Lifelong Insomnia? Don’t Give Up on It Yet

Have you had insomnia all your life? Have your parents said you were a poor sleeper even as a baby?

Trouble sleeping that starts early in life is called idiopathic insomnia. If insomnia is still the black box of sleep disorders, then idiopathic insomnia is the little black box inside the black box.

Here’s what is known about the disorder and options for management.

Lifelong insomnia can be treated by sleep specialist or therapistHave you had insomnia all your life? Have your parents said you were a poor sleeper even as a baby?

Trouble sleeping that starts early in life is called idiopathic insomnia. If insomnia is still the black box of sleep disorders, then idiopathic insomnia is the little black box inside the black box.

Here’s what is known about the disorder and options for management.

What Is Idiopathic Insomnia?

Idiopathic insomnia begins in childhood, sometimes at or soon after birth. Trouble falling or staying asleep or reduced sleep duration is pretty much a nightly affair regardless of situational changes. The disorder is uncommon, affecting less than 1% of the population.

There is no identifiable cause. The presumption is that idiopathic insomnia is driven mainly by biological factors, and at least some of them are probably inherited. Abnormalities in the circadian system or the homeostatic process may be involved and/or there may be a problem in the circuitry controlling sleep and waking in the brain.

A Chronic Sleep Disorder, but How Well Defined?

Idiopathic insomnia is a chronic sleep disorder with familiar insomnia symptoms:

  • Trouble falling or staying asleep, or sleeping long enough, for more than 3 months despite adequate sleep opportunity
  • Daytime distress and impairment, including reduced stamina, low mood, and trouble thinking and learning

Research on the defining features of idiopathic insomnia is mixed. On one hand are a few studies showing significant differences between people with idiopathic insomnia (IdI) and those with psychophysiological insomnia (PI), the garden-variety insomnia that typically develops later in adolescence or adulthood. PI is often triggered by a stressful event; situational factors do not figure in IdI. PI is said to persist mainly due to psychological and behavioral factors that develop in response to poor sleep: conditioned arousal in bed, poor sleep hygiene (going to bed early to catch up on sleep, for example), and anxiety about sleep. Psychological factors are less typical in IdI.

On the other hand is research showing no major differences between PI and IdI when assessed by polysomnography (the overnight test in the sleep lab) or by self-report of psychological symptoms. Research suggests that arousal levels are higher among people with IdI than in people with other kinds of insomnia, though, leading some sleep experts to speculate that IdI is simply a more severe manifestation of PI.

What Can Be Done?

Without scientific certainty about the causes of IdI or whether the disorder is distinct from other kinds of insomnia, IdI is best treated on a case-by-case basis by a sleep specialist. Following are options for treatment.

Especially if a person with IdI has misconceptions and/or anxiety about sleep,

  • Cognitive behavioral therapy for insomnia (CBT-I) may help. CBT-I typically consists of two behavioral components—stimulus control therapy and sleep restriction therapy—and a cognitive component designed to decrease psychological barriers to sleep. Sometimes just changing your attitude about sleep can bring about demonstrable sleep improvements.
  • Acceptance and commitment therapy (ACT) may help. ACT focuses on building mindfulness skills so that, rather than trying to suppress, manage, and control emotional experiences, people develop psychological flexibility and learn to behave in ways that reflect their values and increase well-being. This approach, too, can change the way you feel about sleep and in the process improve your sleep.

If round-the-clock hyperarousal is driving IdI, then therapies designed to decrease arousal may help.

  • Regular, moderate-to-vigorous exercise—activities such as aerobics, calisthenics, biking, running, and weight-lifting—has been shown in recent studies to increase total sleep time and decrease levels of cortisol (a stress hormone).
  • Yoga, too, has been shown to decrease feelings of arousal and promote stress tolerance.

Medication for Idiopathic Insomnia

The issue of sleeping pills for chronic insomnia is increasingly fraught. Many drugs approved for the treatment of insomnia, taken nightly over time, may degrade sleep quality and result in alarming side effects, especially in older adults.

