Sleep Medicine Recommends Only Five Strategies for Insomnia

If you have tried my sleeping tips from the prior article and your sleep is still problematic, there are several things that you can do.

The safest option is to go and see your medical doctor or GP and get a referral to a Sleep Physician. They will be able to do a more comprehensive sleep study with you and see if you have any underlying sleep conditions impacting your sleep and feel. You may have to do a polysomnography (PSG) or sleep study to rule out conditions like sleep apnea, restless legs syndrome, periodic limb movement disorder, delayed sleep phase disorder, narcolepsy or idiopathic hypersomnia.

            If it’s unlikely that you have any of the above sleep disorders, you may have insomnia. As many as 33% of people have sleep problems, and between six to ten percent have serious enough sleep concerns to warrant a diagnosis of chronic insomnia. Once you have had it for a few months, it may not get better on its own without treatment or applying the right strategies to your sleep.

            Everyone will tell you what they think is the solution to sleep problems, from earplugs to eye masks, comfy pillows, new beds and weighted blankets. However, there are still only five strategies with enough evidence to be empirically supported insomnia strategies by the American Academy of Sleep Medicine (AASM). If you think you have insomnia and want to improve your sleep, please try one of these five strategies: Cognitive behavioural therapy for insomnia (CBT-I), sleep restriction, stimulus control, progressive muscle relaxation, and paradoxical intention.

STRATEGY 1: COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA

CBT-I consists of four main components. Psychoeducation, sleep scheduling, relaxation techniques and cognitive techniques. Together, these four components target all three underlying sleep mechanisms. CBT-I has sleep scheduling to improve homeostatic pressure and circadian rhythms. It encourages people to get morning sunlight and remain off bright screens before bed to strengthen circadian rhythms. It also teaches relaxation strategies to help people learn how to relax and reduce their arousal levels. Finally, CBT-I teaches cognitive strategies to help people to challenge their unhelpful beliefs about sleep and further reduce their arousal levels.

            If you want to try CBT-I, you can check out my Udemy course ‘Improve Your Sleep with CBT for Insomnia’. I’ve also seen the positive results published on other online CBT-I courses such as Sleepio or Somryst. CBT-I Coach tries to teach some of these strategies at no cost, including what times are best for you to go to bed and wake up if you do sleep restriction. If you’d prefer in-person CBT-I, you can search on the internet and see if there are any psychologists or behavioural sleep medicine specialists who specialise in CBT-I.          

STRATEGY 2: SLEEP RESTRICTION

Sleep restriction is a strategy that increases homeostatic pressure by reducing your time in bed each night to only the amount of time you are sleeping. It also helps to strengthen your circadian rhythms by improving the regularity of when you go to bed at night and rise from bed in the morning, seven days a week. However, it is important that you set your sleep times at the right time for your body clock to be the most effective. Morning people would better choose earlier to bed and rise times, whereas evening people will need to stay up later and get up later.

            Sleep restriction can increase distress and arousal levels initially. It can be especially difficult for people with chronic insomnia, who are already worried about not getting enough sleep and the consequences they will feel and face during the day. This can make it very hard for people to initially try and even harder to fall asleep or remain asleep at night. Once they sleep better, their arousal levels can drop significantly, as the individual can begin seeing how effective this strategy is.

Sleep restriction instructions are as follows:

1. Determine your average total sleep time over the past 1-2 weeks. If it is less than five hours per night, say it is five hours. 
2. Add 30 minutes to this amount. The total is your new time in bed prescription. Only spend this time in bed every night for the next two weeks.
3. Figure out when you would like to wake up seven days a week. It is your rise time or time to get up each morning. Set the alarm to help you wake up at this time. When the alarm goes off, get out of bed and try not to sleep again until the next night. 
4. Minus your time in bed allocation from your rise time to figure out your bedtime. For example, if you wake up at 6 am and are meant to be in bed for 6 hours and 30 minutes every night, aim to go to bed around 11:30 pm.
5. For sleep restriction to be maximally effective, bedtime should be approximate rather than absolute. For example, if it is 11:15 pm and you notice many sleepiness signs, go to bed rather than wait until 11:30 pm. On the other hand, if it is 11:30 pm and you are wide awake, wait up a little until you feel a bit sleepier. Then go to bed.  
6. Once you have your bedtime, rise time and time in bed prescription, track your sleep for the next two weeks using a sleep diary or activity tracker. Then figure out your sleep efficiency, which is the percentage of your time in bed spent sleeping.
   • If your sleep efficiency for the next two weeks is under 85%, cut your bedtime by a further 15 minutes each night. If it is between 85-90%, keep your time in bed prescription as it is.
   • If it is above 90%, extend your time in bed by 15 minutes each night.
7. Keep tracking for another two weeks and repeat until your sleep efficiency is between 85-90% regularly. 

STRATEGY 3: STIMULUS CONTROL

Stimulus control is a strategy that ensures that your homeostatic pressure is high enough when you are going to sleep by encouraging you to get up at the same time every morning, seven days a week, no matter how well you have slept. By not napping during the day, your homeostatic pressure also remains high. Not going to bed until you feel sleepy means that you won’t go to bed until your brain and body are ready for sleep, which reduces how much time you spend in bed awake. Being out of bed whenever you can’t sleep for 20 minutes also means that you’ll never spend excessive time in bed awake each night.

            Stimulus control also helps to strengthen your circadian rhythm with the regular rising time in the mornings and only going to bed when you feel sleepy. Stimulus control is better than sleep restriction if you strictly follow both of the rules as they are written. Stimulus control helps you to find out when your brain and body most want you to go to sleep, as opposed to going to sleep at the same time every night.

            Like sleep restriction, stimulus control can also initially increase distress and arousal levels, especially for people with chronic insomnia. People with insomnia tend to already be worried about not getting enough sleep and the potential consequences they will feel and face during the day if they do not get enough sleep or have to be out of bed during their usual time in bed. This can make it very hard for people to initially try stimulus control and even harder for them to fall asleep or remain asleep at night.

            Once you begin sleeping better through stimulus control, your arousal levels can drop significantly, as you can begin seeing how effective this strategy is. It also means that you will no longer have to get out of bed after 20 minutes of being awake if you fall asleep regularly within this time, which will likely reduce your worries further. The better you sleep at night and the less tired you feel during the day, the less you will feel the need to sleep in longer in the morning or nap during the day. So, the more effective stimulus control becomes as a strategy, the lower your arousal levels.

The stimulus control instructions are as follows:

1. Only go to bed when sleepy, 
2. Wake up at the same time every day, 
3. Only use the bed/bedroom for sleep and sex, 
4. Avoid naps during the day, and 
5. Sit up or get out of bed if you cannot fall asleep within about 20 minutes of retiring to bed.
6. If you have to get up at night, do something calming or relaxing until you feel sleepy again, and then lie back in bed for sleep. Ideally, this activity during the night should not involve bright light, rigorous exercise or be too cognitively demanding.

STRATEGY 4: PARADOXICAL INTENTION

Paradoxical intention is probably the least used strategy that is effective for chronic insomnia. This is because it is quite counter-intuitive and, therefore, a hard sell to patients that are already struggling with less sleep than they would like. It also doesn’t target circadian rhythms or sleep pressure directly. Paradoxical intention instead indirectly targets both of these sleep mechanisms by helping patients to take off all the pressure they put on themselves to sleep.

            As long as the individual follows the recommended paradoxical intention instructions, it can reduce sleep effort, performance anxiety and hyper-arousal levels. This allows homeostatic pressure and circadian rhythms to work better for the individual, as long as they have been up for long enough during the day and are going to bed at the right time for their internal body clock.

The instructions for paradoxical intention are as follows:

1. Go to bed at your usual bedtime.
2. Lie down in bed with the lights off. 
3. Don’t read or look at your phone or anything else.
4. Try to see if you can stay awake for “just a little bit longer” without doing anything to force yourself to stay awake. 
5. If you are still awake, congratulate yourself for successfully achieving your goal. Then, don’t look at the time on the clock and keep focusing on staying awake for “a little bit longer”. 
6. Keep this up all night if you have to. But, whatever you do, do not try and force yourself to sleep and keep trying to stay awake “just a little bit longer”.

