This detailed self-help article is humbly offered to people suffering from severe insomnia, in the hopes that my expertise and personal experience can be of some 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 conditioning123 — and even if there is a medical cause for your insomnia, behavioural conditioning may still be your best defense.
Why do I have a big article about treating insomnia on a website about pain and injury? Because sleep deprivation is a major, common unsuspected factor in pain, and because I have a great deal of personal experience with it.
Insomnia is a glamorous term for thoughts you forgot to have in the day.
Alain de Botton
I slept poorly from the age of twelve on, and I suffered through three major episodes of extreme insomnia as an adult. In 2005, I feel as though I nearly died from insomnia so savage 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 treated myself successfully. It was quite challenging, and my sleep is still not perfect. However, I have now gone eight years without any more severe insomnia — by far the longest period since I was a child.
Sleep is like a cat: it only comes to you if you ignore it.
Gillian Flynn, Gone Girl
Serious insomnia is nothing to mess around with. At my worst, I felt like I was made of glass, everything hurt, and I was seeing everything through a haze of mental distortions, exaggerated mental tangents, and minor hallucinations. From xkcd a popular geeky webcomic, here’s a strip about sleep deprivation that exactly describes how I felt in the summer of ‘05, and how any sleep-deprived person feels when they start to sink down to less than 3–5 hours per night. (Be sure to let your mouse cursor hover over the comic for an extra caption.)
Hallucinations are just the beginning: 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.4 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 it has any kind of a brain of any kind at all.5
There is even a rare genetic disease, fatal familial insomnia (FFI), that causes such severe insomnia that victims die:
The main symptom of FFI … is the inability to sleep. First the ability to nap disappears, then the ability to get a full night's sleep, until the patient cannot sleep at all. The syndrome usually strikes when the sufferer is in his or her 50s, ordinarily lasts about a year, and, as the name indicates, always ends in death.
“The Secrets of Sleep,” National Geographic Magazine, May 2010
Insomnia is not commonly fatal, of course, because there are all kinds of self-preservation mechanisms that kick in — as long as you don’t have a disease like FFI that absolutely eliminates sleep, you will never come anywhere close to losing enough of the stuff to kill you. But the fact that sleep is so basic strongly suggests that sleep-deprivation is a dangerous problem, even when it falls short of being actually lethal.6 And in fact there is a considerable amount of science confirming exactly this. Here in Vancouver, University of British Columbia psychologist Stanley Coren7 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. Here are several examples:
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.
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 stresses15 or by other medical problems. This kind of insomnia is called “behavioural insomnia.”
I resisted this idea at first. Actually, I strongly resented it for a long time. It sounded like an dismissive “all in your head” diagnosis to me. I certainly did not feel like I had a bad habit. I felt like a victim of some terrible malfunction of my central nervous system.
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:16
The magic is in the behavioural conditioning, and it’s what most of the rest of this article is about. Step one just paves the way, and is mainly a determined application of common sense…
All the behavioural condition in the world will be useless if you sleep in bright, noisy, stuffy bedroom with a snoring spouse and a pesky cat. 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. Seriously. Why not? Remember what’s at stake here. People have transplanted themselves across oceans and continents for much less: jobs, boyfriends, and better scenery.Another sleep deprivation comic from xkcd. I think xkcd creator Randall Munroe knows all about this problem …
Sleep is a complex human behaviour, and 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 “anything goes” with sleep. Sleep behaviour is quite variable and adaptable across cultures and situations, and we can learn and unlearn nearly any kind of sleep habit. And yet of course not all sleep hygiene actually works well. Just because we can learn to sleep in surprisingly sleep-hostile conditions doesn’t mean that it’s a good idea. 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. Depending on the activity, 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 literally couldn’t even put 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.
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.17
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.
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.
The problem is that it is not actually possible for anyone — except cats — to consistently sleep solidly through such a long period. 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!
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.
An insomniac reader provided this good description of his experience of the TTIB 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.
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.
