The most effective treatment for both sleep onset insomnia (trouble getting to sleep) and sleep maintenance insomnia (waking up and not being able to fall back asleep) is called Cognitive Behavioral Therapy for Insomnia (CBT-I or CBTI). CBTI is a comprehensive program to combat insomnia with 5 parts and was developed by one of the pioneers of sleep medicine, Dr. Arthur Spielman, who was the co-director of the Center for Sleep Medicine at Weill Cornell Medical College and Professor of Psychology at CUNY.
70% to 80% of patients with insomnia benefit from CBTI. It's normally done with a psychologist, psychiatrist, sleep coach, with a mobile app, or you could do it yourself (though this isn't recommended). Insomniacs who follow the program usually see improvement in 3 weeks.
Difference Between Sleep Maintenance Insomnia and Sleep Onset Insomnia
Having a problem falling asleep is called sleep onset insomnia, or early insomnia, and the inability to stay asleep is called sleep maintenance insomnia, or middle insomnia. Johns Hopkins Medicine estimates that most people have 2-3 observable wake-ups per night, but 20% of all Americans don't easily get back to sleep. Sufferers of this form of insomnia spend more time in the lighter stages of sleep and are easier to wake up.
Some sleep experts have theorized that before electricity, humans often had to wake up to tend to the fire to keep warm and to keep predators away, or to hunt or fish, so it was common to have a biphasic or bimodal sleep pattern (sleeping in 2 parts), as opposed to a monophasic schedule (sleeping throughout the night), and that not sleeping through the night is a vestige of this sleep pattern. Today some Muslim countries follow the biphasic sleep schedule to be able to pray several times a day, including early mornings.
Both sleep onset and sleep maintenance insomnia can be short-term, lasting less than 3 months, or chronic. It can be primary insomnia or comorbid/secondary insomnia (due to another condition), and can be mixed insomnia, which is a combination of sleep onset, maintenance, or early morning awakenings.
Symptoms of Insomnia
There's a difference between not sleeping enough and having insomnia. Insomniacs have a hard time falling asleep or staying asleep. A person who is tired may not be allowing enough time to sleep.
Insomniacs often experience:
- Daytime tiredness
- Difficulty concentrating
- Irritability, frustration, and confusion
- Increased accidents and poor coordination
- Poor memory
- Increased inflammation
- Weakened immune system
- Increased sensitivity to pain
And there are other symptoms that have a cyclical relationship with insomnia, where the behavior makes insomnia worse, and the insomnia makes the behavior worse:
Who is Most Likely to Be Affected?
There are serious long-term risks of insomnia, including:
- Diabetes and impaired glucose tolerance
- Heart attacks and strokes
- Depressed mood, behavior problems, alcohol use, and attempted suicide
- Increased mortality risk from all causes
Causes of Insomnia
The 3P model, or the Spielman Model, developed by well-known sleep researcher Arthur J. Spielman, explains the causes of insomnia. Long-term insomnia is usually a combination of three factors:
- Predisposing factors: Can be genetic, biological, or psychological. Does your mom or dad suffer from insomnia? Are you a worry wart, or a super driven person who has a hard time turning your brain and/or emotions off? Are you more sensitive to noise and light?
- Precipitating events: These are usually short-term events that make insomnia even worse, such as a job change, moving, death in the family, or divorce.
- Perpetuating behaviors: Some of the most common behaviors are staying in bed while unable to sleep, sleep anxiety, looking at screens too late at night, and going to bed and waking up at different times every day.
Here are some other common factors that can cause insomnia:
- Sleep apnea
- Disturbances in the bedroom (includes noise, light, too high temperature, or a sleep partner who interrupts sleep)
- Sleep disorders such as Restless Legs Syndrome (RLS)
- Pain (such as arthritis)
- Frequent urination at night (nocturia)
- Prescription drugs
- Changes to circadian rhythm such as traveling across time zones, or working a late shift
- Teeth grinding (bruxism)
- Hormonal changes in perimenopause (the transition to menopause) and menopause
- Worry and anxiety (such as generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, social anxiety disorder)
- Using too much alcohol, caffeine, or marijuana, or using them too close to bedtime
- Excessive napping (napping more than approximately 25 minutes, after 3 pm, or more than once per day)
- Diabetics may have hyperglycemia (high blood sugar levels), causing them to use the bathroom because their kidneys are overcompensating, or hypoglycemia (low blood sugar levels), causing nightmares, nighttime sweating, and feelings of confusion or irritation upon waking
Sleep Cycles and Sleep Maintenance Insomnia
According to Johns Hopkins Medicine, most of us have up to 20 mini-awakenings per hour, but we're not aware of them. And most people have 2 or 3 observable wake ups, but up to 20% of the population can't get back to sleep.
