Sleep-maintenance insomnia: how to sleep through the night

Written by Greg Potter, PhD

Sept. 16, 2019

In the previous blog, we briefly reviewed what insomnia is, as well as a few simple strategies you can immediately put to use to sleep better. In this blog, we’re going to focus on how to sleep through the night. In doing so, I’ll discuss a few things we can all learn from the treatment of sleep-maintenance insomnia, a disorder in which people wake frequently and for prolonged periods when they would rather be sleeping. So, if you’re tired of waking up at night, try these tips and let me know the results!

Your daytime activities strongly influence your night-time sleep

In a previous blog, Megan shared loads of tips about sleep hygiene. Here are some numeric guidelines for several particularly important sleep hygiene components:

Get plenty of exposure to daylight: Aim to spend at least 30 minutes outdoors in daylight each day, preferably in the first half of your waking day. Why not take an early lunch break outdoors with others?
Limit your consumption of stimulants such as caffeine: Cap your intake at 2 mg caffeine per kg body mass per day (use this site to estimate your intake), finishing your last caffeine-containing item by at least 9 hours before bedtime. Swap your caffeinated drinks for caffeine-free herbal teas.
Whenever possible, avoid high-intensity exercise shortly before bedtime: finish vigorous-intensity and/or high workload physical activity by at least 4 hours before bedtime, finish moderate-intensity physical activity at least 2 hours before bedtime. Don’t worry, sex doesn’t count and often helps people sleep… so get busy.
Finish consuming all calorie-containing items at least 2 hours before bedtime. Stop consuming fluids at this time too if you’re prone to needing to pee during the sleep period.

Notice that these guidelines are all relative to your sleep timing, not time of day. There are very (very!) large differences between people in how their sleep is affected by these stimuli, but try these guidelines to begin.

Nap judiciously

If you’re struggling with your nighttime sleep, it’s critical that you avoid daytime napping whenever possible.

Yes, naps do confer many acute benefits, especially after sleep loss. These positive effects include reducing sleepiness, bolstering memory consolidation, enhancing subsequent learning, boosting immune function, and restoring strength and power performance.

However, when sleep is dysregulated, naps can be problematic. This is because of the way sleep is regulated.

Sleep regulation can be crudely modelled by the interaction of two processes:

One process is influenced by how much of your time you’ve spent awake of late. This determines how much pressure to sleep you experience: more time awake, more pressure to sleep.
The other process is controlled by your body’s master “clock”, which generates a daily rhythm in alertness. Overall, this drive to stay awake increases from about the time you’d naturally wake each day until near when you’d naturally fall asleep at night. Around bedtime, a precipitous drop in wakefulness drive no longer opposes the pressure to sleep that has accumulated during wakefulness, resulting in a strong urge to sleep.

Why do I mention this?

Because even a brief nap can potently reduce pressure to sleep. As a result, naps can make it harder for people to fall asleep and stay asleep.

So, if you’re struggling to sleep through the night, save naps for when you really need them. But please be responsible - if you work night shifts, for example, naps are at times essential to your safety.

How to sleep through the night: the importance of stimulus control of behavior

The next habit is one that you should implement regardless of your circumstances.

Think about driving. When driving, if you see a red light ahead, your response is to put your foot on the brake to slow down. This is an example of stimulus (the red light) control of behavior (applying force to the brake). We are very efficient at forming these types of associations, which can work in our favour, as in this example. But sometimes the associations we form work against us, and this is often true of people who have sleep problems.

Stricken by looming weariness, people who have insomnia often start spending more and more time in bed in the hope that doing so will help them catch up on sleep. The problem is that they reinforce an association between the bed (the stimulus) and wakefulness (the behavior). They need to break this cycle, which entails doing a few things:

Saving the bedroom for sex and sleep only.
Only going to bed when sleepy: If you’re yawning and struggling to keep your eyes open, you’re ready for bed.
Applying the 20-minute rule: If you wake up at night and don’t then fall asleep within 20 minutes or so, leave your bedroom and do something relaxing and somewhat boring in a different room. Examples of these activities include meditation, doing a crossword, or reading a novel that isn’t riveting. Do not use devices such as phones, tablets, or laptops at this time.
If you have insomnia and find it hard to drag yourself out of bed, make the process as easy and attractive as you can. Keep a dim light on in the other room, make sure the room temperature is comfortable, and leave your crossword out, for example. Just make sure that you expose yourself to as little light as possible during this time. And only return to bed when you’re sleepy once again.

Sometimes, however, applying these strategies is still not enough. This brings us to bedtime restriction therapy (which is commonly referred to as sleep restriction therapy).

Bedtime restriction therapy for sleep-maintenance insomnia

Of all the interventions used to help people get over sleep-maintenance insomnia, one reigns supreme: bedtime restriction therapy. Frankly, this therapy is no fun. And I wouldn’t necessarily recommend that you try it without guidance. But it is very effective, and we can all learn from it. Let’s use a case study to show how it’s implemented.

Amy seemingly always feels sleepy during the day. She is generally meticulous about practising good sleep hygiene, but she just can’t stop waking up for extended periods at night.

She begins tracking her sleep. She learns that, on average, she’s in bed from 10 PM to 8 AM each night - a 10-hour sleep opportunity. But she’s only asleep for 6 of those hours in total, so her sleep efficiency is 60 % (6 / 10 X 100).

Under supervision, Amy begins bedtime restriction therapy. This involves delaying her bedtime (which helps build extra pressure to sleep) such that she only spends 6 hours (her average sleep duration) in total in bed each night. So, her new sleep opportunity is from 2 AM to 8 AM, and she meticulously goes to bed and gets up at precisely the same times throughout this intervention.

At first, this is rough. She’s even more tired than normal. But very quickly her sleep efficiency improves dramatically. When her average sleep efficiency is above 85 % (which is generally considered healthy) for a week, she advances her bedtime by 15 minutes. Her sleep opportunity is now 6 hours and 15 minutes. This process then repeats itself - if her sleep efficiency at the new sleep opportunity is above 85 % for a week, she adds 15 minutes to her sleep opportunity.

Once she is spending as much time asleep as she needs, she retains her new bedtimes. Three months later, she settles on going to bed at 11:30 PM, waking up at 8 AM, and her sleep is 88 % efficient. She feels like a new person.

So, what can we all learn from this?

If you’re struggling to sleep through the night, enforcing regular bedtimes is critical. If your sleep is poor, don’t start going to bed earlier and earlier. Set an alarm for 1 hour before bedtime to ingrain your bedtimes.
It is sometimes smart to wake to an alarm. Please note that I am categorically not advocating alarm clock use if your sleep is healthy though!

How to sleep through the night: a summary of key concepts

That’s all for now. If you’re struggling to sleep through the night, in addition to applying basic principles of good sleep hygiene during the daytime, minimise napping, use the 20-minute rule, and be meticulous about bedtime regularity! Do these things and you’ll reap the rewards of more restorative sleep.

In the next blog, we’ll transition to how to get over another common sleep complaint: sleep-onset insomnia.

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