Stimulus Control

What do you associate your bed with? Good sleep? Frustrations of not sleeping?

 

Stimulus Control as an effective intervention for sleep problems. In stimulus control we attempt to get one to associate their bed with peaceful sleep. We emphasize the association of relaxing, wind down, sleep-promoting activities to the bedroom in general.

 

More importantly we attempt to eliminate wake promoting activities from the bedroom. Such examples may include TV, computer, texting, or telephone use in bed.

 

Understand the principles of Stimulus Control in its treatment of insomnia.

Part of the origin of Stimulus Control goes to early experiments in Pavlov’s dog. The use of association of particular stimulus to help improve sleep was later expanded by Dr. Richard Bootzin. The use of Stimulus Control is now part of the standard of care in treatment of insomnia by the AASM (American Academy of Sleep Medicine). It is also a key part of other behavioral treatments of insomnia such as CBT (Cognitive Behavioral Therapy).

Everyone is capable for Stimulus Control Therapy. Stimulus Control is appropriate for anyone who has any complaint of insomnia or sleep problems. If you have difficulty sleeping 3 nights per week, or even 3 times per year, all people can benefit.

Stimulus Control is an intervention to help change behavior, with the effect of the changed behavior to be better sleep. Regardless of what the cause of insomnia, including with comorbid disorders such as mood disorders, pain, and trauma of either physical or emotional type. And it is important to realize that improving the quality of sleep has been shown to improve the symptoms of other disorders such as pain scales, depression inventory, and anxiety scores.

What is Stimulus Control?

“Stimulus Control therapy for insomnia is based primarily on an operant learning analysis of sleep: In this analysis, falling asleep is conceptualized as an instrumental act emitted to produce reinforcement (sleep). Thus, stimuli associated with sleep become discriminative stimuli for the occurrence of reinforcement. Difficulty in falling asleep, then, may be due to inadequate Stimulus Control. Strong discriminative stimuli for activities incompatible with sleep may be present (Bootzin and Nicassio, 1978, p. 29).”

Stimulus Control is based on learning therapy. It is not a set of instructions. Instructions are components, but it is intended to change the association with sleep. Re-learn to use cues of the bedroom for sleep. There are additional Pavlovian or conditioning aspects associated with sleep.

Note, Stimulus Control is not a unique concept to sleep only. Stimulus Control has been used in weight loss by eating when only certain cues are present as opposed to compulsive eating. The president of Weight Watchers Stuart actually helped in the development of Stimulus Control in general.

Stimulus Control has also been used in learning, attempting to strengthen cues for studying and reducing cues of distractions. Think about this one, if you study on your bed most people are actually pretty likely to fall asleep. Studying at coffee shop will probably lead to its consumption. And if someone is able to successfully study in bed, they may have problems falling asleep in that bed. There active mind cannot shut off.

The use of strengthening cues for sleep and reducing cues that interfere with sleep is attributed to the 1970’s by Dr. Bootzin. Intent is to make cues for sleep to be only used for sleep.

The goals of Stimulus Control is to strengthen cues for sleep as well as to weaken cues that are incompatible with sleep. And we remember our own natural body process and environmental influences towards a sleep wake rhythm, we then learn to recognize the feeling of fatigue and sleepiness to assist with sleep onset and associate it with sleep specific stimulus.

Goals of Stimulus Control are to strengthen our cues for sleep and to reduce cues that are incompatible with sleep. Through the process we use our own sleep-wake rhythm to assist with our sleep onset. This is why we emphasize basic sleep science as it gives us the knowledge to be able to find a predictable and compatible sleep period.

To meet the goals of Stimulus Control there are a set of instructions. However it is very important to understand the concepts and rationale behind the instructions. Otherwise maladaptive behaviors may be changed to other behaviors that are not compatible with sleep.

Basic Instructions – Must be given rational.

