Managing Insomnia

Lesson 1
The Science of Sleep and
Understanding Your Insomnia
Welcome and Lesson Overview
Welcome to the Managing Insomnia Course!

This course is designed to teach you Cognitive Behavioural Therapy (CBT) skills to manage your
insomnia. CBT is the gold-standard, first-line treatment for chronic insomnia. Leo’s story will be
used to explain the techniques used in treatment. Of course, your story will be very personal,
but we hope that you will relate to some aspects of his experience to learn the skills you need to
become your own therapist and overcome your insomnia.

This course is intended for people who have been experiencing insomnia for at least 3 months.
If your sleeping difficulties have started more recently, we suggest you first see our Stress
Management or Intro to Mindfulness course.

This program involves four lessons to be completed in your own time at your own pace, aiming
to complete a lesson every 1-2 weeks. Here is an overview the Program:

Lesson 1 The Science of Sleep and Understanding Your Insomnia

Lesson 2 Managing Sleep-Interfering Thoughts and Behaviours - Part 1

Lesson 3 Managing Sleep-Interfering Thoughts and Behaviours - Part 2

Lesson 4 Tackling Remaining Difficulties, Reviewing Your Skills, and Maintaining Your Gains

We have prepared a Lesson Summary & Action Plan (like this one) for each of the four lessons in
the course. This includes the key information from the lesson slides in a more detailed format as
well as exercises to put the concepts and skills into practice in your daily life. In order to
overcome your insomnia, it is important that you complete the tasks in these lesson summaries.
We encourage you to print each one.

To get the most out of the course, we suggest setting aside a regular time each week to
complete the lessons. It might be helpful to block it out in your diary just as you would a regular
session with a psychologist or doctor. This is your time to start becoming your own therapist as
you learn the concepts and skills necessary to overcome your insomnia.

We hope you find this course interesting and informative! Please don’t hesitate to contact us if
you have any questions at any stage of this course, by email on contact@thiswayupclinic.org or
by telephone 02 8382 1400.

Good luck!

The Team from This Way Up.

www.thiswayup.org.au

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Topics Covered In This Summary & Action Plan
Here is a list of the topics we will cover in this Summary & Action Plan. Tick these off as you go:

1. What is Insomnia? (page 3)

2. The Role of Thoughts and Behaviours in Insomnia (page 5)
3. Your Insomnia Model (page 5)
4. What is CBT for Insomnia? (page 8)
5. Your Goals for this Course (page 9)
6. Understanding Normal Sleep (page 10)
7. The Three Factors that Regulate Sleep (page 12)
8. CHECK-POINT: Prioritising Sleep Hygiene (page 15)
9. Sleep Diary (page 17)
10. Calculating Sleep Efficiency (page 19)
11. Sleep Medications (page 19)
12. Appendix (page 21)
− FAQs
− Common Sleep Medications

1. What is Insomnia?
Insomnia is a sleep disorder that involves dissatisfaction with the quality or quantity of your
sleep. People with insomnia are concerned about initiating and/or maintaining sleep.

You may experience:

 Difficulty falling asleep (“sleep onset insomnia”)
 Difficulty staying asleep, with frequent and prolonged awakenings in the night (“sleep
maintenance insomnia”)
 Early morning wakening, with inability to fall back asleep (“late insomnia”)

It’s normal to have a few nights of poor sleep when you are going through a stressful period
(e.g., loss of a relationship, death of a loved one, work difficulties). For most people, the
insomnia passes once the stressful situation passes. However, for some people, the insomnia
persists despite the stressful period ending. Insomnia is only diagnosed when the symptoms
listed above occur at least 3 days a week, for 3 or more months.

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Insomnia may affect you in a number of different ways during the day. For example, it can affect
your (tick all the boxes that apply to you):

 Energy  Concentration
 Mood  Feeling sleepy
 Anxiety  Other: ______________

Strive to
Many people who have insomnia become preoccupied sleep
with their sleep and over time, get caught up in a
vicious cycle, which is associated with physical and
emotional arousal. Treatment for insomnia will help you
to break this cycle.
Harder to Increased
sleep frustration

Did You Know?

Up to a third of the population report symptoms of insomnia – It is far
more common than you might think. And about 10% of people meet
criteria for an insomnia diagnosis.

