-
CBT Self-Help Guide For Treating Insomnia Based On Sleep Science
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
-
The Beachball Analogy On The Power Of Letting Go: Acceptance And Commitment Therapy
Many people often think of acceptance as the same as giving up or staying stagnant in our lives. They view acceptance as bad and the enemy of change.
However, there is a lot of power in acceptance. In fact, acceptance has formed the core of more recent ‘third wave’ therapies, such as acceptance and commitment therapy and dialectical behavior therapy. These acceptance-based strategies that are based in Eastern philosophies focus on letting go in order to reduce suffering.
In acceptance-based therapies, clinicians like to use a lot of metaphors. One metaphor that I really enjoy and is a great example of the power of acceptance is the beachball analogy.
We are often focused on the thing that is making us unhappy. Maybe we are not at the college that we really wanted to attend. Perhaps there is a coworker we really dislike and wish they would go away. Or we are just trying to push away feelings that we don’t want to have.
In many of these cases, we spend a lot of time either pushing away the bad thoughts, feelings, or experiences. It’s kind of like when we are constantly pushing down a beachball in the ocean. We try to push away these distressing experiences, and we spend all our time and energy in making the bad thing go away.
Unfortunately, what we resist persists. And the beachball will make its way back up to the surface from time to time. Our efforts are in vain.
In acceptance, the idea is to let go of this constant resisting. Instead of pushing the beachball down, we simply let the ball go and allow it float around. And instead of focusing on the beachball, we focus on the beauty that surrounds us. We can play in the water, or we can make sandcastles on the beach. We can enjoy the sunset as the rays of light glisten on the ocean’s surface.
And sure, the beachball might pop from time to time. But that’s okay. Because by accepting that the beachball might be around, we can spend our time on the most important things in our lives.
Just the same, I invite you to think about whether there is something in your life that you are resisting – maybe it’s a painful emotion, maybe it’s a chronic condition, or someone you really dislike in your life. This is your own beach ball. And see if you can decide to let go of constantly pushing it away, accept that experience into your life, so that you can enjoy the rest of the beach. Maybe make a sandcastle while you’re there.
Best wishes,
P
-
Should I Leave Or Stay In Bed When I Cannot Sleep?
In insomnia, people have high anxiety about being unable to sleep. Moreover, they often spend a lot of their time in bed awake and feeling distressed. Over time, their brain begins to make an association between the bed and wakefulness (known as conditioned arousal). If you have ever had the experience of going to bed sleepy, and then feeling wide awake the moment your head hits the pillow, then you understand the experience of conditioned arousal.
Getting out of bed when you cannot sleep
This conditioned arousal is why insomnia therapists ask patients to leave the bed when they are not able to sleep. By limiting the amount of time we spend in bed awake, and spending more of that time in bed asleep, we give our brains the chance to start associating the bed with sleep again.
This is called stimulus control where patients get out of bed to do something quiet (like reading or doing a crossword puzzle) and then go back to bed when they feel the sleepiness come back on.
Can I stay in bed when I am awake?
Stimulus control can be a very powerful technique. However, there is research to suggest that you don’t necessarily have to get out of bed to break the association between the bed and wakefulness.
Ultimately, the idea is to ensure that the bed is seen as a place of relaxation rather than stress. You don’t have to get out of bed to do that. You can also do this through a clinical technique called countercontrol.
Countercontrol means doing all the same things as in stimulus control except changing your position in bed (for example, lying on the other side of the bed instead of your usual side). Again, you would do something quiet and enjoyable until sleepiness comes back – at which point you can go back to sleep.
When should I stay in bed?
Here are a few situations where countercontrol may be more helpful than stimulus control.
1. When safety is an issue – If you are at risk of falling, or pregnant, or there are other reasons why it might be unsafe to get out of bed at night, then staying in bed would be recommended.
2. When there’s too much anxiety about getting out of bed – We should not let perfect get in the way of good. If the idea of getting of bed is a terribly frightening idea and you can’t see yourself doing that at least right now, then countercontrol may be a better fit.
3. When environmental factors don’t allow for stimulus control – If you are living in a studio apartment, or have lots of roommates, then getting out of bed may be challenging. In this case, counter control may be more appropriate.
4. When you are struggling with just sleep anxiety – If most of your fears are about sleep, then doing something light and enjoyable in bed may be more appropriate.
5. If your difficulty is staying asleep at night – there’s some research to suggest that countercontrol may be particularly helpful if the insomnia challenge is waking up a lot at night.
