1. Why drugs do not "cure" insomnia
Zolpidem and lorazepam activate GABA-A receptors and "switch off" consciousness, but they do not restore normal sleep architecture (NREM 3, REM). Result: 7 hours of sleep without recovery, daytime drowsiness, cognitive dulling, and rebound insomnia on discontinuation (3–7 days). After one year, 70% become drug-dependent.
CBT-I directly corrects the behavioral and cognitive causes of insomnia → restores natural sleep without medication.
2. Stimulus Control (Bootzin, 1972) — 6 rules
- Bed = sleep and sex only: no phones, TV, eating, work, or worry in bed
- Go to bed only when sleepy: decided by drowsiness signals, not the clock ("it's 11 PM")
- If not asleep in 15 minutes, get up: do a quiet activity in another room (read, knit). Return to bed when sleepy again. Repeat.
- Same rule for nighttime awakenings: if awake for 15+ minutes, get up
- Fixed wake time: same on weekends (within ±30 min)
- No naps: or ≤ 20 min before 3 PM
3. Sleep Restriction (Spielman, 1987)
The most powerful but hardest element. Principle: less time in bed → more sleep pressure → higher sleep efficiency.
Week 1: measurement
Sleep diary for 7 days:
- Time in bed (TIB)
- Sleep onset latency (SOL)
- Wake after sleep onset (WASO)
- Final wake time
- Total sleep time (TST)
Sleep efficiency (SE) = TST / TIB × 100%. Normal ≥ 85%.
Week 2: time compression
Example: average TST = 5.5h, average TIB = 8h → SE = 69%. Restrict TIB to average TST (5.5h) + 30 min = 6h. Wake at 6 AM → no bed before midnight.
Weeks 3–6: gradual expansion
Measure SE each week:
- SE ≥ 90% → +15 min TIB
- SE 85–90% → maintain
- SE < 85% → -15 min
After 3–6 weeks, sleep efficiency stabilizes at 90%+.
4. Cognitive restructuring — 7 insomnia thought traps
| Distorted thought | Alternative |
|---|---|
| "If I don't get 8 hours, I'm ruined" | "Normal adult sleep is 6.5–7.5h. One bad day is recoverable" |
| "Without sleep I can't work tomorrow" | "Post-insomnia cognitive drop is 5–10%. Not catastrophic" |
| "If I wake at dawn I can't fall asleep again" | "Adults average 5–7 nighttime arousals. Normal" |
| "I can't sleep without pills" | "Sleep is innately possible without drugs. 6 weeks restores it" |
| "I must make up for lost sleep" | "Sleep debt cannot be 'made up'. Tomorrow is a fresh start" |
| "Insomnia is for life" | "70% have normal sleep one year after CBT-I" |
| "I have to 'will myself' to sleep" | "Sleep is not effort. It comes when you let it" |
5. Sleep hygiene (supportive — weak alone)
- Caffeine: stop after noon (half-life 5–6h)
- Alcohol: feels like it helps but blocks REM and causes early awakening
- Electronics: off 1 hour before bed (blue light blocks melatonin)
- Bedroom: 18–20°C, complete darkness, quiet
- Exercise: 30 min in the day; not within 3 hours of sleep
6. Relaxation
- Progressive Muscle Relaxation (PMR): feet to head, 5 sec tension / 15 sec release
- 4-7-8 breathing: inhale 4, hold 7, exhale 8 × 4 cycles
- Body Scan: mindfulness meditation
7. CBT-I resources in Korea
- University-hospital sleep centers: SNU, Samsung, Asan, Severance, etc.
- Digital CBT-I apps: Kkuljam (Korea), Sleepio, Somryst
- Clinical psychologists certified by the Korean Sleep Society
- If you are already on drugs, do not stop alone — combine with CBT-I and taper gradually
