The most useful and efficient way of starting one’s sleep program is by understanding their current sleep–wake patterns. The standard measurement tool for insomnia is the “sleep diary”. Sleep diaries are not really diaries, but simple logs, based on one’s recollection of their last night’s sleep. Because they are the expert on their insomnia, they are the best person to report on each night’s sleep in order to measure their sleep problem. In fact, people with insomnia who go to sleep labs usually have trouble sleeping in the lab, which simply confirms their insomnia. Although the sleep information obtained from consumer wearable devices is appealing, at the time of writing this, these trackers are not yet ready for use in Sleep Therapy. This chapter provides a note about personal electronic sleep trackers and discusses logging your sleep with a sleep diary.

After Week 4 of Sleep Therapy, it is recommended that one should check to see if they are now free from insomnia. One can do this by looking at the same things in their current sleep diary, before they started Sleep Therapy. This chapter provides suggestions to find out the experiences of initial insomnia, multiple awakenings, middle insomnia, and terminal insomnia. If a person takes longer than 30 minutes to fall asleep, he/she is experiencing “initial insomnia”. If a person has more than 3 awakenings per night, he/she can describe it as having “multiple awakenings”. If a person awakes each night, (3 nights or more) for greater than 30 minutes, he/she is experiencing “middle insomnia”. If a person wakes up for more than 30 minutes too early on at least 3 mornings, then he/she has “terminal” or “end-of-night” insomnia.

Sleep Therapy is the term used for the specific program, which combines the most powerful and effective components of cognitive behavioral therapy for insomnia. The first part of the program, called FIRST THINGS FIRST, involves recording one’s sleep using sleep diaries to assess the nature of their insomnia. This chapter focuses on how to uncover, or rediscover, the biological processes that allow one to sleep. It shows how to tailor one’s bedtime and rise time in order to get solid sleep, and how to associate one’s bed with great sleep. The procedures will be summarized in Six Steps to Solid Sleep, the main techniques of Sleep Therapy. With some practice of these relaxation and “cognitive therapy” techniques, one knows how to move their mind into a state that is more conducive to having sleep arrive, to having the velvet hammer descend.

This chapter provides methods to overcome the negative self-talk, by replacing it with balanced thinking that includes some realistic optimism. We humans have problem-solving, thinking brains that are always trying to make sense of our world. Sometimes sleep-related thoughts persist and this is when we need to face them head-on, evaluate them and respond to them in a new way so they are not so alerting and troubling. The chapter introduces us to the “cognitive therapy” component of cognitive behavioral therapy for insomnia (CBT-I). Feelings are basic and instinctive and easier to identify than thoughts. Therefore, the chapter presents an exercise that starts with asking one about their feelings, and then asks them to identify their associated automatic sleep-related thoughts. It provides an example, based on a real person with insomnia.

Hygiene means “principles of maintaining health; the practice of these”. In the strict sense “sleep hygiene rules” are tips for maintaining good sleep health. They include things that our grandmother may have told us, such as don’t eat a big meal before we go to bed. The research concurs: Sleep hygiene alone is not effective for reversing chronic insomnia. This chapter offers the recommendations or the top tips for better sleep. They can be helpful for people who usually sleep well but who have occasional or situational sleep problems in order to prevent further problems. By following them, one can certainly eliminate some of the factors that can interfere with sleep.

There are things over which one have direct control. So, if they are contributing to poor sleep, they can be addressed right away. One will now be perusing their sleep diary for three things: naps, alcohol, and sleep medication. Not that any of these things is bad, one just wants to make sure that they are not interfering with their nighttime sleep. If they are interfering, it is much easier to deal with them now, before one goes further. If one did nap, were the naps inadvertent or intentional? If they were inadvertent, this can be a sign of “excessive daytime sleepiness”. If the naps were intentional, then look at the timing of each nap. If one is taking sleep medication, it is dangerous to also drink alcohol. So, if one takes sleep medication, be sure to read and follow the instructions on the medication label.

Women are more likely than men to have insomnia. A family history of insomnia increases the likelihood of developing insomnia, especially if one’s mother had sleep difficulty. Some girls and women experience worse sleep in the 3–4 days before their menstrual period than at other times in their cycle. This is especially likely if they have premenstrual symptoms like depressed mood, irritability, appetite changes, and feeling tense. Pregnancy increases the risk of developing some other sleep disorders. Childbirth is a time when your sleep is bound to be totally disrupted. Women who develop persistent insomnia sometimes identify childbirth as the starting point of their poor sleep. Effective treatments are available for most sleep disorders. For insomnia, women make up the majority of volunteer participants in treatment studies. Cognitive behavioral therapy for insomnia works to reverse insomnia during most stages of life including young adulthood, midlife, and old age.