These wake ups occur more frequently in the lighter phases of sleep. Our sleep cycle has 2 stages, rapid-eye movement (REM), and non-rapid eye movement (NREM), lasting 90 to 110 minutes, and this cycle repeats 4 to 5 times per night in healthy sleep:
- NREM Stage 1: This is where your heart rate and breathing slow until you're asleep, usually taking 5 to 10 minutes. The brain is still producing theta waves, occurring mostly in the frontal lobe, and it's easiest to be woken up in this stage.
- NREM Stage 2: Your eye movements stop, your temperature drops, and your breathing becomes rhythmic. This stage lasts around 20 minutes.
- NREM Stage 3: This is also referred to as delta sleep, as the brain is producing slow delta brain waves, lasting 20 to 40 minutes. It's difficult to awaken anyone in this stage as it's the deepest sleep, and is when the body repairs and your brain consolidates memories (facts, experiences, and things learned during the day). Hormones are produced that promote muscle and bone growth, and your immunity is strengthened.
- REM: The brain acts similarly as to how it does when awake, lasting 10 minutes for the first period, and increasingly longer in each cycle. The breathing is faster and irregular, the eyes move rapidly, and you dream, but the body is immobilized so you don't act out your dreams. NREM stage 3 and REM are the deepest stages of sleep. Memories are consolidated in this stage, and it's believed that emotions and emotional memories are processed and stored at this time. The brain also commits information into memory. Additionally, the hormone production for bone and muscle growth, as well as the strengthening of the immune system that happens in stage 3 continues.
How to Get to Sleep Quickly and Sleep Through the Night Uninterrupted
Whether your insomnia is an independent disorder (primary insomnia), or a side effect of another condition (secondary insomnia), research suggests that your sleep can be improved in either case. It's sometimes difficult to determine insomnia is secondary or primary as there's a cyclical relationship: a person suffering from depression may have a hard time sleeping due to their depression, or their lack of sleep is causing depression or making their symptoms worse.
Though pharmaceuticals are the most popular option for treating sleep maintenance insomnia, CBTI, Acceptance and Commitment Therapy (ACT), and mindfulness are effective treatment options that have little to no side effects.
Another option that has been researched less, and is considered a sleep aid, is music for sleep (the most well known being binaural beats).
Make Sure You Don't Have Another Sleep Disorder
The first step is to make sure that you aren't dealing with another sleep disorder, the most common being sleep apnea (where you stop breathing for 20 seconds or longer several times throughout the night). The consequences of sleep apnea can be deadly. If you ever wake up during the night gasping for air, or if your partner tells you that you stop breathing during the night, you'll want to talk to your doctor to get a sleep study. Sufferers of sleep apnea usually get tremendous relief from the use of a CPAP machine, which prevents your airway from closing during the night.
Other sleep disorders that CBTI may not help with include restless legs syndrome, shift work, or circadian rhythm disorder. Patients with any of these issues may have developed other bad habits that worsen their insomnia, but it's best to have a complete and thorough sleep assessment from a sleep specialist to determine how to address your sleep issues.
Quick Fixes for Sleep Maintenance Insomnia
For those who wake up to go to the bathroom and can't go back to sleep, sometimes there are little adjustments that can make getting back to sleep easier:
- Use as little light as possible on your bathroom break. Flipping on bright lights can tell your brain that it's daytime, releasing cortisol that increases your awareness and wakes your body up. Instead, use a night light or install a dimmer switch. Some people have had success with keeping their eyes closed as much as possible to prevent them from waking up too much.
- Resist the temptation to start thinking and planning and focus on your breathing. This may be difficult for goal-oriented people, or for those with a lot going on, but watching your breath without controlling it, similar to what is done in some meditation techniques, can be helpful. Try to stay in the passive and relaxed state that won't block you from falling back asleep once you get back in bed.
- Walk to and from the bathroom slowly. Walking quickly will raise your heart rate and may make it difficult to fall back asleep.
- Drink less liquids the closer you get to bedtime.