Conditioned Insomnia
For many people, when their head hits the pillow, this is the first opportunity they have to
process the day’s events and think through any problems or difficulties. This often makes it
difficult to “switch off”, relax, and fall asleep.

As you saw in the lesson slides, Leo leads a busy life and although he’s able to relax a bit in front
of the TV in the evening, once he gets into bed, his mind becomes very active and he has
difficulty falling asleep

Many people with insomnia also develop an association between going to bed
and not sleeping. Going to bed then becomes a trigger for worry and
frustration about not sleeping. This, of course, increases arousal making it
harder to sleep! We call this “Conditioned Insomnia”. So, instead of the bed
being associated with relaxation and sleep, it becomes associated with
frustration, worry, and being alert and awake.

A major aim of this program is to help you to retrain your brain and body so that the bed once
again becomes associated with calmness and sleep. To do this, you’ll first need to learn about
the role of your thoughts and behaviours in maintaining insomnia.

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2. The Role of Thoughts and Behaviours in Insomnia
People with insomnia have three types of symptoms: thoughts, behaviours, and feelings, that
interact to keep insomnia going. For example, in this lesson we saw how Leo worried
excessively about his sleep, causing him to become aroused and frustrated at bedtime, which in
turn caused him to engage in unhelpful behaviours. These symptoms all worked together to
maintain Leo’s insomnia:

“I’m going to be a wreck

tomorrow if I don’t get to sleep.”

Thoughts

Insomnia

Physical
Behaviours Symptoms/
Feelings

Stay in bed, Frustrated,

watch the clock. worried, tense.

3. Your Insomnia Model

Which Unhelpful Behaviours and Thinking Patterns Maintain Your Insomnia?
Now let’s consider how your own thoughts, feelings, and behaviours interact to maintain
insomnia. Understanding the symptoms that contribute to your insomnia is crucial to getting
the most out of this program! On the next page, tick off any of the following that you
recognise:

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1. Common Unhelpful Behaviours (what I do or don’t do)
 Nap
 Use the bed for activities other than
sleep (e.g., watching TV, checking your
email, work, etc.)
 Check your phone in bed when you
can’t sleep
 Stay in bed when you can't sleep
 Have an irregular sleep schedule (e.g.,
sleep in later on the weekends, shift
work)
 Don’t wake up at the same time each
day
 Drink caffeine late in the day/evening
 Drink alcohol late in the evening
 Smoke cigarettes within two hours of
bed time
 Watch the clock in bed
 Sleep in places other than your
bed (e.g., the couch or spare room)
 Other:
____________________________________
Common Unhelpful Thoughts (what I think to myself)
 Worry about not sleeping
 Worry about the impact of insufficient
sleep on your next day functioning
 Worry about life stressors in bed (e.g.,
work, relationships, finances)
 Active mind (e.g., racing thoughts)
 Think about the day ahead
Common Physical Sensations/Feelings (what I feel in my body)
 Worry
 Anxiety
 Tension
 Frustration
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 Stay in bed longer in the morning to try
to get extra sleep when you haven't had
adequate sleep in the night
 Go to bed earlier than you need to
because you are worried you won't get
adequate sleep in the night ahead
 Cancel activities or call in sick when you
haven’t slept well
 Eat a big meal before bed
 Exercise close to bed time
 Work or engage in stressful activities in
the 1-2 hours before bed
 Use electronic devices in bed
 Sleep in a noisy environment
 Sleep in a bright room
 Sleep in a room that is too hot or too
cold
 Under-stimulation (e.g., engage in only
passive activities, do little exercise)
 Over-stimulation (e.g., fit in too much
each day, especially close to bedtime)
 Unrealistic or rigid expectations about
sleep (e.g., “I must have 8 hours of sleep
every night to function”, “My sleep must
be uninterrupted in order for me to feel
rested”)
 Other:___________________________
 Hot
 Discomfort
 Other:
______________________________
6
 By making small changes in one of these areas, you can begin to break the cycle of
insomnia because each component of the cycle affects the others.

Now that you have identified the behaviours, thoughts, and feelings that are likely to
contribute to your insomnia, complete your own insomnia model, like Leo’s example above.

