Chronic insomnia is a troubling sleep problem which is defined by difficulty falling and/or staying asleep, as well as daytime exhaustion.
Most physicians and mental healthcare providers are not very well-equipped to deal with chronic sleep problems. They will usually provide sleep hygiene recommendations or prescribe medication. The problem is that sleep hygiene does not solve insomnia, and people usually do not enjoy using medication.
Specifically, medication is a short-term answer to a long-term problem. When people get off the sleep meds, the insomnia usually returns. Moreover, there are side effects such as grogginess, headaches, and other daytime difficulties. Unsurprisingly, most people would prefer not to be on medication unless they do not have any other solutions.
Evidence-Based Strategies to Treat Insomnia Without Drugs
The question then becomes: “How can we treat insomnia without drugs?”
Fortunately, behavioural sleep medicine, has developed a number of effective strategies that can relieve insomnia symptoms long-term without the use of medication. For example, the gold standard is cognitive behavioural therapy for insomnia (CBT-I). Besides CBT, there are also more acceptance-based strategies that have been developed to help reduce our insomnia struggles.
Before providing these strategies, I believe it is important to first understand the causes of chronic insomnia for these strategies to make sense.
The Causes of Chronic Insomnia
People with insomnia are understandably exhausted. As a result, they will engage in compensatory behaviours to make up for their lack of sleep and energy. For example, going to bed early, staying in bed in the morning, resting on the couch, cancelling plans, and avoiding activity.
These behaviours are very reasonable. However, the problem is that these behaviours reduce our activity and introduce instability into our schedule. This then leads to reduced pressure for deep sleep and negatively effects on the circadian rhythm. For example, not being active enough makes us have less ‘sleep appetite’ at the end of the night. As a result, we feel less able to get the refreshing sleep we want, and we end up with symptoms that feel like jet lag because we are going to bed and getting out of bed at very different times every day.
Additionally, when we spend lots of time in bed awake, our brain starts to associate the bed with wakefulness. Over time, we might actually start feeling more awake when we get into bed. This is known as conditioned arousal.
Evidence-Based Strategies to Deal with Insomnia
Now that we are more familiar with the causes of chronic insomnia, let’s get into the specific strategies:
1. Build more sleep drive: As we discussed, we need to increase our appetite for sleep. We do this by staying active (even though we are tired), avoiding naps, and spending an appropriate amount of time in bed (about as much as we are sleeping).
2. Strengthen our circadian rhythm: This can be done by regularizing our schedules, especially when we go to bed and when we get out of bed. Importantly, we want to get some sunlight in the morning so our internal clock is nicely set to the clock on the wall.
3. Restore association between bed and sleep: To reduce conditioned arousal, we want to use the bed only for sleeping. This means no watching shows or doing homework in bed. We also want to get out of bed if we cannot sleep and do something quiet and enjoyable until we feel the sleepiness come back on. Now, sometimes people worry about getting out of bed because they worry that they cannot fall back asleep. Rest assured that if you get out of bed the same time as usual, you will have a better night because of increased sleep drive.
Dealing with Scary Beliefs About Insomnia
There are some beliefs that make it hard to apply these evidence-based strategies because ultimately insomnia is an anxiety about sleep. Here, I’ll provide some education to hopefully dispel some common worries that people have about sleep to increase the likelihood of following the strategies.
First, not everybody is an 8-hour sleeper. Some folks need more, others need less. It’s not necessarily a bad thing to not be an 8-hour sleeper. Therefore, try not to use the 8-hour guideline as a rigid guideline for how much sleep you need. Focus more on how you feel during the day.
Second, people with insomnia often worry about their performance in the daytime. Research suggests that people with insomnia perform just as well as those who do not have insomnia – it’s just much more effortful. Rest assured that just because you have insomnia, it does not mean that you will make a million mistakes and then get fired from your job. You are more resilient than you think!
Third, getting out of bed can be scary. But as we discussed, you’ll have more sleep drive if you follow the recommendations. Prioritize the next night over trying to save the last night by sticking to a schedule and building the sleep drive.
Finally, there is an inherent belief that being awake at night is bad in insomnia. In a lot of ways, being awake at night is not so different than being awake during the day. Perhaps see this experience as an opportunity to enjoy some solitary time – read a book, watch a nice re-run of Friends, or do some puzzles. If we become less afraid of being awake at night, our anxiety levels will reduce. Less anxiety means more likelihood of sleeping (which is what you want!).
Give these strategies a try and let me know how they work for you!
Best wishes,
P
Simply mental health 