Feel Well Again Blog

Insomnia is one of the most common challenges I hear about from my patients and one of the most difficult to treat.

 In our practice, insomnia is typically due to one of the following: untreated mood or anxiety disorder, substance misuse, or poor sleep habits (inconsistent bedtime/wake time, naps during the day, use of electronics too close to bedtime, among others).  

Of course, we work on treating any psychiatric issues first and this often leads to a reduction in symptoms of insomnia as well. But generally, once those issues are addressed, if insomnia still persists, then it is typically because of poor sleep habits.  The treatment for this is not through medicine: in this situation, behavioral interventions are often a patient’s best option for minimizing or curing their insomnia. 

Behavioral interventions for insomnia include relaxation training, stimulus control therapy, sleep restriction therapy, sleep hygiene, paradoxical intention therapy, cognitive restructuring, and other approaches. In this article, we’ll explore sleep restriction therapy as a method for retraining and strengthening circadian rhythms.

What is Sleep Restriction Therapy?

If you suffer from insomnia, you may be familiar with this cycle: You go to bed and you can’t fall asleep or you fall asleep, but then wake up in the middle of the night and can’t get back to sleep. The next morning, you’re tired. You try to push through by drinking an extra cup (or three) of coffee, but sometime in the afternoon or early evening, you just need to take a nap. You sleep for a couple of hours, get up, and finish your day. Then the cycle repeats.

This cycle suggests that your circadian rhythms have been thrown off and sleep restriction therapy says that you can reset your circadian rhythms by restricting the hours during which you allow your body to sleep. The idea here is that the longer a person stays awake, the less likely it is that they will be able to remain awake, and the more likely it is that they will start to feel sleepy.

In the scientific world, this increasing sleepiness is known as the homeostatic sleep drive and researchers developed sleep restriction therapy for insomnia based on this biological drive for sleep. The goal of sleep restriction therapy is to regulate the sleep-wake cycle by tailoring the time spent in bed to the patient’s true sleep need.

Here’s how Sleep Restriction Therapy Works:

• Patients complete sleep logs for 2 weeks to record duration of time in bed and total time spent sleeping.
• If a patient with insomnia stays in bed for 8 hours, but is only sleeping 5 hours per night, they are advised to limit the time in bed to 5 hours, which is the patient’s “sleep window.”
• This technique seeks to consolidate sleep such that patients spend time in bed sleeping, rather than laying awake.
• The sleep efficacy goal is to reach 85% ([total sleep time / total time in bed] x 100).
• If a person’s sleep efficacy is greater than 90% during any given week, they are given an additional 15-20 minutes of time each night. Weekly sleep efficacy of less than 80% requires a decrease in the sleep window by 15-20 minutes.

By creating a consistent bedtime and wake time schedule, sleep restriction therapy retrains and strengthens circadian rhythms, which have been thrown off by an irregular sleep schedule. Sleep restriction therapy is often combined with other behavioral interventions, such as  stimulus control therapy (patients are encouraged to leave the bed if they can’t sleep), to enhance its efficacy.

Challenges and Benefits of Sleep Restriction Therapy

While some theories about insomnia focus on factors that bring on insomnia or predispose some individuals to develop a sleep disturbance, sleep restriction therapy focuses on factors that perpetuate chronic insomnia. This technique assumes that spending excessive time in bed encourages insomnia, even though it may not have been the initial cause.

It is possible that the initial sleep loss produced at the beginning of sleep restriction therapy is essential to its effectiveness. Unfortunately, this is also one of the biggest challenges for patients going through the therapy. Patients often find it a struggle to stay awake until the prescribed bedtime at first. 

Also, even though patients are warned that they should anticipate mild sleep loss and fatigue during the first weeks of the study, some become alarmed that they feel worse at the start of the treatment. As a result, a substantial number of patients drop out during the first 2-3 weeks of treatment.

Still, the regularity and predictability of sleep produced by this therapy helps many insomniacs by taking away the stress and anxiety produced by the anticipation of not being able to sleep. Another benefit of sleep restriction therapy is that sleep efficacy is calculated by taking into account wake time that occurs both before and after sleep onset. So it may be applicable to individuals with different types of insomnia complaints.

Additionally, this treatment is self-paced because the “sleep window” is determined by each patient’s self-report of sleep efficacy. It’s only when the patient perceives that they are getting sleep with minimal amounts of wakefulness that the time spent in bed is expanded.

Sleep restriction therapy is one behavioral treatment for insomnia which brings a lot of relief for many patients. The ripple effects of treating insomnia also cannot be ignored. People who get enough sleep also report feeling less stressed, anxious, and depressed. Insomnia is not something to ignore. If you suffer from insomnia, and are interested in creating a customized behavioral intervention plan to address it, call us to schedule an appointment.