What to do when sleep hygiene isn’t enough?

Many Australians, young and old, struggle with sleep. It’s estimated that four in ten Australians regularly experience inadequate sleep or poor sleep quality.  While good sleep hygiene is helpful, and certainly has an important role in improving sleep, alone it may not be enough for those whose struggle with sleep has morphed into a diagnosable sleep disorder such as insomnia.

What is insomnia?

Insomnia is a sleep disorder characterised by difficulty falling asleep, staying asleep, early morning awakenings with an inability to return to sleep, or a combination of these. These difficulties cause significant distress or day-to-day impairment for the individual including fatigue or daytime sleepiness, issues with irritability or mood, attention, focus and memory. Insomnia can be:

• situational and last a few days to a few weeks in response to life events or rapid changes to sleep schedules (e.g., moving times zones),

• persistent when symptoms persist 3 or more months after the initial trigger.

• Re-current and associated with the occurrence of stressful events.

Although there can be many triggers for initial difficulties sleeping, like a stressful life experience, illness or injury, or changes to sleep schedule or environment, what keeps these difficulties going for those who go on to develop more persistent insomnia? One factor that can keep insomnia going is conditioned arousal.  

Conditioned arousal: bed becomes a trigger for states of hyperarousal

The longer you spend in bed attempting to fall asleep or get back to sleep, the more anxiety provoking and frustrating this situation becomes. Tossing and turning in bed you may start to worry about how soon your alarm is going to go off, how you will have enough energy to get through tomorrow and how you might cope with this. Anxiety and frustration are states associated with hyperarousal in the body, which is incompatible with falling or returning to sleep.  Over time, bedtime and bed itself may become a trigger for these states of hyperarousal making it even harder to fall asleep and stay asleep. This is turn will worsen preoccupation about sleep, or anxiety about sleep, creating a vicious cycle. This is often referred to as conditioned arousal and may lead to persistent insomnia.

How to break this vicious cycle:

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.

For more information on treatment for insomnia: 

Stimulus control and bedtime restriction therapy are both behavioural strategies that form part of cognitive behavioural therapy for insomnia (CBT-i), which is the gold standard treatment for insomnia. See below for more information on:

• Sleep hygiene
• Treatments for insomnia
• CBT-i

Written by Dr Gemma Healey, Clinical Psychologist