It is two in the morning, and the house is silent. The body is tired, the eyes are heavy, and yet the mind will not stop. It replays a conversation from the afternoon, drafts a reply to an email that has not yet arrived, tallies tomorrow’s obligations, and then turns to a more troubling subject: how little sleep there will be if sleep does not come soon. Each glance at the clock produces a small calculation. Five hours left, then four and a half, then four. The calculation brings no comfort, and the tension it creates makes sleep even less likely. Eventually, perhaps near dawn, sleep arrives in a shallow and unsatisfying form, and the alarm sounds shortly afterward.
Millions of people recognize this pattern. Surveys in many countries suggest that roughly a third of adults experience at least one symptom of insomnia, such as difficulty falling asleep, waking during the night, or waking too early, and that about ten percent meet the criteria for a chronic insomnia disorder. For many of them, the problem is not a lack of opportunity to sleep or an illness of the body. It is a state of mental and physiological arousal that is incompatible with sleep, in which the mind behaves as though it were on guard duty. This is what people mean when they speak of a racing mind.
The good news, which is still not widely known, is that chronic insomnia is highly treatable without medication. The treatment with the strongest evidence is a structured, short-term psychological therapy called cognitive behavioral therapy for insomnia, usually abbreviated CBT-I. Major medical bodies, including the American College of Physicians and the British Association for Psychopharmacology, recommend it as the first-line treatment for chronic insomnia in adults, ahead of sleeping tablets. Yet most people with insomnia have never heard of it, and many are offered medication instead.
This article is a detailed primer on insomnia and CBT-I. It explains what insomnia is, how sleep works, and why a racing mind keeps people awake. It describes the models that account for how a few bad nights become a chronic problem, and it sets out the main components of CBT-I, including sleep restriction, stimulus control, cognitive therapy, relaxation, and sleep hygiene, in enough detail to be understood and, where appropriate, applied. It also discusses what to expect during treatment, how CBT-I compares with medication, when professional help is needed, and how to maintain gains afterwards. The central message is that insomnia is usually maintained by the very things people do to cope with it, and that changing those behaviors and beliefs allows the natural sleep system to recover.
What Insomnia Is and What It Is Not
Insomnia is a persistent difficulty with falling asleep, staying asleep, or waking too early, which occurs despite adequate opportunity and circumstances for sleep and which leads to daytime impairment. The last part of this definition is important. A person who sleeps six hours and feels well the next day does not have insomnia, whatever the clock says, because sleep need varies between individuals. A person who spends nine hours in bed but still lies awake for hours and feels exhausted during the day does.
The Diagnostic Criteria
According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, insomnia disorder involves dissatisfaction with sleep quantity or quality, associated with one or more of the following: difficulty initiating sleep, difficulty maintaining sleep with frequent awakenings or trouble returning to sleep, and early-morning awakening with an inability to return to sleep. The sleep disturbance must cause clinically significant distress or impairment in social, occupational, or other areas of functioning. It must occur at least three nights per week, it must be present for at least three months, and it must occur despite adequate opportunity for sleep. A shorter pattern is called short-term or acute insomnia, which is very common and often linked to a particular stressor.
Daytime symptoms are part of the definition and include fatigue, low energy, difficulty concentrating, problems with memory, irritability, low mood, sleepiness, reduced performance at work or school, and worry about sleep. Notably, many people with chronic insomnia do not fall asleep readily during the day despite feeling tired, a feature that distinguishes insomnia from conditions that produce excessive sleepiness.
Types of Insomnia Complaints
Clinicians often describe insomnia by the pattern of the complaint. Sleep-onset insomnia refers to trouble falling asleep at the beginning of the night. Sleep-maintenance insomnia refers to waking up during the night and having difficulty returning to sleep. Early-morning awakening refers to waking well before the desired time. Many people have a combination, and the pattern may change over time. Sleep-onset difficulties are more common in younger adults, while maintenance problems and early waking become more common with age.
Acute and Chronic Insomnia
Most people will have a period of poor sleep at some time, often during a period of stress, illness, grief, or change. This acute insomnia usually resolves when the stressor passes. For a significant minority, however, the sleep problem continues after the original cause has gone, and it becomes self-sustaining. Understanding this transition from acute to chronic insomnia is the key to understanding why CBT-I works, and it is discussed in detail below.
Insomnia Is Not the Same as Sleeping Little
Some people are natural short sleepers who feel well on five or six hours, and they do not have insomnia. Others have a sleep need of nine hours or more. The need for sleep is partly genetic, and it changes with age, but it is relatively stable in an individual. The test is how a person functions and feels, not an arbitrary figure such as eight hours. The commonly cited eight hours is an average, and it is not a requirement. Attempting to achieve more sleep than the body needs is one of the common mistakes that maintain insomnia, as will be shown.
Conditions That Look Like Insomnia
Several other conditions can cause poor sleep and must be considered. Obstructive sleep apnea, in which breathing repeatedly pauses during sleep, can produce frequent awakenings and unrefreshing sleep, and it is more common in people who snore, who are overweight, or who are older. Restless legs syndrome produces an urge to move the legs that is worst in the evening. Circadian rhythm disorders, such as delayed sleep phase, involve a body clock that is set later than conventional hours, so that the person cannot fall asleep until the early morning but sleeps well if allowed to wake late. Periodic limb movements, chronic pain, thyroid disease, heart or lung disease, reflux, and a range of medications can also disrupt sleep. In addition, insomnia is often associated with depression, anxiety disorders, post-traumatic stress, and substance use. A thorough assessment by a doctor is therefore a sensible first step, and it may include questions about snoring, leg symptoms, medications, caffeine, alcohol, and mood.
How Sleep Works
To understand insomnia, it helps to understand the basic mechanisms of normal sleep. Two systems, working together, govern when and how well a person sleeps, and a third factor, arousal, can override them both.
The Two-Process Model
The two-process model, proposed by the sleep researcher Alexander Borbély in 1982, remains the most useful framework. The first process is sleep pressure, also called the homeostatic drive. From the moment a person wakes, a chemical signal, in which the molecule adenosine plays a key role, accumulates in the brain. The longer a person has been awake, the greater the pressure to sleep. During sleep, the pressure dissipates. This is why a person who has been awake for twenty hours sleeps deeply and why a daytime nap reduces sleepiness in the evening.