When should I get out of bed?
1. When your difficult is falling asleep at night – Research suggests that stimulus control is very effective for treating sleep onset difficulties and helping folks fall asleep when they first get to bed at night.
2. When you are dealing with more generalized worries – if you are more of a worrier in general (rather than about sleep in particular), then getting out of bed may be helpful so that you are not constantly worrying about the next day in bed.
3. When you have a place that works well for stimulus control – if your living arrangements allows you to leave the bedroom and you have a nice place to sit and do something enjoyable, then stimulus control may be a better fit.
4. When you notice that you just can’t relax if you are in bed – In cases where you try to relax and enjoy your time in bed, but find that you are just an anxious wreck, then I encourage you to get out of bed. Listen to your inner wisdom as to what might be more helpful!
5. When you want to rip off the band-aid – stimulus control is one of the most effective strategies in treatment of insomnia. It’s hard to do, but I think of it like ripping off a bandaid. If you can do it, the true healing can really start to happen.
Best wishes,
P
-
Treating Insomnia Naturally Using Science-Based Strategies (Without Drugs)
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
-
How Sleep Problems Stick Around: The 3P Model of Insomnia
Bad nights versus insomnia disorder
Everyone has a bad night from time to time.
However, for some, the one bad night turns into a steady stream of bad nights. Suddenly, you are not having a bad night anymore. You have insomnia.
The question is: why do sleep problems sometimes stick around?
In this post, I describe the 3P model, which is a theory developed by Dr. Arthur Spielman. The 3P model gives us a framework to understand how insomnia develops and why it sometimes does not go away.
The 3P Model – Defining the Terms
The 3P model stands for: Predisposing, Precipitating, and Perpetuating.
1. Predisposing factors: Predisposing factors are essentially anything that makes you more vulnerable to having sleep problems.
2. Precipitating factors: Precipitating factors are the things that set off bad nights.
3. Perpetuating factors: Perpetuating factors keep our sleep problems going over time.
Let’s get into each one a little deeper.
Predisposing factors
Predisposing factors are things that make it a little easier for some folks to end up with bad nights compared to other folks.
For example, there are some people who tend to worry a bit more or are more reactive to stress. Therefore, when something happens in their life, they tend to be more stressed. As a result, their sleep takes a bigger dip.
Take a moment to consider if there’s anything that makes you more vulnerable to sleep problems. Perhaps you are more sensitive to caffeine. Maybe you are prone to ruminating and stressing out when something goes wrong. Or you have a bit of back pain that makes your sleep a little lighter. All of these can be predisposing factors – it doesn’t mean that you will have insomnia, but it can make you a little more susceptible to sleep problems.
Precipitating factors
Precipitating factors can be basically anything that leads to the start of sleep problems. For example, travelling to a different time zone, having a baby, going through a breakup, studying for an exam, or starting a new job.
As you can see, pretty much anything that causes some stress can be a precipitating factor – regardless of whether it’s a good thing (like starting a new job) or a bad thing (like losing a loved one).
The fact that our sleep takes a dip when we are stressed makes complete sense from an evolutionary perspective. In ancient times, when there is danger (like a bear attack) we wouldn’t want to be asleep for it!
The point is not to never have a bad night. The point is to make sure it goes away when the stressor is over. However, sometimes sleep problems do not go away. This is because of the third P.
Perpetuating factors
Sometimes, when people have sleep problems, they begin to change the way they think about sleep and their associated behaviours throughout the day when they have a bad night. This can lead to perpetuating factors that maintain sleep problems.
Importantly, the perpetuating factors are what we focus on in therapy in order to break the insomnia cycle.
When there are multiple bad nights, some folks start worrying about. their sleep. They get scared that they won’t get enough sleep or that it will affect their day.
This can lead to ways of coping that help with anxiety in the short term but do not help in the long term – like going to bed early or reducing activity to save energy throughout the day. However, from what we know about the science of sleep, these behaviours can actually make our sleep problems worse.
For example, spending too much time in bed can affect how much deep sleep we get. It’s kind of like wearing a size 10 shoe when you have size 7 feet. Therefore, if we spend 10 hours in bed but only need 7 hours of sleep, our sleep is very light and we spend a lot of time awake. Moreover, if we spend too much time in bed awake, our brain might start associating the bed with wakefulness (and worrying). This can make it even harder to sleep.
