Can Morning Sunlight Bring Your Body Clock Forward?

The fourteenth variable that I will be manipulating across a two week period to examine its impact on sleep is light exposure. I will see if being obtaining at least 30 minutes of morning sunlight will have a substantial impact on my timing of sleep. 

I will discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. These three factors will be combined for an overall score and grade on how effective morning sunlight is at helping me get to sleep earlier.

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HOW COULD MORNING SUNLIGHT IMPROVE SLEEP?

If you look at my sleep in my temperature experiment, I was sleeping pretty well, but I was going to bed quite late, with an average time to bed of 12:05am. I said that 11:30pm-7:30am is probably my ideal time to be in bed, based on my internal body clock or circadian rhythm.

I’ve always been a bit of a night owl, and sleeping later is actually better for me than trying to force myself to go to bed too early. However, sometimes I have dreams of being able to get up and go to the gym before I go to work. I have, therefore, also studied different ways of how to effectively go to bed earlier and still sleep well.

The best way to do this, based on chronobiology research, is through the timing and duration of our light exposure. By getting even 30 minutes of morning sunlight shortly after awakening in the morning, this might really help me to start to feel sleepy earlier in the evening so that I can bring my bedtime forward without extending how long it takes me to fall asleep.

THE EXPERIMENT

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For the first six days, I tried to avoid getting sunlight as much as possible before noon and wore sunglasses whenever I did go outside in the morning.

For the next 8 days, I went on a cruise up and down the east coast of Australia. I tried to get outside as soon as possible after waking up and made sure that I got at least 30 minutes of sunlight exposure before noon.

Let’s see which strategy led to a better sleep…

THE OUTCOME

 

episode 14 sleep diary

Comparison: No Morning Light vs Morning Sunlight Exposure (at least 30 minutes)

Based on my sleep diary data, the findings were as follows:

  • The number of awakenings:
    1. No morning light – 0.66 per night
    2. Morning sunlight exposure – 1.88 per night
      • less is better
  • Time in bed:
    1. Morning sunlight exposure – 8 hours 29 minutes
    2. No morning light – 7 hours 18 minutes
      • 8 hours is ideal for me
  • Time to bed:
    1. No morning light – 11:29pm
    2. Morning sunlight exposure – 10:21pm
      • 11:30pm is ideal for me
  • Total sleep time:
    1. Morning sunlight exposure – 7 hours 47 minutes
    2. No morning light – 6 hours 50 minutes
      • 7 hours 30 minutes is ideal for me
  • Sleep onset latency:
    1. Morning sunlight exposure – 13.75 minutes
    2. No morning light – 20 minutes
      • quicker is better
  • Wake after sleep onset:
    1. No morning light – 7.5 minutes
    2. Morning sunlight exposure – 28.13 minutes
      • less is better
  • Rise time:
    1. Morning sunlight exposure – 6:50 am
    2. No morning light – 6:47 am
      • 7:30am is ideal for me
  • Sleep quality:
    1. No morning light – 4.5/5
    2. Morning sunlight exposure – 3.75/5
      • higher is better
  • Sleep efficiency:
    1. No morning light – 93.72%
    2. Morning sunlight exposure – 91.77%
      • higher is better

AND THE WINNER IS…

With a count of 5 points to 4 points, avoiding morning sunlight for me led to fewer awakenings during the night, less time awake during the night, and a better sleep quality and sleep efficiency. The poorer sleep on the second week could have had something to do with being on a cruise ship, however, rather than the morning sunlight.

What getting the morning sunlight exposure really did seem to help with was going to bed a lot earlier, as I went to bed at 10:21pm on average the second week, 68 minutes earlier than the second week. Even with this, I still managed to fall asleep 6 minutes faster than I did the first week!

 

IS SEEKING MORNING SUNLIGHT A GOOD SLEEP STRATEGY?

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IS IT EFFECTIVE?

Yes. Even though my sleep quality and sleep efficiency were worse, I put this down to trying to sleep on a cruise ship rather than the negative impacts of getting early morning sunlight. It seemed to help me feel energetic during the day, concentrate better, and fall asleep a lot earlier at night time.

I, therefore, give the effectiveness of this strategy a 17/25.

CAN IT BE APPLIED?

Yes. I often recommend for my clients to try and get 20 minutes of sunlight in the morning if they are wanting to fall asleep earlier.

It can be hard on weekdays, and harder in winter too, but most people can find some time, either whilst eating breakfast, walking the dogs or on their commute. It becomes a lot easier on the weekends and in the warmer months.

If it is too hard to find the time, blue-light glasses such as re-timer glasses can also be put on for 20 minutes as soon as people wake up for an easy to apply (but more expensive) alternative.

I, therefore, give the applicability of this strategy a 16/25. 

IS IT SCIENTIFIC?

Wright Jr. and colleagues (2013) have shown that reduced daytime sunlight and increased bright screen usage at night contributes to a delayed circadian rhythm and later sleep times.

Crowley and Eastman (2015) showed that a single 30-minute exposure to bright light in the morning was as effective as bringing an individuals body clock forward as getting one hour of bright light spread over a 3.25 hour period. It’s not quite as good as getting 2 hours of light exposure, but it can produce 75% of the advance and requires 90 minutes less time each day, which is much more practical for most people.

Stothard and colleagues (2017) have also found that a weekend camping can bring forward people’s circadian rhythm and sleep timing much more than a typical weekend for people living in a modern environment.

I, therefore, give the science of this strategy a 32/50.

Overall, morning sunlight as a way to sleep better gets a score of 17/25 + 16/25 + 32/50 =

65/100: Credit

 

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WHAT I RECOMMEND

Cruises are nice and relaxing and provide a lot of opportunity for getting some sun and not having to worry about anything, but they still didn’t lead to the best sleep for me.

If you are already sleeping at the right time for your internal body clock, then morning sunlight may not add too much of an additional benefit to you.

If you have a delayed circadian rhythm or find it difficult to get to sleep at the start of the night, getting 30 minutes of sunlight soon after you wake up in the morning could help you to wake up a bit quicker, feel more alert and energetic, and help you to get to sleep earlier and faster at night time.

Thanks for reading! If you or your partner suffers from sleep difficulties that impact your quality of life, you may be interested in coming along to our upcoming coastal sleep retreat in Victoria, Australia. Please click here for more information

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The Role of Temperature in​ Sleep

The thirteenth variable that I will be manipulating across a two week period to examine its impact on sleep is temperature. I will see if being too hot or too cold will have a substantial effect on sleep quality. 

Melbourne Just Sweated Through One Of Its Hottest Nights Ever Recorded

I will discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. These three factors will be combined for an overall score and grade on how effective modulating temperature is for improving sleep.

HOW COULD TEMPERATURE IMPAIR SLEEP QUALITY?

Living in Melbourne, Australia, there are usually a few nights every year which are unbearably hot. According to the Burea of Meteorology, 30.6 degrees Celsius is the hottest minimum temperature for a night ever in Melbourne, set in January 2017, with nights in the 27s and 28s occurring a few times in 2017 and 2018 too.

For people that are fortunate to live in places with excellent air conditioning, this may not be a problem. For many others, however, they can lead to a very long night, with frequent tossing and turning. I even remember when I was younger sometimes having a cold shower or jumping into a cold pool late at night with the hope of being able to then fall asleep once I went back to bed.

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The opposite can also be true, with the minimum temperature overnight reaching as low as minus 2.8 degrees Celsius in July. Not quite as cold as North America or Europe, but still cold enough to make it difficult to go to sleep and stay asleep during the night.

THE EXPERIMENT

For the first week, I slept with the window open with only a sheet and a light blanket covering me. As it was the middle of Winter (July 2017), there were some cold nights, with the 2nd of July getting down to 0.8 degrees Celsius, but the 5th of July only dropped to 10.1 degrees.

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For the second week, I closed the window and went to bed with 2 blankets, socks on my feet, a beanie and a big hoodie. The temperature minimum outside varied from 3.2 to 9.9 degrees Celsius, but it felt more like 30 degrees to me with how many layers I had on.

Let’s see if being too hot or too cold was worse for my sleep…

THE OUTCOME

sleep diary temperature

Comparison: Too Hot vs Too Cold

Based on my sleep diary data, the findings were as follows:

  • The number of awakenings:
    1. Too hot – 0.86 per night
    2. Too cold – 1.14 per night
      • less is better
  • Time in bed:
    1. Too cold – 7 hours 42 minutes
    2. Too hot – 7 hours 32 minutes
      • 8 hours is ideal for me
  • Time to bed:
    1. Too cold – 12:04 am
    2. Too hot – 12:07 am
      • 11:30pm is ideal for me
  • Total sleep time:
    1. Too cold – 7 hours 11 minutes
    2. Too hot – 7 hours 8 minutes
      • 7 hours 30 minutes is ideal for me
  • Sleep onset latency:
    1. Too hot – 12.14 minutes
    2. Too cold – 14.43 minutes
      • quicker is better
  • Wake after sleep onset:
    1. Too hot – 12.86 minutes
    2. Too cold – 14.29 minutes
      • less is better
  • Rise time:
    1. Too hot – 7:40 am
    2. Too cold – 7:41 am
      • 7:30am is ideal for me
  • Sleep quality:
    1. Too hot – 4.57/5
    2. Too cold – 4.29/5
      • higher is better
  • Sleep efficiency:
    1. Too hot – 94.48%
    2. Too cold – 93.29%
      • higher is better

AND THE WINNER IS…

With a count of 6 points to 3 points, being too hot is better for sleep than being too cold, with less time taken to fall asleep, fewer awakenings during the night, less time awake during the night, and better subjective sleep efficiency and sleep quality.

IS MODULATING TEMPERATURE A GOOD SLEEP STRATEGY?

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IS IT EFFECTIVE?

Maybe. If you look at the differences between the two on their outcomes, the differences are actually entirely negligible. I slept pretty well both when I was too cold and when I was too hot. Not knowing how temperature would affect my sleep, I tried to compare the two extremes. It is possible that if I was Goldilocks and slept at the exact right temperature that my sleep could have been even better, but I’m pretty happy with how it was on both weeks anyway. Chances are that temperature isn’t the most critical factor for a good night’s sleep.

I, therefore, give the effectiveness of this strategy a 12/25.

CAN IT BE APPLIED?

Yes. It is definitely possible to open windows and put on more layers for most people, especially in Australia. It would be harder for rough sleepers to get warm during the winter without a blanket or extra clothes. It would also be harder for people to cool down without airconditioning on a hot summer’s night.

I, therefore, give the applicability of this strategy a 15/25. 

IS IT SCIENTIFIC?

Haskell and colleagues (1981) assessed six male colleagues who slept in just shorts on top of a bed with at various temperatures ranging from 21 degrees Celsius to 37 degrees Celsius. The 21-degree condition was the most disruptive to sleep, with the colder temperatures generally being more disruptive to sleep than the warmer temperatures, based on the polysomnography findings (Haskell et al., 1981). Some individuals appeared to be much more sensitive to temperature than others, although again there could have been other factors impacting their sleep than just temperature.

Another more recent study by Lan and colleagues (2004) suggested four main findings from their research into the role of temperature on sleep:

  1. Sleep quality is sensitive to changes in air temperature for humans.
  2. Skin temperature increases or decreases concurrently with changes in air temperature during sleep.
  3. When temperatures moderately deviate from what feels comfortable to someone, they take longer to fall asleep, experience less deep sleep as recorded by EEG, and report poorer sleep quality the next morning.
  4. People should try to sleep at the room temperature that feels comfortable to them.

I, therefore, give the science of this strategy a 30/50.

Overall, modulating temperature as a way to sleep better gets a score of 12/25 + 15/25 + 30/50 =

57/100: Pass

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WHAT I RECOMMEND

 

If you worry that you are too hot or too cold when going to bed at night, try to find some cheap and easy strategies that get you to a point where you feel comfortable. While 18 – 24 degrees Celsius is sometimes recommended for people to get the best night’s sleep, try to focus on how you feel and not what the numbers say.

If you wake up shivering or sweating and you believe this is what woke you up, the temperature could be playing a role in reducing your quality of sleep. Outside of this and the few other extreme cases, there are probably many more strategies that you could if you want to improve the quality of your sleep.

I have heard people talk about the Chilipad, which helps you to heat up or cool down your side of the mattress to the temperature that you want it to be, but at over $1000 for a king mattress, I’d recommend spending your money elsewhere.

Thanks for reading! If you or your partner suffers from sleep difficulties that impact your quality of life, you may be interested in coming along to our upcoming coastal sleep retreat in Victoria, Australia. Please click here for more information

My 8 Easy Steps to Improved Sleep

My Sleep Research

Being part of an innovative sleep research team was what led me to do my Doctorate of Clinical Psychology at Monash University. Professor Shantha Rajaratnam is a world-leading expert in Chronobiology and has received major grants for his research. His results have been published in excellent journals, and I knew that I wanted to learn from his expertise.

Given the difficulties that I had faced with my sleep, I wanted to help people function as effectively as possible during their waking hours, and sleep as efficiently as possible at night. Shantha encouraged me to look at the relationship between insomnia and depression, and see how we could help individuals who were suffering from both conditions.

Up to 90% of individuals with Depression suffer from sleep difficulties, and 67% have significant enough problems with their sleep to warrant an additional diagnosis of Insomnia. Insomnia is considered a chronic problem after only one month and unfortunately doesn’t tend to go away on its own without treatment.

Interestingly, Insomnia usually precedes the onset of Depression, and can actually bring on Depression or trigger a relapse if it persists. Sleep difficulties, therefore, need to be directly treated for optimal Insomnia and Depression outcomes.

This is what our research found. By targeting sleep through four sessions of Cognitive Behavioural Therapy for Insomnia (CBT-I), we were able to significantly reduce both Insomnia and Depression severity across the treatment and by three-month follow-up in comparison to a control group. The control group were given the same information about how to improve their sleep but were unable to talk with a qualified therapist trained in CBT-I about their personal sleep difficulties. CBT-I participants were ten times more likely to be in remission from both their Insomnia and Depression by the follow-up, indicating a much lower risk of relapse.

