My middle school music teacher used to say, “If you want to play fast, play slow.” As a behavioral sleep specialist, I find myself saying a similar paradoxical mantra to patients with chronic insomnia, “If you want to sleep more, schedule less time in bed.”
During National Sleep Awareness Week, when the importance of sleep is emphasized throughout the media, I am about to discuss the reduction of time in bed. Why? Because for chronic insomnia, unsuccessfully trying to sleep is a major perpetuating cause. A standard CBT-I recommendation is to avoid bed when sleep does not occur (2004, 2018). Yet, this recommendation is perhaps the most puzzling and the most challenging for patients. Let us demystify this treatment technique and make it work for you as effectively as it does in clinical research studies (2016).
We can start by noting that compensation for sleep loss on a single night by taking a daytime nap or sleeping longer on the next night is perfectly normal—for an otherwise good and consistent sleeper! If a good sleeper takes a nap after a red-eye flight, no problem. If a good sleeper wakes up an hour earlier for an early meeting and then goes to bed an hour earlier the following night, no problem.
But it becomes a huge problem when a person with insomnia spends more and more time reclining in an attempt to compensate for the lack of consistency in sleep. This logic of “good” and “bad” compensation is based on the principle of homeostasis and is just as applicable to other health-related behaviors.
If you have to skip lunch once, it’s OK to eat a little heavier dinner, but if you habitually consume most of your calories in the evening, your metabolism will suffer. If a regular exerciser skips a day, she can exercise longer the next day, but for someone who has not exercised for months spending long hours at the gym is the best way to ensure the inability to lift a finger for at least a week. The same homeostatic principle is applicable to sleep—small and infrequent variations are fine to compensate for, but habitual compensation makes the very physiological fabric of sleep deteriorate.
The effects of extended reclining time on sleep physiology will be explored in the next post. Here, we will concentrate on behavioral analysis. Consider a hypothetical person with chronic insomnia, Jane, presenting with a common pattern. She feels tired throughout the day and goes to bed at about 9 pm, hoping to fall asleep. She turns the TV on as a distraction from ruminations, which are mostly about her insomnia.
A couple of hours later, she notices she’s been dozing on and off and decides to turn off the TV but then feels wide awake. She tosses and turns for a while, looking at the clock, calculating how many hours remain for sleep. She worries about her work performance the next day and starts planning her work activities to ease the worry. She gets up to read, but fearing the negative effects of sleeplessness on her immune and cognitive functions, she soon returns to bed. She tries to relax but continues shifting positions frequently, looking at the clock and ruminating. Determined to force herself to sleep, she remains in bed and finds herself wondering if there is anything physically wrong.
Realizing it’s nearly 5 am, she gives up trying to sleep and resolves to just rest for a while when suddenly the alarm wakes her up at 6:30 am. She snoozes every 10 minutes for nearly an hour, but hardly returns to sleep, and gets up frustrated, exhausted, and rushed. Net result: about 10 hours in bed, and about 2 hours of sleep that Jane can recall.
Leaving out other things that may be going on, let us answer one question: what does being in bed predict for Jane? It predicts TV watching, tossing and turning, clock watching, mental math, work planning, physical unrest and discomfort, making decisions in real-time, scary thoughts, multiple repetitions of an alarm, and about 20 percent likelihood of sleep. If someone invited you to a party with a 20 percent chance of fun and the rest being displeasure, would you go? Under the gun, perhaps. But Jane feels she has no choice and repeats this pattern night after night for months, even years, effectively conditioning herself to do all these alerting and displeasing things in bed, instead of sleep. Fortunately, with CBT-I, there is a better choice.
To understand the nature of this choice, and why it is better, please let us take a look at conditioning. It’s a behavioral term that likely stirs up negative associations in the popular psyche—salivating dogs, electrocuted rats, and A Clockwork Orange. However, it’s better to think of it as a case of unintentional learning.
