Sleep hygiene is so bad at treating insomnia that it's used as the placebo in clinical sleep trials. Before you buy darker blackout curtains, try these expert tips.
Insomnia is one of the most frustrating experiences in our modern existence. You stare up at the ceiling (or worse, at the red numbers on a clock), mind buzzing with random thoughts, tossing and turning while everyone else snores away blissfully. It can really drive a person crazy!
Everyone has insomnia sometimes. Even though I’m a sleep expert (and I was lucky enough to be born with good sleep genes), I still sometimes toss and turn all night. And these occasional sleepless nights are totally fine. They just mean you're excited about something, or you have had one too many cups of coffee, or some other fluke stars aligned to make you unable to shut down for a night or two. All you have to do is ride it out, knowing you'll be back to your normal sleep routine soon.
Chronic insomnia can really disrupt your life. It puts a damper over your everyday mood and turns sleep into a chore instead of a relief.
But for many people, insomnia becomes chronic. If you’re having a really hard time falling or staying asleep a few times per week, and this has been going on for a few months, then we’re dealing with a different animal. Chronic insomnia can really disrupt your life. It puts a damper over your everyday mood and turns sleep into a chore instead of a relief.
If you don’t have chronic insomnia yourself, I bet you know someone who does. About one in ten adults have chronic insomnia by the strictest diagnostic criteria. But if you ask everyone visiting a primary care doctor, one in three will have it. In my own clinic, the average patient has had chronic insomnia for 15 years before finding their way to me because they didn’t know there were treatment options other than Ambien and sleep hygiene.
That’s because most doctors’ go-to for treating insomnia are Ambien (and other prescription sleep medications) and sleep hygiene. As a psychologist and not a medical doctor, it’s not my place to talk in-depth about medications. But I can talk to you about sleep hygiene.
Most doctors’ go-to for treating insomnia are Ambien (and other prescription sleep medications) and sleep hygiene.
I’m sure you’ve already heard some things about it. Here’s what the National Sleep Foundation recommends (slightly paraphrased):
- Avoiding stimulants such as caffeine and nicotine close to bedtime
- Exercising, but not too close to bed time
- Steering clear of food that can be disruptive right before sleep
- Ensuring adequate exposure to natural light
- Establishing a regular relaxing bedtime routine
- Making sure that the sleep environment is comfortable by using blackout curtains, keeping it cool, and banning all screens
But I’ll let you in on the best-kept secret in sleep medicine—sleep hygiene does not cure insomnia. In fact, it's so well-known among sleep experts that sleep hygiene is useless for insomnia that we use it as the placebo treatment in our clinical trials.
So why do doctors tell us to follow sleep hygiene? Why do reputable authorities on sleep, like the National Sleep Foundation, recommend sleep hygiene on their website?
It's so well-known among sleep experts that sleep hygiene is useless for insomnia that we use it as the placebo treatment in our clinical trials.
The answer is complicated. Sleep hygiene, in and of itself, is not bad. The recommendations are not wrong. In fact, I very much support them as general guidelines for healthy sleep, especially the recommendation about getting exercise and exposure to natural light during the day. But while these recommendations are good for general maintenance, they simply do not address the root of the insomnia problem.
Think of it this way: Dental hygiene is great. Brushing and flossing will help to prevent cavities. But once you already have a cavity, no amount of brushing is going to get rid of it. Setting up a comfortable sleep environment is great too, and may prevent your sleep from being disrupted by things like excessive heat. But once you already have chronic insomnia, other biological and psychological processes that are way stronger than temperature have taken over, and no amount of trial-and-error with your thermostat is going to change those processes.
So, what are these other biological and psychological processes? How can we change those instead? If you let me, I’d talk your ear off about this for hours. Instead, let’s focus on two of the most important ones:
1. Insomnia saps your sleep drive, but you can build it back up
The homeostatic sleep drive is like hunger—the longer you go without sleep, the more sleep drive you build up. All you have to do is be upright and awake with your eyes open. Bonus points if you are physically active and get plenty of light.
