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Author: Ron Cridland, MD
As mentioned in the section, “What is Insomnia?”, insomnia is a "symptom" of disturbed sleep, not a diagnosis. The key to effectively managing the symptoms of insomnia is to determine what the contributing factors are. Insomnia may be caused by underlying medical or psychiatric problems, prescription and non-prescription drugs, excessive stress, as well as by other underlying sleep disorders such as, restless legs syndrome, sleep apnea or periodic limb movement disorder. It is a good idea to start with your general practitioner to rule out underlying medical and psychiatric issues.
The Online Sleep Disorder Questionnaire (OSDQ) here on this website can help identify some of the factors contributing to your disturbed sleep along with what sleep disorders you may have. It will also direct you to more information on this website about how to diagnose and treat those conditions.
Depending on the sleep disorder, there are a number of “non-pharmacological” measures that can be used to help resolve insomnia depending on the contributing factors. These measures include sleep hygiene, relaxation techniques, biofeedback, stress management, light therapy, cognitive behavioural therapy for insomnia (CBTi) and other forms of psychotherapy.
One of the most common causes of insomnia is Psychophysiological Insomnia. This is a form of “conditioned insomnia”. Typically, people develop a habit of thinking, worrying, planning or problem solving in bed. They watch the clock and think about what they have to do the next day or worry about not being able to function if the do not get some sleep. The classic example is the mother who has a baby and immediately learns to sleep with “one ear open” for the rest of her life. She becomes conditioned to be "vigilant" at night. The good news is that we know how to change conditioning.
Cognitive Behavioural Therapy for Insomnia (CBTi)
Cognitive Behavioral Therapy (CBT). CBT is a form of psychotherapy that addresses dysfunctional thoughts and emotions along with maladaptive behaviors through problem focused and action-oriented strategies. Reformatting dysfunctional thoughts is an effective way of changing the way you feel about something. This can make circumstances significantly more positive and much less painful without necessarily changing the facts of the situation.
In contrast, some behaviors cannot be controlled through rational thought but nonetheless, can be very effectively changed through the powers of conditioning.
For example, most people think of an alarm-clock as something that wakes them up. I think of an alarm as something that helps you sleep by taking away the responsibility of deciding what time to get up in the morning. It is a different way of looking at it that can have a significant affect on how you feel about the alarm and your success at sleeping. A lot of people with sleep problems don’t like alarms because it reminds them of work or the stress of having to get up when they are still very tired. However, as you will learn on this website, using an alarm is a very effective and often essential component in training and conditioning yourself to sleep deeper and longer.
A typical example of cognitive therapy is in those who catastrophize about being unable to sleep. They worry that they will “be a wreck” tomorrow if they do not sleep. However, their worry about how bad they will function the next day also prevents them from sleeping. Although they feel tired, most people with chronic insomnia function remarkably well during the day and have been doing so for a while. If they remind themselves that even if they do not sleep well tonight, they will still function reasonably well the next day. Taking the pressure off themselves in this way can allow them to sleep easier.
Often people with insomnia will go to bed earlier when they are tired in order to try and catch some extra sleep. However, they usually set themselves up for failure by going to bed before they are biologically sleepy. One very effective behavioral strategy involves going to bed later instead. The extra sleepiness from going to bed later helps force you into sleep. After a few weeks of success at sleeping better, you change your conditioning to that of a good sleeper. Then you can start gradually advancing your bedtime routine until getting enough sleep to feel rested. Going to bed later is one behavioral strategy to help recondition good sleep.
There are many other cognitive and behavioral strategies that can be combined together to meet the specific needs of an individual with insomnia. These strategies go beyond basic sleep hygiene, which many insomniacs are already doing, and focus on changing conditioning.
Cognitive Behavioral Therapy for insomnia (CBTi) as the name suggests is cognitive and behavioral therapy focused on managing insomnia. The medical literature shows that CBTi works in about 80% of people with conditioned insomnia or Psychophysiological Insomnia and is helpful in other insomnias as well. This is actually more effective than sleeping pills. Normally this therapy is conducted by sleep disorders physicians or psychologists. After many years of successfully conducting this therapy with our patients, we have developed an on-line version on this website called the Online Insomnia Management Program (OIMP). The program is designed to essentially “train” or re-condition you to become a good sleeper again.