The second process is the circadian rhythm, the roughly twenty-four-hour internal clock located in a small region of the hypothalamus called the suprachiasmatic nucleus. It is synchronized mainly by light, and it regulates the timing of alertness, body temperature, and the release of hormones such as melatonin. The circadian system promotes wakefulness during the day, with a particularly strong alerting signal in the hours before habitual bedtime, and promotes sleep during the night. Good sleep is generally achieved when high sleep pressure coincides with the circadian signal to sleep. Problems arise when the two are out of alignment, as in jet lag or shift work, or when sleep pressure is reduced by long periods in bed, naps, or inactivity.
The Architecture of Sleep
Sleep is not a uniform state. It is organized in cycles of about ninety minutes, each of which contains stages of non-rapid eye movement sleep and rapid eye movement sleep. Light sleep, the first stages, forms about half of the night. Deep sleep, also called slow-wave sleep, is concentrated in the first half of the night and is important for physical restoration and memory consolidation. Rapid eye movement sleep, associated with vivid dreaming, increases in the second half of the night and is important for emotional processing and learning. Normal sleep includes several brief awakenings, usually unnoticed or forgotten. A person who sleeps well may wake five or more times during the night without remembering it, while a person with insomnia may be aware of each one and interpret it as a failure.
Arousal: The Third Factor
Sleep requires not only high pressure and the right circadian timing but also the absence of excessive arousal. The brain’s alerting systems, which involve noradrenaline and other neurotransmitters, must quiet down for sleep to begin. In people with insomnia, studies have shown signs of heightened arousal at several levels: higher heart rate, higher body temperature, higher metabolic rate, increased fast brain activity during sleep, and elevated levels of stress hormones. This hyperarousal, present even during the day in some individuals, is considered the central feature of chronic insomnia. It is the physiological basis of the racing mind.
The Racing Mind: Why Thoughts Keep You Awake
The phrase racing mind describes a state in which thoughts seem to run on their own, rapidly and uncontrollably, in a way that makes sleep impossible. It is one of the most common complaints of people with insomnia, and research has begun to clarify what lies behind it.
Cognitive Arousal and Pre-Sleep Worry
Studies in which people with insomnia and good sleepers were asked about their thoughts before sleep found that the people with insomnia reported more thoughts and more worrying, and that the main factor delaying sleep was cognitive activity and not bodily tension. The content of the thoughts varied: unresolved problems, plans for the next day, replays of the day’s events, concerns about health, and, very often, worry about not sleeping. This kind of activity is known as cognitive arousal, and it was described in an influential cognitive model of insomnia proposed by the psychologist Allison Harvey in 2002.
The Harvey Cognitive Model
Harvey proposed that insomnia is maintained by a vicious circle of worry, selective attention, and misperception. The person worries about sleep and its consequences, which creates anxiety and bodily tension. The anxiety directs attention toward threats to sleep, such as bodily sensations, noises, and the clock, and the person monitors them constantly. This monitoring leads to a distorted perception: the person underestimates how much they have slept and overestimates the severity of daytime impairment. The distorted perception feeds more worry, and the circle continues. In experiments, people with insomnia often report that they slept far less than polysomnographic recordings show, a phenomenon called sleep state misperception, and they also tend to overestimate how long it took them to fall asleep.
The Effort to Sleep
One of the most important insights from research is that sleep cannot be forced. It is an automatic process, which occurs when conditions are right, and trying hard to bring it on is likely to produce the opposite effect. Studies by the sleep researcher Colin Espie and others have shown that sleep effort, the conscious attempt to control sleep, is a significant factor in insomnia. This idea was captured in his attention-intention-effort model, which proposes that in people predisposed to insomnia, the intention to sleep, combined with attention to sleep-related cues, triggers effortful attempts that raise arousal and impair the automatic process. Good sleepers, in contrast, do not think about sleep. They simply sleep. The paradox of insomnia is that the harder one tries, the further sleep recedes.
Rumination, Worry, and the Unfinished Day
Bedtime is the first quiet moment for many people, and unfinished mental business tends to surface as soon as external demands fall away. Worry, which is concerned with possible future threats, and rumination, which is concerned with past events and mistakes, both occupy the mind in the dark. Research on the Zeigarnik effect, the tendency to remember unfinished tasks, suggests that open loops keep the mind engaged. A study at Baylor University found that people who wrote a detailed to-do list for five minutes before bed fell asleep faster than those who wrote about tasks they had completed, which indicates that offloading unfinished plans can reduce cognitive arousal.
Thought Suppression and Rebound
People often try to stop their thoughts by sheer will, telling themselves to think of nothing. The research on thought suppression described by the psychologist Daniel Wegner shows that this often backfires. In an experiment by Wegner and colleagues, people who were told to try not to think of a white bear reported thinking of it more often, and people who were told to suppress worrying thoughts before sleep took longer to fall asleep in studies of insomnia. The attempt to control thoughts creates a monitoring process that keeps them in awareness. This is one reason why the instruction to stop thinking is unhelpful, and why CBT-I teaches different approaches to the racing mind.
Safety Behaviors and the Clock
Many sleep-related habits that seem sensible are in fact maintaining the problem. Clock watching is a common example. Checking the time increases awareness of how little sleep remains, which triggers worry and arousal. Others include staying in bed longer to catch up, napping, canceling social plans to protect sleep, and consuming caffeine to compensate for tiredness. Like the safety behaviors of other anxiety conditions, they bring short-term relief but keep the problem going, because they preserve the belief that sleep is fragile and must be protected at all costs.
How a Few Bad Nights Become Chronic Insomnia
Why do some people recover quickly from a bad patch of sleep while others develop a long-lasting problem? The most widely used explanation is the three-factor model, or Spielman model, proposed by the psychologist Arthur Spielman in 1987. It identifies predisposing, precipitating, and perpetuating factors.
Predisposing Factors
Predisposing factors are the characteristics that make a person vulnerable to insomnia. They include a tendency to be a light sleeper, a high level of general arousal, a tendency to worry or ruminate, a family history of insomnia, and personality traits such as perfectionism and a high need for control. Women and older adults are at higher risk. Twin studies suggest that the heritability of insomnia symptoms is around thirty to fifty percent. These factors do not cause insomnia by themselves, but they lower the threshold at which sleep is disrupted.
Precipitating Factors
Precipitating factors are the triggers that set off the first episode: a stressful event, a change of job, bereavement, illness, pain, a new baby, shift work, travel, or a major life change. In most people, sleep returns to normal when the trigger passes. Acute insomnia in response to stress is not a disorder but a normal reaction of a sensitive system. Studies of people with chronic insomnia find that most can identify a specific trigger for the onset, and that the trigger is often no longer present.
