Here is some advice on sleep:

Sleep Hygiene advice:

• Avoid caffeine after lunch and alcohol within 6 hours of bedtime
• Avoid nicotine close to bedtime or during the night• Engage in moderate physical activity but avoid heavy exercise within 3 hours of bedtime
• Avoid consuming excessive liquids or a heavy evening meal before bedtime
• Maintain a quiet, dark, safe, and comfortable sleep environment. Minimize noise and light
• Avoid a bedroom that is too hot or too cold
• Avoid watching/checking the clock

Educate the patient about the following issues:

• Alcohol helps with sleep initiation, it impairs sleep maintenance and can exacerbate other sleep disorders
• Nicotine is a potent stimulant with a short half-life that induces awakenings as a result of withdrawal during the sleep period
• Smoking cessation aids (nicotine replacement products and bupropion) can cause insomnia

Sleep Consolidation

Some insomnia patients spend excessive time in bed trying to attain more sleep. Sleep consolidation is accomplished by compressing the total time in bed to match the total sleep need of the patient. This improves the sleep efficiency.

• Devise a “sleep prescription” with the patient: a fixed bedtime and wake time
• Determine the average total sleep time
• Prescribe the time in bed to current total sleep time plus 30 minutes
• The minimum sleep time should be no less than 5 hours.
• Set a consistent wake time (firmly fixed 7 days/week)
• The bed time is determined by counting backwards from the fixed wake time (For example: a patient estimates the total sleep time to be 5-6 hours/night, the total time in bed is 8 hours/night for a sleep efficiency of 5.5/8 = 68%. The prescribed total sleep time would be 6.5-7 hours/night, if the wake time is 6AM then the prescribed bedtime is 11-11:30 PM)
• For the first 2-4 weeks these times should remain consistent and the clinician should monitor the patients adherence to the program with sleep logs (see sleep log attachment)
• Advise the patient that napping will reduce the depth and restorative quality of sleep the following night
• Once the patient is sleeping for >85 to 90 percent of the time spent in bed for two consecutive weeks, then the amount of time spent in bed is slowly increased by 15- 30 minute every week. If sleep efficiency of 90 percent is maintained, then therapy is successful. The average total sleep time for most people is between 6 and 8 hours a night.

1. Advise patients that the goal of treatment is to improve the continuity and restorativequality of sleep, not to make them “8-hour sleepers”. More often than not the total sleep time will be less than 8 hours per night.
2. Advise patients that they may suffer from daytime sleepiness in the initiation phase of compressing their sleep schedule.

Stimulus Control

Stimulus control is designed to re-associate the bed/bedroom with sleep and to re-establish a consistent sleep-wake schedule. This is achieved by limiting activities that serve as cues for staying awake. The treatment consists of the following behavioural instructions:

• Eliminate non-sleep activities in the bedroom. Remove the TV and computer from the bedroom
• Use the bed and bedroom only for sleep and sex
• Go to bed only when sleepy, even if later than prescribed sleep schedule
• Get out of bed if not able to sleep within 15-20 minutes - go to another room and relax. Return to bed only when sleepy
• Set alarm for agreed upon wake time
• Avoid excessive napping during the day - a brief nap (15-30 minutes) during the midafternooncan be refreshing and is unlikely to disrupt nocturnal sleep

anxiety reducing strategies and relaxation therapies
Relaxation therapy is designed to reduce physiological and psychological arousal to promote sleep. Recommended relaxation therapies must be individualized and include:

• Avoid arousing activities before bed (late night phone calls, work, watching TV
• Designate at least one hour before bedtime to help unwind from the day’s stresses - dim light exposure and engage in relaxing activities
• Relaxation techniques such as deep breathing, light exercise, stretching, yoga and relaxation CDs can help promote sleep
• Stress management skills training and relaxation therapies such as progressive muscle relaxation, biofeedback, hypnosis, meditation, imagery training, are usually provided by a trained professional (through books, videos, or face-to-face sessions)
• Techniques for managing worry can be useful for some patients. This may include keeping a worry journal, scheduling worry time, challenging worried thinking, or seeking professional help

Cognitive Therapies

Cognitive behavioral therapy (CBT) addresses the inappropriate beliefs and attitudes that perpetuate the insomnia. The goal of this technique/process is to identify dysfunctional sleep cognitions, challenge the validity of those cognitions, and replace those beliefs and attitudes with more appropriate and adaptive cognitions. Common faulty beliefs and expectations that can be modified include:

• Unrealistic sleep expectations (e.g., “I need to have 9 hours of sleep each night”)
• Misconceptions about the causes of insomnia (e.g., “I have a chemical imbalance causing my insomnia”)
• Amplifying the consequences (e.g., “I cannot do anything after a bad night’s sleep”)
• Performance anxiety and loss of control over ability to sleep (e.g., “I am afraid of losing control over my ability to sleep”)