1. Lie down only when sleep.

2. Do not use bed for anything except sleep.

3. If you find yourself unable to sleep, get up and go into another room.

4. If still cannot sleep, repeat step 3.

5. Set your alarm and get up at the same time every morning.

6. Do not nap during day – Increases sleep deprivation that helps drive sleep onset

-Sleep diaries is a critical ingredient of stimulus control

Lie down intending to go to sleep only when you are sleepy. This is an attempt to get you to be able to pick up on your own biological cues for sleep, rather than just looking at your clock to say its time.

One problem seen in insomnia is that people feel a degree of sleepiness all the time and are not sensitive to the development of their biological process, they may run (or worry) themselves to the point of exhaustion and then crash. Much like a child at a New Years Eve party that then crashes to sleep in the car seat. Goal is to make someone aware that they are sleepy rather than to just push themselves to exhaustion.

Do not use your bed for anything except sleep. Do not read, watch TV, FaceBook, or text in bed. Also, don’t worry in bed. Again, we have to think along the line that a day is 24 hours. And it is rare that a person worries at night only, worry generally occurs all day long or with specific day circumstances that make you concentrate harder to stay focused on a task that needs to be accomplished. Bringing worries to bed is not compatible with sleep. In fact, sleep and panic are not compatible. Have you ever had a dream you missed a step and woke up to a jerk in your body? Yes. Have you ever had a dream that you missed a step and cracked your head with blood everywhere? No, because panic and sleep coexist about as well as a donkey and elephant in a political debate. Though you cannot tell a person not to worry, you can tell them if you cannot sleep because of a sense of worry get out of bed.

Sexual activity is the exception to that rule, as this actually can promote sleep, hence “sleeping together”.

If you find yourself unable to fall asleep, get up and go into another room. Stay up as long as you need to unwind or until you feel sleepy. Although we do not want you to watch the clock, we want you to get out of bed if you do not fall asleep before you start to get thoughts of frustration about not sleeping. Remember that the goal is to associate your bed with falling asleep quickly. There is no magic time of which you should be asleep by. Some have proposed not to be in bed for more than 10 minutes, but others have said that 30 minutes may be normal in getting to sleep. However, if you feel agitated that you are not asleep, the time just doesn’t matter, get out of bed.

Sometimes environmental changes need to be made. You may need to have a different place to watch TV, or for kids have a separate play room.

How long should someone wait before they go back to bed. Again there is no magic number.  Bootzin created Stimulus Control for sleep and he states “stay up as long as you wish”. Michael Perlis is one of the foremost leaders in CBT (Cognitive Behavioral Therapy) for insomnia and I heard him say 30 minute intervals. His rationale is reasonable. He states that no matter how many times you tell someone not to watch TV, they will watch it anyway, hence the period of time of a TV show is his general rule.

What should a person do when they are out of bed? Activity that is restful and not stimulating. I once saw a list of sleep hygiene that a doctor had created. On it is said if you cannot sleep get out bed, do not watch TV, and read a boring book. Just the notion of being told to read a boring book actually bothers me more than not sleeping in bed and to think that is a solution is naïve. Activity such be relaxing not punishing.

What is important is the perception that you are falling asleep, not the time it takes. The goal isn’t to make you watch the clock or watch TV for ½ hour increments, but rather pick up on our biological cues that we are entering the drowsy state of N1 Non-REM sleep with slow roving eye movements and sense your respirations.

If you cannot fall asleep get back out of bed, and repeat this as often as necessary.

Set your alarm and get up at the same time every morning irrespective of how much sleep you got during the night. This will help your body acquire a consistent sleep rhythm. It is with the combination of Stimulus Control and Sleep Restriction that we are able address unites the behavioral science of associating the cues to sleep with the biological science of sleepiness.

Public health note, as well as legal note. If you sleep less than 4 hours then you should not drive. Driving under conditions of sleep deprivation is more dangerous than driving under the influence of alcohol.

Do not nap during the day. When you nap during the day, remember that the deep sleep comes early and that is the refreshing part that reduces our adenosine content (fatigue inducing product discussed in videography). Napping in daytime reduces your sleep drive at night.

