What If Sleep Hygiene Doesn’t Work?
Look up the words “sleep hygiene,” and you’ll find countless suggestions for what to do and what not to do at bedtime. These simple behavioral changes — don’t eat, avoid caffeine, keep pets out of the bedroom, for example — may seem like a cure-all for any kind of sleep trouble. Sleep hygiene is often promoted on medical and sleep websites as the first line of defense against insomnia or a bad night of slumber.
But what if you’ve tried sleep hygiene? What if you’ve darkened your bedroom, put the clock where you can’t see it, turned off your electronics at night, and you’re still having trouble sleeping? What then?
FAQ
Q: What does sleep hygiene mean? A: Originally used to refer to clean bedding and bedclothes, sleep hygiene has evolved to mean sleep-promoting actions and behavioral changes.Note: The content on Sleepopolis is meant to be informative in nature, but it shouldn’t take the place of medical advice and supervision from a trained professional. If you feel you may be suffering from any sleep disorder or medical condition, please see your healthcare provider immediately.
What Is Sleep Hygiene?
Sleep hygiene recommendations are intended to help improve the quality and duration of sleep. (1) They were originally developed to relieve mild to moderate insomnia symptoms, though the term has since become a catch-all phrase for a variety of actions intended to promote healthy sleep.
The term “sleep hygiene” was first coined in the late 1930’s. The protocol has only recently become popular as a magic bullet for everything from occasional trouble sleeping to chronic insomnia. The sleep hygiene checklist may consist of the following suggestions:
- Go to bed and wake up at consistent times, even on weekends (2)
- Create a quiet, dark, and cool sleeping environment
- Avoid eating heavy meals or drinking caffeine or alcohol in the hours before bedtime
- Reduce or eliminate naps
- Keep children and pets out of the bedroom overnight
- Turn off all sources of blue light, including computers, smartphones, televisions, and tablets, at least one hour before bed
- Reserve the bed for sleep and sex only
Most sleep hygiene suggestions are supported by scientific research. Yes, naps can reduce the drive to sleep at night, and a bedroom that is too warm can make sleep more difficult. But research on sleep hygiene demonstrates its effectiveness only for relatively normal sleepers. Sleep hygiene is not a proven treatment for chronic insomnia, which is insomnia lasting three months or longer, at least three days each week. (3)
If you’re a faithful follower of sleep hygiene but still struggle to fall asleep, stay asleep, fall back to sleep, or a combination of all three, you may require a different type of treatment.
Normal sleeper
Someone who routinely is able to get sufficient sleep -- typically between seven and nine hours each night -- without difficulty or anxiety.
What Causes Insomnia?
Short-term insomnia, or transient acute insomnia, last less than three months and has a number of possible causes. (4) These include:
- A major life transition, such as a move, new job, new school, or the birth of a child
- Stress
- Anxiety
- Pain
- Grief
- Depression
Insomnia is considered chronic when it lasts for three months or longer. (5) Insomnia of this duration is considered to be insomnia disorder. Though depression and other mood disorders may be a factor, chronic insomnia usually has one primary cause: negative associations with sleep and the sleeping environment.
This conditioning may begin with an episode of transient insomnia that leads to the fear of being unable to sleep. Once anxiety begins, it can become associated with anything related to sleep, such as showering and switching off lights. Behaviors like lying in bed trying to sleep and watching the clock can worsen anxiety and reinforce a negative response to bedtime. (6)
The brain, circadian rhythm, and nervous system are designed to be sensitive to anxiety and other mood changes, and serve a protective purpose. Human ancestors once slept outdoors and were vulnerable to predators, making it important to remain awake under stressful conditions. Modern stresses and fears are typically less urgent, but no less disruptive to sleep and wake cycles.
FAQ
Q: What is the definition of insomnia disorder? A: Trouble falling asleep, staying asleep, falling back to sleep, or unrestorative sleep. Any combination of these symptoms may occur, but must persist for three months, at least three days each week, to be considered insomnia disorder.Diagnosing Insomnia
Trouble sleeping for three months or longer may indicate a number of sleep difficulties or disorders. Sleep disorders are best diagnosed by a sleep specialist, who will typically request a sleep and medical history. (7) In addition to information about your symptoms, a doctor may:
- Ask about your sleep habits and social environment
- Suggest you keep a sleep diary to track your sleep patterns and identify factors that might contribute to your insomnia issues
- Ask that you take one or several insomnia tests to better understand your sleep habits. These might include questionnaires such as the Insomnia Severity Index or a mental health examination
Because people undergoing sleep studies often sleep less than they would in their usual environment, such studies are rarely helpful for diagnosing insomnia disorder. Once a diagnosis is made, appropriate treatment can be discussed.