Perpetuating Factors
The critical stage is the third. Perpetuating factors are the thoughts and behaviors that develop in response to poor sleep and that sustain it after the trigger has gone. Spielman’s insight was that many of them are attempts to cope. A person who sleeps badly spends more time in bed to catch up, goes to bed earlier, sleeps in, naps, or drinks more caffeine and alcohol. They also begin to worry about sleep, monitor it, and dread the night. Each of these changes weakens the natural processes that produce sleep. Extra time in bed reduces sleep pressure, irregular timing disturbs the circadian rhythm, the bed becomes associated with wakefulness and frustration, and worry raises arousal. The result is that insomnia takes on a life of its own.
This model is both explanatory and hopeful, because it points to the perpetuating factors as the target of treatment. While the predisposition cannot be changed and the original trigger is in the past, the habits and beliefs that sustain insomnia can be modified. This is exactly what CBT-I does.
Conditioned Arousal
An important perpetuating mechanism is conditioning. In a good sleeper, the bed and the bedroom are associated with sleep, and lying down produces drowsiness. In a person with insomnia, the repeated experience of lying awake, tossing, worrying, and feeling frustrated in bed teaches the brain to associate the bed with arousal. The bedroom becomes a cue for alertness and dread. Many people notice that they feel sleepy on the sofa in the evening, but become wide awake as soon as they get into bed. Some sleep better in a hotel or on the sofa than in their own bedroom, which is a sign of conditioned arousal. This is the basis for the stimulus control component of CBT-I.
The Consequences of Insomnia
Chronic insomnia is not merely an inconvenience. It is associated with a range of costs to health, performance, and quality of life, and these costs help to explain why it deserves treatment.
Daytime Functioning
People with insomnia report fatigue, difficulty concentrating, impaired memory, irritability, and reduced motivation. Studies show impairments in attention, working memory, and executive function, although the effects tend to be more subtle than the subjective complaints. Work productivity falls, and the risk of errors and accidents, including road accidents, rises. Insomnia is also associated with absenteeism and presenteeism, which is being at work but performing poorly, and its economic cost is large.
Mental Health
The relationship between insomnia and mental health is close and runs in both directions. Insomnia is a recognized symptom of depression and anxiety, but longitudinal studies show that it is also a risk factor for developing them. People with persistent insomnia are about two to three times as likely to develop depression in the following years as good sleepers. Treating insomnia in people with depression has been found to improve depression outcomes, and CBT-I is increasingly used alongside treatment of other mental health conditions. Insomnia is also associated with an increased risk of suicidal thoughts, and anyone experiencing such thoughts should seek urgent help from a professional or emergency service.
Physical Health
Long-term poor sleep has been linked in epidemiological studies to a greater risk of high blood pressure, cardiovascular disease, type 2 diabetes, obesity, and weakened immune response. The strength and causal direction of these associations are still being studied, and they appear to be strongest for insomnia combined with short objective sleep duration. Pain is another connection: poor sleep lowers pain tolerance, and pain disturbs sleep, producing a mutually reinforcing cycle.
The Fear of Consequences
It is worth noting that the beliefs people hold about the consequences of insomnia can themselves be harmful. A person who believes that a single poor night will ruin the next day, or that long-term poor sleep will cause serious illness, becomes anxious about sleep, and anxiety worsens sleep. While chronic insomnia has real costs, the human body is more resilient to a few nights of poor sleep than most people imagine, and most people with insomnia continue to function adequately. One of the tasks of CBT-I is to correct these exaggerated beliefs without minimizing the real impact of the problem.
What CBT-I Is
Cognitive behavioral therapy for insomnia is a structured, time-limited treatment that targets the thoughts and behaviors that perpetuate insomnia. It usually consists of four to eight sessions, delivered individually or in groups, by a trained therapist, in books, or through digital programs. It does not use medication, and its effects are not limited to the period of treatment: studies show that gains are maintained for months and years afterwards.
The Evidence Base
CBT-I is among the best-evidenced treatments in behavioral medicine. Randomized controlled trials and meta-analyses involving thousands of participants have found that it produces reliable improvements in the time taken to fall asleep, the amount of time awake during the night, and sleep quality. Typical results include a reduction in the time to fall asleep and in wake time after sleep onset by about twenty to thirty minutes each, and roughly half of treated patients, in many trials, achieve remission or clinically significant improvement. Reviews that compare CBT-I directly with sleeping medication find that the two have similar short-term effects, but that the benefits of CBT-I persist after treatment ends, while those of medication generally do not. For this reason, clinical guidelines in the United States, Europe, and the United Kingdom recommend CBT-I as the first-line treatment for chronic insomnia.
CBT-I also works for people with other conditions. Trials in people with depression, anxiety, post-traumatic stress, chronic pain, cancer, and in older adults have shown benefits, and it appears to improve the coexisting conditions as well as sleep. Effects have been found in people who take sleeping medication, and CBT-I can assist in tapering it.
The Core Components
CBT-I typically includes five main elements: sleep education, sleep restriction, stimulus control, cognitive therapy, and relaxation or arousal reduction, with attention to sleep hygiene as a supporting element. Not all components are used for every person, and the combination is adjusted to the individual’s pattern. The sections that follow describe each of them in detail.
The Sleep Diary: Where CBT-I Begins
The starting point of CBT-I is the sleep diary, a simple daily record, kept for at least one to two weeks, of when the person went to bed, how long it took to fall asleep, how many times and for how long they woke in the night, when they finally woke, when they got out of bed, and how they rated their sleep and daytime functioning. Records of caffeine, alcohol, medication, naps, and exercise are often included.
The diary has several purposes. It replaces vague impressions with data, and since people with insomnia often misperceive their sleep, the data can be surprising. It reveals patterns, such as irregular bedtimes, long periods in bed, naps, or the effect of alcohol. It provides the basis for calculating sleep efficiency, a key measure in CBT-I. Sleep efficiency is the percentage of time in bed that is actually spent asleep. If a person spends eight hours in bed and sleeps for six, the sleep efficiency is seventy-five percent. Good sleepers typically have an efficiency above eighty-five to ninety percent. The diary also gives a record against which progress can be judged. Some people find that keeping the diary makes them more anxious about sleep, and the usual advice is to complete it briefly in the morning, without checking the clock during the night, using an estimate.
