Dr. Mohammed Abdul Salam: 7 Tips for Treating Insomnia Without Medication
Dr. Wala’a Hafez: Many believe that treating insomnia begins with sleeping pills, despite the fact that chronic insomnia can evolve over time into a pattern learned by the brain and reinforced by thoughts and behaviors that make falling asleep more difficult. This is where Cognitive Behavioral Therapy for Insomnia (CBT-I) comes into play. Aimed at regulating sleep and modifying the associated thoughts and behaviors, CBT-I is considered the first-line recommended treatment for chronic insomnia in many international guidelines. In an interview with Al-Qabas, Dr. Mohamed Abdel Salam, a senior specialist in Internal Medicine, Respiratory Diseases, and Sleep Disorders, explains the details of this treatment and how it works.
**Insomnia for More Than One Night Is Harmful**
Dr. Abdel Salam clarified that it is normal for a person to experience nights when they cannot sleep due to work pressure, travel, illness, a family event, or ruminating on a specific problem. This type of sleep disturbance is usually temporary and resolves once the cause disappears. However, the problem begins when insomnia persists and recurs, and the anxiety about being unable to sleep becomes part of the problem itself. He said, “It may start due to psychological stress, illness, or a change in life circumstances. Then, the original cause disappears, while the insomnia continues.”
As insomnia persists, a person may start going to bed earlier in an attempt to make up for lost sleep, staying in bed for longer hours, or taking naps during the day. They may also become preoccupied with watching the clock and calculating the number of hours remaining until their wake-up time. With the repetition of these behaviors, the bed gradually transforms from a place associated with rest and sleep into one linked to wakefulness, tension, and the struggle to sleep.
This highlights one of the core principles of CBT-I: sleep is a natural process that cannot be forced. The more a person tries to force themselves to sleep, the more awake and preoccupied they may become with the idea of sleeping, which increases difficulty in relaxing and falling asleep.
**Linking the Bed to Wakefulness**
The body has two main systems that help regulate sleep:
* The first is the biological clock, which determines the natural timing for sleep and wakefulness.
* The second is known as “sleep pressure,” which accumulates gradually the longer one stays awake and decreases during sleep.
He explained, “When a person suffers from insomnia, they often try to compensate in what seems like a logical way, such as spending more time in bed or sleeping during the day. However, these behaviors can reduce sleep pressure in the evening and increase the time spent awake in bed. Over time, the brain learns to associate the bed with wakefulness, thinking, and anxiety.”
He added, “CBT-I does not focus solely on the number of sleep hours; rather, it aims to rebuild the natural relationship between the bed and sleep, regulate sleep pressure, and align the biological clock.”
**The First-Line Treatment for Chronic Insomnia**
Dr. Abdel Salam noted that numerous scientific bodies recommend CBT-I as the first-line treatment for chronic insomnia in adults. The importance of this treatment extends beyond avoiding medication; it is also based on strong scientific evidence confirming its ability to reduce the time needed to fall asleep, minimize frequent nighttime awakenings, and improve both sleep efficiency and quality.
Scientific reviews that aggregated the results of a large number of studies showed that CBT-I leads to significant improvement in insomnia symptoms compared to not receiving treatment. Moreover, a substantial portion of its benefits persists even after the sessions have ended. This is one of the key features that distinguish it from some sleeping medications. While medication may help improve sleep during the period of use, CBT-I aims to teach the patient skills and strategies they can continue to apply in the long term.
This does not mean that sleeping pills are useless or should be avoided in all cases. They may be suitable for some patients depending on the severity of symptoms and accompanying health and psychological conditions. A doctor may prescribe them for a limited period or concurrently with CBT-I. However, the availability of an effective treatment for chronic insomnia without relying on medication changes the way we should view the problem. Instead of focusing on sleep as something that requires medication, we can work on modifying the factors and behaviors that hinder it and regain a more stable sleep pattern.
**Regulating Time in Bed**
Dr. Abdel Salam emphasized that regulating or restricting time in bed is one of the most prominent components of CBT-I for insomnia. Although an insomniac may believe that the solution lies in spending more time in bed, staying awake for long periods may actually reinforce the association between the bed and wakefulness.
He said, “If a person spends eight or nine hours in bed but actually sleeps only six hours, the sleep window is regulated according to the average actual sleep hours, then gradually increased as sleep efficiency improves, until approximately 80% of the time in bed is spent sleeping.”
He clarified that the goal is not to deprive the person of sleep, but to enhance sleep continuity and reduce wake periods. However, it is necessary to apply this method under the supervision of a specialist, especially for the elderly, patients with certain health conditions, and individuals whose jobs require high levels of alertness.
**Avoiding Screens Before Bed**
He continued, “Stimulus control aims to retrain the brain to associate the bed with sleep, rather than using it for browsing, watching TV, working, or thinking. Therefore, it is recommended to go to bed when feeling sleepy, maintain a regular wake-up time, and temporarily leave the bed if sleep is not possible, then return to it when feeling sleepy again.”
**Thoughts That Cause Insomnia**
Dr. Abdel Salam pointed out that insomnia is not linked solely to the bed; it can also be influenced by how we think about sleep. A person may start their day worrying about the coming night, with tension increasing as bedtime approaches. They may become preoccupied with counting sleep hours and watching the clock upon waking. Thoughts such as “not getting eight hours of sleep will definitely lead to illness” or “I have lost my natural ability to sleep” may arise. These thoughts increase anxiety and wakefulness, making relaxation and sleep more difficult.
He explained that the cognitive component of the therapy helps the patient identify and evaluate these thoughts more realistically, with the goal of breaking the cycle of fear of insomnia and preventing sleep from becoming a daily test that the person fears failing.
**Structured Treatment**
Many people confuse CBT-I for insomnia with standard sleep hygiene advice, such as reducing caffeine, keeping phones away, and maintaining a quiet bedroom. Dr. Abdel Salam said, “These tips are useful and fundamental, but they are only part of the treatment and often insufficient on their own to treat chronic insomnia.”
He clarified that the treatment is a structured program that combines stimulus control, time restriction in bed, modification of sleep-related thoughts, relaxation techniques, and education about the sleep mechanism and the biological clock. It is usually applied over several sessions. Chronic insomnia may persist despite improvements in sleep habits, because the problem goes beyond mere unhealthy behaviors.
