published 06/21/06, last updated 10/30/09

Save Yourself from Insomnia!

Serious tips from a veteran of the insomnia wars

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

This article is humbly offered to people suffering from severe insomnia, in the hopes that my expertise and personal experience can be of use to you. Before you place your hopes in any of my recommendations, however, please ensure that there is no medical cause for your insomnia first. That said, many severe cases of insomnia are basically bad habits, and will respond to behavioural conditioning1 2 3 — and even if there is a medical cause for your insomnia, behavioural conditioning may still be your best defense.

I’ve been there … and how

I am a recovered insomniac. In addition to generally sleeping poorly since the age of twelve, I suffered through three major episodes of insomnia as an adult. In 2005, I feel as though I nearly died from insomnia so severe that I slept as little as an hour a night for days at a time, over a period of many months. I was basically immune to pharmaceutical sleep aids that could have put a horse in a coma, and I had given every imaginable popular remedy a fair try. (If you have insomnia, you know all too well that people like to suggest insomnia cures even more than they like cold and flu remedies.) I certainly believed that I had “tried everything.”

Fortunately, I hadn’t actually tried everything.

It’s amazing how much I was willing to suffer before I really took the challenge seriously. After a long struggle and an exhaustive personal investigation into the science of sleep and insomnia, I finally cured myself.

Some consequences of sleep deprivation

Serious insomnia is nothing to mess around with. Sleep deprivation can actually kill. Laboratory animals subjected to extreme sleep deprivation die relatively swiftly of unknown causes — exactly what goes wrong is not clear, but their body temperatures start to drop and then they suffer rapid and widespread physiological failure. This is a very curious thing about biology, that sleep is actually required for life, and in fact required for all life — virtually every living thing sleeps, if has any kind of a brain of any kind at all.4

Insomnia is not generally fatal, of course, because there are all kinds of self-preservation mechanisms that kick in. But the fact that sleep is so basic strongly suggests that sleep-deprivation is potentially dangerous stuff, even when it isn’t lethal.5 And in fact there is a considerable amount of science confirming exactly this. Coren describes sleep deprivation studies in humans showing a number of ominous effects, and his book Sleep Thieves: An eye-opening exploration into the science and mysteries of sleep generally comes to the conclusion that everyone needs to take sleep deprivation much more seriously than we generally do. Other examples:

Insomnia hurts. An internet survey of over 2,500 people with fibromyalgia (a chronic pain condition) showed that insomnia was one of the most commonly identified aggravating factors.6 There is good reason to believe that what makes fibromyalgics hurt probably predisposes healthier people in the direction of increased sensitivity as well. Another survey found the fairly spectacular statistic that 53% of chronic low back pain patients had insomnia, compared with only 3% in pain-free controls.7
Insomnia saps your migraine defenses. A study of 1869 migraines clearly showed that “sleep obviously protects against [migraine] attacks rather than provokes them,” while a whopping 29% were actually caused by insomnia. I don’t know about you, but anything that protects against migraine attacks is good and I don’t want to lose much of it.8
Insomnia makes you sick. A statistical analysis of insomnia’s relationship to absences from work caused by illness clearly found that there’s a connection: insomnia is followed by periods of increased absenteeism from illness and disease.9 Yikes! As if that weren’t bad enough: the evidence shows that the effect is prominent up to two years after insomnia. Shudder. And still more: a 2009 paper shows that people with even minor sleep problems (less than 7 hours per night) get almost three times as many head colds.10
Insomnia can wreck your mood. 40% of psychiatric mood disorders are preceded by insomnia, and insomnia sets in at the same time as another 20% of mood disorders.11 12

This is just a sampling. For a complete discussion of how insomnia probably increases body pain of all kinds (and muscle pain in particular), see Insomnia Until it Hurts.

Sleep deprivation is serious. Take it seriously.

A bad habit

Some insomnia is caused by sleep disorders such as sleep apnea. Or sleep loss may be caused by the pain of another medical condition, such as rheumatoid arthritis. But most insomnia is basically just a bad habit — a learned behaviour, which is usually aggravated into a crisis by emotional stresses13 or by other medical problems. This kind of insomnia is called “behavioural insomnia.”

