Struggling to Sleep? Skip the Doctor

Good news for bad sleepers. A new meta analysis challenges the link between insomnia and an early death. Authors found no difference in the odds of mortality between people with symptoms of insomnia compared people without symptoms.

Not only should this news make insomniacs feel better, but sleep better too. For many of us, anxiety about getting to sleep compounds the problem. Our beds become torture chambers as we learn to associate them with lying awake worrying about the fact that we can’t get to sleep.

Sleeping pills seem like an easy answer. Until you learn they’re associated with fatal overdoses, falls, car crashes, and early death. And they pretty much all become less effective the more we use them. Some also turn to over the counter sleep aids to get a good night sleep. These can seem like a safer answer, but many leave you groggy the next day.

Cognitive Behavioral Therapy for Insomnia (CBT-I) presents a safer, more effective alternative. It’s a type of therapy that works on improving your attitudes, beliefs, and habits around sleep. And CBT-I gets more effective over time with fewer side effects.

In fact, the American College of Physicians (ACP), recommends doctors prescribe CBT-I before pills, or any other treatment, for chronic insomnia disorder. And Consumer Reports has stopped recommending pills for insomnia and now recommends CBT as a first-line of treatment.

Despite recommendations from the ACP, for some reason doctors are still prescribing benzodiazepines, sedatives, and hypnotics for sleep before CBT-I. So if you suffer from insomnia, should you even see a doctor? Or should you go straight for CBT-I?

Decide whether CBT-I is for you

Before deciding whether to try CBT-I, make sure that you’ve got insomnia. Doctors usually diagnose insomnia with a questionnaire and not an overnight sleep study. Here are some questions to ask yourself adapted from the DSM-5 definition of Insomnia Disorder:

  • Do I often not get enough sleep?

  • Do I often have trouble falling asleep, staying asleep, and/or waking up too early in the morning?

  • Are my sleep problems causing distress and/or some sort of problem at work, with others, etc.?

  • Are my sleep problems occuring at least three nights per week over at least three months?

  • Do my sleep problem persist even when I have adequate opportunity for sleep?

  • Are my sleep problems not:

    • Better explained by another sleep disorder?

    • Caused by the effects of a substance?

    • Adequately explained by coexisting mental disorders or medical conditions?

Even if you are fairly confident you have insomnia, you still might want to rule out another sleep problem that you should address first. Only 5-10% of people with chronic sleep deprivation have uncomplicated insomnia. Most are also struggling with at least one other of the more than 70 sleeping disorders or another sleep-disturbing ailment like bipolar disorder or substance abuse disorders. Sleep Apnea, Restless Legs Syndrome, and Narcolepsy are the next most prevalent sleep disorders, and CBT-I doesn’t really work on them.

If you have insomnia and don’t have another sleep disorder that you should fix first, then it’s time to ask yourself some hard questions before determining whether CBT-I is right for you.

Here’s what to ask yourself:

Am I committed?

CBT-I is not a quick fix. It requires significant emotional work and lifestyle changes to be effective. Your sleep might actually have to get worse before it gets better. You need significant motivation, a belief that it will work, and follow-through to see benefit from CBT-I.

In addition, some people associate therapy with a sympathetic ear and constant reassurance. But CBT-I is not that.

Am I open to new facts?

Critics of CBT-I correctly note that many (most) people hold certain beliefs regardless of the facts, and well dismiss out of hand new information that contradicts those beliefs. On these topics, their response is “My mind is made up; don't confuse me with the facts." Terms psychologists use for these beliefs include theology, positive value blocks, and family myths.

The more extra-factual beliefs you hold, and the more impervious your beliefs are to facts, the less effective CBT-I will be for you.

CBT-I works best for people who tend to be skeptical, empirically minded, and open-minded.

Five CBT-I rules to know

While you’ll get the most out of CBT-I in collaboration with a trained therapist, there are steps you can take that can provide some of the benefits of CBT-I today. Try these steps in any order, and try different steps concurrently. “The way my therapist explained it to me was that each ‘rule’ on its own may or may not make a difference,” one reddit user explained. “It is the cumulative and repetitive nature that makes CBTI effective. Going to sleep at the same time every night might only help 5%, and maybe another 5% for no napping. But if you follow all of the new ‘rules’ or behaviours that could make for a 30% or 40% better sleep.”

Rule 1: Tire yourself out

Using your energy stores up during your waking hours builds up what researchers call "sleep drive."

"The more you're awake during the day, the more active you are, the more sleep drive you're going to have,” said Kerry Sopoci, a psychologist at St. Luke's outpatient mental health services.

During the day you want to stand and walk as much as possible and sit and lay down as little as possible. And don’t neglect the brain, which uses most of your body’s glucose. The more difficult the task the more tired your brain will be. Try a crossword or Sudoku puzzle or learn a new skill or language.

Napping during the day can decrease your nighttime sleep quality by killing your sleep drive. “For someone with insomnia, napping is completely out of the question,” said Dr. Colleen Carney, Associate Professor and Director, Ryerson University. “They don’t have enough of that drive for deep sleep built up, and so when they take a nap and clear it that’s going to be a lot more devastating.”


