1 APRIL 2022 ausdoc . com . au in the afternoon is acceptable . Activities to help Martin stay awake and out of bed in the evening ( until his new bedtime ) are discussed , as are setting an alarm clock and planning activities in the morning to motivate him to get out of bed at the desired time .

Session two

One week later , Martin reports that he used stimulus control therapy on the first four nights only as he had sleep-onset difficulties . It is likely that he started to accumulate some sleep pressure over the first four nights of bedtime restriction that helped him fall asleep more quickly at the start of the night .

Martin used bedtime restriction therapy to reduce his time in bed each night over the past week . Apart from staying up slightly later on Friday night and sleeping in on Saturday morning , he was consistent with his bed / rise times . Martin reports that the week was quite difficult , as he has started feeling sleepier in the late afternoon and evening .

The GP reviews Martin ’ s sleep diary at session two ( see figure 6 ). Because his average WASO over the past week is still 30 minutes or more , his time in bed can be reduced by an additional 30 minutes for the coming week . The GP and Martin agree on a new bedtime of 12.30am and rise time of 6am .

M Tu W Th F Sa Su

C

Martin

Martin

C C

C

C

C

C C

C

12:00 am 6:00 am

90 min 90 min

60 min 180 min 150 min

Figure 5 . Baseline assessment sleep diary completed before session one . Because Martin ’ s average SOL and WASO are both at least 30 minutes ( 64 minutes and 116 minutes , respectively ), it indicates the amount of time he spends in bed can be restricted to consolidate his sleep and reduce the amount of time he spends awake throughout the night .

C C

C C

C

C

C

30 min 0 min 60 min

450 min

64 min

810 min

116 min

5.5 h 5.5 h 6.5 h 6 h 6 h 6 h 6.5 h

42 h

6 h

8.5 h 8.5 h 9.5 h 10 h 7.5 h 9 h 10 h

63 h

9 h

Session three

At the third session , Martin reports moderate levels of sleepiness in

Brief awakenings are normal with all experiencing these ; many do not remember these the next morning .

the late evening . Different activities to help him remain awake and out of bed until his set bedtime are discussed . The GP emphasises the importance of avoiding long daytime naps , which can result in a reduction of sleep pressure and the re-emergence of sleep-onset difficulties . The GP reassures Martin that this is a temporary treatment , and they will work together to find the right balance between an appropriate time in bed , sleep time and reducing feelings of sleepiness during the day / afternoon .

Based on his diary ( figure 7 ), Martin ’ s time in bed can be extended by 30 minutes for the next week , with bedtime at midnight and rise at 6am ( see table 4 ).

Session four

At session four , Martin reports he is still feeling sleepy in the evening but is pleased that he no longer spends hours awake each night trying to fall asleep and becoming frustrated .

The GP ensures Martin understands the rationale for bedtime restriction therapy and encourages him to continue enacting his own adjustments over the next few weeks . After he feels that he is acquiring enough sleep during the night to feel rested and alert during the day , he can stop extending his

M Tu W Th F Sa Su

time in bed . Alternatively , if long SOL or WASO start to emerge again , he can reduce his time in bed by 30 minutes .

C

C

C

C C

C C

C

Figure 6 . Sleep diary completed before session two . Martin has restricted his time spent in bed over the past week and has started using stimulus control therapy instructions on the first four nights of treatment . As he started to fall asleep quicker on Friday , Saturday and Sunday night , he no longer used stimulus control therapy instructions . Restricting his time in bed to six hours has resulted in a small reduction of TST compared with last week ( 6h vs 4.8h ) but a larger reduction in his SOL and WASO . His average WASO is 42 minutes ( 30 minutes or more ), indicating his time in bed can be further restricted by 30 minutes , to 5.5 hours , for the next week .

Table 4 . Summary of sleep diary data during each session * Session

Sleep onset latency ( SOL )

Wake after sleep onset ( WASO )

Total sleep time ( TST )

Time in bed ( TIB )

Martin ’ s diary indicates his time in bed can again be extended by 30 minutes during the coming week ( see table 4 ).

Interpretation

Follow-up

During the final session , Martin reports almost no difficulty falling asleep at the start of the night

C C C C

C C

C

60 min 30 min 30 min 30 min 0 min 0 min 0 min

150 min

21 min

60 min 90 min 30 min 30 min 0 min 90 min 0 min

300 min

42 min

4 h 4 h 5 h 4.5 h 5.5 h 4.5 h 6 h

33.5 h

4.8 h

New bedtime

6 h 6 h 6 h 6 h 5.5 h 6 h 6 h

41.5 h

5.9 h

New out of bed

1 64 min 116 min 6 hours 9 hours Time in bed can be restricted to match average sleep time 12.00am 6.00am

Followup

* If sleep-onset latency or wake after sleep onset are 30 minutes , time in bed can be reduced by 30 minutes during the subsequent week .

12.30am

12.00am

11.30pm

11.30pm

6.00am

6.00am

6.00am

6.30am

or long night-time awakenings . He still has some feelings of sleepiness in the evening , as his sleep window is still slightly restricted . The GP