Do you have trouble getting to sleep at night or staying asleep? About 30% of the adult population reports difficulties initiating sleep, sustaining sleep, or experiencing restful sleep. To deal with these problems, many people resort to medications or some form of supplement. But it now appears that there is an effective way to banish insomnia without the use of chemicals, by simply applying the principles of hormesis.
The remedy I want to discuss here is called Sleep Restriction Therapy (SRT). I credit Derek Haswell for bringing SRT to my attention. A 4-8 week course of treatment has been shown to be very effective in restoring normal sleep. The basic idea behind SRT is to limit your sleeping in a controlled manner until it renormalizes. As with any application of hormesis, the solution may at first seem paradoxical: to combat a stress you should apply judicious amounts of that very stress to train the mind or body to adapt. It works for building muscles, improving eyesight, normalizing appetite, and improving immunity. And sleep therapists have now found a way to use hormesis to improve the quality of sleep.
The protocol. Here is how Sleep Restriction Therapy works:
- Determine a fixed time to wake up every morning and set your alarm for that time. This is an absolute requirement: when the alarm goes off you must get out of bed immediately with no snoozing or exceptions. If necessary, use a loud alarm and put it across the room. Some researchers find that exposure to bright morning light upon waking is important to the success of SRT.
- Determine the minimum number of hours you need to sleep. This is usually done by keeping a sleep log for several nights to figure out the average number of hours you are actually sleeping. If you are in bed for 8 hours but are awake for 2 of those hours, then your sleep requirement is 6 hours. In general, the minimum sleep requirment should never be less than 4.5 hours.
- Do not go to bed or even go into your bedroom until the official bedtime. If your wake time is 6 a.m. and your initial sleep time is five hours, that means you cannot go into your bedroom to sleep until 1 a.m. You have to keep yourself awake between 6 a.m. and 1 a..m. the next day. No napping, lying down or nodding off is allowed. This is difficult and can produce drowsiness and grumpiness during the initial days of treatment. In some versions of SRT, slightly longer hours are allowed on weekends as a “reward” for making progress.
- Measure your “sleep efficiency” each night. Calculate sleep efficiency as the hours you actually sleep expressed as a percentage of the total hours you are in the bedroom. To track sleep efficiency, keep a sleep log — a record of when you go to bed and wake up during the night, noting the related circumstances and activities. Your goal is 90% or better sleep efficiency. An alternative method is to use a home sleep monitor such as that made by Zeo. The Zeo sleep monitor is an affordable and comfortble “headband” that wirelessly transmits data on your different sleep phases and sleep efficiency to a bedside “alarm clock”, with the ability to view your progress on your PC. I’ve found the Zeo to be very useful in analyzing sleep patterns. It reveals the inner workings of your sleep in a way that a manual sleep log cannot.
- Adjust your sleep time. If your sleep efficiency is greater than 90%, increase your sleep time by moving your bedtime 15 minutes earlier. If your sleep time is less than 85%, delay your bedtime by 15 minutes.
- Allow your sleep to normalize. Continue the treatment until your sleep time can be increased to ”normal” sleep time of 6-8 hours with at least 90% sleep efficiency and subjective feeling of restfulness upon waking and during the day.
Case study. Here is a very compelling video about the success that one British man had using SRT to overcome insomnia:
A study of SRT in 10 elderly patients found that it significantly reduced both sleep latency (time to fall asleep) and subsequent waking during sleep. And the benefits were still in place 3 months after ending the therapy. SRT appears to be effective for most types of insomnia, except for sleep disturbances related to depression, bipolar disorder, sleep apnea or circardian disorders resulting from, e.g., shift work. One of the immediate benefits that patients note is the reduction of “anticipatory anxiety” — the time and concern spent worrying about what the night will bring. Many insomniacs see their bedroom as a prison or place of dread. SRT very quickly compartmentalizes that anxiety. Once they begin to bank 5 or 6 good hours of sleep each night, the progress itself helps to dissipate the anxiety, which in turn tends to make for better sleep.
As with any application of hormetic stress, SRT at first involves “one step backward” by seeming to make things worse. And indeed the first few days may bring increased drowsiness, while the benefits take weeks to become evident. The reality is that our bodies adapt often slowly, over a period of weeks or longer. And so it is with SRT. But once patients begin to adapt to the new sleep regimen, the quality of their sleep usually improves markedly. Several weeks of drowsiness and irritability seems a small price to pay for a cure that lasts.