Whatever lack of sleep you got from a sleep deprivation moment, you want to use that to help strengthen your sleep drive the next evening, and a nap will dampen that sleep drive and further contribute to body-environment misalignment.

Now even avoidance of napping is not universal. In the elderly that needs to have nap reintroduced we would be better scheduling a short nap of less than 40 minutes to be able to get through the day, but at a time that would not interfere with sleep onset. Also in the shift worker scheduling a nap prior to work is going to allow them to stay awake as they make our 24 hour society run. – Irregularity of the nap is equally damaging as the nap itself.

Adherence:

Completing sleep diaries. One problem with diaries is that you can forget or misplace them if they are on paper.

Not using the bed and bedroom for activities incompatible with sleep or promoting of wake.

Following the instructions for getting out of bed in about 15 minutes. There is a balance between not time watching but having something go on over time.

Going back to bed rather than just staying up. Problem occurs when awakening occurs around 4 A.M., some may say I will not sleep anyway, but even getting an hour extra of sleep is helpful.

Preparing for being out of bed in the winter.

What to do about comorbid disorders. Helping the sleep will help the comorbid disorder without treating the comorbid disorder.

I have a confession to make. If cannot sleep I watch TV. WOW!!! WHAT??? Let me further explain. There was a time in my life in medical school that I had a very specific daily regimen down to the wire. I woke up every day at 6 A.M., I would go for a jog, then I would go to class. After class I would study in the library. I would then eat at Gladstone’s chicken, go back to the library and study some more. When my mind would start to numb I would leave the library and go to Powerhouse gym where I would have intense work outs. Then I would go home and eat rotisserie chicken and cantaloupe. Since they did not teach me about sleep in medical school I had a TV in my room. At that time Star Trek Voyager with Captain Janeway and Chakote was playing. I would lay in bed and fall asleep to Star Trek Voyager. I did this every night, even on the weekends I would hit the gym at the same time and get to bed. The reason this never bored me was because I honestly never saw many Star Trek episodes to its conclusion. My daytime activity and mental energy was so rigid, that indeed I was like a 10 year old that crashed in a car seat after a New Years party. To date, though I no longer have a TV in my room, sometimes I will go to the couch to wind down before bed and I play DVR Star Trek episode on SyFy channel. I still cannot remember the last time watched an episode of Star Trek to completion. My behavioral science has been entrained to feel my biological science.

Now, I don’t watch football at night before bed. In fact I have another confession, anyone who knows me will tell you how much of a football nut I am, but I can’t stand Monday Night Football. I hate it because its on too late. But I also can pin point the day I stopped watching Monday Night Football. It was in 2003. Buccaneers played the Colts after the Bucs won the 2002 superbowl. I went to that game, Bucs were winning and then on Tony Dungy’s birthday Payton Manning made a historic comeback to bring the game into overtime. Then the Colts won the game. I was a first year resident intern in pediatrics that year. I still had to get home, then had to wake up at 5 A.M., then I was on hospital call that next day and went through a 36 hour continuous work period. Besides that the second most exhausting time in my life was the birth of my first child when my wife went into labor at 9 P.M. but my son didn’t want to come out until 4 A.M. I remember my wife waking me up in between contractions that she was even pushing through.

When I connected the dots in writing this book I realize that it was during residency that I began to use melatonin for getting to sleep because the thought of not getting to sleep and being tired the next day infuriated me.

I share my experience not to nullify the work of sleep experts prior. The power of association with positive and negative experiences is real. Its not stone tablets of 10 commandments and follow or you will not sleep. Psychological influences can indeed physical symptoms of sleepiness. And frankly its not unique to sleep.

 

Stimulus Control falls into a general model of social learning and conditioning.

General evidence for the role of conditioning and learning does exists. One example that is commonly seen is the change of sleep that one may have in a hotel. Commonly people will sleep better in a hotel then they do at home. There is a reason why there are commercials of people being alert and doing things they have never done before after staying at a select hotel.

