Sleep Onset Insomnia: 8 Do’s and Don’ts for Better Sleep

Sleep-onset insomnia—trouble falling asleep at the beginning of the night—has been one of the biggest challenges in my life. By now, having gone through insomnia therapy and spent decades observing how changes in behavior and the environment affect my sleep, I know what I need to do—and what not to do—to get the best night’s sleep I can.

If you’ve got sleep-onset insomnia, here are 8 do’s and don’ts that may help to regularize your sleep.

Sleep-Onset Insomnia can be minimized by changing habitsSleep onset insomnia—trouble falling asleep at the beginning of the night—has been one of the biggest challenges in my life. By now, having gone through insomnia therapy and spent decades observing how changes in behavior and the environment affect my sleep, I know what I need to do—and what not to do—to get the best night’s sleep I can.

If you’ve got sleep onset insomnia, here are 8 do’s and don’ts that may help to regularize your sleep.

Do These Things to Fall Asleep Faster:

  • Get up at the same time every day, including on weekends. This one of the hardest—but most important—habits to adopt, and frankly it’s one I struggle with to this day. Especially after a late night or two, it’s hard to stay the course and get up at 6 a.m. But if I don’t stick pretty rigidly to what I’ve decided is the best rise time for me, if I allow myself more than a little flexibility, my sleep goes off the rails. Making up lost sleep at the beginning of the night, rather than at the end, is by far the easier course.
  • Sign off all devices with screens at least an hour before you usually go to bed—and that includes eReaders and smartphones. If you’re a news junkie like me, watching out for headlines so you can read new stories the minute they come out, this can feel like major deprivation. Yet the light emitted by these screens has been shown time and again to interfere with melatonin secretion, delaying sleep onset—exactly what none of us wants.
  • Get regular exercise and eat regular meals. Aerobic exercise late in the afternoon works best for me, and adhering to my daily workout routine has become so ingrained that when I miss my exercise fix my body doesn’t feel like winding down at night. Regular exercise and regular meals—in fact, regularity in almost all activities because it helps regularize internal circadian rhythms—will likely help you sleep better.
  • Pay attention to the temperature of your bedroom and make adjustments early if necessary. The ideal temperature for sleep is a few degrees lower than what you’re comfortable with during the daytime. So, particularly as research suggests that people with insomnia may have trouble down-regulating internal body temperature, get the window fan going well before bedtime so that by the time it comes you’re not too hot to sleep.

Don’t Do Things That Perpetuate Trouble Falling Asleep:

  • Don’t watch the clock at night. Nothing triggers my anxiety about sleep as much as glancing at the clock at, say, 1 a.m. and realizing I’m not sleepy yet. This is one association—between the clock registering time late at night and trouble sleeping—that I’ve never gotten rid of despite my improved sleep. Turning my clocks toward the wall after about 10 p.m. solves the problem, and it might help you sleep better, too.
  • Don’t jump in bed the minute you get home even if you get home late. For me, heading to bed right away gives my brain permission to trot out all the unfinished business of the day and chew on it while I toss and turn in bed. If you get home late, put on your pajamas, brush your teeth and so forth. But then take 20 or 30 minutes to unwind—read a book or listen to music—before you hit the sack.
  • Don’t stay in bed if, after 15 or 20 minutes, you find you can’t sleep. For me, remaining in bed almost always results in continuing wakefulness, exactly the opposite of what I want. Instead, get up and do some quiet, low-stimulation activity—page through catalogs, make a travel list, cull your bookshelves—until you feel sleepy. Then head back to bed.
  • Don’t beat yourself up—when you’ve adopted all the sleep-friendly habits you possibly can—if you’re still feeling wakeful when your normal bedtime comes around. There’s a genetic component to insomnia, and there are genetic factors that determine sleep onset latency. One day, it may be possible to alter gene expression and so improve sleep. For now, acceptance of the occasional bad night is something it pays all of us to learn to do.

If sleep onset insomnia is your problem, what behaviors seem to make it worse and which behaviors, if any, seem to help?

The To-Do List: A Sleep-Friendly Bedtime Activity?

If you’ve got insomnia, you’ve probably heard of “worry lists.” Sleep doctors for years have been urging insomniacs to write our worries down before going to bed, claiming this will alleviate anxiety and sleep will come more easily.