If you’re interested, here’s more information on the how to fix the causes of insomnia disorder.
How the 3P’s all fit together
Here is a visual diagram on how the 3P model comes together. As you can see, the predisposing factors make us a little more vulnerable to sleep problems. When a precipitating event comes up (like an exam or a travel event to a different time zone), it makes it easier for us to cross the insomnia threshold. Usually, this is not an issue and you can see the sleep problems go away when the stressor disappears.
However, sometimes the perpetuating factors take hold and that’s when common sleep disturbances starts moving into insomnia disorder category.
It is important to know when these factors are taking hold because they are the thing we need to address. This article helps you to learn more about the frontline recommended treatment for insomnia disorder – CBT for insomnia.
Best wishes,
P
-
Simple Ways To Get Better Sleep If You Have Insomnia Based on Sleep Science
Introduction
The world is full of myths, misconceptions, and misinformation about how to treat insomnia. For example, people talk about sleep hygiene as a solution to insomnia; in reality, sleep hygiene is not an effective strategy to treat insomnia. Even physicians tend to immediately jump to sleep medication, which most people do not prefer because they have side effects and are a short-term solution to a long-term problem.
The science of sleep research is very effective. However, they are hidden under a scientific guise that makes it hard for people to access. Moreover, treatments like cognitive behavioural therapy for insomnia are hard to come by because it is expensive and there are not a lot of trained folks out there providing the service.
All in all, it is just hard to get the right information in a simple way that can lead to immediate positive benefits in your life. This article provides a few suggestions based on what we know in sleep research that you can use to start breaking out of the insomnia cycle and getting some better sleep.
Insomnia is a vicious cycle
Something that we need to remember about insomnia is that it can be a bit of a trap. That is, our thoughts and behaviours when we have insomnia can often sabotage us and maintain our problem. For example, when we struggle with insomnia and are downright exhausted, we might:
- Go to bed early
- Press the snooze button
- Cancel plans or activities
- Reduce our exercise
- Take naps
- Worry about not getting enough sleep
All of these compensatory behaviours make a lot of sense when we are exhausted. But the problem is that they actually maintain our sleep problem. We need to keep this in mind because the recommendations below are very effective, but they run counterintuitive to what we think makes sense. With that being said, let’s get to the recommendations!
Recommendation 1: Build sleep drive
Sleep drive is how likely we are to fall asleep at any given moment. The more sleep drive. we have, the more deep sleep we get. However, when we are exhausted, we reduce activities that increase build-up of sleep drive that would give us the deep refreshing sleep that we need.
For example, we may decide to stay in the bed instead of going out to take a walk. As discussed, this behaviour makes perfect sense, but it is a recipe to have another night of poor sleep.
To break out of the cycle, we need to engage in behaviours that help us build up sleep drive. This means:
- Getting out of bed in the morning as soon as possible
- Taking walks and staying active throughout the day
- Trying not to go to bed until your typical bedtime
- Avoiding naps and snoozing
Try to spot times in your day that could be contributing to low sleep drive. Although it will be tough at first, making a conscious decision to continue building our sleep drive will be helpful to get the deep sleep that we desperately need.
Recommendation 2: Keep to a consistent daily rhythm
When we have insomnia, we might try to compensate by going to bed early and sleeping in as much as possible. This creates a lot of disruption in our routine and can actually lead to symptoms of jet lag. For example, if you get out of bed on Friday at 8:00am and then Saturday on 11:00am, that’s essentially the same as travelling from California to New York!
Therefore, we need to do our best to stay consistent in our routines. This means going to bed and getting out of bed at fairly consistent times. As a benefit, getting out of bed at the same time even after a crappy night means you will have more sleep drive the next night.
To further strengthen our circadian rhythm, I would also encourage you to generally keep to a similar routine each day even outside of sleeping. For example, timing your meals and exercise. There’s no need for perfection (but it is helpful to have in the back of your mind).
Associate the bed with sleep
People with insomnia has often created associations with the bed and wakefulness. If you notice that you often go to bed sleepy, but then feel wide awake the moment your head hits the pillow, this means that the bed has been associated with wakefulness.
This association is created because people with insomnia spend a lot of time in bed being awake – feeling distressed, worried, and generally just not having a good time. Over time, our brain begins to develop conditioned arousal, which is a fancy term for being anxious anytime we are in our bedroom.