Other research shows that CBT-I consistently reduces the time taken to get to sleep, decreases the amount of time spent awake during the night, and improves sleep quality and efficiency, with improvements persisting after treatment finishes. This is unlike sleeping pills, which typically lead to rebound Insomnia and ongoing sleep difficulties once they are discontinued.

CBT-I is similar in effectiveness to sleeping pills for Insomnia in the short-term and much more useful than sleeping pills in the long-term. It is, therefore, concerning to see that nearly 90% of individuals who go to GPs with Insomnia complaints are given sleeping pills over a referral for CBT-I. Sleeping pills (typically Benzodiazepines such as Temaze or Valium) are not recommended for use beyond 2-4 weeks at a time, and recent research even links long-term Benzodiazepine use with a higher risk of premature cognitive decline.

Hopefully, the awareness of CBT-I as an effective alternative to sleeping pills will continue to increase, but please pass the message on to whoever you know that may be suffering from Insomnia. Even one session of CBT-I was recently shown to significantly improve Insomnia that had been occurring for less than one month. The more people ask for CBT-I referrals, the more doctors will become aware of this effective treatment and/or feel more comfortable in referring patients for this treatment, and the less our society will be impacted by Insomnia, Depression, and dependence on sleeping pills.

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What I Did to Improve My Sleep

By learning what I did through my research and CBT-I treatment, I began to make the following changes to my routine. These steps slowly started to make a huge difference in my sleep, fatigue, alertness and concentration:

#1: I reduced the variability in my sleep from day to day.

I now sleep consistently between 11:30pm and 6:30am, give or take an hour on each side (sleep onset usually between 11-12 and rise time between 6-7am), even on weekends. There are some rare exceptions when I stay up later, but I always make sure that I get out of bed no later than 8:30am, so that I don’t push back my circadian rhythm further. I also never spend more than 8 hours and 30 minutes in bed, and usually, find that 7.5 hours in bed is more than adequate to feel energised and refreshed during the day.

#2: I cut down on caffeine, especially in the afternoons.

Anything under 300mg daily is fine for me, and usually doesn’t noticeably impact my sleep at night. However, it is still much better for me to eat healthily, drink plenty of water, take regular breaks, and get outside and exercise if possible when I am feeling tired. By drinking caffeinated beverages or eating high sugar or high-fat foods and pushing through my fatigue, I was elevating my arousal levels during the day and making it more difficult for me to switch off and sleep well at night.

#3: I stayed away from bright screens in the last two hours before bed, and stopped doing work if I had any at this time too.

By doing this, I helped my brain identify that it was night-time, and my melatonin production began earlier and helped me feel sleepy and transition to sleep more effectively. Looking at bright screens before bed can suppress melatonin release by as much as 22%, and lead to later sleep onset, reduced sleep duration and poorer sleep quality.

#4: I tried to seek sunlight exposure when possible in the mornings.

This helped my brain identify that it was daytime and helped increase my energy levels and alertness, which meant that I could concentrate better during the day. For individuals with DSPD, timing is everything, so it is essential to discuss with a Sleep Physician the exact times that light exposure should take place for optimal alertness and phase-shifting benefits.

#5: I exercised regularly during the day, but not in the three hours before bed when possible.

By doing this, it increased my energy levels and alertness during the day, lifted my mood, reduced my stress and anxiety levels, and improved my sleep pressure for that night. I then felt more tired and ready for bed at around 11:30pm when I wanted to go to sleep.

#6: I made sure that I did things to wind down and relax before bed each night.

This typically took place in the last two hours before bed. Activities varied between chatting with friends or family that I felt calm around, reading a book, engaging in a creative task, listening to a podcast or music, having a hot bath (but not right before bed), or practising relaxation exercises or mindfulness meditation. It is essential to do anything that can reduce arousal levels before bed and can help bring on feelings of sleepiness earlier. As soon as I experienced these signs of sleepiness (eyes or body feeling heavy, losing focus, yawning), I went to bed, assuming that it was around 11:30pm.

#7: Once in bed, I didn’t force myself to sleep.

I allowed it to occur on its own and tended to focus on positive experiences that went well for me during the day or things that I was grateful for instead. I sometimes practised imagery and imagined myself lying on a beach or hiking in the mountains. If that didn’t work, I returned to mindfulness meditation or relaxation exercises and focused on keeping my breath slow and deep and exhaling all of the air with each breath. Before I knew it, I was usually asleep. I sometimes woke up occasionally during the night but had minimal difficulty in returning to sleep if I did.

#8: I ignored sleep inertia.

One of the biggest traps for individuals with DSPD is judging how they’ve slept or if they need more sleep immediately upon awakening. Given that I was typically waking up before my body clock wanted me to, I almost always felt tired immediately upon awakening in the morning and would have no difficulty hitting the snooze button or resetting my alarm for later and returning to sleep. I used to do this a lot before I knew about sleep inertia, and even after two more hours of sleep I would still feel the same way upon awakening. Now I get up no matter how I feel when the alarm goes off, shower and have breakfast or go to the gym, and then review how I’m feeling. By delaying my judgment, it becomes a much more significant indication of how well I’ve actually slept and how I’m likely to function for the remainder of the day. I typically feel energetic and less fatigued during the day and am able to pay attention to whatever it is that is most important to me in each moment. Even without the extra sleep.

I hope that you find some of my personal strategies helpful. If you are struggling with sleep difficulties, change one thing at a time where possible, try it for a week or two, see if it makes a difference to your sleep or how you feel during the day. If it helps, keep it up, and then introduce another change if needed.

Once your sleep is better, it is vital to introduce some flexibility so that you don’t become too preoccupied with needing all of the right conditions to be able to sleep. Good sleepers will tell you that they do nothing to sleep well and could sleep almost anywhere under any circumstances if needed, so it is essential to try to relax where possible and not over think it.

If you have tried many things, but your sleep isn’t getting any better, please seek a referral to a Sleep Physician or a Psychologist who is trained in CBT-I. They will be able to help you understand your sleep difficulty more, let you know if there is any possible underlying condition that may be making your sleep difficulties worse, and give you individualised instructions based on validated research. By putting into practice the strategies that have been shown to be the most effective treatments for the sleep condition(s) that you have, you are giving yourself the best opportunity to become a good sleeper (again, or for the first time). It has worked for me and thousands of others, and it can work for you too!

Thanks for reading! If you or your partner suffers from sleep difficulties that impact your quality of life, you may be interested in coming along to our upcoming coastal sleep retreat in Victoria, Australia. Please click here for more information

 

Dr Damon Ashworth

Clinical Psychologist

Insomnia and Depression: We Need to Start Targeting the Sleep Problems

What is Insomnia?

Insomnia can be defined as the subjective difficulty in the initiation or maintenance of sleep, or non-restorative sleep, resulting in significant impairment in daytime functioning (American Psychiatric Association, 2013).  Common daytime symptoms of Insomnia include low energy, fatigue, impaired concentration and memory difficulties (Edinger et al., 2004).

How common is Insomnia?

Acute or short-term Insomnia is prevalent, with up to 20% of the general population experiencing sleep difficulties on any one night (Staner, 2010). However, once these symptoms have persisted for at least one month, Insomnia becomes classified as chronic, and the prevalence rates drop to about 6% (Staner, 2010).

What impact does it have?
  • Chronic Insomnia is a debilitating and costly condition, with direct health care costs of Insomnia estimated to be $118.7 million in 2010 in Australia (Economics, 2011).
  • Indirect factors are an even more massive burden for society, with reduced employment levels, lower productivity, higher absenteeism, and a higher risk of a motor vehicle or workplace accident as a result of Insomnia accounting for $1.5 billion of costs to Australia in 2010 (Economics, 2011). This higher cost of indirect factors means that Insomnia is under-treated in Australia.
  • Insomnia has been shown to be significantly related to a higher risk of both workplace and non-workplace accidents (Kessler et al., 2012). The average annual costs to government (direct and indirect) found to be 11.9 times higher for individuals with Insomnia than for good sleepers (Daley, Morin, LeBlanc, Gregoire, & Savard, 2009)
  • If Chronic Insomnia is not treated adequately, it results in a higher risk of mental health problems, with up to 61% meeting criteria for another psychiatric disorder (Stepanski & Rybarczyk, 2006).

What’s the relationship between Insomnia and Depression?

Insomnia and Depression are highly correlated with each other, with up to 90% of individuals with Major Depressive Disorder (MDD) having sleep quality complaints, and 67% having severe enough sleep disturbances and daytime impairments to meet an additional diagnosis of Insomnia (Franzen & Buysse, 2008). This equates to a 61% higher prevalence rate of Insomnia in MDD than in the general population.

Insomnia is also thought to share other common features with Depression, including low energy, fatigue, decreased motivation, indecisiveness and impaired concentration (Spielman & Anderson, 1999). Consequently, there appears to be a healthy relationship between low satisfaction with sleep and poor overall mood (Staner, 2010). However, these sleep disturbances are rarely a focus of intervention in the treatment of Depression.

The definition of an MDD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has Insomnia listed as a symptom of Depression (American Psychiatric Association, 2013). Because of this definition, mental health clinicians have tended to overlook the course of Insomnia, view it as a secondary condition to Depression, and therefore not worthy of clinical attention (Stepanski & Rybarczyk, 2006). However, for the Insomnia to be genuinely secondary to Depression, it must have begun with the onset of the depressive episode, and remit once the MDD does. As soon as the course of Insomnia differs to that of an individual’s Depression, a co-morbidity of MDD and Insomnia is present, and an additional diagnosis of Insomnia should be given (American Psychiatric Association, 2013).

young man in bed with eyes opened suffering insomnia and sleep disorder thinking about his problem

What comes first: the poor sleep, or the low mood?

  • Insomnia has an earlier average age of onset in comparison to Depression.
  • Between 40-69% of individuals with Depression reported that their Insomnia appeared before any other depressive symptoms (Franzen & Buysse, 2008; Johnson, Roth, & Breslau, 2006).
  • Eight epidemiological studies have identified that Insomnia at baseline significantly increased the risk of developing MDD by follow-up 1-3 years later (Riemann & Voderholzer, 2003).
  • If an Insomnia episode remained for longer than 2 weeks, there was nearly a 50% chance of developing MDD at a later date (Buysse et al., 2008).
  • While prior Insomnia was found to be significantly associated with the onset of MDD, Depression was not significantly associated with the later start of Insomnia (Johnson et al., 2006).

Even if Insomnia was initially secondary to Depression, once it remains for one month it is likely to have developed into a separate and chronic problem. This is due to the poor sleeping practices, daytime habits, and unhelpful beliefs about sleep that people evolve over time in an attempt to overcome their Insomnia. These perpetuating factors may include excessive time in bed awake, high caffeine during the day or alcohol usage at night, napping during the day, extreme focus on and worry about sleep, and conditioned hyper-arousal at night (Yang et al., 2006). Unless these perpetuating factors are targeted explicitly through treatment for Insomnia, it is unlikely that sleep complaints will improve (Carney, Harris, Freedman & Segal, 2011).

Untreated Insomnia increases both the severity and duration of Depression (Staner, 2010). Furthermore, if Insomnia remains after Depression has remitted, the chance of an MDD relapse is much higher. Research indicates that 40% of individuals with Depression will relapse within a ten month period (Paykel, 2008). Of all the 21-items on the Beck Depression Inventory, sleep difficulties were the only symptom that significantly predicted a depressive relapse over the 4-week period following remission (Perlis, Giles, Buysse, Tu, & Kupfer, 1997). Chronic insomnia must, therefore, be targeted alongside MDD when the conditions co-exist for optimal treatment outcomes.

How do we treat Insomnia and Depression together?

When Depression and Chronic Insomnia occur together and vary in their course, it is important to target them both in an active treatment intervention. Medical practitioners appear to administer antidepressants and hypnotics over psychological treatments because they are more easily accessible, quick to administer and offer lower initial and short-term costs (Economics, 2011). They are also more likely to favour pharmacological over non-pharmacological interventions due to the traditional biomedical model of training in these facilities, which minimises the psychological and social factors involved in mental health disorders (Frostholm et al., 2005). Consequently, antidepressants are the most common treatment for Depression (McManus, Mant, Mitchell, Britt, & Dudley, 2003), and hypnotics are the most common treatment for Insomnia (Charles et al., 2009).

Hypnotics have been found to improve sleep in individuals with Depression alongside antidepressant treatment (Asnis et al., 1999). Another extensive study recruited 545 patients with a diagnosis of both Insomnia and Depression and found significant improvements in sleep efficiency, sleep quality, and total sleep time after both four and eight weeks in a combined antidepressant and hypnotic treatment when compared to an antidepressant plus placebo treatment (Fava et al., 2006). Importantly, Depression improvements were also significantly higher at both week 4 and week 8 (p < .01). Therefore, when co-morbidities exist, explicitly treating both Insomnia and Depression can result in higher amelioration of both conditions.

Sleeping pills vs Cognitive Behavioural Therapy for Insomnia (CBT-I)

Several clinical trials have compared the efficacy of hypnotics to non-pharmacological treatments for Insomnia, and have found similar short-term benefits (Riemann & Perlis, 2009). A meta-analysis comparing the two types of procedures across 21 studies found that that cognitive and behavioural therapies for Insomnia had similar efficacy over 4 weeks to hypnotics, with an average effect size of 0.79 vs. 0.80 (Smith et al., 2002). However, the non-pharmacological treatments produced significantly higher reductions in the time taken to fall asleep at the beginning of the night, known as sleep onset latency (SOL) (Smith et al., 2002).

CBT-I may be preferable over hypnotics for the treatment of Chronic Insomnia due to its low risk of adverse effects (Smith et al., 2002). It also has more considerable empirical evidence of long-term sleep benefits, with research showing therapeutic gains maintained or further improved at 1-month, 3- month, 6-month, 1-year, and 2-year follow-up assessments (Morin et al., 2006; Riemann & Perlis, 2009). In contrast, sleep improvements made through hypnotics are rarely retained through long-term treatment (Riemann & Perlis, 2009) and often return to baseline levels of sleep disturbance following the cessation of hypnotic use (Jacobs et al., 2004). Although CBT-I may be seen as an initially expensive treatment, it becomes more cost-effective than GP visits and hypnotic treatment over time due to its more significant long-term benefits for Chronic Insomnia (Harsora & Kessmann, 2009). As a result, CBT-I should be more widely used than sleeping pills in the treatment of Chronic Insomnia.