The completed sleep diaries will provide very interesting and useful information. This chapter helps the reader to go through their baseline sleep diary and see what it tells us. One will be looking at certain rows of their sleep diary now. The chapter guides us through the sleep diary, pointing out what to look for. It follows the same sequence that the author uses when he examines people’s sleep diaries in the clinic, which is not necessarily the same order in which we filled out the sleep diary. The first mission is to identify what type of insomnia we have. One has just looked at their baseline sleep diary for initial insomnia, multiple awakenings, middle insomnia, and terminal insomnia. It is quite common for people to have more than one type of insomnia problem. Our impression of how we are sleeping is, of course, one of the most important measurements.

One’s sleep diary provides good information about their sleep timing, quality, and quantity, and is the best way to measure sleep if a person has insomnia. For more in-depth examination of sleep by scientists, or sleep medicine clinicians, special equipment is used to track sleep stages and cycles through the night. To determine sleep stages, three main measurements are used: brain waves, eye movements, and muscle tone. These are measured using electrodes that are attached to the scalp, the face near the eyes, and under the chin, respectively. Polysomnography is measurement of sleep overnight in the sleep lab, with electrodes that are attached to the scalp, face, and chin, to determine sleep stages. Actigraphy is another way that sleep can be measured, but only roughly.

Sadness and anxiety are normal human emotions and stress is a normal occurrence in our lives. When we’re feeling somewhat down, anxious or stressed, we can benefit from exercise, relaxation, recreation, eating nutritious foods, allowing time for sleep, and talking to a friend. Clinical depression and anxiety are very common conditions. This chapter looks at what they are, what happens to sleep, and what helps recovery of mood and sleep. It outlines what is known about treating insomnia in three forms of clinical depression: major depression, Seasonal Affective Disorder, and Bipolar Disorder. Research on how people respond to natural disasters has told us that within the first months of disaster, many people develop signs of anxiety, depression and posttraumatic stress. With respect to sleep, people with posttraumatic stress disorder tend to get somewhat less deep sleep, longer periods of being awake during the night, and an overall shorter sleep duration.

There are several helpful strategies for calming active thoughts. To begin with, it is helpful to take an observer’s stance, and notice where exactly one’s mind is going. The chapter discusses the thoughts or worries about the effects of not sleeping, and the worries about things going on in one’s life. It is very common to have worries about work, school, relationships, family, or health issues. If this is true for one, write these issues down. Then consider which are productive worries and which are nonproductive. Nonproductive thoughts and worries are things that can be released and let go of at night. This is more easily said than done. Another approach to get out of problem-solving mode, or overactive-thinking mode, is by training one’s mind with meditation. There are many types of meditation and one can choose the type that suits them best.

This chapter guides one forward after the second week of sleep therapy. It presents a chart called Calculating Your Week 2 Sleep Efficiency. By copying one’s sleep diary answers to Questions 1 to 7 for the typical night into the top section of this chart one can calculate the sleep efficiency for week 2. The chapter also presents a chart that helps to adjust one’s threshold bedtime, and Six Steps to Solid Sleep for week 3. The six steps are: go to bed only when sleepy and not before your threshold bedtime; maintain a regular threshold rise time in the morning; use the bed only for sleeping; leave the bed if you can’t fall asleep or go back to sleep within 10–15 minutes; if sleepiness is overwhelming, one may take a short nap (set aside no longer than 45 minutes) in the afternoon; and maintain a sleep diary.

Although women tend to report insomnia in greater numbers, men have their share of sleep problems. Testosterone, a hormone that occurs in much higher levels in men than in women, influences the development and maintenance of male sexual characteristics, including reproductive organs, body structure, beard growth, strength, sex drive, aggression, and mood. There are important connections between testosterone and sleep. Research shows that the more the father is involved in caring for the infant—both during the day and at night—the better the mother’s sleep and the fewer times the infant wakes at night. There are two sleep disorders that occur more frequently in men than in women. These are “sleep related breathing disorders” and “REM sleep behavior disorder”. This chapter outlines both. With age, men’s sleep, like women’s, becomes shorter and more broken up by awakenings. As with women, men experiencing stress at work are at high risk of insomnia.

