Sleep restriction therapy for insomnia is associated with reduced objective total sleep time, increased daytime somnolence, and objectively impaired vigilance: implications for the clinical management of insomnia disorder
Simon D Kyle, Christopher B Miller, Zoe Rogers, A Niroshan Siriwardena, Kenneth M Macmahon, Colin A Espie, Simon D Kyle, Christopher B Miller, Zoe Rogers, A Niroshan Siriwardena, Kenneth M Macmahon, Colin A Espie
Abstract
Study objectives: To investigate whether sleep restriction therapy (SRT) is associated with reduced objective total sleep time (TST), increased daytime somnolence, and impaired vigilance.
Design: Within-subject, noncontrolled treatment investigation.
Setting: Sleep research laboratory.
Participants: Sixteen patients [10 female, mean age = 47.1 (10.8) y] with well-defined psychophysiological insomnia (PI), reporting TST ≤ 6 h.
Interventions: Patients were treated with single-component SRT over a 4-w protocol, sleeping in the laboratory for 2 nights prior to treatment initiation and for 3 nights (SRT night 1, 8, 22) during the acute interventional phase. The psychomotor vigilance task (PVT) was completed at seven defined time points [day 0 (baseline), day 1,7,8,21,22 (acute treatment) and day 84 (3 mo)]. The Epworth Sleepiness Scale (ESS) was completed at baseline, w 1-4, and 3 mo.
Measurement and results: Subjective sleep outcomes and global insomnia severity significantly improved before and after SRT. There was, however, a robust decrease in PSG-defined TST during acute implementation of SRT, by an average of 91 min on night 1, 78 min on night 8, and 69 min on night 22, relative to baseline (P < 0.001; effect size range = 1.60-1.80). During SRT, PVT lapses were significantly increased from baseline (at three of five assessment points, all P < 0.05; effect size range = 0.69-0.78), returning to baseline levels by 3 mo (P = 0.43). A similar pattern was observed for RT, with RTs slowing during acute treatment (at four of five assessment points, all P < 0.05; effect size range = 0.57-0.89) and returning to pretreatment levels at 3 mo (P = 0.78). ESS scores were increased at w 1, 2, and 3 (relative to baseline; all P < 0.05); by 3 mo, sleepiness had returned to baseline (normative) levels (P = 0.65).
Conclusion: For the first time we show that acute sleep restriction therapy is associated with reduced objective total sleep time, increased daytime sleepiness, and objective performance impairment. Our data have important implications for implementation guidelines around the safe and effective delivery of cognitive behavioral therapy for insomnia.
Keywords: Adverse effects; CBT; insomnia; sleep restriction therapy; sleepiness; vigilance.
Figures
![Figure 1](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3900612/bin/aasm.37.2.229a.jpg)
![Figure 2](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3900612/bin/aasm.37.2.229b.jpg)
![Figure 3](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3900612/bin/aasm.37.2.229c.jpg)
Figure 4
Psychomotor vigilance task (PVT) RT…
Figure 4
Psychomotor vigilance task (PVT) RT (1/mean RT ± standard error) over the course…
Figure 5
Mean (± standard error) Epworth…
Figure 5
Mean (± standard error) Epworth Sleepiness Scale (ESS) scores throughout treatment weeks. **P…
Figure 6
Mean (± standard error) polysomnographically…
Figure 6
Mean (± standard error) polysomnographically (PSG)-determined total sleep time (TST, min) at pretreatment…
- Daytime sleepiness, driving performance, reaction time and inhibitory control during sleep restriction therapy for Chronic Insomnia Disorder.Whittall H, Pillion M, Gradisar M. Whittall H, et al. Sleep Med. 2018 May;45:44-48. doi: 10.1016/j.sleep.2017.10.007. Epub 2017 Nov 2. Sleep Med. 2018. PMID: 29680427
- The effect of sleep restriction therapy for insomnia on sleep pressure and arousal: a randomized controlled mechanistic trial.Maurer LF, Espie CA, Omlin X, Emsley R, Kyle SD. Maurer LF, et al. Sleep. 2022 Jan 11;45(1):zsab223. doi: 10.1093/sleep/zsab223. Sleep. 2022. PMID: 34463762 Clinical Trial.
- Neurobehavioral dynamics following chronic sleep restriction: dose-response effects of one night for recovery.Banks S, Van Dongen HP, Maislin G, Dinges DF. Banks S, et al. Sleep. 2010 Aug;33(8):1013-26. doi: 10.1093/sleep/33.8.1013. Sleep. 2010. PMID: 20815182 Free PMC article. Clinical Trial.
