{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T03:14:48Z","timestamp":1791947688680,"version":"4.3.4"},"reference-count":65,"publisher":"Oxford University Press (OUP)","issue":"1","license":[{"start":{"date-parts":[[2021,8,31]],"date-time":"2021-08-31T00:00:00Z","timestamp":1630368000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"funder":[{"DOI":"10.13039\/501100000272","name":"National Institute for Health Research","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Oxford Biomedical Research Centre"},{"name":"NIHR-HTA","award":["16\/84\/01"],"award-info":[{"award-number":["16\/84\/01"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2022,1,11]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Study Objectives<\/jats:title>\n                  <jats:p>Sleep restriction therapy (SRT) effectively treats insomnia but mechanisms are poorly understood. Theoretical models suggest that potentiation of sleep pressure and reduction of arousal are key mechanisms of action. To our knowledge, this has never been directly tested. We designed a randomized controlled trial with embedded mechanistic measurement to investigate if SRT causally modifies multidimensional assessments of sleep pressure and arousal.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Participants aged 25\u201355 who met DSM-5 diagnostic criteria for insomnia disorder were randomized to four weeks of SRT or time in bed regularization (TBR), a control intervention that involves prescription of a regular but not reduced time in bed. Sleep pressure was assessed through daily diary appraisal of morning and evening sleepiness, weekly Epworth sleepiness scale (ESS) scores, psychomotor vigilance, and non-rapid eye movement (NREM) delta power (0.75\u20134.5 Hz) from ambulatory polysomnographic recordings. Arousal was assessed through daily diary appraisal of cognitive arousal, the pre-sleep arousal scale (PSAS), and NREM beta power (15\u201332 Hz). Outcomes were assessed at baseline (2-week period prior to randomization), during the intervention phase (1\u20134 weeks post-randomization), and at 12-week follow-up. We performed intention-to-treat analyses using linear mixed models. For continuous daily measures, the treatment period was split into early (weeks 1\u20132) and late (weeks 3\u20134) treatment.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Fifty-six participants (39 females, mean age = 40.78 \u00b1 9.08) were assigned to SRT (n = 27) or TBR (n = 29). The SRT group showed enhanced sleep pressure relative to TBR, reflected in (1) enhanced sleepiness in the evening during early (d = 1.17) and late treatment (d = 0.92), and in the morning during early treatment (d = 0.47); (2) higher daytime sleepiness on the ESS at weeks-1 and -2 (d = 0.54, d = 0.45); and (3) reduced psychomotor vigilance at week-1 (d = 0.34). The SRT group also showed reduced arousal relative to TBR, reflected in lower levels of daily-monitored cognitive arousal during early treatment (d = 0.53) and decreased PSAS total score at week-4 and week-12 (ds \u2265 0.39). Power spectral analysis of all night NREM sleep revealed an increase in relative, but not absolute, EEG delta power at week-1 and week-4 (ds \u2265 0.52) and a decrease of relative EEG beta power at week-4 (d = 0.11).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>For the first time, we show that SRT increases sleep pressure and decreases arousal during acute implementation, providing support for mechanism-of-action.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/sleep\/zsab223","type":"journal-article","created":{"date-parts":[[2021,8,31]],"date-time":"2021-08-31T14:10:55Z","timestamp":1630419055000},"source":"Crossref","is-referenced-by-count":53,"title":["The effect of sleep restriction therapy for insomnia on sleep pressure and arousal: a randomized controlled mechanistic trial"],"prefix":"10.1093","volume":"45","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7335-2320","authenticated-orcid":false,"given":"Leonie F","family":"Maurer","sequence":"first","affiliation":[{"name":"Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neuroscience, University of Oxford, Sir William Dunn School of Pathology , Oxford , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1294-8734","authenticated-orcid":false,"given":"Colin A","family":"Espie","sequence":"additional","affiliation":[{"name":"Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neuroscience, University of Oxford, Sir William Dunn School of Pathology , Oxford , UK"},{"name":"Big Health Inc. , San Francisco, CA , USA"},{"name":"Big Health Inc. , London , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2508-9956","authenticated-orcid":false,"given":"Ximena","family":"Omlin","sequence":"additional","affiliation":[{"name":"Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neuroscience, University of Oxford, Sir William Dunn School of Pathology , Oxford , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1218-675X","authenticated-orcid":false,"given":"Richard","family":"Emsley","sequence":"additional","affiliation":[{"name":"King\u2019s College London, Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience , London , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9581-5311","authenticated-orcid":false,"given":"Simon D","family":"Kyle","sequence":"additional","affiliation":[{"name":"Sleep and Circadian Neuroscience 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research","volume":"3","author":"Kazdin","year":"2007","journal-title":"Annu Rev Clin Psychol."},{"key":"2023031316292174300_","first-page":"207","article-title":"The role of common factors in psychotherapy outcomes","volume":"15","author":"Cuijpers","year":"2019","journal-title":"Annu Rev Clin Psychol."