Sleep Restriction
Sleep restriction is often considered the most powerful element of CBT-I, and it is also the one that surprises people most. The name is misleading. It does not mean depriving a person of sleep, but restricting the time spent in bed to match the amount of sleep the person is actually getting, in order to consolidate sleep and build sleep pressure.
The Logic
A person who sleeps an average of five and a half hours but spends eight and a half in bed has three hours of broken, wakeful time in bed. This extra time is the problem, not the solution. It dilutes sleep pressure, it fragments sleep, it conditions the bed to wakefulness, and it feeds the worry of a person who lies awake. Reducing the time in bed to the time actually asleep increases sleep pressure, so that the person falls asleep more quickly and sleeps more continuously. Over time, as sleep becomes more efficient, the time in bed is gradually extended.
How It Is Done
The procedure, developed by Arthur Spielman and colleagues in the 1980s, follows a series of steps. First, the average total sleep time over the diary period is calculated. Second, the person is given a prescribed time in bed equal to that average, with a minimum of about five hours, even if the average is lower, to ensure safety. Third, a fixed wake time is chosen, usually the time the person must get up, and the bedtime is set accordingly. For example, if the average sleep is five and a half hours and the person must rise at six-thirty in the morning, the bedtime is set at one in the morning. Fourth, the person keeps the diary and, each week or so, reviews the sleep efficiency. If efficiency is above about eighty-five to ninety percent, time in bed is increased by fifteen to thirty minutes. If it is below about eighty percent, time in bed is reduced slightly, and if it is in between, it is left unchanged. This process continues until the person is sleeping well for an amount of time that suits their needs.
What to Expect
Sleep restriction is effective but uncomfortable, especially in the first one to two weeks, when the person is likely to feel more tired than before. Daytime sleepiness, difficulty concentrating, and irritability are common in this period, and they are the reason why guidance and support are valuable. Most people find that within two to three weeks, they begin to fall asleep more quickly and sleep more deeply, and that the benefits outweigh the early cost. It is helpful to be aware of this in advance, as the initial fatigue may otherwise appear to be evidence that the treatment is not working.
Safety Considerations
Because sleep restriction temporarily increases sleepiness, it requires care. People who work in jobs that need high alertness, such as driving heavy vehicles, operating machinery, or medical practice, should discuss timing with a clinician and may need a less intensive version. It is not recommended without supervision for people with bipolar disorder or a history of mania, since sleep loss can trigger mood episodes, for people with epilepsy or seizure disorders, for those with untreated sleep apnea, or for people with parasomnias such as sleepwalking, whose symptoms may be aggravated by sleep deprivation. Any person who feels dangerously drowsy while driving should stop and rest. A milder form, called sleep compression, which reduces time in bed more gradually, is available for people who cannot tolerate the standard approach.
Why Naps Are Usually Avoided
During sleep restriction, daytime napping is generally discouraged, since it reduces the sleep pressure that the treatment is trying to build. People who find it impossible to stay awake may be allowed a brief nap of twenty to thirty minutes in the early afternoon. Staying active, going outside in daylight, and avoiding sitting in very comfortable positions during the sleepiest period of the afternoon help to cope with the tiredness.
Stimulus Control
Stimulus control therapy, developed by the psychologist Richard Bootzin in the 1970s, addresses the conditioned arousal described earlier. Its purpose is to re-associate the bed and bedroom with sleep and to strengthen a consistent sleep-wake rhythm.
The Instructions
The standard instructions are simple, and they must be followed consistently for the treatment to work.
- Go to bed only when you feel sleepy, not merely tired. Sleepiness is the tendency to doze off, whereas tiredness is a feeling of low energy.
- Use the bed and bedroom only for sleep and sexual activity. Do not read, watch television, use a phone, eat, or worry in bed.
- If you cannot fall asleep within about fifteen to twenty minutes, or if you wake during the night and cannot return to sleep, get out of bed and go to another room. Do not watch the clock; estimate the time.
- Do something quiet and relaxing in dim light until you feel sleepy, and only then return to bed. Avoid screens and stimulating activity.
- Repeat step three as often as necessary during the night.
- Get up at the same time every morning, regardless of how much sleep you had.
- Do not nap during the day, or limit naps to a brief period early in the afternoon.
Why It Works
These rules gradually break the association between the bed and wakefulness. By leaving the bed when sleep does not come, the person avoids the repeated experience of frustration and arousal in bed. By returning only when sleepy, they pair the bed with the rapid onset of sleep. The fixed rising time anchors the circadian rhythm, which is a powerful regulator of sleep. The approach also removes the effort to sleep, since the person is no longer lying in bed trying to force it.
Common Difficulties
Many people find the instructions hard to follow, especially getting out of bed on a cold night. It helps to prepare a comfortable spot with a blanket and dim light in advance, to choose quiet activities such as listening to calm audio, folding laundry, or reading something undemanding, and to remember that the discomfort is temporary. Some people become anxious about the rule, and begin to worry whether they will be able to leave the bed on time. The rule should be applied flexibly and without strain. The aim is not to get out of bed in a rigid way, but to avoid lying there in a struggle. Stimulus control and sleep restriction are often combined, and together they are very effective.
Cognitive Therapy for Insomnia
The cognitive part of CBT-I addresses the thoughts, beliefs, and worries that raise arousal and sustain insomnia. It aims to replace unhelpful and exaggerated ideas about sleep with more accurate and balanced ones, and to reduce the cognitive activity that keeps the mind racing.
Unhelpful Beliefs About Sleep
Researchers, notably Charles Morin, have developed questionnaires such as the Dysfunctional Beliefs and Attitudes about Sleep Scale, which identify common beliefs that people with insomnia hold. They fall into several categories. Some concern unrealistic expectations, such as “I must have eight hours of sleep to function.” Some concern the consequences of insomnia, such as “Poor sleep will make me ill,” or “I cannot cope after a bad night.” Some concern a lack of control, such as “I cannot predict whether I will sleep tonight,” or “My sleep is out of my control.” Some concern beliefs about the causes, such as “My insomnia is due to a chemical imbalance,” and some concern the value of sleep aids and coping, such as “I need medication to sleep.” Beliefs of this kind raise anxiety, increase effort to sleep, and foster the behaviors that maintain the problem.
