VA Department of Veterans Affairs

Minneapolis VA Medical Center

Patient Education Series

Behavioral Management of Insomnia


Insomnia is an on-going problem of sleeping and waking which does not give you a feeling of rest and energy. It is a very common problem. About one-third of the people in the United States have problems with insomnia. In a national survey one-fifth of the patients complained of insomnia.

Insomnia affects people of all ages. In most cases it lasts for just a night or two, but it can last for weeks, months, or even years.

Sleep is not just a "time-out" from daily life. It is an active state during which the body and mind restore themselves. Yet more than 100 million Americans of all ages regularly fail to get a good night’s sleep.

Sleep Cycles

Normal sleep has multiple stages that repeat themselves through the night. There are stages of non-rapid eye movement (NREM) sleep followed by rapid eye movement (REM) sleep. Periods of REM occur about every 90 minutes and may last up to half an hour. Dreaming usually occurs during REM sleep but also takes place during other sleep stages. REM sleep accounts for about 25% of sleep time. REM sleep is also called paradoxical sleep because even though your muscles are very relaxed, there is a lot of brain activity at this stage. In normal sleep there are about four NREM-REM cycles.

Types of Insomnia

There are different types of insomnia:
·Transient insomnia - up to several nights of poor sleep, often caused by excitement or stress.
·Short-time insomnia - two or three weeks of poor sleep; often happens during ongoing stress at work or at home, such as a job set-back, divorce, serious illness or death.
·Chronic insomnia - poor sleep every night, most nights, or several nights a month is a complex problem with many causes. More than 35 million Americans have chronic insomnia.

The Causes of Insomnia

Insomnia is a symptom, much like a fever or a stomach ache.

Psychological Factors:

·Vulnerability to insomnia: Some people are more likely to suffer insomnia in times of stress, much as others might get headaches or indigestion.

·Persistent stress: People with such problems as a troubled marriage, a chronically ill child, or an unrewarding job often sleep poorly.

·Psychiatric problems: Insomnia, particularly waking up earlier than desired in the morning, is one of the most common symptoms of depression. People with anxiety, schizophrenia, bipolar disorder, post traumatic stress disorder (PTSD), and other psychiatric problems may also sleep poorly.


·Use of stimulants: Even if caffeine near bedtime doesn't interfere with falling asleep, it may wake you up later. Nicotine is also a stimulant. Smokers take longer to fall asleep and sleep more lightly than non-smokers do. Ingredients in many commonly used drugs, including nonprescription drugs for weight loss, asthma, and colds can disrupt sleep.

·Use of alcohol and other drugs: An alcoholic nightcap may help induce sleep, but it also makes sleep more fragile. Getting used to being sober/straight can also cause temporary insomnia.

·Erratic hours: Late hours on weekends as well as shift work schedules that demand frequent changes in sleep times may undermine sleep.

·Lack of exercise:  Being inactive during the day may be associated with poor sleep at night.  This becomes more common with age and illness.

·Learned insomnia:  Often, people who sleep poorly in times of stress worry about not being able to function effectively during the day. They try harder to sleep at night. This effort often makes them more alert, setting off a new round of worried thoughts. This tendency to sleep poorly, even a few times a month, may be all it takes to maintain poor sleep, thus justifying the person's continuing concern about it.

·Misuse or overuse of sleeping pills:  If used every night, sleeping pills could become less effective over time.  Suddenly stopping their use, however, may cause a temporary worsening of sleep.  Ask your doctor what you should do.

Environmental Factors:

·Noise:  Passing traffic, jets flying over, a neighbor's TV, and other noises disturb sleep even if they do not wake you up.

·Light:  Even when your eyes are closed, light comes through.

·Bedroom:  Using your bedroom as an office or activity room may lead to trouble settling down for the night.

·Bed:  Strange beds, old beds, and uncomfortable beds may make for fitful sleep.

Physical Illness:

·Breathing disorders:  Repeated interruptions of breathing during sleep may wake up a sleeper dozens, even hundreds, of times a night.  Severely disturbed breathing during sleep (sleep apnea) may affect people who breathe normally while awake.  Relaxation of muscles needed for breathing or trouble with the brain's control of breathing may occur only during sleep.  Breathing-related sleep problems become more common with age.  Avoid sleeping pills.  They can make breathing problems worse.

·Restless legs syndrome: This can be described as uncomfortable feelings of restlessness in the legs.  These feelings cause movement of the legs.  The legs become increasingly uncomfortable if they are not moved.  Restless legs syndrome can interfere with falling asleep because it usually occurs in the evening, at bedtime.  When restless leg movements occur during sleep, they can interrupt sleep.  Some people also feel this restlessness during the day but it is usually more of a problem as bedtime approaches.  In some cases, restless legs syndrome may be caused by a lack of iron or kidney disease.  Your doctor may order lab tests to rule out these causes.  Medications are available to treat restless legs syndrome.

·Reflux (heartburn):  The back up of stomach contents into the esophagus can wake a person up several times a night.

·Pain:  Disorders like arthritis, angina, lower back injury, headache, and hot flashes associated with menopause may upset sleep.

When to See the Doctor

If your sleep has been disturbed for more than a few weeks and/or interferes with how you feel or function during the day, talk to your doctor, psychiatrist, or nurse.

In some cases information and education can help insomnia.  Not everyone needs eight hours of sleep; some people need more, others less.  Counseling can help those whose insomnia stems from poor sleep habits.  In other cases, a doctor may prescribe short-term use of sleeping pills to break the insomnia cycle.  An evaluation at a sleep disorders center may also be recommended.