That said, while the medication prescribed for IDI is usually a benzodiazepine or a Z-drug such as zolpidem or eszopiclone, a second pharmacological approach, according to a paper by Michael Perlis and Philip Gehrman, involves use of a melatonin agonist such as ramelteon (Rozerem). No studies of the effects of this sleeping pill on the sleep of adults with IdI have been conducted. But in two studies of children aged 6 to 12 years with chronic idiopathic childhood sleep-onset insomnia, melatonin put them to sleep significantly sooner—by 1 hour.

If you’re contemplating managing lifelong insomnia with drugs, get some professional advice. This is one place where you really need the help of a specialist knowledgeable in the medical treatment of chronic insomnia.

At what age did your trouble sleeping start? What kinds of treatments—if any—have helped?

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?

Find the Right Sleep Doctor for Insomnia

When people write in with lots of questions about insomnia, I’ll often recommend seeing a sleep specialist or a sleep therapist who can provide cognitive behavioral therapy for insomnia (CBT-I).

But finding sleep specialists and sleep therapists can be tricky. Here’s why you might want to consult one and how to locate the right provider.

Insomnia sufferers can get help from sleep specialists and CBT providersWhen people write in with lots of questions about insomnia, I’ll often recommend seeing a sleep specialist or a sleep therapist who can provide cognitive behavioral therapy for insomnia (CBT-I).

But finding sleep specialists and sleep therapists can be tricky. Here’s why you might want to consult one and how to locate the right provider.

Why a Sleep Specialist?

Many people turn first to a primary care provider for help with insomnia. Some PCPs may know enough about sleep disorders to diagnose your problem and give you the help you need.

But a 10-minute appointment may not be long enough for a doctor to correctly diagnose your sleep problem—let alone figure out the most appropriate treatment. Also, sometimes I hear complaints about how PCPs respond to people with insomnia. The complaints go something like this:

“He didn’t seem to have much sympathy for my situation.”

“All she wanted to do was prescribe another sleeping pill.”

In contrast, a sleep specialist

  • Will probably have more empathy for your problem. A doctor who completes a one-year fellowship in sleep medicine after a 3- or 4-year medical residency is likely to take insomnia complaints more seriously and show more compassion than doctors without this training.
  • Will spend enough time with you to make an accurate diagnosis. There’s no objective test for insomnia, so sleep doctors have to figure out what’s wrong based on clinical interviews alone. Just because you have insomnia symptoms does not mean the underlying problem is actually insomnia disorder, or that the insomnia is not occurring in conjunction with another health problem. A good sleep specialist may spend 45 or 50 minutes with you in order to arrive at an accurate diagnosis.
  • Has in-depth knowledge of (1) sleep and sleep disorders, (2) the clinic- and home-based tests used to diagnose sleep disorders (rarely used if the suspected diagnosis is insomnia), and (3) the array of treatments available—and is qualified to administer those treatments.
  • May or may not be a certified provider of CBT-I.

Find a Board-Certified Sleep Medicine Specialist

To make sure you’re going to get good care, you’ll want to consult a sleep medicine specialist who is board certified. This means that he or she has passed the certification examination administered by the American Board of Sleep Medicine.

Board-certified sleep specialists are often affiliated with sleep centers accredited by the American Academy of Sleep Medicine. Use this AASM locator tool to find an accredited sleep center (and a sleep specialist) near your home.

Help with Cognitive Behavioral Therapy for Insomnia

But say you’re reasonably certain that yours is a case of persistent insomnia uncomplicated by any other disorder. You might want to try CBT-I and be looking for someone to guide you through it. If so, your quest for help with sleep will follow a slightly different path.

There’s a branch of sleep medicine called behavioral sleep medicine. It addresses the learned behaviors and thought patterns that typically disrupt sleep, and changes that can be made to improve sleep. Providers certified in this field are the ones who can help you out.

Some sleep specialists are certified in behavioral sleep medicine as well. (The credential is written CBSM, which stands for “Certified in Behavioral Sleep Medicine.”) MDs of all stripes are eligible to undergo training and become certified. So are psychologists (PhDs and PsyD’s), nurses, and some master’s-level health care professionals.

