CBT for Insomnia: Where to Find the Help You Need

Here’s a question that often comes my way: “I’d like to try cognitive behavioral therapy for insomnia [CBT-I], so where can I find a sleep therapist?”

The availability of CBT-I providers varies depending on where you live. Here’s where you’re likely to find help and where you’re not, and alternative ways to get the insomnia treatment you’re looking for.

Where to find a therapist who does CBT for insomniaHere’s a question that often comes my way: “I’d like to try cognitive behavioral therapy for insomnia [CBT-I], so where can I find a sleep therapist?”

The availability of CBT-I providers varies depending on where you live. Here’s where you’re likely to find help and where you’re not, and alternative ways to get the insomnia treatment you’re looking for.

Why CBT for Insomnia?

It’s the most effective insomnia treatment known at this time, improving sleep for 70 to 80 percent of the people who try it. CBT-I is more effective and long lasting than treatment with sleeping pills, and it’s effective for many people with chronic insomnia who also have other health problems such as depression, anxiety, or sleep apnea.

For more information on CBT-I, take a quick look at this blog post I wrote at the beginning of last year.

Where Can I Find Treatment?

It depends on where you live, say authors of a paper published last year in Behavioral Sleep Medicine. If you live in New York or California, insomnia therapy is likely close at hand. If you live in Hawaii, South Dakota, Wyoming, or New Hampshire, you’ll have no luck in finding a doctor, psychologist, or nurse practitioner trained in behavioral sleep medicine. Authors of the paper were unable to find a single provider practicing in those states.*

Here’s a chart showing the number of behavioral sleep medicine providers in the US by state:

No. of providers States
73–33 CA, NY, PA, IL, MA, TX
27–22 FL, OH, CO, MN, MI, WA
17–10 MD, NC, TN, AZ, MO, DC
9–6 CT, VA, WI, AL, OR, AR, SC, WV, IN, ME, NJ
5–3 AK, DE, GA, KS, LA, NE, RI, KY, NM, NV, OK, UT, MS
2–0 ID, ND, IA, MT, VT, HI, NH, SD, WY

 

Canada has 37 behavioral sleep medicine providers, but no other country outside the US has more than 7.

Do I Really Need a Sleep Therapist for CBT-I?

There are alternatives to working with a doctor or therapist trained in behavioral sleep medicine. But working with a professional—someone with a clear grasp of the protocol who can lead you through it step by step, motivating you to continue if the going gets rough—is probably the best way to ensure success and maximize the gains you’re going to make.

“Having somebody who’s experienced with this telling me that, if I do this, there’s a good chance everything will turn around is very inspiring,” said a man I interviewed for my book, The Savvy Insomniac, after we finished a group course in CBT-I.

Find a professional trained to administer CBT-I by clicking on this provider directory.

What If I Can’t Get Insomnia Therapy Nearby?

Your next best bet is to take an online course in CBT-I. These interactive courses have been found to be as effective as the face-to-face coaching you’d receive from a sleep therapist, the only downside being that research shows people going through an online course are more likely to drop out. Check these programs out:

  • CBT for insomnia is a 5-week course developed by sleep specialist Gregg D. Jacobs at Harvard Medical School. The cost is $49.95.
  • SHUTi sells its 6-week course, developed by Canadian sleep specialist Charles Morin, for $149. The price includes access to the site for 26 weeks. The extended access might appeal to you if (1) you’re not ready to jump right into the course, (2) something unforeseen happens during therapy and you have to start all over again, or (3) you feel you might like to continue tracking your sleep after the course ends.
  • Sleepio, developed by UK sleep specialist Colin Espie, offers a 6-week course plus a year’s access to the website and a host of supplementary materials for the hefty price of $400. What you’d gain from a whole year’s access to the website isn’t clear to me. But you may be able to access Sleepio for free by agreeing to take part in a research study.

Couldn’t I Just Read a Book?

