CBT-Insomnia techniques that improve energy and sleep through daytime behavior change
STUDY: Lau PH et al, Behavioral Sleep Medicine 2026
STUDY TYPE: Review
FUNDING: Independent
Background
CBT-I produces large effect sizes on sleep, but only small-to-medium effects on daytime symptoms like fatigue and mood. This review looks at ways to improve that by targeting daytime behaviors.
The Study
Stanford researchers reviewed the evidence for behavioral, cognitive, and acceptance-based strategies that address daytime insomnia symptoms and can be added to a standard CBT-I protocol. They drew from sleep science, circadian biology, and health psychology to identify tools with empirical support.
Results
First, some definitions. Fatigue is weariness and depleted energy. Sleepiness is the propensity to fall asleep, driven by accumulated sleep pressure. Insomnia is predominantly a disorder of fatigue, not sleepiness, because hyperarousal and compensatory behaviors (like excessive time in bed) mask sleepiness and blunt normal sleep drive.
Strategies for fatigue
- Activity pacing: neither overexertion nor complete rest; aim for engagement within limits.
- Behavioral activation: particularly for patients who are underactive or low in mood.
- Relaxation exercises (progressive muscle relaxation, diaphragmatic breathing) to reduce sympathetic arousal during the day, not just at bedtime.
- Behavioral experiments: help patients test catastrophic beliefs, e.g., that one poor night’s sleep will cause major errors at work.
- Mindfulness: targets secondary arousal, the distress layered onto fatigue that prolongs and amplifies it.
Strategies for sleepiness
- Short strategic naps (30 minutes, early afternoon) to reduce dangerous sleepiness without disrupting sleep pressure.
- Caffeine timed to periods of peak sleepiness rather than used throughout the day (tip: in a study of doctors on call, only a small amount of coffee was needed to raise alertness, like 1/3-1/2 cup every few hours).
- The RISE-UP routine (refrain from snoozing, increase activity, shower – the colder the better, sunlight, upbeat music, phone a friend). This cut sleep inertia duration from 56 to 35 minutes in a bipolar-insomnia sample. It is also called brisk awakening.
Regarding daytime impairment, patients with insomnia actually perform close to normal sleepers on objective cognitive tests, even when they perceive themselves as impaired. Still, many of them avoid tasks or social events out of fear of poor performance. Cognitive restructuring and behavioral experiments help patients test those perceptions against actual evidence.
Practice Implications
- Sleep is a 24 hour cycle, but patients with insomnia focus too much on one part: how fast they fall asleep. This study brings needed attention to daytime techniques like RISE-UP.
- Aromatherapy is another option, with scents that improve sleep or wakefulness.
- I’d add a dawn simulator to the list. This requires little effort and cuts sleep inertia in half, helping patients wake up at regular times to set the biological clock. Still can’t wake up? Try an activating alarm.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