We need to break this association. Fortunately, there are a few recommendations that are very effective to making sure that we start thinking the bedroom means sleep:
- Only go to bed when sleepy
- Get out of bed when you are not sleepy (do something pleasant instead until you feel sleepy)
- Avoid doing activities in bed outside of sleep (e.g., watching movies in bed)
- Try to not take naps
Typically, if you notice you are fully awake or if sleep has not come in 20-30 minutes, try to get out of bed and do something pleasant. For example, reading a book or watching a comedy show. Don’t try to force yourself to fall back asleep. Simply go to bed when you notice the sleepy come back. If you don’t, just wait until tomorrow night. You’ll have more sleep drive anyway.
Recommendation 4: Reduce arousal
Sleep and stress are incompatible. This makes sense – we wouldn’t want to be sleeping if there was a bear around. However, we need to reduce stress to make sure that sleep comes easily when there is no immediate threat. Typically, relaxation strategies are quite helpful in that regard. I would encourage you do something each day that relaxes you. For example, taking a walk or doing some breathing exercises.
However, one key piece to note is not to intentionally do relaxation exercises in the moment to try to fall asleep. When we start making these strategies part of our efforts to sleep, this can backfire and lead to more anxiety. Therefore, try to use relaxation exercises in morning or early evening to create a routine.
Recommendation 5: Be okay with not being asleep
People with insomnia can be described as having a phobia of being awake. They do everything they possibly can at night to try and fall asleep. However, this tends to lead to more anxiety, which makes it harder to fall asleep. What we resist, persists.
To relieve yourself of your suffering, I would encourage you to try your best to reframe the awakening as something that is positive. For example, maybe watching a show that you like or catch up the book that you have been meaning to read. If we can come to accept being awake, then our anxiety about not sleeping reduces. Paradoxically, this means sleep will likely come more quickly.
Some people might be worried about performance the next day. There is good research to show that people with insomnia’s performance is not that different from good sleepers. It is just that it all feels more effortful. So trust your resilience!
Recommendation 6: Prioritize the next night
We get trapped in the insomnia cycle when we are constantly striving to save the past night. We usually do not do much for the last night and we set ourselves poorly for the next night.
When thinking about your behaviour, consider if they are a way to make sure the next night is better or if you are trying to make up for the past night. By focusing on prioritizing the next night, we give ourselves a fighting chance to. break out of the insomnia cycle.
Conclusion
Hopefully, this post gives you a few tips to support your sleep and think like a sleep scientist. If you find yourself caught in an insomnia trap, remember to do your best to prioritize the next night by building sleep drive, keeping to a regular rhythm, and make sure that the bed is for sleeping (and not being awake). I believe in you – you got this!
Best wishes,
Parky
Photo by Laura Chouette on Unsplash
-
Optimizing Your Sleep: Six Components Of The Sleep Health Framework
The Sleep Health Framework (Buysse, 2014) helps us to understand sleep health in a multidimensional way, in which the sleep-wake cycle is broken into six important components that together optimizes our health and functioning.
These sleep components include:
- Sleep Regularity
- Sleep Satisfaction
- Daytime Alertness
- Sleep Timing
- Sleep Efficiency
- Sleep Duration
In this post, I discuss each of these components in turn and provide strategies to optimize these areas to improve your sleep and overall wellbeing.
Sleep Regularity
Sleep regularity means keeping to a consistent rise and wake time. Regularity in our schedule is very important to keeping our circadian rhythm attuned to the clock on the wall. This is helpful for hormone regulation and keeps the signal strong in terms of when we feel alert and when we should feel sleepy (as well as other functions, like hunger). When our internal clock is out of sync, we tend to feel symptoms similar to jetlag.
When we have a strong signal, our body naturally feels sleepy and more alert at appropriate times which helps support proper sleep health and functioning.
To support strong regularity, we should do our best to keep to a consistent bed and rise time using an alarm if needed. Beyond the nighttime, regular routine (such as when we eat and exercise) and getting exposure to light can be helpful to strengthen our circadian clock.
Sleep Satisfaction
Everyone sleeps, but many people are not happy with the quality of their sleep. The lack of satisfaction in sleep can be a result of a couple reasons.
First, people may not be producing enough deep (slow wave) sleep. Deep sleep is what is needed to produce the consolidated sleep that we find refreshing and it is built through developing our ‘appetite for sleep’. This appetite increases the longer we stay awake and active throughout the day. On the other hand, staying relatively inactive (e.g., sitting on the couch) and spending extra time in the bed awake can affect our drive for deep sleep.