Really? Write about looming deadlines and all the upcoming functions I have to prepare for before I go to bed? That’s sure to send my anxiety through the roof! (not to mention keeping me up for hours).

But the idea may not be as counterproductive as it sounds.

Insomnia because you're worried about tomorrow? Make a to-do-list in the eveningIf you’ve got insomnia, you’ve probably heard of “worry lists.” Sleep doctors for years have been urging insomniacs to write our worries down before going to bed, claiming this will relieve anxiety and sleep will come more easily.

Really? Write about looming deadlines and all the upcoming functions I have to prepare for before I go to bed? That’s sure to send my anxiety through the roof! (not to mention keeping me up for hours).

But the idea may not be as counterproductive as it sounds, a new study suggests.

Nighttime Challenges for Insomniacs

No one likes arguments or bad days at work, but experiences like these can be doubly disruptive for people with insomnia. At night these upsetting events cycle over and over in your head, making it hard—sometimes impossible—to sleep.

Likewise, it can be hard to sleep when you’re looking at challenges ahead. Tests to study for, deadlines to meet, presentations to deliver, events to organize, flights to catch—any unfinished business, especially lots of it, can keep you wakeful long into the night.

Could making a to-do list before going to bed relieve anxiety about tasks ahead and enable sleep to come more quickly? The jury is still out concerning insomnia sufferers per se. But a new study of healthy, normal sleepers conducted at Baylor University and Emory University Medical School suggests it might be helpful.

Polysomnography and a Pencil-and-Paper Task

This study—the first part of a larger study—was simple in design. Participants were recruited on campus and screened for various disorders, including sleep disorders. Sixty participants aged 18–30 were chosen (three were later disqualified). They were randomly divided into two groups.

The evening of the study, participants in both groups went to a sleep lab, where technicians prepared them to undergo an overnight sleep study, wiring them up for polysomnography.

After that, participants in one group were given a sheet of paper and told to spend the next five minutes writing down everything they had to do the next day and in the next few days. Participants in the other group were given a sheet of paper and told to spend five minutes writing down everything they’d accomplished that day and in the past few days.

The sheets were then collected. Lights went out at 10:30 p.m., and participants’ cerebral activity was monitored through the night.

To-Do List More Helpful Than List of Accomplishments

The results were all significant:

  • Participants who made a to-do list at bedtime fell asleep faster than those who wrote about completed tasks. (On average, the to-do list makers fell asleep in about 16 minutes while the others who listed accomplishments fell asleep in about 25 minutes.)
  • Among participants who made the to-do list, the greater the number of items on their list, the faster they fell asleep.

So making a detailed to-do list might actually be a good activity to add to your wind-down routine at night.

Results in Perspective

Other studies suggest these findings aren’t as unusual as they may seem. Researchers studying adults in highly stressful situations, such as having a son or daughter diagnosed with cancer, found that the more specifically parents could map out concrete steps they were going to take to contend with the child’s problem, the less stressed out they felt. Another study showed that first-time pregnant women who could simulate in detail how their labor would go were less worried than women that were less successful in simulating labor.

But back to doctors’ advice about worry lists: It seems to me there’s a difference between a worry list and a to-do list. The one sounds problem focused while the other is focused on solutions—which may make a difference in their effects.

At any rate, if you have insomnia and at night your mind is constantly drifting toward tomorrow and all the things you have to do, try writing down the steps you’re going to take to make things happen before you get in bed. It might relieve your anxiety and slow your busy brain just enough to hasten sleep.

Are Insomniacs Unreliable at Assessing Sleep?

You’ve heard it said before: insomniacs typically overestimate how long it takes to fall asleep and underestimate the amount of sleep we get. Time and again, sleep experts ask us to estimate our sleep time. Then they conduct overnight sleep studies with polysomnography (PSG) and find, on average, that we fall asleep faster and sleep longer than we think.

Are insomniacs just unreliable when it comes to estimating time? What else might account for this discrepancy? Should we be reassured that we’re probably sleeping more than we think?

