What is the next step for a patient prescribed Cognitive Behavioral Therapy for Insomnia (CBTI) with a wake-up time of 6 am and bedtime of 12 am, but actually falls asleep at 2 am and experiences fatigue?

Adjusting CBTI for a Patient with Significant Sleep Onset Delay and Fatigue

For a patient experiencing a 2-hour sleep onset delay and significant fatigue despite adhering to their prescribed wake-up time in CBTI, the next step should be to adjust the sleep restriction parameters by moving the bedtime earlier while maintaining the fixed wake time. 1

Assessment of Current Situation

The patient is experiencing:

• Prescribed bedtime of midnight with 6 AM wake time (6-hour sleep window)
• Actual sleep onset at 2 AM (4-hour actual sleep duration)
• Significant fatigue despite adhering to the prescribed wake-up time
• One week of attempting the current schedule

This pattern suggests:

• The sleep restriction may be too severe for this patient
• The patient's circadian rhythm may be significantly delayed
• The current sleep window is insufficient for adequate restorative sleep

Recommended Intervention

1. Adjust Sleep Restriction Parameters

• Move bedtime earlier by 30-60 minutes (to 11:00-11:30 PM) while maintaining the 6 AM wake time 2, 1
• This adjustment provides a more realistic sleep window of 6.5-7 hours
• Continue to maintain the fixed wake-up time at 6 AM to preserve circadian entrainment

2. Enhance Stimulus Control

• Reinforce getting out of bed if unable to fall asleep within 20 minutes 2
• Return to bed only when feeling sleepy
• Use the bedroom only for sleep and sex

3. Address Circadian Factors

• Add bright light therapy immediately upon waking (≥30 minutes of exposure to bright light) 2, 1
• Limit evening light exposure, especially from electronic devices, in the 2 hours before bedtime
• Consider the possibility of Delayed Sleep-Wake Phase Disorder if symptoms persist 2

4. Manage Daytime Fatigue

• Recommend short (15-20 minute) naps before 3 PM if fatigue is severely affecting functioning 2
• Encourage regular physical activity, preferably in the morning or early afternoon
• Avoid caffeine after noon

Monitoring and Follow-up

• Maintain a sleep diary to track progress
• Reassess after 1-2 weeks on the adjusted schedule
• If sleep efficiency (time asleep/time in bed) exceeds 85% for one week, the sleep window can be increased by another 15-20 minutes 2, 1

Rationale for This Approach

The American Academy of Sleep Medicine guidelines recommend sleep restriction as a standard treatment for insomnia, but emphasize that the initial time in bed should not be less than 5 hours 2, 1. The current patient is effectively getting only 4 hours of sleep, which is below this threshold and likely contributing to excessive daytime fatigue.

Sleep restriction that is too severe can paradoxically worsen insomnia by increasing stress and anxiety about sleep 2. The goal is to find a balance between creating sufficient sleep pressure while avoiding excessive sleep deprivation that impairs daytime functioning.

Common Pitfalls to Avoid

1. Abandoning CBTI too early: CBTI typically takes 6-8 weeks for full effectiveness 1, 3
2. Inconsistent wake times: Varying wake times can disrupt circadian entrainment 1
3. Excessive sleep restriction: Sleep windows that are too short can lead to dangerous levels of sleep deprivation 2, 1
4. Resorting to medication too quickly: Adding sleep medication before optimizing behavioral approaches may undermine the development of natural sleep skills 2, 1

By making these targeted adjustments to the CBTI protocol while maintaining its core principles, the patient should experience improved sleep onset and reduced daytime fatigue while continuing to address the underlying factors perpetuating their insomnia.