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Chronic Insomnia / Insomnia Disorder

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.

Table. Components of Bedtime Restriction Therapy

  1. Determine the patient’s average sleep time by means of a 1-2-week patient sleep diary (recording the amount of sleep and of time spent in bed)
  2. Calculate the patient’s average sleep efficiency (reported time asleep as a percentage of the reported time in bed) - a good sleep efficiency is usually ≥85%
  3. If the patient’s baseline sleep efficiency is <80-85%, the amount of time that they spend in bed can be reduced - this will gradually increase evening sleep pressure, and overcome any conditioned insomnia response
  4. Determine a consistent wake time in consultation with the patient’s preferences by using the average sleep time as the new time allowed in bed (min 5-6 hours to reduce risk of severe daytime sleepiness from sleep restriction, and use less restriction when difficulty adhering to bedtime restriction occurs or patients who drive for work)
  5. Instruct the patient to avoid long daytime naps (if naps are needed, they should be limited to less than 20 minutes and not taken after ~4pm)
  6. Ask the patient to continue completing sleep diaries during each week of therapy. Follow up 2-3 weeks after starting bedtime restriction therapy to adjust the prescribed sleep time as necessary;
  • If sleep efficiency is >85-90%: the time in bed for the next week can be increased by 15-30 minutes
  • If sleep efficiency is <80-85%: the time in bed for the next week should be decreased by an additional 15-30 minutes (min 5-6 hours)

7. Repeat the follow up and adjustment process each week until the patient reports improved sleep efficiency (>85%), reduced insomnia symptoms, and acceptable daytime sleepiness. Ideally, the patient should feel sleepy in the evening before going to bed, but not during the day. It generally takes 4-5 weeks of bedtime restriction and weekly adjustment before a comfortable and satisfying equilibrium between time in bed, insomnia symptoms, and sleepiness is found.


AHI - Apnoea-Hypopnoea Index
BBTi - Brief Behavioural Therapy for Insomnia
BMI - Body Mass Index (kg/m2)
BQ - Berlin Questionnaire
CBTi - Cognitive Behavioural Therapy for Insomnia
CELL - Coblation Endoscopic Lingual Lightening
COPD - Chronic Obstructive Pulmonary Disease
CVA - Cerebrovascular Accident
CPAP - Continuous Positive Airway Pressure
CSA - Central Sleep Apnoea
DASS - Depression Anxiety Stress Scale
DBAS - Dysfunctional Beliefs and Attitudes about Sleep
DBP - Diastolic Blood Pressure
DIMS - Difficulties Initiating and/or Maintaining Sleep
DISE - Drug-Induced Sleep Endoscopy
DISS - Daytime Insomnia Symptom Scale
ENT - Ear Nose and Throat
ESS - Epworth Sleepiness Scale
FOSQ - Functional Outcomes of Sleep Questionnaire
FSH - Follicle-Stimulating Hormone
FTP - Friedman Tong Position
GP - General Practitioner
HANDI - RACGP Handbook of Non-Drug Interventions
HGNS - Hypoglossal Herve Htimulation
ISI - Insomnia Severity Index
K10 - Kessler Psychological Distress Scale
MAD - Mandibular Advancement Device
MAS - Mandibular Advancement Rplint
MBS - Medicare Benefits Schedule
MMA - Maxillomandibular Advancement Surgery
MRA - Mandibular Repositioning Appliance
ODI - Oxygenation Desaturation Index
OSA - Obstructive Sleep Apnoea
PLMD - Periodic Limb Movement Disorder
PT - Positional Therapy
PTSD - Post-Traumatic Stress Disorder
PSG - Polysomnography
QSQ - Quebec Sleep Questionnaire
REM - Rapid Eye Movement
RFTB - Radiofrequency Thermotherapy of the Tongue Base
SBP - Systolic Blood Pressure
SCI - Sleep Condition Indicator
SE - Sleep Efficiency
SF36 - Short-Form (36) Health Survey
SMILE - Submucosal Minimally Invasive Lingual Excision
SNRIs - Serotonin-Norepinephrine Reuptake Inhibitors
SOL - Sleep Onset Latency
SSRI - Selective Serotonin Reuptake Inhibitors
TFTs - Thyroid Function Tests
TIB - Time In Bed
TORS - Transoral Robotic Surgery
TST - Total Sleep Time
UPPP - Uvulopalatopharyngoplasty
WASO - Wake After Sleep Onset

Quick links


  1. Miller CB, et al. The evidence base of sleep restriction therapy for treating insomnia disorder. Sleep medicine Reviews 2014;18(5):415-24night
  2. Sweetman A, et al. A step-by-step model for a brief behavioural treatment for insomnia in Australian General Practice. Australian Journal of General Practice 2021
  3. Kyle SD, et al. Sleep restriction therapy for insomnia is associated with reduced objective total sleep time, increased daytime somnolence, and objectively-impaired vigilance: Implications for the clinical management of insomnia disorder. Sleep 2014;37(2):229-37
  4. RACGP gplearning ‘Managing insomnia in general practicehttps://www.racgp.org.au/education/professional-development/online-learning/gplearning