An individual’s belief that they are able to do a task well is known as self-efficacy (Maciejewski, Prigerson, & Mazure, 2000). Increased self-efficacy towards sleep is more likely to occur when an individual with Chronic Insomnia attributes their sleeping improvements to their own behaviour rather than sleeping medication (Harvey, Tang, & Browning, 2005). Because self-efficacy is thought to play a mediating role between stressful life events and Depression severity (Maciejewski et al., 2000), treating Insomnia with CBT-I is likely to have additional positive effects on mood in comparison to hypnotic treatment. This lends further support to the view that CBT-I needs be implemented in the treatment of co-morbid Insomnia and Depression.

What is CBT-I?

Cognitive behavioural therapy for insomnia (CBT- I) is a multi-modal treatment that combines several individual strategies that have been previously developed and utilised in the non-pharmacological treatment of Insomnia (Edinger & Means, 2005). Many of these unique techniques have been shown to be efficacious as stand-alone treatments. This includes stimulus control (Morin & Azrin, 1987), sleep restriction (Friedman, Bliwise, Yesavage, & Salom, 1991), paradoxical intention (Turner & Ascher, 1979), and progressive muscle relaxation (PMR) (Pendleton & Tasto, 1976).

The four main components of CBT-I include:

  1. Psychoeducation about sleep and sleep hygiene recommendations, which helps people to develop more realistic expectations of their sleep and become more aware of factors that can have a negative impact on their sleep.
  2. Sleep Scheduling, which involves stimulus control (helps people to recondition the bed with calmness, sleepiness and sleep instead of spending excessive time awake in bed alert, worried or frustrated) and sleep restriction (helps people to only spend the amount of time in bed that they need for sleep) interventions.
  3. Cognitive therapy, which challenges some of the unhelpful thinking patterns and beliefs about sleep that typically develops in insomnia, such as “I need 8 hours of sleep to function well during the day!”, “I must catch up on lost sleep”, or “If I don’t sleep well tonight, I’ll be ruined for the rest of the week!” These beliefs only increase the anxiety and pressure around sleeping, which makes the Insomnia severity worse over time.
  4. Relaxation techniques, which helps people to lower their stress and arousal levels during the day and before sleep so will find it easier to get to sleep and stay asleep.

Does CBT-I work?

The research findings on the efficacy of CBT-I in Primary Insomnia participants suggests superior efficacy for CBT-I over wait-list and placebo controls, as well as PMR, sleep hygiene education and pharmacological interventions. The meta-analysis found that multi-modal CBT-I produced large effect sizes in both SOL (1.05) and WASO (0.92), and moderate effect size (0.75) for TST (Morin, Culbert, et al., 1994).

The cumulative findings of the research on CBT-I suggest that it enhances sleep-related self-efficacy, corrects dysfunctional beliefs about sleep, reduces the use of sleep medications, improves mood and reduces anxiety symptoms, and leads to long-term functional improvements in both daytime and night-time functioning (Morin et al., 2006). Given such findings, CBT-I can be considered both highly efficacious and effective treatment for sleep difficulties and related complaints in individuals with Chronic Insomnia. CBT-I is classified as a well-established empirically supported treatment according to the criteria set forth by the American Academy of Sleep Medicine (Morin et al., 2006).

Once CBT-I’s efficacy was established, varied lengths of treatment, as well as forms of administration, were assessed. CBT-I remains efficacious even when protocols vary in length from 4-weeks (Edinger et al., 1992) to 8-weeks (Morin et al., 1993). When it is administered individually (Edinger et al., 2001) or in a group setting (Morin et al., 1999). And potentially even when it is self-administered (Rybarczyk, Mack, Harris & Stepanski, 2011), administered with telephone consultation (Mimeault & Morin, 1999), or delivered via the Internet (Strom, Pettersson, & Andersson, 2004).

The Effectiveness of CBT-I for co-morbid Insomnia and Depression

At the time of my Doctoral research, eight studies had investigated the non-pharmacological treatment of Insomnia symptoms in individuals with co-morbid Depression:

The first study administered a six-week self-help sleep program to 57 individuals with Insomnia and Depression (Morawetz, 2003). At post-treatment, the majority of individuals who substantially improved their sleep had also significantly reduced their Depression severity, with 57% reaching depressive remission based on the Beck Depression Inventory scores, and a further 13% achieving at least a 40% reduction in their ratings. Interestingly, all individuals who failed to make substantial improvements in their sleep also failed to substantially reduce their depression severity (Morawetz, 2003).

The second study assessed six weekly sessions of CBT-I treatment in eight participants with Chronic Insomnia and mild Depression (Taylor, Lichstein, Weinstock, Sanford, & Temple, 2007). They found significant improvements across several sleep measures, which remained significant by the follow-up assessment three months later. Importantly, Depression severity also significantly reduced from pre-treatment to follow-up in all but one participant (Taylor et al., 2007).

A randomised controlled trial (RCT) was then conducted for 30 participants with co-morbid Insomnia and Depression, who were assigned to an SSRI and CBT-I treatment condition or an SSRI and quasi-desensitisation therapy (control) condition for 12 weeks (Manber et al., 2008). The combined treatment group had a 42.3% greater remission rate from Insomnia. A higher remission rate was also found for Depression with CBT-I (61.5%) in comparison to the control therapy (33.3%), but this finding did not reach statistical significance, possibly due to the concurrent commencement of antidepressant treatment in both treatment groups (Manber et al., 2008).

The next RCT recruited 37 individuals with ongoing Insomnia and Depression symptoms following adequate antidepressant treatment and compared treatment-as-usual plus four weekly sessions of CBT-I to a treatment-as-usual control group (Watanabe et al., 2011). At the eight-week assessment, sleep efficiency, Insomnia severity and Depression severity were all significantly better in the CBT-I group. 50% reached remission from their Insomnia compared to 0% of the control group, and 50% achieved remission from their Depression compared to 6% of the control group (Watanabe et al., 2011).

The remaining studies produced promising findings, with CBT-I significantly reducing Insomnia and Depression severity across treatment (Wagley et al., 2012). It also improved sleep and reduced anxiety (Lancee, van den Bout, van Straten, & Spoormaker, 2013; Maroti, Folkeson, Jansson-Frojmark, & Linton, 2011), lessened suicidal ideation, improved energy, self-esteem, productivity, and well-being (Manber et al., 2011).

Why CBT-I for Co-Morbid Insomnia and Depression?

The rationale for CBT-I treatment in individuals with co-morbid Insomnia and Depression is that the Insomnia is thought to be maintaining a level of Depression through poor satisfaction with sleep and impaired daytime functioning (Franzen & Buysse, 2008; Staner, 2010). Initial antidepressant treatment may improve mood substantially, but its inability to directly address the perpetuating factors of Chronic Insomnia means that gains will often stagnate above the remission threshold in co-morbid cases. By directly targeting the Insomnia with CBT-I at this point, Insomnia is likely to improve, which should subsequently result in additional reductions in Depression severity. As long as a control group is used for comparison, it would then be possible to determine how much of the improvements in Depression could be attributed to the CBT-I intervention.

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My Research (Ashworth et al., 2015)

  • The RCT that I conducted as part of my Doctoral Thesis examined this very rationale and found that both Depression and Insomnia severity were significantly reduced over four sessions of CBT-I treatment in comparison to a sleep education intervention.
  • These significant differences were maintained at the 3-month follow-up and resulted in a ten-times higher long-term remission rate from both conditions through CBT-I.
  • Reductions in stress and improved sleep hygiene behaviours seemed to be required for CBT-I to produce short-term improvements in Depression severity, whereas cognitive changes seemed to be needed for short and long-term Insomnia improvements, as well as longer-term enhancements in Depression.
  • Relaxation and behavioural interventions need to be prioritised initially in CBT-I treatment for co-morbid Insomnia and Depression, followed by cognitive interventions for optimal longer-term outcomes.

The cumulative research findings indicate that CBT-I, both on its own, and in addition to antidepressants, is a promising treatment for co-morbid Insomnia and Depression. By optimising the CBT-I intervention for this population and administering it at the right time, significant improvements in sleep and mood are likely to occur, resulting a higher remission rate from both Chronic Insomnia and MDD, and lower risk of relapse into the future, reducing the overall burden of these conditions on society.

Thanks for reading! If you or your partner suffers from sleep difficulties that impact your quality of life, you may be interested in coming along to our upcoming coastal sleep retreat in Victoria, Australia. Please click here for more information

Dr Damon Ashworth

Clinical Psychologist

The Four Key Components of Cognitive Behavioural Therapy for Insomnia

Cognitive behavioural therapy for insomnia (CBT-I) is an efficacious treatment for primary insomnia, resulting in enduring and long-term sleep benefits. It is considered to be an effective treatment for insomnia that is co-morbid with substance abuse, medical and/or psychiatric conditions. Because of the overlap between insomnia, physical health, and psychological health, improving the sleeping quality through CBT-I in these individuals also often results in subsequent improvements in the co-morbid conditions.

CBT-I for individuals with insomnia and depression

Depression is a psychiatric condition that improves through CBT-I. However, the effect sizes of CBT-I are often smaller than those reported through CBT for other mental health disorders (Harvey & Tang, 2003). Furthermore, only 50% of the participants in one of the more successful CBT-I studies for co-morbid insomnia and depression remitted from insomnia (Manber et al., 2008). If insomnia does not remit, then depression is likely to relapse (Perlis et al., 1997), persist or worsen in severity over time (Staner, 2010). It is therefore essential to optimise the four CBT-I components for this population.

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Component One of CBT-I: Psychoeducation

The psychoeducation component of CBT-I consists of general sleep education and sleep hygiene recommendations. This should be introduced in CBT-I before the administration of any behavioural prescriptions or the undertaking of any cognitive restructuring and is typically presented to the client and discussed during the first session. Essential components of general sleep education include information around why people sleep, the stages of sleep, and differences in sleep requirements (Kripke et al., 2002). It also contains what ‘normal’ sleep looks like, what happens to sleep with age and sleep inertia (Jewett et al., 1999). The two process theory of sleep regulation that incorporates circadian rhythms and homeostatic pressure (Borbély, 2000), and a model of insomnia and how it progresses over time (Ebben & Spielman, 2009) are helpful models to include. Sleep hygiene recommendations are also introduced to highlight the factors that may be exacerbating an individual’s insomnia severity and contributing to their poor subjective sleep (Perlis & Youngstedt, 2000).

Although the psychoeducation component of CBT-I is not an empirically supported individual intervention for insomnia (Morin, Culbert, et al., 1994), it is still a crucial component of the multimodal treatment and serves several purposes. Psychoeducation not only provides essential information that can help individuals sleep better, but also gently challenges some of the unhelpful thoughts, beliefs and attitudes that participants may have about sleep with real evidence from scientific research. Elevated dysfunctional beliefs and attitudes about sleep, as measured by the DBAS-16 scale, are significantly correlated with high insomnia, depression, and anxiety severity, but not with sleeping measures (Morin, Vallieres, & Ivers, 2007). Thus, psychoeducation can reduce insomnia and depression severity through lowering the intensity of participant’s firmly held beliefs about sleep, even if it does not directly improve sleep.

Psychoeducation can also be important for developing therapeutic alliance (Krupnick et al., 1996), as discussing essential factors of sleep allows CBT-I treatment to begin in a non-threatening manner. Many of the individual interventions are directive, with little room for discussion, but psychoeducation provides for the development of rapport with the participant through discussion of their sleep difficulties and beliefs as the information is being presented. A strong therapeutic alliance can then increase adherence to later behavioural instructions, result in more openness to cognitive restructuring, and improve overall outcomes for the participant (Trockel, Karlin, Taylor & Manber, 2013). Thus, beginning broadly with psychoeducation is likely to result in a better understanding of how to improve sleep, a reduction in unhelpful beliefs about sleep, and a better therapeutic alliance that can increase the clinical outcome for the other interventions in CBT-I.

1A. Sleep hygiene recommendations

Sleep hygiene recommendations were developed to educate individuals with insomnia about the possible factors that promote and inhibit optimal sleep (Hauri, 1977). By following these recommendations, it was proposed that one’s sleeping practices would no longer be perpetuating their insomnia (Mastin, Bryson, & Corwyn, 2006). However, there is no standard prescription for what optimal sleep hygiene consists of, and no weighting of what factors are most important. Even the developer of sleep hygiene has changed his recommendations over time (Hauri, 1993).

Stepanski and Wyatt (2003) reviewed seven studies that attempted to define sleep hygiene and found 19 different rules. Worse still, there was only one rule that was agreed upon unanimously, and that was to not consume caffeine before going to bed. Six of the studies recommended daily exercise, but not too close to bedtime. Six studies also recommended avoiding alcohol in the evening. Beyond these three items, most of the sleep hygiene rules were only supported by two or three studies (Stepanski & Wyatt, 2003). The lack of a standard definition of sleep hygiene means that it is tough to determine its efficacy, and may explain why it is not a supported intervention for treating insomnia (Morin et al., 2006).

Improving sleep hygiene knowledge has little impact on improving sleep quality, however improving sleep practices in line with sleep hygiene recommendations does (Brown, Buboltz, & Soper, 2002). This means that informing clients about sleep hygiene may not result in behavioural change, but when this does take place, it can have a substantial effect on their sleep and health (Brown et al., 2002).

The aim for sleep hygiene in CBT-I is, therefore, to determine which aspects are most likely perpetuating insomnia and depression in each client, and customise the treatment to the individual. By doing this, clients only have to focus on the issues that are of most concern to them and not waste their time worrying about recommendations that are already followed reasonably well (Hauri, 1993). Administering a questionnaire such as the Sleep Hygiene Index (Mastin et al., 2006) at baseline would also help the therapist target appropriate sleep hygiene factors for each participant during the psychoeducation phase of treatment.

