Sleep Hygiene and CBT-I: Context and Timing are Everything

The good news about sleep hygiene is that if you use these steps at the right time, the benefits will prove considerable. The bad news is that many sleep patients complaining of sleep problems are offered sleep hygiene tips either at the wrong time or under the wrong circumstances. Whereas, the goal should be to steer patients toward the right sleep hygiene step at the right time. In a prior post we have already discussed some of these steps and drilled down into deeper emotional territory, which often explains the underlying reasons for someone to develop bad sleep habits and subsequent poor sleep hygiene.

Let’s start by clarifying who benefits the most from sleep hygiene steps. Sleep hygiene as a first-line and expedient therapy is usually helpful to individuals whose sleep problems are so mild they would never imagine themselves becoming sleep patients. So, if you are suffering from truly mild problems with your sleep, then reviewing a sleep hygiene checklist (there are hundreds of different versions on the Internet) may provide several useful tips.

In contrast, patients who seek care for sleep problems from sleep specialists are likely to be experiencing more than mild sleep complaints. As such, these patients demonstrate less of a chance to make rapid gains in bettering their sleep through simplistic sleep hygiene steps. In fact, sleep hygiene could make matters worse and often does so among severely hypnotic-dependent insomniacs who seek professional help. For example, if you tell this patient to set a regular bedtime and wakeup time, which is one of the classic sleep hygiene steps, along with its variant—get 8 hours of sleep each night—you can see where the insomniac will be puzzled if not flustered by such a self-defeating recommendation in the context of his or her current struggle with failing medication regimens. In this instance, the individual should be told instead something quite opposite than the dictates above, because a regular bedtime is highly unlikely, and 8 hours of sleep may be out of the question. Thus, the best conversation with the patient might turn to the principles of sleep quality and then CBT-I, and possibly in the right circumstances the simple sleep hygiene step of anchoring the morning wake-up time only.

The difference between these two sets of instructions is the basis for the distinction between sleep hygiene steps and cognitive-behavioral therapy for insomnia (CBT-I). A problem arises when patients or doctors mix up their interpretation of these different therapies, which then increases the risk of trying out the wrong step at the wrong time. Part of this discussion is semantics, but the most relevant part is very clinically meaningful. Consider an instruction to stop smoking or drinking alcohol near bedtime. Such advice almost always appears on a sleep hygiene checklist, but just how easily do you think someone could change this better to a degree that would actually benefit his or her sleep?

In my clinical experience, heavy smokers or drinkers are in need of very intensive types of psychotherapies, similar to CBT-I or even more extensive, to change these behaviors. Thus, from a sleep hygiene perspective, these guidelines to stop a behavior may be worthless instructions, and they are likely to irritate patients who already appreciate that their smoking or drinking behavior is part of a larger set of healthcare problems. Even among moderate drinkers, it may prove very difficult to change this behavior near bedtime, because they still may be using the alcohol to facilitate sleep onset near bedtime. For them, the drinking behavior is a positive, regardless of whether or not it leads to middle of the night awakenings due to the mini-withdrawal state that might arise a few hours after bedtime. 

Along the same lines, let’s look at something simpler than sleep restriction therapy (so frequently touted through CBT-I) that still might be of use to the severely hypnotic dependent insomniac whose drugs are failing. A poor man’s version of sleep restriction therapy is waking up every morning at the same time, and this step highlights the huge difference between a sleep hygiene rule and CBT-I. When dealing with a severe insomniac whose drugs are failing, legitimate but often irrational fears arise about the loss of sleep. Thus, if you attempt to explain to this person the physiological basis for sleep restriction to increase sleep pressure with fewer hours of sleep, the argument may be received as rational, but the patient might still experience anxiety about trying to adopt the restricted sleep pattern, leading to feelings which directly re-stimulate fears about losing sleep at night.

On the other hand if you explain to the patient the simple behavioral concept of anchoring your morning wakeup time and sticking with that plan for a while, it is distinctly possible the individual will hear this step as a straightforward sleep hygiene principle and move forward in applying it. While it’s true the patient may develop some loss of sleep, this context is very different than CBT-I where there is a volitional loss of sleep based on the restricted schedule. Anchoring the morning bedtime anticipates some sleep loss, but it does not ask the patient to expressly lose sleep for the step to work. The physiology about morning anchoring can be described as helping to regulate the circadian clock or building up sleep pressure if you happen to have a bad night of sleep.

Thus, anchoring the morning wakeup may be the right sleep hygiene step at the right time for an individual who would otherwise choose to reject the two cardinal principles of CBT-I, stimulus control—get out of bed when not sleepy or sleeping, and sleep restriction—reduce the number of hours in bed temporarily to increase sleep pressure and eventually sleepiness.

One more complex example will be offered to again show the difference between a sleep hygiene step and CBT-I. One of the more challenging insomnia problems, especially among people under the age of 40 is the inability to fall asleep in a desirably short time frame. As one ages, the overall sleep debt in a poor sleeper eventually erases any problems falling asleep, but then new problems set in with awakening during the night. Still, for both conditions patients are faced with the same dilemma, that is, how to fall asleep (bedtime context) or how to fall back asleep (middle of the night context).

What would CBT-I and sleep hygiene instructions recommend for these patients?

Sleep hygiene most often describes the importance of working on a relaxing bedtime ritual that avoids over-stimulation and thereby promotes a relaxed consciousness that might drift off to sleep sooner than later. CBT-I proposes that you slide out of bed if you are not sleepy and wait until sleepiness returns.

Depending upon the context in terms of the patient’s anxiety levels about following new instructions, if the patient is desperate but still rational about hearing new strategies to treat insomnia, then this individual may be capable of digesting the psychophysiological changes that can be generated by leaving the bedroom when not sleepy. With this knowledge, the person realizes the cure is not worse than the disease. Rather, sliding out of bed can lead to less frustration by not trying to force oneself to sleep. And, if the individual redirects his or her energy to some other activity, then sleepiness might return in short order. In contrast, if the patient suffers a more irrational fear about the inability to fall asleep, then a direct method to counter the problem would be to use mind’s eye imagery techniques that in many individuals will distract the person from racing thoughts, after which sleepiness may emerge again in short order.

In the CBT-I scenario, the individual is learning a cognitive technique to be applied behaviorally, and it works very well for those who embrace the thesis and possess the courage to make the attempt. The imagery technique is addressing the concept that you can do something to relax your mind and eliminate the racing thoughts that block sleepiness from emerging in your mental landscape. Even though imagery techniques are not well-researched in the sleep community, there is a great amount of research and books written about imagery techniques for other health purposes and for daily functioning. In our sleep example, the imagery is a simple step that does not require much explanation: you want your mind to relax and you want the wheels in your mind to stop turning, well then, just picture something relaxing and the rest will be forthcoming.

Although some of these distinctions appear subtle, there are anything but subtle if given to the wrong patient at the wrong time. Anyone who specializes in the use of CBT-I techniques for insomnia knows how powerful and effective the program can be, but at the same time, it is less well known that a notable proportion of patients cannot or will not use CBT-I. Thus, CBT-I could also be given to the wrong person at the wrong time. Fitting the best technique, whether it is sleep hygiene first (usually less common) or CBT-I first (more common), to the appropriate patient will lead to faster and stronger results and less frustration for both the patient and the sleep professional.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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