Unfortunately, certified CBT-I providers are still somewhat scarce. They tend to cluster in urban areas—which is also where most sleep centers are located.

Find a CBT-I Provider

But help is closer now than ever before. The Society of Behavioral Sleep Medicine has published a list of behavioral sleep medicine providers. The great thing about this list is that the providers are listed alphabetically by state (rather than by providers’ names). So click on this list of CBT-I providers, find your state (or a nearby state), and set up a consult.

It’s never too late!

If you’ve consulted a sleep specialist or a CBT-I therapist, how did you locate that person and were you satisfied with the help you got?

Psychophysiologic Insomnia: What It Is & How to Cope

Psychophysiologic insomnia: This was my diagnosis when I finally decided to see a doctor about my sleep. I didn’t like the sound of it. “Psycho” came before “physiologic,” and to me the implication was that my trouble sleeping was mostly in my head.

My insomnia felt physical, accompanied as it was by bodily warmth, muscle tension, and a jittery feeling inside. I was anxious about sleep, too, and my thoughts weren’t exactly upbeat. But surely putting the psycho before the physiologic was putting the cart before the horse?

Psychophysiologic insomnia is a sleep problem involving physical and mental factorsPsychophysiologic insomnia: This was my diagnosis when I finally decided to see a doctor about my sleep. I didn’t like the sound of it. “Psycho” came before “physiologic,” and to me the implication was that my trouble sleeping was mostly in my head.

My insomnia felt physical, accompanied by bodily warmth, muscle tension, and a jittery feeling inside. I was anxious about sleep, too, and my thoughts weren’t exactly upbeat. But surely putting the psycho before the physiologic was putting the cart before the horse?

Don’t let the terminology put you off the way I did. Psychophysiologic insomnia (I’ll call it PPI) is a problem in which constitutional vulnerabilities, situational factors, habits, and dysfunctional thinking are so intertwined that it’s hard to sort them out. Here’s a brief description and recommendations on how to manage it.

A Diagnosis Based on Symptoms

No objective test can reliably distinguish between normal sleepers and people with PPI. So the diagnosis is made based on symptoms alone. In PPI as in other types of insomnia, the wakefulness may occur at the beginning, in the middle, or at the end of the night. But people with PPI also:

  • have a lot of anxiety about sleep
  • are prone to intrusive thoughts and involuntary rumination
  • feel physically wound up
  • fall asleep at unusual times and places
  • experience daytime impairments such as fatigue, moodiness, and trouble thinking

Polysomnography (PSG)—the test administered overnight in a sleep lab—is not usually recommended because it doesn’t discriminate well between people with PPI and normal sleepers. But PSG results show that overall, people with PPI sleep less, and spend more time in lighter stages of sleep, than people who sleep well. (In contrast, the PSG results of people with paradoxical insomnia look normal, even though sufferers may feel like they’re getting 1 or 2 hours of sleep at best.)

How PPI Develops

Often it begins in adolescence or early adulthood, showing up as light sleep or periodic episodes of poor sleep.* Some people are naturally more susceptible than others. This may be true, sleep expert Peter Hauri has written, because of “an inherent, mild defect in the sleep-wake system, i.e., either excessive strength of the reticular activating system [the arousal system] or a weakness in the inhibitory, sleep-inducing circuits. Because the sleep-wake balance in such patients might lean toward wakefulness, such people would be suffering from an occasional, neurologically based poor night of sleep long before developing serious insomnia.”

Stressful situations lead to more extended bouts of poor sleep. Sooner or later, concern about sleep sets in. This is when insomnia starts to get “serious,” to use Hauri’s word. Looking for ways to reestablish better sleep, people change their habits—trying harder to sleep, going to bed early, taking naps—in ways that actually make sleep worse. The bed and the bedroom come to be associated with not sleep but rather with wakefulness and worry about sleep.

Thus begins the vicious cycle where long stretches of wakefulness in bed, accompanied by feelings of tension, begin to condition arousal of the brain, in turn fueling more bodily arousal. What began as light sleep or an occasional stress-related bout of insomnia has become a chronic affair.

