University of Alabama at Birmingham sleep specialist Justin Thomas, Ph.D., says he often gets odd reactions from patients when he tells them about one of the most effective ways to overcome insomnia: sleep restriction.

“They cannot get to sleep and have difficulty functioning during the day, and I tell them to spend less time in bed,” said Thomas, director of the Behavioral Sleep Medicine Clinic in the UAB Sleep/Wake Disorders Center and associate professor in the Department of Psychiatry and Behavioral Neurobiology. “That is so counterintuitive, but it works.”

Sleep restriction is one element of cognitive behavioral therapy for insomnia, or CBTi, which has become the leading method of treating the most common sleep disorder. The Centers for Disease Control and Prevention reports that, every year, millions of adults in the United States describe their symptoms of insomnia: difficulty getting to sleep or staying asleep that results in daytime sleepiness or difficulties functioning.

Thomas is one of only three specially trained behavioral sleep medicine specialists in the state of Alabama and a prolific researcher advancing the state of the art in the field, and is currently serving as president of the Society of Behavioral Sleep Medicine. He explains what CBTi is and the four steps that could lead to a better night’s rest for those with insomnia.

CBTi is the front-line treatment

Thomas says CBTi is now the front-line treatment for insomnia. “It usually does a good job and has a more lasting effect than medications.”

With CBTi, patients identify thoughts that are not helpful and come up with more helpful thoughts, which can generalize out to the rest of their lives. According to Thomas, it can make an impact on anxiety and depression as well.

“Especially if one can catch the insomnia earlier, CBTi works really well.”

CBTi generally includes four pieces, Thomas says.

1. Relaxation techniques

Relaxation techniques, such as diaphragmatic breathing, passive muscle relaxation and autogenic phrases, can help some patients get to sleep. For others, it is just the first step in the process.

“There is a roughly 20-minute routine that we teach and that our patients practice every day until they get good enough to do it themselves,” Thomas said. “I tell patients, ‘It is not like Ambien.’ The goal is to get you to relax and calm down and move yourself closer to sleep.”

2. Stimulus control

The stimulus for sleep is the bed, and there needs to be control over the stimulus.

“That is a set of rules to keep people from associating their beds and bedrooms with anything other than sleep and sex,” Thomas said. “Many people with insomnia lie there and toss and turn and get frustrated. The brain learns to associate the bed with wakefulness.”

Thomas says he instructs patients to not go to bed until they are sleepy, and if they cannot fall asleep for a period of time, to get up and go do something quiet and relaxing and return to bed when they feel sleepy.

3. Sleep restriction

Step three might sound like the most counterintuitive part of CBTi.

“We are not really restricting sleep but reducing time in bed to match how much sleep you are actually getting,” Thomas said. “If a person is sleeping for six hours but they are lying in bed for nine hours, we get them to only spend six hours in bed. Most people do the opposite.”

If an individual has a bad night, they will spend more time in bed, drink caffeine during the day and maybe take a nap. That makes it even harder to sleep the next night, and it can start a cycle. Then they find themselves worrying about what will happen the next night, and the cognitive piece comes into play.

4. Cognitive therapy

Finally, there is cognitive therapy, which is a tool psychologists use to identify thoughts that may or may not be accurate.

“Cognitive therapy helps people identify the connection between thoughts and emotions, challenge those thoughts, and help people come up with more helpful and realistic thoughts,” Thomas said. “We tell people, ‘Do not look at the clock.’ They are lying in bed and telling themselves, ‘It is 2 a.m. I need to fall asleep right now or I will not be able to function.’

That behavior is not helpful. It can put pressure and creates performance anxiety. Instead, Thomas says people need to identify those thoughts that are not helpful and come up with more helpful thoughts.

“The nice thing is that it generalizes out to the rest of their lives. It can make an impact on anxiety and depression as well.”

How long does CBTi treatment last?

On average, patients are seen for four or five visits. Thomas said the beauty of CBTi is that once a patient comes through his clinic, they have skills to treat themselves if the insomnia comes back in five or 10 years: “And they do not have to take a sleeping pill for the rest of their life.”

“I kind of joke that we should teach CBT as a life skill,” Thomas said. “It can prevent a lot of mental health concerns, and it is not at all intuitive. It really is a game-changer in terms of life in general.”

Insomnia or a circadian rhythm sleep-wake disorder?

Sometimes, what looks at first like insomnia is actually a circadian rhythm sleep-wake disorder. These are a particular research interest for Thomas. Using light and precisely timed administration of melatonin as treatment, he can help night owls function in a world that gets moving with the sunrise.

“One aspect of treatment in the Behavioral Sleep Medicine Clinic is we get a sense of chronotype, which is the timing of when your body wants to sleep,” Thomas said. “There are morning people, there are intermediates — which is the bulk of people — and there are night owls, and all of that is on a continuum.”

Genetics plays a big role in your ability to sleep, how much a person sleeps and the timing of sleep.

Questions such as “Do you get your best work done in the morning or in the afternoon or evening? On the weekends, do you prefer to stay up later and sleep later?” get at the behavioral output of a person’s chronotype.

“What is really driving that, though, are the underlying circadian rhythms, which dictate when an individual’s melatonin levels rise,” Thomas said. “When it gets dark, the brain starts to produce melatonin,” but the timing of melatonin production varies from person to person,” he explained.

Thomas sees a lot of adolescents with delayed sleep-wake phase disorder, which means their melatonin levels rise later than the average person.

“The clinical presentation is ‘I cannot go to sleep,’ which sounds like insomnia. But if they are given a sleeping pill, that will not necessarily work.”

Instead, what Thomas suggests is to administer bright light in the morning to advance the circadian phase and make it possible for someone to fall asleep earlier and more easily wake up for school or work — “plus or minus some melatonin.”