Overcoming Insomnia with CBT-I: Dr. Ashley Mason's Expert Guide (Peter Attia Drive Summary)

In episode #341 of The Peter Attia Drive Podcast, host Peter Attia welcomes Dr. Ashley Mason, an Associate Professor at UCSF and Director of the Sleep, Eating, and Affect (SEA) Laboratory, as well as UCSF's Center for Obesity Assessment, Study, and Treatment (COAST). This episode provides a comprehensive masterclass on Cognitive Behavioral Therapy for Insomnia (CBT-I), exploring its principles, techniques, and effectiveness in treating chronic sleep problems. Dr. Mason delves into the practical application of CBT-I, including stimulus control, time-in-bed restriction, cognitive restructuring, and managing anxiety related to sleep. The discussion also covers fundamental sleep hygiene practices, the role of temperature regulation, managing medications and supplements, and the accessibility of CBT-I treatment.

Key Insights

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is a highly effective, evidence-based, non-pharmacologic treatment for chronic insomnia, often considered the first-line approach. Its efficacy rates are high, with studies showing 50-60% remission and 70% clinically meaningful improvement, primarily dependent on patient adherence.
• CBT-I focuses on addressing the *perpetuating* factors of insomnia—the maladaptive behaviors and thoughts developed in response to initial sleep disruption—rather than solely focusing on the original trigger.
• Two core behavioral pillars of CBT-I are Stimulus Control (re-associating the bed strictly with sleep and sex, getting out of bed when unable to sleep) and Time-in-Bed Restriction (matching time allowed in bed closely to actual sleep duration to build sleep drive).
• Cognitive techniques, such as Scheduled Worry Time (allocating specific time during the day to address anxieties) and Cognitive Restructuring (challenging negative or unrealistic thoughts about sleep), are crucial for managing the mental aspects of insomnia.
• Optimizing sleep hygiene provides foundational support. Key elements include maintaining a consistent wake time, ensuring a cool and dark sleep environment, managing light exposure (especially activating content before bed), and being mindful of caffeine, alcohol, and food intake timing.
• Gradual and structured tapering of sleep medications (both prescription and over-the-counter), done in collaboration with a physician and focusing on psychological readiness alongside physiological withdrawal, is often a part of successful long-term CBT-I treatment.
• Consistency is paramount across CBT-I interventions, particularly with wake times (even on weekends during treatment), medication timing, and adherence to the prescribed sleep schedule (sleep window).

Understanding Insomnia: Causes and Perpetuation

Dr. Mason begins by defining insomnia not just as a single bad night's sleep, but as a persistent problem (often lasting three months or more) characterized by difficulty falling asleep, staying asleep, or early morning awakenings, coupled with significant daytime distress or impairment. While estimates suggest 5-10% of adults meet clinical criteria at any given time, up to 90% experience insomnia at some point. Importantly, diagnosis is clinical, based on patient report, not a lab test.

She introduces the "3 P's model" to explain how insomnia develops and persists:

1. Predisposing Factors: Underlying traits or characteristics that increase vulnerability (e.g., genetic predisposition to being a light sleeper, higher psychological reactivity, tendency towards anxiety).
2. Precipitating Factors: Acute events or stressors that trigger the initial bout of insomnia (e.g., job loss, divorce, illness, accident).
3. Perpetuating Factors: The thoughts, beliefs, and behaviors adopted to cope with the initial insomnia that unintentionally maintain the problem long after the precipitating factor has resolved. This is the primary target of CBT-I. Examples include excessive time spent in bed trying to sleep, napping during the day, using the bed for activities other than sleep, developing anxiety about sleep itself, and relying on sleep aids (medication, alcohol).

Dr. Mason emphasizes that while patients often focus on the *cause* (precipitating factor), CBT-I is effective because it targets the *current* perpetuating behaviors and cognitions, regardless of the initial trigger or the specific type of insomnia presentation (sleep onset vs. sleep maintenance vs. early awakening).

Foundations of Cognitive Behavioral Therapy (CBT) and CBT-I

CBT, the broader framework from which CBT-I derives, operates on the principle that thoughts, feelings, and behaviors are interconnected (visualized as a triangle). Intervening on one aspect can influence the others. For example, changing a negative thought ("I'll never manage my diabetes") can reduce negative feelings (hopelessness), which can then lead to more positive behaviors (better adherence to diet/meds), reinforcing a positive cycle. CBT-I applies these principles specifically to sleep.

CBT-I itself dates back several decades, with core components like Stimulus Control (pioneered by Richard Bootzin) and Time-in-Bed Restriction emerging in the 1970s and 80s. These remain foundational, and studies show removing either significantly reduces treatment efficacy. Later, cognitive restructuring techniques and relaxation methods were integrated.

