What Is Sleep Hygiene Anyway?
by Jason Ong, PhD, DBSM, HF MAB Member
Sleep hygiene—everybody, including both patients and healthcare providers, has heard that if these rules are followed, sleep will be improved. Right? Most likely you’ve tried to follow a few of the rules, found that they didn’t really help (or barely helped), and then you gave up.
What Sleep Hygiene Is
What is sleep hygiene? And why does everybody talk about it? In my opinion, sleep hygiene is the most overused term in sleep health. At the same time, it might also be the most misunderstood term. Sleep hygiene was originally developed by Dr. Peter Hauri in 1977 as a set of instructions to help people with insomnia (see Table 1 below). Essentially, it was a list of “do’s and don’ts” that was designed to reduce sleep disturbance. Over time, other recommendations were added—some that were based on research, and some that were based on common sense or clinical observations. This led to different versions of sleep hygiene and a lack of scientific foundation. Furthermore, the term sleep hygiene became popular with the media and general public, who often used it to refer to almost any behavioral recommendation related to improving sleep. All of this has led to confusion over the actual sleep hygiene recommendations and for whom and under what conditions it should be used.
What Sleep Hygiene Is Not
First, sleep hygiene is not the same thing as cognitive-behavioral therapy for insomnia, often called CBT-I, which is now the first line treatment for chronic insomnia. Although CBT-I often includes some sleep hygiene recommendations, CBT-I focuses on other cognitive and behavioral techniques that have been tested in research studies. In many of these studies, sleep hygiene was even used as a control group! Second, sleep hygiene should not include other behavioral techniques, such as sleep restriction therapy (which involves systematically reducing time in bed and making adjustments based on sleep efficiency). Finally, sleep hygiene by itself is not considered an effective treatment for people with insomnia or any other sleep disorder, including PWIH (person[s] with idiopathic hypersomnia) and PWN (person[s] with narcolepsy).
What Does This Mean for PWIH and PWN?
For insomnia symptoms, it is reasonable to follow sleep hygiene recommendations as a first step, but one should also consider other treatment options (such as CBT-I) that might be available and appropriate. PWIH and PWN should carefully clarify any sleep hygiene or behavioral treatment plans with their doctor and discuss modifications as needed. This is particularly important with regards to reducing time in bed, since PWIH and PWN might be sensitive to sleep deprivation. At this time, there is insufficient evidence to know if sleep restriction could be helpful for PWIH and/or PWN. In addition, PWIH might find it very difficult to maintain a regular rise time in the morning. It may also be helpful to discuss ways to regulate circadian rhythms. A behavioral specialist, such as a therapist or psychologist can also help, and those with CBSM or DBSM credentials are specially trained in Behavioral Sleep Medicine. Finally, keep in mind that sleep hygiene was developed for insomnia, not IH or narcolepsy. If one doesn’t have trouble falling or staying asleep at night, then strict adherence to sleep hygiene rules probably isn’t needed!
See Nonpharmacologic Treatments for additional treatment options.
Good Sleep Habits for PWIH and PWN
Instead of calling these sleep hygiene, I am calling these recommendations good sleep habits for PWIH and PWN. Since PWIH and PWN can struggle with sleepiness during the day, it is just as important to pay attention to daytime habits as nighttime habits. Here are some tips to help with both:
1. Set aside a regular time for sleep at night.
- Start by setting a regular bedtime and wake up time. In the evening, start to reduce exposure to bright light and screen time about 30 to 60 minutes before bedtime. This will help your brain understand that it needs to prepare for sleep.
- In the morning, try to get exposure to bright light shortly after rising. This will help your brain prepare to be awake. It’s okay if you need some help to get out of bed by asking a family member or friend because PWIH might have a lot of sleep inertia in the morning. Just do your best!
- Make your sleep environment comfortable by adjusting the temperature to your preference and minimizing noise (or use a white noise generator).