This chapter guides one forward after the third week of sleep therapy. It presents a chart called Calculating Your Week 3 Sleep Efficiency. By entering the sleep diary answers for Questions 1 to 7 in the top section of the chart one can calculate the sleep efficiency. The chapter also presents Six Steps to Solid Sleep for week 4: go to bed only when sleepy and not before your threshold bedtime; maintain a regular threshold rise time in the morning; use the bed only for sleeping; leave the bed if one can’t fall asleep or go back to sleep within 10–15 minutes, return when sleepy, and repeat this step as often as necessary during the night; if sleepiness is overwhelming, one may take a short nap (set aside no longer than 45 minutes) in the afternoon, between 1:00 and 4:00 p.m; and maintain a sleep diary.

This chapter guides one forward after the first week of sleep therapy. It presents a chart called Calculating Your Week 1 Sleep Efficiency. By entering the Sleep Diary answers to Questions 1 to 7 for one’s typical night into this chart one can calculate the sleep efficiency for Week 1 of Sleep Therapy. If at any point one realizes that the night chosen is not really representative of the week, then one can try another night and see how close the sleep efficiencies are. If the nights are not consistent, then one may want to calculate all 7 sleep efficiencies and take the average for the week. The chapter also presents a chart that helps to adjust one’s threshold bedtime, and Six Steps to Solid Sleep.

As insomnia develops, one may start to worry about not sleeping. One of author’s friends had a stressful management position over which she started to lose sleep. She then feared that the lack of sleep would negatively affect her work performance. This made it even more difficult for her to sleep because the thought of underperforming increased her anxiety. One can see how this can become a cycle of worry and sleeplessness. This chapter discusses some of the common worries that are linked to insomnia. By examining these topics in the light of day, rather than ruminating during a sleepless night, we achieve a more balanced view of our sleep problem and its effects. Stressful thoughts at night have a way of expanding to fill the dark spaces around us. The chapter provides information that will help to bring one’s sleep-related worries down to earth.

This chapter explains two essential elements form Sleep Therapy, which are based on sleep science and psychology principles. Many people find this background intriguing. What’s more, it is always easier to carry out techniques when one understands how they work. The elements of Sleep Therapy are: uncovering one’s natural sleep processes and associating one’s bed with sleep. By understanding how sleep comes and goes in the natural state one can see more clearly how to restore healthy sleep. Good sleep comes when our biological sleep processes can operate without interference. Associating one’s bed with sleep element of Sleep Therapy is based on something called “conditioning” or “learned associations”. These are connections one make in their mind (automatically) between two things that occur together on several occasions.

Insomnia is a complaint of difficulty falling asleep or staying asleep that impairs the functioning or causes distress. So, compared to a bout of poor sleep, insomnia is a sleep problem that takes on a life of its own. Basically, it is persistent, unsatisfactory sleep that has daytime consequences. When insomnia occurs at least three nights per week and lasts for three months or longer, it is technically called “chronic” insomnia. People with insomnia report low mood, irritability, poor concentration and memory, reduced physical well-being, and some difficulties interacting with other people. They also report having more fatigue-related car crashes than people without insomnia. People with insomnia seem to be able to perform mundane tasks of daily living but they tend to have less enjoyment of their activities and show less “cognitive flexibility”—they tend to think more narrowly and less creatively—than people who sleep well.

Years of research have revealed that certain techniques reliably lead to improved quality and quantity of sleep and increased satisfaction with sleep. Together these techniques can be called “cognitive behavioral therapy for insomnia” (CBT-I). In the mid-1990s two important reports were published on these techniques. These reports were based on meta-analyses. In a meta-analysis, the research data from many studies of a given treatment are carefully combined to provide the overall story on the treatment’s usefulness. In these particular meta-analyses, the authors reviewed studies that had compared CBT-I techniques with no treatment or with a placebo treatment. Research shows that CBT-I is useful even if one have some mild to moderate symptoms of anxiety or depression, or some long-lasting medical problem like chronic pain or cancer. This book shows how to deal with and overcome insomnia if one has insomnia that has lasted longer than 4 weeks.

