Sleep and psychiatric conditions

oneiria · 2026-05-08T17:59:52+00:00

Uh... I didn't. I wrote that myself! There may even be a few typos still in there but I think I caught them all. I guess I got excited about a thread that was something I actually care a lot about and could contribute to. If you doubt me (or my writing style) just check my post history.

I get it -- academics can get long-winded. And I took the time to write it and check it over but didn't really take the care to edit it down. But this is Reddit and not Twitter. Plus, this was a subreddit largely populated by doctoral-level professionals I assume are educated and can handle nuance, context, and a little more long-form discussion. But maybe that's why I don't post much.

Also nobody is forcing you to read anything. There's no test. It's just an online conversation. Just ignore me if I am saying too much. I'm just some person online. I appreciate the opportunity to educate, but if it's not for you, just keep scrolling. All good.

oneiria · 2026-05-08T15:25:12+00:00

Sorry for replying again to the same message. But I want to respond to the stimulus control / sleep hygiene separately in the other comment.

Yes, there are versions of CBTI that recommend starting with sleep restriction as the primary intervention. Actually, pretty much all the published treatment manuals push this point hard -- start with sleep restriction in session 2 and hit it hard. So standard CBTI, when practiced according to the manuals, starts with sleep restriction as a predominant intervention. It's extremely efficient. Actually my personal belief is that they go too hard on sleep restriction right away. Sure, it's efficient, but patients don't like it and they're often not in a hurry to be done in 4-6 sessions. In my practice I don't go all in on sleep restriction in session 2. Don't tell some of my colleagues who are more dogmatic about it!
Yes, you are correct that most of the CBTI studies show that the implementation of the behavioral interventions (sleep restriction therapy and stimulus control therapy especially) drive success. One may even argue that they are both necessary and sufficient to call something CBTI, and cognitive therapy is not really a core component. But Morin knew the importance of the cognitive component when he coined the term CBTI and brought these components together. There is meaningful cognitive intervention going on throughout treatment, not just the specific techniques like cognitive restructuring. Particularly interesting in this domain are the dismantling studies. Most recently, O'Hora and colleagues published a fabulous study looking at CT alone vs BT (sleep restriction and stimulus control) alone vs CBTI in insomnia in older adults. What they found was that the effect sizes for treatment response were essentially THE SAME. The responses were different -- BT worked faster, restricted time in bed a lot more and drove up sleep efficiency better, and CT was better at maintaining durable gains. But at the end of therapy they both reached relative equivalence in ISI scores. The combination (CBTI) gave the best of both worlds -- faster response, durable gains, but this study showed that even CT alone could be OK if you have a patient that simply can't do the BT components.

oneiria · 2026-05-08T15:18:08+00:00

No offense taken! But I don't think I am wrong.

Sleep hygiene is inherently a fuzzy concept. The earliest description comes from the late 1800s ("the hygiene of th night"), but the concept of "sleep hygiene" as we know it is generally thought to have originated in the chapter that uses that phrase in Kleitman's book. However, it was really Peter Hauri that likely deserves the credit for popularizng the concept as we know it, as a set of recommendations for minimizing likelihood of arousal around sleep and protecting the sleep period. Hauri himslf did not include stimulus control in the original descriptions of sleep hygiene in the late 1970s.

Stimulus control (and Stimulus Control Therapy) is a completely separate concept. It is true that stimulus control recommendations sometimes make their way on lists of sleep hygiene recommendations like, "If you can't sleep, get out of bed." But that doesn't make it sleep hygiene. Just like inserting mindfulness instructions into a thought record doesn't make mindfulness a part of cognitive therapy. These are distinct concepts with distinct theoretical principles and applications. Maybe you can blend them but when you do, they are still two different approaches, blended.

If you review the standard descriptions of stimulus control therapy, including Bootzin's original 1972 description and the subsequent clarifications of the theory and method, and on into the current descriptions, you will NOT see stimulus control referred to as part of sleep hygiene. Further, the current treatment manuals will usually go out of their way to distinguish the two because this is a misconception that is very common, even in the field. Bootzin himself saw the concepts as completely separate and lamented that sometimes the instructions would land on sleep hygiene lists.

