Let’s welcome Rissa back to My Bipolar Mind! She would like to share some very beneficial and useful information about Cognitive Behavioral Therapy for Insomnia. She’s gained this information via her doctors and own personal experience. Continue reading below to learn more!
CBT-I is an effective treatment for insomnia. Cognitive behavioral therapy focuses on your thoughts (cognitions), feelings (emotions), and actions (behaviors). CBT for insomnia helps you to manage the behaviors and thoughts that impact your ability to fall asleep and stay asleep.
Below is how your thoughts, feelings, and actions relate to your sleep:
- Cognitive or thoughts
The way you think about your sleep habits, insomnia, feeling tired, not being able to fall asleep etc. They all impact your ability to sleep. This is self-talk about sleep and feeling tired
- Feelings or emotions
The emotions and feeling that you have about sleeping, being unable to fall or stay asleep and feeling tired. You may feel anxious, stressed, frustrated, desperate or angry. These feelings impact your ability to sleep and stay asleep.
Behaviors are the actions or habits that impact your sleep. Some unhelpful behaviors include spending non-sleeping hours in bed, doing wakeful activities in bed and the wakeful activities you do before bed. Example of wakeful activities include screen-time, caffeine, intense exercise.
The 5 Steps of CBT-I
CBT-I steps are like a staircase, but not all the steps are the same size. Improving your sleep begins with the first step, you move up the stairs as needed to improve your sleep. Each step includes working on changing habits and learning new skills. Sleep hygiene, relaxation, and worry management are narrower steps. They are important steps on the way to improving your sleep, but by themselves they might not get rid of your insomnia. Stimulus control and sleep restriction steps are wider. They are more powerful tools for solving your sleep problems. Practicing these CBT-I steps and skills will improve your sleep.
- Sleep hygiene
- Stimulus control
- Sleep restriction
- Worry management
This is a good time to think about the reason why you want to improve your sleep. What benefits will you have in your life with improved quality of sleep? How will better sleep change the things that are important to you?
Plan to spend one week on each of the 5 CBT-I steps
Begin with step one which is sleep hygiene and practice the changes you choose to make in this module. Write down how the things you try each week impact your sleep. Repeat this with step 2 on the second week, step 3 on the third week, step 4 on the fourth week and step 5 on the fifth week. Unless of course your health provider prefers another schedule then follow their recommendation if you have discussed this with them.
Step 1 – Sleep Hygiene
What is sleep hygiene? Glad you asked, sleep hygiene is a set of healthy sleep habits. These actions are helpful for everyone who wants a good night’s sleep. If you have Insomnia, sleep hygiene is the first step towards better sleep. Let’s begin improving your sleep with some info about the first step.
Which of the following might you use to prepare your bedroom for better sleep?
- Lower the thermostat to 60 – 70 degrees F (15.5 – 21.1 degrees C)
- Use blinds, curtains, black – out curtains or blankets to darken the room
- Use a fan or a white noise machine to create a steady background sound to block noise
- Use an eye mask or ear plugs if needed to block light and sound. These can help you if you have a bed partner like i do who snores like a freight train
- Remove television and other screens (computers, electronic games, phone, iPad, tablets, etc.) from your bedroom
Limit caffeine in the afternoon and evening as caffeine is a stimulant and will make it harder for you to fall asleep. Caffeine comes in many forms including soda, energy drinks, coffee or tea (hot or iced) and chocolate. It is important to avoid all forms of caffeine 8 – 10 hours before bed. Now think about what form of caffeine you are currently using in the afternoon and evening, what will it mean for you to change this habit? How might you make this change?
Limit tobacco and alcohol in the evening as tobacco is a stimulant and will make it more difficult for you to fall asleep. Avoid tobacco 2 hours before bed. Alcohol is a depressant; it may seem to help you fall asleep but makes it harder to stay asleep all night. Avoid alcohol 3 – 4 hours before bed.
If you use alcohol or tobacco before bed think about one or two small changes you could do to make sleep easier.
Avoid large amounts of fluid in the evening as drinking such large amounts of liquids can increase the number of times you wake up during the night to use the restroom. If you take medications before bed please take them as your health care team recommends.
