Stimulus Control Therapy - How To Treat Insomnia

By Melissa S. Lim, M.D., FAASM

‘Begin at the beginning and don’t leave anything out’ states Ghosh, the brilliant internist turned reluctant surgeon in Abraham Verghese’ novel Cutting for Stone (2009, Knopf, 2010 Random House). Ghosh asks this of each patient he examines, listens carefully to every word, knowing that the key to the patient’s diagnosis lies in the story they are about to tell.

The day to day practice of modern medicine may not require the diagnostic acumen and sharp listening skills needed in Ghosh’s Ethiopia, but the importance of the patient’s story remains true. But how much time does a patient need to spend with their doctor to live longer? How can we even treat insomnia? We often get asked how to treat insomnia, but we don’t really know. Maybe a 30 minute visit would not make a difference in your survival compared to a 15 minute visit, but you would probably rate your experience higher and trust that your doctor heard you, with a longer visit. And chances are, your doctor’s satisfaction with your visit would be higher as well.

The treatment of insomnia patients presents a particular challenge in the setting of a typical doctor’s office visit. Most patients with insomnia see their family doctor first with complaints of poor sleep. In fact, insomnia is the most common sleep diagnosis, with 50 million adults in the US having insomnia at some point in their life, and 15 million experiencing long term, or chronic, problems falling and/or staying asleep. The 15-minute office visit may be totally fine for evaluating a patient with cold symptoms, but will not scratch the surface of evaluating someone with insomnia. Short visits with the doctor increase the chances of a patient getting a prescription for a medication instead of a therapy session. Although that may be easier for both the patient and doctor, the long term safety of taking sleeping pills on a regular basis needs to be viewed with caution.

As a pulmonologist first, and sleep specialist second, I needed to find my own framework for treating patients with insomnia. Doctors in our specialty are generally more comfortable treating obstructive sleep apnea, since we inherently understand the physiology of collapsible tubes (i.e. the upper airway that becomes blocked during sleep in people that suffer from obstructive sleep apnea). But when we dare to treat the broader range of people with sleep problems, we will come up against the beast of insomnia. The common concomitant psychiatric diseases such as depression and anxiety seem too daunting. Plus, getting people to change the way they think and behave around their sleep-wake schedule seems impossible to achieve. But do we just “punt” our insomnia patients to the nearest insomnia support group and wait for those consultations to return to our inbox?

That may be the best decision, depending on the doctor’s ability to accommodate insomnia patients into their practice, but I personally did not want turn away my patients with insomnia. I turned instead to Canadian psychologist and researcher Charles Morin, Ph.D. I attended a lecture of his on Insomnia back in 2003, and came away with many practical tools I use today to treat my insomnia patients.

For years I have been working with my office staff to create a program for insomnia patients that now looks something like this:

Initial visits are 1.5 hours, and I ask patients to ‘begin at the beginning and don’t leave anything out’. I need to know about family structure and upbringing, violence experienced and witnessed, sleep patterns over their life span, when did the insomnia begin and what were the precipitating factors? Are there signs and symptoms of depression or anxiety? Do they have a type A personality (this is the person who thinks something should have been done yesterday). What medications, both over the counter and prescribed, have they tried and what were the reactions? Are there signs or symptoms of other sleep disorders like obstructive sleep apnea or periodic limb movements? At this first visit I explain the behavioral approaches to treating insomnia, since these are safer, more effective, and longer lasting than medications.
The next follow-up visit is scheduled for 2-3 weeks to review sleep logs, and then monthly for 6 additional visits. We usually schedule these follow-ups at the time of the first visit, since the waiting time for an appointment can be 2-3 months otherwise. A note here: if frequent follow-ups are not arranged then the likelihood of changing behavior decreases significantly.
My goal by the end of the first visit is to determine the patient’s ideal wakeup time, and we SET THIS TIME with an alarm clock. If they follow stimulus control principles alone and get out of bed when the alarm goes off, sometimes that is enough to work out of their insomnia pattern.