You could. Stephanie Silberman’s book, The Insomnia Workbook: A Comprehensive Guide to Getting the Sleep You Need, leads you step by step through everything you need to know to go through CBT-I using the book as your guide. But here’s a warning: while I know it’s possible to succeed in self-administering CBT-I using only a book as a guide (I did), I hear some people complain of failure. Make sure you succeed by starting out right:

  1. Read all you can about the CBT-I protocol before starting therapy. It’s important to understand the process before you begin.
  2. For 1 to 2 weeks before you start therapy, keep a sleep diary (download a sleep diary here), recording bed and rise times and relevant habitual activities.
  3. From the data you’ve gathered, calculate your average nightly total sleep time and set your initial sleep window accordingly. (But if you sleep less than 5 hours a night, set your sleep window at 5 hours.)

Stick closely to the protocol and hang tight. Your sleep should start to improve in a couple of weeks.

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*To gather data, the authors consulted a directory of professionals certified in behavioral sleep medicine, BSM provider lists, and BSM listservs.

Early Treatment of Insomnia May Improve Mental Health

Insomnia and mental health problems go hand in hand. It’s firmly established now that insomnia can be a causal factor in depression and that treatment for insomnia can improve both sleep and mood.

A new study shows that insomnia may also be a causal factor in psychotic experiences such as paranoia and hallucinations, and that CBT for insomnia (CBT-I) may lead to better mental health. Here’s a quick look at the research and what it suggests for us.

Web-based cognitive behavioral therapy for insomnia improves sleep & moodInsomnia and mental health problems go hand in hand. It’s firmly established now that insomnia can be a causal factor in depression and that treatment for insomnia can improve both sleep and mood.

A new study shows that insomnia may also be a causal factor in psychotic experiences such as paranoia and hallucinations, and that CBT for insomnia (CBT-I) may lead to better mental health. Here’s a quick look at the research and what it suggests for us.

Sleep and Mood: An Intimate Relationship

People with mood disorders and other mental health problems often experience insomnia. Until recently their trouble sleeping was viewed as a symptom or a consequence of the mental health problem. Successful treatment of that problem would take care of the insomnia, too—or so they thought.

Then along came research that upset the apple cart. It showed that insomnia was sometimes a causal factor in depression, and that treatment with CBT for insomnia (CBT-I) helped to resolve both problems better than treatment for depression alone. This led to a related question: could other psychiatric symptoms linked with insomnia—paranoia, hallucinations, anxiety, mania—be triggered in part by insomnia and could treatment with CBT-I head off their development?

A Large-Scale Study

Paranoia and hallucinations have strong links to insomnia. Researchers in the UK recruited 3,755 university students with insomnia from 26 different college campuses to see if treating their insomnia with CBT-I would lessen their risk of experiencing these psychotic symptoms.

Randomly the researchers divided student participants into two equal groups. One served as a control group. Students in the other group participated in an individualized online insomnia treatment program called Sleepio.

Similar to other research-based online insomnia treatments (SHUTi and CBT for Insomnia, for example), Sleepio is a 6-week program that delivers CBT-I over the internet. It includes behavioral components such as sleep restriction and stimulus control; cognitive components that challenge unhelpful beliefs; and education about sleep and sleep hygiene.

Student participants in both groups also took a battery of pencil and paper tests at four different times during the 6-month study period to assess the severity of their insomnia symptoms and the state of their mental health. Statistical analysis of the data included looking at whether reductions in insomnia symptoms correlated with better mental health outcomes.

Insomnia Treatment Improves Sleep, Reduces Psychotic Symptoms

Here are the main results, all statistically signficant. Compared with participants in the control group, participants who underwent the Sleepio treatment ended the program with

  • greatly improved sleep
  • fewer experiences of paranoia and hallucinations

The Take-Away

The results of this relatively large study led to the following claims:

  1. Online insomnia treatment programs like Sleepio work for university-age students with trouble sleeping. They’re inexpensive and can be accessed at home.
  2. While insomnia might not be the principal cause of psychotic experiences, it may well be a contributing cause.
  3. CBT-I may have promise as an early intervention for some psychiatric problems.