Cognitive Restructuring
In cognitive restructuring, the person learns to identify such thoughts, test them against the evidence, and generate more balanced alternatives. For example, the thought “If I don’t sleep tonight I will not be able to function tomorrow” can be examined. The person may recall that, on previous poor nights, they did manage to function, though not at their best, that the body tends to compensate with deeper sleep afterwards, and that the thought itself causes anxiety that makes sleep less likely. A more balanced thought might be, “A bad night is unpleasant, but I have coped with them before, and my body will catch up.” Over time, the person’s anxiety about the night falls, and the pressure to sleep eases.
Paradoxical Intention
Paradoxical intention is a technique in which the person, instead of trying to fall asleep, tries to stay awake, lying in bed with eyes open, quietly and without effort, for as long as possible. Because the person is no longer trying to force sleep, performance anxiety declines, and sleep often follows. Studies by Colin Espie and others have shown that it can reduce sleep effort and sleep-onset latency. It must be done with a relaxed attitude, not as a trick in which the person secretly hopes to fall asleep, since it is the removal of effort that is therapeutic.
Worry Time and the Constructive Worry Technique
To reduce pre-sleep worry, people are often asked to set aside a scheduled worry period earlier in the evening, perhaps twenty minutes at around six or seven in the evening, away from the bed. During this time, they write down their worries and, for each, consider a possible next step or note that nothing can be done now. The aim is to deal with concerns in a structured manner, so that they are less likely to appear at night. If a worry appears in bed, the person reminds themselves that it has been recorded and will be dealt with at the scheduled time. Related techniques include writing a to-do list for the next day before bedtime, which, as noted above, has been shown to shorten the time to fall asleep.
Cognitive Defusion and Acceptance
Approaches from acceptance and commitment therapy and mindfulness have also been incorporated into insomnia treatment. Instead of arguing with thoughts, the person learns to notice them as mental events that come and go, without engaging or trying to suppress them. A thought such as “I will never sleep” can be labeled as “I am having the thought that I will never sleep,” which reduces its power. This approach recognizes that the struggle with thoughts is itself a source of arousal. Studies of mindfulness-based therapy for insomnia show improvement in sleep and in the person’s relationship with their sleep problem, although the evidence is less strong than for the core behavioral components of CBT-I.
Reducing Clock Watching and Monitoring
As part of cognitive work, people are advised to turn the clock away or to remove it from view, and to stop calculating how much sleep remains. Because monitoring raises anxiety, reducing it removes a trigger. People who rely on their phone as a clock should place it out of reach and use a simple alarm instead. The instruction to avoid checking can cause anxiety at first, but after a few days most people find it a relief.
Relaxation and Arousal Reduction
Because hyperarousal is central to insomnia, relaxation training is often part of CBT-I, although it is considered less essential than sleep restriction and stimulus control. Techniques should be practiced during the day or early evening, and not used as a method to force sleep in bed.
Progressive Muscle Relaxation and Breathing
Progressive muscle relaxation involves tensing and then releasing different muscle groups in sequence, which teaches the person to recognize and reduce tension. Slow diaphragmatic breathing, with a longer exhalation than inhalation, stimulates the parasympathetic nervous system and lowers heart rate. Both skills improve with regular practice, and they provide the person with a sense of having some tools for calming the body.
Imagery and Body Scans
Guided imagery involves picturing a calm, absorbing scene in detail, which occupies the mind with neutral content and displaces worry. The body scan, a mindfulness practice, directs attention in turn to different parts of the body, without trying to change anything. These practices can be used before bed or when waking in the night, as long as the attitude is one of gentle attention, not effortful attempts to fall asleep.
Winding Down
A wind-down period of thirty to sixty minutes before bed, with dim light, quiet activity, and no demanding tasks, helps the transition from the day. This is a time for something pleasant and undemanding, such as listening to music, light stretching, a warm bath, or reading. A warm bath one to two hours before bed has been found to help in some studies, probably because the subsequent drop in core body temperature promotes sleepiness. The wind-down also gives the mind a chance to settle. It should not become a rigid ritual that creates new anxiety if it is disrupted.
Sleep Hygiene
Sleep hygiene refers to a set of habits and environmental factors that support healthy sleep. It is often the first advice given to people with insomnia, but research indicates that on its own it is not an effective treatment for chronic insomnia. It is best viewed as a supportive element within CBT-I, which helps to remove obstacles but does not address the perpetuating mechanisms.
Caffeine, Nicotine, and Alcohol
Caffeine blocks the adenosine receptors that carry the sleep-pressure signal, and its effects last for many hours. It has a half-life of roughly five to six hours in most adults, so a coffee drunk in the afternoon is still active at bedtime. People with insomnia are generally advised to limit caffeine, and to avoid it after midday or early afternoon. Nicotine is also a stimulant, and smoking close to bedtime or during the night can disturb sleep. Alcohol is a more subtle problem. It may help a person fall asleep initially, but it fragments sleep in the second half of the night, suppresses rapid eye movement sleep, and can worsen sleep-disordered breathing. A pattern of using alcohol as a sleep aid can lead to tolerance and worsening insomnia.
Light, Timing, and Routine
Exposure to bright natural light in the morning and during the day strengthens the circadian rhythm and improves sleep at night. Dim light in the evening supports the natural rise of melatonin. Bright light, especially from screens, in the hours before bed may delay the body clock, although the effect of screens on sleep is partly due to the stimulating content of what is viewed. A regular schedule, with consistent rising time, meals, and activity, reinforces the rhythm. A consistent wake time is more important than a consistent bedtime, since it anchors the clock.
Exercise and Food
Regular moderate exercise improves sleep quality and reduces symptoms of insomnia, particularly when it takes place earlier in the day. Vigorous exercise very close to bedtime may be stimulating for some people, though evidence is mixed. A heavy meal close to bedtime can cause discomfort, and going to bed hungry can also disturb sleep, so a light snack may help. Large amounts of fluid in the evening can lead to night-time trips to the toilet.
The Sleep Environment
The bedroom should be dark, quiet, and cool, at around sixteen to nineteen degrees Celsius, with a comfortable mattress and bedding. Earplugs, blackout curtains, or an eye mask can help. The bedroom is best kept free of work materials and used for sleep. Pets or partners who disturb sleep may need to be accommodated in other ways. These changes are useful but rarely sufficient by themselves for chronic insomnia.
What CBT-I Treatment Looks Like in Practice
A typical course of CBT-I is organized into a series of weekly sessions, and the structure helps to understand what the person can expect.