Your example: …………………………………………………………………

…………………………………………………………………

Thoughts

Insomnia

Physical
……………………………… Behaviours Symptoms
………………………………
……………………………… /Feelings
………………………………
……………………………… ………………………………

All of the symptoms in the list above can negatively impact your sleep. Most people with
insomnia recognise that a number of these symptoms contribute to their poor sleep, with some
being more important than others in maintaining chronic insomnia. The good news is that once
you have identified the symptoms that influence your poor sleep, you know what you need to
change.

The lessons in this course will address these three types of symptoms one by one so you know
how to tackle them effectively. Once you’ve worked out the “what” (by creating your own
insomnia model and learning more about normal sleep) we will show you the “how”
(throughout this course). That is, we will teach you evidence-based skills to change unhelpful
thoughts and behaviours so that you can get your sleep back on track.

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4. What is CBT for Insomnia?
Cognitive Behavioural Therapy or CBT is the gold-standard treatment for insomnia. This course
uses an evidence-based, CBT approach. You will learn all the same skills and strategies that you
would learn by seeing a clinical psychologist in-person. This online course, which has been
developed by clinical psychologists and psychiatrists who specialise in CBT, is a new way of
delivering treatment. Online CBT has been shown to be as effective as face-to-face CBT.

CBT for insomnia, or CBT-I, is based on scientific knowledge about sleep. It combines cognitive
and behavioural strategies to address thoughts, behaviours, emotions, and physical symptoms
in your body (e.g., arousal) that interfere with your sleep. The aim of CBT-I is to help you to
develop sleep-positive behaviours and to reduce anxiety about sleep and daytime functioning.

Did you know?

The C in CBT-I refers to Cognitive factors affecting your sleep. These include thoughts and
expectations about sleep that interfere with good sleep. In particular, we will address anxiety
about not sleeping, as well as worry about stressful life events and associated hyper-arousal.
The B in CBT-I refers to Behavioural factors affecting your sleep. These include sleep habits
that tend to prevent people from getting a good night’s sleep, such as extended time in bed,
using your bed for activities other than sleep, and irregular sleep/wake times. We will also
consider other factors such as alcohol and caffeine use as well as your sleep environment.

CBT-I will assist you in developing more helpful behaviours that promote sleep. It will also assist
you in better managing stress and anxiety as well as adopting more helpful ways of thinking
about sleep so as to reduce arousal levels.

Behaviours
that promote
sleep

Helpful ways Manage

Good
of thinking stress and
about sleep Sleep anxiety

Reduce
arousal

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As cliché as it sounds – what you put in, is what you get out. The skills described in this
program are not complex. However, it does take motivation to put the skills and strategies into
place and to stick to them for several weeks. We recommend that you consider the next couple
of months as “boot camp” for your sleep. Our courses have been shown to be highly effective,
however the benefit is much less in those people who don’t complete all of the lessons in the
course.

If you are doing this course, you have been experiencing insomnia for a while now. It will likely
take 2-3 months to get your sleep back on track. Don’t expect your sleep to improve over night
(pardon the pun!). This will only place more pressure on your sleep, keeping you aroused, and
making it harder to sleep. As best as you can, make an effort to implement the strategies in the
course whole-heartedly – there may be some short-term pain for long-term gain.

5. Your Goals for this Course

It’s important to spend a few minutes thinking about what your goals are for the course.

What would you like to achieve as a result of doing this course?

We have listed some common general goals below (Tick the boxes that apply to you):

 Understand why I experience  Reduce time taken to fall asleep

insomnia  Feel less stressed about my sleep
 Learn how to improve my sleep
 Keep a consistent sleep schedule
 Reduce sedative medication use
 Have better quality sleep
 Improve my daytime functioning
 Sleep like I used to before I had
 Sleep longer at night time insomnia
 Reduce long periods of wakefulness
in the night

Other goals:
_____________________________________________________________________________________

_____________________________________________________________________________________

____________________________________________________________________________________

Try to make your goals as realistic as possible. That is, it’s not realistic to have the goal of
never waking in the night (because we know that brief wakings are a normal part of sleep)
or to sleep 8 hours every night (because there are individual differences in sleep needs and
people don’t typically get the same amount of sleep every single night). Plus, it isn’t helpful
to put such unrealistic expectations on yourself. Start small with your goals and build up!