Training for recovery from behavioural insomnia is usually most easily cured by restricting sleep to an inadequate, 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:
Put a small dish of food out … for ten minutes only. 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 a lot less choosy. After a few missed meals, even the fussiest of all possible cats is going to get hungry enough to eat whatever is in the bowl.
By compressing your TTIB into just a few hours, the message to the body is "this is all you're getting, so make the best of it."
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.
One of the most common objections I’ve heard to sleep compression therapy is that it doesn’t matter if your insomnia has a medical or psychiatric cause, such as pain, or severe anxiety.
This is not true. It matters more.
It may not work as well … but the need is actually greater. The more difficulty you have sleeping for any reason, the more important it is to have good sleep hygiene.
Consider pain, for example. There is no question that it can wreck sleep! And no amount of improvement in sleep hygiene is going to magically make that pain go away — obviously. But there is only one thing worse than sleep-destroying chronic pain, and that is chronic pain plus crappy sleeping habits. The chronic pain patient who makes every effort to maximize their chances of sleeping is going to be better off, every time, than the chronic pain patient who does not.
No matter what is wrong with you, no matter what is disturbing your sleep, it is important to have sleep behaviour that is as good as possible under the circumstances.
Sleep isn’t an escape, it’s an act of rest.
Jock McKeen & Bennet Wong, founders of Haven
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.
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!
Inevitably, there are going to be times when you find yourself awake when you don’t want to be, and one of the stickiest issues in insomnia management is what to do with those times. Even the most effective sleep compression regimen takes time to work. But trickier still is that being awake some during the night is probably perfectly normal, part of a healthy waking-up-at-an-ungodly-hour rhythm in human sleep. The science news:
We often worry about lying awake in the middle of the night — but it could be good for you. A growing body of evidence from both science and history suggests that the eight-hour sleep may be unnatural.
I agree that it is getting pretty clear that humans aren’t really built to sleep through the night (with the exception of my wife, apparently, who can sleep 10 hours without so much as rolling over). In fact, we probably have a natural wakeful period in the middle of the night in the same way that we are prone to naps in the afternoon — a sort of mirror image. They even tend to occur around the same section of the clock face: 2–4pm and 2–4am.
So you want to respect the fact that being awake may be fine, while at the same time being quite careful that you’re not awake for the wrong reasons or for dysfunctionally long. The distinction between healthy and unhealthy wakeful patches can get pretty blurry and confusing, especially for the groggy, exasperated insomniac.
I’d actually known about this idea of a normal awake patch for several years. I first learned about it from a terrific radio documentary back in 2006. It probably didn’t really sink in because I was in the middle of my first major successful recovery from insomnia, and there just wasn’t much room in my head for another wrinkle. My recovery progressed more or less normally, even though I continued to wake up in the middle of the night. I tried just standing on the deck in midwinter, quite cold and uncomfortable, doing nothing until I couldn’t stand it any more and was desperate to get back into bed.It wasn’t a failure to be up for a bit, as long as I could get back to sleep in a reasonable time. Which I did.
My intention at the time was to make it downright unappealing to be awake — to actively discourage it, to break any habit of being awake at that time. I thought the goal was to avoid “rewarding” my nervous system for being awake by doing anything pleasant. That was the advice in this tutorial for years, and it dovetailed well with sleep compression therapy.
But I never really followed my own advice!
I tried a few times. For instance, I tried just standing on the deck in midwinter, quite cold and uncomfortable, doing nothing until I couldn’t stand it any more and was desperate to get back into bed. But that kind of nonsense didn’t last long. Over a year or two, I “fought” wakefulness less with discomfort, and settled into the mild-mannered compromise that I’m still working with today: I don’t turn on any lights, and I don’t do any work or “engage” with the world at all; but I do make myself comfortable, and do something pleasant but mellow, like reading or listening to an audiobook. I’m usually quite content for 20-30 minutes, after which I can hardly imagine staying awake.
I did that for years without thinking about it much, accepting my wakeful patches for the wrong reason, treating them like a minor, vestigial remnant of my insomnia that wasn’t worth fighting — rather than a natural, healthy part of my circadian rhythm that actually should be embraced, not resisted.
