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| The Unconventional Power of Sleep Restriction: Retraining Your Brain for Deep, Restorative Sleep |
You know, one of the conventional tips for sleep you can find all over the Internet. You can hear idiots like me speaking about the five tips of better sleep hygiene, and there's very good evidence for why those are sensible things to put in place. But what about the unconventional? And one of the unconventional components is to limit your sleep time, as you said. The principal Insomnia Treatment should not be the first line defense of sleeping pills that we discussed in the last episode.
CBT-I: The Gold Standard for Insomnia Treatment
The current recommendation is something called Cognitive Behavioral Therapy for Insomnia (CBT-I). As you can tell by the term, it works on two things: cognitive things—in other words, your thoughts and your beliefs about sleep—and then your behaviors: what are you not doing that you should do to help your sleep, and what are you doing that you shouldn't be doing and you should stop doing to help your sleep? That's the CBT-I component.
If you look across the studies, and CBT-I has a number of different features in this treatment/therapy approach, one of the most potent tools in the box of the CBT-I therapist is what we call Sleep Restriction Therapy, which sounds paradoxical.
Let's say you come to me, and I'm your sleep clinician. You say, "I am not sleeping well. I'm in bed for about eight hours, but I think I only maybe sleep four, four and a half hours. I'm just not getting enough sleep. Can you help me?"
And my response to you is: "Excellent, I've got a great treatment for you. It's called Sleep Restriction Therapy."
You hear the kind of the record scratch, and you say, "Hang on a second! I just told you I'm not getting enough sleep, and you're telling me we're gonna restrict my sleep?"
It's actually a poorly termed phrase. It should really be called Bedtime Restriction Therapy.
The Science of Sleep Restriction and Sleep Pressure
The therapy works in the following way: if you take that example, you're in bed for eight hours and you're sleeping for four hours. You have a miserable sleep efficiency—a sleep efficiency of 50%. Half of the amount of time that you're in bed, you're awake; half the time you're asleep. We want to see that around about 85% or greater in terms of your sleep efficiency. That's what we think is healthy.
So, rather than actually having you stay in bed for any longer, we do the opposite. We use the biology of your brain and something called sleep pressure.
The Adenosine Accumulation
From the moment that both you and I woke up, we've been building up a chemical that we've sort of discussed with regarding caffeine, which is adenosine. Adenosine builds up the sleepier and sleepier you feel. The longer that you're awake, the heavier that weight of sleepiness will be weighing you down.
Just take the extreme: let's say you pull an all-nighter or you're awake for 36 hours. Imagine how tired you are at that point. When you get into bed that following night, it's almost as though nothing's going to stop you—earthquakes, wildfires—you're just going to get into bed and you're going to be knocked out. Why? Because you've just got so much sleepiness built up, so much adenosine that hasn't been removed.
We do a diluted version of that in CBT-I with Sleep Restriction Therapy.
Implementing Bedtime Restriction Therapy
Let's use a clear, practical example of how to implement Bedtime Restriction Therapy:
Establish Current Schedule: You're going to bed just for argument's sake at midnight and you're waking up at 8 AM.
Compress the Window: "Now what I want you to do is actually compress that window of time. I want you to go to bed not at midnight, but now push it. Go to 2 AM or 2:30 AM or let's say 3 AM, but you still wake up at the same time."
The Focus on Bedtime: Where we restrict your sleep is not by having you wake up any earlier, which is kind of miserable. Most people feel it's easier to go to bed later than wake up any earlier. So we start there. We limit the amount of time that you're in bed and we restrict it down to maybe six hours or five hours.
The next day you're going to feel miserable. You've only been in bed for five hours. But what happens is that as long as you commit to it—and it has to be committed, and you have to work with someone who's going to motivate you—it is hard, but it works.
After the second night of being in bed for five hours, you've been awake for longer. Now you've been awake for 19 hours during the day, and you're only in bed for five hours. That increase in your adenosine because you're awake now for 19 hours straight, for one day, for a second day, for a third day, it all starts to accumulate.
The Breakthrough and Confidence Reset
Then, at one point—and it depends on the patient, let's say about four or five days after that—they get into bed at 2:30 AM or 3 AM, and then the next thing that they remember is their alarm going off at 8 AM. For the first time ever, they have slept all the way through, from front to back.
In that example, I've restricted the Bedtime by three hours, and they're now sleeping a solid five hours. But remember, that's better than where they were. They were in bed for eight hours, and they were only sleeping for four hours. So, I've added an extra hour, and they're in bed for less time.
The Gradual Expansion
Then gradually, what we do is we start to back that up. Once you're stable and your sleep efficiency is 85-90%, then we'll say, "Okay, now go to bed at 2 AM," and then, "Now let's go to bed at 1:30 AM," and, "Now let's try 1 AM." Gradually, we back it off.
Essentially, it's like hitting the reset button on your Wi-Fi router. You are retraining the Sleep System.
Eliminating Sleep-Related Anxiety
In doing so, you can start to get people's confidence renewed, because that's a big problem with insomnia. It seems like principle among the reasons that would work is that you are resetting sleep-related anxiety.
100%. Because when you are suffering from insomnia—and I've had my bouts too, and I know that you've spoken publicly about struggles before—you go into the bedroom, and the bed just looks like the enemy. You have lost all confidence in your ability to sleep, and at that point, your sleep controls you.
But by way of CBT-I and Sleep Restriction Therapy, you turn the tables. Now you control your sleep, not your sleep controlling you, and you regain confidence. That is a huge win. I can't tell you how big that is for people with insomnia. It's a terrible fear when they go into the bedroom; they just convince themselves it's not going to be their night.
The commitment to Bedtime Restriction Therapy replaces that fear with biological certainty and restored self-efficacy, making it a powerful and effective long-term Insomnia Treatment option for those seeking a non-pharmacological solution.
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