A second explanation for the lack of satisfaction is that some individuals, especially those with insomnia, sometimes have unhelpful beliefs about sleep. They may incorrectly believe that people should fall asleep the moment their head hits the pillow (they shouldn’t), stay asleep the whole night (they won’t), and wake up feeling rested after 8 hours (which is unlikely).
In fact, even good sleepers can take up to 30 minutes on average to fall asleep, wake up a couple times throughout the night, and feel a little groggy when they wake up in the morning. To learn more, here’s a helpful post on common sleep norms.
Sleep Timing
Sleep timing refers to when we prefer to go to bed at night. Some of us are early birds and others are more evening owls.
Finding out your own ideal sleep window of when we prefer to go to bed and wake up is like finding the right shoe size. It fits well and feels comfortable.
For some people, they may notice that their window is not great fit for their lives and routine. For, example people with Delayed Sleep Phase Disorder might prefer to sleep very late and wake up later in the morning/afternoon. In this case, this might not be a good match for their job or responsibilities. In this case, light therapy can be a helpful strategy to shift our bedtime closer to a more socially normed period.
Daytime functioning and sleepiness
People are often most concerned about how their poor sleep affects their day ahead. They may worry that they won’t be able to focus on important work tasks, lack concentration, or feel excessively sleepy.
Getting consistent and adequate sleep is important to improve our daytime functioning. However, it is not the only answer. There can be many reasons why we are lacking in energy throughout the day: dehydration, inactivity, caffeine rebound, poor diet, hormonal issues, underlying medical conditions, among many more. To support your energy levels, consider areas in your life that may be affecting energy levels and experiment with tackling these issues.
To feel better in the morning, here’s a post on how to reduce sleep inertia.
Sleep Efficiency
Sleep efficiency is the proportion of time we spend sleeping compared to how much time we spend in bed. For example, if a person sleeps for a total of 5 hours but spend 10 hours in bed, their sleep efficiency is 50%.
Typically, you should aim for a sleep efficiency between 85 to 90%. If your sleep efficiency is too low, this can affect how consolidated our sleep is (i.e., you might toss and turn in bed) and makes the sleep much less refreshing.
Sleep efficiency can be supported by using our bed only for sleeping (to establish an association between sleep and bed in our brain) and getting out of the bed if we are not sleepy. Over time, this creates a strong signal that our bed is a place for sleeping and our body naturally prepares itself for sleep when you enter the bedroom environment.
Sleep Duration
When we do not get the hours of sleep our body needs, we feel sleep deprived. This may increase our risk of accidents, be harmful to our health, and lead to excessive sleepiness during the day.
However, the right number of hours differs from person to person – not everyone needs 8 hours of sleep (some need more, some need less). Determining this magic number for you and giving yourself a consistent opportunity to reach this target can be immensely helpful for improving your sleep.
Best wishes,
P
-
Examples Of SMART Goals For Sleep
Sleep is arguably one of the most important parts of our life. When we sleep well, we feel much happier and more effective in our day-to-day life. Work comes easier, conversations flow smoother, and things are just a bit brighter.
It comes as no surprise then that improved sleep is a goal for many people. However, goals for better sleep are often quite vague, such as “I want to sleep better and feel better”.
This is a great goal but it is not specific nor necessarily actionable. Many of us have a sense of what better sleep might look like; however, this may not always be realistic or actually lead to better sleep.
SMART Goals (Specific, Measurable, Actionable, Relevant, Time Bound) offer us a way to capture what sleeping better and feeling better actually looks like during the day and night. That is, what behaviours lead to more restful and consolidated sleep.
However, before we discuss SMART goals for sleep, we need to understand typical sleep norms and tackle sleep myths to develop a healthy attitude towards sleep.
Norms and myths for sleep patterns
Falling asleep – Good sleepers typically fall asleep between 10 to 30 minutes on average throughout the week. Contrary to popular opinion, falling asleep immediately is not necessarily a good thing; in fact, this can be a sign of excessive sleepiness which could be related to sleep deprivation or an underlying medical condition (e.g., sleep apnea).
Staying asleep – People can wake up multiple times throughout the night. These awakenings usually last for a few brief moments (e.g., going to the bathroom and getting back asleep) or you may not even remember them. All that to say, these awakenings are definitely normal and not a concern unless you are up for a significant period (e.g., more than 20 to 30 minutes).
