CHAPTER 14
CBT TECHNIQUES FOR DEALING
WITH INSOMNIA
We will go over a comprehensive tutorial of the behavioral components of CBT as related to insomnia: good sleep hygiene, stimulus control therapy, and sleep restriction therapy. Your baseline self-assessment and sleep logs will help you decide what changes might be necessary to increase your chances of getting deep, solid, restorative sleep. You will be given the rationale for each strategy to help you think about your motivation to make changes. Many of these strategies may be familiar to you. Often, the most effective sleep interventions don’t consist of one simple change like a sleeping pill, the right sound machine, or the perfect pillow. The most effective interventions are typically ones that address the whole sleep system: the mind, the body, and the environment, as well as thoughts, emotions, and behaviors. Successful interventions typically involve making a series of changes in your sleep behaviors.
In general, hygiene is about daily practices that keep us healthy and prevent disease. Personal hygiene includes all the basics—bathing, washing our hair, and washing our hands. In the same vein, sleep hygiene is about staying healthy by building daily practices that increase the probability that we will get good quality sleep. However, it is easy to develop habits that are enjoyable and feel restful but do not support long-term restorative sleep. This makes sense—it feels good to curl up in bed and watch a movie when you are fatigued or take an afternoon nap when you are sleep deprived. But these types of behaviors may be perpetuating and exacerbating insomnia. In the following sections, I’ll discuss some alternatives that tend to promote and support healthy sleep.
Going to bed and getting up at about the same time every day, including on the weekends, is a habit that will support your body’s internal clock via external cues. This is discussed more in the section on stimulus control therapy (see “The Pavlov Connection: Stimulus Control Therapy” ). This is an important part of improving your sleep hygiene.
Napping during the day reduces our sleep drive, and you may want to try and give them up altogether until you reach your sleep goals. If you do need to nap, try to keep it to 20 to 30 minutes and avoid early evening naps.
It’s important that you have checked the following things in your sleep environment:
What substances we ingest can have a huge impact on the quality and quantity of our sleep. The effects can last much longer than we realize:
CAFFEINE: works by blocking the effects of adenosine, a chemical that builds up in the body over the course of the day when we are awake. Adenosine fuels the sleep drive, and once its concentration peaks, you begin to feel very sleepy—unless, of course, caffeine is standing in the way. Caffeine has a half-life of about five to seven hours, which means that even seven hours after your last cup of coffee, you may still have up to 50 percent of that caffeine in your system. Sensitivity to caffeine and its effects varies, but if you think caffeine is a contributing factor to your insomnia, it is best to stop ingesting it as early in the day as possible—ideally before noon or even earlier. Also, remember that caffeine not only exists in coffee, soda, and some teas but also some energy drinks, medicines (including some pain relievers and decongestants), and chocolate. Decaffeinated coffee contains up to 30 percent of the caffeine in a regular cup of coffee.
NICOTINE: can cause fragmented, lighter sleep even hours after smoking. Regular smokers may also wake earlier than they want to due to nicotine withdrawal. If you smoke, quitting is one of the best things you can do for your health.
ALCOHOL: may appear to help you fall asleep, but evidence shows that it reduces the amount of deep sleep we experience and causes sleep to be more fitful throughout the night. Skipping the nightcap is helpful, avoiding alcohol for at least three hours before bed is even better, and for some people, not drinking alcohol at all is the best choice for sleep.
MEDICATIONS: can also impact your ability to obtain restorative sleep for many reasons. Discuss your medications with your physician to see if they may be contributing to insomnia.
Some people believe that the relaxing effects of alcohol help them sleep more soundly. Sleep researcher and neuroscientist Matthew Walker is an expert on why the opposite is true. In Why We Sleep , he explains that alcohol is a central nervous system depressant and works by sedating the brain. The prefrontal cortex of the frontal lobe is the first area impacted by alcohol. This is the part of the brain responsible for restraint and controlling our impulses, so when it is sedated by alcohol, we experience the initial feelings of well-being and letting loose. Over the course of an evening of drinking, the impact of alcohol on the brain causes us to feel more tired, but, as Walker states, alcohol-induced sleep is not natural sleep, as evidenced by altered electrical brainwave activity. Alcohol disrupts the structure of our sleep and reduces the amount of time we can achieve both REM and slow-wave deep sleep. Even moderate-to-light drinking can cause more arousals during the night—awakenings we may not be aware of. Finally, alcohol’s relaxing effects can loosen muscles, including those of your airway, which can increase snoring and is especially concerning for those individuals with sleep apnea.
Melatonin is a naturally occurring hormone in the brain that promotes sleep. Light, including both sunlight and artificial light, suppresses the release of melatonin, causing us to feel more awake. Bright light early in the morning is a helpful way to wake up and shake off sleep. It is helpful to reduce light exposure one hour before bedtime, including turning off all screens and dimming the lights, so that melatonin can be released.
There is a reciprocal relationship between physical activity and sleep. Regular daily exercise is linked with deeper, longer, better quality sleep, and getting a good night’s sleep is linked to more physical energy and exertion the next day. Exercise alone has been shown to have strong positive effects on mental health (such as reduced depression and anxiety). Building this cyclical relationship can lead to a multitude of mental and physical health benefits. The timing of exercise is also important, however, as physical exertion too close to bedtime can disrupt the body’s ability to initiate sleep. Aim to do your workout at least two to three hours before bedtime.
Diets heavy in carbohydrates, especially sugar, are associated with less deep sleep and more frequent awakenings, so monitoring sugar intake and lowering your intake if it is high is a good idea. You can also time your last meal so that it promotes restorative sleep. It’s better to avoid heavy meals close to bedtime and aim to feel neither too hungry nor too full before bed. If you are in the habit of snacking right before bed, you may want to keep the snack on the smaller side and avoid things like soda, candy, cookies, chocolate, ice cream, or other high-sugar foods.
Practicing a calming bedtime routine every night helps your body and mind unwind. Your bedtime routine can include reading, meditating, or any activity that feels calming, settling, and pleasant. A warm bath can also be especially helpful. After getting out of the bath, our core body temperature tends to cool quickly, and a decrease in core temperature enables the body to initiate sleep.