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6. Understanding Normal Sleep
Sleep is not one continuous process but rather it consists of cycles of different sleep stages.
Sleep cycles last for about 90 minutes and we have about 4 or 5 of these a night.
Sleep cycles are divided into REM (Rapid Eye Movement) and non-REM sleep.

Why is REM and non-REM sleep important?

 REM sleep, during which dreaming occurs, is important in learning and memory, and is
particularly important in helping you to process and regulate emotions.
 Non-REM sleep appears to be important for conservation of energy and restoration as well
as the consolidation of certain types of memories. Non-REM sleep is divided in to three
stages (Stages 1, 2, and 3).
Stage 1 – Light Sleep. This stage only lasts for 5-10 minutes, mostly as you are falling off to
sleep. If you are woken during this phase, you may not actually realise that you
had been sleeping.
Stage 2 – Moderate Sleep. This stage lasts for about 30-45 minutes in each sleep cycle. Our
minds are active during sleep. If you are woken in this phase, you may think you
were already awake.
Stage 3 – Deep Sleep. A restorative period of sleep in which slow wave sleep occurs.

The graph below shows an example of a normal sleep pattern in an average adult.

As you can see, it’s normal to wake up a few times during the night. These awakenings can be
brief and you may not even be aware of them.

Graph adapted from http://www.howsleepworks.com/types_cycles.html

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What is Melatonin?
Exposure to light and darkness plays a very important role in regulating sleep, through its action
on melatonin.
− Melatonin is a natural hormone in the body that makes us sleepy.
− It is released in darkness and suppressed in light.
− Melatonin levels rise in the evening.
− When you’re exposed to light, melatonin release gets turned
off, which tells your brain it’s time to wake up.
− It’s not just the sunlight that will turn off the melatonin switch. Light from your computer
screen, phone, and TV also reduces melatonin.

Did you know?

The number of times you wake up after falling asleep typically increases with age. This
graph shows the average number of awakenings in “good sleepers” across age groups.
9
8
Awakenings after sleep onset

7
6
5
4
3
2
1
0
3-5 6-9 10-12 13-15 16-19 20-29 30-39 40-49 50-59 60-69 70-79
Age Group

Graph adapted from: http://sleepdisorders.sleepfoundation.org/chapter-1-normal-sleep/age-and-sleep

Remember,
− The amount of sleep one needs varies from person to person.
− Sleep needs change from about middle-age.
− Older adults typically experience less deep sleep and more lighter sleep as they age.
− This lighter sleep does not impact daytime functioning. Studies suggest that older adults
cope better with sleep loss, than younger adults.
− Even if you have a great night’s sleep, your energy levels do not stay consistently high
throughout the day.
− It’s normal to experience peaks and dips in energy throughout the day.
− Most people experience a dip in energy in the mid-afternoon, after lunch.

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7. The Three Factors that Regulate Sleep
Understanding the factors that regulate normal sleep is crucial when tackling symptoms of
insomnia.

Sleep regulation is dependent on three key factors: sleep drive, circadian rhythm, and arousal.

1. SLEEP DRIVE
Sleep drive is an automatic process involving the normal build-up of sleep
debt as the day goes on.

You can think of your sleep drive or pressure to sleep like your “sleep
appetite”. Sleep drive is lowest in the morning when you wake up and
gradually increases as the day goes on. It decreases again when you sleep.

Sleep drive is dependent on the time since your last sleep, as well as the duration of the
previous sleep. Therefore, sleep drive is highest when the last sleep was some time ago and also
when we are sleep deprived.

What factors weaken your sleep drive? (Tick those that apply to you)
 Napping.
− You can think of this like having a snack before you go out for dinner. In that situation,
your appetite is reduced so you don’t feel as hungry for dinner. Similarly, when you
nap or doze, your “sleep appetite” is reduced for your main sleep in the night time.
 Sleeping longer than usual (e.g., oversleeping in the morning).
− When you oversleep in the morning, less time is available to build up sleep drive
before your next habitual bedtime.
 Consuming caffeine.

CBT-I aims to strengthen your sleep drive, thereby making it easier to fall asleep.

What can you do to strengthen your sleep drive?

− Refrain from napping and dozing.
− Be active during the day – exercise, work, socialise.
− Don’t spend excessive time in bed.
− Sleep deprivation will also strengthen sleep drive.

