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.

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.

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.

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.

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.

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.

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.

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.

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.