Management Options

Once the PPI train pulls away from the station, it’s hard to get off. For decades I tried every trick in the book—sleeping on the couch, watching nature programs, listening to white noise, scenting my pillows, rhythmic breathing, drinking tea made from Chinese herbs. Nothing worked for long or without cost.

The good news is that PPI, unlike some other types of insomnia, responds well to treatment with cognitive behavioral therapy for insomnia (CBT-I). (While the name might suggest that it’s similar to conventional talk therapy, CBT-I is mainly focused on helping people modify habits.) For me, sleep restriction therapy, a treatment offered as part of CBT-I, was especially useful. Sleep restriction led to an awareness that my sleep could be reliable if I timed it right.

Equally important, though, for people whose insomnia feels physical (like mine) is finding a way to tamp the physiological arousal down. What works best for me is daily aerobic exercise. Research also suggests that mind-body therapies such as yoga, tai chi, and mindfulness meditation are helpful in this regard.

If this sounds like the type of insomnia you’ve got, check into CBT-I and physical training. There’s nothing to lose and much to gain.

How do you manage your insomnia? Has your strategy worked?

* Lee-Chiong T. Sleep Medicine: Essentials and Review. New York: Oxford University Press; 2008: 84.

An Insomnia Treatment in Brief

Cognitive behavioral therapy for insomnia (CBT-I) is now the gold standard in drug-free treatments for insomnia. The benefits are often long lasting.

Researchers have created and are now testing a briefer form of CBT-I called brief behavioral treatment for insomnia (BBTI). BBTI isn’t widely available yet. But with health insurance companies clamoring for providers to rein in costs, BBTI is the wave of the future.

Brief insomnia treatment involves setting later bedtime at nightCognitive behavioral therapy for insomnia (CBT-I) has become the gold standard in drug-free treatments for insomnia. Between 70 and 80 percent of the people who try it see results: They fall asleep faster and have fewer awakenings. Their sleep quality improves and they feel more rested in the morning. The gains are often long lasting.

But CBT-I is not a quick fix for insomnia. Improvements in sleep occur gradually over 6 to 8 weeks of treatment, and not everyone can or wants to commit to attending weekly therapy sessions for 6 to 8 weeks. Treatment is costly, too.

Also, the number of therapists trained to provide CBT-I is relatively small. In some parts of the United States there are none at all. (Recently a woman from Billings, Montana, wrote to me asking if I could help her find a qualified therapist within driving distance of her home. Using an online locator, I could not find a single treatment provider in all of Montana or any of 4 nearby states!)

With these problems in mind, researchers have created and are now testing a briefer form of CBT-I called brief behavioral treatment for insomnia (BBTI). BBTI isn’t widely available yet. But with health insurance companies clamoring for providers to rein in costs, BBTI is the wave of the future.

How Is BBTI Different from CBT-I?

The therapies are more similar than different. The word cognitive might imply a psychological approach to treating insomnia, yet the key components of CBT-I are behavioral: sleep restriction (reducing time in bed) and stimulus control (keeping wakeful activities outside the bedroom). Sleep restriction and stimulus control form the backbone of both CBT-I and BBTI.

In CBT-I, the therapist also addresses psychological aspects of insomnia: negative beliefs about sleep, for example, or catastrophic thinking about insomnia. Clients are guided through a process designed to help them arrive at a more realistic mindset. (Read my blog on changing negative thoughts to get a sense of what the cognitive component of CBT-I involves.)

As described by researchers at the University of Pittsburgh, BBTI is an overtly behavioral approach to improving sleep. It holds that insomniacs can set our bodies’ sleep systems to right by simply changing habits.

A Shorter Course

BBTI is completed in 4 weeks. Therapist and patient meet twice during the course of treatment. There are also 2 phone conferences lasting 20 minutes or less.

While the treatment itself may be shorter than full-blown CBT-I, progress toward better sleep occurs gradually. But the results of the few studies conducted on brief behavioral treatments for insomnia show, at least in the short term, that the outcomes are similarly positive. University of Pittsburgh researchers also found that BBTI was equally efficacious in improving the sleep of people who were using sleeping pills as those who were not.