Caveats for the Sleepless Whether or Not Mental Health Is an Issue

CBT-I, for all its effectiveness, involves commitment to a weeks-long process and the discipline to follow a rigorous set of guidelines. In this study there was a 50% drop-out rate among participants assigned to the Sleepio program—higher than the dropout rate for the control group. Feeling sleep deprived and lacking stamina, some insomniacs may be unsuccessful at completing a CBT-I program in the absence of face-to-face coaching and encouragement from a trained sleep therapist.

But 50% of the participants stuck with the Sleepio program long enough to reap sleep benefits. This success rate is comparable to that found in research on other web-based insomnia treatment programs.

Our options do not stop with online treatment programs. I’ve found it’s also possible to improve sleep by following instructions in books about CBT-I (see, for example, The Insomnia Workbook by Stephanie Silberman, The Insomnia Answer by Paul Glovinsky and Arthur Spielman, or chapter 8 of my book, The Savvy Insomniac). I myself used CBT-I to improve my sleep after reading a training guide for sleep therapists (Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide by Michael Perlis and colleagues).

Regardless of how it’s accessed, CBT-I remains our best defense against sleepless nights and draggy days—and it may also preserve our mental health and well-being.

If you’ve tried CBT-I, how did you access treatment and how useful was it in helping to improve your sleep?

Paradoxical Insomnia: A Second Look at Treatments

Paradoxical insomnia: a diagnosis given to people whose sleep studies show they sleep a normal amount but who perceive they sleep much, much less. When I wrote about it in 2015, the word was that cognitive behavioral therapy (CBT)—the gold standard in treatments for insomnia—might not be an effective treatment for it.

But a brief testimonial that recently appeared in American Family Physician argues otherwise. Here’s an update on this puzzling sleep disorder.

Paradoxical insomnia may respond to treatment with CBT & therapies lowering arousalParadoxical insomnia: a diagnosis given to people whose sleep studies show they sleep a normal amount but who perceive they sleep much, much less. When I wrote about it in 2015, the word was that cognitive behavioral therapy (CBT)—the gold standard in treatments for insomnia—might not be an effective treatment for it.

But a brief testimonial that recently appeared in American Family Physician argues otherwise. Here’s an update on this puzzling sleep disorder.

A Subjective-Objective Discrepancy

Time and again we hear that people with insomnia tend to underestimate sleep duration. Up to 50 percent of the time, the electroencephalograms (the graphic records of brain waves produced during overnight sleep studies) of insomnia sufferers reporting insufficient sleep look the same as those of normal sleepers, registering 7 or 8 hours of sleep.

But in people with paradoxical insomnia, the discrepancy between their sleep study results and their subjective assessment of their sleep is huge. The woman whose story appeared in American Family Physician perceived that she was routinely “awake all night.” Yet when she finally went in for an overnight sleep study, the record of her brain waves showed she’d slept a total of 7 hours and 18 minutes. She couldn’t believe it.

A Heavy Burden

You might think, since paradoxical insomniacs are getting a normal amount of sleep, that their insomnia symptoms would be less severe than those of “objective” insomniacs, whose sleep studies show they get less (sometimes considerably less) than 7 or 8 hours. Paradoxical insomnia may sound like “insomnia lite.”

Apparently it isn’t. Research has shown that paradoxical insomniacs tend to be more confused, tense, depressed, and angry than normal sleepers. They also have a higher metabolic rate, which suggests an overall higher level of arousal.

In-depth analyses of brain activity at night attest to this heightened arousal. Compared with objective insomniacs, paradoxical insomniacs experience more high-frequency activity, and less low-frequency activity, in the brain at night. Their sleep is light and vigilant.

Yet it’s often hard for people with paradoxical insomnia to convince others that anything is wrong. When the woman writing in American Family Physician complained about not having slept all night, her husband countered with insistence that she’d slept soundly the whole night. Her friends and colleagues were skeptical too, noting that she had a normal amount of energy and competence at work. She felt increasingly tormented—“not only because of the insomnia,” she wrote, “but also because of a loss of trust from my husband and friends. They said they wondered whether I was pretending just to get sympathy.”

