Modifying sleep restriction for insomnia can lead to more satisfying sleepA few weeks ago I got an email from Julie, who’d written to me about her insomnia before. Here’s how she began:

“I am happy to share with you, 5 months later, that I am sleeping peacefully and soundly! It didn’t happen overnight, but my improvement did happen because of the sleep restriction you recommended!”

This woman is persistent, I thought, and read on. I discovered that, while Julie’s first attempts at this insomnia treatment were strikeouts, rather than give up, she found ways to modify the sleep restriction protocol so it eventually worked.

“I can now say that I’ve gone over a full month without any bad sleep,” she wrote, “and I’m now sleeping 7 plus hours a night!”

I decided to interview Julie, and here are excerpts from the conversation:

Insomnia Returns

Your insomnia started several months ago. What threw your sleep off track?

A health scare, which later turned out to be a false alarm. I didn’t sleep a wink that night, worrying about all the possibilities. . . . All it took [was] 4 bad nights to send me into the chronic insomnia pattern I experienced for the next 5 months: a few good nights followed by sleepless nights—up and down the roller-coaster.

You decided to try Sleep Restriction Therapy (SRT) for insomnia. What led to that decision?

I’d had an insomnia problem 14 years earlier that lasted for 2 years. It was caused by a bladder problem after the birth of my last baby. . . . I tried SRT but was unsuccessful with it because I needed to cure the bladder problem first.

I never expected to sleep poorly again after what I went through and solved 14 years ago. It was a total shock that the insomnia came back as horribly as before, only this time I couldn’t blame it on my bladder! I decided to take aggressive action. I purchased The Savvy Insomniac, and a book by Dr. Arthur Spielman. Everything I read encouraged me to try SRT again.

A Rocky Start

How much did you restrict your sleep at first, and how did you fare?

To begin SRT, I averaged my previous week’s sleep and came up with 4½ hours. I decided to stay up until 1 am and get up at 5:30. At first, I decided to stay in bed during those 4½ hours whether I was sleeping or not. My results were terrible! I alternated between zero sleep nights and 2 to 3 hours [of sleep]. Determined to force this to work, I started to get out of bed when I wasn’t sleeping. That didn’t work, either. I got an occasional 4-hour night but I was so sleep deprived [that] I didn’t feel comfortable driving at night, which was a deal-breaker for me.

You say that SRT called up lots of anxiety. Can you elaborate?

Being that regimented just threw me for a loop. I really dreaded the evenings. I would be up for hours after my family went to bed, waiting to fall asleep until the right time. For me, staying up later than the gang was . . . stressful. [And] looking at the clock, especially at bedtime, seemed to cause me stress.

Also, there was an 11-mile hike I was looking forward to in a month, and I put pressure on myself to be in good shape by then. Every day that I couldn’t . . . increase my time in bed, I would get discouraged and feel that going on the hike would be an impossibility. I also worried that health-wise it was not good to spend [such a] short time in bed for an extended period—and this was not looking to be a short-term project for me.

Rewriting the Rules

So you decided to make some changes. What were they?

The thing I discovered is I had to do [SRT] in a flexible way that worked with my environment and my personality. I decided to come up with a modified version of SRT, one I could stick with long-term.

First, I needed to be able to go to bed when my family did. . . . And I needed to start with 6 hours [rather than 4½].

I was not going to watch the clock strictly. I [would go] to bed at approximately 11:30 and get up at 5:30, but it worked best if I didn’t look at the clock.

Since even in normal times I usually had a few wake-ups an hour or 2 before it was time to get up, I vowed to get out of bed at one of these wake-ups, or at 5:30, whichever came first.

I did not put a time limit on how long I would keep up this routine, so there was no pressure to improve. I also vowed to make this a background project in my life—do my 6 hours in bed and go about the rest of my life.

How well did your modified protocol work?

I had one of my longest periods of good sleep . . . followed by some “off” nights. Then another record-long period of good nights, followed by 2 weeks of off-and-on.

Once I got past that, things improved at a quicker pace. I went a month with only 1 bad night, then a month with 3 bad nights, then, finally, a month with no bad nights. Two months into the project, I bumped up my time in bed by 15 minutes. Two weeks later, I added 15 minutes more. I’m now up to about 7½ hours’ sleep per night.

Julie’s right where she wants to be with her sleep. The way she got there–and the changes she made to SRT–wouldn’t be helpful for everyone. But my hat’s off to anyone who can take this insomnia treatment and tweak it in ways that work.

If you’ve managed a similar feat, please share your story here.

