Insomnia is very common. According to a recent epidemiological study (Morin & Jarrin, 2022), approximately 10% of the adult population suffer from an insomnia disorder and another 20% experience occasional insomnia symptoms. Insomnia can also be chronic, with a 40% persistence rate over a 5-year period. Women and older adults are more vulnerable to insomnia.
To better understand insomnia, one must first understand what constitutes normal sleep.
What is “normal” sleep?
The number of hours of sleep typically recommended is 8, but this is a loose number. Some people may need 6 hours and some people may need 10 hours. Statistics of how many hours people sleep are available by gender and for different age groups and countries. What really matters is the number of hours that you, as an individual (based on genetics, health, and lifestyle) need in order to feel good. That number can also vary across time; for instance, if you are a woman, you may notice that you need more sleep at different times in your menstrual cycle; intense physical exercise may make you feel the need for more sleep, etc. Sleep also varies across the lifespan, and can be poorer during transitions, like menopause, and in older adults.
We tend to sleep in 90-minute cycles and wake up between cycles, but mostly these are short awakenings that we may or may not be aware of.
Deep sleep is more common in the first half of the night and rapid eye movement (REM) sleep more in the second part of the night.
It is perfectly normal to have a “bad night of sleep” once in a while. On average, people report sleeping well about 80% of the time.
We are all susceptible to having a poor night’s sleep when stressed. Who has not slept poorly the night before the start of a new school year, a big presentation or an interview, a long trip or a medical intervention?
What is insomnia?
Insomnia is when one feels unable to sleep well for an extended period of time. Its strict definition, based on the DSM-V, requires that period of time to be at least 3 months of experiencing poor sleep at least 3 times/week.
If you suffer from insomnia, we can help you sleep!
Insomnia is not the same as sleep deprivation. New parents, for instance, may be sleep deprived because they do not get the opportunity to sleep enough with a newborn to care for. We would not say that they suffer from insomnia. Insomnia is really about being in bed trying to sleep and instead finding oneself tossing and turning.
Everyone has some “good” nights of sleep and some “bad” nights of sleep and everything in between! The issue is when one starts to experience what they see as too many “bad” nights of sleep. Then the following can set in:
Unhelpful thoughts:
The prediction of poor sleep: “I hope that I won’t toss and turn all night again tonight”
Thoughts about control: “I should be able to make myself sleep”
The prediction of negative short-term consequences: “Tomorrow, I won’t be able to concentrate or be productive. I’ll feel lousy, impatient, etc.”
The prediction of long-term consequences: “This insomnia will affect my health. I’ll end up sick. I won’t be able to keep my job if I keep feeling sleepy, etc.”
Unhelpful behaviours:
Trying to go to bed early: “I didn’t sleep last night and I am so tired that tonight I will be in bed at 7 pm”
Behaviours that aim to “make” one sleep (e.g., taking melatonin to force sleep)
Letting sleep take over one’s life, especially with chronic insomnia: Thinking about sleep a lot, not engaging in certain activities because one does not know if they’ll be awake enough (e.g., not volunteering to give a talk or accept a promotion), avoiding “exciting” activities that take place in the evening (e.g., not going to parties anymore or out for a movie), avoiding travel, or any other activity that has the potential to disrupt sleep.
Cognitive Behaviour Therapy for Insomnia (CBT-I) is recognized in the field of medicine as the first line of treatment for insomnia.
If you suffer from insomnia, we can help you sleep!
Treatment
CBT-I targets the unhelpful thoughts and behaviours listed above.
In this framework, insomnia = unregulated sleep drive + hyperarousal
Sleep drive is the natural mechanism that regulates sleep. For instance, if you have been up for 20 hours during exam period, sleep drive will be very high and you will sleep deeply and for a decent amount of time; but if you wake up at noon after a full night of sleep and go for a nap at 2 pm, you are not expecting to sleep very deeply or for very long. In insomnia, unregulated sleep drive typically occurs because one will try to nap and sleep in to make up for lost sleep, and because the normal sleep pattern (e.g., sleep 8 hours, be awake 16 hours) and circadian rhythm (day/night) is disrupted.
How to regulate sleep drive?
Sleep drive can be regulated through sleep consolidation. This is where, with your therapist, you will start where you already are in terms of sleep, and then narrow the sleep window a bit to then systematically widen it over time. The goal is to have you sleep at least 85% of the time set aside for sleep (85% is an arbitrary number, but the logic is to make it such that time set aside for sleep is time spent actually sleeping). So, let’s say you need to get up at 7 am on weekdays, and right now you estimate that you are getting 6 hours of sleep every night, you would start going to bed at 1 am every night. After a week or so of waking up every day, not just on weekdays, at 7 am and going to bed at 1 am, you should notice that you are sleeping for at least 85% of the time that you are in bed. If so, we can then proceed and widen the window by 15 minutes, so that, for the following week, you are going to bed at 12:45 am and getting up at 7 am. Provided you are sleeping for the bulk of the time (85%), we would then continue to progressively widen the window, so that you would go to bed at 12:30 am, 12:15 am, 12 am, 11:45 pm, etc., until the desired time to go to bed is reached, while maintaining 85% sleep efficiency.
