Treating insomnia with CBTI
While I focus most often on anxiety and trauma in my work with clients, insomnia symptoms are often part of the picture. Many individuals who are challenged with anxiety, stress or traumatic memories also have difficulty getting good sleep. For some people it is a challenge to fall asleep, others wake up in the middle of the night and can’t get back to sleep, and some individuals feel that what sleep they do get isn’t very restful at all.
Sometimes insomnia occurs in direct response to a stressful situation like a new job, experiencing the death of a loved one, or some other major life event. Some people experience insomnia for years with little relief. The good news is that there is an evidence-based treatment for insomnia: Cognitive Behavioral Therapy for Insomnia (CBTI). CBTI focuses on behavioral changes you can make to get better sleep.
How does sleep work, exactly?
sleep cycles
It can be helpful to start with understanding the components of sleep. If you have a watch or other device that tracks sleep cycles you may already know about this. Sleep is not a single experience but rather a cycle of phases that we move in and out of throughout the night. In a typical night an individual will cycle through several phases;
light sleep, where it is easy to be awoken
deep sleep, characterized by slower brain and muscle activity, and it can be more difficult to be awoken and
rapid eye movement (REM) sleep, where dreaming occurs.
Sleep cycles last 80-100 minutes with deep sleep cycles happening earlier in the night and REM sleep cycles happening later in the night.
Understanding sleep cycles matters because when we think about insomnia, we aren’t just deficient on sleep, we may be deficient in specific types of sleep depending on our sleep patterns, e.g. decreased deep sleep or decreased REM sleep.
sleep systems
There are three systems that affect sleep. The interplay of these three systems is what promotes wakefulness and sleep. CBTI works with each of these systems to treat insomnia.
circadian system
The circadian system is your internal body clock. It is the system that controls when it is time to go to sleep, how many hours you typically sleep and when it is time to get up. If you’ve experienced jet lag you’re very familiar with the circadian system. Your body wants to go to sleep and wake up at times that are not in sync with local time and it often takes several days for your circadian system to adjust.
sleep drive system
The sleep drive system works like the battery on your phone. You start the day with a fully charged phone and as you go about your day the charge gets used up. Eventually your phone signals that it is time to recharge. The sleep drive system works the same way - it is the system that moves your body toward sleepiness and wakefulness. When you wake up sleep drive is very low. As you expend energy throughout your day sleep drive builds. Later in the evening sleep drive will be strong and your body will signal that it is time for sleep (think of nodding off in front of the TV and feeling like you can’t keep your eyes open).
arousal system
The arousal system allows you to wake up from sleep when it is necessary. If you hear a loud noise you will wake up because your arousal system will override your circadian and sleep drive systems. While it makes sense that this system is necessarily from an evolutionary and survival perspective, the arousal system is often what contributes to insomnia for those who experience anxiety and/or trauma. Anxiety symptoms will often keep individuals awake, even when the circadian system says it is time for sleep and the sleep drive system is high. Anxious thoughts and feelings, as well as as trauma symptoms like flashbacks and nightmares, can prevent you from getting to sleep or staying asleep.
Insomnia defined
Insomnia is defined as difficulty sleeping for a prolonged period. Typically to diagnose insomnia an individual will have been struggling with getting to sleep or staying asleep for longer than three months. Sleep that isn’t restorative can also be considered insomnia.
CBTI is an effective treatment for insomnia, however, there are some caveats. You will want to consult with your physician if you use sleep aids (prescribed or over-the-counter) before starting with CBTI and if there are other possible sleep concerns such as sleep apnea. Issues like sleep apnea, where breathing is obstructed causing the individual to wake up, need to be treated separately from insomnia. Sleep studies are often part of diagnosing other sleep issues, but not generally necessary for insomnia alone.