A Typical Course
In the first session, the clinician assesses the sleep problem, the medical and psychological background, and the person’s goals, and explains the model of insomnia. A sleep diary is introduced. In the second session, the diary is reviewed, and the sleep schedule, including the time in bed and the fixed rising time, is prescribed on the basis of sleep restriction. Stimulus control instructions are introduced. In subsequent sessions, the clinician reviews the diary, adjusts the sleep window, deals with difficulties, and introduces the cognitive and relaxation components. In the last sessions, the focus shifts to consolidating gains, planning for the future, and preventing relapse. Sessions usually last thirty to sixty minutes, and some programs are shorter and use telephone or online contact.
Formats of Delivery
CBT-I can be delivered face to face with a specialist, in groups, by telephone, in self-help books, or through digital programs. A growing body of evidence shows that digital CBT-I, delivered through websites or apps with automated personalized guidance, is effective, with results approaching those of face-to-face treatment, and with the advantage of wide availability. Programs developed for the National Health Service in the United Kingdom, and others, have been tested in large randomized trials with good results. Stepped care, in which people begin with self-help or digital treatment and move to therapist-delivered treatment if needed, is increasingly used. For people with complex conditions, such as severe depression, sleep apnea, or bipolar disorder, a clinician-delivered approach is recommended.
A Composite Example
The following example is a composite and does not describe a real person. A man in his forties begins to sleep badly after a period of stress at work. Over the following months, he begins to go to bed at nine in the evening to ensure more rest, reads on his phone in bed, checks the clock repeatedly, and drinks several cups of coffee during the day to cope with tiredness. At the weekend he sleeps late and naps. His diary shows that he spends nine hours in bed and sleeps for about five and a half, with a sleep efficiency of around sixty percent. He lies awake for an hour at the beginning of the night and wakes for another hour in the early morning.
His therapist explains the three-factor model and prescribes a sleep window from one-thirty to seven in the morning, with a fixed rising time, no napping, and the instruction to leave the bed if awake for more than twenty minutes. The first two weeks are hard, and he feels exhausted. By the third week, he is falling asleep within fifteen minutes and waking less often, and his sleep efficiency exceeds ninety percent. His time in bed is extended step by step to seven hours. In parallel, he works on his belief that he cannot function after a bad night, writes down worries in the early evening, removes the clock from view, and reduces coffee. After six weeks, he sleeps for about six and a half hours with few awakenings, and, importantly, he no longer dreads the night. A poor night now is an annoyance and not a catastrophe.
CBT-I Compared With Sleeping Pills
Many people with insomnia are offered sleeping medication, and the question of how it compares with CBT-I is often asked. The comparison is worth examining carefully.
What Medications Can and Cannot Do
Benzodiazepines, such as temazepam, and the so-called Z-drugs, such as zolpidem and zopiclone, shorten the time to fall asleep and reduce awakenings in the short term. They are useful for brief periods of acute insomnia. However, their effects diminish with regular use due to tolerance, and they carry risks, including daytime drowsiness, memory problems, falls and fractures in older people, impaired driving, dependence, and rebound insomnia on stopping. Guidelines generally recommend that they be used at the lowest dose for the shortest time, usually no more than a few weeks. Sedating antidepressants such as low-dose trazodone or doxepin, antihistamines, and melatonin are sometimes used, although evidence for their effectiveness in chronic insomnia varies, and several have side effects. Newer drugs that block orexin, a wake-promoting neurotransmitter, such as suvorexant, lemborexant, and daridorexant, are available in some countries and have been shown to improve sleep, but long-term data and comparisons with CBT-I are limited.
The Durability Advantage
The main advantage of CBT-I is durability. Trials comparing CBT-I with zolpidem and other drugs have found that, while medication may act faster in the first weeks, the benefits of CBT-I are equal or greater by the end of treatment and are maintained at follow-up, whereas the benefits of medication tend to fade once the drug is stopped. CBT-I also has no risk of dependence. For this reason, it is the recommended first step, and medication is best reserved for short-term use or as an adjunct.
Stopping Sleeping Pills
People who have taken sleeping tablets for a long time may fear that they cannot sleep without them. CBT-I can be combined with a gradual taper under medical supervision, and studies show that people who receive CBT-I are more likely to succeed in stopping. Tablets should not be stopped abruptly, especially benzodiazepines, as withdrawal can cause rebound insomnia, anxiety, and, in rare cases, more serious effects.
Melatonin and Supplements
Melatonin is a hormone involved in the timing of sleep, and not a sedative in the usual sense. It has modest effects on the time to fall asleep and can be useful for circadian rhythm problems such as jet lag and delayed sleep phase, but its effect in chronic insomnia is small. Supplements and herbal remedies, such as valerian, have limited or inconsistent evidence. Quality and dosage of over-the-counter products vary, and people should discuss them with a doctor, particularly if they take other medications or are pregnant.
Special Situations
Insomnia occurs in many contexts, and CBT-I is adapted to each of them. A few merit separate discussion.
Insomnia and Depression or Anxiety
Because insomnia and mood disorders are so closely linked, sleep difficulties should not be dismissed as merely a symptom. Treating insomnia in its own right in people with depression improves both sleep and mood in many trials, and it may reduce the risk of relapse. Where anxiety is prominent, techniques for worry and arousal are particularly relevant. People with mood disorders should receive CBT-I under the care of a clinician who is aware of their condition, and sleep restriction in particular should be adapted if there is any history of mania.
Insomnia in Older Adults
Sleep changes with age: it tends to become lighter, with more awakenings and earlier waking, and the circadian rhythm advances. These changes are normal, but they can become troublesome when combined with long periods in bed, daytime inactivity, naps, pain, and medication. Older adults respond well to CBT-I, and it is a safer option than sleeping pills, which carry a higher risk of falls and confusion. Treatment is adjusted, for example by using a gentler form of sleep restriction and by paying attention to safety and to physical health.
Shift Work and Circadian Problems
Shift workers and people whose body clocks are misaligned face a different problem, since sleep pressure and circadian timing do not coincide with their work schedule. Strategies include consistent sleep timing as far as possible, controlling exposure to light, using blackout curtains for daytime sleep, planned napping, and, in some cases, timed melatonin or bright-light therapy under medical guidance. Standard CBT-I may need adaptation, and specialist advice is helpful.