Be Physically Active
Plan for 30 minutes of exercise each day
- Exercise during the day instead of close to bedtime
- Light physical activity like stretching, yoga, or tai chi may help you feel more relaxed before bed
- Avoid vigorous physical activity 4 hours before bed
Think about your activity schedule, including physical activity in your day may improve sleep. Is there a way to work exercise into your routine early in the day?
Keep TV & Electronic Screens Out of Your Bedroom
Move your tv, monitor, tablet and laptop out of your bedroom. Charge your cell phone in another room or away from your bed. If your partner uses screens in the bedroom consider using an eye mask or ear plugs.
Move Your Clock Away from Your Bed
Checking the time during the night may increase your anxiety and worry about not sleeping. Move your clock away from the bed so your bed so you won’t be looking at it nonstop while you’re unable to sleep.
Only Use Your Bed for Sleep
Use your bed only for sleep and sexual activities. Daytime activities like reading, using the computer and watching tv should take place in another room. This helps your body associate your bedroom with sleeping and not wakeful activities.
Avoid Napping During the Day
Taking a nap during the day is similar to eating a snack right before dinner. If you eat before dinner you “spoil your appetite for dinner” making you less hungry for your meal. Napping “spoils your appetite for sleep” it makes you “less hungry” for sleep at night. Napping disrupts your sleep and encourages the insomnia cycle. If you have severe daytime sleepiness (unable to keep your eyes open and or falling asleep during an activity) take a short, 30-minute nap in the middle of the day. this is less likely to affect your ability to sleep at night.
Making Changes in Your Sleep Hygiene Habits
Making changes in sleep hygiene takes planning and effort for you and your bed partner. Keep in mind your goals for better sleep and the positive changes feeling rested will make your life better.
Here are some tips for making the changes in your sleep hygiene habits:
- Begin with 1 or 2 sleep hygiene changes to avoid being overwhelmed
- If some of the changes are challenging (reducing caffeine, avoiding naps) make changes gradually.
- Share this information with your bed partner and see if they are willing to support the changes to improve your and most likely their sleep as well
- If your bed partner is not ready, willing or able to make changes then you have to focus on the things that you are able to control.
Step 2 – Stimulus Control
What is stimulus control you ask, well stimulus control is when your brain learns from experiences. If you have insomnia your brain has probably learned that your bed and bedroom are used for a lot of different activities that are not sleep related. Your brain is expecting that your bed and bedroom is for daytime activities (like tv, gaming, reading etc.). It no longer associates or connects your bed and bedroom with sleep. The wakeful activities that have been done in your bed or bedroom are the stimulus or the signal for your brain to stay awake. Your brain has learned to be awake in your bed and in your bedroom. stimulus control is a way of retraining our brain to sleep when you lay down in bed.
Stimulus control – is simply changing the connection that your brain has to your bed and bedtime. You will change the signal or stimulus of the bed and bedroom so your brain connects with sleep and not with daytime or wakeful activities. The goal is to set a bedtime routine to signal that sleep is coming and to create an association so your bedroom and bed become a stimulus or signal for sleeping.
Will Stimulus Control Training Help Me?
- Stimulus control is most helpful if you feel ready for bed but become wide awake when you lay down. it can also help if you toss and turn when you get into bed
- Stimulus control help if you have trouble falling or staying asleep
- If you are at risk of falling or have limited ability to move, changes to stimulus control are important. Work with your PCP to find a therapist who can help identify how to adjust stimulus control
Getting Started with Stimulus Control
Begin with making some basic changes in your bedroom environment and the “awake” activities you have been doing in bed.
- Make your bedroom comfortable for sleeping. Cool, dark, quiet and restful
- Go to bed and wake up at the same time every day. Even on weekends and holidays. Keep a consistent schedule for sleep
- Don’t do “awake” activities in bed. Don’t read, watch tv, scroll social media or text
- Create a regular routine of quiet, calming, enjoyable, and relaxing activities that you will do in the 30 minutes before bed
- Do the same relaxing or “wind-down” routine every night before bed
Ideas for Bedtime Routines That Promote Sleep
- Quietly work with your hands (knit, crochet, paint, draw, stitch, etc.)