If you're waking up because you're too hot, there are several solutions:
- Drop the temperature of your room before you go to bed, use fewer or thinner blankets, and/or use a fan. Remember that your core temperature drops by one or two degrees at night as you're getting tired, and it starts to rise a few hours before you wake up.
- If your mattress is too hot, it's usually because it's a foam mattress. The foam in these mattresses compresses, and after a few hours the heat is reflected back to you. If you don't want to replace your mattress, buying a cooling mattress topper may reduce the heat. Another option is to use a ChiliPad, or an equivalent, which sends cooled water through a mattress pad where you can control the temperature. If you want to buy a new mattress, inner-spring mattresses have large gaps of air that let your body heat pass through and won't heat up. There are also many cooling mattresses.
- If you're eating a large dinner within a couple of hours of sleep, this may cause you to heat up. Try eating earlier or eat less.
- If you're waking up because of noise, you can use a white noise app, or a fan. If the noise is your partner snoring, you may need earplugs, or your partner may need to address their snoring.
CBTI: The Gold Standard for Ending Your Insomnia
CBTI is recommended as the first treatment for sleep issues by the Mayo Clinic, The American College of Physicians, and the American Journal of Lifestyle Medicine. It's a comprehensive program with 5 components:
- Cognitive restructuring: Finding and changing negative thoughts and feelings about sleep. Many insomniacs get stressed at the thought of sleep, and these negative thoughts and feelings can prevent restful sleep. Insomniacs are encouraged to use positive affirmations such as, "Since I slept bad last night, I'll probably sleep well tonight because I'm so tired," or "Even people who usually sleep well occasionally sleep badly and don't make a big deal out of it; I'll be fine."
- Stimulus control: Only associating your bed with sleep. The only recommended activities are sleep and sex. Everything else - watching TV, social media, reading, talking on the phone, should happen outside of the bedroom. This will train the brain to only associate the bed with sleep.
- Sleep hygiene: Following the rules of sleep. A few common guidelines are going to bed and waking up at the same time every day, getting light exposure in the morning and afternoon, but not before bed (including light from screens), exercising regularly, not watching the clock when you can't sleep, and lowering the bedroom temperature before bed.
- Relaxation training: Creating a nightly ritual to ease you into sleep. This can include reading, meditation, prayer, progressive muscular relaxation, stretching, taking a bath or shower, or any relaxing activity that you do every night to create a cue for your brain to know it's time to sleep. If you've experienced long periods of stress, your cortisol levels may be out of balance, making stress reduction and restoring balance to the HPA axis extremely important.
- Sleep restriction: Restricting sleep for a limited period to train the brain to consolidate sleep. If someone regularly spends 8 hours in bed per night, but only sleep 6 hours, they would have a sleep period of only 6 hours (and usually allowing some extra time for falling asleep and getting out of bed). This process will increase the sleep drive, helping the patient to sleep more deeply with fewer interruptions. As the starting sleep efficiency score (the time sleeping divided by time in bed) was 75% (6 / 8 = 0.75 x 100 = 75%), the goal is to be over 90%. Once you reach 90%, then you add 15 minutes of sleep to your schedule per week until you reach 7-9 hours of sleep, as long as your sleep efficiency doesn't drop.
Prescription Drugs Vs. CBTI
Research has found that both CBTI and pharmaceuticals are effective, but with some important differences. Medications work faster, but CBTI has a longer-lasting impact. CBTI also has the advantage of little to no side effects. For these reasons, CBTI is considered the first option for insomnia, unless a physician is looking for immediate relief.
According to the AJMC, nonbenzodiazepines ("Z" drugs such as zolpidem, zaleplon, and eszopiclone) are effective for insomnia, and are the most commonly prescribed. Risks include daytime sleepiness, tolerance, anterograde amnesia, thinking and moving slowly, and when used in combination with other sedatives, overdose. Other behaviors such as sleep driving, sleep eating, and sleep walking have been reported by users.
Though CBTI is accepted as the first choice for treatment, medication is often prescribed. This is in part due to who is providing care: mental health and sleep clinics are more likely to prescribe CBTI, while primary care providers and specialty providers (such as pain and cardiology) are more likely to prescribe drugs. There's also a lack of providers of CBTI, limiting the availability and awareness of CBTI.
How to Start CBTI
Harvard Medical School Division of Sleep Medicine explains that the most recent survey of the 4-year medical school curriculum reveals that less than 2 hours of formal education is given regarding sleep. For this reason, if your doctor doesn't prescribe medication, they will most likely refer you to a sleep clinic, psychiatrist, or psychologist.