What Could Be Wrong? What Can Be Done?

Scientists can’t explain exactly what the problem is. One hypothesis holds that paradoxical insomnia has something to do with sleep quality, and that treatments that train paradoxical insomniacs to perceive sleep when they’re objectively determined to be asleep may help. (See my other post about paradoxical insomnia here.) But adjusting people’s perceptions may not necessarily resolve all their insomnia symptoms or improve their long-term health.

Other researchers have proposed that paradoxical insomnia occurs due to heightened brain activity during sleep, a condition which is accurately perceived by those who experience it but will require more sophisticated measures to assess scientifically. If it’s true that in paradoxical insomnia the main barrier to satisfying sleep is excessive brain activity and vigilance at night, then therapies designed to lower arousal levels—exercise, yoga, meditation—may help.

How About CBT for Insomnia?

Some experts have expressed doubts about whether CBT for insomnia (CBT-I) has the potential to work as well for paradoxical insomnia as it does for the more common psychophysiologic insomnia. The main value of CBT-I is its ability to help people fall asleep more quickly and decrease nighttime wake-ups. At least when their sleep is assessed objectively, paradoxical insomniacs don’t usually have these particular problems.

But CBT-I also helps to dispel negative beliefs and excessive worry about sleep, which can make any type of insomnia worse. It was an effective insomnia treatment for the woman writing in American Family Physician. “After receiving cognitive behavior therapy,” she wrote, “I began to feel much better and now am able to sleep well most of the time.”

So if it feels like you’re hardly sleeping at all, consult a sleep doctor or a sleep therapist for a proper diagnosis and help in improving your sleep. There may be more insomnia treatment options than you think.

If you feel you’ve benefited from reading this post, please like and share on social media. Thanks!

Tai Chi When Insomnia Isn’t the Only Problem

Insomnia combined with other health problems is bound to cause distress.

But help is at hand. New research shows that tai chi reduced insomnia symptoms in breast cancer survivors, suggesting that it may help with insomnia linked to other health problems, too.

Tai chi may improve sleep for insomnia sufferers with other health problemsA reader wrote yesterday asking for advice: “I’ve been reading through your website but have yet to see an article on how to manage sleep with chronic illness. I’m currently experiencing health challenges that are keeping me awake at night. What would you recommend for people experiencing health issues, especially moderate to severe ones?”

Insomnia combined with other health problems is bound to cause distress. But help is at hand. New research shows that tai chi reduced insomnia symptoms in breast cancer survivors, suggesting that it may help with insomnia linked to other health problems, too.

When Insomnia Is Not the Only Problem

Sometimes insomnia is the only health problem a person has. But insomnia more commonly occurs in conjunction with other health issues—everything from mood disorders and chronic pain to gastrointestinal problems and heart disease.

Part of the solution when you’re in this situation (sometimes referred to as comorbid insomnia) lies in getting treatment for the associated health problem. This will involve consulting a medical or psychiatric specialist.

But even when treatment is successful at controlling other health problems, trouble sleeping often persists. Women successfully treated for breast cancer have twice the rate of insomnia as occurs in the general population, as well as depression and fatigue. This is hardly surprising: A diagnosis of breast cancer is distressing in and of itself, never mind the invasive (although often effective) treatment options. But then you never know if or when the cancer might come back. Such chronic health concerns take an emotional toll that can interfere with sleep.

CBT for Insomnia Can Help

Cognitive behavioral therapy (CBT) is the gold standard in treatment for insomnia these days. This combination of sleep restriction, stimulus control, and talk therapy has been shown to be an effective treatment for insomnia in cancer survivors. Research shows it’s also effective in relieving insomnia in people with depression and people with other psychiatric and medical conditions.

But CBT for insomnia is not widely available nor can everyone afford it. Besides, it can be challenging to adhere to the protocol. CBT does not suit everyone.