Posted by Lois Maharg, The Savvy Insomniac

Lois Maharg has worked with language for many years. She taught ESL, coauthored two textbooks, and then became a reporter, writing about health, education, government, Latino affairs, and food. Her lifelong struggle with insomnia and interest in investigative reporting motivated her to write a book, The Savvy Insomniac: A Personal Journey through Science to Better Sleep. She now freelances as an editor and copy writer at On the Mark Editing.

21 Comments

  1. Thanks for sharing Julie’s interview. This is a fantastic example of how someone with insomnia takes core principles (like spend minimal time in bed alert, or don’t check the time) and figures out what works. I try to reassure patients I work with that they likely will be the one (not me) who ultimately discovers how to best apply the CBT principles, and to explore variations. Such a great example of this in Julie’s interview!

    Michael

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    1. Hi Michael,

      I too think Julie’s account of how she improved her sleep–based on things she’d learned about CBT for insomnia and sleep restriction–is fantastic, and I’m happy to share it. She stuck to the core principles, as you say, and was thoughtful in adapting them to her needs. It’s interesting that you encourage your patients to do the same sort of thing, and thank you for the appreciative comment!

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      1. Hi Lois

        I’ve tried SRT a few times and I got to admit that I can really relate to julie. I stayed up until 12.30am the last two nights( wake up time at 5.30am) and only got less than 4.5 hours of sleep on both nights. When I tried SRT before this I took a flexible approach like Julie and my sleep started to improve averaging 5 to 6 hours a night. That’s going to bed around 11.15-11.30pm. I think I’m going to try and go to bed around 11.30pm and have my wake up time at 5.30am.I think SRT is a great way to improve sleep but when it gets too aggressive you start stressing too much about it too Having a flexible approach like this could really help.

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      2. Hi Moe,

        I’m always glad to hear from people who find ways to make sleep restriction work for them. Doing what works is really the only thing that makes sense.

        There isn’t much that’s flexible about the sleep restriction protocol. The regular and shortened sleep schedule people are asked to adhere to, together with the (usually) mild sleep deprivation they experience in the first few weeks of treatment, enable a fairly rapid build-up of sleep drive. The result is that people begin to fall asleep more rapidly than before and wake up less frequently at night. This rather rigid protocol is aimed at getting results as quickly as possible—which is what most people want.

        But I suspect the dose of restriction some people are given—which is based on how long they’re actually sleeping—can feel too aggressive. Also, people going through SRT have to keep track of the time at night in order to avoid going to bed too early. Looking at the clock at night can cause anxiety, which of course is incompatible with sleep.

        So some people may be better off modifying the SR protocol. But whatever modifications you contemplate making, the morning wake-up time should remain absolutely firm. Sleeping beyond the rise time you’ve set for yourself will likely derail the process, and then you’re back where you started again.

        Good luck in finding ways to make this work—and keep working.

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  2. This is encouraging as my journey with SR has been up and down as well. I would have a stretch of good nights and then a bad night, which then discourages me. Sometimes I can pin point the reason for a bad night but sometimes I have no idea why. Thanks for posting.

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    1. You’re welcome for the post, Sherry, and best of luck in improving your sleep. If you continue with the SR program, I think you’ll find that the bad nights occur less and less often. And try to get some aerobic exercise every day–that too should help.

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    2. Hi Lois
      My sleep is still between 5.5-6 hours a night. Can you ask Julie if she had a naps before she went to bed at night when she did SRT? I feel very exhausted during the day

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      1. Hi Moe,

        I no longer have Julie’s email address. But the exchange we had prompted me to look into research under way right now on adding a brief, 15- or 20-minute nap BEFORE dinner to the sleep restriction protocol. Here’s the blog I posted:

        https://thesavvyinsomniac.com/naps-sleep-restriction-could-this-be-a-happy-marriage/

        If you do decide to try napping to increase stamina and alertness during the daytime, you’ll want to keep the nap fairly short (so it doesn’t reduce the sleep pressure that builds during the day) and make sure to do it before 5 p.m.

        It sounds like you’ve made some gains with sleep restriction. I encourage you to stick with the process—many people (including me) find their sleep continues to improve as time goes on.

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  3. Hello Lois

    Thanks for the quick response. My sleep has improved a lot and anxiety about poor sleep has reduced. What I’m seeing now is that the more I’m willing to accept night time wakefulness and less I worried about it makes me sleep better

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    1. Hi Moe,

      The same thing happened to me as I went through CBT-I and sleep restriction. As my sleep began to stabilize, I found myself worrying about it less and less. Now, several years later, it’s rare that I experience any anxiety about my sleep. And my old fear of sleeplessness, which I struggled with for decades, is simply gone.

      It sounds like the treatment is helping you in a similar way, and I’m glad to hear it. Thanks for writing in.

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  4. Hi Lois

    My sleep has improved a lot I’m sleeping 6.5 hours plus most nights but just want to ask u. Falling asleep just before my bed time in front of the tv on the couch for like 5-10 minutes, can it effect my sleep efficiency and sleep drive? Can you please tell me if this would have an effect?