Why does it work? Looked at from a behaviorist perspective, SRT is a form of behavior modification based upon stimulus control. Because patients are truly much more tired when they are finally allowed to climb into bed, the association between the action of getting into bed and the response of falling asleep is strengthened, and the association with “tossing and turning” is weakened. Undoubtedly, at the level of neuropeptides and receptors in the hypothalamus, SRT must be restoring a functional homeostasis. The neuronal pathways, transmitters, and receptors involved in sleep regulation are quite complex. The ascending arousal system located in hypothalamus interacts with sleep-active neurons in the ventrolateral preoptic nucleus (VLPO) producing a “flip-flop switch” that produces distinct sleep-wake states with abrupt transitions. The sleep disruptions characteristic of insomnia are believed to involve an excess of corticotropin-releasing factor (CRF) secreted by the hypothalamic-pituitary-adrenal (HPA) axis. This results in excess production of the hormones ACTH and cortisol, leading to hyperarousal. It appears that Sleep Restriction Therapy quiets the HPA, leading to improved sleep.
Regardless of the underlying mechanism, Sleep Restriction Therapy appears to be an excellent example of hormesis, a chemical-free way to teach your body to adapt, by exposing it to controlled doses of the very same stress than you want to tolerate more effectively.
I’ve used sleep reduction therapy with great success. I have never had trouble sleeping, but the quality of my sleep wasn’t where it needed to be.
I also used a Zeo to track my sleep patterns and have drastically increased the percentage of REM and Deep sleep. I think it’s interesting that so many people believe they have to be in bed for 7-8 hours a night. They might only sleep for 4 hours, but they force it anyway.
Have you heard of any negative effects on circadian rhythms with people using SRT?
I’m also curious to know whether or not this small period of sleep restriction can make someone more resistant to sleep loss in the future. Such as on a trip or when they might be sick.
Great article. I’ll devour anything on sleep hacking
Thanks man,
-Armi
found your blog about three weeks ago and have been extensively applying hormetism in many areas of my life. cold showers, food, exercise, intermittent fasting, you name it i am trying it and experiencing significant gains. just wanted to share my thanks and that i look forward to reading more future posts. Sanjay
This very method was recommended to me by a sleep specialist doctor in about 2005. He said this method almost never fails.
That’s good to hear, Dill. Did you try SRT? If not, why not?
I used SRT with great success.
One tool that I have found very useful is an iPhone application called “Sleep by MoyionX”. This allows me to count my sleep cycles and wake up at the optimal time in a sleep cycle. It’s perfect for SRT.
Song Lee,
Thanks for weighing in on this. I’d be interested if you could write a bit more about your actual experience with SRT. How bad was your insomnia before starting SRT and how long did it take to normalize your sleep?
The iPhone app you describe looks interesting. I wonder how it compares with the Zeo system, which also has a feature that wakes you at the right time during your sleep cycles.
Todd
I’m first week into restrictive sleep therapy, 2 nights ago I couldn’t stay up till 12 went to bed at 11 and was up most of the night then last night went to bed at 12 and was up most of the night. I never have trouble getting up at 6am and am OK during the day but was so much better at the beginning of the week when I was getting 5 hrs!!! of sleep. Help? suggestions?
Judy,
It’s clear that you are not staying up late enough. If you are still waking up a lot of the night, then your sleep efficiency is less than 90%, and you need to further DELAY your bedtime. Take a look at rule 5 in the protocol:
.
Following the protocol strictly is critical to success. You need to stay up until you are dead tired and can barely keep your eyes open. And you need to force yourself to wake up until 6 am. Do whatever it takes to get up by 6 am without fail.
The key here is to first squeeze your sleep time down to whatever it takes to force sleep. From that point on, you can gradually lengthen sleep time. You will feel tired and drained during the beginning of the therapy. But if you stick with it, your sleep will improve, especially as you start to lengthen your sleep time.
Let me know if you have any questions about this. Good luck, and let us know how it goes.
Todd
Hi Todd,
I have been struggling with sleep for 2 months – gone from 8 hours to 5.5 broken sleep and I am exhausted. I have always woke in the night, but generally got back off fine…now i lay awake. Middle of the night waking is my main problem. I had some stress at the outset of these problems but now I believe I have just got into a bad habit. I therefore, intend to try sleep restriction therapy. I have a couple of questions…
I normally get up @ 7 but my wife gets up at 6. Should I get up at 6 when I try the therapy and if so, can I stretch my waking time back to 7 if the therapy works?
Also will I be adding to my problems if I change to the spare room either just for the period of therapy or if i wake in the middle of the night. Is it best to tough it out in the marital bed???
Finally if I wake a 5 and my wake time is 6 and I don’t drop back on in half hour should I get up or just lay in bed till 6?
