Have you ever caught yourself lying in bed awake, in the middle of the night, and as the time passes you check your phone while thinking “If I fall asleep now, I will get a this-or-this amount of sleep”?
We all know this story too well. The truth is, our sleep pattern often gets disrupted due to our work, obligations, and even if we try to go to bed “on time” we often spend more time in bed rather than being asleep. But what is interesting is that many people often mistake light sleep for being awake. This is because your cognitive abilities might still be active, and as you drift out and into light sleep, your mind is still processing some information, though chances are you won’t remember them later.
Light sleep is still better than no sleep, but unfortunately, it does not provide the restorative effects that our body needs, which is why experts recommend trying techniques specifically developed for treating symptoms of insomnia, like sleep restriction in combination with CBT-I.
What is Sleep Restriction Therapy?
Sleep restriction was first invented in 1982 by Dr. Spielman and his colleagues in order to focus more on the efficiency of sleep and decreasing the time that a person spends in bed. It is based on the idea that deprivation of sleep will boost your sleep drive and keep you asleep. It might be a challenge for people who struggle with insomnia, but when we consider the fact of misinterpretation of being awake and being in light sleep, it is worth a shot.
Another goal of sleep restriction is to break the connection that your mind is making between bed and wakefulness. As time passes and you are not able to fall asleep in bed, the conditioned stimulus for being awake will be your bed. To understand better the conditioned stimulus and conditioned response let’s illustrate it:
If you ever had food poisoning, you might already know where I’m going with this. Imagine that you ate a taco and for some reason it made you feel sick after a short time. Now every time you think or smell taco (conditioned stimulus), you will associate it with feeling sick or wanting to vomit (conditioned response).
For the second one, imagine you get attacked by a dog while riding a bike. Now every time you are near the place of the attack (conditioned stimulus) your brain will automatically connect it with the attack; hence you will feel fear (conditioned response) as you pass it. The list can go on; the point is that our subconsciousness can do wonders and we shouldn’t underestimate it.
How Does Sleep Restriction Therapy Work?
The first thing that should be done is to estimate three primary factors of sleep:
- Usual sleep duration
- Wake up time during the workday
- Sleep efficiency
An example will help you to create a mental picture of how sleep restriction works (roughly). Let’s talk about Bob. Bob is an office worker (a typical 9-5 job). He usually wakes up at 7 am and goes to bed at 11 pm. But here is the catch, Bob has insomnia, which means he sleeps around 5 hours or less. To implement sleep restriction therapy, the first step is to limit his time in bed. Meaning, if he sleeps 5 hours, he should be in bed for 5 hours, going to bed at midnight and waking up at 5 am. It might seem harsh, but after a week or two the time spent awake during the night will decrease and increase sleep efficiency, but more on that later.
The best way to follow that pattern is to keep a sleep diary.
- Usual Sleep Duration
The first couple of weeks use the sleep diary to keep track of your sleeping pattern, when do you go to bed when do you wake up, when do the sleep disruptions occur, etc. Once you have collected the data, calculate how many hours of sleep you get on average each night by reviewing your sleep diary. The easiest way to calculate it is simply by adding the number of hours during the whole week and then dividing by 7 (the days). For instance, if you have slept for 38h in one week dividing it by 7 gives you the average number of 5.4h a night.
- Schedule wake up time that works for you
Since you will spend less time in bed, your waking up time will probably be slightly earlier than usual. Based on your choice you should schedule your optimal bedtime. You can do that by calculating backward, compared to the time you would wake up. In the previous example, we had 5.4h of average sleep per night. Adding 30 extra minutes as a start would lead us to about 6h allowed in bed. That means if you chose to wake up at 6 am, you should go to bed at 12 am. Sometimes it can be challenging to stay awake until chosen time but try your best to follow the schedule because that kind of sleep deprivation will limit the time awake in bed, and it will make you will fall asleep quicker.
- Sleep Efficiency
As with most new situations, it will be a bit difficult to get used to it, but as you track your sleep at the end of your first week, you’ll notice that it’s gradually improving. Naturally, there will still be some disruptions. Also, at the end of the week, you should calculate the efficiency of your sleep. You can do that by calculating the number of hours you spent asleep and dividing that with the number of hours you spent in bed in total. Going back to the mentioned example, let’s say you spent the whole 6h in bed, but due to disrupted sleep or sleep latency, the real amount of sleep varied from 4-5.5h. It means you spent 44h in bed while getting approximately 34.5h of quality sleep. The percentage of sleep efficiency is around 78.
That percentage determines whether you should add more or deduct time spent in bed which you adjust every week.
- If the sleep efficiency is greater than 85 percent and you feel that you need more rest to function properly during the day, you should add 15-30 minutes to your allowed time in bed.
- If sleep efficiency is less than 80 percent, you should decrease your time in bed by 15-30 min., but you shouldn’t spend less than 5.5h in bed.
- If sleep efficiency is between 80 and 85 percent, you should continue with the current schedule.
*All deductions and increases in TIB should be supervised and determined by clinician or therapist of your choice.
For best results combine sleep restriction therapy with CBT-I and make sure you are supervised by a therapist who has experience with this type of treatment. Another benefit of having a therapist is that he/she can help you if you experience some side effects. Sometimes people who have bipolar disorder can feel moody due to sleep restriction. Others might feel that their seizures are getting worse. With the help of an expert, those side effects can be controlled or even avoided.
It is hard to say how long you should implement this therapy strictly as it all depends on your progress. It can all be modified to minimize the symptoms of sleep disorders that can cause disruptions and help you get the best sleep quality to function in your day to day life properly.
Tips for Stimulus Control
These tips are designed to help your brain connect bed with sleep instead of associating it with wakefulness.
- Regular wake up time – It will help our circadian rhythm get stronger and regulate wakefulness and sleep.
- Wind down before bedtime – Relaxing activities like reading or listening to music can help you prepare for sleep, and it may help you fall asleep quickly as those activities slow you down.
- Go to bed when you feel sleepy – It will make you fall asleep faster but don’t confuse fatigue and sleepiness. Fatigue is when you are feeling like your energy is low and sleepiness is when you cannot stay awake (like when you doze off while watching something on TV).
- If you cannot fall asleep, and toss and turn in bed instead, try getting out of bed and going back when you feel sleepy. Use that time to do something that will relax you and promote the sleepy feeling.
- Try to avoid long naps during the day – Power naps that last up to 30 minutes are an excellent way for you to feel refreshed without disturbing nocturnal sleep.