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Component Two of CBT-I: Sleep Scheduling

Both stimulus control and sleep restriction therapies can be combined under the term sleep scheduling. Taken together, sleep scheduling aims to eliminate the behaviours in insomnia that commonly disrupt sleep. By breaking conditioned responses, increasing homeostatic pressure for sleep and re-entraining the natural circadian rhythms, sleep scheduling results in both higher sleep quality and sleep efficiency (SE) over time, which increases the perception of a restorative night’s sleep (Ebben & Spielman, 2009; Vitiello, 2007). Sleep scheduling is usually administered after the psychoeducation component and before any formal cognitive therapy in CBT-I treatment.

2A. Stimulus control

Stimulus control therapy was initially conceived in the early 1970s as a direct application of instrumental conditioning principles to break the conditioned response of the bed, bedroom and bedtime in patients with insomnia (Bootzin, 1972). Any stimulus is thought to be able to produce several reactions in people, depending on their conditioning history with the stimulus. Individuals with insomnia are so used to being awake and frustrated in bed that over time the bed becomes conditioned with being aroused, annoyed and alert rather than with feeling tired and sleeping (Ebben & Spielman, 2009).

The stimulus control instructions aim to limit the time in bed awake so that the bed becomes reconditioned with the feeling of sleepiness and the behaviour of well-consolidated sleep. These include only going to bed when tired, waking up at the same time every day, just using the bed/bedroom for sleep and sex, avoiding naps during the day, and getting up if unable to fall asleep within 20 minutes of retiring to bed, (Lieberman & Neubauer, 2007).

Stimulus control is thought to help individuals with insomnia and depression in some ways. Firstly, by removing all other conditioned responses except for sleep, the bed soon becomes reassociated with falling asleep quickly. This reduces the time spent in bed ruminating, and over time positive associations can develop, where the individual becomes tired and sleepy whenever they retire to bed (Ebben & Spielman, 2009). Secondly, waking up at the same time each day allows for entrainment of the circadian rhythms, which then promotes sleepiness for the participant at a similar time each night. By not changing the waking time, regardless of when the individual goes to sleep or how many times they get out of bed during the night, this also mildly deprives them of sleep, and combining this with no naps during the day strengthens the homeostatic drive for sleep. This then allows the participant to fall asleep quicker when they finally do go to bed at night (Ebben & Spielman, 2009). All of these factors combine to improve sleep self-efficacy, sleep efficiency and sleep quality, which helps participants’ feel less concerned, more refreshed and more in control of their sleep.

Stimulus control as a stand-alone therapy is a supported behavioural treatment for chronic insomnia, according to the AASM (Morin et al., 2006). It has reliable and robust effect sizes in the available research in the field (Lacks, Bertelson, Gans, & Kunkel, 1983; Riedel et al., 1998; Turner & Ascher, 1979). The main difficulty with stimulus control is adherence to the instructions (Riedel & Lichstein, 2001). The guidelines appear somewhat counter-intuitive, and individuals with insomnia and depression have many preconceived notions as to what the cause of their insomnia is that does not involve instrumental conditioning (Bootzin, 1972). It is therefore essential to explain the rationale in substantial detail for participants to actually get out of bed after 20 minutes and to wake up at the same time each day. If the guidelines are not followed, their bed will not become reconditioned with sleep, their circadian rhythms will not be re-entrained, and their sleep will be unlikely to improve (Harvey, 2002). It is therefore vital to introduce cognitive techniques after stimulus control in CBT-I, so that any dysfunctional beliefs or safety behaviours that may limit willingness to adhere to stimulus control instructions are explored, understood and overcome.

2B. Sleep restriction

Sleep restriction, or bed restriction as it is sometimes known, was initially conceived in the mid-1980’s to take advantage of the positive benefits of sleep deprivation on various sleep measures (Spielman et al., 1987). It is a useful technique for the treatment of insomnia (Morin et al., 2006) that involves limiting the time in bed to an individual’s average subjective daily amount of sleep (Spielman et al., 1987). By only spending enough time in bed for sleep, sleep restriction temporarily induces sleep deprivation, which increases the homeostatic drive for sleep, decreases sleep fragmentation and consequently improves SE (Vitiello, 2007). However, it is important to prescribe the sleep at a constant time that is in line with an individual’s circadian rhythms and lifestyle (Ebben & Spielman, 2009).

Sleep restriction is similar to relaxation in reducing sleep onset latency (SOL) and wake after sleep onset (WASO) across CBT-I treatment, and more effective in maintaining these improvements by follow-up 3-months later (Friedman et al., 1991). After 12 months follow-up in another study, WASO had gotten worse since post-treatment with relaxation but continued to improve with sleep restriction (Lichstein et al., 2001). Therefore, one benefit for sleep restriction appears to be its enduring long-term insomnia improvements, which is essential in reducing the risk of depressive relapse (Perlis et al., 1997).

The downside of sleep restriction is that it temporarily increases daytime somnolence and reduces vigilance in the initial phases of treatment (Kyle et al., 2014) so adherence to this treatment may be difficult to obtain from individuals who are already concerned about daytime consequences of insomnia (Riedel & Lichstein, 2001). If there is excessive daytime sleepiness, caution should also be given regarding driving or operating machinery, and some time off work may be required. However, this increase in sleepiness prevents individuals with insomnia and depression from lying in bed ruminating or worrying, and it has been shown to significantly improve sleep initiation and increase overall sleep quality (Lieberman & Neubauer, 2007).

At 12 months follow-up, both stimulus control and sleep restriction adherence were the most significant predictors of ongoing improvements in SOL and WASO (Harvey, 2002). Consequently, as long as the long-term benefits of sleep scheduling are made salient and adherence issues are addressed in therapy, both stimulus control and sleep restriction can produce dramatic and robust improvements in insomnia symptoms.

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Component Three of CBT-I: Relaxation

Relaxation reduces excessive physical tension and calms pre-sleep cognitive activity, fostering a more positive outlook and reducing overall concerns about sleep disturbances (Harsora & Kessmann, 2009). Relaxation techniques are therefore carried out across the entire CBT- I intervention with the objective of reducing physiological and cognitive arousal so that an individual can transition to sleep quicker and have a deeper, more restorative sleep (Edinger & Means, 2005).

Relaxation techniques sometimes included in CBT-I include:

  • imagery training (Morin & Azrin, 1987),
  • meditation (Woolfolk et al., 1976),
  • thought-stopping (Levey et al., 1991)
  • biofeedback training (Freedman & Papsdorf, 1976),
  • diaphragmatic breathing (Smith & Neubauer, 2003),
  • autogenic training (Simeit et al., 2004) and
  • progressive muscle relaxation (Bernstein et al., 2000).

3A. Progressive Muscle Relaxation

Progressive Muscle Relaxation (PMR) is the most commonly used relaxation technique in CBT-I and is efficacious as a stand-alone treatment for insomnia (Morin et al., 2006). PMR involves tensing and releasing different groups of muscles throughout the body to reduce physiological arousal. It may have some additional cognitive benefits through focusing on and paying attention to particular areas of the body, but it is not as cognitively based as autogenic training, imagery training, thought stopping, or meditation.

In comparison to autogenic training and biofeedback training, PMR was not significantly different (Freedman & Papsdorf, 1976; Simeit et al., 2004). However, cognitive relaxation techniques were found to be more effective for reducing SOL (Morin, Culbert, et al., 1994). Consequently, cognitive relaxation techniques should be incorporated into CBT-I protocols more frequently.

Rather than administering only one relaxation technique in CBT-I for insomnia and depression, it may be more beneficial to briefly introduce several methods (both cognitive and somatic focused) and let the individual determine which techniques are the most effective in reducing their arousal levels and allowing them to feel relaxed both during the day and at night. Mindfulness meditation has been increasing in popularity immensely lately and has also been proving to be helpful in reducing arousal in more recent studies by Ong, Shapiro and Manber (2008).

In one study that treated individuals with insomnia with relaxation techniques, SE was found to increase from 67.0% to 78.8% over 6 weeks of treatment (Lichstein et al., 1999). Both anxiety and depression scores were also reduced after the 6 weeks of relaxation (Lichstein et al., 1999). Relaxation has been found to be the most effective when initially practised during the daytime so that the participant can practice reducing their arousal levels rather than using the techniques to help them fall asleep (Harsora & Kessmann, 2009). Once arousal levels are efficiently being reduced, relaxation treatments can reduce  SOL more than sleep hygiene education or the combination of stimulus control plus sleep restriction (Waters et al., 2003). Although CBT-I is typically superior to relaxation alone (Edinger et al., 2001a), the additional benefits of relaxation on depression (Jorm et al., 2008), stress (Kaspereen, 2012) and anxiety (Manzoni, Pagnini, Castelnuovo, & Molinari, 2008) warrant it being added to a CBT-I intervention for co-morbid insomnia and depression.

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Component Four of CBT-I: Cognitive Therapy

The term cognition refers to all mental activities, which are experienced in the form of verbal thoughts or images. Many cognitive processes have been found to be critical in differentiating individuals with insomnia from ‘normal sleepers’, including attention, perception, memory, beliefs, attributions and expectations (Harvey et al., 2005). These differences contributed to higher anxiety levels and increased cognitive arousal in individuals with chronic insomnia (Harvey & Tang, 2003).

To help break the cycle of insomnia, emotional distress and further sleep disturbances, specific cognitive techniques need to be implemented alongside the behavioural interventions in CBT-I. Cognitive techniques are formally introduced in CBT-I after both the psychoeducation and sleep scheduling components have been administered. Cognitive techniques for insomnia include cognitive restructuring (Edinger & Carney, 2008; Morin, 1993), cognitive control (Morin & Espie, 2003), constructive worry (Edinger & Carney, 2008), distraction (Ree, Harvey, Blake, Tang, & Shawe-Taylor, 2005), paradoxical intention (Broomfield & Espie, 2003), and mindfulness and acceptance of thoughts (Ong, Shapiro, & Manber, 2008).

4A. A cognitive model of Insomnia

Through research on the cognitive processes involved in insomnia, Harvey and colleagues developed a cognitive model that identified the five main aspects that were likely to be perpetuating insomnia (Harvey, Sharpley, Ree, Stinson, & Clark, 2007). The model proposed that individuals with insomnia typically:

  • Spend excessive time ruminating about why they have not slept well in the past, and worrying about not sleeping well in the future.
  • Misperceive their sleep to be worse than it is, overestimating initiation and maintenance of sleep problems and underestimating total sleep achieved, which exacerbates their anxiety and arousal over time.
  • Pay more attention to both external and internal threats to sleep in bed at night and to functional impairments and tiredness during the day.
  • Have many unhelpful and unrealistic beliefs about sleep, including hours of sleep needed, consequences of poor sleep, causes of their insomnia, and what they should do about it, and
  • Maintain these attentional biases and unhelpful beliefs about sleep through safety behaviours, such as not going to work after a miserable night’s sleep, napping during the day, and spending extra time in bed in an attempt to catch up on ‘lost sleep’.

Harvey and colleagues (2007) then developed a cognitive therapy for insomnia, which consisted of Socratic questioning and carefully planned behavioural experiments, to address all aspects of their cognitive model. They found significant improvements in SOL (over 50%), WASO (37%) and total sleep time (TST – 11%) by post-treatment, with findings maintained by follow-up 1 year later and all 19 participants no longer meeting diagnostic criteria for chronic insomnia (Harvey et al., 2007). Significant improvements were also found in work and social adjustment, unhelpful beliefs, worry, depression severity and anxiety severity (Harvey et al., 2007).

Although these findings were promising, there was no control group in the study of cognitive therapy, and the duration of treatment varied between 6 and 22 weeks. As the optimal dose of CBT-I is 4 sessions across 8 weeks (Edinger et al., 2007), it may be possible to target all five factors from the cognitive model (Harvey et al., 2007) and achieve similar gains, but in a shorter period of time than what is found through purely cognitive interventions for insomnia. This is supported by a recent study by Roane and colleagues (2012), who found that the behavioural and cognitive interventions of CBT-I both produced significant reductions in unhelpful beliefs and attitudes about sleep, but created these cognitive changes in different areas.

4B. Constructive worry

To target worry and rumination in co-morbid insomnia and depression, both the constructive worry (Edinger & Carney, 2008) and the cognitive control (Morin & Espie, 2003) techniques could be efficiently used in CBT-I. The constructive worry technique instructs individuals with insomnia to spend time earlier in the evening problem solving any issues that they believe may keep them awake or cognitively aroused in bed at night (Edinger & Carney, 2008). Cognitive control also instructs individuals to spend 20 minutes reflecting on the day that has been a few hours before going to bed and to write a to-do list about what needs to be done the next day (Morin & Espie, 2003). By targeting these concerns earlier in the evening, less information needs to be processed in bed, and this can subsequently result in less cognitive arousal and frustration. If anything new comes up that they have not thought about, they can also quickly write this down on a notepad next to their bed and then continue to relax and allow sleep to come (Morin & Espie, 2003). These cognitive techniques are likely to be effective alongside sleep scheduling instructions in CBT- I by reconditioning the bed with sleepiness and sleep instead of worry, rumination and a racing mind.

Out of all the cognitive processes, individuals with insomnia have a propensity to use thought control strategies more frequently than normal sleepers (Ree et al., 2005). The strategies of aggressive suppression and worry appear to be particularly unhelpful, with their use predicting increased sleep impairment, anxiety and depression (Ree et al., 2005). Conversely, cognitive distraction is used more frequently by normal sleepers and predicts better sleep quality (Harvey & Payne, 2002). Thus, cognitive distraction techniques are likely to be helpful in allowing individuals to reduce their cognitive arousal levels and should be encouraged in CBT-I interventions for comorbid insomnia and depression.

4C. Imagery training

One particularly beneficial distraction technique is imagery training. Although it is often considered to be a relaxation exercise, imagery aims to distract the individual from obtrusive and pre-occupying sleep-related thoughts by using visualisation techniques. Thinking in the form of images has been found to resolve worry more efficiently than thinking in the form of words (Nelson & Harvey, 2002). Imagery can therefore also be considered as a cognitive technique in CBT-I.