- The acute effects of sleep restriction therapy for insomnia on circadian timing and vigilance.Maurer LF, Ftouni S, Espie CA, Bisdounis L, Kyle SD. Maurer LF, et al. J Sleep Res. 2021 Aug;30(4):e13260. doi: 10.1111/jsr.13260. Epub 2020 Dec 13. J Sleep Res. 2021. PMID: 33314496 Clinical Trial.
- The clinical effects of sleep restriction therapy for insomnia: A meta-analysis of randomised controlled trials.Maurer LF, Schneider J, Miller CB, Espie CA, Kyle SD. Maurer LF, et al. Sleep Med Rev. 2021 Aug;58:101493. doi: 10.1016/j.smrv.2021.101493. Epub 2021 Apr 21. Sleep Med Rev. 2021. PMID: 33984745 Review.
- Factors influencing the efficiency of cellphone-based CBT for treating sleep disorders.Hu N, Xu Y, Mao H. Hu N, et al. Front Psychiatry. 2022 Oct 10;13:974888. doi: 10.3389/fpsyt.2022.974888. eCollection 2022. Front Psychiatry. 2022. PMID: 36299534 Free PMC article.
- Effects of a hybrid digital cognitive-behavioural therapy for insomnia and emotion regulation in the workplace (SLEEP): study protocol for a randomised waitlist control trial.Moukhtarian TR, Patel K, Toro C, Russel S, Daly G, Walasek L, Tang NKY, Meyer C. Moukhtarian TR, et al. BMJ Open. 2022 Jul 15;12(7):e058062. doi: 10.1136/bmjopen-2021-058062. BMJ Open. 2022. PMID: 35840305 Free PMC article.
- Intensive sleep retraining treatment for insomnia administered by smartphone in the home: an uncontrolled pilot study.Mair A, Scott H, Lack L. Mair A, et al. J Clin Sleep Med. 2022 Jun 1;18(6):1515-1522. doi: 10.5664/jcsm.9892. J Clin Sleep Med. 2022. PMID: 35641889
- Study Protocol for a Randomized Controlled Trial Assessing the Effectiveness of Personalized Computerized Cognitive Training for Individuals With Insomnia.Tapia JL, Puertas FJ, Duñabeitia JA. Tapia JL, et al. Front Behav Neurosci. 2022 Feb 28;16:779990. doi: 10.3389/fnbeh.2022.779990. eCollection 2022. Front Behav Neurosci. 2022. PMID: 35296055 Free PMC article.
- Impact of chronic sleep restriction on sleep continuity, sleep structure, and neurobehavioral performance.Xin Q, Yuan RK, Zitting KM, Wang W, Purcell SM, Vujovic N, Ronda JM, Quan SF, Williams JS, Buxton OM, Duffy JF, Czeisler CA. Xin Q, et al. Sleep. 2022 Jul 11;45(7):zsac046. doi: 10.1093/sleep/zsac046. Sleep. 2022. PMID: 35218665 Free PMC article. Clinical Trial.
- Clinical Trial
- Attention / physiology*
- Cognitive Behavioral Therapy*
- Female
- Humans
- Male
- Middle Aged
- Psychomotor Performance
- Sleep Initiation and Maintenance Disorders / physiopathology
- Sleep Initiation and Maintenance Disorders / psychology
- Sleep Initiation and Maintenance Disorders / therapy*
- Sleep Stages / physiology*
- Time Factors
- Treatment Outcome
- Wakefulness / physiology*
- Full Text Sources
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NCBI Literature Resources
The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.
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![Figure 4](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3900612/bin/aasm.37.2.229d.jpg)
Figure 5
Mean (± standard error) Epworth…
Figure 5
Mean (± standard error) Epworth Sleepiness Scale (ESS) scores throughout treatment weeks. **P…
Figure 6
Mean (± standard error) polysomnographically…
Figure 6
Mean (± standard error) polysomnographically (PSG)-determined total sleep time (TST, min) at pretreatment…
- Daytime sleepiness, driving performance, reaction time and inhibitory control during sleep restriction therapy for Chronic Insomnia Disorder.Whittall H, Pillion M, Gradisar M. Whittall H, et al. Sleep Med. 2018 May;45:44-48. doi: 10.1016/j.sleep.2017.10.007. Epub 2017 Nov 2. Sleep Med. 2018. PMID: 29680427
- The effect of sleep restriction therapy for insomnia on sleep pressure and arousal: a randomized controlled mechanistic trial.Maurer LF, Espie CA, Omlin X, Emsley R, Kyle SD. Maurer LF, et al. Sleep. 2022 Jan 11;45(1):zsab223. doi: 10.1093/sleep/zsab223. Sleep. 2022. PMID: 34463762 Clinical Trial.
