Although cognitive behavioral therapy for insomnia (CBT-I) is recognized as the preferred insomnia treatment, some of its components can be challenging. For example, CBT-I requires insomnia sufferers to be highly disciplined and motivated when it comes to limiting time in bed. If you are desperate for more sleep, being told to get out of bed when you can’t sleep can be a difficult concept to accept and commit to, particularly when it may lead to further short-term sleep loss.
Because CBT-I is only effective when insomnia sufferers adhere to the treatment (and because positive results tend to take three to four weeks), non-compliance is a serious impediment to a successful outcome. This led researchers in Australia to investigate whether a new behavioral therapy known as intensive sleep retraining could address these issues. The intensive sleep retraining treatment period is less than 24 hours, compared to the six to eight weeks of a typical CBT-I course. Their research was published in the journal Brain Sciences in 2017.
What is intensive sleep retraining?
Intensive sleep retraining (ISR) is based on the idea that prolonged sleep deprivation leads to the accumulation of sleep pressure, which inevitably leads to sleep.
The day before ISR, individuals are told to spend no more than five hours in bed. The next night, they report to a sleep lab and are given an opportunity to fall asleep every half hour over the course of 24 hours.
Whenever the participant falls asleep, they are woken up after just three minutes. This occurs throughout the night and the continued sleep disruption and sleep deprivation leads to increased sleep pressure, inevitably leading to repeated short periods of sleep. This process can lead to an individual falling asleep up to 48 times in a 24-hour period, thus allowing them to feel what it’s like to fall asleep and to recognize that they are capable of falling asleep. It also allows insomnia sufferers to reacquaint themselves with the feeling of sleepiness rather than fatigue.
How effective is intensive sleep retraining?
The authors of the 2017 study highlighted two clinical studies that investigated ISR. Those studies found that, following ISR treatment, participants fell asleep up to 30 minutes faster and got up to one hour of additional sleep each night, as measured by sleep diaries. Furthermore, the benefits of ISR were evident in the first week following treatment, whereas the benefits of stimulus control therapy (the component of CBT-I that requires individuals to get out of bed when they can’t sleep) took between three and four weeks to reach similar levels.
How to try intensive sleep retraining at home
Studies involving ISR typically take place in a laboratory environment where participants are supervised for 24 hours by a trained polysomnographic technologist. As a result, the treatment is costly and not available to most insomniacs. This has led to speculation about whether a self-administered version could be designed to be equally effective as lab-based ISR.
The Sleep On Cue app attempts to bring the concept of ISR into the home environment. Instead of a sleep lab technician waking participants every few minutes, the app periodically emits a faint tone that prompts the user to give their phone a gentle shake to indicate they are still awake. If the user doesn’t shake their phone after a couple of missed tones, the app presumes that the user has fallen asleep. At this point, the phone vibrates to wake the user and asks them if they think they fell asleep. It then displays the correct answer for the user. The app then prompts the user to leave the bed for a few minutes and return for another sleep trial.
In the morning, users can review their sleep training summary graph, which displays their ability and awareness of falling asleep.
In an interview with HealthCentral, Michael Schwartz, creator of the Sleep On Cue app, said that the app works well for people who have struggled with sleep on and off for an extended period of time, and for those who are trying to wean themselves off sedative-hypnotic sleeping pills. He suggested that users try 12-15 sleep trials around bedtime the night after a poor night of sleep.
Schwartz told HealthCentral that he encourages any doctors or therapists practicing CBT-I to consider adding sleep training with Sleep On Cue to enhance their therapy.
Another device that aims to bring the benefits of ISR into the home is the Thim smart ring. This wearable device measures when you are asleep from your movements in a similar way to other sleep trackers. When it detects that the user is asleep, it emits a sound after three minutes to wake the user. As of December 2017, the device was still in the production process and not publicly available (although it can be pre-ordered).
The future of intensive sleep retraining
Studies investigating ISR have demonstrated its effectiveness when administered by trained health practitioners in a laboratory setting. The expense and scarcity of such a treatment option has led to the development of devices based on ISR that can be used at home. But more research is needed to determine the effectiveness of these devices before they can be universally recommended.
With that being said, they do hold promise — particularly for insomnia sufferers who have tried CBT-I without success.
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Martin is the creator of Insomnia Land’s free insomnia sleep training. His online course uses CBT techniques to teach participants how to sleep better without relying on sleeping pills. More than 5,000 insomniacs have completed his course and 97 percent of graduates say they would recommend it to a friend.