Insomnia sufferers underestimate how long they sleepYou’ve heard it said before: insomniacs typically overestimate how long it takes to fall asleep and underestimate the amount of sleep we get. Time and again, sleep experts ask us to estimate our sleep time. Then they conduct overnight sleep studies with polysomnography (PSG) and find, on average, that we fall asleep faster and sleep longer than we think.

Are insomniacs just unreliable when it comes to estimating time? What else might account for this discrepancy? Should we be reassured that we’re probably sleeping more than we think?

Time Estimates in the Daytime

Normal sleepers are fairly accurate when it comes to assessing their sleep. Their estimates of sleep onset latency (the time it takes to fall asleep) and total sleep time are in sync with the results of PSG.

Overall normal sleepers are also quite accurate at estimating time during the day. They can reliably estimate various time intervals (5 seconds, 35 seconds, 19 minutes) and keep a steady beat in a finger tapping task.

So can insomnia sufferers. Research suggests that overall, we, too, are quite accurate at estimating time intervals and keeping a steady beat during the daytime. It’s not the perception of time per se that gets distorted in insomnia. Insomniacs’ unreliability in estimating the passage of time occurs only at the night.

“It Takes Me Over an Hour to Fall Asleep”

Most studies show that people with chronic insomnia tend to overestimate sleep onset latency. For example, after having a sleep study, you’re told you drifted off 25 minutes after closing your eyes but you could swear it took you at least twice as long to nod off. How to account for this discrepancy?

One thing to keep in mind is that Stage 1 sleep—the lightest sleep stage, when the faster, unsynchronized brain waves associated with wakefulness are slowing down into more synchronized alpha and theta rhythms—is easy to perceive as wakefulness. In fact, if you’re woken up during Stage 1 sleep, you may feel you were never sleeping at all.

Research has also shown that unlike good sleepers, insomniacs tend to have elevated levels of high-frequency brain activity in the period leading up to sleep. These faster brain waves are associated with pre-sleep cognitive arousal—with thinking, rumination, and worry. They’re also associated with low-level awareness of what’s going on in the environment—a flushing toilet, a flash of lightening, the smell of skunk wafting through the window.

Unsurprisingly, insomniacs have been shown to take twice as long as normal sleepers to descend into deep sleep. So we’re hovering longer in the lighter sleep stages. All these things could help explain why we perceive we’re taking longer to fall asleep than PSG says we are.

“I Don’t Get Much Sleep”

Not all insomniacs are created equal. When it comes to estimating total sleep time, some insomnia sufferers are relatively good at it. (And results of some studies suggest that some insomniacs actually overestimate their total sleep time.) These are the so-called objective insomniacs, whose estimates of sleep time match up pretty well with their assessments by PSG. The diagnosis for this type of insomnia is often psychophysiological insomnia.

People whose sleep studies indicate they’re consistently sleeping less than 5 hours a night are called “short sleepers.” Short sleep is associated with physiological hyperarousal and an elevated risk for related medical disorders, as well as persistent trouble sleeping. Of all the variants of insomnia, short sleep is thought to be the most severe.

All I Get Is 1 or 2 Hours”

Other insomniacs’ perceptions of sleep duration are wildly at odds with assessment by PSG. A person who complains of getting just 1 or 2 hours’ sleep a night and goes in for a sleep study is often found to be sleeping 6, 7, or even 8 hours a night. The diagnosis in this situation is paradoxical insomnia, a disorder affecting about 26 percent of people with chronic insomnia.

Because their sleep duration is normal and their sleep architecture (as assessed by PSG) largely intact, the thinking is that these insomniacs are getting most of the benefits that sound, sufficient sleep affords. This may be reassuring. But the jury’s still out on the underlying mechanisms at play. Multiple irregularities may contribute to the feeling of being awake when most of the brain is asleep.

The Upshot

Should we be relieved to know that most of us are getting at least a little more sleep than we think? It’s not a bad idea. Once I stopped caring about how much I was sleeping, my sleep improved. Whether or not this would be borne out in a sleep study, it feels like I fall asleep faster and sleep longer than I did before.

If you can swallow the idea that in this one place your perceptions might be a tad unreliable (believe me, I know how hard this can be!), you won’t regret it.

Cerêve Sleep Device Approved for Treatment of Insomnia

Would you wear a cap at night if it helped you fall asleep faster?