UCLA investigators wanted to find a more accessible, less expensive type of therapy for breast cancer survivors experiencing insomnia that would equal CBT in efficacy. So they conducted a randomized, partially blinded study pitting CBT against tai chi.

Why Tai Chi?

Tai chi, a practice involving slow, flowing movement combined with meditation and deep breathing, is said to alleviate stress and anxiety and promote energy and stamina. In the words of the study’s authors, tai chi emphasizes “control over physical function and arousal-related responsiveness . . . through the mindful performance of repetitious, nonstrenuous, slow-paced movement.”

This type of activity might have an effect on sleep. And in fact a handful of studies have shown that tai chi does indeed relieve insomnia symptoms.

So investigators recruited 90 breast cancer survivors, aged 42 to 83 years, who were experiencing insomnia, depression, and fatigue. Half of them then received three months of weekly instruction in CBT for insomnia. The other half received three months of weekly instruction in a westernized form of tai chi called tai chi chih.

Impressive Results

At 15 months following the start of treatment (one year after treatment ended), nearly half of the participants in both groups showed marked improvement in their sleep, or complete or nearly complete remission of their insomnia symptoms. Both groups also experienced a robust reduction in fatigue severity and depression.

The novelty of this result is that for these survivors of breast cancer, the practice of tai chi chih resulted in sleep improvements equivalent to those obtained with CBT. Tai chi may be similarly useful for insomnia sufferers with other distressing health problems.

Lowering Arousal, Reducing Inflammation

The mechanisms by which tai chi relieves insomnia symptoms aren’t understood. But research has shown that tai chi:

  • Cuts down on arousal of the sympathetic nervous system. The sympathetic nervous system becomes active when you detect a threat, increasing vigilance and triggering bodily preparations to fight or flee.
  • Reduces inflammation. Inflammation is part of the body’s response to infection and tissue damage and is necessary to the healing process. But when inflammation becomes chronic it leads to disease.

Both arousal and inflammation have a negative effect on sleep. So it follows that a practice such as tai chi, which reduces them, might help.

Tai chi is worth checking into for people with comorbid insomnia and other distressing health conditions. Classes are offered in many locales. You can even learn tai chi by watching YouTube videos or using a smartphone app.

If you’ve practiced tai chi, what effect, if any, did it have on your sleep?

2017: Resolve to Improve Your Sleep

Do you have a persistent sleep problem? Make cognitive behavioral therapy for insomnia your No. 1 New Year’s resolution for 2017.

Here’s what you stand to gain, what may stand in the way, and where to find help.

CBT for insomnia should be your no. 1 resolution for the new yearDo you have a persistent sleep problem? Make cognitive behavioral therapy for insomnia your No. 1 New Year’s resolution for 2017.

Here’s what you stand to gain, what may stand in the way, and where to find help.

A Treatment That Improves Sleep

Cognitive behavioral therapy for insomnia is focused on boosting sleep drive and removing psychological barriers to sleep. It’s become the front-line treatment for chronic insomnia because it gets results. Most people who undergo therapy can expect to:

  • Improve sleep efficiency. In other words, you’ll cut the time it takes to fall asleep in half, and cut the number of nighttime awakenings—and their duration—in half.
  • Improve sleep quality. You’re likely to sleep more soundly and wake up feeling more refreshed in the morning.
  • Sleep moderately longer, especially if you’re young or middle aged.

So why hesitate?

The First (and Maybe Biggest) Barrier to “Yes”

If you’re like I was, the biggest barrier to trying cognitive behavioral therapy (CBT) for insomnia may be the belief that nothing can improve your sleep. This is actually a logical way of thinking if you’ve had insomnia for a long time. After years of trying to improve your sleep by means you’ve read about elsewhere—chamomile tea, talk therapy, relaxation exercises—and getting poor results, why would your expectations for CBT for insomnia be anything but low? Hope is hard to come by after years of insomnia and failed attempts to improve sleep.

