What to do when sleep hygiene isn’t enough?

Stimulus Control

Aims to strengthen the association between bed and feelings of relaxation and sleepiness, and to break the association between bed and feelings of anxiety, worry, frustration or wakefulness.

To implement stimulus control:

1. use your bed for sleep and sex only and avoid other activities in bed like scrolling on your phone, responding to work emails, watching tv, or even arguing with your partner.

2. If you have been awake in bed for longer than 20-30-minutes, get up out of bed and only return to bed when you feel sleepy (i.e., as if you could actually fall asleep). When up out of bed, avoid blue light from screens or other physiologically arousing activities like intense exercise, or reading a gripping novel. Instead, pick something relaxing like listening to a meditation, doing some gentle stretching, or colouring. In cold winter months, prepare for stimulus control by having slippers, blankets or jumpers next to your bed so it is easier to get up out of bed.

Bedtime Restriction therapy

Bedtime restriction therapy aims to consolidate sleep or to improve sleep efficiency, with better sleep efficiency being associated with improved perception of sleep quality and reduced daytimes sleepiness and fatigue. That is, we are better off spending 6.5 hours in bed and getting 6 hours of sleep, than we are spending 10 hours in bed and getting 6 hours of sleep. This is because that additional 3.5 hours in bed, as mentioned above, is probably spent feeling anxious, worried or frustrated about not sleeping.

We can break this vicious cycle wherein which bed becomes a trigger for states of hyperarousal, by implementing bedtime restriction.

To implement bedtime restriction you will need to:

1. Keep a sleep diary for at least 7-nights and days.
2. From your sleep diary, you will need to calculate two averages. The average of your total time in bed and the average of your total sleep duration. If there is a big difference between the two (i.e., >30-minutes), then you may want to consider implementing bedtime restriction.
3. The initial recommended sleep window is restricted to your calculated total average sleep time. For example, if you spent on average 10 hours in bed, but only an average of 6 hours asleep, then your new sleep window becomes 6-hours.
4. Don’t panic about the above! Periodic adjustments are made to increase this sleep window until your preferred sleep duration is reached.
5. Choose a regular wake-up time to suit your personal needs and stick to it 7-days a week.
6. Set your regular bedtime by subtracting your average total sleep time from your regular wake up time. For example, if your wake-up time is 7:00am and your average total sleep time is 6 hours, then your bedtime becomes 1:00am. Stick to this for a full week.
7. At the end of this week, if you’re falling asleep more quickly, returning to sleep more quickly upon waking during the night, and feeling very sleepy before bed, then you can increase your sleep window by 30-minutes, by going to bed 30-minutes earlier. If you are awake in bed for more than 30-minutes on average then don’t extend your bedtime just yet, stick with your original bedtime for another week.
8. And repeat. If after the second week, you are falling asleep more easily, returning to sleep more easily, and feeling very sleepy before bed increase your bedtime by 30-minutes again, by going to bed 30-minutes earlier. If, however, you find that excessive wakefulness in bed has returned, you’ve extended your sleep window too long, too quickly. At this stage, decrease your bedtime by 30-minutes, by going to bed 30-minutes later.
9. Keep repeating step 8 until you are satisfied with the quality of your sleep (i.e., less than 30-minutes awake in bed) and feeling less sleepy/fatigued during the day.
10. Once you’ve found your ideal bedtime and sleep routine, stick to it.

When implementing bedtime restriction, be prepared for and expect an initial period of worsening daytime sleepiness and fatigue, and feeling more tired when your alarm goes off in the morning. By going to bed late and getting up at the same time each morning, you are creating greater sleep pressure meaning it will be easier to fall asleep when you do go to bed. For this reason, it is also important that you avoid napping during the day or accidentally falling asleep on the couch watching tv in the evening (as this will decrease your sleep pressure). It may be helpful to plan some non-sleep interfering activities to do in this wakeful time to keep you awake.