Insomnia disorder is sleep problem defined by difficulty falling and/or staying asleep that happens at least three times a week and has persisted for at least three months. Additionally, these nighttime problems are combined with daytime symptoms, like exhaustion, irritability, and difficulty concentrating. The problems also happen even if you give yourself enough time to sleep.
Often, people think that they have to rely on over-the-counter drugs, such as melatonin, or sleeping medication prescribed by their doctor to get a good night’s rest. However, there is research to suggest that non-drug options, like cognitive behavioural therapy for insomnia, is just as helpful as medication to treat insomnia. Not only is it similar in efficacy in the short-term, CBT has a more durable effect on insomnia because it treats the underlying causes of sleep problems and leads to increased sleep confidence.
In this post, I discuss the main strategies used in CBT for insomnia so that you can apply them to your own sleep problems.
Understanding how insomnia develops
In order to understand how we treat insomnia, we first need to understand how insomnia develops.
A very common experience that I hear people say is that: “I started having sleep problems when X thing happened. I’m not worried about that thing anymore, but I still can’t sleep.” The reason why we cannot sleep anymore is because the insomnia has taken life of its own and there are certain thoughts, emotions, and behaviours that keep the insomnia alive.
People with insomnia are constantly exhausted. As a result, they react to bad nights very differently compared to good sleepers. For example, they may think: “I’m going to have another terrible night” or “tomorrow is going to be exhausting.” They may also feel anxious or frustrated as a result. Moreover, they may also do things to try and catch more sleep or conserve energy, like staying in bed, taking naps, reducing activities, and going to bed early.
As we will discuss, these reactions and behaviours are very reasonable, but they actually maintain our sleep problems.
Learning about the systems that lead to sleep
There are essentially three systems that govern sleep:
1. Sleep Drive
Sleep drive is like our appetite for sleep. The more that we are awake and active, the more ‘appetite’ that we build up for sleep. Importantly, this sleep drive is linked to how much deep sleep we get, which is the sleep that makes us feel refreshed. When people have insomnia, they unintentionally engage in behaviours that reduce appetite for sleep, such as staying in bed for long than they are sleeping and taking naps (which is like taking a sleep snack in place of a larger dinner).
2. Circadian rhythm
Our circadian rhythm tells us when we are sleepy and when we are awake. However, our internal clock needs to be set every day because it’s not exactly 24 hours. We can set a strong rhythm by engaging in regular activities, such as getting out of bed at a regular time (and getting some sunlight in the morning) and keeping to a fairly regular schedule. However, people with insomnia tend to have more irregular schedules or tend to go to bed too early or wake up too late, which is not in sync with their body clock (e.g., being more of a night owl vs early bird). These behaviours can lead to poorly timed sleep or ‘jet lag’ symptoms.
3. Hyperarousal
Even if we have sufficient sleep drive and good timing, good sleep can sometimes still be stumped if we are very anxious. People with insomnia often struggle with a lot of sleep anxiety and they spend a lot of time in bed feeling frustrated and distressed. Over time, their brain begins to associate the bed with wakefulness rather than sleep. Consequently, we need to reduce arousal. Some ways to do that include regular relaxation practice, challenging unhelpful thoughts, and reducing the amount of time we spend in bed awake and frustrated.
The good sleep formula
The formula for good sleep is = high sleep drive + good circadian timing + low arousal.
The strategies for increasing sleep drive are by spending time you are not sleeping outside of bed at night and increasing activity throughout the day. I would encourage to do activities that are consistent with your life and values – for example, taking walks, doing yoga, and spending time with loved ones.
The strategies for improving circadian input are by waking up at a regular time each day, getting out of bed at that time and getting some sunlight. It is also important to try and follow your own internal clock. If you are a bit more of an early bird, then consider finding ways to get to bed a little earlier.
Finally, there are a number of strategies to reduce arousal. Some benefit from having a nice winddown period, others enjoy having a worry time, and others still need help with challenging unhelpful beliefs about sleep. Here is a post on reducing arousal at night.
A case formulation approach to insomnia
Now that you are aware of the main principles in treating insomnia, the goal is for you to identify the factors that are most relevant for you. In therapy, this is called case formulation – what is the thing maintaining my sleep problem?
For example, are there behaviours in your life that might impact sleep drive or circadian rhythm? Perhaps there are certain things in your life that could be increasing stress? I would invite you to ponder on some of these possible contributors to poor sleep and begin to use the strategies outlined to support your sleep goals.
Remember: build sleep drive, keep to a regular circadian rhythm, and use different strategies to reduce arousal. You got this!
Best wishes,
P
Simply mental health 