Gearing up to try yet another insomnia treatment can reawaken hope. But it also opens up the possibility of failing again. Just how comfortable is that? Besides, undertaking CBT for insomnia involves going through a process—and that process may not sound particularly quick or easy. It can be hard to silence these objections and commit yourself to another insomnia treatment.

A Second Possible Barrier: Fear of Sleeplessness

The prospect going through sleep restriction (the part of CBT for insomnia that involves curtailing your time in bed and observing prescribed bed and rise times) may make you uneasy. Sleep restriction was a red flag for me.

What if, during my allotted time in bed, I never fell asleep at all? This was scary to contemplate. As described in Chapter 8 of The Savvy Insomniac, my sleep anxiety was sky high when I went through treatment and drove me to do some pretty strange things.

No doubt my fear of sleeplessness made the first few days of treatment harder. But the gains I made were quick in coming. By the fourth night of treatment, I was falling asleep at my designated bedtime and sleeping right through the night—a pattern that was touch and go for a while but has held up very well over time. My sleep anxiety is now a thing of the past.

Take some advice from a lifelong insomnia sufferer who dithered around for 11 years longer than she should have before finally taking the plunge: just do it.

Finding a Sleep Coach

CBT for insomnia is typically administered by a trained sleep therapist over the course of 6 to 8 weeks. This is still the preferred form of treatment for the many insomniacs who like the idea of face-to-face coaching (and have insurance covering treatment or can afford to pay for it themselves).

Here’s how to find a sleep therapist certified in behavioral sleep medicine:

Some behavioral sleep medicine professionals offer a condensed form of CBT-I called brief behavioral treatment for insomnia (BBTI). Therapy takes place over 4 weeks (rather than 6 to 8) and involves two face-to-face meetings with the therapist and two follow-up phone calls. Read more about it in this blog post about BBTI.

CBT for Insomnia Online

What if you live in the hinterlands and there are no behavioral sleep medicine therapists nearby? With access to the internet, you’re still in business. Three interactive online programs—SHUTi, Sleepio, and CBT for Insomnia—are excellent resources for insomniacs in far-flung locales and those on a limited budget:

  • The SHUTi program ($135 for 16 weeks of access and $156 for 20 weeks of access) was recently shown in a clinical trial to get results equivalent to those obtained in standard face-to-face CBT-I.
  • A clinical trial of the Sleepio program ($300 for 12 months of access) is under way right now.
  • The CBT for Insomnia program is a 5-session program created by Dr. Gregg Jacobs, author of Say Goodnight to Insomnia, for the nominal cost of $44.95.

Insomnia sufferers, suspend your disbelief and try this out. I can’t promise it will relieve your insomnia—but the odds are greatly in your favor.

Good night, and good luck.

What doubts do/did you have about CBT for insomnia?

Q&A: Will Regular Rest Curb Sleep Anxiety?

“I have nights when I can’t sleep at all and other nights when I sleep a lot,” Philippa wrote last week. “If I don’t fall asleep straight away I find I often don’t sleep the whole night! Do you think sleep restriction would work for me?”

My answer to Philippa’s question is an unqualified “yes.” But first I want to look at sleep that’s inconsistent and unpredictable and how anxious it can make you feel.

Anxiety about sleep is treatable with CBT for insomniaMy sleep used to be erratic. Really, really erratic. The Sandman could come as early as 10 p.m. . . . but he might not show up till daybreak.

Occasionally I hear another insomnia sufferer voice a variation on the same complaint. Here’s what Philippa wrote last week:

 

 

I have nights when I can’t sleep at all and other nights when I sleep a lot. I don’t have a problem waking up at night and, if I do, I can go back to sleep. However, if I don’t fall asleep straight away I find I often don’t sleep the whole night! Do you think sleep restriction would work for me?

My answer to Philippa’s question is an unqualified yes. But before I talk about making sleep more regular, I want to look at sleep that’s inconsistent and unpredictable and how anxious it can make you feel.