Imagery involves visualising an interesting and engaging situation that is also pleasant and relaxing immediately before sleep (Harvey & Payne, 2002). Rosen and colleagues (2000) compared imagery to PMR and sleep hygiene education across 4 weeks of treatment, and found significant improvement in SE and WASO in both the imagery and PMR groups by post-treatment. Furthermore, the imagery group exhibited 16 minutes less WASO than the PMR group and had increased self-efficacy and depression severity by the 6-month follow up (Rosen, Lewin, Goldberg, & Woolfolk, 2000). Imagery should, therefore, be incorporated into a CBT-I intervention for comorbid insomnia and depression as both relaxation and a cognitive distraction technique.

4D. Highlighting sleep-state misperception

Another critical area that may need to be challenged cognitively is sleep-state misperception. To challenge sleep state-misperception, an individual’s objective sleep data, which is usually provided by a wrist activity monitor (Hauri & Wisbey, 1992), needs to be compared with their subjective sleep data from their sleep diaries. If a significant discrepancy is found between objective and subjective sleep, it often indicates that individuals perceive themselves to be awake during the light stages of sleep (stages 1 and 2) (Harvey et al., 2007).

Providing information that highlights the inconsistencies between objective and subjective sleep and giving information that sleep becomes lighter as the night goes on will often reduce anxiety about an individual’s quality of sleep, and result in better subjective sleep and increased the perception of a more restorative night’s sleep. Stimulus control is also a useful behavioural intervention for sleep state misperception, as it is not possible for the participant undergoing CBT-I to get up out of bed after 20 minutes of being awake if they are actually sleeping (Lieberman & Neubauer, 2007). Cognitive restructuring (Morin, 1993) can then be administered to look at the validity and utility of thoughts around being awake when they might actually be asleep.

4E. Cognitive restructuring

Cognitive restructuring is introduced after sleep scheduling in CBT-I to address and challenge any unhelpful beliefs and attitudes about sleep that may be perpetuating insomnia. To determine how strongly held participant’s beliefs are in CBT-I interventions, the DBAS-16 is often administered (Morin et al., 2007). The DBAS-16 highlights four main areas of unhelpful beliefs about sleep, including excessive worry about not sleeping, catastrophising the consequences of insomnia, having unrealistic expectations for sleep, and overestimating the effects of sleep medications (Morin et al., 2007).

Cognitive restructuring aims to elicit, identify, discuss, appraise, and correct any unhelpful thought processes that may be maintaining catastrophic beliefs about sleep and insomnia through Socratic questioning (Harvey et al., 2007). These questions focus on the accuracy of beliefs about sleep that an individual has, the evidence to support these beliefs, whether there are any alternative explanations for these beliefs, whether they underestimate their ability to cope with any problems they have, what they fear will happen if these beliefs are correct, and what they can do to address the issue (Morin, 1993). A reduction in these scores predicts better outcomes for individuals after CBT-I treatment (Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001b).

4F. Mindfulness or acceptance-based techniques

Individuals with insomnia also exhibit an attentional bias for sleep-related threat during both the day and night. One way to target this is through the introduction of mindfulness or acceptance-based techniques (Dalrymple, Fiorentino, Politi, & Posner, 2010; Lundh, 2005; Ong & Sholtes, 2010). These techniques involve a non-judgmental, present-focused awareness, which means being aware of any thoughts, feelings or sensations that arise without changing them in any way. It also involves bringing back attention to whatever is occurring in the present moment and getting in touch with the breath or any of the five senses rather than getting caught up in the past or future (Dalrymple et al., 2010; Lundh, 2005; Ong & Sholtes, 2010).

Mindfulness and acceptance-based therapies theorise that it is not the content of thoughts that are troublesome to individuals, but rather the judgments or evaluations that are made about these thoughts. By remaining in the present and practising ‘defusion’ and acceptance techniques (Harris, 2007), the impact that these perceived sleep threats have should diminish over time. This could result in lowered arousal, more restorative sleep, and fewer impairments in daytime functioning (Dalrymple et al., 2010; Lundh, 2005; Ong & Sholtes, 2010).

Several studies have found modest improvements in sleep through mindfulness, as an individual intervention for sleep (Britton, Shapiro, Penn, & Bootzin, 2003; Heidenreich, Tuin, Pflug, Michal, & Michalak, 2006). However, recent findings have been more promising (Gross et al., 2011), especially when mindfulness is combined with other sleep interventions (Ong et al., 2008; Ong, Shapiro, & Manber, 2009). Although increases in mindfulness skill were not significant across all participants by post-treatment (Ong et al., 2008), participants with reduced pre-sleep arousal and sleep effort were found to be less likely to have had an insomnia relapse by follow-up one-year later (Ong et al., 2009).

Another study also found that mindfulness improved self-regulation of sleep by allowing it to occur naturally rather than forcing it, which subsequently predicted greater well-being (Howell, Digdon, & Buro, 2010). Adding mindfulness to CBT-I can therefore not only reduce insomnia severity but also improve daytime functioning. Mindfulness-based cognitive therapy is thought to be an effective treatment for relapse prevention in MDD (Ma & Teasdale, 2004). Because of the long-term improvements found for both conditions, mindfulness should be incorporated in some capacity in CBT-I interventions for co-morbid insomnia and MDD.

4G. Safety behaviours

The last cognitive aspect of insomnia that needs to be addressed in CBT-I is safety behaviours, which are habitual sleep-related behaviours or routines that people develop because they think that it helps with their insomnia (Harvey et al., 2007). Safety behaviours may lead to reduced adherence to behavioural interventions in CBT-I and need to be addressed through behavioural experiments for homework, to ensure optimal outcomes for co-morbid insomnia and depression.

Paradoxical intention is one such intervention that can be implemented as a behavioural experiment to reduce pre-sleep arousal and sleep effort, which can subsequently reduce the likelihood of insomnia relapse following the conclusion of CBT-I treatment (Ong et al., 2009). By instructing an individual that has continued to put considerable effort into sleeping that they should try to remain awake in bed for as long as possible, they are likely to obtain a more restorative night’s sleep (Broomfield & Espie, 2003). It is then possible to explain that it is their effort and performance anxiety that often leads to increased pre-sleep arousal and poorer quality of sleep throughout the night (Broomfield & Espie, 2003). Once the individual understands this, durable cognitive change is likely to occur, and more significant benefits can be obtained from the CBT-I intervention.

Due to the varied cognitive perpetuating factors for each individual with insomnia and depression, it is unlikely that a standard cognitive technique will be sufficient to help all individuals undergoing CBT-I. Conversely, if all cognitive strategies are provided, many of these will be unnecessary, and result in an excessively lengthy cognitive component of CBT-I (Harvey et al., 2007). As a result, the cognitive factors that appear to be perpetuating insomnia severity for each individual should be thoroughly assessed initially and then monitored throughout the CBT-I, with a particular focus on any adherence issues. By tailoring the cognitive treatment to the individual characteristics of each case of insomnia, it is then possible for optimal outcomes to be achieved.

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How Can CBT-I Be Optimised Further?

For optimal outcomes to be achieved through CBT-I treatment, it must be flexible enough to be tailored to the patient and their primary presenting concerns. The most prominent risk of administering manualised CBT-I is if it is being implemented in a directive rather than a collaborative manner between the therapist and the patient (Cahill et al., 2008).

Treatment goals need to be negotiated with the patient rather than assumed, and any structure that is implemented should be provided in an autonomy-supported rather than a controlling way (Ryan & Deci, 2008; Zuroff et al., 2007). To achieve this, the patient needs to feel validated and understood with their concerns (Ryan & Deci, 2008), be provided with meaningful rationales for any suggested interventions or homework exercises (Deci, Eghrari, Patrick, & Leone, 1994), and have minimal pressure by the therapist to change in a particular direction (Miller & Rollnick, 2002).

It is also essential to view the patient with unconditional positive regard (Assor, Roth, & Deci, 2004) and provide them consistent support irrespective of their treatment decisions (Moller, Deci, & Ryan, 2006). Self-determination theory suggests that these factors help to ensure that an individuals’ psychological needs for competence, relatedness and autonomy are met (Ryan & Deci, 2008). If CBT-I therapists can meet these needs while educating patients about the effective interventions that are likely to help their insomnia and other presenting concerns, optimal improvements can be achieved.

If a patient undergoing CBT-I has an external locus of control, they are likely to attribute their difficulties to factors outside of their influence, and may, therefore, struggle to find an autonomous motivation to improve their situation. In these cases, motivational interviewing strategies (Miller & Rollnick, 2002) could be implemented either before or during the CBT-I intervention to enhance support, motivation and therapeutic alliance. This can subsequently improve adherence to treatment recommendations and result in higher overall treatment outcomes (Trockel et al., 2013; Zuroff et al., 2007).

A motivational interviewing intervention before CBT for anxiety has been shown to reduce resistance to CBT interventions (Westra, 2011), improve compliance with homework, and produce more significant overall reductions in worry in comparison to a CBT only intervention (Westra, Arkowitz, & Dozois, 2009). Encouraging family members or partners to help motivate and support the individual undergoing CBT-I can also improve adherence rates to the CBT-I interventions (Ellis, Deary, & Troxel, 2014), and could be utilised more if motivational ambivalence is present. The most optimal CBT-I treatment may, therefore, be one that supports the patients’ needs for autonomy while also motivating them to adhere to empirically supported interventions.

Although CBT-I consistently reduces psychological symptoms and distress, other daytime improvements through CBT-I have been less consistent (Morin et al., 2006). Acceptance and commitment therapy (ACT), and especially the values clarification and committed action components of ACT, can help patients endure more emotional discomfort and overcome barriers to change in the pursuit of their value-driven goals (Harris, 2009). A case-study of ACT principles following CBT-I (Dalrymple et al., 2010) indicates the potential for an amalgamation of ACT with CBT-I whenever presenting concerns consist of a lack of purpose or meaning. Mindfulness has already been shown as a helpful addition to CBT-I for certain individuals (Ong et al., 2008), and ACT teaches four mindfulness skills and concepts as core components of its treatment (Harris, 2009). Positive Psychology principles (Seligman, Rashid, & Parks, 2006) have been included alongside CBT to improve positive emotion, engagement and overall well-being in individuals with depression (Karwoski, Garratt, & Ilardi, 2006), but has yet to be attempted alongside CBT-I.

By incorporating more evidence-based interventions with CBT-I when necessary, and personalising the treatment approach to the characteristics of the client, optimal outcomes can be achieved in a higher proportion of individuals with depression seeking treatment for insomnia.

Thanks for reading! If you or your partner suffers from sleep difficulties that impact your quality of life, you may be interested in coming along to our upcoming coastal sleep retreat in Victoria, Australia. Please click here for more information

Dr Damon Ashworth

Clinical Psychologist

The Best Relaxation Strategies for Great Sleep

The twelfth variable that I will be manipulating across a two week period to examine its impact on sleep is relaxation. I will see if abdominal breathing, progressive muscle relaxation or imagery have a positive effect on sleep quality. 

I will discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. These three factors will be combined for an overall score and grade on how effective relaxation strategies are at improving sleep.

HOW COULD RELAXATION STRATEGIES HELP?

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As I’ve previously mentioned, hyper-arousal is one of the leading problems for people with sleep difficulties. It can be especially problematic for individuals who are suffering from insomnia, parasomnias, bruxism, restless legs and periodic limb movement issues.

Anything that helps us to lower these arousal levels both during the day and before we go to bed at night will improve our chances of falling asleep quickly, sleeping more, and having an excellent quality of sleep. Learning relaxation strategies is therefore definitely worthwhile if you had ever felt “tired but wired” and were unable to get a good night’s sleep even though you were exhausted before you went to bed.

Abdominal breathing

Abdominal, or diaphragmatic breathing is the most straightforward relaxation strategy to learn. It is also something that is helpful to work on first before trying any other relaxation strategies because most of these will also incorporate the breath to some degree for them to be beneficial.

If you are interested in trying this out, then three things are essential to focus on:

  1. The rate of breath – if you breathe too quickly it will lead to you feeling more anxious and worked up. By actively trying to slow it down, it can help you to feel more calm and relaxed. Some people try the 4-7-8 breathing pattern and breathe in for 4 seconds, hold for 7 seconds then breathe out for 8 seconds. Personally, I find this too long and tend to breathe in for about 3 seconds, pause for 1 or 2 seconds, and then breathe out for about 4 seconds. Anything slower than Move breaths per minute is thought to be potentially relaxing, so experiment with what is comfortable and what works best for you.
  2. The depth of breath – if you breathe too shallowly it can make you feel anxious and worked up. To see if this is you, place one hand on your chest and one hand on your stomach and take in a big breath. If the hand on your chest moved more than the one on your stomach, you are probably not breathing deeply. To breathe more deeply, you want to actively engage your diaphragm and push out your stomach as you breathe in. The deeper it is, the more calming and relaxing it should be for you.
  3. The exhale – when people first start to practice breathing deeply, they will often try to take nice deep breaths in, and not worry about breathing out. This is the quickest pathway to hyperventilating, which can even bring on a panic attack if you do it long enough. Focus on breathing out all of the air with each breath first, which will balance out the oxygen to carbon dioxide ratio, and help you to feel more calm and relaxed.
Progressive muscle relaxation

Progressive muscle relaxation (PMR) is an excellent strategy to do in the last hour or so before bed if you notice that you are particularly tense in your body. It may be that you have had a stressful day, have been on your feet all day or have been sitting at a computer screen for too long. If this is the case, or you just notice that you are tense in your shoulders, neck, jaw, back, stomach or legs, then this strategy would be worth a try.