I resisted this idea at first. Actually, I resisted it for a long time. It sounded like an “all in your head” diagnosis to me. I certainly felt like a victim of some terrible malfunction of my central nervous system, not a guy with a bad habit! I thought I had a “real” problem.

But it turns out I was just a guy with a bad habit, and the proof was in the results. Granted, it was a really bad habit — or several of them — but it really did come down to just learning how to sleep again. The cure was ultimately simple, and consisted of a simple 2-point plan:14

sleep environment upgrading
behavioural conditioning

The magic is in the behavioural conditioning, and it’s what most of the rest of the article is about. Step one is just a determined application of common sense: it is absolutely vital to have a sleep environment that is reasonably conducive to sleep, and it’s amazing how many things most insomniacs can do to improve their sleep environment.

Cover your windows with blackout curtains. Install sound-proofing eggshell foam. Find more comfortable earplugs. Get an air conditioner or a dehumidifier. Kick the dog out of bed. Get a squirt bottle and wage war on the cat until she learns that waking you up at 4:00 AM is going to get her nothing but soaking wet. Use a white noise machine or a fan. Buy the best mattress money can buy, get a deluxe pillow, and 900 thread count sheets. Fix the leaky tap. If your husband snores, get rid of him: separate bedrooms, separate lives, whatever it takes, even if it’s only until you learn to sleep again. Get rid of the phone too: permanently eliminate the possibility of it ever waking you up at 2:00 AM again.

If your husband snores, get rid of him.

Getting the idea? Everyone’s circumstances are different, and the solutions will be unique, but stop at nothing to make your bedroom as sleep-friendly as humanly possible. And if you can’t do it — if there is something intrinsically sleep-hostile about your living space … move.

Sleep hygiene

Sleep is a behaviour. Insomnia is a dysfunctional sleep behaviour — sleep behaviour that results in sleep that is at odds with what we want, usually not enough of it and at the wrong times. Either we start sleeping at the wrong time, and/or we can’t continue sleeping as long as we’d like, and/or we can’t sleep as deeply as we need to.

The sum of our sleep behaviours is called our “sleep hygiene.” Insomniacs usually have lousy sleep hygiene.

Sleep anthropologists — yes, that’s an actual field of sleep research, though admittedly a pretty small one — have taught us that sleep is pretty variable and adaptable across cultures and situations that we can learn and unlearn nearly any kind of sleep habit, that “anything goes.” And yet of course not all sleep hygiene works well. Just because we can learn to sleep in surprisingly sleep-hostile conditions doesn’t mean that it’s a good thing. That adaptability can work for or against us: it is easy to inadvertently teach ourselves sleeping habits with unpleasant long term consequences. It is less easy to deliberately teach ourselves better ones.

Without a doubt, my readers mostly suffer from civilization-induced insomnia. That is, they have learned bad sleeping habits that are strongly associated with an electrical world. It’s easy to stay up. There’s stuff to do at night.

We can learn nearly any kind of sleep habit — and unlearn it.

Many insomniacs will start protesting at this point: “But I try to go to sleep and I can’t!” Sure. But there are a thousand sneaky ways in which you teach your brain not to go to sleep. There are several common themes, but let’s start with one of the worst and most common ways of training to become a champion insomniac …

Most insomniacs, when they have trouble falling sleep, get frustrated, get up, and do something. This is dangerous. This is a message to your brain. The message is, “1:00 AM is for checking my email. Reading a book. Watching a bit of boring telly. Having a snack.” Your ancestors didn’t have those options. Through most of our biological history, they couldn’t even turn on a light.

It’s this simple: whatever you repeatedly do at 1:00 AM, that is exactly what your brain will think 1:00 AM is about! You are teaching your nervous system not to sleep, and like the miraculously adaptable thing that it is … it learns.

Behavioural conditioning

Learning to sleep again is something like training a dog: endless repetition, and positive reinforcement. Only instead of doggy biscuit rewards … your reward is sleep. Sounds good, doesn’t it?