Many thanks,
Phil
Hi Phil,
Sleep restriction therapy should help with your middle-of-the-night waking. I’ll try to answer your questions:
The therapy should work fine if you keep your wake up time at 7 a.m. and sleep together with your wife. The advantage of this is that once the therapy works, there are no additional changes required to your behavioral pattern. However, ask you yourself whether there is anything about sleeping in the same bed as your wife that leads to more waking or restlessness. Does she toss or turn, snore, get up in the night, talk to you, get romantic, or engage in any other behaviors that tend to wake you in the middle of the night? Or are there other disturbing noises or light in your main bedroom? If so, you may find it easier to temporarily move to the spare room, and maybe shift your wake time until 6 a.m. if that works better.
Ultimately, however, the therapy will work either way you try it. The key is to set a fixed wake up time and to be ABSOLUTE about it. Do not hit the snooze button. If you don’t do anything else, be resolute about rising at a fixed hour.
The second imperative is to keep delaying your bedtime by an additional 15 minutes each night, until you are able to sleep through the night. If you feel tired during the day, that’s typical. Don’t take naps. Force yourself to restrict your sleep time to as short a period during the night as necessary to force continous sleep through the night.
If you wake up earlier than your set time, lay in bed and don’t get up until your set time. Even if it is boring. And resolve to stay up 15 minutes the next night.
Be absolutely faithful to this protocol. It will be uncomfortable and you’ll feel sleep deprived for 2-3 weeks. Then you’ll start sleeping better. Make the investment, and you’ll be happy you did.
It works.
Todd
Thanks for your quick reply Todd. I was just wondering whether knowing the wife’s alarm will go off @ 6am might mess up the process given that I get up @ 7. That’s why I considered getting up an hour early for a while. Two final questions. Should I use a light box upon waking to regulate the sleep cycle (I’ve read this makes therapy more likely to succeed)? Secondly, I have also read that you should stay up all night the night before starting the therapy to really up the sleep drive (like hitting the reset button). Any thoughts on these points?
Oh and finally, finally some studies say that if you wake in night and cant get back to sleep within 20 mins to get up until you feel sleepy and then go back to bed (to break negative association with laying in bed awake). Do you advocate this approach or should you stay in bed no matter what between your sleep and wake times??
Thanks,
Phil
Phil,
I think the question of whether to get up at 6 (with your wife) or sleep past that alarm and wake at 7 is really a judgement call. The therapy should work either way, it’s really a matter of what you find most practical. But once you pick a wake up time, stick with it rigidly and don’t waver for 2-3 weeks.
The light box is an interesting option and may help. My recommendation would be to skip the light box for now. You want to do a “single variable test” of sleep restriction therapy. If you combine it with the light box and it doesn’t work, you don’t know what to conclude. You can always add the light box later, as a refinement, if you decide to.
I would not stay up all night the night before you start the therapy. That seems pretty extreme to me, and it is likely to throw off your biorythms. I would also not get up and stay up if you wake up prematurely. That approach works on a different principle which has some validity, but in this case it’s counterproductive because you are trying to get your body to sleep continuously and without interruption. If you are waking up during your sleep time, you definitely need to delay your bed time further — but without changing your wake time.
The real key to SLT is that it makes a single change (condensing your sleep time), followed by gradual adjustment of the sleep time by no more than 15 minutes per night, until you finally overcome your insomnia. Don’t complicate things. And try to avoid any stimulating foods or drinks during the evening. You want to feel dead tired when you head to bed.
Keep things simple. Make only this change in your life and commit to it like a religious zealot, with no exceptions. It takes a few weeks to work its magic. You WILL feel miserable for a few days.
Please let us know how it goes — both the good and the bad.
Todd
Hi Todd.
An update as requested on sleep restriction.
Having averaged 6 hours of broken sleep for a while, I started out with 7 hours in bed. 12-7 (although I have used a window between 11:30 and 12:00 for bed and strict 7am get up.
I have been averaging between 5.75 and 6 hours sleep. I get to sleep ok. I still wake in the the night but go back to sleep pretty quick which is good.
HOWEVER, I seem to wake around 6:15 and am awake for my final 45 mins in bed.
I am still tired during the day but not completely wrecked, although I have a low patch early afternoon and about 10pm. I generally feel more sleepy at 10 than at my 12 bedtime.
I want to stay asleep for that final 45 mins but am worried restricting anymore will just train me to get by on less sleep. Perhaps I could bring getting up time earlier? But I want to wake at 7 really…
Any advice?
Also as the therapy starts to work should I increase time in bed per night or try a new bed time for a few nights/week before changing again? I have seen conflicting advice on this?