Pregnancy, Perimenopause, and Hormonal Change
Sleep is often disturbed during pregnancy, the postpartum period, and the menopausal transition due to physical discomfort, hormonal changes, hot flushes, and the demands of newborn care. CBT-I has been shown to be effective in these groups, with adaptation to circumstances, such as allowing flexible sleep windows for new parents. Hormonal causes should be discussed with a doctor, since treating hot flushes can improve sleep.
Children and Adolescents
Insomnia also occurs in young people, in whom it is often linked to irregular schedules, late-night use of devices, anxiety, and a delayed body clock typical of adolescence. Behavioral approaches, including consistent routines, limits on evening screen time, morning light, and, for older adolescents, adapted forms of CBT-I, are recommended. Parents of younger children can seek the advice of a pediatrician, since sleep difficulties in children have different causes and require different approaches.
When to Seek Professional Help
Occasional poor nights are normal, and most acute insomnia resolves without treatment. It is advisable to seek professional help if sleep problems occur at least three nights a week for three months or more, if they cause significant daytime impairment or distress, if they are accompanied by low mood, anxiety, or thoughts of self-harm, or if self-help has not worked. A doctor should be consulted promptly if there are signs of another sleep disorder, such as loud snoring with breathing pauses, gasping at night, morning headaches, irresistible daytime sleepiness, an urge to move the legs, or unusual behavior during sleep. Insomnia that begins suddenly in the context of a new medication or medical problem also deserves attention.
When looking for a CBT-I therapist, it is reasonable to ask whether they have specific training in behavioral sleep medicine. Many countries have registries of qualified providers, and digital programs offer an alternative where specialists are scarce. People with severe or complicated insomnia should be treated by a clinician, but for many, a structured self-help program provides a good start.
Practical Strategies You Can Start With
While the full CBT-I program is best done with guidance, several elements can be used by anyone who has milder problems or who is waiting for treatment. The following suggestions are based on the principles described above and should be used with common sense. People who have any of the conditions listed under the safety considerations should seek advice before attempting sleep restriction.
Anchor Your Wake Time
Choose a consistent time to get up each day, including weekends, and keep to it for several weeks. Go outside into daylight soon after waking. This is the single most useful step for stabilizing the body clock, and it increases sleep pressure by the evening.
Do Not Spend More Time in Bed Than You Sleep
Look at your diary and avoid going to bed far earlier than you tend to fall asleep. Avoid staying in bed in the morning to catch up. If you are spending several hours awake in bed, consider gradually reducing your time in bed, but not to less than five hours.
Use the Bed Only for Sleep
Do not watch screens, work, or worry in bed. If you are wide awake after a while, leave the bed and do something calm in dim light until sleepy. Return to bed only when you feel drowsy.
Park Your Worries Earlier
Set aside time in the early evening to write down worries and plans, and note one possible next step for each. Before bed, write tomorrow’s to-do list. When thoughts arise in bed, remind yourself that they have been recorded and can be handled later.
Let Go of Checking and Effort
Turn the clock away, avoid calculating how much sleep you have lost, and try to let sleep come without effort. If you find yourself trying hard, remind yourself that sleep is automatic, that rest in bed is still restorative, and that a single poor night will not harm you.
Moderate Stimulants and Alcohol
Reduce caffeine, especially after midday, avoid nicotine near bedtime, and do not rely on alcohol to fall asleep.
Be Patient
Improvement generally takes weeks, and sleep may worsen briefly during the early stage of sleep restriction. Keep a diary and judge progress over weeks and not nights.
Relapse Prevention and Long-Term Maintenance
After treatment, sleep problems may return at times of stress, illness, or change, and it is helpful to be prepared. A brief bad patch does not mean that treatment has failed. In most people who have completed CBT-I, a short return to the principles resolves it.
Useful steps include keeping a regular wake time, avoiding the temptation to compensate for poor nights with long periods in bed or naps, resuming the diary for a week or two to identify drifting habits, and, if necessary, tightening the sleep window again for a short time. It is helpful to keep a written summary of the techniques that worked. Studies show that most people maintain their gains for a year or more, and some continue to improve after treatment ends, as confidence grows. A shift in attitude is also important: people who recover from insomnia learn that sleep is robust, that occasional bad nights are normal, and that they have tools to deal with them.
Common Myths About Insomnia
Several beliefs about sleep are widespread and can prolong the problem. The first is that everyone needs eight hours of sleep. Sleep needs vary, and the figure is an average. The second is that lying in bed resting is as good as sleeping. While rest is helpful, extended wakefulness in bed conditions arousal and is best avoided. The third is that a nightcap helps sleep. Alcohol disrupts sleep architecture and worsens it in the second half of the night.
A fourth myth is that insomnia is always a symptom of another condition and cannot be treated directly. While it is often associated with other problems, research shows that treating insomnia directly is effective and often improves the associated conditions. A fifth is that the only effective treatment is medication. As this article has shown, CBT-I is the first-line recommendation, with more lasting benefits. A sixth is that napping is a harmless way to compensate. For people with insomnia, naps reduce sleep pressure and can perpetuate the problem. A seventh is that one bad night ruins the next day. The body is more resilient than most people expect, and the belief itself raises anxiety.
Conclusion
Insomnia and the racing mind are bound together in a cycle. A period of stress or change disturbs sleep, and the natural response, which is to spend more time in bed, to monitor the clock, to worry about the consequences, and to try harder to sleep, raises arousal and weakens the biological systems that produce sleep. The bed becomes a place of wakefulness, the mind learns to race at night, and the problem continues long after the original trigger has gone. This is not a failure of character or a mysterious defect of the brain. It is the predictable result of normal coping efforts applied to a system that cannot be commanded.
CBT-I turns the model around. By restricting time in bed to build sleep pressure, by re-associating the bed with sleep through stimulus control, by examining unhelpful beliefs and reducing worry and effort, and by lowering arousal through relaxation and better routines, it addresses each of the factors that perpetuate insomnia. It is a brief, drug-free treatment, supported by a large body of evidence, and it produces improvements that last. Anyone whose sleep has been poor for months, who is suffering in the daytime, or who is relying on medication, is encouraged to speak with a doctor and to ask about CBT-I or a digital program based on it. Sleep, in the end, is something that returns when it is no longer chased, and the path back to it is clearer than most people realize.
FAQ About Insomnia and CBT-I
What is CBT-I and how is it different from ordinary cognitive behavioral therapy?
