Insomnia Resolution Protocol

CBT-I (Cognitive-Behavioral Therapy for Insomnia): Gold standard, more effective than medications long-term - 6-8 sessions with trained therapist or app-based (Sleepio, CBT-I Coach). Components: Sleep restriction (paradoxically restricts time in bed to consolidate sleep), stimulus control (bed for sleep/sex only, not TV/phone/reading), cognitive restructuring (address anxiety about sleep), relaxation techniques

Sleep restriction therapy: Core CBT-I component - calculate sleep efficiency (time asleep / time in bed). If <85%, restrict time in bed to match actual sleep time (e.g., if sleeping 5 hours but in bed 8, only allow 5.5 hours in bed). Consolidates sleep. Once efficiency >85%, gradually expand window. Sounds counterintuitive but highly effective

Stimulus control: Bed = sleep only (not TV, phone, reading, worrying). If can't sleep in 20 min, get up, go to another room, do quiet activity, return when sleepy. Retrains brain: bed = sleep

Sleep hygiene: Consistent sleep/wake time (even weekends), dark room (blackout curtains or eye mask), cool temperature (65-68°F optimal), quiet (white noise if needed), comfortable mattress/pillows, no screens 1-2 hours before bed (blue light suppresses melatonin - use blue blockers if must use), no caffeine after 2pm (half-life 5-6 hours), no alcohol close to bedtime (disrupts sleep architecture), no large meals 2-3 hours before bed, no vigorous exercise 3 hours before bed (gentle yoga OK)

Melatonin: 0.3-3mg 30-60 min before bedtime (most people use too much - 0.3-0.5mg is physiologic dose, >5mg causes next-day grogginess. Timed-release for sleep maintenance issues)

Magnesium: 400-800mg before bed (calming, GABA support, muscle relaxation - glycinate form best for sleep)

Glycine: 3g before bed (calms nervous system, lowers core body temperature - improves sleep quality in studies)

L-theanine: 200-400mg (promotes alpha waves, relaxation without sedation)

Tart cherry juice: 8 oz before bed (natural melatonin source, tryptophan - studies show improves sleep)

Valerian: 400-900mg (sedating, GABA-ergic - helps some, not others, worth trying)

Ashwagandha: 600mg at night (reduces cortisol, calming, improves sleep quality)

Passionflower: 500mg (GABA-ergic, calming, improves sleep onset)

5-HTP or L-tryptophan: 100-300mg 5-HTP or 500-2000mg L-tryptophan (serotonin precursors → melatonin. Take with carb snack for better absorption)

CBD: 25-75mg at night (improves sleep in studies, non-intoxicating)

Lavender oil: Aromatherapy (lavender scent on pillow or diffuser) or oral Silexan 80mg (improves sleep quality)

Apigenin: 50mg (from chamomile, GABA-ergic, sedating - used in Bryan Johnson's sleep stack)

Phosphatidylserine: 300-600mg at night (lowers cortisol if elevated at night - "wired and tired")

Light exposure: Bright light 10,000 lux for 30 min in morning (sets circadian rhythm), dim lights in evening, avoid bright lights/screens at night (suppresses melatonin)

Exercise: Regular exercise improves sleep (but not within 3 hours of bedtime - raises core temp and cortisol)

Avoid: Caffeine after 2pm, alcohol (initially sedating but disrupts sleep architecture, REM suppression, rebound waking), large meals before bed, napping after 3pm (>30 min naps impair nighttime sleep), clock-watching (increases anxiety)

Relaxation techniques: Progressive muscle relaxation (tense and release each muscle group), 4-7-8 breathing (inhale 4, hold 7, exhale 8), body scan meditation, guided imagery, read boring book

Cognitive strategies: Address "catastrophic thinking" about sleep ("I'll never sleep, I'll be exhausted tomorrow, I need 8 hours or I can't function") - CBT-I addresses these thoughts, reduces sleep anxiety

Rule out sleep disorders: Sleep apnea (snoring, daytime fatigue, witnessed apneas - test with home or lab sleep study, treat with CPAP), restless legs syndrome (uncomfortable sensations in legs, urge to move - iron deficiency common, treat with iron if ferritin <75, dopaminergic agents), periodic limb movements, circadian rhythm disorders (delayed sleep phase - can't fall asleep until 2-4am, melatonin and light therapy help)

Address underlying causes: Depression/anxiety (treat), chronic pain (manage), medications (stimulants, steroids, decongestants, some antidepressants disrupt sleep - adjust timing or switch), hormones (menopause hot flashes, low testosterone - treat), hyperthyroidism (check TSH)

Medication: If non-pharmaceutical approaches insufficient: Trazodone 25-100mg (off-label, sedating antidepressant, safe long-term, no tolerance), mirtazapine 7.5-15mg (sedating, increases appetite - good for underweight insomniacs), doxepin 3-6mg (antihistamine at low dose, FDA-approved for insomnia, no tolerance), Belsomra (orexin antagonist, newer class, no tolerance but expensive), Avoid: Benzodiazepines (Restoril, Halcion - tolerance, dependence, cognitive impairment, rebound insomnia), Z-drugs (Ambien, Lunesta - similar to benzos, tolerance, next-day impairment, parasomnias like sleep-eating)

Sleep tracking: Wearables (Oura ring, Whoop) provide data on sleep stages, HRV - useful but can cause "orthosomnia" (obsession with perfect sleep score worsening anxiety) - use judiciously

Paradoxical intention: CBT-I technique - try to stay awake instead of trying to sleep (reduces performance anxiety)