Sleep coaches are another option. There's a wide range of quality, with some coaches having a track record of helping many people, and those who haven't. Sleep coaches aren't covered by insurance and often charge $75-$150/hour. And there's no formal certification or licensing to be one. Some coaches work locally and will visit your home to see your sleep environment, but many coaches will use video conferencing or coach via phone calls.
It's possible to guide yourself through this process, but not recommended. It saves money, but unless you're very disciplined, and you understand the process thoroughly, you probably won't get the results you're looking for.
An option that's becoming increasingly popular is to use a sleep app that utilizes CBTI, sometimes referred to as digital CBT (dCBT). Note that there are many sleep tracking apps, and wearable technology that tracks your sleep that aren't based on CBTI. At this point there's not enough research on the efficacy of CBTI-sleep apps, but here are a few apps worth noting:
- SHUTi was found to help insomniacs after 9 weeks and they were sleeping normally after a year according to a 2018 study, and has 4 other published randomized controlled trials with positive sleep improvements.
- Sleepio has received NICE guidance (National Institute for Health and Care Excellence), which has recommended Sleepio as a cost-saving option for insomnia.
- CBT-i Coach was developed by psychologists at the Department Veteran Affairs.
- Sleep Reset guides the user step by step through the process, and offers sleep education with a live sleep coach.
Acceptance and Commitment Therapy (ACT)
ACT was developed in 1982 by Dr. Steven C. Hayes, Professor at the University of Nevada Department of Psychology, and became more popular in the late 1980's. It's sometimes described as a form of CBT. It's unique in that it doesn't try to reduce symptoms, but focuses on patients living in ways that are consistent with their values. It has several goals:
- Patients learn to not overreact to private events (thoughts, feelings, sensations, and memories).
- ACT helps people to recognize their thoughts as thoughts that may not be reality or fact.
- Because pain is an unavoidable part of life, and the perception of pain can make pain much worse, patients learn to make healthy contact with private events to be able to face previously avoided issues.
- To make a patient psychologically flexible and increase motivation to participate more in life activities, or to stop avoiding unpleasant circumstances, stop trying to control events, and to stop living in the past or future. This includes not living with inflexible rules.
Several studies have reported positive impacts on numerous mental disorders, as well as cancer, pain management, heart disease, and diabetes. Some research has found it to be an appropriate treatment method to improve insomnia. This systematic review looked at 19 studies with a total of 1,577 patients with both primary and comorbid insomnia, all between 2012 and 2020.
ACT is known as a third-wave behavioral therapy (whereas CBT is considered second generation), where patients learn to change their relationships with private events through 6 core processes:
- Be in the moment: Learning to not focus on the past or the future leads the patient to have a non-judgmental, more flexible, and responsive attitude.
- Defusion: Separating private events from identity, so patients learn to have some distance from negative emotions and thoughts.
- Acceptance: Being able to have private events and feelings without feeling guilt, and to not avoid past events that have previously been seen as too difficult to face.
- Self-as-context: There are 2 aspects to the mind, the thinking self and the observing self. This process focuses on just observing the thoughts without judgment.
- Values: Identifying what is truly important to the patient.
- Committed action: Taking action consistent with the patient's deepest purpose.
How to Find an ACT Therapist
Here are a few ways to find an ACT therapist:
- Association for Contextual Behavioral Science (ACBS) for searches within and outside of the United States.
- Association for Behavioral and Cognitive Therapies (ABCT) for searches within the United States.
Mindfulness for Improving Sleep
Mindfulness meditation is rooted in Buddhism and Hinduism, and has been around for thousands of years. It focuses on developing self-awareness, non-judgment, and compassion, being in the present moment. One of the most important influences in popularizing mindfulness was Jon Kabat-Zinn, who studied under Thich Nhat Hanh and other Buddhist teachers. Kabat-Zinn founded the Center for Mindfulness at the University of Massachusetts Medical School and the Oasis Institute for Mindfulness-Based Professional Education and Training, and developed an 8-week program called Mindfulness-Based Stress Reduction (MBSR) that is now offered in over 500 clinics. MBSR has been used to improve symptoms in fibromyalgia, cancer, substance abuse, and eating disorders.
