Sleep Disorders Center


Behavioral Treatment of Insomnia

We have conducted a thorough evaluation of your sleep problem and, based on our findings, we believe that you will benefit from some information about sleep and some recommendations designed to help you change your sleep habits. When sleep problems linger on, as they have in your case, usually bad sleep habits develop and add to the sleep problem. The treatment you receive will educate you about your sleep problem and help you correct your bad sleep habits so that you can again have a more normal sleep pattern. You will be asked to complete a sleep log and to follow some simple rules.

In some respects, sleep loss may have a positive following night's sleep. In fact, the drive to sleep gets stronger the longer one is awake through each day in order to build up enough sleep drive to produce a full night's sleep.

Extended periods of sleep loss, of course, may have some bad effects as well. If people are totally deprived of a night's sleep, they usually become very sleepy, have some trouble concentrating and generally feel somewhat irritable. However, they typically can continue most normal daytime activities even after a night without any sleep at all. When allowed to sleep after a longer than normal period of being awake, most people will tend to sleep longer and more deeply that they typically do on a normal night. Although people tend not to recover all of the sleep time they lost, they do typically recover the deep sleep they lost during longer than usual periods without sleep. Hence, your body's sleep system had some ability to make up for times when you don't get the amount of sleep you need.

You may notice, after you have kept a sleep log for several weeks, that you occasionally have a relatively good night's sleep after one or several night of poor sleep. Such a pattern suggests that your body's sleep system has an ability to make up for some of the sleep loss you experience over time. Although your sleep is not normal, you can take some comport in this observation. The important point to remember is that you do not need to worry a great deal about lost sleep nor should you actively try to recover lost sleep. Needless worry and attempts to recover lost sleep will only worsen your sleep problem.

This recording is not intended to "make light" of your sleep problem. You do indeed have a sleep problem that needs to be treated. This recording is intended to help you to understand your problem. With this knowledge you should now understand the purpose for the treatment recommendations.

Rule 1: First it is important that you choose a standard wake-up time and stick to it every day regardless of how much sleep you actually get on any given night. This practice will help you develop a more stable sleep pattern. Changes in your sleep-wake schedule can disturb your sleep. In fact, you can create the type of sleep problem that occurs in jetlag by varying your wake-up time from day to day. If you stick to a standard wake-up time, you will soon notice that you usually will become sleepy at about the right time each evening to allow you to get the sleep you need.
Rule 2: While in bed, you should avoid doing thing that you do when you are awake. Do not read, watch TV, eat, study, use the phone, or do other things that require you to be awake while you are in bed. If you frequently use your bed for activities other that sleep, you are unintentionally training your self to stay awake in bed. If you avoid these activities, while in bed, your bed will eventually become a place where it is easy to go to sleep and stay asleep. Sexual activity is the only exception to this rule.
Rule 3: Never stay in bed, either at the beginning of the night or during the middle of the night, for extended periods without being asleep. Long periods of being awake in bed usually lead to tossing and turning, becoming frustrated, or worrying about not sleeping. These reactions, in turn make it more difficult to fall asleep. Also, if you lie in bed awake for long periods, you are training yourself to be awake in bed. When sleep does not come on or return quickly, it is best to get up, go to another room, and only return to bed when you feel sleepy enough to fall asleep quickly. Generally speaking, you should get up if you find yourself awake for 20 minutes or so and you do not feel as though you are about to go to sleep.
Rule 4: Do not worry, mull over your problems, plan future events, or do other thinking while in bed. These activities are bad mental habits. If your mind seems to be racing or you can't seem to shut off your thoughts, get up and go to another room until you can return to bed without this thinking interrupting your sleep. If this disruptive thinking occurs frequently you may find it helpful to routinely set aside a time early each evening to do the thinking, problem-solving, and planning you need to do. If you start this practice you probably will have fewer intrusive thoughts while you are in bed.
Rule 5: You should avoid all daytime napping. Sleeping during the day partially satisfies your sleep needs and, thus, will weaken your sleep drive at night.
Rule 6: In general, you should go to bed when you feel sleepy. However, you should not go to bed so early that you find yourself spending far more time in bed each night than you need for sleep. Spending too much time in bed results in a very broken night's sleep. If you spend too much time in bed and what times you should go to bed at night and get out of bed in the morning.

After a two week sleep log is evaluated, you will be given a time in bed prescription and a standard wake up time. You should try this sleep-wake schedule for one week and determine how well you sleep at night and how tired or alert you feel in the daytime. If you sleep well most nights and are as alert as you would like to be in the daytime, then you probably should make no changes in your time in bed each night. If, however, you find you are sleeping well at night, but you feel tired most days, you should try increasing your time in bed at night by 15 minutes. If, for example, you begin with 7 hours in bed per night the first week and find that you are tired in the daytime despite sleeping soundly at night, you should try spending 7 hour and 15 minutes in bed each night during the second week. If, with this amount of time in bed, you continue to sleep soundly at night but still feel tired in the daytime, you can add another 15 minutes in bed during the tired week and so on. However, when you notice an increase in the amount of time you are awake in bed each night, you will know that you are spending too much time in bed at night. If this occurs, you should decrease your time in bed by 15 minutes per week until you find the amount to time that enables you to sleep soundly through the night and feel reasonably alert in the daytime. You should also decrease your time in bed after the first week if the initial amount of time in bed we choose together today does not reduce your time awake in bed each night.

To help you make decisions about changing your time in bed, it may be helpful for you to perform a simple calculation each day using the information you recorded on your sleep log. You can divide the amount of time you slept during the night by the amount of time you spent in bed. If, for example, you sleep 6 hours but your spend eight ours in bed on a particular night, you would divide 6 by 8 and get a value of .75 as a result. Generally speaking, you should increase your time in bed following a week during which the average of these values you calculate for each night is .85 or higher and you continue to experience daytime sleepiness. In contrast, you should decrease you time in bed following a week during which your average of these values is less that .80.

Please continue to complete sleep logs during this phase of therapy.

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