- Read a relaxing book
- Wash your face, brush your teeth, shower or bathe
- Do gentle stretching, yoga, meditation or deep breathing, and other relaxing activities
Which of the following would fit into your regular bedtime routine?
- Take a relaxing shower or bath
- Brush and floss your teeth
- Put on Jammies
- Give myself a foot massage
- Walk or groom my pet
- Read a relaxing or short story
- Get clothes ready for tomorrow
- Stretch or practice gentle yoga
- Meditate or pray
- Practice relaxation – deep breathing, muscle relaxation, relaxing imagery
- Other calming / relaxing activity that you enjoy
Think about your current bedtime routine. What changes could you make to prepare yourself for sleep. Finding relaxing habits that you can use every night is so very important.
3 Steps to Stimulus Control
It is important to follow directions for stimulus control. it may not be easy to change your sleep routines. These changes may be uncomfortable at first but will help to improve your sleep in the long run.
Only go to bed when you are sleepy, not when you are just tired. If you are not sleepy at your bedtime do not go to bed. Do calming, relaxing activities instead. Tired is the feeling of having little energy. Sleepy means that if you feel like you are going to fall asleep. You know you are sleepy when it is hard to keep your eyes open and your head up. You are sleepy when you begin to drift off to sleep.
If you are still awake after 15 – 20 minutes in bed get up. Get out of bed, leave your bedroom, sit up in a straight back chair and do something boring or relaxing.
When you begin to feel sleepy, go back to bed and try again. This is not considered to be failing it’s just a hurdle we all have to deal and cope with. Remember, feeling sleepy means you are having trouble keeping your eyes open and your head up.
Repeat this cycle all through the night, if you don’t fall asleep in 15 – 20 minutes get up again, leave the room and sit in a straight back chair and do something boring or relaxing. Each time you feel sleepy return to bed. If you can’t sleep, get up and do the same thing as earlier and continue to repeat those 4 steps until you fall asleep.
Remember, when you can’t sleep:
DO NOT DO THE FOLLOWING
- Turn on bright lights
- Lay down on the couch or recliner
- Read an exciting book
- Listen to loud, upbeat music
- Use your computer, tablet, or phone
- Watch tv
- Send emails or txt messages
- Make phone calls
- Don’t do awake activities (chores, bills, homework)
DO THE FOLLOWING
- Keep the lights off or use dim lights
- Sit quietly in a straight back chair
- Read a short or non – engaging book
- Listen to calm or soothing music
- Doodle in a coloring book
- Practice light yoga gentle stretching or tai chi
- Practice meditation or prayer
- Practice a relaxation skill or squeeze a stress ball
- Give yourself a massage
- Pet your dog or cat or any pet you have
- Diffuse essential oils
Step 3 – Sleep Restriction
Sleep restriction is an insomnia treatment that helps you sleep better by limiting the time you spend in bed. Sleep restriction sets up a schedule so that you are only in bed during your sleep window. Using sleep restriction, you slowly increase the time you allowed for sleeping as your sleep improves you allow more time for sleep. Sleep restriction can greatly improve the sleep for those who struggle with insomnia.
Who should use sleep restriction?
- Sleep restriction is most helpful if you wake up many times in the middle of the night
- Sleep restriction can also help if you have trouble falling asleep or staying asleep
- If you have had a traumatic brain injury or have been diagnosed with epilepsy or bipolar disorder adjustments to your sleep restriction plan are important. Contact your health care provider to find a therapist who can help modify stimulus control.
Tips for Practicing Sleep Restriction:
- Do not go to bed before your sleep restriction scheduled bedtime
- Get up at the same time every day even on weekends and holidays
- Continue the sleep hygiene habits (keep bedtime routine, avoid napping)
- Counite practicing the stimulus control principles (only go to bed when sleepy, get out of bed if you do not fall asleep in 15 – 20 minutes)
- Sleep restriction is one of the wider steps in CBT-I. Sleep restriction reduces the amount of time that you spend in bed to have the amount of time you are sleeping
- To stay motivated to follow the sleep restriction, remind yourself of the way better sleep you get if you keep working hard and pushing forward. Better sleep improves your life and support the things you value in your life
Step 4 – Relaxation
Relaxation skills are helpful in calming your body and mind. Relaxation is helpful for everyone and can be very helpful if you notice your body feels tense or your mind is busy. There are many types of relaxation skills. Practice a few to find the ones that work best for you.
