Spend less time in bed and sleep better

Recent research shows that insomnia affects up to 40% of adults at some point in their lives and can become chronic in around half of cases (22% of the population). Given the importance of sleep to overall health, the fragmented, low-quality sleep that those suffering from insomnia experience often leads to decreased daytime performance, e.g. when driving, at work or any other task requiring concentration.

In addition, severe psychological distress can develop from the inability to fall asleep which may result in the appearance or worsening of depressive or anxious symptoms as well as attempts to self-medicate, e.g. through increased alcohol consumption or over-the-counter remedies.

Although these strategies may prove useful in the short term, they aren’t a permanent solution and come with their own problems such as the risk of addiction and side effects. So a longer lasting, non-pharmacological solution tailored to each individual sufferer is preferable of which there are many. We’ll focus on one of the most effective for now - sleep restriction therapy. This is a practice where the time in bed, and therefore the time allowed for sleep, is deliberately reduced, usually as part of a more comprehensive CBT for insomnia (CBTi) programme.

The theory behind sleep restriction therapy

Sleep restriction therapy is based on the idea that the time someone with insomnia spends awake in bed results in the formation of a negative set of beliefs about going to sleep (e.g. that they will never be able to get to sleep, or that their sleep is “broken”) and that having those beliefs makes falling and staying asleep harder. This is because a sufferer goes to bed dreading the time they’ll spend lying awake once there, which ultimately means they won’t be able to sleep due to the resulting worry. They will also have their negative beliefs about their own sleep reinforced, which in turn makes it harder to get to sleep, and so on. In theory then, addressing these beliefs should help recovery from insomnia and is just as important as treating the underlying causes of the disorder.

By intentionally limiting the time in bed and inducing mild sleep deprivation, two things happen:

  • the person with insomnia falls asleep more readily once they finally get into bed because sleep deprivation leads to deeper sleep with a faster sleep onset.
  • the high quality sleep that results enables the negative beliefs associated with sleep to be challenged.

This eventually translates to a mindset where going to bed is no longer associated with a struggle to fall asleep.

How it works in practice

Sleep restriction therapy can be implemented in a variety of ways depending on the individual, and treatment is influenced by a person’s age, pre-existing medical conditions, medication history, lifestyle choices and other factors. This means it is important to work with a good sleep therapist either in person, or over the internet using a service like Sleepstation, to guarantee the best possible outcome if you’re seeking help for your insomnia.

Usually, a clinical interview will be conducted to determine if you will benefit from sleep restriction therapy, after which you will be asked to complete a sleep diary across a few weeks. Your sleep diary will include estimations of the length of time you were actually asleep, the total length of time spent in bed, any disturbances to sleep and any activities that may cause sleep issues, such as drinking coffee or using a mobile phone before going to bed.

On the basis of this information, the therapist will set the total time permitted in bed. Typically, the time is based on the average time you spend asleep, restricted to no less than 5 hours per night to prevent excess fatigue. The times of the day that are set to go into and leave your bed depend on the type of insomnia that you exhibit; if you have trouble falling asleep a later bedtime is likely to be recommended. Conversely, if you can fall asleep easily but wake up too early, then the bedtime is unaffected, but an earlier time will be set to leave bed.

The altered bedtime schedule is then followed until a consistent increase in the time spent asleep compared to the time spent in bed is observed, at which point more time in bed is permitted.

Once out of your bed for the day, it is usually forbidden to lie down, nap or to be in bed at all until the next scheduled bedtime. Throughout the process, you will be regularly monitored, so that adjustments to the sleep schedule are easily made. Treatment is usually completed within a few months.

The first few weeks

Given the fairly drastic changes in sleep habit that sleep restriction therapy demands, many people find the first few weeks incredibly difficult with complaints of daytime sleepiness, reduced alertness, mood disturbance and impaired performance when working or socialising. Despite some of these effects also being down to the underlying insomnia more than the treatment, they can be extremely discouraging to anyone beginning sleep restriction therapy.

Since sleep restriction therapy leads to improved sleep over time, these adverse effects are usually gone within the first three weeks of treatment. During those first few weeks, it’s important to have support available to you. That’s why, at Sleepstation, we provide access to a team of sleep coaches and therapists. Our team can provide perspective and motivation to get you through the tough times and can also help identify ways to make sleep restriction therapy more compatible with your lifestyle.

Once through this difficult initial period, many people report that their attitudes towards sleep and going to bed have changed because of the long-lasting sleep improvements that sleep restriction therapy often leads to.

What are the benefits?

Unlike a course of sleeping pills, sleep improvements from a course of sleep restriction therapy last for a number of months after treatment, with studies reporting consistent increases in the time in bed spent asleep, and fewer awakenings while in bed and reduced times in bed. Perhaps unsurprisingly, brain scans of some insomnia sufferers who have undergone sleep restriction therapy show brain activity that is closer to that good sleepers while in deep sleep, suggesting that the longevity of the improved sleep effects may be down to some ‘re-wiring’ of neural pathways physical changes in the brain.

Furthermore, patients who have undergone sleep restriction therapy have also reported improved mood, reduced daytime fatigue, fewer sleep worries and napping tendencies compared to when they went untreated.

Most importantly sleep restriction therapy can be successfully implemented as part of a wider array of non-pharmacological treatments on a diverse range of people. These include people who have lived with insomnia for several years, those with complex mental health issues, traumatic brain injuries, and the elderly. This would suggest that no matter how bad you think your individual circumstances may be, if you have insomnia, sleep restriction therapy may well be a viable treatment option.

In short:

  • Up to 40% of adults have insomnia
  • Negative beliefs about sleep and being in bed are thought to make insomnia worse
  • Sleep restriction can be used to challenge those beliefs
  • This breaks the link between negative beliefs and poor sleep leading to lasting sleep benefits
  • Sleep restriction can be used in cases of severe insomnia across a diverse population

If you’d like us to develop a tailored sleep plan for you and to support you through those tough first few weeks of sleep restriction therapy you can sign up today. Simply answer a few short questions to find out which package would be best for you.

Researched and produced by Dr Raminder Mulla