It goes as following:

  1. Start with your arms. Clench them as tightly as you can, bringing your forearms up to your biceps so that they are tense too. Really notice the tension. Then, while still clenching, take in a deep breath. Pause. Then exhale all of the air, and as you do release the tension in your arms and let them drop down, hanging loosely by your side. Notice the difference between when they were tensed and how relaxed they feel now. Repeat one more time.
  2. Move to your face and jaw. Raise your forehead, furrow your brow, shut your eyes tightly, scrunch your nose and clench your jaw. Notice the tension. Then, while still clenching, take in a deep breath. Pause. Then exhale all of the air, and as you do release the tension in your face and let your jaw hang loose with your mouth slightly open. Notice the difference between when you were tense and how relaxed you feel now. Repeat one more time.
  3. Move to your shoulders. Raise them up to your neck, pushing them up as highs you can while pushing your head and neck down. Then, while still clenching, take in a deep breath. Pause. Then exhale all of the air, and as you do release the tension, let your shoulders be as loose as possible and let your head droop down, no longer using your neck to support it. Observe the difference between how you felt when tense and how relaxed you feel now. Repeat one more time.
  4. Move to your stomach. Tense. Breathe in. Pause. Breathe out. Relax the belly. Repeat.
  5. Move to your upper legs and buttocks. Tense. Breathe in. Pause. Breathe out. Relax your legs and butt. Repeat.
  6. Move to your calves and feet. Tense. Breathe in. Pause. Breathe out. Relax your lower legs and feet. Repeat.
Imagery

Sometimes known as visualization, this strategy is based on the neuroimaging findings that the same areas of our brain light up when we are tapping our fingers as when we only imagine ourselves tapping our fingers. What this means is that our thoughts can have a huge impact on how we feel emotionally and physically, and what we then do behaviourally. If you are worried about sleeping and imagining yourself not sleeping, this can raise your arousal levels. But if you instead imagine yourself lying in a beautiful hammock on a tropical island on a warm sunny day, it could help you to feel calm and relaxed instead. I like to do this in bed at times, but if you haven’t tried it yet, I encourage you to practice it outside of bed first.

The instructions are as follows:

  1. Find somewhere nice and quiet to sit or lie down where you are unlikely to be disturbed for the next 5-10 minutes.
  2. Take a few deep breaths to centre yourself in the here and now.
  3. Then close your eyes and try to picture yourself in the most calming, peaceful and relaxing environment that you can imagine. It can be a place from your childhood, from a favourite holiday, or a place that is entirely made up. A lot of people find a beach, forest, lake or mountain to be exceptionally relaxing, but it can be a cozy room too. Just wherever you feel safe, calm and relaxed.
  4. Try to engage as many of your senses as possible in the place that you are. If you are on the beach, feel your feet on the sand or the sun on your skin, hear the waves crashing in or the seagulls chirping as they fly overhead. Smell the salty water or the coconut in your sun lotion, or sip on a nice refreshing drink.
  5. Walk around and explore the area, or find a nice place to sit and look out, taking in the scenery around you.
  6. Once the 5-10 minutes is up, open your eyes, ground yourself in the present and take that sense of calm with you.

 

THE EXPERIMENT

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For the first five nights, I practised PMR for 10-15 minutes each night in the last hour before going to bed. Generally, this was while watching the TV.

For the middle five nights, I practiced abdominal breathing for 10-15 minutes in the last hour before going to bed. I also continued to focus on my breath once in bed, exhaling all the air with each breath, as well as breathing slowly and deeply until I was asleep.

For the last four nights, I practiced imagery for 10-15 minutes in the last hour before going to bed. The TV was always off when I did this. Once in bed, I would continue to practice imagery until I was asleep.

Let’s see which relaxation strategy was best for my sleep…

THE OUTCOME

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Comparison: PMR vs Abdominal breathing vs Imagery

Based on my sleep diary data, the abdominal breathing relaxation strategy was the most effective for me, followed by imagery, and then progressive muscle relaxation. Here were the findings:

  • The number of awakenings:
    1. Abdominal breathing – 0.4 per night
    2. Imagery – 0.75 per night
    3. PMR – 1.2 per night
  • Time in bed:
    1. Abdominal breathing – 8 hours
    2. PMR – 7 hours 44 minutes
    3. Imagery 7 hours 30 minutes
  • Time to bed:
    1. PMR – 11:48pm
    2. Abdominal breathing – 12:06am
    3. Imagery – 12:15am
  • Total sleep time:
    1. Abdominal breathing – 7 hours 47 minutes
    2. PMR – 7 hours 16 minutes
    3. Imagery – 7 hours 6 minutes
  • Sleep onset latency:
    1. Imagery – 6.75 minutes
    2. Abdominal breathing – 9 minutes
    3. PMR – 11 minutes
  • Wake after sleep onset:
    1. Abdominal breathing – 4 minutes
    2. Imagery – 15 minutes
    3. PMR – 17 minutes
  • Rise time:
    1. PMR – 7:32am
    2. Imagery – 7:45am
    3. Abdominal breathing – 8:06am
  • Sleep quality:
    1. Abdominal breathing – 4.8/5
    2. Imagery – 4.25/5
    3. PMR – 4/5
  • Sleep efficiency:
    1. Abdominal breathing – 97.29%
    2. Imagery – 94.72%
    3. PMR – 93.97%

 

IS PRACTICING RELAXATION STRATEGIES BEFORE BEDTIME A GOOD SLEEP STRATEGY?

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IS IT EFFECTIVE?

Yes. Depending on what your problem is, different relaxation strategies are thought to be better. For a busy mind, imagery is believed to be good. For a tense body, progressive muscle relaxation is thought to be good. For me, simple deep and slow breathing was the most effective, with excellent sleep quality and sleep efficiency and 7 hours and 47 minutes of sleep per night.

I, therefore, give the effectiveness of this strategy a 22/25.

CAN IT BE APPLIED?

Yes. Each strategy requires a little bit of training during the day first for it to be effective. Once you feel that it helps you to relax when your arousal levels are high, you can then try to add it to your pre-bed wind-down strategy. If that is helping it can then be utilised in bed. No technology is needed for any of the techniques either, which means it can be done anywhere.

I therefore give the applicability of this strategy a 22/25. 

IS IT SCIENTIFIC?

Progressive Muscle Relaxation (PMR) is the most commonly used relaxation technique in CBT-I and is efficacious as a stand-alone treatment for insomnia (Morin et al., 2006).

In comparison to autogenic training and biofeedback training, PMR was not significantly different (Freedman & Papsdorf, 1976; Simeit et al., 2004). However, cognitive relaxation techniques such as imagery were found to be more effective for reducing time taken to get to sleep (Morin, Culbert, et al., 1994).

Relaxation has been found to be the most effective when initially practiced during the daytime so that the participant can practice reducing their arousal levels rather than using the techniques to help them fall asleep (Harsora & Kessmann, 2009). Once relaxation strategies efficiently minimize arousal, these strategies can reduce the time taken to get to sleep more than sleep hygiene education or the combination of stimulus control plus sleep restriction (Waters et al., 2003).

Cognitive behavioural therapy for insomnia (CBT-I) is typically superior to relaxation alone for improving insomnia severity (Edinger et al., 2001a). However, the additional benefits that relaxation can have on depression (Jorm et al., 2008), stress (Kaspereen, 2012) and anxiety (Manzoni, Pagnini, Castelnuovo, & Molinari, 2008) warrant it being used to help people sleep better. Training in relaxation strategies can also be used alongside a CBT-I intervention for people with insomnia.

I, therefore, give the science of this strategy a 37/50.

Overall, regularly practicing relaxation strategies before bed as a way to sleep better gets a score of 22/25 + 22/25 + 37/50 =

81/100: High Distinction

 

WHAT I RECOMMEND

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If you feel tense and stressed often, or struggle to switch off, unwind and relax at night, this could be one of the main reasons that you are having difficulties sleeping. Try to find a relaxation strategy that helps you to lower your arousal levels whenever you are feeling stressed or wound up. This could be abdominal breathing, PMR or imagery, or it could be yoga or meditation even.

Practice relaxation strategies during the day first so that you can see if they help you to calm down and relax. If they are working during the day, then try them for a week or two in the last hour before bed. Even 10-15 minutes each night can help. Only use these relaxation strategies in bed if you feel confident that they are a helpful strategy for you.

Lastly, remember that any relaxation strategy aims to lower your arousal level and to keep it low, not to get you to sleep. If you are using something to get you to sleep, it will often backfire and not work, because sleep is an involuntary process that is out of our control. The more we try to get to sleep, the harder it will be.

By winding down before sleep, going to bed once you are sleepy and keeping your focus on something relaxing once you are in bed, you are giving yourself the best chance of having a good night’s sleep.

Thanks for reading! Stay tuned for my next episode on if being too hot or too cold can impact the quality of your sleep. If you would like some individualised help on improving your sleep, please check out my CBT-I and Personalised Sleep Reports services.

Does Writing Down Thoughts, Feelings or Plans Improve Sleep?

The eleventh variable that I will be manipulating across a two week period to examine its impact on sleep is writing. I will be seeing if journalling or writing down plans at least two hours before bedtime has a positive effect on sleep quality. 

I will discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. These three factors will be combined for an overall score and grade on how effective writing is at improving sleep.

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HOW COULD WRITING HELP?

Journalling

In modern society, we have so many distractions and so many tasks to keep us busy that we often forget to stop, tune in, reflect on what we have done, and clarify what we would like to do next.

After a busy workday, the last thing that most people want to do is take the time to reflect or write words down, but what if it helped you to learn more about yourself, switch off from work more, feel more focused on whatever it is that you are doing, and sleep better?

Journalling is something that is extremely common and has been in practice for hundreds of years. One of the main benefits I see to journalling is that it helps us to stop and reflect on our days and how we have felt about them. If no one is reading what we are writing it also helps us to be truly honest with ourselves about what we did and what we want.

Most people know about the importance of goal setting, but trying something new or challenging ourselves to do something differently is only one part of the equation to long-term behavioural improvement. The second part is a reflective process, where we can review how things have gone, look at what was positive and negative, and get feedback from objective measures or other people if possible. These thoughtful insights help to inform our new goals and plans, as we can then determine if we would like to do things differently the next time that we are in a similar situation in the future.

Planning

Writing down our plans are thought to be useful because of the two concepts known as the ‘Zeigarnik effect’ and the ‘Ovsiankina effect’. The Zeigarnik effect says that we are more likely to remember things that are incomplete, and the Ovsiankina effect means that we will have intrusive thoughts when a task is interrupted or incomplete that will encourage us to take up the job until it is completed. These effects are beneficial from an evolutionary point of view because we are less likely to forget what is important to us and more likely to achieve what we have set out to do.

Where it becomes problematic is when people start to worry about things that they can’t actually do anything about at that moment. Let’s say that you have to buy a new light globe, but you are in bed trying to sleep, and the store is not open during the middle of the night. Little things like this can keep people with insomnia awake all night. Even though they know that it really isn’t that big of a deal, they struggle to stop thinking about it or quieten their mind.

Fortunately, the Zeigarnik and Ovsiankina effects can also be exploited to solve this dilemma. By writing down a plan to address the unfinished task and stating when you will do it, your brain will treat the written plan as being almost identical to the job having already been completed. The business book ‘Getting Things Done’ by David Allen further highlighted the benefits to me of actually writing down our plans (rather than just thinking about them) and having a system and daily routine to clear all the mental clutter that accumulates each day.

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People that want to be productive will often write to-do-lists, and this can be good for helping us prioritise things during the day. Writing a to-do-list at the end of the day or at night is less helpful, however, as often this just reminds our brain of all the incomplete tasks that we still need to do and therefore think about. A much better approach that is commonly used in the sleep field is called ‘Constructive Worry’ by Edinger and Carney (2008). The Constructive Worry strategy should be completed either at the end of the workday or in the early evening at least 2 hours before bed. Their instructions are as follows:

  • Write down the problem(s) facing you that has the greatest chance of keeping you awake at bedtime, and list them in a ‘concerns’ column on the left half of your page.
  • Then, think of the next step that might help fix it.  Write it down in a ‘solutions’ column on the right half of your page. This need not to be the final solution to the problem, since most problems have to be solved by taking steps anyhow, and you will be doing this again tomorrow night and the night after until you finally get to the best solution.
    1. If you know how to fix the problem completely then write that down.
    2. If you decide that this is not really a big problem, and you will just deal with it when the time comes, then write that down.
    3. If you decide that you simply do not know what to do about it, and need to ask someone to help you, write that down
    4. If you decide that it is a problem, but there seems to be no good solution at all, and that you will just have to live with it, write that down, with a note that maybe sometime soon you or someone that you speak with will give you a clue that will lead you to a solution.
  • Repeat this for any other concerns you may have
  • Fold the page or close the book and change your focus to enjoying your night or winding down until bedtime.
  • At bedtime, if you begin to worry about any of these concerns again actually tell yourself that you have already dealt with your problems in the best way you know how, and when you were at your problem-solving best.  Remind yourself that you will be working on them again tomorrow evening and that nothing you can do while you are so tired can help you any more than what you have already done; more effort will only make matters worse. Then change your focus to whatever will help you to stay calm and relaxed until you fall asleep.

Reproduced from: Edinger & Carney (2008). Overcoming Insomnia: A cognitive-behavioral therapy approach workbook. Oxford University Press, pp. 28-31.

THE EXPERIMENT

For the first week, I decided to journal using the online website 750 words. The reason that I like this website as opposed to journalling in a book is that it takes up less space and can be accessed online from wherever I am. This was done each night when I first arrived home from work, and would typically take me about 15 minutes to reach 750 words. It also gives me stats on what my writing content is focused on each day, which helps even more with my reflection process. Here’s an example from one of my days:

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For the second week, I created my own Constructive Worry worksheet template in a word document on my computer and did this exercise as soon as I arrived home from work. On most days it only took about 5 minutes to complete. Here’s an example:

Name: Damon Day/Date:  14/06/2017
CONCERNS SOLUTIONS
1. TV presenter course tomorrow night – how will I go with the filming of my piece? I keep getting the same feedback that I need to be more energetic and expressive!

2. Supervision training – the two-day workshop is coming up soon, and I need to complete the first component readings and tests before then. 

3. Feel tired – having something on every night this week is really tiring me out!

  1. Practice during my lunch break tomorrow and after work until the course starts. I can’t expect to be great at something that I haven’t done a lot of. Just try my best and be receptive to the suggestions that are given.
  2. Start supervision training Saturday morning after doing grocery shopping and then finish whatever I don’t do next Monday.
  3. Rest until Basketball tonight and schedule some downtime for this Sunday afternoon to rest and recuperate.