There is a huge amount of literature on this type of learning in everyday human life and in clinical practice, from muscle memory to emotional states, from phobias to substance addiction, from sexual and immune responses to word connotations. Broadly, conditioning may be defined as unintentionally establishing a habit—good or bad—that is hard to change partly because its development went under the radar of conscious intention. As early as in 1972, Dr. Richard Bootzin recognized the role of conditioning in insomnia, which became a cornerstone of the behavioral approach to healthy sleep and led to the foundation of CBT-I (2004).
Consider an example: a person who lost a job tries to gamble to make a living. Due to the nature of gambling, gains and losses are quite random, and overall the gambler barely breaks even but continues to gamble because of the inkling that maybe the next time there will be again. This inkling is to a large extent the result of conditioning. Now, what if someone offers to pay the gambler a small but consistent salary for working fixed hours? In the case of gambling, most of us would firmly say, “It’s a good start.” But if we are faced with a similar situation in sleep, if we are asked to spend only a few hours in bed to get only a few hours of sleep, we hesitate, because we already have a sense that sleep is obtained by being in bed, so the technique seems counterintuitive.
We follow our intuition in case of a brief sleep disturbance and compensate by spending a bit more time in bed the next night, often with the desired result. But if the disturbance lasts longer than just a few nights, increasing the amount of time in bed, or even keeping it at 7-8 hours recommended for good sleepers, sets the stage for bringing all kinds of wake-promoting activities into bed. As the likelihood of sleeping in bed gets smaller, going to sleep becomes similar to gambling. Once this “sleep gambling” behavior takes root, insomnia becomes chronic, and eliminating the source of initial sleep disturbance alone does not solve the problem any longer. That is why CBT-I offers a better choice of reducing the time in bed and taking waking activities out of bed. Making this choice will help you eliminate alertness, tension, and frustration from the bedtime and make the bed a good predictor of sleep again.
The choice of not gambling on sleep involves three equally important parts. The first part is scheduling consistent times to go to bed and to get up to start the day. For many patients, scheduling 6 hours in bed is a good start, but, depending on the person, the initial schedule may vary between 5 and 7 hours. Remember, staying in bed much longer than your average sleep or reclining during unscheduled times perpetuates the insomnia pattern.
The second part is taking all waking activities out of bed (except sex). The main goal here is to re-establish the bed as a place for sleeping, not for worrying and straining. To this end, select a relaxing routine that does not involve looking at a screen or using bright lights and repeat it consistently every night immediately prior to getting into bed. If sleep does not occur promptly, if you catch yourself worrying or straining in bed at any point during the night, it’s time to get out of bed and repeat your relaxing routine, no clock watching required. After you gather some drowsiness during the relaxing routine, bring that drowsiness back to bed and give sleep a chance. With consistent repetition and across multiple nights, relaxation will lead to drowsiness and drowsiness will lead to sleep in bed predictably at the scheduled time.
And third, as with any behavioral method, it is important to make a long-term commitment to establishing a good sleep pattern. Insomnia that has been present for a long time will take time to abate. Remember, forcing a rapid increase in the average amount of sleep is not likely to be successful, but consistency in your behavior will lead to consistency in your sleep. As sleep becomes more predictable, the amount of scheduled time in bed can be gradually increased, especially if you started with only 5-6 hours. But initially, “if you want to play fast, play slow.”
Morin, C. M. (2004). Cognitive-behavioral approaches to the treatment of insomnia. Journal of Clinical Psychiatry, 65, Suppl. 16, 33-40.
Anderson, K. N., (2018). Insomnia and cognitive behavioural therapy–how to assess your patient and why it should be a standard part of care. Journal of Thoracic Disease, 10 (Suppl 1), S94-S102. doi: 10.21037/jtd.2018.01.35.
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165, 125-33. doi: 10.7326/M15-2175.
Bootzin, R. R. (1972). Stimulus control treatment for insomnia. Proceedings of the American Psychological Association, 7, 395-396.