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2. CIRCADIAN RHYTHM
We all have an internal biological clock that regulates many of our bodily
processes such as digestion, body temperature, and sleep. This clock works
approximately on a 24-hour period.

Irregular sleep schedules weaken our internal clock, which is why it is helpful
to keep regular wake times. Light is a particularly powerful cue to reset our
internal clock each day.

The most important thing you can do to optimise your circadian rhythm is to wake up at the
same time each day, including weekends. Wake time is the anchor to your sleep-wake cycle. You
need to reset your body clock every morning and the best way to do this is to wake up at the
same time every day. You can also help keep your circadian rhythm in alignment by exposing
yourself to light at around the same time each morning.

What factors weaken circadian rhythms? (Tick those that apply)

 Irregular sleep patterns
 Irregular meal times
 Irregular light exposure
 Travel to other time zones will also alter your internal body clock temporarily

CBT-I aims to strengthen circadian rhythms through regular sleep-wake times and routines,
thereby making it easier to fall asleep.

What can you do to strengthen your circadian rhythm?

− Wake up at the same time each day (including weekends), even when you haven’t slept
much the previous night.

− Get exposure to light first thing in the morning.

− Reduce light exposure at night time – dim the lights before bed.

− Try to stick to regular meal times.

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3. AROUSAL
Feeling on edge or anxious interferes with sleep. When we worry or perceive
a threat of any kind, our arousal levels increase and we can often feel tense
in our body.

Worry or having an active mind makes it difficult to “switch off”, relax, and
fall asleep. In addition, many people with insomnia develop an association
between going to bed and not sleeping. In turn, going to bed becomes a trigger for worry and
frustration about not sleeping. This, of course, increases arousal making it harder to sleep.

What factors increase arousal?

(Tick those that apply)
 Worrying about current problems
 Worry about sleep
 Sleep effort (actively trying to sleep)

CBT-I aims to reduce emotional and physiological arousal by quieting your mind, eradicating
sleep effort, and reducing physical tension, thereby making it easier to fall asleep.

Did you know?

 General worry = worry about things that are causing you stress, like work and family.
 Sleep worry = worry about the consequences of not sleeping.
 Sleep effort = putting too much pressure on needing to fall asleep and actively trying to fall asleep.

What can you do to reduce arousal?

− Reduce sleep effort (more on this in the next lesson!).
− Engage in a competing task.
− Keep the bed for sleep and intimacy only.
− Challenge catastrophic concerns about insufficient sleep.
− Manage your worries through cognitive restructuring, problem solving, worry time, and
mindfulness (more of this in the next lesson!).
− Practice relaxation (see Lesson 4).
− Physical exercise.
− Unwind before bed time (see Lesson 2).

We will expand on these strategies in the coming lessons.

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 8. CHECK-POINT
Are you prioritising sleep hygiene?
Sleep hygiene simply refers to habits that promote good sleep. Here is a checklist. Tick off
the ones that apply to you and start making these sleep promoting changes today!

Sleep Hygiene Checklist

− It will increase your amount of deep sleep and also help you
 Prioritise exercise to reduce your anxiety and stress, and improve your mood.
− Don’t exercise too close to bed time as this may hype you up
and disrupt your sleep.
• Don’t do vigorous exercise within 4 hours of bed time.
− Do try to do exercise every day or most days.
− Relaxing exercises like stretching and yoga can be done
before bedtime to promote relaxation.

− Keep it comfortably cool (but not cold), dark, and quiet.

 Improve your sleep
environment − Sometimes there are noises that we can’t control – try to
keep calm and use ear plugs if you can.
− A drop in body temperature can cue your body for sleep.
Taking a bath or shower 60-90 minutes before bed is not only
relaxing but it also allows your body to then experience a dip
in temperature at the time you want to sleep. Consider
making this part of your pre-bedtime routine.

− Our circadian system likes it when we eat at regular times,

 Keep a routine socialise at regular times, and perform other daily activities at
regular times so keep a routine.

− Living a sedentary lifestyle isn’t helpful for good quality sleep.