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    1. Hi Moe,

      It sounds like you’ve really been persistent with sleep restriction and are reaping the benefits. I’m glad to hear it!

      Falling asleep for 5 or 10 minutes before your bedtime is not going to cut down on your sleep drive. You “pay off” sleep drive during deep sleep, and under normal conditions it’ll take about 30 minutes after sleep begins to descend into deep sleep.

      The trouble is, though, that the TV is liable to lull people to sleep quite a bit earlier than their normal bedtime. It might feel like only 5 or 10 minutes but in reality be more like 50 or 60 minutes. When that happens there probably will be less pressure to sleep at bedtime because through deep sleep some of that pressure has already been relieved.

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  5. Hi! I just started SRT. 26 y/o, have been on SRT for 4 nights. My time in bed is restricted to 2am to 8am. I have not been taking day time naps. I feel really anxious from 8am to 11am…over the last few weeks my time in bed was 10 hours and sleep time of 5-7 hours. Typical bed time was 1230 or 1am.

    I’m trying to get back on a 10pm-6am sleep schedule though. How should I work to adjust my clock backward 4 hours?

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    1. Hi Mark,

      If your sleep time has been averaging 5 to 7 hours a night, then restricting your time in bed to 6 hours a night sounds about right.

      Adjusting your 6-hour sleep window to an earlier time, so that you’re in bed from 12 to 6 rather than from 2 to 8, will likely be hard to accomplish all at once. My suggestion would be to do it gradually over the course of 6 or 8 days, all the while maintaining your 6-hour sleep window.

      For the 6-day transition: set your sleep window back by 20 minutes every night. Night 1: 1:40 a.m. to 7:40 a.m. Night 2: 1:20 a.m. to 7:20 a.m. Night 3: 1 a.m. to 7 a.m. And so forth until you’re in bed from 12 to 6.

      For the 8-day transition: set your sleep window back by 15 minutes a night until you’re in bed from 12 to 6.

      Stick with the 6-hour sleep window (12 to 6) for another week. At the end of that week calculate your sleep efficiency to determine whether you need to stay the course for another week or to enlarge your sleep window.

      If your sleep efficiency is 90% or better, increase your time in bed by 15 minutes, adjusting your bedtime: 11:45 p.m. to 6 a.m. Stay with this new sleep window for a week. If at the end of that week your sleep efficiency is 90% or better, give yourself 15 more minutes in bed: 11:30 p.m. to 6 a.m. And so forth, continuing to adjust your bedtime by 15-minute increments for as long as your sleep efficiency continues to be 90% or better.

      This blog post goes into more detail about establishing your sleep window during sleep restriction:

      https://thesavvyinsomniac.com/qa-sleep-efficiently-for-a-better-nights-rest/

      Best of luck in improving your sleep.

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      1. Thank you for the timely reply. The 6 and 8 day recommendations seem doable. Great advice.

        Best,

        Mark

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  6. Hi Lois,
    Thank you for this interview with Julie. It is very inspiring. I have followed your blog for a while, and bought The Savvy Insomniac book.
    I’ve done SRT before but only for 2-3 days, and then my sleep stabilized somewhat, then it gets wobbly. I am going to start doing SRT properly this time.

    Here is my current uncertainty/reservation about doing SRT: My current sleep window is 6 hours. With 6 hours, I build up enough sleep drive to knock out any sleep anxiety every night. but as I add more time each week, I’ll reach a sleep window (7 hours for me) where there’s not that much sleep debt to knock out the sleep anxiety, and I am going to have a bad night, and then I have to go back at 6 hours again.

    On one hand I am glad we have a system that helps us to get regularity in sleep, but on the other hand I think we always have to be somewhat sleep deprived to keep that regularity.

    Please let me know your opinion. I hope my theory above is wrong. I hope that during the process of SRT, I will find something that helps with my confidence about being able to fall sleep. Right now, it’s either I fall asleep in 5-10 min, or I get more and more worried/aware/awake if I am still awake after 10 min.

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    1. Hi Ko,

      I’m glad to hear you find Julie’s story inspiring, and that it’s led to a decision to try SRT yourself. Doing SRT properly, adhering to all the rules, is probably your best chance of success.

      In the beginning, I, too, wondered if I was always going to have to feel a little bit sleep deprived to be able to fall asleep at my chosen bedtime. My sleep window was 5.5 hours, and if I enlarged it much beyond that, I couldn’t fall asleep.

      From my perspective now, I believe it was my anxiety about not being able to sleep that made it necessary for me to stick to that 5.5-hour sleep window for the many weeks that I did.

