Today’s post is essentially the written version of a typical Session 1 of brief cognitive-behavioral therapy for insomnia (CBT-I). This non-medication insomnia treatment is the first-line treatment for insomnia recommended by the American College of Physicians and by the American Academy of Sleep Medicine, which means that this treatment, compared to others such as pharmacotherapy or relaxation training, has the most evidence supporting its efficacy. CBT-I is the treatment I do with my patients. And below is what I almost always deliver during the first treatment session (after a careful assessment that takes into account several sources of data, including medical history, co-occurring medical or psychiatric concerns, life circumstances etc.):
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At any given moment, “sleep drive” and “arousal” are on opposite sides of a see-saw. If sleep drive is stronger, you are likely to fall asleep soon. If arousal is stronger, you are likely to stay awake. When you have insomnia, it feels like arousal is often winning when you don’t want it to. Our goal is to boost your sleep drive and decrease your arousal during the night.
The homeostatic sleep drive is like a balloon you fill up when you’re upright and wakeful. The balloon gets bigger and bigger as you go through your day, and most adults need about 16-18 hours of wakefulness to fill their balloons. At the end of the day (i.e., bed time), you get to cash in the sleep drive that you’ve saved up—the bigger your balloon, the more sleep drive you’ve got, and the more likely you are to fall asleep, stay asleep, and get good quality sleep. However, you are not filling your balloon when you’re in bed, and taking a nap is like letting air out of the balloon during the day. When you sleep in or lay in, you’re also depriving yourself of opportunities to build sleep drive.
Arousal refers to your body and brain’s general level of alertness, which can be influenced by many factors—caffeine, excitement, anxiety, physical/mental stimulation etc. Arousal can also be learned over time. Think of it this way: If every time you go to grandma’s house, you get delicious treats, your body will start to anticipate getting goodies (e.g., getting hungry, salivating) as soon as you enter her house. Similarly, if every night you spend lots of time in bed tossing and turning, worrying, getting frustrated, and being awake, then your body learns to anticipate being wakeful and frustrated as soon as you enter your bedroom. This is called “conditioned arousal.”
How to boost sleep drive
Increasing your sleep drive is the easiest way to get relief from insomnia. The good news: it’s not rocket science! The simple formula is based on the principle that the longer you are upright and active, the more you’re filling up your balloon with sleep drive. Here’s how:
1. Wake up at the same time every day
…regardless of how much sleep you actually got, and get out of bed within a few minutes after your alarm rings.
2. Go to bed when you are sleepy, but not before
Remember that being sleepy is different from being tired. If you do not feel sleepy at this time, wait until you do feel sleepy to get into bed.
3. Avoid daytime napping
…but if you believe that sleepiness compromises your safety, do take a nap.
How to decrease conditioned arousal
There are many ways to decrease arousal. Let’s start with decreasing sleep-related conditioned arousal by re-teaching your brain to associate your bed with sleepiness, rather than with wakefulness (and frustration). Here’s how:
1. If you can’t sleep, stop trying
Get up and do something calming, and return to bed only when you are sleepy again. If you’re wide awake again after getting back into bed, repeat this instruction.
2. Use the bed only for sleep (and sex)
Do not do other wakeful activities, such as watching TV, eating, talking on the phone etc. The most important activity to eliminate from the bed is the activity of “trying to sleep.”
In addition to the above instructions, I also work with patients to prescribe a personalized time in bed window that will maximally reboot their sleep drive. That is, I will give them a standard bed time and rise time for them to follow in the next week or two weeks, during which they will keep a “sleep diary.” The data from the sleep diary, including each night’s time in bed window as well as how much sleep and wakefulness they experienced, will help to determine next week’s time in bed prescription.
One thing patients often ask is: Do I have to strictly follow these rules for the rest of my life? Can I really never sleep in on a weekend, or watch a movie in bed, ever again?
Rest assured! These instructions are not meant to be a forever lifestyle change, at least not at this draconian level. What we’re doing here is “sleep boot camp,” a big reset button for your sleep regulating systems that will restore your body’s natural ability to sleep. Along the way, you’ll also learn to trust your sleep and stop struggling against it. By the end of treatment, usually lasting 4-6 sessions in my clinic, your relationship with sleep should have been restored enough that you can be more relaxed about your sleeping behaviors and more confident in interpreting your body’s signals.
The bottom line is this: If you can’t sleep, stop trying. The act of trying to sleep, like flailing in quicksand, is probably the worst thing you can do in an insomnia moment. Remember that your body knows what it’s doing, and you’ll get the sleep that you need if you would only get out of its way.
And remember—sleep is a friend to be welcomed when she arrives, not a fugitive to be hunted down. If you have a good relationship with this friend, she’ll show up every night and keep you good company. Sometimes, she may arrive later than usual and leave you during the night, and that’s okay. She’ll be back. Be forgiving and enjoy your “me” time until she comes again.