Treatment of Insomnia: Sleep Hygiene Vs. CBT-I
In the case of transient insomnia, symptoms usually resolve on their own and treatment is rarely necessary. If the sufferer of transient insomnia has bedtime habits that make sleep more difficult, sleep hygiene may help.
Chronic insomnia persists despite the use of sleep hygiene, and generally does not go away on its own. (8) Chronic insomnia is often treated with cognitive behavioral therapy for insomnia, also known as CBT-I. CBT-I is a multi-session treatment usually conducted by a sleep professional, such as a psychologist who specializes in the treatment of sleep disorders.
Sleep hygiene may incorporate some aspects of cognitive behavioral therapy, but is not a specific protocol designed for sufferers of chronic insomnia. When suggested for more than mild sleep troubles, sleep hygiene may delay treatment and become an ineffective substitute for CBT-I and related methods. Unlike sleep hygiene, CBT-I is proven in multiple studies to be more than 80% effective in improving chronic insomnia. (9)
Chronic insomnia sufferers who try sleep hygiene may find the results disappointing, further increasing anxiety and exacerbating the disorder. Frustration with sleep hygiene may make patients more reluctant to engage in CBT-I treatment, and less confident about the chances of success once they do.
CBT-I Essentials
Sleep professionals generally suggest CBT-I as the primary treatment for insomnia disorder. Basics of the protocol include:
- Sleep restriction therapy. Sleep restriction therapy limits time in bed to the average number of hours spent sleeping (10)
- Stimulus control therapy. Stimulus control therapy is designed to strengthen associations with the bed as a place to sleep
- Relaxation training. Relaxation training can help insomnia sufferers reduce anxiety and physical tension, allowing the nervous system to relax and making sleep more likely
- Cognitive behavioral therapy. The therapy component of the protocol addresses negative attitudes and misconceptions about sleep
CBT-I usually requires time and patience, and may take several sessions before results become apparent. Though the effects aren’t immediate, the protocol can be remarkably effective, even for those who’ve suffered from insomnia for months or years. (11)
Stimulus control
A behavioral psychology term that refers to a predictable pattern of behavior that occurs in the presence of a certain stimulus, and another pattern that occurs in the absence of that stimulus.
Last Word From Sleepopolis
Sleep hygiene is a popular set of behavioral changes and suggestions that are intended to make sleep easier and more efficient. Though sleep hygiene may be helpful for those with poor bedtime habits and mild sleep difficulties, there are few if any studies demonstrating its efficacy for chronic insomnia.
Most people who experience insomnia typically try many behavioral changes in an effort to fall asleep faster and stay asleep. If sleep hygiene doesn’t work, difficulties with sleep may be more responsive to proven insomnia treatments such as CBT-I. Studies show that CBT-I is effective for most people with protracted insomnia, improving symptoms and making sleep more efficient.
References
- David F. Mastin, Assessment of Sleep Hygiene Using the Sleep Hygiene Index, Journal of Behavioral Medicine, June 2006
- 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 Medicine Reviews, Aug. 1, 2016
- Sharon Schutte-Rodin, M.D., Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults, Journal of Clinical Sleep Medicine, 2008
- Chien‐Ming Yang, Shih‐Chun Lin, Chung‐Ping Cheng, Transient Insomnia Versus Chronic Insomnia: A Comparison Study of Sleep‐Related Psychological/Behavioral Characteristics, Journal of Clinical Psychology, June 24, 2013
- Roth T., Insomnia: Definition, Prevalence, Etiology, and Consequences, Journal of Clinical Sleep Medicine, Aug. 15, 2007
- Bonnet MH and Arand DL. Hyperarousal and Insomnia: State of the Science. – PubMed – NCBI, Feb. 14, 2010
- Saddichha S.Diagnosis and treatment of chronic insomnia, Annals of Indian Academy Neurol. 2010 Apr.13
- Sharma MP, Andrade C., Behavioral interventions for insomnia: Theory and practice, Indian Journal of Psychiatry, Oct-Dec. 2012
- Kalyanakrishnan MD, Scheid MD, Treatment Options for Insomnia, American Family Physician, Aug. 15, 2007
- Simon D. Kyle, Towards standardisation and improved understanding of sleep restriction therapy for insomnia disorder: A systematic examination of CBT-I trial content, Sleep Medicine Reviews, Feb. 2015
- Morin, CM, Cognitive-Behavior Therapy, Singly and Combined with Medication, for Persistent Insomnia: Acute and Maintenance Therapeutic Effects, JAMA, Mar.8, 2011
