18 Years of Insomnia. Here’s What Works

Cognitive Behavioral Therapy for Insomnia (CBT-I), with a Couple Additions

Being awake in the middle of the night, when you want to be asleep, is the worse. Tossing and turning, too hot then too cold, overthinking and not able to get out of the loop, watching the clock as your opportunity to sleep slips away. This is insomnia, I’ve been there myself. Years ago when I did a chart review, 18 years was the average duration of insomnia amongst the adults in my practice. And for kids it was 3 years. That’s a long time to suffer from any condition, especially one that impacts your daytime energy, mood, relationships, and ability to function.

Thankfully, there are treatments that work, the primary one being Cognitive Behavioral Therapy for Insomnia (CBT-I). That’s what I use with patients, after they’ve been correctly diagnosed, along with strategies to strengthen their circadian rhythm. If you’re struggling with insomnia, I encourage you to search out a licensed practitioner to do this approach with. And don’t wait! People typically wait years to get insomnia treatment, and that whole time they are suffering the effects.

The Components of CBT-I
CBTI is a systematic program with several main components. The standard has been 6 to 8 appointments over about 8 to 10 weeks. You do a little bit of each component at each session to rebuild your sleep. Typically in my office we do fewer sessions, usually 3-4 total. Part of the success is working with highly motivated people!

Sleep Restriction
The first component is ‘sleep restriction’ or ‘sleep compression’. The term sleep restriction often makes people uncomfortable, since they’re already not getting enough sleep. A more accurate phrase would be “time in bed restriction,” though that doesn’t roll off the tongue as easily. Often when people have insomnia, they spend increasing amounts of time in bed. They’re thinking along these lines “I’m only getting 6 hours of sleep, though I do best with 8. So, I’ll spend another 2 hours in bed to get the sleep I need.” Although the math works, what happens is that sleep gets further fragmented, frustration with sleep increases, therefore insomnia gets worse.

So, in sleep restriction, you spend just the amount of time in bed that you are currently sleeping. There’s an art to this step. Together, you figure out what is the best time to schedule this sleep window, in accordance with your natural circadian rhythm and the ideal sleep window you’re aiming for. For circadian principles, I like to have less shift in the waketime over weeks, with more variability in the bedtime. It’s typically easier to stay up later, and a consistent waketime improves sleep. For example, our person who’s only sleeping six hours between 11pm to 7am. They’re using the snooze button that last hour, and would really like to get up at 6am. At the first session their sleep schedule would be set to midnight to 6am.

At each future session you assess sleep efficiency, ie what percent of time in bed are they actually asleep? If sleep efficiency is 85% or more, you increase their time in bed slightly, 15 to 30 minutes more. This is a classic example of slow and steady wins the race. In my experience, increasing slowly works best, as it allows cognitive aspects of the insomnia to shift. You slowly keep increasing, increasing, increasing time in bed until you are getting the sleep that you need, but you aren’t spending any extra time in bed.

This step is critical. Sometimes people feel worried about getting even less sleep on this schedule. That can happen, but typically only for the first 2-3 nights. In my experience, without this component CBT-I is less likely to work.

Stimulus Control
Stimulus control is another component. It’s all about creating a very strong association with your bed as some place to sleep. After so many hours being awake and frustrated, your bed has likely become associated with wakefulness. Think of it like a Pavlovian response. This is why you often hear people with insomnia say they sleep better in hotel rooms, in a friends’ guest room, or on the sofa.

Stimulus control involves your actions during both the day and night. During the day, avoid doing any wakeful activities in the bed. No watching TV, reading the news, discussing things with your bedpartner, or lingering in bed. What we love about hanging out in bed is being supine, in our comfy clothes, cozy with pillows and a blanket. All that is dreamy, so we don’t want to change the routine necessarily, just the place. Re-create that environment in another room, on the sofa or a beanbag chair. This includes reading in bed before sleep, which creates the association of the bed as someplace to be awake. Do the same sequence of your evening routine, just read in another place until you’re sleepy, then go straight to bed.

In the night, if you are wake for what seems like 15 minutes or more, get up. Do something boring in low light until you feel sleepy, then go back to bed. Common barriers are the cold, and having a plan of what to do. Put a robe and slippers so they’re handy, along with something boring to read. It’s important that there’s no positive reward for whatever you choose to do. One of my mentors said to have people read the refrigerator manual. I’ll always remember a woman with insomnia who’d decided she’d read her husbands’ stereo magazines. At the third appointment she said she woke up and thought “If I go back to sleep, I don’t have to read those *#?! magazines.” And so she went back to sleep, and had no more mid-night awakenings. If you find yourself looking forward to that middle-of-the-night activity then it’s not sleep-promoting. Once a client, who’d recently moved, told me how she enjoyed planning her new garden in the middle of the night. It was something worth being awake for, so we had her switch to something boring that didn’t reinforce that midnight waking.

