Sleep issues are pervasive in Long COVID, often taking the form of insomnia, restless nights, or unrefreshing sleep. In the latest episode of Long Covid MD, I had the privilege of speaking with Stanford psychologist Dr. Hylton Molzof, who specializes in behavioral sleep medicine. We explore the biologic and emotional influences on sleep, and the ways Cognitive Behavioral Therapy for Insomnia* (CBT-I) can be adapted for those of us navigating chronic illness. CBT-I is considered the gold standard treatment for chronic insomnia, but the traditional behavior modifications that the practice emphasizes are simply not accessible to many of us with chronic illness. Luckily, Dr. Molzof, who also has a masters in public health, is one of a growing number of sleep psychologists who recognize the need to adapt evidence-based treatments for people who have conditions like Long COVID.
Our conversation is loaded with information. We explain what sleep is, potential causes of disordered sleep, and the most effective ways to track our sleep (hint: it might not be a device).
But that’s not all! In addition to explaining sleep and CBT-I, Dr. Molzof has shared multiple resources with Long Covid, MD followers, even some she uses in her Stanford CBT-I course. She also shares directories you can use to find a CBT-I practitioner. They are all linked below.
In this post, I share some of the highlights of our conversation and Dr. Molzof’s suggestions. Subscribe to Long Covid, MD, so you don’t miss the next episode on sleep, which will be a review of medication sleep aids.Subscribe
*You might find Cognitive Behavioral Therapy offered as a treatment for Long COVID, and used as code for ‘mind over matter’. Please note that in this episode my guest and I are speaking specifically about CBT for insomnia, a structured and studied treatment strategy. We’re not talking about CBT as a cure for post-viral illness.
Understanding Sleep Dynamics
Dr. Molzof broke down the physiology of sleep:
- Sleep is dynamic and cyclic
- Sleep cycles vary but include both REM (active, dreaming sleep) and non-REM (restorative) stages.
- Healthy sleep isn’t just about duration—quality, regularity, and how restorative it feels matter more.
- Waking up briefly during the night is normal; even healthy sleepers may experience 8–12 arousals nightly.
Sleep Tracking Tips
Tracking sleep can provide valuable insights, but Dr. Molzof advises simplicity:
- Focus on subjective measures like perceived sleep onset, wakefulness, and overall restfulness.
- Avoid relying too heavily on wearable devices, as they can induce anxiety and are often less accurate for those with sleep challenges.
- Tools like the Consensus Sleep Diary (included below) help document patterns without overburdening.
Adapting CBTI for Long COVID
Classic CBTI techniques often need adjustment for those with chronic illness:
- Stimulus Control: If leaving the bed during wakefulness is impractical, try strategies like using different blankets or altering your sleeping position to cue your body for rest.
- Sleep Consolidation: Instead of rigidly reducing time in bed, consider sleep compression—gradually trimming wakeful periods to build sleep hunger. As always, listen to your body. With Long COVID, I rely on small changes over time, and adapt my approach accordingly.
- Constructive Worry Exercise: Allocate time before bed to jot down worries and solutions, separating sleep time from problem-solving. Print the worksheet used in Stanford CBT-I course, included below.
The 3 P’s
Dr. Molzof explained how insomnia often evolves:
- It’s important to evaluate causes of disordered sleep, including sleep apnea and restless leg syndrome. Please consult with a medical sleep professional to identify possible underlying causes of sleep disruption. Sleep studies can often be done at home.
- What wakes you up, may not keep you up. Dr Molzof explains the 3P’s of insomnia: Predisposing Factors, Precipitating Factors, and Perpetuating Factors. Often, medical conditions can disrupt our sleep. Worry and anxiety can further inhibit our ability to fall asleep or fall back asleep.
- CBT-I aims to rebuild trust in the body’s natural sleep system by identifying the precipitating and perpetuating factors that can be improved with behavior modifications.
Reframing Thoughts About Sleep
Sleep-related anxieties can intensify insomnia. Dr. Molzof recommends:
- Practicing detachment. Your thoughts are not necessarily reality. They are thoughts.
- Techniques like cognitive restructuring (rethinking unhelpful beliefs) or defusion (repeating or reframing thoughts) can lessen their power. Defusion worksheet below!