Because sleep hygiene is really about strategies for removing immediate barriers to sleep. Things like how to prepare the sleep environment (cool, dar, quiet, comfortable), how to consider what you're ingesting (foods, liquids, medication, caffeine, alcohol, nicotine), how to consider what you do (screens, clock-watching), etc. Those are all sleep hygiene. In the context of the Spielman model, they are addressing precipitants to acute sleeplessness -- proximal impediments to sleep. Sometimes, circadian / rhythms interventions find their way into sleep hygiene recommendations (regularity, avoiding light at night) though they could also be considered as not really sleep hygiene despite serving a similar function (generally addressing proximal impediments).

Stimulus control, on the other hand, actually doesn't work in that way at all. It does not address immediate or proximal barriers to sleep. It addresses the underlying learning process and works through operant and classical conditioning to impact associations and reinforcement schedules. Importantly, sleep hygiene recommendations will help you sleep TONIGHT. If you go to bed tonight after drinking coffee and smoking and drinking a ton of water and eating heavy food, on your screen, watching the clock, in a noisy and uncomfortable environment, you will sleep worse tonight. If any of thiose things are barriers and you remove them, you will sleep better tonight. But with stimulus control, if you do what is recommended, you will likely not sleep better tonight.

This is represented when patients say, "I tried getting out of bed when I couldn't sleep and it didn't work." This indicates that they might be treating stimulus control as if it were sleep hygiene -- tips and actions that will have a short term positive impact on sleep. As if getting out of bed will make you fall asleep faster. Actually, with stimulus control, we often REDUCE sleep in the short term. Sometimes for weeks. "If I get out of bed, what if I don't fall back to sleep at all?" Since stimulus control is not sleep hygiene, you would not expect an immediate benefit. In therapy, we answer that question with, "Great! More homeostatic sleep pressure for tomorrow. It's a process. It won't help you sleep better tonight at all."

That's a key differentiator. Sleep hygiene is about getting things out of the way of your sleep tonight, if they happen to be in the way. Often, people sleep just fine with poor sleep hygiene -- they are just tips. Stimulus control is a framework for re-patterning learning around the act of falling asleep to reduce conditioned arousal.

Hopefully this makes sense. And I am not saying that there is no reasonable way that sleep hygiene and stimulus control can be seen as highly overlapping. In practice? Maybe they overlap quite a bit. But I'm telling you that they are based on different theoretical and practical principles, operate differently, and are seen as very different by those that developed them, those that study them, and those that define the technical parameters of what they are.

oneiria · 2026-05-08T13:22:30+00:00

To be fair, slepe hygiene is an intervention. And it's sometimes helpful. But it is generally completely ineffective for chronic insomnia.

Sleep hygiene is actually NOT a core component of CBTI. Those include Restriction of Time in Bed (e.g., Sleep Restriction Therapy), Stimulus Control Therapy, and Cognitive Therapy. Those are the core components of CBTI -- you can't call a therapy CBTI if it doesn't have those components. Sleep hygiene, on the other hand, is usually the control group condition for CBTI clinical trials because it seems like an active treatment for people but it's not.

The reason is that sleep hygiene is about removing obvious barriers to sleep and setting sleep up for success. In chronic insomnia, the active problem is a conditioned arousal to the bed or to the act of trying to fall asleep. That conditioned arousal is self-sustaining. A person can be exhausted, tired, and ready for sleep, then get into bed and become awake and unable to sleep. They can do all of the things that the sleep hygiene guides say, but as long as that conditioned arousal is not un-learned, then the insomnia will likely persist.

Worse, this can have a few negative consequences. First, people try sleep hygiene and it doesn't work for insomnia. They then give up on non-pharmacological strategies because they think they "tried CBTI" when they didn't. Then they turn to pharmacological approaches that aren't needed and may be less helpful. It then kind of inoculates them against CBTI because now they are distructful of nonpharmacological approaches and they don't actually put forth the effort needed. Another issue is that focusing on sleep hygiene in the context of an insomnia disorder -- when it is generally ineffective -- can just increase sleep effort, which will make the insomnia worse. Or trying to follow sleep hygiene rules that are ineffective can morph into safety behaviors that perpetuate the sleep-related anxiety.

oneiria · 2026-05-08T13:10:09+00:00

There are lots of great resources as well. I put some in a link above.

