Insomnia, that inability to sleep that may have your mind racing or your body tossing and turning, can cause a profound disruption to people’s lives. About 10-30% of the population experience insomnia.¹ Sleep problems have gotten a lot more attention by the public in the last year due to the pandemic. Insomnia is increased in survivors of COVID-19 infection.² People suffering insomnia often seek care in their primary provider’s office, making it a condition most of us will be called upon to treat.

What is insomnia? According to The International Classification of Sleep Disorders, the patient must have difficulty sleeping or resistance going to bed, and daytime consequences due to the nighttime sleep difficulty, which cannot be explained by insufficient time in bed or sleep disruption.³ For a diagnosis of chronic insomnia the sleep problem must be experienced at least three times a week for three months. For short-term insomnia all criteria are the same, except that there is no criteria for number of times per week, and the duration is less than three months. (For the full criteria see Table 1)

Insomnia can be found in people of all ages, with 36% of preschoolers, 20% percent of children, and 24% of teens experiencing insomnia.⁴ Women tend to report more insomnia, at 19% versus 13% of men,⁵ and 75% of seniors.⁶

Mechanisms/Causes

There are many possible causes of insomnia. As holistic providers, treating the cause is our aim; and for that, we must first identify it. Insomnia can originate from the physiological or psychological. In this paper we will focus on the psychological, though of course there is an interplay between the physical and psychological.

Hyperarousal is a key component of insomnia. Part of that is the idea of sleep reactivity, which is the extent to which sleep is disrupted by stress. People with normal sleep who have high sleep reactivity are at increased risk of future insomnia. Family history, genetics, and stress along with gender all increase sleep reactivity. Nighttime rumination and worry, both types of cognitive-emotional reactivity, contribute to insomnia as well.⁷

Other psycho-emotional states that contribute to insomnia include depression. Depression and insomnia have a bi-directional relationship, each contributing to the other, without a clear first cause. Newer research has indicated that insomnia may be a prodromal symptom of depression.⁸ With this thinking, it’s important to treat both simultaneously.

A little-known factor that contributes to insomnia, and may be particularly important in these times, is loneliness. It’s thought that we need to feel socially secure in order to sleep well, thereby setting aside vigilance. The relationship between sleep and loneliness appears bi-directional, suggesting that treating sleep problems may decrease loneliness.⁹

Treatments

The recommended first line treatment is cognitive behavioral therapy for Insomnia (CBT-I). First developed by Charles Morin and presented in his book Insomnia,¹⁰ there are four main components, which are implemented in a series of appointments over the course of weeks. At each appointment the clinician advances treatment in each of the four components that are relevant for that patient.

The first component of CBT-I is sleep restriction (this is a misnomer, it really is “time in bed restriction” which somehow doesn’t roll off the tongue as easily). In sleep restriction, you first identify how much sleep the person is getting on average. You then start the treatment process by giving a scheduled time in bed that allows only that amount of sleep. Then, at each appointment, you evaluate the patients’ sleep efficiency, which is total sleep time divided by time in bed. So long as their sleep efficiency is 85% or more, you increase their opportunity to sleep by 15-20 minutes each week. This strategy increases their sleep drive, making it easier to fall asleep and stay asleep through the night. Once they are getting the amount of sleep they need, an increase in time in bed will result in more wake time. At that point you can stop increasing their time in bed, or even take one step back to the total time in bed where they had high sleep efficiency. In my experience, it is best to take a slow steady approach increasing their total sleep time. The slow approach allows them to have success and reverse the negative sleep associations they have built up over the course of their insomnia experience. Including this component of CBT-I is essential. Sleep restriction is contraindicated in untreated sleep apnea, parasomnias, bipolar disorder, and seizure disorder.¹¹ In my clinic, I’m cautious about recommending less than six hours in bed and always advise people that more time out of bed should not mean more time on tasks.

This strategy may help insomniacs in terms of the “Sleep to remember, sleep to forget” theory. In REM sleep memories are consolidated and also pruned so that our synapses aren’t overwhelmed with information. In healthy sleepers this function is intact. In animal models of medical conditions known to have sleep disorders such as PTSD and autism, this forgetting function is impaired. By consolidating sleep and potentially restricting some REM sleep, the insomniac may be spared some time when unhelpful information is being re-enforced rather than pruned ¹²

The next principle is called ‘stimulus control,’ which aims to re-associate the bed with sleep. The patient is instructed to avoid all wakeful activities in the bed and even in the bedroom. In the evening, or in the morning after waking, they need to do their restful activities elsewhere. Sometimes people lament the loss of that cozy experience – in bed, in their comfy clothes, supine with low lighting, pillows and blankets. In that case, I encourage folks to have that pleasant experience, simply move to another place in their home such as the sofa or a bean bag chair. This is especially important for those insomnia patients who find they are able to sleep well elsewhere, just not in their own bed. This principle also comes into play in the middle of the night, with patients being instructed to get out of bed if they have been awake for approximately 15 minutes. They should do something boring in low light. I’ve found that the ‘boring’ part is important, as you want to avoid re-enforcing those mid-night awakenings with a pleasant experience. C.S. Lewis said, “Many things – such as loving, going to sleep, or behaving unaffectedly – are done worst when we try hardest to do them.” Getting up when not sleeping gets your patient away from trying hard.