Thanks
Phil
Phil,
For the short time you have been doing this, you are making reasonable progress. But you are waking up 45 minutes early and still waking during the night. Therefore, you need to further delay your bed time by an additional 15 minutes. I would target 12:15. I realize that you will feel tired during the day, but this is the temporary price you have to pay for ultimately normalizing your sleep. As hard as it is, try to gut it out.
Once you are able to sleep through to 7 a.m., you can gradually move to earlier bedtimes, 15 minutes at a time. And when you are sleeping through the night, you’ll find that your daytime tiredness greatly diminishes.
Like all good things, short term pain brings long term gain.
Keep up the good work!
Todd
Hi Todd how are you? I came to your blog by searching “sleep restriction therapy”, because my sleep doctor told me to do it. I used to sleep very bad and wake up many times in the night, for many years, son I finally decided to go for the sleep test (polisomnography). The doctor saw the test and he told me I was in the bed for 7 hours, and I only slept 4 with many gaps. In those 4 hours, I woke up 20 times.
So he told me to start with the SRT. My wake up time, 7. And he told me to start sleeping at 3 AM for a week, next week 2.30 AM, the other 2 AM and finally 1:30 AM.
It was tough, but the SRT worked for me. The thing is strange, because my sensation is that you sleep and rest by being always restless. So when you finally go to the bed, you get the sleep very fast. But, as I told my doctor, it’s not magic. Before I used to sleep 5 hours more o less getting up many times. Now I can sleep 4 o 5 hours, depending on the day at a shot, then go to the bathroom and continue sleeping for 1-1.5 hours more or less but this last sleep is without quality. The first sleep that I catch is very good, and the thing is the sensation is better. I don’t know how to explain it, but it works.
The only thing is that appart from no taking naps, you have to wake up in the weekends at the same time, at 7, even after finishing the therapy? That’s what my doctor told me. He told me to continue with this behavioural thing, and after 2 o 3 weeks, again put 3 or 4 days sleeping very late and continue waking up at 7.
I am doing it, and I reach to the nights tired and many times I discover myself snoring ( I have never snored before!). The only thing is that SRT works, but in the middle you can get nights like before, waking up many times to the bathroom, or the little baby cries, or my wife, and that night your sleep and your rest is awful, and these nights are very depressing.
The thing is that if these behavioral has to be always, sometimes it’s difficult many times with your life. For example, if today that it’s Saturday, I go with my wife to have dinner and some drinks, and sleep at 2 or 3 am, it’s difficult to continue sleeping till 7, even when my SRT has finished.
What is the behaviour supossed after finishing the month of SRT?
And the other thing is that, as I told you, when after finishing or in the middle you have a bad night (many times because of you or because of the circumstances (baby,wife,bahtroom, noise,…)) what to do? My doctor told me that nothing. Continue waking up as stablished and think that the other night you will sleep better.
One of the positive things about the SRT is that you change your mind about sleeping, and even if you don’t sleep well, you tend to think positive. It’s like autocoaching for the mind
But it’s very tough, and also the thing is that you have to be always tired to get good sleep. It’s a bit paradoxical.
My wake up time it’s at 7, and I completed my therapy a few weeks ago. Yesterday It was holiday here in Spain, and I was woke up with my wife till 2 AM. Since 11 pm I was falling asleep, it was tough, we also were wathing a movie and I was falling asleep, but I carried till 2 AM. And today, I could not woke up at 7. I decided to woke up at 9:30, that too is early. Because the same thing a few months before, before knowing and experimenting with SRT I would have woken up today at 11 or 12, depending if the baby continued sleeping. But now , as I have completed my therapy, I don’t want to break the balance achieved.
But even though, being in bed today for 7 hours and a half, did not get good sleep. My wife woke me up at 3, my baby at 5, I went to te bahtroom at 7. So it was like a typical night of before, before the SRT.
These nights are a bit confusing, and you seem yourself lost, thinking that you could get the energy to complete the SRT, and you also continue with the same behavoiur (no naps, try to get up at same time weekends,..) but this has to be for always and same time it’s very tough.
I look forward to hear your opinion , Todd.
Thank you very much for your kind attention.
Deepak
Hi Deepak,
Thanks for sharing your experience with SRT. As your story reveals, sleep restriction theory is a mixed blessing. You do get much better quality sleep, but it is not always perfect. And you pay a price by having to stick to a pattern. So there is a trade off, but most people in your situation find it a trade off worth making.
With time, perhaps many months, once your sleep pattern is normalized, perhaps you can make more exceptions. But as with learning any new behavior — to control eating, drinking or other habits — it is necessary to allow enough time for the new pattern to take hold, before you can trust it.
Que decanses — sueños dulces
Todd