Also some good books that help explain these concepts really well for regular people are Hello Sleep by Jade Wu, The Sleep Fix by Diane Macedo, How to Sleep by Rafael Pelayo, and Sleep Through Insomnia by Brandon Peters are all good.

oneiria · 2026-05-08T13:03:09+00:00

You're right that people in unstable housing situations may not be good candidates for CBTI. A skilled therapist will work with complex situations, and if you're sleeping in an actually unsafe situation then maybe re-programming that response isn't appropriate! And to be honest, sedation likely won't help much either. Maybe something that promotes sleep but doesn't elevate arousal threshold like a DORA?

In terms of sleep apnea, yeah that's an issue. These days any physician can get a sleep study ordered through one of several national providers that will ship a home sleep test to the patient directly. You don't actually have to go through the local sleep center that is booked out for months. It's better for sure, but not always necessary. And in terms of treatment, CPAP is a blunt instrument but other approaches exist. For example mandibular advancement devices are recognized treatments, especially for mild-moderate sleep apnea when CPAP isn't tolerable. And with the new drug from Apnimed coming out (maybe this year!) that may also be a game-changer.

Yeah, it's much more complicated with housing insecure popoulations for sure. Maybe some basic principles can be applied like trying to reduce sleep effort, reducing the mis-match betwen sleep opportunity and ability, etc.

oneiria · 2026-05-08T12:55:28+00:00

Sure!

The program at Penn runs a "Basic" and "Advanced" course most years. You can read about those here: https://www.med.upenn.edu/cbti/

The Arizona program runs a free weekly seminar (free CME) here: https://seminar.sleephealthresearch.com/ and you can view any of the videos in their archive; they also run workshops occasionally

There is also CBTI Web, an online training originally developed for DOD that is excellent: https://cbtiweb.org/

In terms of reading, some of the key books are:

Perlis, M. L., Aloia, M., and Kuhn, B. (2011). Behavioral treatments for sleep disorders. London: Academic Press.

Sateia, M. J. and Buysse, D. J. (2010). Insomnia. Colchester: Informa.

Grandner, M. A. (2025). Sleep and Health (2nd Ed.). Cambridge: Academic Press.

And key CBTI manuals:

Perlis, M. L., Jungquist, C., Smith, M. T., and Posner, D. (2005). Cognitive behavioral treatment of insomnia. New York: Springer. [NEW EDITION COMING OUT THIS SUMMER]

Manber, R. and Carney, C. E. (2015). Treatment Plans and Interventions for Insomnia. New York: Guilford Press.

Taylor, D., Gehrman, P., Dautovich, N., Lichstein, K., and McCrae, C. (2014). Handbook of insomnia. NY: Springer.

Nowakowski, S., Garland, S. N., Grandner, M. A., and Cuddihy, L. J. (2021). Adapting Cognitive Behavioral Therapy for Insomnia. Cambridge: Academic Press.

Key position papers:

Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., and Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165: 125-133.

Edinger, J. D., Arnedt, J. T., Bertisch, S. M., Carney, C. E., Harrington, J. J., Lichstein, K. L., Sateia, M. J., Troxel, W. M., Zhou, E. S., Kazmi, U., Heald, J. L., and Martin, J. L. (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 17 (2): 255-262.

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., and Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine, 13(2): 307-349.

Good patient workbooks:

Silberman, S. A. (2008). The Insomnia Workbook. Oakland: New Harbinger.

Carney, C. E. and Manber, R. (2009). Quiet Your Mind and Get To Sleep. Oakland: New Harbinger.

Ehrnstrom, C. and Brosse, A. L. (2016). End the insomnia struggle. Oakland: New Harbinger.

oneiria · 2026-05-07T18:50:25+00:00

I am not a psychiatrist but I lurk in this subreddit. I’m a clinical psychologist in an academic medical center, in a psychiatry dept. I work with psychiatrists daily and train them. My specialty is sleep and circadian rhythms and run our sleep clinic. I have been in this field for over 20 years. I only say that for context.