Let’s see if journalling or planning was better for my sleep…

THE OUTCOME

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Comparison: Journalling vs Constructive Worry

Based on my sleep diary data, which came out a bit crooked in the scan, planning using the Constructive Worry strategy was more effective at improving my sleep than journaling. After journaling, I:

  • woke up 0.29 more times per night,
  • went to bed 49 minutes later each night,
  • spent 19 minutes less time in bed each night,
  • got out of bed 20 minutes later each morning,
  • slept 19 minutes less per night,
  • was awake for 2.86 more minutes during the night
  • had poorer sleep quality (4.14/5 vs 4.29/5)
  • had reduced sleep efficiency (96.15% vs 96.60%)

Journalling did seem to help me feel better and process my emotions more, but the only element of my sleep that was better in comparison to planning was my sleep onset. I fell asleep in 7.86 minutes on average the first week, 1.43 minutes faster than I did the second week using the Constructive Worry strategy.

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Based on the Misfit Ray data, both journalling and planning were helpful for my objective sleep quality, with journalling actually coming out slightly better.

Comparing Jun 6 (5/6/2017 on the sleep diary data) to Jun 13 (12/6/2017 on the sleep diary data) you can see that on both Monday nights I was able to obtain over 8 hours of sleep, with a restful: light sleep ratio of 2.12 for journalling and 1.74 for Constructive Worry.

IS WRITING DOWN YOUR THOUGHTS, FEELINGS OR PLANS IN THE EARLY EVENING A GOOD SLEEP STRATEGY?

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IS IT EFFECTIVE?

Yes. Planning seemed to quieten my mind a bit and meant that I went to bed earlier, fell asleep within 10 minutes, awoke less than once per night, and slept 7 hours and 47 minutes per night. Journalling improved my misfit quality of sleep more and helped me to fall asleep quicker, but planning was generally more effective for me.

I, therefore, give the effectiveness of this strategy a 20/25.

CAN IT BE APPLIED?

Yes. Planning can be done on the computer, in a journal, or on any scrap bit of paper, and takes no more than 5-15 minutes per night. Journalling is a bit more labour intensive, and the website 750words.com costs $5 per month to use but has the added benefit of giving you feedback on what might be troubling you.

I, therefore, give the applicability of this strategy a 21/25. 

IS IT SCIENTIFIC?

The reliability of the Zeigarnik effect has been brought into question in subsequent papers on the topic (Butterfield, 1964; Goschke & Kuhl, 1993; Marsh, Hicks, & Bink, 1998), If people rapidly forget their intentions in demanding situations (Einstein, McDaniel, Williford, Pagan & Dislikes, 2003), then Constructive Worry could be helpful by ensuring that we don’t forget something important that we want to do at a later date. Either way, writing important things down seems to help.

Constructive worry has been found to reduce worry and pre-sleep arousal in university students who were suffering from sleep problems due to an overactive mind (Digdon & Koble, 2011). More importantly, it also improved sleep after only one week of the intervention, although not significantly more than a gratitude intervention (Digdon & Koble, 2011).

When added to a stimulus control and sleep restriction intervention, a constructive worry intervention resulted in a larger reduction in insomnia severity and level of worry by the end of a 4-week period in comparison to just a stimulus control and sleep restriction intervention(Jansson-Frojmark, Lind & Sunnhed, 2011).

For journalling to be most effective, it should incorporate both cognitive and emotional processing elements rather than just stating the facts of the day or describing how you felt (Ullrich & Lutgendorf, 2002). By trying to make sense of events and how you would like to manage them going forward, journalling can reduce compassion fatigue and burnout (in registered nurses), and help people to make more reasonable decisions (Dimitroff, Sliwoski, O’Brien & Nichols, 2017)

I, therefore, give the science of this strategy a 30/50.

Overall, writing down your thoughts, feelings and plans as a way to sleep better gets a score of 20/25 + 21/25 + 30/50 =

71/100: Distinction

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WHAT I RECOMMEND

If a racing mind or worrying thoughts are keeping you awake at night, then writing down your plans for when you will address these issues and the first step that you will take (the Constructive Worry strategy) is definitely worth a try. Experiment a bit with the right timing for you, but it is preferable to do it at least two hours before bed.

Journalling may not be as helpful for sleep but is definitely worth doing from an emotional processing and reflection point of view. Even something like a gratitude journal where you write down 3 things that you are grateful for or appreciate each day has been shown to be quite effective for reducing depression severity and is a nice way to reflect on the positives and counterbalance most people’s general inclination to look at what went wrong rather than what went well.

You should be able to get a sense of whether or not these strategies are helping you within a week or two. If it doesn’t, please check out my other blog posts for helpful tips on getting a good night’s sleep.

Thanks for reading! If you or your partner suffers from sleep difficulties that impact your quality of life, you may be interested in coming along to our upcoming coastal sleep retreat in Victoria, Australia. Please click here for more information

Can Reading or Listening to Books Before Bedtime Improve Sleep?

The tenth variable that I will be manipulating across a two week period to examine its impact on sleep is reading. I will be seeing if reading a physical book or if listening to an audiobook before bed is a helpful way to improve sleep quality. 

I will discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. These three factors combine for an overall score and grade on how useful books are at improving sleep.

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HOW COULD READING HELP?

When you were younger, how did your parents help you to transition into sleep?

For many people, the answer is that they were given a bedtime story. This could have been a made-up story, folklore, or something read from a book, but it is a popular strategy. For this practice to be so widespread and prolific, surely it must make a difference, right?

I love reading, and do typically find that it does help me to wind down and relax before sleep. It also tends to bring on sleepiness for me earlier than if I am on the computer or watching TV.

Not everyone reports these positive benefits, however. Some of the clients that I see say that their minds become more active when they are reading, as they get so engrossed in the story and want to keep turning the pages to find out what is going to happen next. As a result, they struggle to switch off and get to sleep afterward.

THE EXPERIMENT

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For the first week, I decided to spend at least an hour before bed winding down by reading a book. My book of choice was a non-fiction book by Michael Bond titled ‘The Power of Others: Peer Pressure, Groupthink, and How the People Around Us Shape Everything We Do.’ It was an interesting book, but not so engaging or exhilarating that I expected it to be a page-turner that was going to keep me up all night.

For the second week, I decided to spend at least an hour before bed winding down by listening to the audiobook ‘The Village Effect’ by Susan Pinker. Once again, this book has some fascinating information, but it wasn’t likely to get me too excited before bed. Considering that both books were in the general area of social psychology also helped me to feel that the topic of the book wasn’t going to confound the results.

Let’s see if reading or listening to stories was better for sleep.

THE OUTCOME

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Comparison: Reading a book vs. Listening to an audiobook

Based on my sleep diary data, listening to audiobooks for at least an hour before sleep seemed to be better than reading a physical book. I went to bed over an hour earlier by lying down on the couch and listening to an audiobook than I did when I read a book. This was quite a surprising finding to me, as I thought that reading physical books may make my eyes more tired sooner.

I also slept 30 minutes longer per night after the audiobook, woke up less per night, had less time awake during the night, got out of bed 37 minutes earlier in the morning, and had a better sleep efficiency (96.62% vs. 96.18%).

The one thing that was rated higher after reading in comparison to the audiobook was sleep quality, but both were pretty good (4.43/5 for reading vs 4.29/5 for listening). My average time to fall asleep in both weeks was 7.86 minutes per night, which is excellent too.

Based on the Misfit Ray data, both reading and listening to audiobooks before bedtime helped with my sleep quality.

Comparing May 24 (23/5/2017 on the sleep diary data) to Jun 1 (31/5/2017 on the sleep diary data), you can see that both nights have much more restful sleep than light sleep. Listening to audiobooks comes out slightly on top again, with a restful: light sleep ratio of 1.90, slightly ahead of the reading restful: light sleep ratio of 1.80.

This means that either listening to a story or reading one before bed is helpful, but listening to an audiobook maybe even better, especially if you want to go to sleep earlier.

IS READING BEFORE BED A GOOD SLEEP STRATEGY?

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IS IT EFFECTIVE?

Yes. It was not the best sleep that I’ve had all year, but it was terrific. I slept more than 7 hours per night each week, didn’t take more than 10 minutes to fall asleep once in bed, woke up less than once per night for less than 10 minutes each time, and had a sleep efficiency of over 96% on both weeks.

I, therefore, give the effectiveness of this strategy a 21/25.

CAN IT BE APPLIED?

Yes, but it does require a bit of time. If you want to go to bed on the earlier side, definitely try out audiobooks or take turns with your partner reading to each other before bed. An hour does seem like a bit of time and would require a bit of discipline, in the beginning, to switch off the bright screens, but as soon as you begin to feel sleepy around your bedtime, you can close the book or switch it off.

I, therefore, give the applicability of this strategy a 17/25. 

IS IT SCIENTIFIC?

There doesn’t appear to be too much research on this specific question.

A 2008 study on Nigerian university pharmacy students found that habitual night reading was significantly associated with poorer sleep quality, which was then negatively associated with poor academic performance (Adeosun, Asa, Babalola & Akanmu, 2008). For this study, they considered ‘habitual night reading’ to be between the hours of 8 pm and 5 am, however. The benefits of reading relaxing material before sleep versus continuing to study pharmacy readings through the night were not separated, nor was reading before bedtime versus reading in bed (Adeosun et al., 2008).

I would never recommend going to bed before you are sleepy, or spending more than 30 minutes awake reading in bed each night, so it is tough to determine if these results are indicative of what I am trying to figure out. What is similar is that both their study and my personal experience found shorter sleep times when people read more after 8 pm.

Another 2008 study compared participants who listened to audiobooks for 45 minutes at bedtime to those who listened to classical music for 45 minutes and those who had no intervention (Harmat, Takacs & Bodizs, 2008). They found that audiobooks had no significant benefit to people’s sleep quality over those who had no intervention. What did make a substantial difference to not only sleep quality but depressive symptoms was classical music (Harmat, Takacs & Bodizs, 2008).

While this still doesn’t look at the benefits of listening to audiobooks before sleep, but the findings suggest that listening to classical music might be an even better option than either reading or listening to audiobooks.

 I, therefore, give the science of this strategy a 25/50.

Overall, reading or listening to stories before bed as a way to sleep better gets a score of 21/25 + 17/25 + 25/50 =

63/100: Credit

WHAT I RECOMMEND

Whether you read, listen to an audiobook or do something else such as socializing or listening to classical music in that last hour before bed, the key is to find something to help you to lower your arousal levels. If your arousal levels are low and you are going to bed at the right time for your body clock, you will tend to feel sleepy before going to bed, fall asleep quickly, and have a good night’s sleep.

Please do try each of these strategies for at least a week to see if they benefit you if you are interested. If there is something else that helps you wind down before sleep in a more effective way than reading or audiobooks, then that is fine too.

Thanks for reading! If you or your partner suffers from sleep difficulties that impact your quality of life, you may be interested in coming along to our upcoming coastal sleep retreat in Victoria, Australia. Please click here for more information

Does Exercise Improve Sleep Quality?

The ninth variable that I will be manipulating across a two week period to examine its impact on sleep is exercise. Using my Misfit Ray data, I will be seeing if doing over 10,000 steps a day will be better for sleep than doing less than 10,000 steps. 

I will discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. These three factors will be combined for an overall score and grade on how useful exercise is at improving sleep quality. 

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HOW COULD EXERCISE HELP?

Homeostatic Pressure is one of the three primary variables that are responsible for proper sleep quality. It is also known as sleep debt, and it is something that builds up during the day regardless of what we do unless we have a nap during the day or fall asleep at night. It is what TAC talks about in their latest ad ‘Drowsy Driving – You Can’t Fight Sleep’:

I have some clients with insomnia who would disagree with this ad because they manage to fight sleep every night. The difference with falling asleep on the road and in bed is the intent though. A driver who is trying to stay awake will drift off to sleep, and a person who is working hard to fall asleep in bed will stay awake. The reason that most people with insomnia can’t sleep is due to hyper-arousal rather than sleep pressure, and they are more likely to benefit from winding down before sleep or meditating rather than exercising more.

Exercise, as long as it isn’t done in the 3 hours before sleep, is meant to be great for our health, stress levels and sleep pressure. Essentially doing anything cognitively or physically demanding during the day can increase our sleep pressure at a faster rate, because it creates a greater need for restoration and recovery. Exercise can therefore potentially help us to feel sleepy earlier and have a better night’s sleep.

I’ve definitely had days where I have been extremely active, either from hiking all day to Mt Feathertop or playing a Beach Volleyball tournament. On these rare occasions, I’ve been extremely exhausted and have subsequently crashed before 10pm and slept over 9 hours. It will be interesting to see if these are one-offs, however, or if doing a bit more exercise each day really could help.

THE EXPERIMENT

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I’m generally pretty active and also play organised sport three times a week. Rather than trying to stop exercise altogether, what I’ve decided to do is monitor my steps each day using a Misfit Ray activity tracker, and compare the 7 most active days to the 7 least active.

If I wanted to be even more thorough, I could look at the data for the entire year, but I’ll just keep it to these two weeks for now and compare it to what the scientific research and literature says about sleep and exercise.

THE OUTCOME

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Comparison: Over 10,000 steps to under 10,000 steps

Based on my sleep diary data, the average of the more exercise week was 11,985 steps in comparison to the less exercise week average of 5852 steps. This means I did more than twice the amount of steps on the active days than the non-active days, which should be enough to see if more exercise makes a difference.

In spite of this, doing more exercise actually led to more awakenings per night, less time in bed, 30 minutes less sleep per night, and bedtime that was 33 minutes later than when I exercised less.

What exercise did seem to help with was time awake in bed, as I fell asleep 4 minutes quicker, spent 2 minutes less awake during the night, and had a better sleep efficiency.