How CBTI works
sleep logging
An important part of diagnosing insomnia and identifying treatment goals is keeping a sleep log. Typically a log is kept for at least two weeks and captures information about total time asleep, total time in bed, sleep and wake times, as well as other things that might be having an impact in sleep. Pen and paper can be used to log and there are also a number of apps that will log as well.
stimulus control
Once a two-week log is analyzed a therapist may give recommendations for behavioral changes that can help improve sleep. The CBTI term for this is stimulus control. Stimulus control is a set of behaviors that can help to promote better sleep.
For many people who have experienced insomnia, sleep becomes associated with frustration and struggle. Some behaviors can actually make getting good sleep more challenging. Stimulus control is about addressing these behaviors. Examples could include limiting non-sleep activities in bed and only going to bed when you’re sleepy. It can also include having a consistent wake time and refraining from daytime naps.
sleep efficiency training
Based on your sleep log a CBTI therapist may also recommend behaviors to make sleep more efficient. Sleep efficiency can be thought of as sleep that is restful and feels solid. Many individuals challenged with insomnia often find that they wake up often or feel like they aren’t getting restorative sleep. Sleep efficiency training can help to improve the quality of sleep. Typically this is done by using information from sleep logs to adjust sleep and wake times to improve the quality/efficiency of sleep.
arousal system interventions
As mentioned above, we need the arousal system to wake us up or keep us awake when it matters for survival. Unfortunately many people struggle with anxiety that prevents sleep. Arousal system interventions often looks like other anxiety interventions - working with thoughts, feelings and behaviors that can help calm the arousal system and signal that sleep is OK. There are a variety of interventions including relaxation breathing, journaling, and restructuring challenging thoughts.
What about sleep hygiene?
Sleep hygiene is a set of behaviors intended to promote or improve sleep. This could include keeping the bedroom dark, quiet, and cool; avoiding caffeine; and not consuming a large meal right before bedtime. While all of these practices can promote healthy sleep, research has shown that they aren’t sufficient to treat insomnia. While sleep hygiene practices are encouraged, additional CBTI work is typically needed to effectively treat insomnia.
What can you do right now?
Keeping your own log, whether a paper log or using an app, can be helpful for seeing patterns and noting exactly what kind of sleep you’re getting.
There are a variety of behaviors (stimulus control) that can promote better sleep.
Create a space for sleep - designating the bed as a place for sleep (and sex) is an important part of promoting good sleep. Avoid other activities in bed (and preferably the bedroom) including watching TV, working, etc.
Create a regular sleep schedule - this can be challenging for some people but sticking to a regular sleep schedule is an important aspect of promoting good sleep. While having a regular bedtime is helpful, having a consistent wake up time if even more important. Consistent bedtimes and wake up times can help train the mind that it is time for sleep.
Get out of bed when you’re unable to sleep - this can be tough for some people but a good rule-of-thumb is that if you’re aren’t falling asleep in about 20 minutes it is a good idea to get out of bed and do a quiet activity until you feel sleepy. Why? Because staying in bed and struggling to get to sleep rarely helps and can condition the mind to view the whole sleep process as a struggle.
Arousal system interventions - working with anxious thoughts and feelings is an important aspect of promoting better sleep. One intervention I often share with clients is to schedule worry time. I recommend scheduling worry time for early evening (not right before bedtime). Set a timer for 10-15 minutes and write all of the things you are concerned about. Sometimes it may be to-do items for the next day or bigger worries. Keep writing and capturing these worries on paper. Often this exercise can help calm the mind and the arousal system.
There are a number of apps available that utilize the principles of CBTI. These will typically start with tracking sleep with a log and then offering some of the suggestions listed above. And, of course, if you find insomnia symptoms aren’t improving, working with a therapist trained in CBTI can help treat this issue.
Insomnia is a common but treatable issue. CBTI is an evidence based therapy that can help using techniques like sleep logging, stimulus control, sleep efficiency training, and arousal system interventions, Whether through self-help strategies or working with a CBTI trained therapist, meaningful relief from insomnia is possible—and restful, restorative sleep can become a reality.