Cognitive Reframing
Next address any dysfunctional beliefs or attitudes about sleep. Often people tell me something like “After dinner, when I’m washing up the dinner dishes, is when I start worrying about my sleep. How am I going to sleep tonight? Am I going to be able to do my work tomorrow? Because if I don’t sleep well, I won’t be able to do my work.” So there’s several hours of worry before they get into bed. Those are reasonable thoughts. And the thoughts create a lot of performance pressure, a lot of performance anxiety, which makes it even more difficult to sleep. Worrying about anything for 3 hours beforehand makes it more difficult. Cognitive reframing is shifting those sleep disrupting thoughts into sleep promoting thoughts. This takes skill on the part of the CBT-I expert to help you identify the sleep disruptive thoughts (since so much of our internal dialog can be automatic), and shift them into sleep promoting thoughts.

Sleep Education
The last component is sleep education and sleep hygiene. What is normal sleep? An example that comes up often is worry about the feeling that sleep is “light” towards the morning. They may be having more dreams and they’re worried that it’s not good quality of sleep. During our last sleep cycle, if we’re really getting the sleep we need, there will be more REM sleep, which can feel lighter with more dream activity as the brain waves are most similar to waking. This is normal. Those features of sleep are discussed in the sleep education component of CBTI, so you really know what is a normal experience.

The good news about CBTI is that it is effective in 70 to 80% of the people who do the CBTI program. What I particularly love is that it’s effective for some special populations too. It’s effective for people who have PTSD, who have chronic pain, for people who are having insomnia related to a cancer diagnosis or surviving cancer. CBTI really teaches people skills around their sleep. Some research looked at where people’s sleep was immediately after they finished the CBTI program, compared to where was it three months after they finished. Sleep actually continued to improve even after the CBTI program ended. That means people were still continuing to refine their skills, learn what works for them, and advance their personal empowerment around their sleep. I just love that.

Find a Qualified Provider
If you are interested in CBT-I for your insomnia problem, find a trained provider. Most cities have a sleep center which can help. Or find a behavioral sleep specialist around the country, or even internationally here: Society of Behavioral Sleep Medicine Member Directory

Variations of CBT-I
With insomnia impacting over 10% of adults every year, it’s a major problem, and there are just not enough trained CBT-I providers. Several worthwhile alternatives have arisen. Group CBT-I can be very effective, as you learn the strategies together and get the support of others with a similar experience. The VA has remote groups in more rural settings where there is no practitioner in person, and these have been quite successful. Brief Behavioral Treatment for Insomnia (BBTI) is another option, which is typically 4 sessions once weekly. There are also online programs and apps, such as Sleepio.

Limitations of CBT-I
The American Academy of Sleep Medicine recommends CBT-I as the first line therapy for insomnia. Medications can be used short-term in conjunction with CBT-I, or if CBT-I has failed. Sometimes insomnia is so severe that it’s appropriate to go to the emergency room. If you have been sleepless for an extended period, or if it is affecting your mental health, please get immediate medical care.

A Caveat: Get a Correct Diagnosis First
Unfortunately, other sleep disorders can mimic insomnia by causing some of the symptoms. Obstructive sleep apnea, and periodic limb movement disorder, can both interrupt sleep and keep you in just the light stages. This can be mis-diagnosed as insomnia. These two conditions should be treated first, then see what insomnia symptoms remain, if any!

Circadian disorders can also present as insomnia, particularly Delayed Sleep Wake Phase Disorder (DSWPS). In DSWPS the circadian rhythm is shifted later than average. People are typically not sleepy until between 1-6am, and therefore need to sleep until 9am to 2pm. Those late wake times don’t work for many of us. These folks end up going to bed at the earlier time they “should,” but they are just not physiologically sleepy so can take hours to fall asleep.

Make sure you’ve gotten a good workup from a licensed healthcare provider first, to make sure that what you’re suffering is insomnia, and that CBT-I is the right treatment for you.

My Unique Approach
My approach is what I call C,CBT-I: Circadian CBT-I. Most people right now are living a lifestyle which mutes their circadian rhythm, so it’s at lower amplitude than people have historically experienced. It’s the lighting conditions: light deficiency during the day when we’re spending 95% of our time indoors, combined with darkness deficiency at night, with the majority of people living under artificial light at night. This can decrease melatonin levels at bedtime, a contributing factor to the long sleep onset experienced in insomnia. So along with implementing the components of CBT-I at each visit, I also give recommendations to increase their circadian amplitude with light recommendations and other zeitgebers. We’ve talked about this a lot before, check out the archives for more.

I hope this has been helpful for you. If you are suffering from sleepless nights, please take action to get an accurate diagnosis, and then treatment. Everyone deserves a good night’s rest!

Sleep well and dream big,
Dr. Catherine