Rule 2: Keep to a schedule

Your body has an internal clock which tells your brain and body when to go to sleep and when to wake up. Your circadian rhythm determines when, for example, your brain starts to release the sleep-inducing hormone melatonin and when to have it taper off when it’s time to wake up.

People with insomnia often have off-kilter circadian rhythms. There are tons of ways to disrupt your circadian rhythm, including changing your sleep times due to travel or shift work or just partying. When you go to bed at 2:15 a.m. on a Saturday and 10:15 the next night you’re crossing four time zones in the space of a day in terms of impact to your circadian rhythms.

To reset your circadian rhythm around sleep, Sopoci recommends going to bed within a half hour of the same time every night. And always wake up at the same time, even on weekends.

Rule 3: Stop stimulating yourself

Many insomniacs experience anxiety while trying to get to sleep. What starts as frustration “Why can’t I get to sleep?” turns into fear “I’m going to feel terrible tomorrow.” This pattern leads to more frustration and an anxiety spiral with racing thoughts and physiological arousal that makes sleep impossible.

When this happens over time, the brain starts connecting bed with anxiety, and merely thinking about getting into bed can cause anticipatory anxiety. Stimulus Control Therapy (SCT) works by breaking the connection between bedtime and anxiety and is especially helpful for getting to sleep more quickly.

Start doing things you will later associate with good sleep. These activities should be first and foremost relaxing, and ideally not involve screens. Reading a good-but-unexciting book or magazine or taking a hot bath or doing a crossword or Sudoku puzzle could work. Avoid anything exciting or stressful within an hour of bed, such as discussing something fraught with your partner or watching the news.

Rule 4: Only sleep and have sex in your bed

CBT-I is all about making new positive mental associations and breaking old bad ones. If your bed is associated in your mind with sleep, you’ll get to sleep faster after getting into bed. If your  bed is mentally associated with reading, watching tv, scrolling through Instagram, etc. then when you get into bed your mind won’t be primed for sleep.

Only sleep and have sex in your bed. Virginia Runko, PhD, CBSM Behavioral Sleep Medicine Specialist recommends that you never read, watch TV, eat, or worry in bed. And don’t lie in bed, stare at the ceiling, and wonder how long you’ve been in bed.

Sopoci suggests getting out of bed if you can’t fall asleep within about 15-20 minutes. Make a "cozy nest" for yourself in another room and do something relaxing until you're sleepy. Avoid exercising, eating, smoking, or taking warm showers or baths when you’re out of bed.

Rule 5: Argue with yourself

Negative thoughts about what will happen to you if you don’t sleep enough only add to your anxiety and make it harder to get to sleep. Some of these thoughts are based in reality. Others aren’t. One trick for getting insomnia under control is to challenge your unhelpful, false beliefs.

Before accepting that not getting to sleep right away will kill your performance at work tomorrow, cause you to miss out on pay and promotions, get fired, etc. evaluate the evidence. Runko says it can be helpful to keep a diary of nights of poor sleep and days of poor work performance. Then you’ll be able to calculate the likelihood that a night of poor sleep will lead to poor work performance.

Let’s say you’ve had insomnia for the past five years. You have it about three times per week. That gives you 780 “bad” nights total. How many days of truly poor work performance have you had in the past 5 years? If you’ve had 100, the formula would be 100/780 = 13%. Which means on any given night of sleeplessness you have a 13% chance of performing poorly at work due to fatigue.

Other benefits of CBT-I

In addition to helping with insomnia, CBT-I may also reduce chronic pain. One pilot study showed that eight weeks of CBT-I may slow or even reverse cortical gray matter atrophy of patients with insomnia and fibromyalgia. A 2018 meta-analysis showed that patients with chronic migraine receiving CBT-I got headaches 6.2 fewer days per month. A study of inmates who received CBT-I showed 73% saw reduced insomnia along with their anxiety and depressive symptoms within a month.

Going forward

If you want help, but going to therapy sounds expensive and time-consuming, never fear. You may be able to get the same benefits from an app. NPR points to studies showing that patients with insomnia see improvements through CBT-I apps. One recent study found that participants who used Sleepio reported fewer insomnia symptoms and increased overall wellbeing. But keep in mind that the lead study author, Colin Espie, is a co-founder of Sleepio developer Big Health.

There’s also CBT-I Coach, a free app built for the Veterans Administration in a collaboration with the Stanford sleep lab. Dr. Holly O’Reilly, head of the armed services’ Deployment Psychology program, called the app a “great supportive tool” and encourages clinicians to use it.

If you do use a therapist, choose one with plenty of experience. “Research consistently shows that the experience of the therapist is related to the effectiveness of the treatment even more so than the type of therapy,” writes Clinical Psychologist Monica A. Frank. Here are some other things to know before starting therapy.

If you’re confident that you’re suffering from uncomplicated insomnia, you can probably skip your general practitioner and go straight to trying CBT-I, either with these tips or with an app or the old-fashioned way.

For more content delivered weekly to your inbox, subscribe to our newsletter here!

Read next: Cognitive Based Therapy for Insomnia

Cathy Reisenwitz