Your Sleep Questions, Answered | Donn Posner
Dr. Donn Posner, a leader in Cognitive Behavioral Therapy for insomnia and Stanford professor, normalizes common sleep problems. He offers actionable strategies, emphasizing structure and wake time, to prevent acute insomnia from becoming chronic.
Deep Dive Analysis
22 Topic Outline
Introduction to Dr. Don Posner and Sleep Problems
Defining Acute vs. Chronic Insomnia
Causes of Increased Acute Insomnia During Pandemic
Importance of Sleep Structure and Wake Time
Understanding and Avoiding Social Jet Lag
Guidelines for Maintaining Good Sleep Health
Napping: The Right and Wrong Way
How to Determine Your Individual Sleep Needs
Debunking the 'Everyone Needs 8 Hours' Myth
The Dangers of Sleep Fixation and Trying to Sleep
Preventing Chronic Insomnia: What to Do When Awake
When to Seek Professional Help for Insomnia
Telehealth for Insomnia Diagnosis and Treatment
Why Some People Are Sleeping Better During COVID-19
The Critical Role of Light Exposure in Sleep
Addressing Middle-of-the-Night Awakenings and Rumination
Impact of Alcohol on Sleep
Using Devices in Bed and Blue Light Filters
Over-the-Counter Sleep Aids vs. Prescription Medications
Marijuana as a Sleep Aid
Dealing with Delayed Sleep Phase and Late Bedtimes
Resources for Finding Sleep Specialists
7 Key Concepts
Insomnia Disorder (Chronic Insomnia)
This is defined by trouble initiating sleep (taking over 30 minutes), maintaining sleep (being awake for a combined 30 minutes in the middle of the night), or waking more than 30 minutes earlier than desired, occurring three or more nights a week for longer than three months, with associated daytime symptoms like fatigue or concentration problems.
Acute Insomnia
This refers to insomnia symptoms (difficulty initiating or maintaining sleep) lasting less than three months. It is usually triggered by a stressor from the biopsychosocial spectrum and is considered a normal, adaptive reaction to stress, often remitting when the stressor resolves or adaptation occurs.
Social Jet Lag
This describes the feeling of jet lag experienced when a person significantly varies their wake times, such as getting up at different hours on weekdays versus weekends. This inconsistency disrupts the body's internal circadian clock, leading to symptoms similar to traveling across time zones.
Circadian Rhythm
This is an internal biological clock that regulates various bodily functions, including sleep-wake cycles, on an approximately 24-hour schedule. This rhythm is primarily 'entrained' or set by external cues, with light exposure being the single most important input.
Sleep Inertia
This is the temporary state of grogginess, disorientation, and impaired performance that can occur immediately after waking from sleep, especially after a longer nap or deep sleep. A short 'power nap' is designed to minimize this effect.
Perpetuating Factors (Insomnia)
These are behaviors, thoughts, or conditions that, while initially attempts to cope with poor sleep, inadvertently make insomnia worse and keep it chronic. Examples include altering sleep schedules, trying too hard to sleep, or associating the bed with wakefulness and worry.
Benzodiazepine Receptor Agonists
This is a class of newer sleep medications, such as zolpidem (Ambien), Sonata, and Lunesta, that are more specifically targeted to promote sleep rather than general sedation. They are distinct from older benzodiazepines and are generally intended for short-term sleep problems.
12 Questions Answered
Acute insomnia involves sleep problems lasting less than three months, often due to stress, while chronic insomnia (insomnia disorder) involves problems initiating or maintaining sleep for more than three months, occurring at least three nights a week, with associated daytime impairment.
Increased stress from global events, job loss, health worries, and disruption of daily routines (like working from home) can trigger acute insomnia, which, if not managed, can transition into chronic insomnia.
The single most important structural element for healthy sleep is a consistent wake time, which also dictates the first exposure to daylight and helps entrain the body's circadian rhythm.
Maintain a consistent wake time, avoid compensating for bad nights by sleeping in or napping excessively, and if you wake up in the middle of the night, get out of bed and do something relaxing until you feel sleepy again, rather than ruminating in bed.
The amount of sleep needed varies by individual, typically ranging from about six to nine hours, with the average being closer to seven and a half hours. You know you're getting enough sleep if you feel fine and function well during most of the day, not just immediately after waking or after compensating.
Yes, becoming overly fixated on achieving a specific number of sleep hours can undermine the natural sleep process and lead to insomnia, as sleep is an automatic process that cannot be forced.
If you're awake in the middle of the night, especially if ruminating, get out of bed and go to another room to do something fun and relaxing until you feel sleepy again, then return to bed. Avoid staying in bed and associating it with wakefulness and worry.