The third piece is cognitive reframing. This component is meant to raise to awareness of any dysfunctional beliefs and attitudes that are making sleep difficult. A good tool to start the process is the Dysfunctional Beliefs and Attitudes Scale (DBAS). There are both short and long versions with sleep statements the patient is asked to rate from strongly agree to disagree on a ten-point scale. One example is: “I am worried that I may lose control over my ability to sleep.” Often patients tell me that they start to have these thoughts after dinner, continuing until they get into bed hours later. Once those sleep-disrupting thoughts are identified, the work is to intentionally shift to sleep-promoting thoughts. With the patient, examine one of their dysfunctional thoughts, then discuss ways in which it may not be true. You’re simply trying to gently introduce other possibilities. It’s important to work with their specific thoughts, and the time of day these come up. For instance, people may have sleep-disrupting thoughts during the day, possibly attributing every difficulty to their sleep. Sometimes it’s useful to write down sleep-positive alternatives for people to read when their thoughts turn negative. The clinical key is that these sleep positive statements must have the power of truth for that individual patient; generic affirmations will not be as effective, if at all.

The last piece is sleep education or sleep hygiene, depending on the author. Here is where the patient receives sleep hygiene recommendations such as no caffeine after noon, no alcohol or meals three hours before bed, to observe whether exercise in the evening interferes with sleep, etc. Education on how sleep works can also be useful. For instance, patients may report a sensation of lighter sleep or more dreams close to wake time. Teaching them about REM sleep being close to wake time and the brainwaves being more similar to waking brainwaves can help them understand their experience is normal.

Cognitive behavioral therapy for insomnia has been proven helpful in some special populations, including depression, for breast cancer survivors, fibromyalgia patients, and children, among others.^13-16

Case Study

First office call: M.P., a 34-year-old single male with chronic insomnia of three years.

Until the insomnia began, M.P. would sleep 10:30 pm to 5:30-6:00 pm. He feels best with 7-7.5 hours of sleep but is now getting only 4-6 hours per night total. Daytime impairment includes difficulty concentrating at work, especially in meetings. He will walk into rooms and not remember why and is more clumsy around the house. His girlfriend has also noticed he’s been more low energy, especially at the end of the day. 

Treatment Plan #1:

1. Sleep times – 11 pm to 5 am, which is the 6 hours he is currently reporting. This is the first step of sleep restriction.

2. At 5 am get up and use your dawn simulator light box so that it’s at full light at 5:30a, and leave on full brightness until 5:40a. Light therapy in the morning strengthens the circadian rhythm.

3. Journaling exercise 1 hour before bed. Then once you are in bed, use thought-stopping and sleep promoting exercises. See handout (Table 2).

4. For the hour before bed be in low light. If you’d like to measure use lux meter, goal is 3-10 lux

5. L-Theanine 200 mg 2-3 times a day. Morning, afternoon, and evening to decrease stress and anxiety. This is in effort to decrease hyperarousal.

6. 3 mg of melatonin 30 minutes before bed for sleep and tinnitus.

Return office call, two weeks later: MP was on vacation, so it was harder to keep the recommended sleep hours. Before vacation he had at least two nights that he slept the entire six hours. He shifted his sleep hours to 11:30-5:30am. Feels good about that progress. Using the light box as instructed, feels good “like waking up to the sun.” On vacation he got an up-close view of his dad’s health problems that worry him. We discussed the three steps of calming his mind at night. In the night he will tell himself “I’m organized, and I know from past experience I’m on top of it. I want to spend this time sleeping. I will take care of stuff tomorrow when I can think.” He is doing something relaxing for the hour before bed—house work or journaling in low light—and thinks it helps him sleep. He will insert another 30 mins between journaling and bedtime. His anxiety has been much lower in the last couple weeks, even before the vacation. He thinks L-theanine is helping.

Treatment Plan #2:

1. For another week, sleep 11:30p-5:30a. After that, evaluate your “sleep efficiency” by dividing your total sleep by the time in bed. So long as you are sleeping 85-90% of the time in bed then increase your sleep hours by 20 minutes. After each week you can do this, until you are getting how much sleep you need. 

2. Move journaling another 30 minutes before bedtime, so you have a full hour of wind-down.

3. Keep the wind-down time as calm as possible. Discuss with your girlfriend the importance of being in the parasympathetic state before getting into bed and that problem solving will be much better in the light of day.