 Keep active Sometimes people reduce their activity levels because of
insomnia (e.g., feeling too tired to go out or feeling that they
need to conserve energy or stick to very rigid night time
routines). However, it’s important to stick to your regular
activities. This will increase your sleep drive and improve your
sleep.
− Sometimes people reduce their activity levels because of life
changes (e.g., retirement or physical injury).
• Plan activities each day to ensure adequate stimulation
and activity levels (see Lesson 4 for more details).
• If you have a physical condition that has altered your
capacity for activity, see a physio or GP to make a plan to
safely ensure adequate daily stimulation.

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 − Avoid having caffeine after about 3pm, as it interferes with
 Avoid Caffeine & getting to sleep and staying asleep.
Nicotine
− Some people are more sensitive to caffeine than others, so
you may need to have your last intake even earlier than 3pm,
whilst some people can tolerate drinking it later in the
afternoon.
− At the very least, avoid caffeine within 6 hours of when you
want to sleep because the half-life of caffeine is 6 hours –
That is, it takes your body about 6 hours to break down only
half of the amount of caffeine you’ve consumed.
− Nicotine is also a stimulant so reduce intake before bedtime.
− Although many people use alcohol to unwind, it interferes
 Limit alcohol use with your sleep quality.
close to bed time
− Even if it helps you to fall asleep, alcohol reduces sleep quality
and causes you to wake up more in the night.
− Try to limit consuming alcohol too close to bedtime.
− It takes about 1 hour for your body to process one standard
drink.

− If you find that your sleep is disturbed because you need to

 Limit fluid intake get up to urinate, try to limit drinking of beverages before
2hrs before bed bed.
− Be aware that both caffeine and alcohol stimulate your
bladder so if night-time urination is a major problem for you,
it may be a good idea to cut back on these altogether.

− If you get hungry at night time or wake up in the night

 Limit food intake hungry, a light snack before bed can be helpful.
before bed

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9. Sleep Diary
Now that you’ve identified some of the thoughts and behaviours that could be maintaining your
insomnia, it is important to start keeping a diary of your sleep. Keeping a Sleep Diary is an
integral part of this program and getting your sleep back on track. Filling out a sleep diary each
morning will give you important information about your sleep so that you can better
understand your sleep, track your progress, and help you to make the necessary adjustments to
improve your sleep.
You can complete the one below or the electronic one on your dashboard when you log in to
your course. We encourage you to use the electronic one because this will automatically
calculate your “Sleep Efficiency” for you, which you need to keep track of throughout the
program. But the main thing is that you complete a sleep diary each day, so use whichever diary
you think will make it most likely that you complete the sleep diary consistently.

− When completing the sleep diary, just use your best guess. That is, don’t use
the clock to work out exactly how long it took you to fall asleep or how long
you were up in the night - studies have shown that checking the time
increases anxiety about sleep, making it harder to sleep.
− It’s normal to feel groggy for the first 15-30 minutes after waking up, and this
can last up to 60 minutes. We call this ‘Sleep Inertia’. Because of this, don’t
rate your sleep quality until about an hour after waking up.
− Please complete the sleep diary every day! We have included a copy with
space for one week’s entries in each of the Lesson Summaries. If you take
more than one week in between lessons, please copy the diary so that you
can complete the sleep diary every day.
− A copy of the sleep diary can be found on the last page of this document.

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 Sleep Diary - Complete This Every Morning
(or use the electronic version on your dashboard when you log in to your course) Week: ______
Example

In the morning, fill out the information Night Tuesday _______ _______ ______ _______ _______ _______ _______
for the prior night. Date 25/03 / / / / / / /

1. Yesterday, I napped from ___ to ___ 1:50pm to

(Note the times of all naps) 2:30pm

2. What time did you go to bed last night? 10:45pm

3. What time did you try to go to sleep/turn off the lights? 11:15pm

4. How many minutes did it take for you to fall asleep after
40 min.
turning out the lights?
5. How many times was your sleep interrupted last night, not
2
counting your final awakening?
6. In total, how long did these awakenings last? 60 min.

7. How many times did you leave your bed last night? 1

8. What was the time of your final awakening? 6:15am

9. What time had you planned to wake up at? 6:30am

10. What time did you get out of bed for the day? 6:45am

11. Did you take any over-the-counter or prescription Medication:

medication(s) to help you sleep last night? Relaxo, 5mg

12. What was the quality of your sleep? 3

(1 = Very poor, 2 = Poor, 3 = Fair, 4 = Good , 5 = Very Good).