No, most over-the-counter sleep aids (often antihistamines) are not very effective, and both they and marijuana are generally not recommended for long-term management of chronic insomnia. They can create psychological dependence and don't address underlying perpetuating factors.
To shift your sleep schedule earlier, consistently set an earlier wake time. Getting up earlier will increase your sleep drive and make you more prone to falling asleep earlier when bedtime comes.
If you've tried general sleep hygiene tips and your sleep problems persist beyond three months (i.e., become chronic insomnia), or if you suspect other sleep disorders, you should seek a proper assessment from a behavioral sleep medicine specialist.
Yes, cognitive behavioral therapy for insomnia (CBTI), the recommended treatment for insomnia disorder, can be effectively delivered exclusively online through telehealth, as it does not typically require a sleep study for diagnosis.
Light, especially daylight in the morning, is crucial for entraining the body's circadian rhythm and setting the internal clock. Conversely, minimizing light exposure in the bedroom before waking and keeping the bedroom as dark as possible at night helps maintain this rhythm and prevent early awakenings.
23 Actionable Insights
1. Prioritize Consistent Wake Time
Establish a consistent wake time, at least five days a week, as it is the single most important input for entraining your internal biological circadian rhythm and maintaining healthy sleep. This also ensures consistent first exposure to daylight.
2. Avoid Compensating for Poor Sleep
Do not compensate for a bad night’s sleep by waking up later, going to bed earlier, or napping during the day. Stick to your regular wake time and sleep duration to allow your internal sleep regulation mechanism to self-correct.
3. Don’t Try to Force Sleep
Recognize that sleep is an automatic, autonomic process, similar to digestion or heart rate, and you cannot consciously force yourself to sleep. Trying too hard to sleep in bed is counterproductive and will make it more difficult.
4. Leave Bed If Awake At Night
If you wake up in the middle of the night and cannot fall back asleep, get out of bed immediately. Go to another room, do something fun or relaxing, and only return to bed when you feel sleepy again to avoid associating your bed with wakefulness and rumination.
5. Normalize Sleep Problems
If experiencing poor sleep, don’t panic or freak out, as it is a natural, normal, and fixable reaction to stress. This mindset helps prevent acute insomnia from becoming chronic.
6. Assess Sleep Need by Daytime Function
Determine your individual sleep need by how you feel and function throughout the day, rather than fixating on a specific number of hours. If you feel fine, are not excessively tired, and can concentrate well, you’re likely getting enough sleep.
7. Avoid Sleep Fixation
Do not become overly fixated or anxious about your sleep, as this can undermine the natural sleep process and perpetuate insomnia.
8. Implement Pre-Bed Wind-Down Routine
Transition to lower light levels and quieter, more relaxing activities at least an hour or two before bedtime, avoiding work or stressful calls right up until sleep. This prepares your body for sleep.
9. Get Morning Light Exposure
Upon waking, expose yourself to as much natural light as possible by opening curtains, sitting by a window, or going outside. This helps entrain your circadian rhythm, especially if you are experiencing sleep problems.
10. Ensure Dark Bedroom Environment
Keep your bedroom as dark as possible, especially before your desired wake time, using sleep masks, room-darkening shades, or shutters. Minimizing light exposure helps prevent early awakenings and maintains circadian patterns.
11. Add Daily Routine Regularity
Enhance circadian entrainment by maintaining regular meal times, consistent exercise schedules (e.g., a walk at the same time daily), and overall daytime activity. Being active during the day promotes better sleep.
12. Align Bedtime with Wake Time
Determine your desired wake time, set an alarm, and then backtrack the necessary sleep hours to establish an appropriate bedtime. Avoid going to bed before you feel sleepy.
13. Practice Power Napping
If napping, aim for a short 20-minute power nap, ideally seven to nine hours after waking, and set an alarm to avoid sleep inertia. This helps compensate for lost sleep minimally without disrupting night sleep.
14. Avoid Alcohol as a Sleep Aid
Do not use alcohol as a sleep aid, as it may induce initial drowsiness but can lead to fragmented sleep and awakenings in the middle of the night as its effects wear off.
15. Manage Device Blue Light
If using devices (phones, tablets) during night awakenings or before bed, activate blue light filters to reduce the impact on your circadian rhythm. For general use, prefer screens at a distance (like TV) over handheld devices close to the eyes.
16. Set Bedtime Alarm
To combat “doom scrolling” or delaying bedtime, set an alarm on your phone for the time you intend to start your wind-down routine and prepare for bed.