Core Behavioral Pillars of CBT-I: Stimulus Control and Time-in-Bed Restriction

These are the workhorses of CBT-I:

1. Stimulus Control: Based on classical conditioning, this aims to re-establish the bed as a strong cue for sleep. The rules are strict:
   • The bed is ONLY for sleep and sex. No reading, watching TV, scrolling phones, eating, or worrying in bed.
   • Go to bed only when feeling sleepy.
   • If unable to fall asleep (initially or after waking) within roughly 15-20 minutes (subjective estimate), get out of bed.
   • Go to another room and engage in a quiet, relaxing, *unrewarding* activity (e.g., reading boring material, gentle stretching, listening to calm music – *not* work, stressful news, engaging social media, or highly enjoyable hobbies).
   • Return to bed only when feeling sleepy again. Repeat as necessary.
   • Maintain a fixed wake-up time every single day, regardless of how much sleep was obtained.
   • Avoid daytime naps (or strictly limit them if absolutely necessary, e.g., 25-minute max opportunity, typically discouraged in early treatment).
2. Time-in-Bed (TIB) Restriction: This tackles the common behavior of spending excessive time in bed hoping to catch more sleep, which often leads to fragmented, poor-quality sleep.
   • Based on detailed sleep diaries kept by the patient, the therapist calculates the average actual sleep time per night over a week.
   • A "sleep window" (total time allowed in bed) is prescribed, typically calculated as the average sleep time plus about 30 minutes (with a floor often around 5.5 hours).
   • A consistent wake time is anchored first (Dr. Mason uses diary data to set a realistic wake time, rather than letting patients choose aspirationally).
   • The bedtime is then calculated by working backward from the fixed wake time based on the prescribed sleep window (e.g., 7 AM wake time, 6 hours average sleep + 30 mins = 6.5 hour window -> 12:30 AM bedtime).
   • This initially causes sleep deprivation, which powerfully increases "sleep drive" (Process S), making sleep more consolidated and efficient.
   • Sleep efficiency (Time Asleep / Time in Bed) is calculated weekly from diaries. Once efficiency consistently hits ~85% or higher, the time in bed is gradually increased (usually by adding 15 minutes, often by moving the bedtime earlier). This continues until the patient is obtaining sufficient sleep without sacrificing efficiency.

Dr. Mason notes that establishing the consistent wake time is often the very first step, sometimes even before formal TIB restriction begins, as it alone can start to regulate the body's clock for some individuals.

Cognitive Strategies: Managing Thoughts and Anxiety

Insomnia is often fueled by anxiety and unhelpful thoughts about sleep:

• Scheduled Worry Time: Borrowed from anxiety treatment, this involves setting aside a specific time (e.g., an hour) during the day to actively worry or problem-solve. When worries arise outside this time (especially near bedtime or during the night), the person acknowledges the thought and "postpones" dealing with it until the scheduled session. This prevents worries from hijacking sleep time.
• Cognitive Restructuring: Identifying, challenging, and modifying dysfunctional beliefs about sleep (e.g., "I absolutely need 8 hours or I'll be useless tomorrow," "My insomnia is permanent"). This often involves examining the actual evidence for and against a thought and developing a more balanced perspective.
• Tracking Belief in Thoughts: For recurring intrusive thoughts (e.g., waking at 1 AM worried about Project X), Dr. Mason suggests rating the belief intensity throughout the following day. Often, the belief is much weaker during the day, highlighting that the thought's power might be tied to the time (1 AM) rather than its objective truth.
• Relaxation Techniques: Progressive Muscle Relaxation (PMR) is commonly included – tensing and releasing different muscle groups to promote physical relaxation and shift focus from racing thoughts to bodily sensations.

Essential Sleep Hygiene: Low-Hanging Fruit for Better Sleep

While not sufficient alone to cure chronic insomnia, good sleep hygiene supports CBT-I:

• Temperature: A cool room (mid-60s °F / ~18°C) is ideal. Use breathable bedding like cotton blankets (avoid heat-trapping duvets/comforters). If extremities get cold (which can hinder sleep onset), use socks or a small heating pad at the foot of the bed, but keep the core cool. Warming hands/feet before bed (e.g., warm shower/bath) can aid heat loss and sleep onset.
• Light: Keep the bedroom as dark as possible. Use blackout curtains and cover/remove light-emitting electronics. Eye masks can be very helpful, especially for early morning awakenings caused by light sensitivity. Dr. Mason is cautious about blue light being the primary culprit versus the stimulating *content* consumed on devices before bed (work email, social media). However, for some with sleep onset issues despite managing content, orange-tinted "blue-blocking" glasses worn 1-2 hours before bed might be worth trying.
• Caffeine: Cut off all caffeine (including decaf, which can contain significant amounts) by late morning (e.g., 11 AM). Dr. Mason advises *moving* caffeine intake earlier, not necessarily reducing the total amount initially, to avoid withdrawal.
• Alcohol/Marijuana: These disrupt sleep architecture. During CBT-I treatment, Dr. Mason requires patients to eliminate or maintain a consistent, minimal intake (agreed upon beforehand) to get a clear picture of underlying sleep patterns.
• Food: Avoid large meals within 3 hours of bedtime.
• Exercise: Generally beneficial for sleep, but intense exercise close to bedtime can be disruptive for some due to elevated heart rate and core body temperature. Timing and type matter (relaxing yoga might be fine, HIIT might not). Consistency is key.
• Medication Timing: Take all medications consistently at the same time each day, and ensure they are taken at the optimal time (e.g., stimulating meds in the morning). Discuss potential circadian effects of medications with a physician.

Addressing Medications and Supplements

Many patients arrive using sleep aids:

• Supplements (Melatonin, etc.): Dr. Mason expresses skepticism about the efficacy and quality control of most sleep supplements like melatonin (citing studies showing inaccurate labeling) and ashwagandha. Generally, she has patients discontinue these during CBT-I to establish a baseline, unless there's a specific indication (e.g., low-dose melatonin for someone on a beta-blocker, which inhibits natural melatonin production). She emphasizes melatonin primarily signals sleep onset ('starts the race') rather than maintaining sleep.

• Prescription/OTC Medications (Ambien, Benzodiazepines, Trazodone, Antihistamines): Patients often want to discontinue these due to dependency or concerns about side effects. Dr. Mason's approach involves:

  1. Collaborating with the prescribing physician.
  2. First, *stabilizing* the dose and timing (eliminating erratic or middle-of-the-night use) *during* the CBT-I treatment.
  3. *After* sleep has improved with CBT-I, initiating a very slow, gradual taper plan.
  4. Using highly precise methods (like gem scales) to make tiny decrements (e.g., 0.25mg) based on the patient's psychological comfort level (using Subjective Units of Distress Scale - SUDS).
  5. Holding the dose steady for weeks between small reductions to build confidence and minimize withdrawal.
  6. Pausing the taper during significant life stressors.

  This patient-centered, psychologically-informed taper contrasts with often-attempted rapid reductions that frequently fail.

The CBT-I Treatment Process: Structure, Efficacy, and Access

• Structure: Effective CBT-I is typically structured and time-limited (Dr. Mason uses an intake plus 5 weekly group sessions and a follow-up). Weekly sessions allow for timely adjustments based on sleep diary data. Progress is tracked using standardized questionnaires (e.g., Pittsburgh Sleep Quality Index - PSQI, Insomnia Severity Index - ISI).
• Adherence: Success hinges on the patient's willingness to follow the often-challenging behavioral prescriptions (especially TIB restriction and consistent wake times).
• Non-Responders: The ~30% who don't achieve significant improvement often struggle with adherence or may have underlying issues like untreated sleep apnea, RLS, or are perhaps genetically short sleepers who became distressed about normative sleep patterns (sometimes triggered by wearables).
• Sleep Trackers: Generally discouraged during active CBT-I treatment as they can increase sleep-related anxiety (orthosomnia). Paper sleep diaries remain the clinical standard.
• Access: There's a shortage of trained CBT-I providers, leading to long wait times. Resources include the Society of Behavioral Sleep Medicine provider directory. Telemedicine has significantly improved access. Self-help options like the book "Quiet Your Mind and Get to Sleep" by Carney, Manber, and Bootzin, and emerging CBT-I apps (though adherence can be challenging without therapist support) offer alternatives.
• Ruling out Other Disorders: Screening for conditions like sleep apnea (snoring, gasping) and Restless Legs Syndrome is essential, often done before CBT-I begins or via referral if suspected during intake.

Conclusion

Dr. Ashley Mason provides a compelling case for CBT-I as a powerful, structured, and highly effective treatment for chronic insomnia. The core message is that while insomnia can feel overwhelming and intractable, it is often maintained by learned behaviors and thought patterns that can be successfully modified through dedicated effort and evidence-based techniques. The focus on behavioral consistency (especially wake times), stimulus control, managing sleep-related anxiety, and gradually reclaiming a healthy relationship with sleep offers hope and a clear path forward for individuals struggling with insomnia. While the process requires commitment and can be challenging initially, the potential reward - regaining restorative sleep and improving quality of life - is substantial.