Comments (if applicable)

I have a cold

Time in bed 8hr

Total sleep time 5hr,20min.

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10. Calculating Sleep Efficiency
Often people with insomnia spend a lot of time in bed trying to sleep while actually sleeping
very little. For example, you might be in bed for 9 hours but only sleep for 5. The longer you are
in bed without sleep, the more likely you are to feel frustrated, which only keeps your insomnia
going. That’s why throughout treatment, we’ll be aiming to improve your sleep efficiency. You
will be able to work out your Sleep Efficiency from your sleep diary.
− Your sleep efficiency is a calculation of how much you’re sleeping in relation to the time
you spend in bed.
− We calculate your sleep efficiency by working out how much time you spent asleep
divided by how much time you spent in bed, and then multiply this number by a
hundred.
− So, if you were in bed for 8 hours but only slept for 6 hours, your sleep efficiency would
be 6/8 x 100 = 75%.
− Over treatment, we are aiming for a sleep efficiency of 85% or more.
− This number will be calculated automatically if you use the online sleep diary.
− If you want to calculate it yourself, do the following based on your sleep diary entries for
the past week:
A. Work out the average time you spent in bed per night.
 Time in Bed = ______
B. Work out the average amount of sleep you got per night.
 Total Sleep Time = ______

Sleep efficiency = Total Sleep Time x 100

Time in Bed

− Although you will calculate your sleep efficiency each night of the week, the more
important number is your average sleep efficiency over the week.

11. Sleep Medications

There are many medications that are frequently prescribed to treat insomnia. Even though the
most effective long-term treatment for insomnia is Cognitive Behavioural Therapy (CBT) rather
than medications, medications are still sometimes used in the short-term (maximum 1-2 weeks).
Ongoing use of sleeping tablets may not only lead to side effects and even addiction, but also
interfere with developing good sleep habits independent of medication, thereby only prolonging
sleep difficulties.

It is important to know a few things about these medications before starting and make sure you
discuss these with your General Practitioner (GP) or Psychiatrist before commencing any
medication.

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Do not take any medications if you are pregnant or trying to become pregnant (even over the
counter medications) without discussion with your doctor first.

Side Effects
All medications have potential side effects and sleeping pills are no different; these include
over-sedation, headache, dizziness, amnesia, confusion, disinhibition and difficulty breathing, all
of which can be worsened when mixed with other medications, drugs or alcohol. Careful
consideration with driving or operating machinery must be considered.

Longer term use of sleeping tablets can lead to “addiction”, where higher and higher doses are
needed to get the same effect and considerable difficulty or “withdrawal” when trying to come
off sleeping tablets.

Discontinuation
Stopping medications suddenly can lead to rebound insomnia and (if used for a longer period,
such as a few weeks or more) a withdrawal syndrome. Withdrawal symptoms can include;
rebound insomnia, increased agitation, anxiety, shakes and in extreme circumstances, seizures
and even death.

It is important to discuss with your doctor before stopping any medication, especially if you
have been using it for a prolonged period. Most doctors will recommend a gradual tapering
regime of lower and lower doses over the course of weeks, sometimes months (and even a
switch to a longer acting mediation) to lessen any of these potential withdrawal symptoms. See
the Appendix at the end of the summary for information about common medications used for
insomnia.

12. Your Action Plan

Congratulations on completing Lesson 1! Your tasks to do following this lesson are:
 Review Lesson 1 slides again.
 Print out, complete, and re-read this lesson summary.
 Complete your Insomnia Model (page 5-7) so you know what symptoms to work on in
the remaining lessons to get your sleep back on track.
 Fill out your sleep diary every morning.
− Calculate your average Sleep Efficiency over the week.
 Start implementing sleep hygiene today.

Please schedule a time to complete Lesson 2 in your diary. It will become available in 5 days. It
is important that you read this lesson summary and complete the homework tasks before you
go onto Lesson 2. Good luck!

The Team from This Way Up.

www.thiswayup.org.au

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13. Appendix
Frequently Asked Questions (FAQs)
My mood has become much worse - what should I do?
Many people who have insomnia also experience anxiety and depression. If at any stage of the
course you feel that your mood has severely deteriorated or your anxiety has worsened, then
please contact your GP or other mental health provider. If you cannot get in contact your GP,
you can also call Lifeline on 13 11 14 (www.lifeline.org.au). Lifeline is available 24/7.

