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Insomnia is a very common problem, with about 20 percent of adult Americans reporting cases of it regularly. This sleep disorder directly or indirectly affects many aspects of your daily life, from work performance to your immune system or mental and emotional stability. Most sleep disorders happen without clearly defined causes, which can make treatment problematic, especially since a lot of recommended medication comes with side effects that could amplify the symptoms or cause unrelated conditions. For this reason, a lot of insomniacs are looking for a way to treat their condition without heavy medication use, as their work performance or social life would worsen dramatically due to those side effects.
Sleep restriction therapy (or SRT for short) is a part of cognitive behavior therapy for insomnia (CBT-I), a revolutionary treatment procedure that can be conducted without the use of risky medications. The concept for SRT is based on the idea that excessive time spent in bed can often perpetuate or amplify insomnia. By making a very strict sleep schedule and lowering the amount of time spent in bed (without going under five hours for obvious health-related reasons), we can work our way to higher sleep quality and quantity in the long run. Think of it like diet plans or exercise – sleep restriction therapy takes time and dedication. In this article, we will go over the basics of CBT-I and its components, focusing on sleep restriction therapy as a core method of dealing with insomnia without using prescription medication. Let’s get into it.
Cognitive Behavior Treatment for Insomnia (CBT-I)
The purpose of CBT-I is to change the patient’s behavior patterns and habits that help perpetuate or amplify insomnia. These habits include poor sleep hygiene, bad lifestyle habits, hyperarousal and so on. This technique can be used without or alongside medication treatment, although as always, meds carry the risk of very inconvenient side-effects that could be counterproductive for the whole therapy process.
Before any treatment procedure is initiated, the patient should have their sleep patterns evaluated, or document them themselves. This usually involves sleep tracking methods like keeping a sleep journal, as it’s very important for the patient to take note of everything in their life that could contribute to insomnia. These things can include stress from work or environments, too much time spent in front of screens, a bad diet plan, overstimulation from caffeine and similar sources, etc. If there is another condition that acts as the underlying cause of insomnia, it’s crucial to be aware of it.
Once all of these factors are taken into account, treatment can begin. CBT-I consists of several methods that all work alongside each other to improve the patient’s sleeping habits and remove misconceptions about sleep that can influence their decision-making. These methods include:
– Stimulus control, a regime where the amount of things the patient uses their bed for is limited to sleeping and sex, and daytime napping is forbidden. Additionally, the patient is instructed to move to a different room if they stay awake in their bed for fifteen minutes or longer. This is done to prevent the mind from associating their bedroom with stress and frustration.
– Sleep hygiene education, an approach where the patient learns about sleep-ruining habits and behaviors. They get educated on the consequences of heavy caffeine intake, alcohol consumption, exposure to TV, smartphone or computer screens before bed, and other factors. By knowing how to arrange a good sleeping environment (including how to create an ideal sleeping temperature and noise management) and properly wind down at the end of the day, the patient can maintain a healthier sleep schedule.
– Relaxation exercises vary from method to method, but all have the same purpose: to help the body relax throughout the day, especially as bedtime starts approaching. Depending on the person in question, these exercises may include yoga sessions, self-hypnosis, meditation, breathing exercises, progressive muscle relaxation, etc. Most relaxation exercises require no financial investment to perform and can be a healthy habit even if you’re not dealing with insomnia.
How Sleep Restriction Therapy Works
The main goal of sleep restriction therapy is to reduce the amount of time insomniacs spend in bed without sleeping. One of the main concerns sleep experts and therapists have is that excessive time spent tossing and turning can create a mental connection in the patient that connects their bed to frustration and anxiety. The bigger the percentage of time spent sleeping while in bed, the higher the sleep efficiency. To this end, it may be best to shorten the sleeping period to improve that efficiency.
As a whole, sleep restriction carries several benefits that help the patient over time. Because their nocturnal sleep window is reduced significantly, they become tired earlier in the day. While this can cause certain problems (which we’ll discuss later), it means that the patient is always tired and sleepy when it comes time to go to bed. Sleep onset latency is reduced considerably, which is one of the primary goals of SRT and CBT-I treatment in general. Much like with stimulus control, their newfound ease of falling asleep will help their brain make a positive association between their bed and relaxation, severely reducing the amount of anxiety the patient experiences in bed.