Mindfulness-Based Therapy for Insomnia (MBTI or MBT-I) is an 8-week mindfulness-based treatment (MBT) that uses some behavioral strategies for insomnia from CBTI (stimulus control and sleep restriction) with mindfulness principles and meditations.
The principles of MBTI help to eliminate sleep anxiety and any stressful associations with sleep:
- Beginner's mind: Be willing to try something different, as what you've been doing up to this point isn't working.
- Non-striving: Sleep is a passive process and learning to let it happen vs. forcing it is important.
- Letting go: Give up any negative thoughts regarding your poor sleep history.
- Non-judging: Letting go of any judgments about not being able to sleep and being tired can release some of the stressful thoughts, emotions, and memories that come with chronic insomnia that prevent restful sleep.
- Acceptance: When you can't sleep, it's helpful to get out of bed and do something relaxing until you feel tired again. Accepting that lying in bed frustrated will only prevent sleep will help you take the correct action.
- Trust: Believe in the process and have a positive expectation for improvement in your sleep.
- Patience: As you may have been sleeping poorly for a long time, it may take weeks or more to fix your sleep.
Evidence from randomized controlled trials on insomnia have shown MBTs to be effective. In 5 studies that incorporated sleep diaries, total sleep time increased between 3 and 28 minutes, sleep efficiency increased between 5% and 8%, and total wake time decreased between 20 and 40 minutes. Further research is recommended to determine who would benefit from MBTI or under what conditions patients should consider MBTI instead of the more heavily researched CBTI.
There's currently a lack of availability of practitioners trained in MBTI, so getting this therapy face-to-face may be difficult. However, there are online programs, such as Kabat-Zinn's UMass Mindfulness Programs, as well as other therapists who offer online therapy.
Entrainment: Using Binaural Beats and Other Music for Improved Sleep
There are some non-traditional means that may help insomniacs fall asleep and sleep through the night that are still not deeply understood. These methods use a process called entrainment, where the brain is encouraged to sync with external stimulation, helping the brain enter different states through light, sound, touch (vibrational), or electromagnetic fields. Often when sound is used, there are relaxing sounds included along with the brain-wave music. Entrainment is being used for other conditions such as ADHD and anxiety.
- Gamma: 35-100 Hz, contributes to rapidly processing information.
- Beta: 12-35 Hz, normal state of wakefulness, common during conversation, debate, or someone giving a speech.
- Alpha: 8-12 Hz, a relaxed state associated with meditation and walking in nature.
- Theta: 4-8 Hz, occur during dreaming, daydreaming and deep meditation, also a state associated with creativity and intuition. This state often occurs during freeway driving or taking a shower when someone can mentally disengage from the task and have a flow of ideas.
- Delta: 0.5-4 Hz, occurs during deep, dreamless sleep, and even deeper meditation
When someone falls asleep they go from high frequency, low amplitude to high amplitude, low frequency: beta to alpha, then to theta, and then delta. Waking up is the opposite.
Listening to beats in these ranges can be used to enter the accompanying states. Someone studying may listen to gamma or beta music, someone trying to do creative work alpha or theta. The benefits may include lowering stress and anxiety, and increased focus, relaxation, mood, creativity, as well as aid in managing pain. There are a lot of YouTube videos and phone apps with each of these three types of beats.
For improving sleep, the most important beats are in the delta, which are the slowest brain waves and produced in stage 3 of sleep, also known as delta sleep or slow-wave sleep (SWS). Some have questioned whether any music would act as white noise, which may improve sleep, but one study found that white noise only didn't have a positive effect on sleep, nor REM brain-wave music, but slow-wave sleep-brain music had a positive influence on sleep quality and reduced sleep latency (the time it takes to go fall asleep).
There are 3 different ways to listen to these beats:
- Isochronic tones: Single tones that repeat in a rhythmic pattern that don't require headphones.
- Binaural beats: Listening to binaural beats requires earbuds or headphones as it entails hearing one tone in one ear, and another in the other that's a different frequency, making your brain process a beat at the difference of the frequencies, creating an "auditory illusion." If for example one ear hears a 330 Hz tone, and the other a 300 Hz tone, your brain will perceive 30 Hz. A few small studies have indicated the potential for binaural beats to lengthen stage 3 sleep, increasing the amount of deep sleep, improving sleep quality, and reducing anxiety.
- Monaural beats: Two tones of similar frequency are combined and presented to one or both ears. No headphones are required. Its similar to binaural beats in that your brain perceives the two frequencies as one beat.