- Neurobehavioral dynamics following chronic sleep restriction: dose-response effects of one night for recovery.Banks S, Van Dongen HP, Maislin G, Dinges DF. Banks S, et al. Sleep. 2010 Aug;33(8):1013-26. doi: 10.1093/sleep/33.8.1013. Sleep. 2010. PMID: 20815182 Free PMC article. Clinical Trial.
- The acute effects of sleep restriction therapy for insomnia on circadian timing and vigilance.Maurer LF, Ftouni S, Espie CA, Bisdounis L, Kyle SD. Maurer LF, et al. J Sleep Res. 2021 Aug;30(4):e13260. doi: 10.1111/jsr.13260. Epub 2020 Dec 13. J Sleep Res. 2021. PMID: 33314496 Clinical Trial.
- The clinical effects of sleep restriction therapy for insomnia: A meta-analysis of randomised controlled trials.Maurer LF, Schneider J, Miller CB, Espie CA, Kyle SD. Maurer LF, et al. Sleep Med Rev. 2021 Aug;58:101493. doi: 10.1016/j.smrv.2021.101493. Epub 2021 Apr 21. Sleep Med Rev. 2021. PMID: 33984745 Review.
- Factors influencing the efficiency of cellphone-based CBT for treating sleep disorders.Hu N, Xu Y, Mao H. Hu N, et al. Front Psychiatry. 2022 Oct 10;13:974888. doi: 10.3389/fpsyt.2022.974888. eCollection 2022. Front Psychiatry. 2022. PMID: 36299534 Free PMC article.
- Effects of a hybrid digital cognitive-behavioural therapy for insomnia and emotion regulation in the workplace (SLEEP): study protocol for a randomised waitlist control trial.Moukhtarian TR, Patel K, Toro C, Russel S, Daly G, Walasek L, Tang NKY, Meyer C. Moukhtarian TR, et al. BMJ Open. 2022 Jul 15;12(7):e058062. doi: 10.1136/bmjopen-2021-058062. BMJ Open. 2022. PMID: 35840305 Free PMC article.
- Intensive sleep retraining treatment for insomnia administered by smartphone in the home: an uncontrolled pilot study.Mair A, Scott H, Lack L. Mair A, et al. J Clin Sleep Med. 2022 Jun 1;18(6):1515-1522. doi: 10.5664/jcsm.9892. J Clin Sleep Med. 2022. PMID: 35641889
- Study Protocol for a Randomized Controlled Trial Assessing the Effectiveness of Personalized Computerized Cognitive Training for Individuals With Insomnia.Tapia JL, Puertas FJ, Duñabeitia JA. Tapia JL, et al. Front Behav Neurosci. 2022 Feb 28;16:779990. doi: 10.3389/fnbeh.2022.779990. eCollection 2022. Front Behav Neurosci. 2022. PMID: 35296055 Free PMC article.
- Impact of chronic sleep restriction on sleep continuity, sleep structure, and neurobehavioral performance.Xin Q, Yuan RK, Zitting KM, Wang W, Purcell SM, Vujovic N, Ronda JM, Quan SF, Williams JS, Buxton OM, Duffy JF, Czeisler CA. Xin Q, et al. Sleep. 2022 Jul 11;45(7):zsac046. doi: 10.1093/sleep/zsac046. Sleep. 2022. PMID: 35218665 Free PMC article. Clinical Trial.
- Clinical Trial
- Attention / physiology*
- Cognitive Behavioral Therapy*
- Female
- Humans
- Male
- Middle Aged
- Psychomotor Performance
- Sleep Initiation and Maintenance Disorders / physiopathology
- Sleep Initiation and Maintenance Disorders / psychology
- Sleep Initiation and Maintenance Disorders / therapy*
- Sleep Stages / physiology*
- Time Factors
- Treatment Outcome
- Wakefulness / physiology*
- Full Text Sources
- Other Literature Sources
- Medical
- Research Materials
- Miscellaneous
NCBI Literature Resources
The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.