STRATEGY 5: PROGRESSIVE MUSCLE RELAXATION

Progressive muscle relaxation is a sleep strategy that predominantly reduces how much physical tension someone feels before bed. Spending much of the day stressed or worried can lead to physical tension, especially around the neck, shoulders and upper back area.

            Progressive muscle relaxation can also reduce cognitive arousal levels by helping individuals focus on different parts of their bodies and become more aware of their feelings. It is, therefore, a much better cognitive strategy than either suppression or worry.

            Progressive muscle relaxation really doesn’t help with someone’s homeostatic pressure or circadian rhythms. It is an intervention that specifically targets someone’s hyper-arousal, particularly any physical tension they feel. It can help people feel more relaxed and calmer; therefore, the other two sleep components can work effectively and help them sleep enough at the right times.

PMR instructions are as follows:

1. Tense the muscles in your arms, bringing your hands towards your shoulders to feel your biceps tighten. Then take a deep breath through your nose and down into your stomach. Then relax your arms as you breathe out the air through your mouth. Next, let your hands hang down by your side and give them a shake. Then repeat one more time by tensing, breathing and relaxing your arms.  
2. Then tense the muscles in your face, including the ones in your forehead, nose, jaw and around your eyes. Notice the tension. Then take in a deep breath through your nose and into your belly. Relax all the muscles in your face as you breathe all the air out through your mouth. Let your facial muscles droop as your jaw hangs loose. Then repeat one more time.   
3. Tense the muscles in your neck by bringing your shoulders up to your head. Hold this pose tight for a few seconds. Then take a deep breath through your nose into your stomach. Pause for a second or two. Then breathe all the air out through your mouth as you relax your neck and let your shoulders drop. Next, move your head around slowly in a circular motion if this helps you to relax your neck. Then repeat once more. 
4. Tense the muscles in your stomach and back, bringing your abdomen closer to your spine. Hold this for a second, then take a deep breath into your belly while keeping your stomach and back tense. It may make it a little harder to breathe in as deeply as with the other muscle groups. Then breathe all the air out of your mouth as you slump down and push your belly out. Repeat one more time.  
5. Tense the muscles in your buttocks and thighs, squeezing them tightly. Take a deep breath, pause, and relax these muscles as you breathe all the air out. Shift back and forth from left to right in your seat, then repeat.  
6. Lastly, stretch out your legs and tense your calves and feet, bringing your toes back towards your body. Breathe in, pause, breathe out and relax your calves and feet. Shake out your legs, and then repeat one last time. 

 

HOW DO YOU KNOW WHAT TO TRY FIRST?

Based on what I have written above, trying CBT-I is good if you think all three underlying sleep mechanisms are an issue. CBT-I is also the most recommended if you currently have some beliefs about sleep that are unhelpful for you.

            If your sleep pressure is not high enough at night when going to bed, but your arousal levels are okay, try sleep restriction. Try stimulus control if your circadian rhythms impact your sleep or if you spend lots of time awake in bed each night. Stimulus control can help to recondition your bed by feeling calm and sleepy and sleeping well over time, so it can be a helpful strategy in several ways.

            If elevated arousal levels are your main issue, but you are doing okay otherwise, give progressive muscle relaxation a proper go. If you find that you are putting in too much effort to try to sleep at night and your pre-sleep arousal is too high, I would recommend trying paradoxical intention first.

            No matter what you try, try it every night for at least a week, ideally two, before deciding if it is the right or wrong strategy. Both stimulus control and sleep restriction are difficult and anxiety-provoking initially. Still, they can have some of the largest improvements for you and your sleep if you stick to the instructions over time. Even a year after people have completed a course of CBT-I treatment, the best predictor of who continues to sleep well is individuals who still follow the sleep restriction and stimulus control rules.

Dr Damon Ashworth

Clinical Psychologist