Number of hours – The 8-hour myth is just that – a myth. Most adults need between 7 to 8 hours of sleep, but the actual optimal number of sleep a person needs is unique to the individual. This is also true of the person’s preference of going to bed and waking up – some people are early birds and others are more night owls.
Stress and sleep – When we are stressed because of an exam, work, relationships – or something else – sleep naturally takes a dip. This does not mean that our sleep systems are broken or there is something wrong; people naturally have a day here and there where sleep is not ideal – and that’s okay. It is only when sleep problems are maintained over longer periods of time that we should be concerned.
Energy – Many people believe that sleeping better means immediately feeling better when we wake up and throughout the day. However, even after a great night’s sleep, we can still feel a little groggy in the morning because of sleep inertia. Another reason for fatigue during the day is that better sleep is only one part of how we feel. Other factors, such as activity, light exposure, and stress, can also play a role.
SMART Goals for Sleep
Below are a few examples of SMART goals for sleep based on these norms:
1. Falling asleep on average between 10 to 30 minutes
2. Staying asleep with a couple awakenings lasting no more than 20 to 30 minutes on average
3. Keeping to a consistent number of hours and sleep schedule that follows the body’s unique rhythm
4. Get out of bed within 5 minutes of waking up for the final time (and engaging in behaviours to break out of sleep inertia)
Using values to support our goals
Although these goals sound great in theory, they may not be perfectly aligned with your life and values. For example, there may be nights you need to stay up late to finish up some work or spend some extra time with friends/loved ones. There may also be times where you want to take an extra 30 minutes or an hour to just snuggle in bed because it’s a cozy Sunday.
And that’s completely okay! Sleep is important, but it doesn’t always have to be the number one priority in our lives. Never let perfect get in the way of good, and never let sleep get in the way of living.
Based on the norms and goal examples provided above, you can tailor these goals to match well with your life and schedule.
To support these goals, here is a post on how we can leverage our sleep system to support deep and refreshing sleep.
If interested, I have also published a book on treating insomnia and improving sleep health using science-backed strategies! You can find it here by clicking on the link: The Insomnia Paradox.
Best wishes,
P
-
Getting Over Your Fear Of Being Awake At Night
People with sleep problems, such as an insomnia, tend to be particularly afraid of being awake in the middle of the night.
Specifically, they find this situation to be quite dangerous and they are filled with thoughts about the implications:
- “I’m going to be awake all night”
- “I’m never falling back asleep”
- “Tomorrow is going to be terrible”
- “This can’t be good for my health”
Unfortunately, these thoughts tend to ramp up our anxiety and make sleep even less likely to come. Moreover, people who find themselves awake might spend the night in distress, worrying about the fact that they cannot sleep. These negative thoughts can lead to a negative association between the bed and being awake.
All in all, a fear of nighttime wakefulness can be a key problem that leads to insomnia.
Why we should get over our fear of being awake at night
In clinical practice, big symptom relief in insomnia is found in an experiential shift in how we see the night. When we see it as a place of fear, insomnia persists. When the same person begins to see the night as something more benign, our insomnia symptoms begin to dissipate. This is a key concept in paradoxical intention, which is an evidence-based therapy where a person tries to stay awake (as opposed to trying to sleep – hence, paradoxically) for as long as possible.
In this post, I discuss some strategies to change the perspective of a wakeful night from disastrous to something a tad more enjoyable.
1. Understanding the sleep systems
One way to alleviate our fears when it comes to being awake in the middle of the night is to understand how our sleep systems work.
This is especially true for the sleep drive. The sleep drive is our propensity to fall asleep at any given moment and builds up the longer we remain active and awake. When we sleep, we expend our sleep drive to produce the deep sleep that we need.
For people with insomnia, they often have high anxiety about their sleep, which runs opposite to their sleep drive. Moreover, they may engage in behaviours that make it hard to build sleep drive, such as lying in bed for long periods of time, cancelling plans, and getting sleep whenever they can.
One way to reframe from the fear of being awake is that we’re actually doing our sleep drive a favour when we get up and engage in something pleasant. We are building sleep drive for the next night. As long as we stay the course (and not nap or rest all day), the next night will be better.
2. See the awakenings at night as an opportunity
During the day, we are often drowning in commitments: to our job, our partners, our friends, our family, and other obligations.
For some, it can be helpful to reframe the nighttime as a time to spend with oneself rather than a time of despair. For example, being able to finally watch that show or movie you never get a chance to see; or read a book that is usually sitting on your shelf. Regardless, to treat this as a time for yourself as a nice and peaceful night can help reduce distress. Ironically, this acceptance and embracing of the night may actually let you fall back asleep quicker!
