By Elisha Carcieri, Ph.D.
“A ruffled mind makes a restless pillow.” Charlotte Bronte
In our self-obsessed culture, monitoring and tracking heartbeat, steps, exercise, food intake, and sleep is commonplace. My sister has recently been tracking her sleep using an app on her smartphone, and she encouraged me to do it too. My first response was, “Why? I know I’m sleep deprived. I don’t need an app to tell me that.” I was still nursing my baby once a night at the time and I was pretty positive this was negatively impacting my sleep and my ability to function in general. Skeptical, I downloaded the app and started it each night before bed for about a week. The application’s primary measure of sleep quality is called ‘sleep efficiency,’ which is the amount of time you are asleep divided by the amount of time you are in bed, and is represented as a percentage. This is the same measure of progress I use with clients in cognitive-behavioral therapy for insomnia (CBT-I). Typically, sleep efficiency of 85% or higher is considered “normal,” “healthy,” “good” sleep. For example, if you are in bed for 8 hours, asleep for 7.5 of those hours, with 20 minutes to fall asleep and two episodes of waking for 5 minutes each, your sleep efficiency is 94%.
The app uses the microphone on your smart phone to measure whether you are awake or asleep based on movement. Years ago, when I worked as a student clinician at a sleep and pulmonary disorder clinic, we used actigraphy watches which then had to be downloaded, interpreted by hand, and then compared with self-report data. Amazing what smart phones can do!
I was somewhat surprised at what the app told me. Many of the nights I was sure my sleep was poor, “I didn’t sleep a wink last night,” the app indicated that, while I was awake for some of the time (feeding my baby), I was out like a light during the time I was in bed. A user-friendly graph depicted the movement associated with my sleep, and decent average sleep efficiency. I learned from a week of monitoring that I should prioritize getting to bed earlier, because when I am in bed, I’m sleeping. While I am not suffering from insomnia, the little experiment reminded me of the benefits of brief self-monitoring, and inspired me to share some information about insomnia and its treatment.
What is insomnia, anyway?
Most people have bouts of insomnia at some point in their lives, usually in response to a stressful event. These short episodes of sleeplessness usually resolve and don’t require treatment. Chronic insomnia last for months or years and can be characterized by:
- Difficulty falling asleep
- Difficulty staying asleep
- Waking up too early
- Poor quality sleep
Consequences of insomnia include fatigue, sleepiness, difficulty with thinking (attention, concentration, memory), irritability, headaches, poor work performance, and persistent worry about sleep.
It is thought that insomnia develops as a result of three factors: predisposing factors, precipitating factors, and perpetuating factors. Predisposing factors are risk factors for developing insomnia, such as a highly sensitive biological sleep system or a tendency toward high arousal. Precipitating events are usually stressful events that result in an initial loss of sleep; for example, loss of a loved one, a stressful move, a new job, etc. Most people recover from this initial sleep loss once the stressor resolves. But the perpetuating factors play one of the biggest roles in the development and maintenance of insomnia. Some people become highly focused on their sleep difficulty, which results in heightened anxiety, maladaptive behavioral responses (going to bed early, staying in bed late, avoiding evening activities for fear that it may interfere with sleep, developing sleep rituals, or “crutches”), and unhelpful thoughts, attitudes, and beliefs about the sleep problem. Some examples of these common dysfunctional beliefs are:
“I need 8 hours of sleep to feel refreshed and function well during the day.”
“When I sleep poorly on one night, I know that it will disturb my sleep schedule for the whole week.”
“When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.”
“Medication is probably the only solution to sleeplessness.”
These beliefs tend to perpetuate insomnia by further increasing worry and arousal, focusing attention on negative consequences of lost sleep, and decreasing belief in your ability to control your sleep problem. These patterns of thinking, in addition to the well-intentioned but detrimental behavioral responses to sleep loss are the critical targets of CBT for insomnia.
How is insomnia treated with CBT?
Many people believe that medication is the only answer to chronic insomnia. However, CBT for insomnia (CBT-I) is safe, brief (usually 4-5 sessions), has lasting effects, and is well researched. CBT-I is composed of education about sleep, stimulus control strategies, sleep restriction, relaxation training, and “sleep hygiene.”