National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
![Figure 5](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3900612/bin/aasm.37.2.229e.jpg)
Figure 6
Mean (± standard error) polysomnographically…
Figure 6
Mean (± standard error) polysomnographically (PSG)-determined total sleep time (TST, min) at pretreatment…
- Daytime sleepiness, driving performance, reaction time and inhibitory control during sleep restriction therapy for Chronic Insomnia Disorder.Whittall H, Pillion M, Gradisar M. Whittall H, et al. Sleep Med. 2018 May;45:44-48. doi: 10.1016/j.sleep.2017.10.007. Epub 2017 Nov 2. Sleep Med. 2018. PMID: 29680427
- The effect of sleep restriction therapy for insomnia on sleep pressure and arousal: a randomized controlled mechanistic trial.Maurer LF, Espie CA, Omlin X, Emsley R, Kyle SD. Maurer LF, et al. Sleep. 2022 Jan 11;45(1):zsab223. doi: 10.1093/sleep/zsab223. Sleep. 2022. PMID: 34463762 Clinical Trial.
- Neurobehavioral dynamics following chronic sleep restriction: dose-response effects of one night for recovery.Banks S, Van Dongen HP, Maislin G, Dinges DF. Banks S, et al. Sleep. 2010 Aug;33(8):1013-26. doi: 10.1093/sleep/33.8.1013. Sleep. 2010. PMID: 20815182 Free PMC article. Clinical Trial.
- The acute effects of sleep restriction therapy for insomnia on circadian timing and vigilance.Maurer LF, Ftouni S, Espie CA, Bisdounis L, Kyle SD. Maurer LF, et al. J Sleep Res. 2021 Aug;30(4):e13260. doi: 10.1111/jsr.13260. Epub 2020 Dec 13. J Sleep Res. 2021. PMID: 33314496 Clinical Trial.
- The clinical effects of sleep restriction therapy for insomnia: A meta-analysis of randomised controlled trials.Maurer LF, Schneider J, Miller CB, Espie CA, Kyle SD. Maurer LF, et al. Sleep Med Rev. 2021 Aug;58:101493. doi: 10.1016/j.smrv.2021.101493. Epub 2021 Apr 21. Sleep Med Rev. 2021. PMID: 33984745 Review.
- Factors influencing the efficiency of cellphone-based CBT for treating sleep disorders.Hu N, Xu Y, Mao H. Hu N, et al. Front Psychiatry. 2022 Oct 10;13:974888. doi: 10.3389/fpsyt.2022.974888. eCollection 2022. Front Psychiatry. 2022. PMID: 36299534 Free PMC article.
- Effects of a hybrid digital cognitive-behavioural therapy for insomnia and emotion regulation in the workplace (SLEEP): study protocol for a randomised waitlist control trial.Moukhtarian TR, Patel K, Toro C, Russel S, Daly G, Walasek L, Tang NKY, Meyer C. Moukhtarian TR, et al. BMJ Open. 2022 Jul 15;12(7):e058062. doi: 10.1136/bmjopen-2021-058062. BMJ Open. 2022. PMID: 35840305 Free PMC article.
- Intensive sleep retraining treatment for insomnia administered by smartphone in the home: an uncontrolled pilot study.Mair A, Scott H, Lack L. Mair A, et al. J Clin Sleep Med. 2022 Jun 1;18(6):1515-1522. doi: 10.5664/jcsm.9892. J Clin Sleep Med. 2022. PMID: 35641889
- Study Protocol for a Randomized Controlled Trial Assessing the Effectiveness of Personalized Computerized Cognitive Training for Individuals With Insomnia.Tapia JL, Puertas FJ, Duñabeitia JA. Tapia JL, et al. Front Behav Neurosci. 2022 Feb 28;16:779990. doi: 10.3389/fnbeh.2022.779990. eCollection 2022. Front Behav Neurosci. 2022. PMID: 35296055 Free PMC article.
- Impact of chronic sleep restriction on sleep continuity, sleep structure, and neurobehavioral performance.Xin Q, Yuan RK, Zitting KM, Wang W, Purcell SM, Vujovic N, Ronda JM, Quan SF, Williams JS, Buxton OM, Duffy JF, Czeisler CA. Xin Q, et al. Sleep. 2022 Jul 11;45(7):zsac046. doi: 10.1093/sleep/zsac046. Sleep. 2022. PMID: 35218665 Free PMC article. Clinical Trial.
- Clinical Trial
- Attention / physiology*
- Cognitive Behavioral Therapy*
- Female
- Humans
- Male
- Middle Aged
- Psychomotor Performance
- Sleep Initiation and Maintenance Disorders / physiopathology
- Sleep Initiation and Maintenance Disorders / psychology
- Sleep Initiation and Maintenance Disorders / therapy*
- Sleep Stages / physiology*
- Time Factors
- Treatment Outcome
- Wakefulness / physiology*
- Full Text Sources
- Other Literature Sources
- Medical
- Research Materials
- Miscellaneous
![Figure 6](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3900612/bin/aasm.37.2.229f.jpg)
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