Sleep Restriction Therapy

Aka: Sleep Restriction Therapy, Cognitive Behavioral Therapy for Insomnia, CBT-I, Sleep Phase Chronotherapy, Temporal Control Therapy

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II. Category

  1. Cognitive Behavioral Therapy for Insomnia technique

III. Indications: Insomnia

  1. Difficulty initiating sleep or difficulty maintaining sleep
  2. Patient wakes up later to compensate for sleep loss
  3. Prolonged periods of lying in bed awake

IV. Contraindications

  1. Epilepsy
  2. Bipolar Disorder
  3. Parasomnias such as Sleep Walking
  4. Untreated Obstructive Sleep Apnea

V. Goal

  1. Time asleep should approach time in bed (with a Sleep Efficiency >90%)

VI. Precautions

  1. Should be performed under the guidance of a provider trained in Cognitive Behavioral Therapy for Insomnia (CBT-I)
  2. Typically patient is seen for an initial assessment to determine whether they are appropriate for CBT-I
  3. May also be performed via web-based CBT (as effective as in-person or group therapy)
    1. Ritterband (2017) JAMA Psychiatry 74(1): 68-75 [PubMed]
    2. McCurry (2021) JAMA Intern Med 181(4): 530-8 [PubMed]

VII. Protocol

  1. Follow Sleep Hygiene guidelines
  2. Step 1: Determine total sleep time (TST)
    1. Log the total time asleep for at least one week
    2. Consider monitoring with Actigraphy (accelerometer worn by patient records movement)
    3. Calculate an average duration of time asleep per night (TST)
    4. Example
      1. Patient goes to bed at 10 pm and awakens at 6 am, a time in bed (TIB) of 8 hours
      2. Total sleep time (TST) however averages 5 hours
  3. Step 2: Determine new sleep schedule
    1. Determine a consistent wake up time (and maintain 7 days per week)
    2. Establish a new bedtime that is on average allows for only the total sleep time (TST) that was calculated in step 1
    3. Do not limit sleep to less than 4.5 hours per night
    4. Example:
      1. New bedtime: 1 am
      2. Constant awakening time: 6 am
  4. Step 3: Initiate new sleep schedule
    1. Monitor with log (and consider Actigraphy) nightly
    2. If prolonged awakening occurs (>15-20 minutes)
      1. See Sleep Stimulus Control technique
  5. Step 4: Review log on a weekly basis
    1. Re-evaluate Sleep Efficiency weekly (100 * TST / TIB)
      1. Where TST is total sleep time
      2. Where TIB is time in bed
    2. Adjust bedtime based on weekly log results
      1. Sleep Efficiency >90%
        1. INCREASE time in bed by 15-20 minutes/night
        2. New bedtime is 15-20 minutes EARLIER (with same awakening time)
      2. Sleep Efficiency <80%
        1. DECREASE time in bed by 15-20 minutes/night
        2. New bedtime is 15-20 minutes LATER (with same awakening time)
  6. Step 5: Repeat cycle for 8 weeks
    1. Monitor with log (and consider Actigraphy) nightly
    2. If prolonged awakening occurs (>15-20 minutes), practice Sleep Stimulus Control technique
    3. Continue cycles of nightly logging followed by weekly Sleep Efficiency calculation and adjusted bedtime

VIII. Resources

  1. Clinician CME to learn CBT-I Techniques
    1. https://www.med.upenn.edu/cbti/

IX. References

  1. Perlis (2005) Cognitive Behavioral Treatment of Insomnia
  2. Maness (2015) Am Fam Physician 92(12): 1058-64 [PubMed]
  3. Morin (2015) Ann Intern Med 163(3): 236-7 [PubMed]
  4. Trauer (2015) Ann Intern Med 163(3): 191-204 [PubMed]

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