      Very gradually, though, I lost my fear of sleeplessness and gained confidence in my ability to fall asleep at a regular hour. I also realized that looking at clocks at night made me anxious, so I began turning my clock to the wall after about 9 p.m. and waiting until I was really, really sleepy to go to bed.

      Now, I can’t really say with conviction that I know how much I sleep at night. But I DO know that most nights I fall asleep quickly, and the sleep I get on most nights feels sufficient. If you’ve read my book you know how vastly different my current situation is from where I was before.

      Once you (and your mind and body) become confident that you CAN sleep, you may find yourself sleeping 7 hours a night. But since anxiety about sleep is part of the picture now, you may need to restrict your sleep to 6 or 6.5 hours for a period of time before you’re able to enlarge your sleep window further.

      Follow the protocol and chances are that eventually you’ll be happy with the results.

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  7. Thank you for your reply and insight Lois. How crucial is Stimulus Control to the success of CBT-i? Did you find it beneficial to condition your bed as a positive cue for sleep? The obvious benefit that I could see is it piles sleep drive quite fast so that one will conk out after 2-3 days, as opposed to just lying in bed half awake half asleep.

    I do not mind doing Sleep Restriction for 6 hours and I feel like I at least deserve that 6 hours of bed rest. However, the idea of getting in and out of bed many times a night after a long day is just so unintuitive, unnatural, cruel almost.

    I don’t have any negative feelings about my bedroom or my bed. I find them quite inviting, so I am quite skeptical if the Stimulus Control Therapy would work for me.

    However, at nights when I lie in bed half awake, half asleep, body tired all over the place, I often wonder if Stimulus Control might be the answer but it is so hard and I can’t imagine doing it long-term.

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    1. Hi Ko,

      I, too, found Stimulus Control Therapy to be unappealing. Getting out of bed at 2 a.m. when my body was screaming for rest and repair seemed counter-intuitive and, besides that, it was just plain hard to do. I did it, though, and I’m sure that’s part of the reason my sleep started to regularize as quickly as it did.

      That said, although sleep restriction and stimulus control therapies are usually combined in standard CBT for insomnia, both therapies have been found to be effective on their own.

      So if you find stimulus control to be too onerous to comply with, keep plugging away with sleep restriction therapy (as Julie did). Odds are that eventually you’ll improve your sleep and feel more rested when you wake up in the morning.

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  8. I just saw a neurologist (specializing in sleep disorders) due to being desperate to try anything to improve my sleep, which has been chronically bad since I reached menopause (and continue with a very stressful job). He just “prescribed” me to do SR — to now go to bed at 1 and wake up at 7:30. He did not ask me to do a sleep log and this (I think) was based on my estimate that I normally sleep 5-7 hours (but think I need 8 or 9 to function well) due to multiple prolonged wake ups, anxiety about not sleeping, functioning poorly at work due to foggy brain, etc. The doctor is asking me to do this SR schedule for 3 weeks.

    My question is this. I have now just completed a week of this SR schedule. I am dying to go to bed by midnight and I “cheated” the other night and went to bed at 12:30 and slept well (slept after 20 min or less, only one wake up to use the restroom). Honestly I am dying to go to sleep earlier that 1 in order to get more rest. The good news is that my sleep when I am in bed now is more sound with less wake ups (so something good is happening). Do you think it is OK to alter my SR schedule to go to bed a bit earlier than 1 and still get the benefits of adjusting/improving my sleep? Also, was it a big mistake that he did not have me do a sleep log?
    Thanks for any feedback or observations here.

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    1. Hi Suzanne,

      Your neurologist may not be sticking to the conventional protocol for sleep restriction, but it sounds like you’ve already achieved some very good results. Would it be possible for you to email the neurologist and put the question you’ve asked about bedtime to him or her? That would probably be the best thing to do here.

      There are several reasons for keeping a sleep diary before beginning sleep restriction. One is to get a more accurate idea of how long you’re actually sleeping, on average. Your actual sleep time then becomes your sleep window during the first week of sleep restriction. People who skip the sleep diary step run the risk of starting with a too-small sleep window (in which case they’ll experience some sleep deprivation as they go through the process) or starting with a too-generous sleep window, in which case they may not see the gains they’re hoping for.

      Since your sleep has already begun to improve, you probably started in the right place.

      As for enlarging your sleep window, normally the way that’s done is by calculating sleep efficiency at the end of every week to determine whether it’s time to adjust the sleep window or not. See this blog post:

      https://thesavvyinsomniac.com/qa-sleep-efficiently-for-a-better-nights-rest/

      When you do start enlarging the sleep window, do it gradually—adding 15 or 20 minutes to the window from week to week—so you don’t lose the gains you’ve already made.

      Best of luck in continuing with the sleep restriction process.

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