Patients also get a workbook. It contains supplementary information about the forces controlling sleep and waking and lays out rules for better sleep and adjustments to make as sleep improves.

BBTI May Have Broader Appeal

Pittsburgh investigators claim this strictly behavioral (as opposed to psychological and behavioral) approach to treating insomnia may be more acceptable in primary care settings–the first place many insomnia sufferers go for help. Healthcare professionals can be more quickly trained to administer BBTI. Treatments that are not “psychological” may be more attractive to people with insomnia, too.

Sleep specialists have been experimenting with briefer behavioral treatments for insomnia for several years. Now as before, the biggest problem seems to be the lack of professionals prepared to help those in need.

Q&A: During CBT, Do I Have to Stop My Sleep Meds?

A long-term user of sleeping pills wrote to Ask The Savvy Insomniac with questions about cognitive-behavioral therapy for insomnia. “Before I go through CBT, will I have to give up my sleeping pills? I’d like to get off them eventually, but every time I think of doing it I freak out.”

Recently I looked into research on insomnia sufferers going through CBT while at the same time tapering off (or reducing reliance on) sleeping pills. What I found was encouraging.

Insomnia sufferers who use sleeping pills can taper off them while undergoing cognitive-behavioral therapyA long-term user of sleeping pills wrote to Ask The Savvy Insomniac with questions about cognitive-behavioral therapy for insomnia.

“Before I go through CBT, will I have to give up my sleeping pills? I’d like to get off them eventually, but every time I think of doing it I freak out.”

Some sleep therapists ask people with insomnia to refrain from using sleeping pills while undergoing CBT, a treatment that promotes sleep-friendly practices and a positive mindset. But this rule may be hard to comply with for people who’ve used sleeping pills for months and years. So hard, in fact, that it may discourage them from trying CBT at all.

Recently I looked into research on insomnia sufferers going through CBT while at the same time tapering off (or reducing reliance on) sleeping pills. What I found was encouraging, so I’ll share it here.

Sleeping Pills? I Love Them!

My aim isn’t to convince people comfortable with their sleep meds to come off them. I use hypnotics occasionally myself, and frankly I get tired of people demonizing them as if they were on par with heroin or crack cocaine.

But some nightly users complain, even when taking sleeping pills, that their sleep isn’t very satisfying. This perception is probably related to the fact that many sleep meds, especially when taken over time, tend to change the nature of sleep. Also, studies linking long-term use of sleeping pills to increasing vulnerability to colds, depression and mortality are not reassuring. It’s easy to see why some long-term users are interested in a path to sleep that feels more “natural.”

Tapering Off Sleep Meds

If you’ve used hypnotics for a long time, it’s not a good idea to go cold turkey, say Lynda Bélanger and colleagues in a paper on hypnotic discontinuation. Stopping abruptly puts you at greater risk for withdrawal symptoms and health complications. Hypnotic drugs should be discontinued gradually, they say–ideally with guidance from a trusted physician.

No guidelines exist showing what the optimal rate of tapering is. Your doctor might propose decreasing the initial dose by 25 percent every week or every other week. But, say these Canadian researchers, the pace of the tapering “may need to be adjusted according to the presence of withdrawal symptoms and anticipatory anxiety; it can also be slowed if the person finds it too difficult to cope or feels unable to meet the reduction goal.”

CBT Assists Tapering and Improves Sleep

In most studies of sleeping pill users undergoing CBT for insomnia, CBT has helped wean them off drugs (or reduce the amount they use) and improved their sleep. Here’s a snapshot of the results:

  • CMAJ, 2003: About 77 percent of those undergoing CBT while on a drug tapering program came off their meds, vs. 38 percent on the drug tapering program only.
  • American Journal of Psychiatry, 2004: About 85 percent of those undergoing CBT while on a drug tapering program came off their meds, vs. 48 percent on the drug tapering program only. CBT groups also reported greater sleep benefits than the group doing the taper alone.
  • BMC Psychiatry, 2008: Added to a drug tapering program, CBT improved sleep quality in hypnotic users even more than it did in people who didn’t use drugs.
  • Sleep Medicine, 2014: In this novel study, adding hypnotic medication to traditional CBT improved subjects’ sleep faster than CBT alone. (By the end of therapy, the sleep of both groups had improved equally).

