| Possible Maintaining Factors for Insomnia | Cognitive Behavioral Therapy Components |
| Environmental factors – light; noise; temperature; uncomfortable bed; behavior of other people and/or animals | Modify the environment |
| Anxiety and tension | Address sources of anxiety and learn relaxation skills (e.g., diaphragmatic breathing, progressive muscle relaxation, visual imagery) |
| Overstimulation – Substance use (caffeine, alcohol, tobacco) – Engaging in stimulating activities too close to bedtime (e.g., eating, working) – Lack of a pre-bedtime calming ritual | Decrease substance use Establish calming pre-bedtime behaviors |
| Conditioned arousal to bed/bedroom, caused by: – Engaging in activities in the bedroom other than sleep and sex – Lying in bed awake, particularly if upset | Only use the bedroom for sleep and sex. Get out of bed if awake for more than 15 minutes or if upset. Only get in bed when sleepy. Do not fall asleep elsewhere. |
| Decreased sleep drive caused by: – An irregular sleep schedule – Spending excessive amounts of time in bed (e.g., >8 hours) – Getting primarily poor quality sleep (e.g., shallow, discontinuous sleep) – Daytime napping – Lack of physical activity | Maintain a regular sleep schedule, particularly a regular wake time Avoid daytime naps. Increase physical activity Consider employing the “sleep restriction method”: Temporarily restrict the time allowed in bed to the average number of hours of sleep per night from the previous week. This produces mild sleep deprivation, increases the sleep drive, and results in deeper and more continuous sleep. |
| Unrealistic beliefs about sleep – About what is normal – About how bad the consequences of sleep loss actually are | Learn about what is normal Develop a more accurate appraisal of the actual consequences of sleep loss |
| The effectiveness of CBT-I: Reliably produces about a 50% improvement in symptoms during the treatment phase, with continued improvement over 12 months. Improvement is as good if not better than sleep medications, without the side effects and decreasing effectiveness over time. Side effects: Temporarily results in less total sleep time. | |
Strengthen the association of the sleep environment with sleep
People with insomnia often engage in behaviors that come to associate the bedroom and bed with being stimulated or upset. These include:
Doing things in the bedroom other than sleeping (e.g., working, watching TV)
Lying in bed for extended periods while awake
Lying in bed while thinking, planning, or worrying
Lying in bed and worrying about sleeplessness
Think of how a cat comes to associate the sound of a can opener with food. In the case of insomnia, the sleep environment similarly comes to trigger an automatic association with being awake and/or upset. This is why you can be very tired and sleepy, and yet the minute your head hits the pillow, you can feel wide awake.
To re-establish the association of the sleep environment and sleep, it is important to follow the following instructions:
(1) Avoid any behavior in the bed or bedroom other than sleep or sexual activity.
(2) Lie down in bed intending to go to sleep only when sleepy.
(3) If you lie in bed awake for more than 15 minutes, leave the bedroom. Alternatively, leave the bedroom as soon as you feel you are “clearly awake” or are experiencing annoyance over the fact that you are awake.
(4) Occupy yourself with a low-intensity activity (e.g., reading) and return to the bedroom only when you feel sleepy. Do not fall asleep on the couch.
(5) Avoid clockwatching (which may increase your anxiety), and let go of worries about the consequences of sleeplessness
(6) Keep a fixed wake time 7 days a week. Getting up at the same time will set your “sleep homeostat” and make it more likely that you will be able to fall asleep at night.
FAQ
1. Q: Isn’t it likely that following these instructions will cause me to get less sleep? A: Yes, this is likely in the short-run, but this actually is a good thing. It makes it more likely that on the next night you will be sleepier, and your sleep will be deeper and more continuous.
2. Q: Why can’t I just lie in bed and wait for sleep to come? At least I might get some rest, and I’ll already be in bed should I start to feel sleepy. A: By lying in bed, you are continuing to associate being in bed with being awake, and run the risk of associating it with unpleasant emotions such as worry. It is also likely that any sleep you will get will be shallow and fragmented.
3. Q: Why shouldn’t I fall asleep on the couch? A: We don’t want to miss an opportunity for you to be able to associate your bedroom with sleep.
4. Q: If my alarm goes off at my fixed wake time and I am sleepy, what is the harm in sleeping in? A: By sleeping in, you are setting the stage for not being as sleepy the following night, perpetuating the cycle of insomnia.
The Sleep Restriction Method
Insomnia often involves difficulty remaining asleep, often with multiple awakenings and extended periods of wakefulness. This prevents a person from getting good quality sleep. A procedure called sleep restriction can address this problem. It involves limiting the amount of time you spend in bed to the average amount of sleep you are currently actually getting. This will temporarily cause mild to moderate sleep deprivation, which will likely result in faster sleep onset, and deeper and more continuous sleep. As your sleep quality improves, the amount of time allowed in bed is gradually increased.
Here’s how sleep restriction works:
(1) You will be provided a sleep diary to record your sleep for at least a week. From this, we will calculate the average amount of time you are actually sleeping.
(2) We will set a regular time for you to awake and get out of bed. This will be your “prescribed rise time.” For sleep consolidation to work, you need to get out of bed at this time, regardless of how much you have slept.
(3) We will set your bedtime by subtracting the average amount of time you actually slept the previous week from your prescribed rise time. This will be your “prescribed bed time.”
(4) You are to stay awake and out of the bedroom until the prescribed bedtime. Create a list of activities that you can engage in to help you stay awake, such as reading, movies, or an art project. In the hours before your bedtime, keep your light exposure relatively low and do not eat heavy meals or drink alcohol.
(5) Continue to use the sleep diary. After a week, we will calculate your “sleep efficiency,” which is a ratio of your average total sleep time (TST) to the amount of time you spend in bed (TIB). (The formula for calculating sleep efficiency is TST / TIB X 100). If it is greater than 90%, we will move your prescribed bedtime 15 minutes earlier. If it is 85-90%, the bedtime will remain the same. And if it is below 85%, we will delay your bedtime by 15 minutes.
FAQ about Sleep Restriction
1. Q: If I do this, won’t I be so sleep deprived that I cannot function? A: You will still likely be able to function, just not at your best. We can look at various options such as: scheduling the hardest part during a long weekend or vacation, or judiciously using caffeine or another stimulant in the morning.
2. Q: What if I have difficulty staying awake until the prescribed bedtime? A: There are several things you can try, including: avoiding recumbent body positions, scheduled physical activity during the evening hours, and/or cold compresses to the extremities or small of the back.
3. Q: Does this actually work? A: Yes. There is a lot of research showing that it decreases the time to fall asleep and the number of nighttime awakenings, improves the quality of the sleep, and may increase the amount of sleep.