- How much time you set aside for sleep depends on how much sleep you need, which could be different depending on your age and other factors. Consult with your doctor for more specific guidance.
2. Develop a plan for managing energy levels during the day.
- Keep an activity diary, noting times of day when sleepiness is at its worst and any behaviors that seem to improve or worsen sleepiness, such as naps, meditation, exercise, food, etc.
- Naps: Some PWH (person[s] with hypersomnias) are somewhat refreshed by naps—naps may just take the edge off of the overwhelming need to sleep, or they may be more refreshing. This may depend on the length of the nap and the level of subsequent sleep inertia, so it may be helpful to experiment to find your optimal nap timing and length, which may range from 20 minutes to a couple of hours. Also, some PWH may find they feel best with more than 1 daily nap.
- Meditation: Some PWH find that meditation can help to rest their brain and reduce sleepiness. Meditation may inadvertently lead to sleep, so it’s a good idea to be prepared for a nap. Movement meditations, such as yoga or mindful walking, may reduce the likelihood of an accidental nap. Other PWH may find that quiet activities increase their sleepiness. Meditation can also help with managing stress and staying mentally fit.
- Exercise: Some PWH find that exercise, or staying busy with movement, can help improve their wakefulness. PWH who are trying to avoid naps that result in severe sleep inertia may find higher physical activity helpful.
- Food: Some PWH find that a full stomach increases sleepiness (this is true for many people without sleep disorders but often even more so for PWH). It may be useful to eat more frequent, smaller meals and/or to time meals to fit with your daytime sleep schedule.
- Read more HERE.
- Look for times during the day when you have more energy to exercise or engage in tasks that require more mental or physical energy. You might notice a pattern, such as having more energy in the late morning or late afternoon. This can give you clues about your circadian rhythm and help you plan activities during the day to fit your “feel-best rhythm”.
- Pay attention to how you use caffeine and alcohol. In general, caffeine use late in the day can disrupt sleep and alcohol use might make you sleepier (and lead to more disrupted sleep). Note any patterns and discuss with your doctor if you use these substances.
Try to be consistent about following these tips, but don’t get caught up in being too rigid. It’s okay to fall off the wagon on occasion, but the key is to get back to your regular routine as soon as you can. Keeping track of your sleep and daily activities can help you identify when you have veered off course and help you get back on track sooner.
Table 1 – Original Sleep Hygiene instructions (Hauri, 1977)
- Sleep as much as needed to feel refreshed and healthy during the following day, but not more. Curtailing time in bed a bit seems to solidify sleep; excessively long times in bed seem related to fragmented and shallow sleep.
- A regular arousal time in the morning seems to strengthen circadian cycling and to naturally lead to regular times of sleep onset.
- A steady daily amount of exercise probably deepens sleep over the long run, but occasional one-shot exercise does not directly influence sleep during the following night.
- Occasional loud noises (e.g. aircraft flyovers) disturb sleep even in people who do not awaken because of the noises and cannot remember them in the morning. Sound attenuating the bedroom might be advisable for people who have to sleep close to excessive noise.
- Although an excessively warm room disturbs sleep, there is no evidence that an excessively cold room solidifies sleep, as has been claimed.
- Hunger may disturb sleep. A light bedtime snack (especially warm milk or similar drink) seems to help many individuals sleep.
- An occasional sleeping pill may be of some benefit, but the chronic use of hypnotics is ineffective at most and detrimental in some insomniacs.
- Caffeine in the evening disturbs sleep, even in persons who do not feel it does.
- Alcohol helps tense people to fall asleep fast, but the ensuing sleep is then fragmented.
- Rather than trying harder and harder to fall asleep during a poor night, switching on the light and doing something else may help the individual who feels angry, frustrated, or tense about being unable to sleep.
Hauri, P (1977). Current Concepts: The Sleep Disorders. The Upjohn Company, Kalamazoo, Michigan.