It may be healthy and normal to have a little early AM wakefulness … but it’s still problematic for insomniacs.
It is psychologically important for insomniacs not to indulge in much night-time activity. It would be foolish to turn on all the lights, pump up the volume, and catch up on household chores — not because it’s at odds with biology at that time of night, but because that would probably be part of a much bigger life problem (workaholism, overstimulation, anxiety) that tends to wreak havoc on sleep at all other times. It probably would be okay for non-insomniacs to get quite active for a spell during the night, just like it’s okay to have a hard two-hour nap after lunch (if you’ve got that in you). A healthy person can fall asleep after midnight romps.
But probably not someone with terrible insomnia! The insomniac has to be a little more careful — maybe a lot more careful — not to let a little natural alert period get out of hand.
I’m content to defy my natural biological rhythms a little by keeping things pretty low-key all night long, because it helps me keep my workaholic demons at bay. Plus it’s just practical to mostly go with the “sleep all night” cultural flow. My wife is never awake at that time, and it would be a bit problematic if I were to start making a habit of consistently getting up for a couple hours in the middle of the night. Not awful, just awkward. I suspect this is how most people will feel.
At the same time, it’s not necessary to aggressively fight that wakeful patch, however. There’s no need to deprive yourself of all comfort in an effort to drive yourself back to bed, as my tutorial has recommended for years. So my advice thise days is to respect the fact that it’s probably normal and healthy to be awake a bit in the middle of the night. It has little to do with most insomnia, especially if you stay calm and just — quietly, calmly — go along with it.
Here’s a more step-by-step summary:
Repeat until asleep.
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!
Friday, January 25, 2013 — Rewritten section, “How to fill those sleepless moments.” The section now deals with the likelihood that it is actually healthy and normal to be awake for a little bit in the middle of the night. A small thing, but the section pretty much had to be completely revised.
Wednesday, May 4, 2011 — Added a small but imortant point about the trouble with hot baths.
Thursday, September 16, 2010 — Added this quote: “Sleep isn’t an escape, it’s an act of rest.” (McKeen)
Monday, August 9, 2010 — Finally started logging updates for this document, although it’s been around since 2006. Today I added two interesting references and the XKCD comic strip about sleep deprivation.
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.”BACK TO TEXT
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.”BACK TO TEXT
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.”BACK TO TEXT
Science may produce an explanation for this over the next few years, and some very interesting clues have already emerged. For instance, in 2007 the radio show Radio Lab did a whole show about sleep, quite brilliantly reporting this tidbit that I’d never heard before: that sleep deprivation may do its dirty work by (somehow) interfering with protein folding (starting about minute 29, transcription a bit imprecise because of the complex mix of sound bytes):
BACK TO TEXT
Dr. Allan Pack, a “rabid biologist,” has been looking at sleep at the cellular level, and one of the things he’s found over and over and over — shown in mice, shown in rats, shown in fruit fly — is that certain cells in all those different types of animals, when they are sleep-deprived … what happens is that you don’t get proteins properly folded.
Excuse me? Proteins properly folded? This is a phenomenon called the unfolded protein response. But what on earth does that mean? Why do you need proteins to “properly fold”? Well, you’re made of proteins. Proteins are the essence of you. If your proteins are misshapen, if they’re not folded properly, if they don’t have the right three-dimensional structure, and as a result they start accumulating inside the cell, then these unfolded proteins can start to aggregate together and form clumps inside the cell and essentially clog it up and it’s really quite toxic. Clumpiness equals tiredness!
But when you get sleep, a group of cleaner-uppers have gone through your cells and removed the misshapen proteins so that, in effect, sleep is the best housemaid you’ve ever had, in the hotel of you.
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.BACK TO TEXT
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.”BACK TO TEXT
The results of this very large and well-conducted survey are “consistent with insomnia being a risk factor for the development of anxiety disorders.”BACK TO TEXT
From the text: “There are good theoretical and empirical reasons to believe that SHE [sleep hygiene education] improves sleep.” In other words, reading this will put you to sleep!BACK TO TEXT