CBT-I is a form of cognitive behavioral therapy designed specifically for insomnia. Ordinary cognitive behavioral therapy for anxiety or depression focuses on thoughts and behaviors related to those conditions, whereas CBT-I targets the particular habits, beliefs, and physiological processes that maintain poor sleep. Its core components are sleep restriction, which consolidates sleep by limiting time in bed, stimulus control, which re-associates the bed with sleep, cognitive therapy for unhelpful beliefs and worry, relaxation techniques, and sleep education. It is brief, usually four to eight sessions, structured, and focused on practical changes. It has been shown in many trials to be more durable than medication, and it is recommended as the first-line treatment for chronic insomnia in major clinical guidelines.
How long does it take for CBT-I to work?
Many people begin to notice improvements within two to four weeks, and the full course usually lasts between four and eight weeks. The first week or two of sleep restriction can be uncomfortable, since the person may feel more tired as sleep pressure builds, and this is a normal part of the process. After that, most people fall asleep more quickly, wake less often, and feel more rested. Improvements in daytime functioning and in worry about sleep may take a little longer. Gains generally continue after the end of treatment, and studies show they are usually maintained for a year or more. Digital and self-help versions follow a similar timeline, though they depend on the person’s consistency.
Is sleep restriction safe, and will I be sleep deprived?
Sleep restriction temporarily limits the time in bed to roughly the amount the person is actually sleeping, so there is a period of mild sleep deprivation at the start, which is the mechanism by which sleep pressure is built. It is safe for most people when done properly, with a minimum time in bed of about five hours and gradual extension as sleep improves. It requires caution in people who drive or operate machinery for work, and it is not advised without medical supervision for those with bipolar disorder, epilepsy, untreated sleep apnea, or certain parasomnias. Anyone who feels dangerously drowsy should not drive. A clinician can adjust the approach, for example by using a milder form called sleep compression.
Why do I wake up at three in the morning with my mind racing?
Early-morning waking with an active mind is common in insomnia and has several contributors. Sleep pressure is lower in the second half of the night, because much of it has been used up, so sleep is lighter and awakenings are easier. The circadian system also begins to promote arousal as morning approaches, and stress hormones such as cortisol rise toward the early hours. In a person who is prone to worry, the quiet and darkness allow thoughts about problems to surface, and once the mind is engaged and the person notes the time, anxiety about lost sleep builds. Strategies include not checking the clock, leaving the bed if awake for a long period, using relaxation or a body scan, and dealing with worries earlier in the evening. Persistent early waking with low mood should be discussed with a doctor, as it can be a sign of depression.
Should I stay in bed if I cannot sleep?
For most people with chronic insomnia, the advice is not to lie in bed awake for long periods. Staying in bed while struggling to sleep conditions the bed to wakefulness and frustration, and it increases sleep effort. Stimulus control recommends getting up after about fifteen to twenty minutes of being awake, going to another room, doing something quiet and relaxing in dim light, and returning only when sleepy. This does not mean that a person should leap out at every brief awakening. If you are relaxed and drowsy, you may remain in bed, and if you are alert and anxious, it is better to get up. The key is to avoid associating the bed with struggle. Estimating the time, and not checking the clock, helps to apply the rule flexibly.
Are sleeping pills ever appropriate?
Sleeping medications can be appropriate for short-term use, for example during acute insomnia caused by a stressful event, and some people with severe or treatment-resistant insomnia use them under medical supervision. However, they are not recommended as the first-line or long-term treatment for chronic insomnia. Their effectiveness tends to diminish with regular use, and they carry risks, including daytime drowsiness, impaired memory and coordination, falls in older adults, dependence, and rebound insomnia after stopping. They also do not address the factors that maintain insomnia. A doctor can discuss the risks and benefits, and, if medication is used, it is usually at the lowest effective dose for the shortest possible time, ideally alongside CBT-I.
Does the blue light from screens cause insomnia?
Light from screens, particularly short-wavelength light, can suppress melatonin and delay the body clock when it is bright and viewed close to bedtime, but the effect of typical device use is smaller than often claimed. Content matters as well: emotionally engaging or stressful material, such as news, social media, or work messages, increases cognitive arousal and delays sleep, regardless of the light. Screen use in bed can also condition the bed to wakefulness. A sensible approach is to reduce screen use in the last hour before bed, dim the lights, keep devices out of the bed, and choose calm activities. Night-mode filters may help slightly, but they are not a substitute for changing the habit of using the device in bed.
Can insomnia be cured permanently?
Chronic insomnia is not usually described as cured in the same sense as an infection, since vulnerability to poor sleep often remains. However, most people who complete CBT-I achieve substantial and lasting improvement, and many no longer meet the criteria for insomnia disorder. Follow-up studies show that gains are generally maintained for a year or longer. Occasional bad nights, particularly at times of stress, are normal even for good sleepers, and the difference is that people who have learned the principles of CBT-I can respond to them without turning them into a chronic problem. Keeping a regular wake time, avoiding long periods in bed and naps, and responding calmly to bad nights help to maintain the gains.
Can I do CBT-I on my own or online?
Yes, for many people. Self-help books and digital programs based on CBT-I have been tested in randomized trials and found to be effective, with results close to those of face-to-face therapy, especially when they provide personalized guidance on the sleep window. Success depends on following the program consistently and keeping a sleep diary. People with mild to moderate insomnia and no other significant conditions often do well. Those with severe insomnia, depression, bipolar disorder, suspected sleep apnea, or other medical or psychiatric problems should work with a clinician, who can adapt the treatment and ensure safety. It is also reasonable to begin with a digital program and to seek further help if progress is limited.
Recommended Books on Insomnia and Sleep
- Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain by Colleen E. Carney and Rachel Manber
- Say Good Night to Insomnia: The Six-Week, Drug-Free Program by Gregg D. Jacobs
- Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach, Workbook by Jack D. Edinger and Colleen E. Carney
- Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night’s Sleep by Colleen E. Carney and Rachel Manber
- Overcoming Insomnia and Sleep Problems: A Self-Help Guide Using Cognitive Behavioral Techniques by Colin Espie
- The Sleep Book: How to Sleep Well Every Night by Dr. Guy Meadows
- Why We Sleep: Unlocking the Power of Sleep and Dreams by Matthew Walker
- Sleep Smarter: 21 Proven Tips to Sleep Your Way to a Better Body, Better Health, and Bigger Success by Shawn Stevenson
- The Insomnia Workbook: A Comprehensive Guide to Getting the Sleep You Need by Stephanie Silberman
- Principles and Practice of Sleep Medicine, edited by Meir H. Kryger, Thomas Roth, and William C. Dement