I am feeling suicidal - what should I do?

If you are suicidal and feel at serious risk of self-harm, you should immediately call emergency
services (Ambulance/Police) on 000 or your local hospital mental health crisis team.

I have some suggestions for improving the Course – who should I tell?
Please send us all your positive and negative feedback, and please keep it constructive. We are
dedicated to helping you to feel better, so we want to do the best job that we can. We value
your feedback in helping us to do this! You can contact the This Way Up team by emailing
contact@thiswayupclinic.org, or by calling 02 8382 1400.

Common medications for insomnia

Benzodiazepines
These are probably the most commonly prescribed sleeping tablet, taken by up to 10% of
people at one stage over the course of a year. They come in varying forms and speed of action
and not only aid sleep and decrease anxiety but may be used medically for muscle relaxation or
to stop seizures. When used for longer periods, these medications can be highly addictive.
Benzodiazepines include temazepam (Temaze), diazepam (Vaium, Valpam, Antenex, Ranzepam),
nitrazepam (Alodorm, Mogadon), oxazepam (Serepax, Murelax, Alepam) flunitrazepam
(Rohypnol, Hypnodorm), clonazepam (Rivotril), and alprazolam (Xanax).

Zopiclone and Zolpidem

Zopiclone (Imovane, Imrest) and zolpidem (Stilnox, Somidem, Dormizol, Stildem) work in a
similar way to benzodiazepines and long term use is also not advised due to the potential for
addiction. Side effects are similar to benzodiazepines but also include taste disturbance and
even hallucinations, nightmares, and sleep-walking has been reported.

Melatonin
Melatonin is a naturally occurring hormone that rises in levels in the evenings preceding the
onset of natural sleep. Melatonin (Circadin) tablets may be beneficial in shifting sleep time in
those that have problems falling asleep late and waking up late, or in shifting sleep patterns due
to jetlag or shift work, but there is little evidence for their use in insomnia. Side effects include
headache, stomach upset, back and joint pain.

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Sedating antihistamines
Antihistamines such as doxylamine (Dozile, Restavit), promethazine (Allersoothe, Phenergan),
and diphenhydramine (Snoozaid) are commonly used as sleeping tablets as they can be bought
without a prescription in Australia. While they might be effective for use for 1-2 nights, they
appear to be not effective in chronic insomnia.

Antidepressants
Some antidepressants such as mirtazapine (Avanza, Mirtazon), doxepin (Deptran, Sinequan),
nortriptyline (Allegron), and amitriptyline (Endep) may cause secondary sedation, however they
are not recommended for use solely as a sleeping tablet.

Bibliography
Buscemi, N., Vandermeer, B., Hooton, N., Pandya, R., Tjosvold, L., Hartling, L., Baker, G., Klassen, T.P. and Vohra, S.
(2005). The efficacy and safety of exogenous melatonin for primary sleep disorders. Journal of general internal
medicine, 20(12), 1151-1158.

Carskadon, M. A., & Dement, W. C. (2005). Normal human sleep: an overview. Principles and practice of sleep
medicine, 4, 13-23.

Demyttenaere, K., Bonnewyn, A., Bruffaerts, R., De Girolamo, G., Gasquet, I., Kovess, V., Haro, J.M. and Alonso, J.
(2008). Clinical factors influencing the prescription of antidepressants and benzodiazepines: Results from the
European study of the epidemiology of mental disorders (ESEMeD). Journal of Affective Disorders, 110(1), 84-93.

Kaplan, K.A. & Harvey, A.G. (2013). Treatment of sleep disturbance. In D. Barlow (Ed), Clinical Handbook of
Psychological Disorders, 5th Edition. New York: Guilford Press.

Manber, R., & Carney, C. E. (2015). Treatment Plans and Interventions for Insomnia: A Case Formulation Approach.
Guilford Publications.

Mason, E. C. and Harvey, A. G. 2015. Insomnia and Sleep Disorders. Emerging Trends in the Social and Behavioral
Sciences: An Interdisciplinary, Searchable, and Linkable Resource. 1–12

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