Behavioural conditioning is most familiar to us in the context of animal training. Unfortunately, this does not mean that we can easily “get it.” As any dog trainer will tell you, people really suck at training animals, and generally need far more training than the animals. Recently I heard a woman on the street outside my apartment angrily yell at her dog, “Come here right now, dammit!” Yeah, that’s gonna work …

People are no better at training themselves, probably even worse. We’re biased, emotionally messy, full of appetites and neuroses, a soup of stress hormones and a lifetime of habits already so well-established that they seem like a permanent part of the fabric of our lives. Saying that behavioural insomnia is just a bad habit is like saying that cancer is just a few bad cells. Habits are the most powerful forces in our lives. Learned adaptation is one of the basic organizing principles of our nervous systems. Going up against that is never going to be easy. But it can be done, just like professional animal trainers can get results that seem almost impossible to amateurs.

But behavioural conditioning itself is a skill that has be learned. It isn’t intuitive.

The total time in bed (TTIB) problem

Most insomniacs spread their sleep too thin: for instance, maybe you go to bed early because you’re exhausted, wake up a lot during the night because you’re an insomniac, and then of course you sleep in as much as possible to try to recover from the fragmented sleep. Your total time in bed may be 9, 10, even 11 or 12 hours sometimes.

Obviously, it is not actually possible for anyone to consistently sleep solidly through such a long period (cats excepted). If you go to bed at ten and don’t get out of bed until nine the next morning, gaps in your sleep are inevitable!

Another insomniac describes his experience with this problem:

I have often slept in a little to recover from a rough night, but going to bed at 10:00pm is actually not a good plan if I actually want to sleep past five or six … which I usually try to do. I have actually been going to sleep too early because I am anticipating trouble with sleep … I know I’ll have trouble, so I want more time to recover before the next day starts, so I start trying to sleep sooner. You can see how that might lead to sleep getting stretched thinner and thinner, where I’m actually causing the same problem I’m trying to solve.

This “total time in bed” is such a crucial concept that it should be acronymized: TTIB! Basically, as long as you have a high TTIB, good luck sleeping through the night.

Although there may be many things that wreck your sleep, TTIB is one of the most controllable and significant aggravating behavioral factors. And TTIB is usually most obviously aggravated by an inconsistent waking time. Many insomniacs get the idea of focussing on getting to bed at a consistent time, but rarely worry about wake time and semi-regularly stay in bed as long as possible trying to recover from the bad night of sleep. Unfortunately, this simply stretches out your TTIB and strongly reinforces the tendency to wake up in the night.

To have any hope of sleeping through the night, you have to have a consistent bedtime and a consistent waking time. Which brings us to sleep compression therapy.

Sleep compression therapy

Training for recovery from behavioural insomnia is usually most easily cured by restricting sleep to a barely adequate and fixed period each night, and then gradually increasing it. It’ll be unpleasant at first … but you’ve got nothing to lose.

The idea of sleep compression therapy is pretty much identical to the logic behind the method used to train cat not to be a fussy eater, which works like this: you put a small dish of food out … for ten minutes. If the cat doesn’t eat the food in that period of time, you take it away until the next meal time, by which time the cat is starting to feel considerably less picky about what you put in the dish. After a few missed meals, even the fussiest of all possible cats is going to get hungry enough to eat whatever is put in front of him.

Sleep compression therapy is pretty much identical to the method used to train cat not to be a fussy eater.

By restricting your TTIB, the message to the body is "this is all you're getting, so make the best of it."

Instructions:

Start with a 6-hour period, give or take: less than you need, but more than you are getting.
Set the waking time you want to stick with. Count six hours backwards. That’s your new bedtime. i.e. if you want to get up at 7:00am for the rest of your life, your new training bedtime is 1:00am.
Start this on a weekend or when you have a day or three off from work. You don’t want to operate heavy machinery when you’re starting this process, because you will almost certainly lose sleep during your sleep period and have no opportunity to recover … until the next night.
Do not nap. This is a significant challenge in itself. Do whatever you have to do. For the serious insomniac, a lot is at stake. All I can tell you is that it’s worth it.
Repeat for 3-14 days. Decide in advance and stick to it. Basically, the worse your insomnia, the longer you need to really reinforce the “idea” that you’ve only got a few hours to sleep each night.
At the end of the first phase, move your training bedtime 15-30 minutes earlier, and repeat for another 3-14 days. Increase your sleep in smaller increments for difficult cases.

The sleep “pressure” will accumulate enough so that you can hardly imagine not sleeping in the time available.

Sleep compression therapy is the beating heart of this article. The remaining sections are basically about how to make it better, how to troubleshoot it.

