This topic is near and dear to me because I struggled with sleep difficulties while studying for my licensing exams this past year, particularly on the nights leading up to a major exam. Insomnia can be so disruptive because not only is it frustrating to lie awake for hours at night, but functioning the next day is undoubtedly affected. The need to be high-performing while sleep-deprived can create a lot of stress, leading to even more sleep deprivation; thus quickly becoming a vicious cycle.
The official diagnosis of insomnia is based on a dissatisfaction with sleep quality or quantity that is associated with either difficulty falling asleep, staying asleep, or with early morning awakening; occurring at least 3 nights per week for 3 months (1). Insomnia can occur on its own or can be secondary to a psychiatric disorder, substance use disorder, or other medical condition, and is typically deemed chronic if it persists for more than 6 months. Chronic insomnia is the most common sleep disorder affecting 6-10% of adults in the general population (2). For the sake of this article, we’ll focus our attention on acute and chronic insomnia without a clear cause aside from stress and poor mental health.
Sleep hygiene is often recommended as a non-pharmacologic remedy for sleep issues. It refers to a set of behavioural and environmental modifications carried out prior to sleep that are thought to improve sleep quality. These modifications include but are not limited to stress management, noise and light reduction, maintaining a regular sleep-wake schedule, regular daily exercise, avoiding daytime napping, avoiding caffeine, alcohol, and nicotine in the evenings, and avoiding liquids within 2 hours of bedtime. All of these recommendations would seem to promote better sleep, especially in combination, but the evidence around sleep hygiene implementation for the treatment of insomnia is limited (3).
That being said, having good sleep hygiene has its advantages for the general population, and potentially as a solid foundation whereon more potent therapy for insomnia can take effect. Sleep hygiene education is readily available, does not require delivery by a health professional, and is relatively inexpensive. Although in some cases significant lifestyle changes need to be made in order to “clean up” habits that may be affecting sleep (3). I would also argue that most people who struggle with sleep are already familiar with sleep hygiene recommendations, so sending patients home with just a sleep hygiene handout is usually not enough, especially for those living with chronic insomnia.
When I was dealing with my sleep difficulties I knew that the root of the issue was my heightened anxiety levels, so stress reduction became my main goal. I had to work hard to reframe my relationship with my upcoming exams, take the breaks I desperately needed, and try to lessen the pressure I was putting on myself to perform. Certain sleep hygiene techniques helped such as decreasing my caffeine intake, making time for exercise, and breaking the habit of watching shows in bed, but I can’t credit sleep hygiene measures alone for my eventual improvement. In fact, now that my licensing exams are over and I’ve become better at managing my stress levels I don’t have to maintain perfect sleep hygiene in order to sleep well. For me, sleep hygiene played a supportive role, while addressing underlying psychological factors with the help of a licensed therapist was the key.
Cognitive behavioural therapy for insomnia (CBT-I) is a psychotherapeutic strategy aimed at addressing the behaviours, cognitions, and associations that people with insomnia adopt over time (2). These cognitive distortions can perpetuate insomnia regardless of the cause; be it primary or secondary to a medical or psychiatric concern, and can worsen mental health if not treated appropriately (4). CBT-I addresses both sleep hygiene as well as the emotional arousal and wakefulness that most people with insomnia experience at bedtime (2). This approach provides practitioner-led sleep education that is tailored to the patient’s individual behaviours, environment, and mindset, and uses additional techniques such as stimulus control, sleep restriction, and progressive muscle relaxation to obtain long-term relief.
Bottom line: sleep hygiene is just one piece of the insomnia puzzle. CBT-I is an evidence-based therapy that provides a comprehensive approach to sleep difficulties. There are a growing number of CBT-I resources out there including online programs, books, and apps, but seeing a certified provider trained specifically in CBT-I remains the most effective option. Other therapeutic options not discussed in this article include pharmacotherapy, nutraceuticals, and botanical medicines which may be helpful for the short-term management of insomnia. It’s always best to discuss your options with your healthcare provider prior to initiating any therapy.
Author: Emily Howard, ND, BSc
References
1. CTC 2019: Compendium of Therapeutic Choices. Ottawa, ON: Canadian Pharmacists Association; 2018.
2. Williams J, Roth A, Vatthauer K, McCrae CS. Cognitive behavioral treatment of insomnia. Chest. 2013;143(2):554-565. doi:10.1378/chest.12-0731
3. Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH. The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep Med Rev. 2015;22:23-36. doi:10.1016/j.smrv.2014.10.001
4. Taylor, Daniel J., Pruiksma, Kristi E. Cognitive and behavioural therapy for insomnia (CBT-I) in psychiatric populations: A systematic review. International Review of Psychiatry. 2014;26:2, 205-213, DOI: 10.3109/09540261.2014.902808