Nearly half of all Americans suffer from occasional sleeplessness, and a staggering 15 percent have chronic, unremitting insomnia. We live in a culture where resorting to medication tends to be the first-line treatment. Most people only know about the medications available to treat insomnia: We constantly hear about them on TV, and many friends write about their insomnia sleeping pill use on social media (in the middle of the night). Medications can indeed be helpful for insomnia, and they surely have their place in insomnia management. However, many people are not aware that sleep specialists do not consider sleeping pills to be the first-line treatment for insomnia. Instead, sleep medicine’s gold standard treatment for insomnia is cognitive behavior therapy for insomnia, which is also known as CBT-I.
CBT-I is a non-drug, short-term treatment and has benefitted people of all ages and many types of patients who have trouble sleeping, including those with insomnia related to chronic pain, depression or anxiety. CBT-I consistently produces results that are comparable to, or even exceed, those of sleeping pills. Even one year after ending treatment, many patients continue to sleep well (rates that far outperform sleeping pills).
There are many ways one can engage in CBT-I, starting with self-help tips that I will mention in this post. There are a number of books on the market that focus on CBT-I as well as apps that you can download that will take you through the treatment in a more focused way. If you consistently try the techniques here (or in a book or app) and it isn’t working, consider seeing a specialist who will specifically target treatment to your particular situation. You can find a specialist here. Most sessions with a specialist last between three and 12 visits.
CBT-I is based on the concept that chronic insomnia is sustained by a variety of factors that maintain the problem. Examples of these behaviors are sleeping in, going to bed early, napping, using alcohol as a sedative, caffeine use, worrying about your sleep and tossing and turning in bed. These factors are the focus of the treatment.
The first step in CBT-I is tracking your sleep. Completing a sleep diary for two weeks can bring to light issues with sleep hygiene and sleep scheduling and make you more objective about your overall sleep pattern. There are many sleep diaries available online, but a good one should track your bedtime, wake time, how long it takes you to fall asleep and how much you are awake in the middle of the night. It should also record caffeine intake, exercise, napping, alcohol and sleeping pill use. Look for any patterns in your sleep diary. For example, do you notice it takes you longer to fall asleep on nights where you napped or dozed off earlier in the day?
The next module is sleep hygiene. Sleep hygiene should be thought of as the basic building blocks for insomnia treatment. If you don’t have proper sleep hygiene, the other modules won’t work as well. However, fixing sleep hygiene alone typically isn’t a cure for more chronic insomnia. It is the starting point in treatment. Sleep hygiene rules include limiting caffeine within eight hours of bedtime, stopping alcohol, heavy meals, liquids, nicotine and exercise within three hours of bedtime, avoiding clock-watching at night, engaging in exercise in the late afternoon/early evening, avoiding screens/electronics, winding down within one hour of going to bed and keeping your bedroom quiet, dark, comfortable and cool throughout the night.
Stimulus control is a highly effective and essential component of CBT-I. Insomnia patients often lie in bed watching TV, reading, worrying and thinking. As a result, the bed becomes associated not only with sleep, but also as a place to be awake. The rule is simple: The bed is only for sleep and sex. If you are awake in bed (usually for roughly 20 minutes, but don’t look at the clock — just guess!), get up, go to a different room (or if you’re in a studio, get up and sit in a chair next to the bed) and do something quiet, calm and relaxing in dim light. When you get sleepy again, go back to bed. If you don’t fall asleep after a little while, repeat the process. No lying in bed awake, no TV in bed, no eating in bed, no phones/computers in bed or during the night. Do this throughout the night until your alarm clock goes off in the morning. It is tough, but very effective when done consistently.
The next module, sleep restriction, limits your time in bed, therefore increasing your body’s drive to sleep. It goes squarely against common sense that tells us to go to bed earlier or sleep in during the morning to try and “catch up” on lost sleep. However, it’s this common sense that gets us in trouble. Although books, apps and working with a therapist will give you much more detailed and personalized instructions for stimulus control, the overall principle is simple. If you have trouble sleeping, go to bed later and wake up at the same time every single day. For example, if you only sleep six hours on average per night (based on your sleep diary data), set a fixed wake time daily, count back six hours from that time and this is your wake time. Reassess a week later, and if you’re improving, go to bed 15 minutes earlier each week. Keep the wake time the same. Don’t restrict to less than five hours, and if you have other issues such as sleep apnea, epilepsy, sleepwalking or bipolar disorder, speak with a sleep specialist before doing full-on sleep restriction.
The cognitive module teaches patients to recognize and modify inaccurate thoughts that affect your ability to sleep. A number of my patients have the thought “I must get eight hours of sleep tonight to function well tomorrow.” This thought puts additional pressure on patients to get eight hours of sleep, causing them to be tense and anxious — a state that clearly does not induce sleep. Try to swap inaccurate thoughts for more evidence-based ones. It is quite possible that you might function well on seven hours of sleep instead.
Relaxation exercises can be used to help quiet the mind and relax the body. There are a number of techniques that can be taught, such as muscle relaxation, deep breathing and biofeedback. You must find what works for you, and many websites (as well as therapists) can guide you through techniques. Patients who feel tense before bedtime show the most benefit from this module.
You do not necessarily need to discontinue sleep medication to benefit from CBT-I. Many patients gradually taper off their sleep medications once they have learned alternative techniques for their insomnia. This is a highly effective treatment for many people, but it isn’t as easy as taking a pill. The key is to remember that insomnia develops over time in many people, and it isn’t cured overnight. Consistency is key with insomnia management: The more you stick with the treatment, the better the outcomes.
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