This chapter summarizes the strategies of sleep therapy in 6 specific steps. The steps of sleep therapy appear to be simple, but they require some time and effort. The most important factor that determines whether their sleep will improve is the consistency with which one follows the steps. The chapter discusses fifth and sixth steps. Fifth step is if sleepiness is overwhelming, one may take a short nap (set aside no longer than 45 minutes) in the afternoon, between 1:00 and 4:00 p.m. Many programs recommend that one avoid daytime naps entirely because naps may make it harder to sleep at night. While this is partially true, one also knows that humans are biologically predisposed to have a nap in the afternoon if circumstances permit. Sixth step is maintaining a sleep diary. Keeping a sleep diary will show how one’s sleep improves as a result of their actions.

This chapter discusses the advantages and disadvantages of the current medications that are used for sleep. If a doctor prescribes a medication to help one sleep, it is most likely to be a benzodiazepine receptor agonist (BzRA). If one needs sleep immediately, BzRAs will most likely help. Sometimes, instead of prescribing a BzRA for sleep, physicians prescribe a low dose of an antidepressant or antipsychotic medication. For people who are depressed, the sedating antidepressants can improve sleep, more so than some other classes of antidepressants. Standard (immediate-release) melatonin can sometimes be useful for prevention of east-bound jet lag and for certain shift work schedules, and it may be helpful in the short term (up to 1–2 weeks) for sleep difficulty. Orexin is a neuropeptide that is involved in the regulation of wakefulness and sleep as well as other functions such as appetite regulation.

Sleep is increasingly being recognized as the third pillar of health, along with nutrition and exercise. All three health behaviors (yes, sleep can be considered a behavior) interact with one another. If our sleep is good, we are more likely to eat well, to exercise and to be healthy. This chapter shares some fascinating new research findings about these interrelationships. Sex has rarely been discussed in relationship to sleep. The chapter examines what we know, or don’t know, about this relationship. Men with these sleep disorders have high rates of erectile dysfunction. A recent online survey revealed that worse sexual functioning was linked with worse sleep. Looking from a positive perspective, this also means that those with better sexual functioning experienced better sleep. Just as with nutrition and exercise, sexual functioning is related to sleep bidirectionally: each influences the other.

This chapter comes up with two numbers that are essential for Sleep Therapy. Sleep Therapy combines the most effective components of Cognitive Behavioral Therapy for Insomnia (CBT-I); it involves tailoring bedtime and rise time for sleep needs, and associating bed with great sleep. Knowing the numbers will allow one to tailor their sleep improvement procedures. The first number is one’s “total sleep time”, which is how much sleep they are getting now. The second number is “sleep efficiency”, which is how solid their sleep is. One can use their baseline sleep diary to estimate fairly accurately their baseline values for total sleep time and sleep efficiency. The chapter shows how to estimate one’s baseline sleep duration, based on a night from their sleep diary.

Surveys from all over the world show that people who have medical conditions are especially likely to have sleep problems. A medical condition can lead to a sleep problem, and a sleep problem can lead to a medical condition. Each can exacerbate the other. There is a particularly strong link between chronic pain and sleep difficulty. Most people with chronic pain have insomnia. Research shows that cognitive behavioral therapy for insomnia improves the sleep of people who have heart disease and insomnia. People with lung cancer and women with breast cancer are especially likely to experience sleep difficulty. People who experience seasonal allergies are more likely than other people to have insomnia, to snore and to have sleep related breathing problems. The chapter also summarizes some of the findings about sleep when a person has Alzheimer’s disease, Parkinson’s disease, or multiple sclerosis.

Often people who are starting to improve their sleep worry that their progress is only temporary and that poor sleep will return. If a person had insomnia for several years, he/she may be especially prone to this fear of relapse. Maintenance starts with reminding oneself that they have acquired new knowledge about their sleep and mastered the strategies that improve it. This is very important to remember; it means that one will never be back at square one. This chapter provides some very practical steps to anticipate what could happen. Once a person knows the strategies for improving sleep he/she can use them as needed.

This chapter provides information on some substances that are not exactly “pills” but they are often marketed as sleep aids. They include over-the-counter products, natural health products including herbal remedies, and cannabis. Over-the-counter sleep aids do not require a prescription and they are quite widely available through pharmacies. If a person has seasonal allergies, these medications may help them sleep on those nights when their allergy symptoms would otherwise disturb their sleep. Natural health products may help induce sleepiness and help some people who have mild difficulty falling asleep, and who are otherwise healthy (having no medical or mental health problems). There are several downsides of using recreational cannabis for sleep. Regular use of any form of cannabis can lead to dependence and difficult withdrawal symptoms including irritability, insomnia, depression and anxiety. Importantly, it can impair brain function, especially in people under age 21, whose brains are still developing.