3. Challenge the scary thoughts
Oftentimes, the reason why someone is afraid of being awake in the middle of the night is because of a strong underlying belief or scary thought.
- “What if I never fall asleep?”
- “I won’t be able to function.”
- “My health is going to deteriorate.”
In these cases, it is often helpful to directly challenge some of those thoughts. For example, is it really true that you cannot function at all if you don’t sleep – or is it just harder? Will you really never fall asleep? Would one poor night truly destroy your health?
Often times, we are able to still get the most important tasks done in a day – though they may feel more uncomfortable and effortful in insomnia. As discussed before, we are also continually building sleep drive the more active we are, so at some point the sleep we desire will come (and we are simply getting out of the way of these processes).
By taking a moment to evaluate these thoughts, we might come to the conclusion that perhaps our thoughts are a bit excessive and we can come across a more balanced thought. Thought records can be a helpful tool to evaluate these thoughts.
4. Change our relationship to our thoughts and emotions
Besides changing our thoughts and emotions directly, we can also change our relationship with these experiences through regular mindfulness practice.
Mindfulness teaches out to become more present and aware of our inner and outer experience, but in a non-judgmental manner. We learn to attend to thoughts, emotions, and sensations objectively and then let them go.
Conclusions
When we really think about it, there may not be as big of a difference being awake in the day compared to being awake at night. We place a lot of significance in being awake at night, but perhaps that’s more of a subjective perception rather than an objective problem. Perhaps it can even be fun to use this an opportunity for an impromptu enjoyable (though relaxing) nighttime activity and simply let sleep take you away when your ready to hear its lullaby.
If the nighttime still elicits a bit of a fear response, hopefully some of these strategies can be helpful to change your nighttime experience. I have also written a book on treating insomnia using science-backed strategies if you’d like to learn more!
Best wishes,
P
-
Everything You Need To Know About CBT For Insomnia
Cognitive Behavioural Therapy for Insomnia (CBT-I) is considered the frontline, gold standard treatment for chronic insomnia.
However, people are generally less familiar with CBT-I compared to other available treatment options, such as sleep medication. Therefore, it can be helpful to understand more about what CBT-I is and how it works.
In this post, I discuss everything you need to know about CBT-I to hopefully make a more informed decision regarding treatment.
Acute vs Chronic Insomnia
CBT-I treats chronic sleep disturbances that are maintained by sleep anxiety and disruptions to natural sleep systems. Therefore, it’s important to distinguish between acute (short-term) and chronic (long-term) types of insomnia.
Acute insomnia is typically a response to stress. When we are preparing for an exam, planning a wedding, or transitioning into a new role at work, it makes sense (and evolutionarily advantageous) that we are stressed and sleep becomes worse for wear. Acute insomnia is not a concern and will usually pass once the stressor is over (e.g., you are finished your exams).
Unlike short-term sleep problems, chronic insomnia lasts well after the stressor is over; sleep problems begin to take on form of its own. Typically, chronic insomnia is defined by a period of sleep disturbances that last at least 3 months, occurring 3 times a week. That being said, many people with chronic insomnia have sleep problems lasting years.
A summary:
Acute Insomnia
- Short-term (lasts a few weeks to a month)
- Results from stressors in life
- Goes away once the stressor is over
Chronic Insomnia
- Lasts at least 3 months and occurs at least 3 times a week
- Caused by sleep-specific issues rather than on-going stressors
- Generally requires treatment to alleviate
What does CBT-I look like?
CBT-I includes multiple components of evidence-based therapies for insomnia. They are designed to treat the causes of insomnia.
Sleep restriction therapy
Sleep restriction therapy is a way to limit the amount of time a person spends in bed awake to put pressure on our sleep systems.
People with insomnia often spend an excessive amount of time in bed because they feel fatigued and desire more sleep. This counterproductively leads to a significant amount of time spent awake (e.g., sleeping 6 hours but spending 10 hours in bed). An analogy to this problem is like wearing a size 10 shoe when you have size 6 feet – it feels uncomfortable.
Therefore, sleep restriction therapy brings down the amount of time we spend in bed to be closer to how much sleep we are producing. The idea is that the more time spent outside of bed will increase pressure for sleep, allowing for more deeper, consolidated sleep to occur (reduced nighttime awakenings).