 

We can use Stimulus Control to change our thoughts about our room, our bed, our sleep. If we have negative thoughts, thoughts that lead to insomnia, we try to unlearn these behaviors. The perception of how one sleeps can interfere with one’s sleep more than the underlying cause of poor sleep. Poor perception of how we sleep can even cause a state of Hyperarousal; wake up at a pin drop so to speak.

In fact, a common observation in treatment of insomnia is that one may sleep better in a different environment. Sometimes patients with chronic insomnia may not take their sleep aids on vacation but sleep well during that time.

People with insomnia are frequently very mentally engaged in worries and environmental factors as they try to sleep.

There are some important factors in the treatment of insomnia that need to be addressed before attempting to treat. One is the self-monitoring of sleep. Monitoring of sleep can be done with daily self diaries. Paper diaries have been traditional but with the technology age these can be done electronically including on one’s smart phone. I have seen some patients download applications on their smart phone that can calculate the amount of motion one has during the day time, and when that is compared to motion decrease in the night time it can estimate a degree of sleep. Daily logs help provide information that a monthly questionnaire may not provide, as if the perception of poor sleep is present one can report they only get one good night of sleep per night when in fact they get adequate sleep more nights of the week then poor nights of sleep. This also helps in being able to monitor progress of the sleep tx, otherwise every bad night of sleep makes the individual feel there is no progress being made.

One note that I would make is that daily logging of our sleep should be done with the assistance of person trained in behavioral sleep medicine or CBT (Cognitive Behavioral Therapy) trained psychologist. One theoretical problem that can arise is the clock watching that occurs may contribute to Psychophysiological insomnia.

Commonly people with insomnia feel they are a victim of their problem. They feel there is nothing that can be done, because they feel that everything has already been done. It is important to change is the attitude of being a victim, to rather developing coping skills of what to do when there is a night of bad sleep.

It is important to develop coping attitudes towards a night of bad sleep. After all, even when sleep begins to gradually improve in someone who prior did not sleep well 3 nights per week is bound to have other days in the month where there is a night of bad sleep.

Daytime thoughts need to be addressed as well. Even though we frequently are trying to treat the “sleep”, the thoughts of the poor sleep may consume the 24 hour day. Stresses during the day can further influence night sleep.

Treatment of additional/independent day time issues are important as well as we don’t want to misattribute that to be a result of poor sleep, which can further fuel our frustrations of insomnia.Insomnia

2 Responses to “Stimulus Control”

  1. Helen

    I have recurrent chronic insomnia and discovered sleep restriction therapy for myself about 10 years ago. Although it works for me, it takes a very long time and every year or two I have a recurrence of my insomnia. This time I’ve had for 4 months and I’m not seeming to make progress–constantly spinning my wheels. After reading your article, I think the problem is that I go through the motions of stimulus control, but all the time I feel huge anxiety that continually builds through the night every time I get up to do a “soothing” activity. I’m not feeling sleepy when I go back to bed and therefore, I don’t fall asleep and stay up the whole night quite often. How does one deal with this kind of anxiety that builds when attempting to follow stimulus control? My whole life is topsy turvy because of the degree of sleep deprivation that I am experiencing. I can’t drive the car and feel like I am not coping well. Thanks for any tips. . Up to now I’ve always managed this problem without any support from professionals but I’m starting to think I need some help with this.

    Reply
    • Dr Jose

      First and foremost, sorry for your difficulties. I’ve been through insomnia and understand the difficulties that it brings.

      Second and most important, you have brilliant insight towards yourself. Up till now you have managed without professional help, and I think you pointed out to yourself that it is time for professional help. CBT-Online through Sleepio.com may be helpful if you do not have a behavioral sleep medicine specialist in your area.

      Lastly, I personally believe that the difficulty with Sleep Restriction, CBT, and Stimulus Control methods is that they are commonly done alone. I strongly advise some type of relaxation response be added.

      How do you control your anxiety at night? By first having full control of it during the day!

      For sleep tips that may help tonight, check out Bubbles to Sleep and Mindfulness Links on this website.

      Reply

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