You may think this sounds draconian (we are asking you to go to bed late and limit your sleep), but in reality, we are not asking you to do anything terribly different from what you are already doing if you are really sleeping about 6 hours a night. Also, keep in mind that it is a very temporary process, done over the course of approximately 8-10 weeks, where you keep getting more and more sleep as the process continues.
What if I am still awake during my time in bed? After 10-15 minutes, get up! Only go back to bed when sleepy. This is the stimulus control component of CBT-I. We want to break the association of “bed + frustration/anxiety/sleeplessness” and create a strong “bed + sleep” association.
How to tackle hyperarousal?
First, there has to be awareness that sleep cannot be forced, it can only be invited. If you suffer from insomnia, chances are you have already tried a bunch of things, like melatonin, magnesium, herbal teas, baths, kiwifruit, etc., but have found that none can reliably make you sleep.
To fall asleep, you need to be relaxed, but here comes the tricky part: relaxing with the goal of sleeping typically does not work.
It’s the difference between “I enjoy having a nice bath, followed by my sleepy tea and reading a book because it is my “me-time” and it is so relaxing” versus “I am drinking this tea because it is supposed to make me sleep“.
Inviting sleep can be done through:
Sleep hygiene: Keeping one’s room dark and cool. Staying away from stimulants (caffeine, nicotine, etc.) and alcohol, improving bed comfort, room air quality, having an enjoyable bedtime ritual. There are also things one can try to help with relaxation that may not have strong scientific evidence, but that can be beneficial if you enjoy it, like a weighted blanket, tea for sleep, etc. If you believe in taking supplements, you can also discuss these with your medical doctor or pharmacist.
Including day hygiene: This is probably an understated key element! One cannot go from a full-adrenaline state to asleep in a minute. Time is needed to decompress, and that decompression window can vary from one person to the other, and from one situation to another. A good habit can be to “put the day to bed” before putting yourself to bed. At the end of your workday, before or after dinner, write down the things you need to do, things that worry you, written as problems that can be solved, etc., so it is all on paper and out of your head.
Maintain a regular schedule, not just for sleep, but also for eating, exercising, light exposure (bright light in the morning, low light in the evening), etc., These are all healthy habits. The circadian rhythm is not just about bedtime. Most bodily functions follow a circadian rhythm.
Ideally, relaxing activities should be incorporated into one’s day rather than done at night “to sleep”; like meditation, relaxation, mindfulness, etc.
If you suffer from insomnia, we can help you sleep!
Cognitive restructuring (changing thoughts)
The surest way to not be able to sleep is to stress about it! To look at the clock and make terrible predictions for how awful the next day will be. In a way, insomnia is like a phobia of a “bad night of sleep”. Instead of being ok with having a “bad night of sleep”, you develop a fear of this happening. This leads to avoidance and control behaviours that only maintain the fear.
Part of cognitive restructuring is simply psychoeducation about sleep to realize that:
– Sleep cannot be controlled by “trying harder”.
– You can definitely have a “bad night” and have a “good day”.
– Sleep deprivation can negatively impact health, but so can so many things (genetics, lack of exercise, poor diet, smoking, etc.) and sleep deprivation is not the same as insomnia
– It is NOT true that everyone “should” sleep 8 hours exactly, and this every night.
– Most insomniacs underestimate how much sleep they get (we know this from sleep studies), so you may be getting more sleep than you think.
– Lack of sleep can affect performance, but it is not a perfect correlation. Who has not had a great night of sleep and felt rested, only to procrastinate and not be productive on the tasks of the day? Who has not, conversely, had little sleep, but somehow took it one task at a time and ended up having a lovely productive day?
– There are certain things one can do to cope with daytime sleepiness (depending on health status), including drinking coffee or another caffeine-containing drink; putting on bright lights (or going outside); listening to fast-paced music, moving, etc.
– Sometimes, thoughts can have quite a large influence on how we feel. You may feel tired, lethargic and in a bad mood after not sleeping well, but if you just learned that you won a million dollars, the tiredness would probably lift rather quickly!
– Finally, it may be more helpful to view sleep quality on a continuum rather than in “good or bad” categories. Having sleep that we rate as a 5-6/10 in quality feels less dramatic than a “really bad night”.
Can I do CBT-I if I am taking sleep medication?
Yes, CBT-I is effective without medication and in combination with medication. If you are taking sleep medication and want to stop, you need to speak to the prescribing physician to find out how to gradually do so.
If you suffer from insomnia, we can help you sleep!