So if you’d like to try CBT but are anxious about stopping your sleep meds, shop around for a sleep specialist who’s willing to work with you to tailor a program suited to your needs. What’s not to like about the prospect of improving your sleep and at the same time reducing your dependence on drugs?

What concerns do you have about CBT and sleeping pills?

Ease Insomnia by Changing Negative Thoughts

Could simply changing your thoughts about insomnia lead to better sleep? Some sleep therapists claim it works this way. They promote a process called “cognitive restructuring,” typically offered as part of cognitive-behavioral therapy for insomnia. It involves identifying negative thoughts about sleep and then challenging them. The goal is to wind up with thoughts that are more sleep friendly.

Sounds like a tall order, right? I agree. I’ll say up front that I had limited success with it myself. But the experts say this exercise is helpful for many who struggle with chronic insomnia. You may be one.

writing-bedCould simply changing your thoughts about insomnia lead to better sleep? Some sleep therapists claim it works this way. They promote a process called “cognitive restructuring,” typically offered as part of cognitive behavioral therapy for insomnia. It involves identifying negative thoughts about sleep and then challenging them. The goal is to wind up with thoughts that are more sleep friendly.

Sounds like a tall order, right? I agree. I’ll say up front that I had limited success with it myself. But the experts say this exercise is helpful for many who struggle with chronic insomnia. You may be one.

Take a Quiz

Do you find yourself thinking that

  • you must have 8 hours of sleep to function well during the day
  • you’ve lost control of your ability to sleep
  • one bad night wrecks your sleep for the rest of the week.

Thoughts like these create anxiety and make it harder to get to sleep and get back to sleep. These are the thoughts you examine during the process of cognitive restructuring.

Examine Your Negative Thoughts

Take a minute to download a Dysfunctional Thought Record right now (or do it after you finish reading the blog).

When you can’t sleep and you’re worrying about it, write your thoughts and feelings down in the Record. Then answer a series of questions, using the prompts at the bottom of the six columns. The goal of the exercise is to ease your worries about sleep.

Here’s an Example

Let’s say you can’t sleep one night and you start to grow anxious. Now would be a good time to get out the Dysfunctional Thought Record and set to work, asking yourself questions and writing down answers.

Situation. What led to the worry about sleep? “An early morning meeting where I have to make a presentation, the clock striking 12 and me not feeling the least bit sleepy.” What physical sensations do you have? “A racing sensation in my chest and feeling way too hot.”

Automatic Thoughts. What thoughts or images are going through your mind? “I won’t be at my best tomorrow. I’m going to bomb my presentation, and everybody’s going to ignore what I say.” How much do you believe that? “95 percent.”

Emotions. What emotions do you feel, and how intense are they? “Frustration that I can’t sleep! Fear that I’m going to do a poor job on the presentation. It’s pretty intense.”

Distortion. In what ways might your thinking be distorted? Are you catastrophizing? overgeneralizing? jumping to conclusions? “I’m probably catastrophizing.”

Alternative Thoughts. Here’s your chance to do a kind of reality check to see if your negative thinking is realistic or not:

  • Q: So, what are the chances you’re not going to sleep at all tonight?
  • A: Low. I usually get some sleep.
  • Q: How did you sleep last night?
  • A: Pretty well.
  • Q: So how realistic is it to think that a single short night’s sleep is going to incapacitate you tomorrow morning?
  • A: Probably less realistic than I thought.
  • Q: Have you prepared for this presentation, or is it something you’re doing on the fly?
  • A: I’ve been preparing for two weeks.
  • Q: How realistic is it to think that a short night’s sleep is going derail a presentation you’ve worked on for two weeks? . . . And so on.