Stimulus control
In insomnia, the bed becomes associated (like Pavlov’s dog) with wakefulness. This is because people with insomnia spend so much time tossing and turning, ruminating, and worrying in bed. Over time, our brain begins to make a connection with the bed and being awake.
Stimulus control is a strategy meant to restore the association that bed equals sleep, rather than the bed being a place of fear and uncertainty. This is typically done by using the bed only for sleep and getting out of bed if sleep is not coming (doing some pleasant, such as reading a book, in the meantime).
Cognitive therapy
People with insomnia have unhelpful beliefs about sleep that increase the feelings of pressure of needing to sleep. And as we know, the more we try to sleep the further away sleep gets.
Unhelpful beliefs include: “I need 8 hours of sleep or I won’t be able to function”, “I can’t handle being awake in the middle of the night”, and “I’ll never be able to fall asleep”.
Therefore, cognitive therapy, which tackles and tests these beliefs, help to reduce anxiety and set more heathy expectations of sleep and functioning. For example, testing the question “is it really true that you are unable to function without sufficient sleep?”. In this case, the person can probably come up with examples in the past where they have been able to perform relatively well despite a poor night’s sleep.
Relaxation and Mindfulness practices
Exercises like regular relaxation and mindfulness practices can also be helpful as part of the CBT-I package to reduce general arousal levels and our reaction to scary thoughts or feelings. These practices can facilitate better sleep.
Sleep hygiene
Sleep hygiene include best practices to optimize the environment and behaviours for sleep, such as not drinking coffee in the evening and setting up a nighttime routine. Although these practices can be helpful to support sleep health, sleep hygiene not a standalone effective therapy for insomnia.
Effectiveness of CBT-I
CBT-I is a very effective therapy for insomnia symptoms. CBT-I works in a number of different populations suffering from comorbid conditions, meaning that most people can benefit from CBT-I. Clinical trials at our research laboratory finds that approximately 4 out of 5 people go from being above the insomnia threshold to becoming a good sleeper within four sessions.
Besides sleep, CBT-I also interestingly improves other outcomes, such as mood (Lau et al., 2022), anxiety (Zhang et al., 2015), and chronic pain (Finan et al., 2014). All in all, CBT-I is very effective when recommendations are followed.
CBT-I vs Sleep Medication
CBT-I and medication (e.g., the ‘Z-drugs’) are both evidence-based treatments of chronic insomnia. There are pros and cons of using either treatment.
Medication is effective and simple to use. There is also evidence that medication is equally as effective as CBT-I. However, medication tends to treat insomnia symptoms but does not address the causes of insomnia. Therefore, sleep problems tend to come back if medication is continued. Moreover, some medications cause side effects and generally is not preferred by patients nor providers.
On the other hand, CBT-I has greater durability and its effects last well after treatment is completed. This is because CBT-I restores one’s own confidence in sleeping well and addresses the underlying causes of insomnia.
The drawback of CBT-I is that it requires persistence and effort to see desired benefits. Following the recommendations can be tough and may not be consistent with everybody’s needs and values. For example, some people prefer not having to follow a standard schedule or a specific time in bed, which would pose a barrier to CBT-I.
Strategies to get the most out of CBT-I
Below are a few approaches that you can take to most effectively benefit from CBT-I:
1. Be willing to try out the recommendations! Some of the recommendations of CBT-I feel counterintuitive – such as getting out of bed when sleep is not coming. “But what if I never fall back asleep?”. Anxious thoughts might keep you from fully engaging. However, being curious and experimental in your approach will take you far to break out of the sleep anxiety and get your sleep back on track.
2. Sleep data from a sleep diary can be helpful. If you are working with a therapist, then completing a sleep diary can be helpful to get a sense of your general sleep patterns. Sleep diaries are self-report daily dairies that ask questions such as “when you got into bed” and “how long it took you to fall asleep” to get a picture of your sleep. The therapist can then provide individualized recommendations to support your sleep needs.
3. Reflect on your sleep goals and beliefs. Some sleep goals can be tricky because they don’t reflect reality. For example, many people come in with the goal of sleeping 8 hours but the number of hours we produce is actually completely unique to our own body. Other people might think that better sleep will mean that they have lots of energy throughout the day. However, fatigue is multifaceted and there can be a number of factors that could be contributing to feelings of tiredness (such as lack of activity or caffeine rebound). If you’re interested, here is an article on six strong goals for sleep.
Best wishes,
P