Night-to-Night Sleep Variability

Actually, there’s not much talk about night-to-night variability in people’s sleep. We hear a lot about sleep need, but that’s always stated as an average, as in “most people need about 7 hours of sleep a night.”

But plenty of research shows there’s night-to-night variability in when, how long, and how well each person sleeps. Unsurprisingly, some people’s sleep is more variable than others’. According to a new paper published in Sleep Medicine Reviews, from night to night, your sleep is more likely to vary in duration, timing, or quality if

  • you’re young
  • you live alone
  • you’re a person of color
  • you’re a night owl
  • you’re overweight or obese
  • you have physical health conditions
  • you have bipolar or depressive symptoms
  • you’ve had lots of stressful life events
  • you have insomnia.

Insomnia and Sleep Variability

The word insomnia means “the condition of not being able to sleep.” Yet even if your insomnia is chronic, chances are you don’t sleep poorly every night. In fact, like Philippa, on some nights you probably sleep passably or even quite well. But good sleep is not dependable, and that’s a problem.

There may be certain situations you’ve identified that typically give rise to bad nights. For example, you may know your sleep will suffer after a bad day at work or if you have to give a speech the next day.

But the good and bad nights may not necessarily correspond to stressors you can put your finger on. And this lack of predictability can cause big-time anxiety. It certainly did for me.

A Pattern of Good and Bad Nights?

Is there an underlying pattern to insomniacs’ poor sleep and, if so, would discerning that pattern be reassuring? Maybe it would for some people with insomnia.

Researchers in Scotland looked at the sleep diaries of over 100 insomniacs and found a predictable pattern of good and bad nights in about two-thirds of the study participants. Most of these participants could count on a good night’s sleep after 1 to 3 bad nights.

It could be reassuring to know that a better night’s sleep is just a day or two away, the authors wrote. A predictable pattern of good and bad nights might alleviate some anxiety about sleep.

In a study conducted at the University of Pennsylvania, investigators concluded that insomniacs can expect a “better-than-average” night’s sleep within 3 days—but that “good” sleep may come only 1 night in 6. This doesn’t sound very predictable or reassuring to me.

Take the Bull by the Horns

It might be helpful to keep a sleep diary and see if you can identify a pattern of good and bad nights. Seeing method in the madness might allow you to dispense with some of the uncertainty that’s probably contributing to your anxiety about sleep at night (and driving your insomnia).

But getting rid of erratic sleep—and making sleep predictable—is a more effective approach to curtailing anxiety about sleep. Undergoing CBT for insomnia, which includes sleep restriction therapy, is a good way to do that, research shows. And both this blog and my book, The Savvy Insomniac, are a testimonial to what CBT for insomnia—combined with regular exercise—has done for my sleep.

I’ve written more about sleep restriction therapy because it’s the part of treatment that helped me the most. To read more about it, just click on “Blog” at the top of this page, type “sleep restriction” in the site search box, and start browsing.

Q&A: Panic About Insomnia Relapse

Lately I’ve been hearing from people who improved their sleep using sleep restriction or full-blown CBT for insomnia (CBT-I) and then experience a relapse. They have a few bad nights and fear they’ve lost all the gains they made. Here’s how one reader recently described her plight:

“I realize that sometimes I will get scared when I have one or two bad nights once in a while. I’m afraid that insomnia will haunt me once again. Is this normal? What can I do?”

Insomnia sufferers should do something quiet at night until they're sleepyLately I’ve been hearing from people who improved their sleep using sleep restriction or full-blown CBT for insomnia (CBT-I) and then experience a relapse. They have a few bad nights and fear they’ll never sleep well again. Here’s how one reader recently described her plight:

 

 

I realize that sometimes I will get scared when I have one or two bad nights once in a while. I’m afraid that insomnia will haunt me once again. Is this normal? What can I do?

Normal or Abnormal?

When cognitive behavioral therapies for chronic insomnia work—and they do improve sleep for 70 to 80 percent of the insomniacs who try them—it can feel like such an achievement. “At last,” you think, “I’ve got this monkey off my back!”