My sleep quality was rated as precisely the same (4.14/5) regardless of how much exercise I did, with both a 3,552 step and a 15,180 step day obtaining a sleep quality rating of 5/5, and both a 4,456 and a 10,486 step day obtaining a sleep quality rating of 3/5. It appears that other things are more important to sleep quality than exercise.

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Based on the Misfit Ray data, the depth of my sleep had no real relationship with the amount of exercise that I did.

Let’s compare the Sunday night from the first week (May 08 on the Misfit data – 7/5/17 on the sleep diary), where I did 13,410 steps the day before, to the Friday night of the first week (May 13 on the Misfit data – 12/5/17 on the sleep diary), where I did 4,456 steps the day before. If you were to look just at this, you could say exercise improves objective sleep quality.

However, my best night of sleep for the two week period was the Thursday of the second week (May 19 on the Misfit data – 18/5/17 on the sleep diary), where I only did 3,552 steps. This was the least steps on any day for the entire two weeks, and the best objective sleep, with a restful:light sleep quality ratio of 4.01:1. This is one of my best sleeps for the year, and all I could put it down to was an exhausting day at work.

IS EXERCISING MORE A GOOD SLEEP STRATEGY?

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IS IT EFFECTIVE?

Maybe. I didn’t compare it to no exercise at all, and I still slept fairly well for the whole two week period, but doing more exercise than normal didn’t really seem to have much of an additional benefit for me.

I, therefore, give the effectiveness of this strategy a 16/25.

CAN IT BE APPLIED?

Yes, but with how time poor we all are these days, mostly thanks to our increased screen time in red in the graph below by Adam Alter, it might be hard to justify spending more time exercising if your only reason to do it is so that you can get better sleep.

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If you are exercising with others for social interaction or for better overall health than that is a different story, but it is still important for each of us to determine how we’d like to spend the minimal personal time that we have, as indicated by the white and yellow in the graph above.

Only 30 minutes five times per week is enough to have a positive benefit on mood, so I’ll give the applicability of this strategy a 15/25. 

IS IT SCIENTIFIC?

A 1996 Meta-Analytic review of the effects of exercise on sleep by Kubitz and colleagues said that a lot of the research has conflicting results and interpretations. With their re-analysis, they found that both acute and chronic exercise can help people to fall asleep faster, sleep longer and obtain more deep sleep. The negative of exercise is that is reduces rapid eye movement (REM) sleep, which is useful for emotional processing and learning.

Another review by Taylor and Driver (2000) indicated that exercise “can be beneficial to general well-being but may also stress the body”, which means that it shouldn’t be done too close to bedtime. They also said that even though some modest effect sizes have been found, “the sleep-promoting efficacy of exercise in normal and clinical populations has yet to established empirically” (Taylor & Driver, 2000).

A 2008 study by King and colleagues found that a 12-month moderate-intensity endurance exercise program in older adults reduced their amount of stage 1 sleep, increased their stage 2 sleep and reduced their awakenings during the first third of a polysomnography study. Participants in this study also subjectively reported falling asleep quicker each night, having fewer sleep disturbances, and feeling more rested in the morning (King et al., 2008).

A 2010 study by Reid and colleagues also found that sedentary adults over 55 with insomnia who began exercising aerobically for 16 weeks improved their subjective sleep quality, the time taken to get to sleep, total sleep time and sleep efficiency. Furthermore, they also experienced less daytime dysfunction and sleepiness and rated themselves as being less depressed and having more vitality than before they began the exercise program (Reid et al., 2010).

Because of all of the scientific benefits of exercise on health in general, as well as the modest benefits of regular exercise on sleep, I, therefore, give the science of this strategy a 30/50.

Overall, exercising more as a way to sleep better gets a score of 16/25 + 15/25 + 30/50 =

61/100: Credit

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WHAT I RECOMMEND

A moderate exercise regime of both cardio and strength training is going to be good for your health, but do see a doctor for a check-up first before beginning an intensive program. In the long run, regular exercise could lead to better sleep for you too. Just try not to engage in vigorous exercise in the last three hours before bed too often, as this can raise your arousal levels and make it harder to get to sleep at the start of the night.

If you are currently experiencing severe insomnia, increasing your exercise is probably not the first step that I would recommend taking, especially if you are already quite active and feeling exhausted before you go to bed each night. A better approach would be not spending too much time in bed, minimising your alcohol intakestaying off bright screens in the last two hours before bed, and doing things to wind down before sleep.

Thanks for reading! If you or your partner suffers from sleep difficulties that impact your quality of life, you may be interested in coming along to our upcoming coastal sleep retreat in Victoria, Australia. Please click here for more information

The Negative Impact of Spending Too Long In Bed

The eighth variable that I will be manipulating across a two week period to examine its impact on sleep is the length of time in bed. I will be seeing if spending too long in bed is harmful to sleep quality, and if restricting time in bed is an excellent way to improve it. 

I will discuss what my data shows, how easy or difficult I found this strategy to implement, and what previous research says. These three factors will be combined for an overall score and grade on how effective sleep restriction is at improving the quality of our sleep. 

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IF I AM ALREADY TIRED, SHOULDN’T I SPEND MORE TIME IN BED?

It’s all over the media these days: the majority of people are sleep deprived. They say that we need to prioritise sleep and get more of it. They also say that we used to sleep more and blame our lack of sleep for a multitude of problems, from more accidents, our lack of productivity, higher rates of depression and anxiety, and even weight gain.

What they don’t tell you is how to get more sleep. The obvious answer would be to spend more time in bed or get to bed earlier. This may help for some people, especially those who do not experience any difficulties in getting to sleep at the start of the night or staying asleep during the night.

For people with insomnia, however, spending more time in bed awake is potentially the worst thing that they can do, especially if it leads to them becoming more worried or frustrated about their sleep difficulties. People with insomnia are already focusing on sleep too much, and are also usually going to bed before their body is ready for sleep each night.

If you are having difficulties with getting to sleep at the start of the night, even though it is quite counter-intuitive, waiting up until you feel sleepy before going to bed is one of the best ways to ensure that you will fall asleep quickly once you are in bed.

If you are having difficulties with waking up during the night, one of the quickest ways to reduce the amount of time that you spend awake during the night is to reduce your time in bed.

WHAT IS SLEEP RESTRICTION?

It sounds pretty scary to people that are already not sleeping enough, but sleep restriction doesn’t aim to reduce the amount of time that you sleep each night at all. What it is actually seeking to do is reduce the amount of time that you spend in bed awake each night. For this reason, at the Melbourne Sleep Disorders Centre where I work, we call it bed restriction, not sleep restriction.

Let’s say that you feel that you need 7 hours of sleep on average, but are currently only getting 6 hours of sleep per night. You want to get that extra hour, so you start spending 9 hours in bed instead of your usual 8 hours. By doing this, you expect your total sleep time to improve, but instead, it stays about the same. Worse still, you are now spending nearly 3 hours in bed awake each night rather than the 2 hours that you were previously. Your sleep efficiency (percentage of time in bed spent sleeping) has decreased from 75% to 66.67% and now the nights seem to be dragging on for ages!

With sleep restriction what we want to do is the opposite. 85-90% is considered an ideal sleep efficiency to aim for, so if you are currently sleeping 6 hours per night, we would actually want to cut down your time in bed to between 6.5 and 7 hours per night. This will make you more tired initially, but very quickly your sleep efficiency would reach the desired 85-90% range, while still obtaining 6 hours of sleep per night. Even better, you are now only awake for 30-60 minutes in bed per night, rather than 2-3 hours, which will help make the night go quicker and give you better quality sleep.

Once you are sleeping better and spending less time in bed awake each night, we can then slowly increase your time in bed again, by 15 minutes per night every 1-2 weeks. As long as your sleep quality remains high, you might even be able to increase your total sleep time until you are reaching that 7 hours of sleep per night.

THE EXPERIMENT

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For the first week, I tried to show the negative impact of spending longer than usual in bed. Because I had to get up for work and am so used to waiting until I feel sleepy before going to bed this was actually quite hard, but I managed to spend nine hours in bed on average. 7 hours and 45 minutes was the shortest time in bed the first week, and 9 hours and 30 minutes was the longest.

For the second week, I tried to implement a sleep restriction routine. I managed to restricted my average time in bed to under 7 hours. The longest time in bed on any night for the second week was 8 hours and 10 minutes, and the shortest was 5 hours.

THE OUTCOME

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Comparison: Too much time in bed vs Sleep restriction

Based on my sleep diary data, I managed to sleep 8 hours a night the first week, which was an hour and 28 minutes more than the second week. I also managed to get to bed by 11:01pm during the first week, which is more suitable to my work week than the 12:39am bedtime the second week. This is where the good news stops, however.

By implementing sleep restriction during the second week, I fell asleep in under 10 minutes, 13.5 minutes quicker than the first week. I only woke once per night rather than twice and spent 12 minutes awake each night, rather than 38 minutes the first week. My sleep quality was a full point higher (4.29/5) during sleep restriction than it was when I was spending too long in bed (3.29/5). My sleep efficiency was also 6% higher with sleep restriction (94.81%) than it was the first week (88.78%).

Based on my data, after only a week of sleep restriction, my sleep was getting right back on track to where it was before the silent meditation retreat. I was feeling more tired by the end of the work week, especially after only 4 hours and 40 minutes of sleep on Wednesday night, and this was evident by my turning to caffeine on the Wednesday, Thursday and Friday morning. The Thursday night was potentially the best sleep that I’d had in a month though, thanks to the positive impact of increased sleep pressure.

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Based on the Misfit Ray data, the depth of my sleep was way better the second week during sleep restriction than it was the first week when I was spending too long in bed.

Let’s compare the Thursday night from the first week to the Thursday night from the second week. Even though the Misfit Ray didn’t pick up on any awakenings during the first Thursday (Apr 28 – 27/4/17 on the sleep diary), my restful: light sleep ratio was 0.83. The following week (May 05 – 4/5/17 on the sleep diary) I didn’t have any awakenings on the sleep diary or the Misfit data, and my objective restful: light sleep ratio was 2.69, which is incredible.

Even though I was in bed for 35 minutes less the second Thursday night, I was able to obtain nearly 2 hours more restful sleep than during the first Thursday night. Sleep restriction = better objective sleep quality.

IS SLEEP RESTRICTION A GOOD SLEEP STRATEGY?

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IS IT EFFECTIVE?

Yes. Only being in bed for the amount of time that I need to sleep is one of the most effective ways for me to improve my sleep quality and ensure that it remains good over time. As long as I am going to bed at the right time for my body clock, keeping these times fairly consistent from night to night and that I am trying to wind down and relax before sleep, this strategy is one of most effective for me.

I, therefore, give the effectiveness of this strategy a 23/25.

CAN IT BE APPLIED?

For me, yes. But the downside of sleep restriction is that it temporarily increases daytime somnolence and reduces vigilance in the initial phases of treatment (Kyle et al., 2014). Adherence to sleep restriction may also be difficult to obtain from individuals who are already concerned about daytime consequences of insomnia (Riedel & Lichstein, 2001).

If there is excessive daytime sleepiness, caution should be given regarding driving or operating machinery, and some time off work may be required. However, this increase in sleepiness prevents individuals with insomnia from lying in bed ruminating or worrying, and it has been shown to significantly improve sleep initiation and increase overall sleep quality (Lieberman & Neubauer, 2007).

I, therefore, give the applicability of this strategy a 13/25. 

IS IT SCIENTIFIC?

Sleep restriction is considered a highly efficacious and effective treatment for insomnia (Morin et al., 2006). It was initially conceived of in the 1980s and involves limiting the time in bed to an individual’s average subjective daily amount of sleep (Spielman et al., 1987). By only spending enough time in bed for sleep, sleep restriction temporarily induces sleep deprivation, which increases the homeostatic drive for sleep, decreases sleep fragmentation and consequently improves sleep efficiency (Vitiello, 2007). However, it is important to prescribe the sleep at a constant time that is in line with an individual’s circadian rhythms and lifestyle (Ebben & Spielman, 2009).

Sleep restriction is similar to relaxation in reducing the time taken to get to sleep and time awake during the night across the treatment period, and more effective in maintaining these improvements by a 3-month follow-up assessment (Friedman et al., 1991). After 12 months follow-up in another study, time awake during the night had gotten worse since post-treatment with relaxation but continued to improve with sleep restriction (Lichstein et al., 2001). Another study of CBT-I found that sleep restriction adherence was one of the two best predictors of ongoing sleep improvements 12 months later (Harvey, 2002). Consequently, as long as adherence issues are addressed, sleep restriction can produce dramatic and robust improvements in insomnia symptoms.

I, therefore, give the science of this strategy a 45/50.

Overall, sleep restriction as a way to sleep better gets a score of 23/25 + 13/25 + 45/50 =

81/100: High Distinction

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WHAT I RECOMMEND

  1. Complete a two-week sleep diary or use an activity tracker to get a baseline measure of your sleep.
  2. Figure out your average total sleep time.
  3. If this is under 5 hours per night, try to spend 5 hours and 30 minutes in bed per night.
  4. If it is over 5 hours, add 30 minutes to your total sleep time for your initial time in bed prescription.
  5. Figure out what time you would like to get out of bed each morning. Set your alarm for this time each day for the next 1-2 weeks.
  6. Minus your time in bed prescription from your wake time to figure out your to bedtime.
  7. Go to bed each night around your to bedtime, as long as you are feeling sleepy. If you are not sleepy yet, do something to try to wind down and relax, and then go to bed once sleepy.
  8. After 1-2 weeks, if your sleep efficiency is:
    • less than 85% = cut down your time in bed by an extra 15 minutes the following week.
    • between 85-90% – keep your time in bed the same
    • over 90% – increase your time in bed by 15-30 minutes the following week.

This is the most scientific way that you can figure out what is the right amount of time in bed for you. If these recommendations are too general or confusing, you can always send me your two weeks of sleep data, and I will score up your sleep and give you some specific and tailored recommendations for what you can do to improve it. For more information, check out my Personalised Sleep Reports services.

Thanks for reading! If you or your partner suffers from sleep difficulties that impact your quality of life, you may be interested in coming along to our upcoming coastal sleep retreat in Victoria, Australia. Please click here for more information