Trouble falling asleep?

Trouble staying a asleep?

Trouble getting back to sleep?

Back To Sleeping Program

can really help make it happen!

Want to fall asleep, stay asleep and fall back to sleep quickly if you do wake in the night?

Want to feel rested in the morning?

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A 2002 Canadian Community Health Survey found that 13% of Canadians aged 15 years or older (3.3 million Canadians) report insomnia and 44% report occasional insomnia (Tjepkema, 2005). Similarly, the National Sleep Foundation (1998) found that 22 % of Americans report nightly (or almost nightly) insomnia and 48% percent report occasional insomnia.

The two most common forms of insomnia are sleep onset insomnia and breakthrough insomnia.

Sleep onset insomnia is when you are having trouble falling asleep. While there are no particular criteria for an abnormal length of time to fall asleep, up to a 1/2 hr. is generally considered normal. However, the principal criterion for sleep onset insomnia is whether trying to fall asleep is distressing. This may be because you feel restless, agitated and you can't turn your thoughts off. You are probably also concerned about the length of time that it's taking to fall asleep and you're concerned about not getting "enough" sleep.

Breakthrough insomnia is when you are waking in the night and having trouble falling back to sleep. Again there are no hard and fast rules about how many times a person wakes up in the night or how long it takes to fall back to sleep. You may wake once or twice, go to the bathroom, go back to bed and fall back to sleep right away. If you're waking in the morning feeling reasonably refreshed, then this is probably not a problem. While waking frequently can be a significant issue in terms of quality of sleep, the most common problem is difficulty falling back to sleep and the distress that this causes.

Insomnia can be intermittent or chronic. If it lasts for a week or two, it is often referred to as transient. It is probably caused by acute situational stress (the holiday season, exams, deadlines, new job etc.). If the insomnia lasts for 1 to 6 months, it is referred to as short-term and may be associated with significant life stress (illness, loss of a loved one, job loss etc.). If the insomnia persists past six months, it is usually referred to as chronic. This could mean that it is associated with, or is a consequence of, other disorders (e.g. depression, sleep apnea). Or it could be that life stress has continued beyond six months. And/or it could be that other factors are now contributing to maintaining the insomnia (e.g. irregular sleep cycle, alcohol, daytime napping, poor sleep habits, anxiety about not sleeping etc.).

The primary focus of the 'Back To Sleeping' program is to teach individuals how to reduce physiological arousal in bed, which allows sleep to occur. The program has three levels of intervention: physiological, behavioural and cognitive. It is the combination of these three levels of intervention that produces the most effective and reliable results in even the most entrenched of insomnias.


Level #3 - Cognitive

Cognitive behavioral therapy (CBT) focuses on an individual's thinking, which may be generating arousal, and assists individuals in developing more 'adaptive thinking', resulting in less arousal. CBT for insomnia typically focuses on two categories of thought: thoughts related to life stresses and thoughts about sleep itself (e.g. excessive preoccupation and worry concerning sleep). Worried thinking about sleep includes thoughts about the subsequent impact on daytime functioning (e.g. "If I don't get 8 hours of sleep, I won't be able to function").

Level #2 - Behavioural

The behavioural area involves examining, and making appropriate changes to, an individual's pre-bed and bedtime behaviours and/or bedtime conditions. These behaviours or conditions may, or may not, be part of the cause of the insomnia, but at the very least, they will likely be helping to maintain insomnia once it has started. Behavioural treatments help change sleep habits and regulate the sleep schedule (e.g. what to do when you can't sleep, when to go to bed and when to get up).

Good Sleep Hygiene is important to ensure a good night's sleep. This includes such things as avoiding catnaps, reducing caffeine intake and increasing exercise.

Stimulus Control Therapy is designed to re-associate the bedroom and the bed with sleepiness and sleeping instead of arousal, thinking, and not sleeping.

Systematic desensitization for insomnia is a procedure designed to counter-condition (undo) automatic increases in arousal (tension) that have become conditioned to (attached to) to the bedroom and/or the bed. For example, if an individual spends a lot in time in bed awake, the bed will gradually become a conditioned (learned) stimuli for being awake. This is often the reason we can feel drowsy on the sofa but wide awake the moment we get into bed.. This is now an automatic response. Systematic desensitization is a powerful imagery procedure that counter-conditions (undoes) these automatic responses and allows you to more effectively relax and fall asleep once in bed.

Level #1 - Physiological

The physiological area involves teaching skills that will allow individuals to reduce arousal (e.g. anxiety, agitation, excitement). Heightened levels of arousal can prevent the brain from shutting down for the night. Being able to get into bed and reduce arousal level often allows the individual to fall asleep.

Relaxation training involves a combination of learning muscle relaxation exercises to reduce muscle tension and mental strategies to replace racing thoughts with a quiet mental state.

Biofeedback training is a procedure in which arousal levels are measured using sensors and a computer system. The individual is then provided with immediate feedback regarding his or her level of tension. This procedure has been shown in the research literature to be very effective in teaching individuals how to reduce their arousal levels. Respiration biofeedback is a training procedure designed to teach diaphragmatic breathing. If learned properly, diaphragmatic breathing is often effective in reducing the time that it takes to fall asleep or fall back to sleep.

The Back To Sleeping Program

What to do about insomnia

Anyone experiencing a problem with insomnia should first consult his or her physician. It is important to first rule out medical disorders that may be a factor. Also, if the problem is severe, short-term use of medication might be important to stabilize the situation. Assuming that there are no contraindications, a referral to the 'Back To Sleeping' program could be made.


Back To Sleeping Program

Sample of recent evidence for common precipitating factors in insomnia

Bastien et al. (2004) found that the most common precipitating factors of insomnia were related to family, health, and work-school events. Staner et al. (2003) found that hyperarousal was a significant factor in the sleep initiation difficulties of individuals with primary insomnia. Carey et al. (2005) found that individuals with chronic insomnia felt that their insomnia had a pervasive impact on their lives and they felt misunderstood by significant others around them. However, Semler & Harvey (2005) found that impaired daytime functioning reported by insomnia patients was maintained, at least in part, by their subjective perception of sleep quality as opposed to the actual quality of sleep. Subjects who were told that they had a poor quality of sleep in a sleep lab had more daytime distress than subjects who were told that they had a good quality of sleep, even though there was no difference between the two groups in the actual quality of their sleep.

Sample of recent evidence of effectiveness of these interventions

Seventy to eighty percent of people with insomnia benefit significantly from sleep-focused treatments (Morin, 2004). A review paper by Wang et al. (2005) found that stimulus control, sleep restriction, sleep hygiene education and cognitive restructuring resulted in improved sleep efficacy, sleep onset latency and reduced sleep medication. Cervena et al. (2004) found that these interventions improve both subjective and objective sleep quality. Jacobs et al. (2004) found that these interventions were more effective than medication.


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