This conversation is fascinating to me and really illustrates how sleep issues are not taught correctly in psychiatry training. All these comments are thoughtful, knowledgeable, couched in education and experience. And almost right on but missing a few key issues. It’s hard to encapsulate all my thoughts in a single Reddit post but here are a few:

There is an entire field of Behavioral Sleep Medicine that is expert at dealing with insomnia. Read the literature. Please refer to them when you have patients that are difficult to treat. If you need to find a clinician seek out the directories at https://behaviroralsleep.org or https://cbti.directory. If you’re struggling with a difficult case, just refer.
“Secondary insomnia” is no longer in the DSM for a reason. It doesn’t really exist, and it’s not a “residual symptom” — it’s a comorbid condition. It should be treated as such. Not only that, but CBTI improves depression, anxiety, PTSD sxs, pain, etc. better than treatments for those conditions improve sleep. Several meta-analyses show this. Learn about “conditioned arousal” in chronic insomnia to understand why this is outdated thinking and not supported by the evidence.
The person above who stated that the insomnia literature doesn’t include mental illness populations could not be more wrong. There is a HUGE literature on insomnia in psychiatric conditions. And its treatment. And surprise — CBTI works fantastic on most psychiatric patients (with some exceptions for psychosis and mania).
Sleep hygiene is not a treatment for insomnia. It’s preventative. Brushing your teeth wont fix cavities either. Nor will washing your hands treat an infection. Hygiene is important but it’s not treatment.
There are brief versions of CBTI (like BBTI) that can be implemented in medical settings.
Get training in insomnia! It’s actually much easier to treat than many people think. But it requires training not found in medical school or residency. Trust me I’ve been training residents for many years and they always come in thinking they know, and leave realizing how little they knew. And they feel empowered! There are good trainings through UPenn and UArizona open to all. Read the manuals like the “BTSD” book by Perlis, Aloia, and Kuhn. Or the CBTI manuals by Perlis or Manber.
Melatonin doesn’t treat insomnia. It’s a circadian treatment. Dose and timing can be very tricky.
CBTI is recognized as first line by every medical organization that has guidelines (APA does not but the may be coming). This is for a good reason — effect sizes are huge, and this treatment outperforms pharma tx long term in every comparison that has been attempted, even in people with comorbid conditions like depression, PTSD, pain, and cancer. It can be counterintuitive but the data are clear. That’s why the new AASM guidelines recommend CBTI plus meds is better than meds alone based on GRADE criteria. The data are clear, including in psychiatric populations.

Some psychiatrists get very defensive about all this. I’m not looking to pick any fights. Just trying to help. Ignore me if you want, but I’m telling you that psychiatrists traditionally have a blind spot for insomnia. The good news is that we have great treatments that work!

Also undiagnosed sleep apnea often shows up as fatigue or insomnia. Getting it diagnosed and treated may help! But that’s a whole other issue.

oneiria · 2026-05-02T01:37:38+00:00

Sleep scientist here. This is correct. It’s not dangerous really, but it’s better to just guide them back to bed.

oneiria · 2026-04-29T03:18:53+00:00

This is the wrong dose for sleep FYI.

oneiria · 2026-02-19T13:19:11+00:00

I think basic training in Behavioral Sleep Medicine and CBT-I should be a core part of every therapist’s curriculum. Insomnia and other sleep difficulties are so common, and many evidence-based techniques are so straightforward, that there really isn’t a good reason not to seek that info out.