Can Sleeping Pills Help?

Used as prescribed, sleeping pills may help provide sounder sleep and improve alertness the following day.  Sleeping pills do not "cure" insomnia.  For some types of insomnia, such as that caused by breathing disorders, sleeping pills may be dangerous because they may make the problem worse.

Sleeping pills (sedatives and hypnotics) are usually prescribed for a brief time.  Do not use sleeping pills and alcohol or street drugs together.

Avoid over-the-counter sleeping pills.  Sleeping pills that you can buy without a prescription get their sleep-inducing effect from antihistamine, like cold medications.

Making Changes - Early Steps

Changing sleep habits and patterns takes time.  You must be willing to work on it for at least four to eight weeks.  Remember, you can learn to improve your sleep habits and patterns.

It is important to establish normal wake-sleep cycles (circadian rhythms or internal clock).  By reviewing a sleep diary, you will have some clues about what to change.  Remember, the same things do not work for everyone.  You must be willing to try new things for at least a few weeks before you can expect to see any change. 

Sleep Diary

If you want to improve your sleep, you need to know what your sleep and wake habits are.  You can do this by keeping a sleep diary.
Use a sleep diary to keep track of:
·The time you go to bed

·The time you get up

·If you wake up during the night, write down what time you woke up and when you got back to sleep; also note how long it took you to fall back to sleep

·What you were doing right before you went to bed

·How much exercise you got during the day

·What you had to drink at dinner

·What you ate and drank before you went to bed

·Rate your mood in the morning on a scale from 1 (lousy) to 10 (great).

·Caution: Do not let keeping the diary make you worry so much that your insomnia gets worse.

Keep the sleep diary for as long as needed to assess your sleep habits and patterns. Review it to see if you can find any patterns. For example: every time you drank pop after dinner you had trouble getting to sleep and woke up often to go to the bathroom. You may then want to try switching to decaffeinated pop or limiting liquids at night. Another example: when you ate a light snack right before bedtime you slept better.

Sleep Hygiene - the Next Step

Good sleep hygiene means that you are taking steps that lead to a good night's sleep. A good night's sleep makes for a better day!

During the Day:

·Set your alarm clock and get up at the same time every day. Do this no matter what time you go to bed. Do this on weekends too. You will probably be very tired at first. Eventually you will get tired about the same time every night.

·Try very hard not to nap. Naps disturb the sleep-wake cycle. If you find yourself getting sleepy, get up and do something. If you must nap:
oDo so at the same time every day, early afternoon is the best time
oLay on your bed for the nap; do not nap on couches or chairs
oSet your alarm -- do not nap for longer than an hour
oIf naps do not interfere with your nighttime sleep, enjoy!

·Get as much physical exercise as possible. This includes brisk walking.  Physical exercise helps reduce stress and improves emotional health and sleep.  It helps your body know it is time to be awake.  The best time to exercise is in the afternoon or early evening - not too close to bedtime.  Use your sleep diary to see how the timing of exercise affects your sleep.  You need to exercise for 20-30 minutes three times a week to really get the benefit.

·Limit caffeine intake.  Get in the habit of reading labels on soda pop.  Drink decaffeinated coffee and soda pop.  Mix half decaffeinated with half-caffeinated to help ease the transition.

·Limit cigarettes both at bedtime and in general.  Nicotine is a stimulant.  Smokers take longer to fall asleep and sleep more lightly than non-smokers.  The craving for nicotine can wake you up in the middle of the night.  That is why you feel better after having a cigarette.

·Keep your bedroom for sleep and pleasure.  Sexual activity often promotes sleep.  Avoid reading, watching television, and paying bills in your bedroom.

·Limit the amount of liquids you drink after dinner.  Be sure to empty your bladder before you go to bed.


·Go to bed only when you are tired.  Do not go to bed just because you are bored.

·Develop a bedtime routine.  This may include having a glass of warm milk, taking a bath, watching the news, doing relaxation exercises, or eating a light snack.

·Use non-medication sleep aids such as:
·Relaxation exercises
·Background noise such as a fan, a "white noise" machine, a humidifier
·Eating a light snack
·Drinking a glass of warm milk
·Counting sheep
·Ear plugs
·Sleep mask

·If you have not fallen asleep 15 to 20 minutes after going to bed, get out of bed and out of the bedroom.  Do something relaxing.  You may want to read a book or watch television.  When you get tired follow your bedtime routine again.  Get up at your scheduled time!

Changing Your Sleep Environment:

·A cool room promotes better sleep.  Temperature can be changed by turning down the heat, opening a window, adding blankets, and wearing fewer/more nightclothes.

·Check your mattress to make sure it is to your liking.  If you are buying a new mattress, buy it from a business that will let you have a trial period so you can return it if it is not comfortable.

·Add carpeting and /or drapes to reduce noise.  Think about getting room-darkening shades.


·Insomnia is a symptom -- it is not an illness.

·Everyone does not respond the same way to sleep aids.

·Sleep patterns can change.

·Changing your sleep habits takes time and commitment.

·As your physical and mental health improves, your sleep will often improve.

·You can change the quality of your sleep.


·Insomnia is a symptom it is not an illness.

·Everyone does not respond the same way to sleep aids.

·Sleep patterns can change.

·Changing your sleep habits takes time and commitment.

·As your physical and mental health improves, your sleep will often improve.

·You can change the quality of your sleep.