The importance of ritual

This is particularly important for insomniacs who have trouble falling asleep.

Spend some time and create a carefully planned and scheduled bedtime ritual of at least half an hour to repeat every night until you are cured, and frequently for the rest of your life.

The purpose of the ritual is to (a) wind down, and (b) learn to associate your bedtime with a series of predictable steps. It actually makes a difference whether you wash your face and then brush your teeth, or brush your teeth and then wash your face — it doesn’t matter which order you do it in, but it does matter that you always do it in the same order. The more consistent the ritual, the more quickly your brain can learn that face washing followed by teeth brushing equals bedtime.

The timing should be really consistent, too. The ritual should start at exactly the same time every time.

Morning rituals also work well for insomniac’s who wake up too early, although not as well, for the obvious reason that the part we control — the ritual — comes after the part we wish we could control — the sleeping. Nevertheless, it’s just as important to teach your brain that waking time is well-defined.

What to do if you still can’t sleep

People who honestly stick to a basic sleep compression regimen rarely fail. When they fail, it is usually because they aren’t actually doing it — they are finding ways to “cheat.” However, some people have insomnia so severe that even a compressed sleep schedule does not work. I know this because I was one of those people! To make my sleep compression work, I had to up the ante. I needed to make myself even more exhausted.

If you need to up the ante, simply do whatever you have to do to be so exhausted that sleep is the only option. Just feeling tired doesn’t necessarily mean that you are exhausted enough to sleep, so don’t judge your sleep readyness only by how “tired” you are. Most insomniacs feel very tired, of course, but still can’t get to sleep. I have never been so tired in my life as I was during those long sleepless nights in 2005. A subjective feeling of tiredness is a poor measure. What you need is not just to "feel tired," but to actually "be exhausted." So you need to go to greater efforts to ensure that you are well and truly worn out: more fresh air, more exercise, a shorter sleep cycle, no naps, etc ... anything you can think of to make yourself more truly exhausted at bedtime.

And remember that this is behavioural conditioning. Simply keeping upping the deprivation ante until you reach the level where you can teach your body that your bedtime is the time when you fall asleep. Trust me, as long as there is no medical reason for your insomnia, there is a level of exhaustion at which even you will konk out!

How to fill those sleepless moments

Inevitably, there are going to be times when you find yourself awake when you don’t want to be. Even the most effective sleep compression regimen takes time to work. One of the stickiest issues in insomnia management is what to do with those times until the happy day when they stop happening.

One of the worst pieces of amateur advice about insomnia goes like this: “Do something relaxing when you’re awake in the middle of the night. Avoid stimulating activities like video games or going for a walk. Instead, take a lukewarm bath or read a pleasant novel.” While I couldn’t agree more than late-night video games are a bad idea, replacing them with something pleasant is foolhardy.

Do not “reward” your nervous system for being awake. Do not do anything pleasant. Do not make it good, or even especially tolerable.

So … what should you do?

Nothing. Well, almost nothing. This is the procedure:

Attempt to sleep in 20-30 minute blocks of time. If you can’t sleep, don’t lie in bed getting more frustrated. That creates a (really) negative association with bed. You don’t want that any more than you want a positive association with getting up. Simply remain calm, and get up.
Do not turn on any lights. Do not put on something warm and comfortable. Do not have a snack. Do not do anything whatsoever. Go sit, in the dark, on a not-too-comfortable chair. Place value on the peace and quiet. Let your mind drift. I wouldn’t call it “meditation,” but you can if you want.
Wait until you feel really pretty bored and cold and uncomfortable … and then stay a little longer, a few minutes. Then return to bed. Notice how good bed seems at this point.

Repeat as necessary.

It is a very unusual person who can go through more than three of these cycles without finally falling asleep!

More importantly, the goal of this procedure is not precisely to put you to sleep, but rather to avoid dysfunctional conditioning. The goal is to prevent bed from becoming a place where you toss and turn endlessly and just get frustrated … and to prevent getting up from becoming a comforting escape from that frustration. It neutralizes. This procedure helps sleep compression therapy work.

How long will it take?

