaged in improving my sleep pattern? Or is this creating negative emotion, making me more anxious about my sleep?" And if that's the case, then perhaps they should try a break. Give it a week or two.

It's not that that data isn't necessarily helpful, but you don't need to have that data to have a good night of sleep. And sometimes allowing yourself to sleep and experience your experience of it versus looking at what a device tells you can be more reassuring and less stressful.