By Dr. Alex Dimitriu, March 12, 2019
Insomniacs know all about good sleep hygiene. They’ve lowered the temperature in the bedroom, hung room-darkening shades, eliminated nicotine, caffeine, and liquids before bedtime, taken warm baths, and banished electronic devices from the bedroom. Many have tried prescription sleeping pills but were groggy the next day. Natural relaxation and sleep remedies may have been calming and soothing but otherwise unhelpful as regular nights of restful, restorative sleep have remained elusive. Trouble falling asleep or long periods of wakefulness during the night or too-early awakening or combinations of all three persist for millions of people. These sufferers from chronic insomnia may be candidates for a seemingly contradictory therapy known as “sleep restriction.”
Sleep restriction is a behavioral therapy for insomnia that aims to retrain the brain to sleep more efficiently and eliminate prolonged periods of wakefulness during the night. It might more accurately be called “time in bed” restriction as it limits the time in bed to the time actually spent sleeping. The idea is that spending time in bed tossing and turning contributes to insomnia by causing the brain to associate time in bed with wakefulness. So if you can train the brain to associate time in bed with sleeping – and not with the anxiety of being unable to sleep – you will sleep more efficiently and restfully. For this reason, it is recommended that if you can’t fall asleep after fifteen minutes or so, you should get out of bed and sit or lie down quietly someplace else until you feel ready to sleep and only then return to bed. Over time, you will gradually increase the time in bed as you sleep more.
Sleeping more efficiently means spending more time asleep relative to the time spent in bed. Sleep efficiency can be calculated by dividing the hours spent asleep by the hours spent in bed. So if you spend eight hours in bed but sleep for only six hours, your sleep efficiency is 6/8 or 75%. Ideally, sleep efficiency should approach 100%. Sleep restriction therapy starts by limiting your time in bed. During this phase of the program, you may feel tired and like you’re not getting enough sleep but if you stick with it you will gradually increase your time-in-bed – and your time sleeping.
Here’s how it works:
The first step is to determine how much time, on average, you’re actually sleeping. Keep a log for two weeks that tracks the number of hours you sleep each night and then calculate the average. Adding thirty minutes to your average sleep time is your initial time-in-bed. For example, if you’re averaging five-and-a-half hours of sleep a night, your initial time in bed will be six hours. (Note: To avoid impaired functioning the next day, do not stay in bed for less than 5.5 hours, even if you feel you’re sleeping less.)
Set a wake-up time that will be the same every morning, weekends included, no matter how much sleep you had the night before.
Calculate your bed time by working backwards from your wake-up time, based on your time-in-bed. If your time-in-bed is six hours and your wake-up time is 6am, your bed time is midnight. Stay out of bed until midnight, even if you feel sleepy before then.
After a week or two on this schedule, you will probably find that your sleep efficiency has improved – that you’re awake less during the night. When your sleep efficiency stabilizes around 85%, add fifteen minutes to your time-in-bed by going to bed fifteen minutes earlier. Add fifteen minutes to your time-in-bed each week until you feel that you are well rested and not sleepy during the day and your sleep efficiency is around 90%.
Tips: Avoid napping. In particular, avoid falling asleep in the evening in front of the TV. In the hour or so before bed time, wind down with something relaxing, like reading, listening to quiet music, or a warm bath.
Studies have shown sleep restriction therapy to be an effective drug-free technique for overcoming insomnia but just as not everyone needs eight hours of sleep a night, sleep restriction therapy isn’t for everyone. With the help of a behavioral sleep therapist who can help assess your individual needs and supervise the therapy, you might find that a good night’s sleep is well within reach.
Alex Dimitriu, MD, is founder of Menlo Park Psychiatry & Sleep Medicine in Menlo Park, CA. He is dual board-certified in psychiatry and sleep medicine.