Illustration: Kieran Blakey

The Nuance

The Best Remedy for Insomnia Is the One You Haven’t Tried

Most people do exactly the wrong thing during a bout of sleepless nights

Stress and worry are major insomnia triggers, and so it’s hardly a surprise that the pandemic has set off a wave of lost sleep. Earlier this year, research in the journal Sleep Medicine found that the emergence of SARS-CoV-2 caused a 37% jump in the incidence of clinical insomnia.

Even before the pandemic, insomnia was commonplace. Each year, about one in four adults develops acute insomnia, which is defined as a problem falling asleep or staying asleep a few nights a week for a period of at least two weeks. That’s according to a 2020 study in the journal Sleep.

Fortunately, that study found that most people — roughly 75% — recover from these periods of short-term insomnia. But for others, the problem persists for months or years. “A bad night of sleep can be a one-and-done, it can be a couple of nights for a couple of weeks, or it can turn into a chronic problem,” says Michael Perlis, PhD, first author of the Sleep study and director of the Behavioral Sleep Medicine Program at the University of Pennsylvania.

One of the reasons that acute insomnia turns into chronic insomnia, Perlis says, has to do with a common mistake people make after a night or two of poor sleep. Even among those who have struggled for years with insomnia, many continue to employ this same counterproductive strategy — a strategy that is based on a fundamental misunderstanding of how sleep works. On the other hand, Perlis says that one of the very best remedies for insomnia is also one of the simplest, and it works because it prevents people from making that mistake.

“Do nothing. That’s what I tell people who’ve had a bad night of sleep, or two or three,” he says. “But it’s the hardest nothing you’ll ever do. And I’ll explain why.”

The power of sleep debt

Perlis says that the common, insomnia-perpetuating error that most people commit is that they try to make up for lost sleep; they take naps, they go to bed early, and they sleep in late. “All of this contributes to sleep dysregulation, which is a recipe for long-term insomnia,” he explains.

When he tells people to “do nothing,” he means that they should not try to make up for lost sleep. Instead, they should stick to their usual sleep-wake routine even on days when they’re exhausted and dying for a nap or a sleep-in. “I tell people to be awake in the service of sleep,” he says. “If you build up enough sleep debt, sooner or later that will be enough to force you into deep and prolonged sleep. The ship will right itself.” (To be clear, naps can be fine for healthy sleepers, but for those with insomnia, they can make matters worse.)

Sleep debt is such a powerful anti-insomnia force that sleep therapists and clinics often employ a technique known as sleep restriction. This involves limiting the time a person is allowed to spend in bed each night to just six or seven hours — sometimes less — which augments the body’s need for sleep. “Sleep is a homeostatic process, which means that for every hour you’re awake, you’re increasing the pressure [the body feels] to balance that with sleep,” Perlis says. Eventually, if a person doesn’t relieve that pressure by taking naps or sleeping in late, the body’s homeostatic need for sleep will overwhelm whatever is keeping that person awake at night.

“If you build up enough sleep debt, sooner or later that will be enough to force you into deep and prolonged sleep. The ship will right itself.”

Other sleep doctors echo Perlis’ advice — and his warnings. “Patients ask all the time, ‘What happens if my sleep is thrown off? How much do I need to make up?’ But that’s not how sleep works,” says Michael Grandner, PhD, director of the Sleep and Health Research Program at the University of Arizona College of Medicine in Tucson. “Sleep is not like a bank account where if you pull money out and then put money in, it will all balance out.”

Grandner once worked with Perlis at the University of Pennsylvania. In support of his old colleague’s recommendation to “do nothing,” he offers a useful analogy. “If you have no appetite at dinner, you wouldn’t fix that by eating snacks all day long,” he says. “That would create a cycle where you’re eating at the wrong times and you don’t have any hunger when it’s actually time to eat.”

Similarly — and due to some related biological systems — he says that naps and other attempts to make up for lost sleep can reduce the “sleep hunger” a person feels in bed at night. This lack of sleepiness often leads to another night of poor sleep, which leads to more compensatory efforts to make sleep up the next day, and all of this disrupts the cycles and processes that govern healthy sleep.

Grandner says that an important element of the “do nothing” approach is the maintenance of a stable sleep-wake schedule, which helps align the body’s circadian clocks and rhythms. This means going to bed and getting up at roughly the same times (give or take 30 minutes) each day — including on weekends. “Sleep is highly programmable,” he says. “You can train it like you train a dog, but in both cases you have to be consistent.”

“Doing nothing doesn’t mean ignoring the problem,” he adds. “It really means staying the course and not overcorrecting after a few bad nights.”

“Do nothing. That’s what I tell people who’ve had a bad night of sleep, or two or three.”

When “do nothing” fails

For many insomniacs — especially those who experience only acute and sporadic bouts of problem sleep that are brought on by stress — Perlis’ “do nothing” advice will do the trick. But if a person’s insomnia is severe and entrenched, there’s another remedy that surprisingly few problem sleepers try despite its sky-high rates of success. That remedy is cognitive behavioral therapy for insomnia, or CBT-I.

CBT-I is a form of individualized psychotherapy that has become the “gold standard” for people with chronic insomnia, and that more than a decade of research has shown to be highly effective. In its clinical practice guidelines, the American College of Physicians recommends CBT-I as its “first-line” treatment for chronic insomnia.

“CBT-I is magic,” Perlis says. Like other forms of psychotherapy, CBT-I is tailored to each individual’s situation and challenges. It usually combines a handful of interventions that target a person’s thoughts, behaviors, and sleep routines, and it requires a sleep specialist’s oversight, he explains.

“The problem for people with insomnia is that when they experience it, they play the short game, not the long game,” he adds. The short game involves trying to catch up on lost sleep, and prioritizing feeling better fast over more durable remedies.

The long game may require more work. But the payoff can be a lifetime of better sleep.

I write about health and science. I live in Detroit with my wife and kids. I’m trying to learn German, but my progress so far is nicht gut.

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