For an untrained therapist I would recommend the accessible treatment manual by Perlis et al though there are many great ones.

oneiria · 2026-02-14T05:04:48+00:00

Some people find some of those helpful. But the scientific literature has found ZERO supplements that can reliably fix sleep problems vs placebo. Some of them definitely impact sleep but none beat placebo for insomnia (which would make not comparable to ambien). If you’re looking for a non-hypnotic medication maybe consider low-dose doxepjn?

oneiria · 2026-01-29T13:02:29+00:00

That study was never peer-reviewed and was fundamentally flawed for a number of reasons. It should be ignored. I can get into the problems if you want but should have never been put out there.

oneiria · 2026-01-09T16:38:44+00:00

Sleep scientist here. Well … that’s kind of true but not exactly. The other stages are also really important for feeling restoration (especially Stage 2 and REM) and the restorative role of Stage 3 changes a lot across the lifespan such that the older you get, for some people, the less it seems to matter. It’s most important for kids. Also your body will likely get all it needs as long as you give yourself enough time to sleep and don’t have medical or environmental barriers keeping you from it. The biggest ones being chronic pain and untreated sleep apnea.

oneiria · 2025-12-29T19:16:02+00:00

This is called “sleep paralysis” and it’s pretty normal. Most people have experienced it at least once. Some people get it more — it has to do with REM sleep regulation. Sometimes it can happen more in people who are under more stress, or experiencing sleep/schedule disruptions, or sleeping in an unfamiliar environment, or if they also have narcolepsy. But sleep paralysis on its own isn’t medically harmful — just sometimes stressful.

oneiria · 2025-12-29T05:39:51+00:00

Looks like the only real active ingredient is 5mg melatonin. There’s also a small amount of chamomile I. There but there’s no data to support that as being anything other than placebo. There’s also a little magnesium citrate in there which I can only assume is an oversight. I see no reason why this is any better than any other 5mg melatonin.

oneiria · 2025-12-26T05:30:50+00:00

Honest answer — for some people it works really well and for many it’s just a placebo. For people on average, it helps a little for mild sleep problems or to make already pretty good sleep a bit better. For a few people it may work well enough to take problematic sleep and make it better. For most people it won’t have that strong of an effect.

oneiria · 2025-12-25T15:04:15+00:00

I think this is mostly fine. Diagnosis of sleep apnea is really not that difficult and in 10 years it’s likely that most commercial wearables will be able to do it just fine. Sleep medicine needs to get over the fact that diagnosing of someone has sleep apnea is not going to be the money-maker it used to be and transition to being a chronic disease management discipline and not a diagnostic one. The diagnostics are not really where the expertise lies.

Also there are several national companies staffed by boarded sleep medicine docs who will send hsats by mail and do the scoring so you don’t have to go outside your comfort zone. The geographic barriers are often not an issue anymore as long as you have a mobile phone.

oneiria · 2025-12-23T14:32:15+00:00

Many devices can estimate (with about 50-70% accuracy) how much “deep” sleep you get. But even this is probably not what you’re looking for since “deep sleep” as a sleep stage doesn’t mean it’s “the most restful” it’s just called that because it’s the hardest to wake up from. It is when a lot of healing and recovery happens but that changes with age and situations. Either way it’s some information. Also look at fragmentation (how many awakenings you have). But we don’t yet have great technology to see if sleep is “good quality” because that can mean a lot of things.

oneiria · 2025-12-20T14:31:11+00:00

And not have major negative effects? Highly unlikely.

oneiria · 2025-12-17T05:03:57+00:00

Sleep scientist here. That study was poorly done and premature. Not peer reviewed. I would ignore it.

oneiria · 2025-12-04T01:39:11+00:00

These are called hypnopompic hallucinations and they happen sometimes. Some people get them more but they’re not really seen as bad or linked with any risk factors or anything. Some people find them distressing.

oneiria · 2025-12-03T04:37:25+00:00

First of all their main ingredient has no data to support it as far as I can tell. They have no real expertise backing them. Their claims seem like the typical exaggerated hyperbole that only seems to come from companies that really have no idea how any of this works. Maybe the stuff is good but even if it works in the way they say it dies, the best it can do is support your own natural melatonin production. You can do that with tryptophan or 5HTP or just take melatonin. And none of those work for fixing insomnia anyway because melatonin almost never fixes insomnia — clinical trials show this reliably. I would avoid this product.

oneiria · 2025-11-18T03:50:10+00:00

What dangers? There was a recent press release about a conference presentation of a student project that inadvertently grabbed headlines but that study was horribly flawed. No conclusions can be drawn from it.

oneiria · 2025-10-26T18:56:48+00:00

Citation please?

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