Cognitive Behavioral Therapy for Insomnia Part 2: Stimulus Control

Better management of cues for sleep can help overcome insomnia.

Posted May 26, 2009

In the last post I discussed ways to evaluate your sleep. After determining what your sleep pattern is and what factors are contributing to your insomnia, you are prepared to start working actively on getting better sleep. One of the most effective cognitive behavioral techniques available for this purpose is "stimulus control." This method was originally developed by Richard Bootzin and is one of the most widely used interventions for insomnia. The approach has been somewhat modified by other researchers and professionals but the basic concept is the same. Stimulus control is designed to overcome the conditioning that occurs with repeated and unsuccessful attempts to sleep that result in negative associations being built up between the preparation for sleep and the sleep environment with the effort to fall asleep.

The idea of conditioning started with Pavlov's experiments with salivation in dogs. The dogs were given meat powder so that the saliva produced could be studied. It was discovered that the dogs would begin to anticipate the presentation of the meat powder if there were any regularly occurring cues that the food was about to be given. If a bell regularly rang a few seconds before the meat powder was delivered, the dogs learned to start salivating at the sound of the bell in anticipation of the food. This is a reliable and basic form of non-verbal learning that occurs in all animals including humans. Many basic emotional states are conditioned by the pairing of frequently co-occurring events. An emotional or physiological response can thus be conditioned to events in the environment. Advertising depends on the ability of our nervous systems to associate products with the positive or negative emotional states depicted in commercials. Notice also the importance of repetition in this type of advertising- as you see the same commercial again and again and again....

So it is with sleep. When sleep is disrupted for a period of time, for example over a month or more, there is ample opportunity for negative associations to develop between pre-sleep rituals or the bed environment and the physiological process of trying to fall asleep. This is, of course, the environment in which insomnia usually develops - a precipitating event, usually some form of stress or sleep disruption - leads to the onset of acute insomnia. If the insomnia persists it can become chronic and continue long after the original stress or disruption has ended. A major factor in the process of insomnia becoming chronic is the development of conditioned associations between the process of trying to fall asleep and the sleep environment.

If conditioning has occurred so that getting ready for bed or getting into bed arouses negative associations and increases arousal then it will be very difficult to fall or stay asleep. These negative associations can result in suddenly feeling wide awake upon getting into bed or when trying to fall back asleep after waking during the night. Stimulus control can be helpful in these situations. It is designed to break up these negative associations and instead develop positive associations between pre-sleep rituals and the sleep environment, and feeling sleepy.

The stimulus control instructions are designed to re-associate bedtime with the rapid onset of sleep and to establish a regular sleep-wake schedule that is consistent with the circadian (24 hour) sleep/wake cycle. The instructions are:

1. Only go to bed when sleepy. Bear in mind being sleepy is not the same thing as being tired. It is important to be aware of this difference. Sleepiness is signaled by behavioral signs such as dropping eyelids, involuntary head nodding and yawning. This rule helps prevent lying in bed engaging in negative sleep thoughts. Thoughts about how you don't feel like sleeping, how bad it will be tomorrow if you don't sleep tonight, going over everything you have to do in the morning and so on just create arousal and make it harder to fall asleep.


2. If after about 20 minutes you are unable to fall asleep or awaken and find it difficult to fall back asleep, leave the bed and go to another room and engage in a relaxing activity such as some light reading or using a relaxation technique until you do feel drowsy. Then return to bed and repeat as often as necessary until you do fall asleep. It is important to not watch the clock while doing this. It is your subjective estimate of time that is important. It is also important to not engage in stimulating activities such as watching late night horror movies on Fear Net.


3. Use the bed only for sleep and sexual activity. Do not engage in sleep-incompatible activity in bed such as eating snacks, watching TV (especially the evening news with the reports of the several murders that happened in a nearby neighborhood earlier today), or working on your IRS tax audit. These activities obviously will result in arousal and make it difficult to fall asleep. Repeatedly engaging in these kinds of activities helps condition arousal to the bed environment when instead you want to condition a feeling of relaxation to being in bed.


4. Keep a regular morning rise time no matter how much sleep you got the night before. This will help regularize the circadian (24 hour) schedule and if you don't sleep well one night, the drive to sleep will be higher the following night - if you don't dissipate it with low quality, light morning sleep by staying in bed later than planned.


5. Avoid napping. (There is more to napping that will be discussed in a future post but for now the stimulus control instruction is to avoid it.) This prevents reducing sleep drive earlier in the day that can make it harder to fall asleep at night.

With the use of stimulus control many people can begin to overcome their insomnia. In the next post further techniques for managing insomnia will be reviewed.