Here are the most common maintaining factors for insomnia:
(1) An irregular sleep schedule
There are two reasons for this:
(A) It destabilizes a person’s circadian rhythm. This results in more alertness during the desired sleep period and less alertness during the desired time to be awake.
(B) It can prevent the accumulation of a sufficient amount of sleep drive. Sleep drive is a biological force that increases the longer we are awake. Generally, it takes about 16 hours of wakefulness to accumulate enough sleep drive to sleep for 8 hours.
If someone has insomnia and an irregular sleep schedule, the single most important thing they could do would be to establish a regular wake up time every day of the week (using an alarm), limit napping to no more than 20 minutes per day, and go to bed no earlier than 8 hours prior to their wake up time or only when they are really sleepy (whichever time is later). This will help stabilize the circadian rhythm and allow a sufficient amount of sleep drive to accumulate prior to bedtime.
(2) A significant discrepancy between total sleep time and time spent in bed
People with insomnia often spend a significantly greater amount of time in bed than they are actually sleeping. For example, someone might spend 8 hours in bed on average, but only actually get 6 hours of sleep on average. In this case, the body is only generating 6 hours of sleep. If the person continues to spend 8 hours in bed, recurrent insomnia becomes almost inevitable. Sleep onset becomes unreliable and sleep continuity becomes fragmented.
The best thing someone could do in this scenario would be to use a strategy that I call “systematic sleep scheduling.” Assuming that the person is only getting an average 6 hours of sleep, they would be instructed to spend only 6 hours in bed for one week, while maintaining a regular wake up time (using an alarm). This tends to result in more reliable sleep onset and better sleep continuity. Once this has been achieved, the person can increase the amount of sleep by gradually moving their bedtime earlier. Please note that using this method properly requires more guidance than is provided by this simple example.
(3) Conditioned arousal
Chronic insomnia often consists of the experience of repeatedly being awake, frustrated, and anxious for extended periods while in bed. As a result a person can develop strong associations between these negative experiences and their bed. These associations can unconsciously make them feel more awake and anxious whenever they are in bed.
To restore a strong association of the bed with sleep, the best thing someone can do is to avoid the experience of being anxious and frustrated while in bed and to avoid long periods of being awake in bed. People are encouraged to get out of bed and go to another room if they are awake for longer than 20 minutes or are feeling anxious or frustrated. They are encouraged to return to bed only when they feel really sleepy. This strategy works best when combined with the other strategies described in this handout.
(4) Trying too hard
Many people with chronic insomnia employ strategies that require exerting effort while in bed to attempt to get back to sleep. Examples could be tossing and turning to try to get comfortable, using relaxation or meditation techniques, or listening to music or podcasts while in bed. The problem is that sleep does not come from effort. It comes from the lack of effort.
Rather than using effortful methods, a person would be better off using the methods of described in this handout that help to restore the natural forces that make sleep possible.
(5) Psychological and physical tension
Daytime worries can intrude in to the sleep period. The best strategy for pre-empting worrying in bed is scheduling a “worry and problem solving” period in the evening at least an hour before bedtime, and then engaging in a pleasant “wind down” period in the hour before bedtime.
Muscle tension that accumulated from the stress of the day can continue to be present at bedtime. Specific muscle relaxation techniques can be used prior to bedtime to decrease this tension.
(6) Other factors
Other common factors that play a role in maintaining insomnia are:
Insufficient physical activity during the day.
Exposure to excessive light before bedtime or during the sleep period.
Engaging in activities in bed other than sleep and sexual intimacy (e.g., reading, watching TV).
Substances that disrupt sleep: Caffeine, alcohol, certain prescription medications, heavy foods.
Maintaining factors for chronic insomnia
In order to sleep, we need to be physiologically sleepy and physically and mentally relaxed.
(1) Factors that undermine being sufficiently sleepy
An irregular sleep schedule.
A sleep window that is often too big (e.g., >9 hours) or often too small (e.g., <7 hours).
Too much exposure to blue light during the evening or at night.
A lack of physical activity during the day.
Napping during the day (>20 minutes) or dozing in the evening.
(2) Factors that undermine being sufficiently relaxed
Not having a wind-down period before getting into bed (>30 minutes).
Not becoming sufficiently relaxed mentally and physically prior to getting into bed.
Lying in bed for extended periods while frustrated and/or worried, particularly being worried about not getting enough sleep.
Inaccurate or unhelpful beliefs about sleep and insomnia.
Trying too hard to fall asleep.
Psychological dependency on sleep medication.
(3) Other factors
Substances that interfere with sleep (e.g., caffeine, alcohol, some medications)
A non-optimal sleep environment (e.g., not cool, dark, quiet, and comfortable).