Sleep hygiene and behavioral interventions

Sleep Hygiene - Counting Sheep 101

• Routine: Maintain a consistent sleep-wake schedule, including weekends.
• Environment: Keep bedroom dark, quiet, cool, and comfortable.
• Bed Association: Use bed for sleep/intimacy only. No work or screens.
• Intake: Avoid caffeine, nicotine, and alcohol 4-6 hours before bed. No large meals.
• Activity: Limit daytime naps to <30 mins. Exercise regularly, but not within 2-3 hours of bedtime.

⭐ Stimulus Control: If not asleep in ~20 minutes, get out of bed. Do a relaxing activity in another room. Return to bed only when sleepy. This re-associates the bed with sleep.

CBT-I - Mind Over Mattress

• Core Principle: A first-line, multi-component therapy that breaks the vicious cycle of chronic insomnia by restructuring maladaptive sleep-related behaviors and cognitions.
• Key Components:
  • Stimulus Control: Strengthen the bed-sleep connection.
    • Use the bed for sleep and sex ONLY.
    • Go to bed only when sleepy.
    • Leave the bedroom if awake for >20 minutes; return only when sleepy.
    • Maintain a fixed wake-up time, regardless of the previous night's sleep.
  • Sleep Restriction: Consolidate sleep by limiting time in bed to actual sleep time, building homeostatic sleep drive.
    • Increases sleep efficiency ($SE = \frac{Total Sleep Time}{Time in Bed} \times 100$).
    • Time in bed is gradually increased as SE improves >90%.
  • Cognitive Therapy: Identify and challenge dysfunctional beliefs about sleep (e.g., catastrophizing).

⭐ CBT-I is the recommended first-line treatment for chronic insomnia, demonstrating greater long-term efficacy than pharmacotherapy without the associated side effects or risk of dependence.

Behavioral Interventions - Bedroom Bootcamp

• Primary Goal: To re-associate the bedroom with rapid sleep onset by breaking the conditioned arousal linking the bedroom with wakefulness (Stimulus Control Therapy).
• Key Instructions:
  • Lie down to sleep only when feeling sleepy.
  • If not asleep within ~20 minutes, get out of bed. Go to another room and engage in a relaxing, low-stimulation activity. Return to bed only when sleepy.
  • The bed is exclusively for sleep and intimacy. No reading, TV, eating, or working.
  • Set a consistent wake-up time every morning, regardless of the previous night's sleep duration.
  • Eliminate or minimize daytime napping.

⭐ Stimulus Control Therapy (SCT) is the behavioral intervention with the strongest evidence base for treating chronic insomnia, demonstrating superior long-term efficacy compared to hypnotic medications.

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia, proving more effective long-term than pharmacotherapy.
• Stimulus control is a core component: use the bed only for sleep and intimacy. If not asleep within 20 minutes, leave the bedroom.
• Sleep restriction limits time in bed to the actual time spent asleep, which increases sleep efficiency.
• Key sleep hygiene includes a consistent sleep-wake schedule and avoiding stimulants like caffeine or alcohol before bed.