17. Seek Professional Help for Chronic Insomnia
If you’ve experienced insomnia for more than three months (chronic insomnia), seek professional help from a behavioral sleep medicine specialist, as targeted non-pharmacological treatment like CBT-I is often necessary to resolve the issue.
18. Prioritize CBT-I for Insomnia
For chronic insomnia, prioritize Cognitive Behavioral Therapy for Insomnia (CBT-I) as the first-line treatment, as it is a non-medication therapy recommended for long-term solutions, unlike medications which are better suited for short-term problems.
19. Utilize Telehealth for CBT-I
Seek treatment for insomnia through telehealth, as Cognitive Behavioral Therapy for Insomnia (CBT-I) can be effectively delivered exclusively online, making professional help more accessible.
20. Insomnia Diagnosis Doesn’t Need Sleep Study
Understand that diagnosing insomnia typically does not require a sleep study, unless other occult sleep disorders are suspected, making online diagnosis and treatment feasible.
21. Use Sleep Meds for Acute Insomnia Only
Use sleep medications, including over-the-counter options, only for short-term or acute insomnia under medical guidance, as they are not designed to fix the underlying perpetuating factors of chronic insomnia and can lead to dependency.
22. Use Marijuana for Short-Term Sleep Aid
If using marijuana as a sleep aid, treat it like any other sleeping pill and use it only for short-term issues, as long-term use can lead to tolerance and difficulty sleeping when discontinued.
23. Maintain Sleep Structure (Well-Sleeper)
If you’re already sleeping well, aim to get up at the same time five days a week and largely go to bed at the same time or after you’re sleepy five days a week to maintain good circadian entrainment.
8 Key Quotes
If you're sleeping poorly right now, he says, don't freak out about it. It's natural and normal and fixable.
Dan Harris (quoting Dr. Don Posner)
Sleep is deferred when the lion walks into the mouth of the cave.
Dr. Don Posner
You cannot make yourself sleep. You cannot. Sleep is such an autonomic, automatic process.
Dr. Don Posner
Good sleepers do nothing. When you ask them what happened last night when you got into bed, they say, I got into bed and then I don't remember. That's what it should feel like, Dan.
Dr. Don Posner
If you're getting overly fixated on your sleep, because somebody has told you that sleep is important, you're going to undermine the whole machine.
Dr. Don Posner
The treatment of choice for insomnia disorder is cognitive behavioral therapy for insomnia, which is a non-medication therapy for insomnia, which goes after all these things we've talked about.
Dr. Don Posner
I always like to say that the rest of the world has gotten the memo and we missed it. We seem to have missed it in a lot of things now. The rest of the world got this memo. And the memo is we were born in caves and we should have stayed there.
Dr. Don Posner
You know what works for insomnia sometimes? Everything, including magic pajamas.
Dr. Don Posner
3 Protocols
Maintaining Good Sleep Health (for people already sleeping well)
Dr. Don Posner- Get up at the same time at least five days a week.
- Largely go to bed at the same time (or after, if not sleepy) five days a week.
- Maintain regular meal times, avoiding random grazing.
- Maintain regular exercise times, taking a walk at the same time daily.
- Stay active during the day, as activity helps sleep.
- Transition into lower levels of light and quieter, more relaxing activities at least an hour or two before bedtime.
- Keep your bedroom as close to really dark as possible, ideally dark enough to develop film.
- If napping, aim for a short nap (around 20 minutes) during the postprandial dip (7-9 hours after waking) and set an alarm.
- Avoid napping if you foresee returning to a schedule where naps are not possible soon.
- Avoid using alcohol as a sleep aid, especially near bedtime, as it can cause middle-of-the-night awakenings.
- If using devices in bed, download and use a blue light filter and try to keep the screen at a distance from your eyes.
Preventing Acute Insomnia from Becoming Chronic
Dr. Don Posner- Don't panic; understand that acute insomnia is a normal reaction to stress.
- Maintain a consistent wake time, even after a bad night's sleep.
- Do not compensate for a bad night's sleep by sleeping in later, going to bed earlier, or napping during the day.
- If you wake up in the middle of the night and can't get back to sleep, get out of bed and go to another room to do something fun and relaxing.
- Wait until you feel sleepy again before returning to bed.
- Avoid overthinking or trying too hard to make yourself sleep.
Finding a Behavioral Sleep Medicine Specialist
Dr. Don Posner- Visit the Society of Behavioral Sleep Medicine website (www.societyofsbsm.org).
- Use the 'provider search' feature on the website.
- Click on your state on the provided map to find a listing of certified behavioral sleep medicine specialists in your area.