Some improvements in sleep hygiene combined with sleep compression therapy alone will resolve behavioural insomnia for most people within 4-6 weeks. I had such a severe case that I took three times that long, and progress in the first month was sketchy — but it still worked. Eventually I removed the sleep compression restrictions and stopped using the rigid bedtime ritual, but I still return to these tactics regularly, whenever I suspect there’s a need to shore up my defenses — and now they always work quite quickly. In fact, it’s amazing how I start getting sleepy as soon I start to go through the steps of the bedtime ritual. Like a well-trained dog!

Notes

Jacobs et al. Archives of Internal Medicine. 2004. From the abstract: “These findings suggest that young and middle-age patients with sleep-onset insomnia can derive significantly greater benefit from cognitive-behavioral insomnia therapy (CBT) than pharmacotherapy and that CBT should be considered a first-line intervention for chronic insomnia. Increased recognition of the efficacy of CBT and more widespread recommendations for its use could improve the quality of life of a large numbers of patients with insomnia.” Return to text.
Edinger et al. Sleep. 2001. From the abstract: “[Cognitive-behavioral insomnia therapy] is effective for reducing dysfunctional beliefs about sleep and such changes are associated with other positive outcomes in insomnia treatment.” Return to text.
Edinger et al. Journal of the American Medical Association. 2001. From the abstract: “[Cognitive-behavioral insomnia therapy] leads to clinically significant sleep improvements within 6 weeks and these improvements appear to endure through 6 months of follow-up.” Return to text.
Coren. Sleep Thieves. 1996. Stanley Coren discusses this sort of thing in considerable detail in his book. Very interesting stuff! Return to text.
U.S. Department of Health and Human Services. Morbidity & Mortality Weekly Report. 2009. This report by the U.S. Department of Health and Human Services’s presents evidence that sleep-deprivation is common and serious: about 30% of American adults are getting less than 7 hours per night (and of course many of those are getting much less), and at least 10% of people have gotten “insufficient rest or sleep on all days during the preceding 30 days.” That’s one in ten people getting inadequate rest every night for 30 days in a row!

Consider: if 1 in 10 people have gotten inadequate rest every night for 30 days … how many got inadequate rest for 29 days? 28? 27? The report concludes:

The importance of chronic sleep insufficiency is under-recognized as a public health problem, despite being associated with numerous physical and mental health problems, injury, loss of productivity, and mortality. Health-care providers should consider adding an assessment of chronic rest or sleep insufficiency to routine office visits so they can make needed interventions or referrals to sleep specialists.

I have long believed that this was an almost completely neglected consideration in chronic pain care. Return to text.
Bennett et al. BMC Musculoskeletal Disorders. 2007. Return to text.
Tang et al. Journal of Sleep Research. 2007. Although of course it may be low back pain that is keeping these people awake, in fact my clinical experience suggests that this is by no means the case: chronic low back pain patients are often poor sleepers, and insomnia may routinely precede episodes of pain! Return to text.
Alstadhaug et al. Headache. 2007. Return to text.
Akerstedt et al. Journal of Sleep Research. 2007. From the abstract: “… disturbed sleep and fatigue are predictors of long-term absence [from work due to sickness] and it is suggested that impaired sleep may be part of a chain of causation, considering its effects on fatigue.” Return to text.
Cohen et al. Archives of Internal Medicine. 2009. For a good summary of this research, see Sleepless Nights Equal More Colds In U.S. Study. Return to text.
Ohayon et al. Journal of Psychiatric Research. 2003. Return to text.
Neckelmann et al. Sleep. 2007. The results of this very large and well-conducted survey are “consistent with insomnia being a risk factor for the development of anxiety disorders.” Return to text.
It’s been well-established by scientific research that insomnia is strongly linked to stress. For instance, see Knutson: Reduced sleep duration and quality are associated with elevated blood pressure, according to researchers with the CARDIA study. They used wrist activity monitors to monitor associations between sleep behaviors and BP among more than 500 adults in their 30s and 40s, finding that shorter sleep duration and poorer sleep maintenance were each associated with increased systolic and diastolic BP. The authors say the sleep-BP link is supported by previous research and “laboratory evidence of increased sympathetic nervous activity as a likely mechanism underlying the increase in BP after sleep loss.” Return to text.
Waters et al. Behav Sleep Med. 2003. From the text: “There are good theoretical and empirical reasons to believe that SHE [sleep hygiene education] improves sleep.” Return to text.