Being very tired right when they should go to bed helps people maintain a sleep schedule. A strict time-frame for sleeping is healthy for the body because it helps stabilize one of the most important processes our bodies are governed by – the circadian rhythm. Our brain has what amounts to a built-in biological master clock, and all of our hormonal secretions, metabolic functions, etc. are regulated and managed by this clock. Unfortunately, it is very easy to ruin our circadian rhythm through factors like alcohol consumption, heavy exercise before bed, stress, etc. The demographics with the biggest risk here are shift workers or long-distance drivers and pilots – these people either have to change their sleep schedules drastically to serve the needs of their occupation, or they (and their potential passengers) are particularly susceptible to the dangers of drowsy driving while on the road or in the air. Fragmented sleep is one of the main causes of daytime fatigue, as the affected person doesn’t spend enough time in deep sleep or REM sleep. These sleep stages are responsible for a large portion of physical and mental repairs, as the immune system, tissue repair, and memory consolidation primarily occur at this point in the sleep architecture. SRT is very effective in dealing with fragmented sleep – think of all those moments where you sleep like a log after dealing with fatigue all day. Your sleep becomes more restorative as a result of this therapy method.
The step by step process is fairly simple. The patient is instructed to maintain a sleep journal, usually starting several weeks before SRT begins properly. Through that sleep journal, the doctor receives information about the realistic number of hours the patient spends asleep each night. If they sleep only six hours but spend more than that amount of time tossing and turning in bed, then the sleep period is set to just under six hours (but never under five hours), to maximize initial sleep efficiency. The schedule is arranged, so the patient always goes to bed and gets out of bed at the same predetermined times. The patient is forbidden from taking naps or going to bed earlier than what was established.
Once their schedule is set, the patient must stick to it while working on the sleep journal. If the person estimates that their sleep efficiency is over 85 percent (meaning that at least 85 percent of their time in bed is spent sleeping) for a given week or two, the sleep period is increased by 15-30 minutes for the following 1-2 weeks. Should their sleep efficiency ever drop below 80%, the doctors will decrease the patient’s allowed sleeping time to correct that problem. A sleep efficiency value of 80-85 percent results in another week or two without changes. Over time, this technique is expected to not only improve sleep efficiency but help the patient sleep healthily throughout the night, as their insomnia symptoms get resolved.
Sleep Restriction Therapy Downsides and Risks
While its effectiveness has been noted many times, sleep restriction therapy isn’t without its share of controversy and critique. Most of these criticisms focus on the negative effects of sleep deprivation and excessive daytime sleepiness on the patient’s daily life. The fatigue that comes as a result of insomnia doesn’t normally go away during this therapy plan, which can put the patient in danger during their work commute or at their workplace. Drivers and pilots are particularly unsuitable for SRT, as their jobs require a very high level of vigilance and awareness – something that cannot coexist with fatigue. Shift workers can also find it incredibly hard to stick to one predetermined sleep schedule due to the nature of their unstable work hours. During studies, subjects have dropped out solely out of concern that their work performance and other aspects of life would be ruined by extra sleep deprivation.
Some sleep labs may set an initial “time in bed” value as low as 4-4.5 hours. Studies have concluded that going under five hours can create serious deficits in the patient’s attention span, cognitive sharpness and immune system, which is why some experts propose a mandatory lower limit of five hours. Anything less than that makes the person a liability at work and in traffic if maintained as a regular sleep schedule.
However, no connection has been drawn between SRT and increased daytime fatigue thus far (assuming the patient was given a sensible initial sleep window). This method rarely forces a patient to sleep for less time than they normally would – it only decreases how much time the patient spends in bed without sleeping. Additionally, the fatigue tends to disappear from the patient’s life slowly, as their insomnia starts to subside.
Note: If you experience unforeseen negative consequences of sleep restriction therapy, inform your doctor immediately. They may recommend an alternative treatment method or some natural sleep aids since those are much safer than the prescription medication you may be trying to avoid. Be thorough and dedicated when writing information down in your sleep journal, since your doctor will need anything you can give them.
Sleep Restriction Therapy and Depression
Depression is a potentially crippling mental health condition, and sleeping problems are some of its core symptoms. There is a reason that a lot of depressive people get tested for sleeping disorders – the two go hand-in-hand. When a doctor suspects their patient may have depression (which is important to know when diagnosing further problems), they often pose questions about the person’s sleeping patterns. Both insomnia and hypersomnia are possible outcomes of depression.
A vicious cycle can form in depressed people. As we’ve established, depression can result in all manner of sleeping problems, and those sleeping problems cause daytime fatigue. This fatigue negatively affects the person’s performance at work and their ability to socialize and stay energized or motivated. The mood drop that results from these problems fits in perfectly with how depression affects a person’s self-image and outlook on life, which can directly or indirectly contribute to further sleeping problems, repeating the cycle.
The consolidation of sleep achieved through SRT helps alleviate some of those problems by eliminating fragmented sleep. As a result, sleep restriction therapy is often used as a short-term depression reliever while a more concrete and thorough mental health care plan is constructed.