In reality, though, only a minority of the people who undergo CBT-I report that their insomnia is “cured.” The rest of us experience occasional insomnia relapses.

As anyone who’s read The Savvy Insomniac knows, I went through CBT-I with a group of 4 other insomnia sufferers. At the final group meeting, the therapist gave us a handout on how to maintain the gains made during treatment and what to do in case of relapse. Not only are occasional relapses not abnormal; for many of us, they’re probably inevitable.

All Is Not Lost

The first relapse can feel like such a downer and provoke lots of anxiety. “What? I restricted my sleep only to end up right back where I started, and maybe even worse?” It’s easy to appraise the situation this way: you’re short on sleep, fatigued, and out of sorts. Everything about it feels depressingly déjà vu.

But all is not lost. What occurs during CBT-I is a process some scientists liken to a rewiring of the brain. Neural pathways related to new thoughts and behaviors are established as sleep becomes more regular and the bed and the bedroom come to be associated with sleep.

Older pathways active during insomnia do not disappear. Rather, the new pathways—to continue speaking figuratively—are superimposed on the old. With every good night of sleep, neural connections along the new pathways are strengthened. You expect to sleep well at night and you do.

The older pathways and ways of thinking are still there, though, and due to stress or anything else disruptive to sleep, they may regain some influence. Insomnia returns, and you’re as anxious about it as you ever were. But there’s good news, too: once the newer pathways are established, they’re easier to return to.

I’ll attest to this from personal experience. Before I went through CBT-I (and sleep restriction therapy), my bouts of insomnia could drag on for weeks. Now when I experience insomnia and (in rare cases) my fear of sleeplessness returns, I’m able to return to better sleep and dispense with the anxiety in a few days. I do it pretty much by following instructions I received during CBT-I. Here’s how:

What To Do in Case of Relapse

  • Don’t go to bed unless you’re sleepy. If after 15 to 20 minutes you’re not asleep, get up, go to another room, and do something quiet until you’re sleepy again. Then return to bed. If this doesn’t help after a few days, try the next suggestion.
  • Restrict your sleep by an hour or more for a few days. Be strict about getting out of bed at a consistent wake time—even on weekends.
  • Once your sleep is solid again, extend your time in bed by half-hour increments every 2 nights until you return to your desired bedtime.
  • Be sure to get daily aerobic exercise throughout the process.

If you’ve experienced a relapse of insomnia, please take a minute to share how you got your sleep back on track.

Sleep Restriction: Up Close and Personal

Some insomnia sufferers who visit my website head straight for the posts on sleep restriction. So I decided to create a video trailer where I could talk about my own experience of sleep restriction: how off-putting the idea was at first, and the results I later achieved.

Some insomnia sufferers who visit my website head straight for the posts on sleep restriction. So I decided to create a video trailer where I could talk about my own experience of sleep restriction: how off-putting the idea was at first, and the results I later achieved.

I posted the video on Facebook last week and got an interesting comment from a friend (who does not have insomnia himself). To him, the idea of restricting sleep time, and then increasing it bit by bit, did not sound counterintuitive at all. He compared it to the building of strength and dexterity that occurs with physical training, and the development of musical ability that occurs with daily practice on an instrument. The idea of improving sleep through the disciplined restriction of time in bed sounded perfectly reasonable to him.

There’s logic in what he says. Yet to those of us with insomnia, sleep restriction can sound daunting and downright scary. We know what it’s like to struggle with the daytime symptoms of insomnia: the fatigue, mood swings, and days when we can’t put two and two together or remember names. Why choose to subject ourselves to a treatment that involves slogging through a period when our symptoms may get worse?

Yet my own experience—and the experience of other insomniacs I went through group therapy with—suggests the bad days are numbered. By the second week we were already noticing improvements in our sleep and daytime stamina. Some of us found relief even sooner. Watch the video and see if you’re convinced.

As usual, I’d love to hear your comments.