You may soon have the opportunity: the cap, a medical device for the treatment of insomnia, has received approval from the FDA, clearing the way for it to come to market.

new insomnia treatment approved by FDAWould you wear a cap at night if it helped you fall asleep faster?

You may soon have the opportunity: the cap, a medical device for the treatment of insomnia, has received approval from the FDA, clearing the way for it to come to market.

“We are thrilled that the FDA has cleared the Cerêve Sleep System for treating people with insomnia,” sleep specialist and company founder Eric Nofzinger was quoted as saying in a press release. “The Cerêve System offers a clinically proven and safe alternative to pills, with the potential to help millions of Americans get to sleep fast.”

A Novel Insomnia Therapy

It isn’t just any old cap. This cap, made of soft plastic, comes with a software-controlled bedside device that continuously pumps fluid to a pad that rests against your forehead and cools the brain. You wear it all night.

I found out about the cap and the cooling process—called frontal cerebral thermal transfer—at a conference on sleep and sleep disorders in 2011. My first reaction was disbelief. Really? I said to myself. Now they’re proposing to cure my insomnia by sticking an ice pack on my brain? No way!

Despite my skepticism, I showed up for a poster session where Nofzinger was talking about results of clinical trials conducted on insomniacs who used the device at night. Patients responded positively, he said. “They describe it as sort of like a spa treatment.”

But what did wearing a cooling cap have to do with insomnia? I asked him. What was the relationship between the two?

“Insomniacs have too much metabolic activity in the frontal cortex,” Nofzinger said. “It’s very soothing to be able to settle that brain activity” by cooling the frontal region of the brain. “It’s as if your grandmother put a washcloth on your forehead.”

Something cold against my forehead sounded unappealing, I told him. I can’t sleep when I’m cold.

The temperature can be adjusted within a comfortable range of coolness, was Nofzinger’s response.

Origin of the Concept

Formerly, Nofzinger directed the Sleep Neuroimaging Research Program at the University of Pittsburgh School of Medicine. He and his colleagues studied neural activity in the human brain. What they knew from past studies was that the brains of normal sleepers are largely quiet at night: there’s not much metabolizing of glucose. But in functional brain imaging studies of insomnia patients, the researchers saw something different.

In insomniacs at night, quite a bit of glucose was being metabolized in certain areas of the brain, especially the frontal cortex (the part responsible for thinking, planning, and other executive functions). Excessive activity in the frontal cortex might be a biomarker of the hyperarousal believed to underlie insomnia, and decreasing this activity by gently cooling the frontal lobe might lead to sounder sleep.

Testing the Device

Once the device was created, it had to be tested for safety and efficacy on insomnia patients. The first two studies were small and the main results were as follows:

  • The devices reduced brain metabolism during sleep, especially in the frontal cortex.
  • They also reduced participants’ core body temperature (also favorable to sleep).
  • The cooler the setting, the greater was the benefit.
  • Worn all night at the coolest setting, the devices enabled insomnia patients to get to sleep as quickly and sleep as efficiently as normal sleepers.

A third much larger clinical trial—randomized and placebo controlled—was conducted with funding from the National Institutes of Health. The caps were found to reduce the time it took insomniacs to reach Stage 1 and Stage 2 sleep, effectively helping them fall asleep faster. Regarding safety, Cerêve Sleep System was classified by the FDA as a novel, low-risk device.

Now that the FDA has granted its approval, what remains to be done is to ramp up production and roll out a marketing campaign. These things always take more time than you’d like them to, but as of now Cerêve expects to launch the product in the second half of 2017.

Does this sleeping cap sound like something that might help your sleep? Why or why not?

Q&A: Sleep Efficiently for a Better Night’s Rest

A reader—I’ll call her Chantal—wrote in June with questions about insomnia and sleep restriction. A few weeks ago I heard from her again:

I’m now in week 6 of sleep restriction and I have to say my sleep is getting better. I mostly sleep for 5.5 hours a night. When I started it was 3.

But the last couple of nights, I’ve woken up in the middle of the night and had trouble falling back to sleep. I have no idea why I’m waking up. Do you have any tips for staying asleep?