4. In the night if your mind starts reviewing tasks, tell yourself “I’m organized, and I know from past experience I’m on top of it. I want to spend this time sleeping. I will take care of stuff tomorrow when I can think.” Modify this statement as needed so it has the power of truth. Then instead do one of the sleep-promoting activities on the “Put Your Thoughts to Rest” handout.

Return office call, three weeks later: Did well on East coast sleeping 1 am to 7:30 am, with intention of staying on PST. Sleep was good before travel, sleeping most of the night straight through, over 85% of time in bed. Daytime impact – feeling more tired at bedtime at 11:30 pm (previous bedtime was 10 pm, feels that he has more energy in the middle of the day. Getting 5.5 hours sleep nightly. Still waking 15-30 minutes before his alarm. Moving journaling earlier helped, and what especially helped was the affirmations that things are handled and he doesn’t need to think in the night. He talked with his girlfriend about no negative conversations in bed.

Treatment Plan #3:

1. Sleep 11:10-5:30 am for 7-10 days. Then assess, if you are sleeping more than 85% or more of your time in bed, then go to bed 15-20 minutes earlier the next week.

2. When doing your journaling and thought-stopping before wind-down time, add in that you’re not going to think about concerns until 6:30 am. If you wake up thinking, tell yourself “That is handled, and I’ll have time to think about it later, now is time to sleep.” Goal is to go back to sleep, by training yourself not to think about things before waketime.

In further appointments M.P. was instructed to continue adding to his total time in bed, as long as additional time translated into additional sleep. The sleep education component continued as questions arose, and cognitive reframing was addressed as sleep-disrupting thoughts were identified. Once his sleep is as he wishes, supplements will be evaluated and withdrawn if possible.

Conclusion

For people with insomnia due to hyperarousal, these cognitive behavioral strategies can re-build positive sleep while unraveling negative associations with the bed, and shifting dysfunctional sleep thoughts to sleep-promoting thoughts. With established efficacy and minimal negative side effects, this is a great tool to use. In the integrative clinic, we can also combine this strategy with nutrient and botanical medicine to help our patients sleep well, and get all the benefits of a good night’s rest.

References

1. Roth, T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med. 2019;3(5):S7-S10.

2. Taquet M., Geddes J.R., Husain M., Luciano S., Harrison, P.J. 6-month neurological and psychiatric outcomes in236,379 survivors of COVID-19: a retrospective cohort study using electronic health records. Lancet Psychiatry. 2021; 8: 416–27.

3. The International Classification of Sleep Disorders, 3^rd Edition. 2014. American Association of Sleep Medicine.

4. Donskoy, I., Loghmanee, D. Insomnia in adolescence. Med Sci (Basel). 2018;6(3)72.

5. Chen Y, et al. Characteristics and correlates of sleep duration, daytime napping, snoring and insomnia symptoms among 0.5 million Chinese men and women. Sleep Med. 2018;44:67-75.

6. Nguyen V. George T, Brewster GS. Insomnia in older adults. Curr Geriatr Rep. 2019;8(4):271-290.

7. Kalmbach DA, et al. Hyperarousal and sleep reactivity in insomnia: current insights. Nat Sci Sleep. 2018;10:193-201.

8. Fang H, et al. Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment. J Cell Mol Med. 2019 Apr;23(4):2324-2332

9. Griffin SC, et al. Reciprocal effects between loneliness and sleep disturbance in older Americans. J Aging Health. 2020;32(9):1156-1164.

10. Insomnia: Psychological Assessment and Management. Charles Morin. 1996.

11. Behavioral Treatments for Sleep Disorders. Editors Michael Perlis, Mark Aloia Brett Kuhn. 2011.

12. Poe GR. Sleep is for forgetting. J Neurosci. 2017;37(3):464-473.

13. Carney CE, et al. Cognitive behavioral insomnia therapy for those with insomnia and depression: a randomized controlled clinical trial. Sleep. 2017;40(4):zxs019.

14. Zachariae R, et al. Internet-delivered cognitive-behavioral therapy for insomnia in breast cancer survivors: a randomized controlled trial. J Natl Cancer Inst. 2018;110(8):880-887.

15. McCrae CS, et al. Cognitive behavioral treatments for insomnia and pain in adults with comorbid chronic insomnia and fibromyalgia: clinical outcomes for the SPIN randomized controlled trial. Sleep. 2019;42(3):zsy234.

16. Ma ZR, Shi LJ, Deng MH. Efficacy of cognitive behavioral therapy in children and adolescents with insomnia: a systemic review and meta-analysis. Braz J Med Biol Res. 2018;51(6)e7070.

    
    

Table 1. The clinical criteria for chronic insomnia as excepted from The International Classification of Sleep Disorders; all must be present.

Table 2. Calm Your Mind Handout