Bedtime Restriction Therapy

Bedtime restriction therapy involves reducing the time spent in bed to strengthen the relationship between being in bed and being asleep by increasing evening sleepiness and consolidating sleep throughout the night.¹

It is important to provide the patient with basic information about the structure of sleep during the night, and some of the factors that control our sleep. This can help the patient understand the rationale for bedtime restriction therapy, and promote sustained engagement with this treatment over 3-4 weeks.²

Patients with insomnia disorder commonly spend more time in bed than is necessary, in the hopes of acquiring/catching up on lost sleep. However, this increased time in bed more commonly results in more time spent awake in bed, rather than more time spent asleep in bed. For an individual who is already concerned about their sleep and the effects of sleep loss, this time spent awake in bed can result in further frustration, worry and concern while awake during the night. After repeated pairing of time awake in bed, and feelings of frustration, alertness, and arousal, a conditioned/learned insomnia-response to the bedroom environment can develop. This means that the bedroom environment can cause feelings of alertness/frustration, rather than a state of rest and relaxation. Bedtime restriction therapy aims to reduce time spent awake in bed, and break this conditioned insomnia response. A patient who experiences a restricted sleep period on one night will experience greater sleep pressure, which will promote shorter wake-time during the subsequent night.²

The rule of thumb when prescribing bedtime restriction is that the allowed time in bed is the same as the average amount of sleep the patient reports, with a minimum of 5-6 hours to avoid severe bedtime restriction. As the patient’s sleep is consolidated and they are asleep for most of the time that they spend in bed, their bedtime window can gradually be extended until a comfortable and satisfying equilibrium between sleepiness, time in bed, and sleep time is achieved based on the patient’s perspective. The insomnia would have developed over a long period, it is therefore important to engage with this treatment over multiple consecutive nights and weeks. Insomnia improvement occurs at a gradual rate, but is sustained over time.

It is important to prepare patients for what to expect to increase motivation and engagement with therapy. This includes informing the patient that the behavioural therapy should result in gradual improvement in symptoms over 2 to 4 weeks, particularly if insomnia has been sustained over a long time. The patient may feel sleepier during the day, but this is a desired and expected side effect (it may not be advisable to start behavioural therapy during a busy time at work). All patients should be warned of feelings of increased daytime sleepiness during bedtime restriction therapy – especially in the late afternoon, and during the initial 1-3 weeks of therapy.³ Commercial drivers in particular should be informed of increased sleepiness during the day.⁴

Exercise caution in bedtime restriction therapy for those with epilepsy or muscle spasms, currently pregnant, driver for work, high daytime sleepiness. Referral to a ‘sleep’ psychologist is recommended for such patients, who may have more experience balancing the safety and efficacy of CBT-I in these populations.