Outcome. How much do you now believe your automatic thoughts (that you’re going to be wasted tomorrow and give a lousy presentation)? “Maybe it’s down to 40 percent.” What are your emotions now, and are they less intense? “I’m feeling less tense and maybe a little more confident . . .”

You get the idea. Feeling less tense and more confident can only make it easier to get to sleep.

After going through this process a few times, you may be able to dispense with the paper and pencil and simply talk yourself out of catastrophizing in your head. With luck you’ll eventually develop a more positive attitude toward sleep—at least, that’s what you’re aiming for.

Parting Thoughts

I can’t say this exercise has worked well for me. (Other therapies—such as sleep restrictionhave helped.) But the American Academy of Sleep Medicine says cognitive restructuring is beneficial for some insomnia sufferers—and I’d guess they know what they’re talking about.

If you haven’t yet tried cognitive restructuring and are open to experimentation, have a go at it. Then please write in and tell me how things turn out.

Surviving Sleep Restriction

A new study confirms that in the early weeks of treatment, sleep restriction—a part of cognitive behavioral therapy (CBT) for insomnia—really is a cross to bear.

Seems like a no-brainer to me. But in research, quantification is important, and what these UK researchers have done is actually a good thing. (I’ll explain why later on.) Here are five tips for insomnia sufferers planning to undergo treatment.

sleep restriction often leads to mild sleep deprivationA new study confirms that in the early weeks of treatment, sleep restriction—a part of cognitive behavioral therapy (CBT) for insomnia—really is a cross to bear. Not only did the subjects in the study sleep significantly less than usual during the first three weeks of treatment. Sleep restriction also decreased their vigilance and reaction time on tests and made them sleepier in the daytime.

“Oh, please,” you may be thinking, “they had to do a study to figure that out? Wouldn’t sleep restriction by definition lead to sleep loss at night and sleepy days?”

Seems like a no-brainer to me. But in research, quantification is important, and what these UK researchers have done is actually a good thing. (I’ll explain why later on.) Here are five tips for insomnia sufferers planning to undergo treatment. (Sleep restriction has a pretty good track record, so it is worth trying, punishing though it may sound.)

Plan Ahead

  • When you go through treatment, expect to be off your game for at least a few weeks. Try to schedule therapy for a period when you’re not swamped with other commitments.
  • You’re going to have extra time on your hands for a few weeks—maybe even two or three hours a day. Don’t wait until the first night of sleep restriction to decide what you’re going to do with it. Before the short nights begin, come up with some activities that don’t require a lot of energy or concentration, but which are not so passive—watching TV, for example—that you find yourself drifting off. Hobbies, crafts, looking at photos or coffee table books, meal planning, and even light chores are all good choices.

During Treatment

  • This is the hard part: follow all the rules. If during the first week your sleep window is from 12 to 5 a.m., stay away from the bed at all other times. To do otherwise will lessen the effectiveness of the treatment and draw it out. Why suffer longer than necessary?
  • Make judicious use of caffeine if you feel logy or sleepy during the day. While caffeine may interfere with sleep at night when used later in the day, used sparingly in the morning or early afternoon, it can help you function better in the first weeks of treatment. If caffeine doesn’t agree with you, check with your physician about a short-term prescription for modafinil. This drug has been shown to cut down on daytime sleepiness in subjects undergoing sleep restriction.
  • Take special care when driving. Naps are generally off-limits when you’re going through CBT for insomnia, but drowsiness behind the wheel can be lethal. If you start to feel sleepy while driving, pull off the road and take a quick nap, or drink a cup of coffee.

The Benefits

The point of the pain associated with sleep restriction is to wind up with some gain: ease in falling asleep, fewer wake-ups, and sounder, more restorative sleep.

As for the benefits of the new study, it suggests that the current method for determining how much to restrict person’s sleep—based on sleep diaries—may be inadequate in some cases. Patients who report sleeping very little may be found in sleep studies to sleep more than they realize. When such a disparity exists, say the researchers, patients should start sleep restriction with a larger sleep window to avoid excessive daytime sleepiness.