- Deep Breathing
- Passive muscle relaxation
- Progressive muscle relaxation
- Guided imagery
Have several small amounts of relaxation throughout your day. The more you practice the better you will get at it. Practice makes perfect.
Mindfulness is an especially good way to relax. concerns and worries force you to focus inward on distressing thoughts. Mindfulness helps you learn how to change your focus to the environment around you. You will learn to intentionally focus your attention on the present moment. When you are mindful, notice the thoughts, feelings and physical reactions that come up. Accept then as being present but do not judge or focus on them. Turn your attention back to the present moment. When you are being mindful, you are present in the moment and accept the moment as it is. This practice can be very calming.
Grounding is intentionally focusing your attention on the present using your 5 senses. That can include sights and sounds around you, physical sensations in your body and strong smells and tastes.
Deep breathing is also called belly or diaphragmatic breathing. The focus on breathing air into your abdomen instead of your chest. Deep, slow breaths reduce your “flight or fight” response and creates relaxation in your body.
Find a quiet place where you can be comfortable. keep your chest and shoulders down.
Inhale breathe in slowly through your nose untill you feel full feel your stomach push out as you breathe in.
Exhale breathe out slowly through your mouth feel your stomach pull in as you breathe out
To deliberately relax muscles, you focus on individual muscle groups that may be tense. This process can be either passive or progressive.
Passive Muscle Relaxation – Uses your thoughts to focus on and relax muscles.
Progressive Muscle Relaxation – Is an active exercise that involves tensing and relaxing groups of muscles. It teaches you to recognize when your muscles are tense so you can learn to relax them.
Guided Imagery – Use all of your senses to create a scene in your mind that is relaxing to you. Your imagery may be enhanced by lighting a scented candle, playing nature sounds in the background or using a lamp or fan to feel the “sun” or “wind”.
Step 5 – Worry Management
What is worry management? It is a way to think about things in a different, more flexible way. The goal is not to “just think positive”, it is to think about things in a more helpful and accurate way. Worry management can be helpful for everyone. But it is very helpful if you have incresed anxiety, worries and ruminations before you go to sleep or when you should be sleeping.
Worry causes physical changes in your body that make sleep difficult…
Worries can get in the way of sleep. When you worry your body’s fight or flight response is activated. The responses increase your heart rate, sweating and other physical symptoms. This worry response makes it hard to go to sleep.
Worrying about sleep makes it hard to sleep…
Worries about sleep can become a self-fulfilling prophecy. The more you worry about sleep the more difficult it is to sleep. Common worries about sleep include:
- I won’t get enough sleep or im not getting enough sleep
- I’m not getting the recommended amount of healthy sleep
- If I don’t get some sleep, I’ll be too tired to function
- Not getting enough sleep is going to make my health problems worse
Other worries also interfere with sleep…
It is common for worries about both sleep and daily life to pop into our head when we are trying to get to sleep. If you are struggling with significant worries, contact your PCP to find a therapist to help manage those worries.
Writing down your worrisome thoughts…
Writing down your worries lets you deal with them in a healthier way. Look at each thought you wrote down and ask yourself these questions:
- What is another, less bad way to look at this thing that i am worrying about?
- What is the actual likelihood or chance that these worries will actually happen?
- What actual evidence do i have for these worries?
- What evidence do i have against these worries?
- How have i managed and coped with situations like this in the past?
When to practice worry management…
They are most helpful to use during the day, at least an hour before your bedtime routine. Using them right before bed may increase your anxiety and make it harder to sleep. It may be strange to plan a time to worry!! But scheduling a time to write down and work through the questions about your worries is helpful to manage worry.
Maintaining your sleep improvements over time…
Managing your sleep continues over time. Be aware of the quality of your sleep, how rested you feel, how much time you spend in bed sleeping vs not sleeping.
- Identify what skill helped you improve your sleep and continue to use those skill
- If you notice your sleep starts to get worse and your skills are not helping, contact your PCP to work with a therapist.
- If you notice new sleep problems (waking up gasping for air, creepy – crawly sensations in your legs, etc.) contact your PCP as these could be signs of another sleep disorder.