},{"issue":"6","key":"2023031316292174300_","first-page":"675","article-title":"European guideline for the diagnosis and treatment of insomnia","volume":"26","author":"Riemann","year":"2017","journal-title":"J Sleep Res."},{"issue":"3","key":"2023031316292174300_","first-page":"191","article-title":"Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis","volume":"163","author":"Trauer","year":"2015","journal-title":"Ann Intern Med."},{"key":"2023031316292174300_","first-page":"3","article-title":"Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis","volume":"38","author":"van Straten","year":"2018","journal-title":"Sleep Med Rev."},{"issue":"7","key":"2023031316292174300_","first-page":"664","article-title":"Mediators of cognitive-behavioral therapy for insomnia: a review of randomized controlled trials and secondary analysis studies","volume":"32","author":"Schwartz","year":"2012","journal-title":"Clin Psychol Rev."},{"key":"2023031316292174300_","first-page":"102027","article-title":"How does cognitive behavioural therapy for insomnia work? A systematic review and meta-analysis of mediators of change","volume":"86","author":"Parsons","year":"2021","journal-title":"Clin Psychol Rev."},{"issue":"5","key":"2023031316292174300_","first-page":"275","article-title":"The selection and design of control conditions for randomized controlled trials of psychological interventions","volume":"78","author":"Mohr","year":"2009","journal-title":"Psychother Psychosom."},{"issue":"3","key":"2023031316292174300_","first-page":"195","article-title":"Comparing the effects of single-and multiple-component therapies for insomnia on sleep outcomes","volume":"16","author":"Sidani","year":"2019","journal-title":"Worldviews Evid Based Nurs"},{"issue":"6","key":"2023031316292174300_","first-page":"797","article-title":"Dismantling multicomponent behavioral treatment for insomnia in older adults: a randomized controlled trial","volume":"35","author":"Epstein","year":"2012","journal-title":"Sleep."},{"issue":"2","key":"2023031316292174300_","article-title":"Treating chronic insomnia in postmenopausal women: a randomized clinical trial comparing cognitive-behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education","volume":"42","author":"Drake","year":"2019","journal-title":"Sleep"},{"issue":"1","key":"2023031316292174300_","first-page":"45","article-title":"Treatment of chronic insomnia by restriction of time in bed","volume":"10","author":"Spielman","year":"1987","journal-title":"Sleep."},{"key":"2023031316292174300_","first-page":"293","article-title":"Insomnia: sleep restriction therapy.","volume-title":"Insomnia","author":"Spielman","year":"2016"},{"key":"2023031316292174300_","first-page":"127","article-title":"How does sleep restriction therapy for insomnia work? A systematic review of mechanistic evidence and the introduction of the Triple-R model","volume":"42","author":"Maurer","year":"2018","journal-title":"Sleep Med Rev."},{"issue":"5","key":"2023031316292174300_","first-page":"415","article-title":"The evidence base of sleep restriction therapy for treating insomnia disorder","volume":"18","author":"Miller","year":"2014","journal-title":"Sleep Med Rev."},{"issue":"2","key":"2023031316292174300_","first-page":"263","article-title":"Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment","volume":"17","author":"Edinger","year":"2021","journal-title":"J Clin Sleep Med."},{"key":"2023031316292174300_","first-page":"101493","article-title":"The clinical effects of sleep restriction therapy for insomnia: a meta-analysis of randomised controlled trials","volume":"58","author":"Maurer","year":"2021","journal-title":"Sleep Med Rev."},{"key":"2023031316292174300_","first-page":"726372","article-title":"A preliminary evaluation of the physiological mechanisms of action for sleep restriction therapy","volume":"2013","author":"Valli\u00e8res","year":"2013","journal-title":"Sleep Disord."},{"issue":"8","key":"2023031316292174300_","first-page":"735","article-title":"No pain, no gain: an exploratory within-subjects mixed-methods evaluation of the patient experience of sleep restriction therapy (SRT) for insomnia","volume":"12","author":"Kyle","year":"2011","journal-title":"Sleep Med."},{"issue":"2","key":"2023031316292174300_","first-page":"229","article-title":"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","volume":"37","author":"Kyle","year":"2014","journal-title":"Sleep."},{"issue":"3","key":"2023031316292174300_","first-page":"266","article-title":"Ecological momentary assessment of daytime symptoms during sleep restriction therapy for insomnia","volume":"22","author":"Miller","year":"2013","journal-title":"J Sleep Res."},{"issue":"12","key":"2023031316292174300_","first-page":"e0145317","article-title":"Physiological markers of arousal change with psychological treatment for insomnia: a preliminary investigation","volume":"10","author":"Miller","year":"2015","journal-title":"PLoS One."},{"issue":"3","key":"2023031316292174300_","first-page":"237","article-title":"The lancet psychiatry commission on psychological treatments research in tomorrow\u2019s science","volume":"5","author":"Holmes","year":"2018","journal-title":"Lancet Psychiatry."},{"key":"2023031316292174300_","first-page":"1","article-title":"Dismantling studies of psychotherapy.","volume-title":"The Encyclopedia of Clinical Psychology","author":"Papa","year":"2014"},{"issue":"1","key":"2023031316292174300_","first-page":"29","article-title":"Research domain criteria: cognitive systems, neural circuits, and dimensions of behavior","volume":"14","author":"Morris","year":"2012","journal-title":"Dialogues Clin Neurosci."},{"issue":"2","key":"2023031316292174300_","first-page":"102","article-title":"Why do antidepressants take so long to work? 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