Stimulus control strategies address the issue of the bed and sleeping environment becoming associated with wakefulness, rather than sleep. In a nutshell, the recommendations go something like this:
- Go to bed only when sleepy (not just fatigued or tired)
- Use the bed and bedroom only for sleep (and sex)
- If unable to sleep, get out of bed and return to bed only when sleepy
- Wake up at the same time every day regardless of how much you slept
- Do not nap
Simply put, implementing stimulus control strategies is not fun. Getting out of bed when not sleeping is annoying and takes work. Also, many people with insomnia have the unfounded belief that if they just stay in bed and “rest,” they will increase their likelihood of falling asleep and will at least get some R&R. In reality, more time spent in bed awake will only perpetuate the insomnia, and rest is not equal to sleep.
Occasionally, a strategy called sleep restriction is used in which the amount of time in bed is restricted to the amount of sleep a person typically needs to feel rested. This process can also be unpleasant as it results in an initial loss of additional sleep. However, after a few days, most people begin to see results.
Relaxation training can help to address the increased anxiety and arousal associated with insomnia and the process of sleep. Learning breathing and muscle relation techniques such as progressive muscle relaxation can be important targets for the management of insomnia. If bothersome thoughts and worries are a major component of insomnia (which is often the case for those who have difficulty falling asleep), taking time out of the day to focus on worries and write them down can be helpful.
Sleep hygiene recommendations are a beneficial add-on to the treatment of insomnia (but are not usually sufficient treatment) and are applicable to most “normal” sleepers. The following are some of the guidelines I’ve found to be the most powerful:
- Wake up at the same time each day regardless of bedtime – This is part of the stimulus control instructions as well. Bedtime can be more difficult to keep consistent.
- Avoid naps – Especially in the afternoon, naps reduce your sleep drive and may make it more difficult to get to sleep at bedtime.
- Get regular, daily exercise – …but not right before bedtime (this can delay sleep onset).
- Don’t watch the clock!!! – Checking the clock during a normal, middle-of the night waking can trigger many of the negative cognitions associated with insomnia and is likely to promote wakefulness.
- Keep a quiet and comfortable sleeping space
- Establish a pre-sleep routine and follow it nightly (e.g. wash your face, brush your teeth, change into pajamas, read for pleasure)
- Avoid going to bed hungry
- Avoid coffee, alcohol, and nicotine – especially in the afternoon and evening.
The use of electronic devices around and up to bedtime and in bed is a problem that is becoming more and more ubiquitous and is associated with poor sleep outcomes. Using a cell phone, tablet, computer, etc so close to bedtime can be problematic for a couple of reasons, listed below:
- Blue light exposure – Smart phones and other devices emit light that has the potential to disrupt the sleep cycle and the brain’s “understanding” that it’s time for sleep.
- Alertness/stimulation – Engaging with your device in the bedroom environment, especially in bed, serves to associate bed and the bedroom with alertness, rather than sleep.
- Worry – Checking email right before bedtime or in the middle of the night can initiate worry and anxious thoughts about the following day, tasks that need to be done, etc.
Remember, if you do not have a sleep problem and “problematic” sleep hygiene-related behaviors are not affecting your sleep in a negative way, don’t worry about it! But these behaviors can be important aspects to consider for those who are suffering from a long-term sleep problem.
There are good self-help resources for insomnia both online and in book form. The Centre for Clinical Interventions (CCI) has some solid information sheets, and the book Quiet Your Mind and Get to Sleep is recommended. It can sometimes be difficult to find a CBT-I provider, but there is a directory of member providers on the Society of Behavioral Sleep Foundation website: www.behavioralsleep.org.
Carney, C., & Manber, R. (2009). Quiet Your Mind and Get to Sleep. New Harbinger Publications.
Morin CM; Vallières A; Ivers H. Dysfunctional Beliefs and Attitudes about Sleep (DBAS): Validation of a Brief Version (DBAS-16). SLEEP 2007;30(11):1547-1554.
Spielman AJ, Caruso L, Glovinsky P. A behavioral perspective on insomnia. Psych Clin N Am 1987; 10: 541±553.