When healthy sleepers go to bed, they have enough sleep drive built up to cash in for a night of good quality sleep. People with chronic insomnia probably don’t for a few reasons.
- They try to sleep in or go to bed early in order to “make up” for lost sleep, so they don’t have as much wakeful, active time to build up their sleep drive
- They try to nap or lie down to rest during the day, so they’re dipping into the sleep drive they’ve been saving up, leaving less for the nighttime
- They’re less active during the day because they’re either trying to conserve energy or they feel too tired or cranky to fully engage in activities
These feed a vicious cycle where the more someone has insomnia, the less they get what they need—solid sleep drives. Here’s how to get out of that cycle:
- Get up at the same time every day, even if you didn’t sleep well. This guarantees you’ll at least reset for today with a robust sleep drive.
- Don’t go to bed until you’re sleepy. By “sleepy,” I don’t mean sluggish, washed out, and so done with the day—that's fatigue, which is not the same thing. Sleepy means your eyes are drifting shut, it’s hard to concentrate on the book you’re reading or the show you’re watching, you’re yawning a lot, and you may even be catching yourself nodding off.
- Don’t try to nap during the day (unless you’re driving and nodding off). Brute force your way through that after-lunch dip, knowing that you’re saving up sweet, sweet sleep drive for later tonight.
2. Insomnia makes your brain hyperactive in bed, but you can reset that switch
One thing that works against sleep drive in people with insomnia is called “conditioned arousal.” It’s just a scientific term for the experience where you begin to feel sleepy, and it seems like a reasonable time for bed, but as soon as you lie down it’s like a switch has turned on and your brain is suddenly super awake.
Why does this happen? Only because our brains are very good at putting two and two together.
After you've had insomnia enough times, your brain has trained itself to expect insomnia when you go to bed. And what your brain expects, it does.
If every time you go to your favorite restaurant you eat yummy food, then your mouth will start to automatically water when you see a commercial for that restaurant. If every time you lie down in bed you have insomnia and “busy brain,” then your mind will automatically start acting up when you go to bed. You can't even control it! After you've had insomnia enough times, your brain has trained itself to expect insomnia when you go to bed. And what your brain expects, it does.
So how do you hit the reset button and retrain your brain to see your bed as a place for sleep again? Here are some ways to help:
- Just as above, don’t go to bed unless you’re sleepy. And don’t linger in bed once you're fully awake for the day. This limits the amount of time you spend awake in bed.
- If you can’t fall asleep for about 20-30 minutes—or fall back to sleep after waking in the night—get out of bed. Sometimes it’s tempting to try for a little more sleep. You think that if you move slowly and don’t make noise, you could trick your brain into just drifting off. What’s really happening is that you’re risking spending even more time awake in bed, hammering home the message that the bed is a place for not only being awake but for struggling.
- It’s not necessary to watch the clock to track the 20-30 min. In fact, this will backfire by making you even more anxious or frustrated. The exact amount of time to wait before getting up is less important than the feeling of being awake or struggling to fall asleep. If you feel very awake, or you're starting to fret about sleep, that’s your cue to get up and do something to take your mind off insomnia.
One caveat is that these recommendations are designed for adults. They may not apply to teens, depending on their sleep habits and other factors that affect their sleep. For example, if the reason a 15-year-old can’t fall asleep is because he’s been playing first-person shooter video games all evening, then waiting to feel sleepy for bedtime is not the answer. For teens, I’d be much more inclined to recommend good old fashioned sleep hygiene.
If these tips aren't enough to break you out of your chronic insomnia cycle, it’s time to consult an insomnia expert.
If these tips aren't enough to break you out of your chronic insomnia cycle, it’s time to consult an insomnia expert. Ask your primary care doctor and your friends about cognitive behavioral therapy for insomnia. Usually, someone who's trained to provide this treatment is a psychologist, but other healthcare professionals like nurses and social workers may be able to provide it as well. It’s a short treatment that is worth the investment! After all, sleep is like food and water—one of our basic biological needs. Getting it right sets you on solid footing for living your healthiest and happiest life.