Insomnia sufferers can improve their sleep by spending less time in bedA reader—I’ll call her Chantal—wrote in June with questions about insomnia and sleep restriction. A few weeks ago I heard from her again:

I’m now in week 6 of sleep restriction and I have to say my sleep is getting better. I mostly sleep for 5.5 hours a night. When I started it was 3.

My sleep window starts between 11 and 12 and ends at 6. I was having trouble staying awake until midnight, and by allowing myself to go to bed at 11 (or soon after that) I can fall asleep faster.

But the last couple of nights, I’ve woken up in the middle of the night and had trouble falling back to sleep. I have no idea why I’m waking up. Do you have any tips for staying asleep?

Chantal’s sleep has improved a lot with sleep restriction therapy. She’s nearly doubled her sleep time, going from 3 to 5.5 hours of sleep a night. But now her sleep is interrupted with wake-ups. If she wants to stay asleep at night, she needs to improve her sleep efficiency. Regardless of whether you’re going through sleep restriction therapy, it’s helpful to understand this concept if you want to improve your sleep.

Why Sleep Restriction?

Sleep restriction therapy is an insomnia treatment that consolidates sleep by first limiting time in bed to the actual amount of time a person is sleeping. (That chunk of time is sometimes called the sleep window.) Most insomnia sufferers experience sleep deprivation in the first week or two. But studies show that fairly soon this leads to deeper, more efficient sleep. In the process you gradually enlarge your sleep window until you’re sleeping efficiently and as much as you can.

Sleep Efficiency—What It Is and Why It Matters

Sleep efficiency refers to the percent of time you’re actually sleeping when you’re lying in bed at night. The sleep of good sleepers is highly efficient (i.e., they’re asleep 90% or 95% of the time they’re in bed). They drop off quickly and sleep soundly through the night.

If you have insomnia, your sleep is probably inefficient, interrupted by patches of wakefulness. You may only be sleeping 70% or 75% of the time you’re in bed.

Restricting time in bed will help you (1) fall asleep faster and (2) cut down on sleeplessness in the middle of the night. In other words, your sleep will become more efficient—and efficient sleep is typically sounder and more refreshing.

Calculating Sleep Efficiency

If you go through sleep restriction therapy, you’ll calculate your sleep efficiency at the end of each week. Here’s how to make the calculation:

  • Sleep Efficiency (SE) equals Total Sleep Time (TST) divided by prescribed Time in Bed (TIB) multiplied by 100.
  • The formula looks simpler using abbreviations and symbols: SE = TST ÷ TIB X 100.

Increased sleep efficiency is good in and of itself. But during sleep restriction, your sleep efficiency is also used to establish your sleep window for the following week:

  • A high sleep efficiency suggests it’s time to enlarge your sleep window.
  • A low sleep efficiency (anything less than 80%) suggests a need to tighten up your sleep window until your sleep is solid again.

Reducing Wake-Ups at Night

Chantal says she’s averaging 5.5 hours of sleep a night but that she’s now having wake-ups. The problem may lie in her variable bedtime (between 11 p.m. and midnight) and the amount of time she’s spending in bed. It’s easy to see if we do the math:

If on most nights she goes to bed at 11 p.m. and gets up at 6 a.m. (for a total of 7 hours in bed), her sleep efficiency may be low: 5.5 ÷ 7 X 100 = 78.6%. Inefficient sleep is characterized by patches of sleeplessness.

In contrast, if on most nights Chantal restricts her time in bed to 6 hours (as would occur if she delayed her bedtime until midnight and got up at 6 a.m., or set her sleep window from 11:30 p.m. to 5:30 a.m.), her sleep efficiency will probably be high: 5.5 ÷ 6 X 100 = 91.7%. She can increase her time in bed by 15 or 20 minutes the following week.

Tightening up her sleep window now may enable Chantal to maintain consolidated sleep as she gradually increases her time in bed.

Bottom Line

If you’re going through sleep restriction, don’t make the mistake of enlarging your sleep window too fast too soon. At the end of each week, calculate your sleep efficiency and adjust your time in bed accordingly. Slow and steady wins this race.

For those who simply want to cut down on middle-of-the-night wake-ups, try spending less time in bed.