STIMULUS CONTROL THERAPY:

Go to bed when you feel sleepy, not when you think you should go to bed.
Get out of bed if not sleeping for more than 15-20 minutes.
Eliminate naps.
Use the bed and bedroom for sleep only.
Maintain a regular wakeup time, and get out of bed close to the time you wake up.
At the second visit we review their sleep logs and see what patterns emerge. I do NOT have patients keep sleep diaries since that is more information than I need to see (but can be optional and serve as a sleep “calorie counter” for the patient). By keeping sleep logs, patients graph their own data.
- Sleep log instructions and example:
  ____________12 AM_________________6AM_____________
  ______________IIIIIIIIIIIIIII IIIIIIIIIIIII IIIIIIIIIIIIIII_________
  - Each morning, draw an arrow down when you got into bed and an arrow up when you got out of bed.
  - Color in the times you think you were sleeping.
  - If you miss a day, just skip it and move on to the next.
The follow-up visits can be lengthy as well for insomnia patients, since the issues—both medical and psychological– that keep the pattern of insomnia going, often need to be reviewed. If Stimulus Control Therapy alone is not enough, we move on to Sleep Restriction Therapy (SRT), which is a program of controlled sleep deprivation. We start with the patient’s wake up time, set it in stone as much as possible, then subtract 7 hours from the wake-up time to determine the patient’s first intended bed time. Note here that the many published studies validating SRT as an effective treatment restrict patients more severely, to 5 hours per night, initially. However, even mentioning this time restriction to a patient may cause anxiety and panic—“What do I do for that much time? How can I handle being that exhausted?” And since I am treating people in the context of a medical practice, not a support group setting or therapist meeting, I usually start with “SRT Light” –6 or 7 hours–instead of 5 hours.

My written prescription for SRT looks like this:

Set a regular wake-up/get-up time: __________.
Do not attempt to get into bed until _______hours before this time, so for example, if you pick a wake up time of 7 AM, and a sleep restriction program of 7 hours, you would not get into bed until 12 midnight.
Keep sleep logs and track your sleep efficiency.
Once your sleep efficiency is >=85% for about 2 consecutive weeks, add 15 minutes to your bedtime. In the above example, this would mean going to bed at 11:45 PM.
Continue adding 15 minutes to your sleep time about every 2 weeks, until you feel refreshed during the day and have achieved ~85% sleep efficiency.

(*Sleep Efficiency=Time asleep/Time in bed x 100)

Note that this is a prescription, even if no medications are prescribed, and I sign and date it.

Why emphasize “Sleep Efficiency”? Although we would all like a “magic sleeping pill,” something that will “knock us out” for 7-8 hours per night, give us the right amount of all the stages of sleep, and come with no side effects, such a miracle drug has not been invented. We do not have a way to directly improve sleep quality, so instead we focus on sleep behavior—what we can control is when we get in and out of bed. We cannot control when we fall asleep. Our brains are way more powerful than the average sleeping pill out there—prescribed or not–so even if we take a pill before bed, we sometimes lie awake wondering if we will ever fall asleep, disappointed time again in the medications. It turns out that keeping a regular schedule and focusing on our sleep efficiency is the best path towards improving sleep quality.

SRT shrinks the window of opportunity to sleep, increases the pressure to sleep, thus utilizing sleep deprivation as a tool to improve sleep efficiency. Once our brain knows when our wake up time is, it can deliver the stages of sleep to us in the proper proportion at the right time. We go through all the stages of sleep, non-REM (rapid eye movement) and REM, multiple times in a given night. Deep stage sleep (Stage 3 Non-REM sleep) predominates in the first 3^rd of the night, and REM sleep concentrates in the last 3^rd, and gets longer with each round. We feel the most refreshed, like we really had a good night’s sleep, when we wake up after that last long REM period in the morning.

Under SRT, once sleep efficiency improves to 85% for 2 weeks, then sleep time is added to the bedtime little by little (i.e., by going to bed earlier).

Do we all need 8 hours of sleep per night? No. Forget the 8-hour myth! Most adults need somewhere between 7-9 hours per night as their ideal, but the normal range may be as wide as 6-10. How much sleep a person needs is an individual determination, based on how much sleep it takes to feel generally refreshed and alert during the day. There are short sleepers and long sleepers, although the “super short” and “super long” ones appear to have more health problems.

So, in my journey to becoming a non-psychiatrist doctor that treats insomnia patients, I have learned many things about how to treat insomnia. Pardon me in advance for these generalizations, but these are just some observations collected over the years:

It is possible to treat insomnia in a medical practice, and focus on behavioral treatment, which is safer and longer lasting than medications.
Behavioral therapy takes time. (My staff follow the “2 insomnia patients per day” rule.)
Changing behavior is hard to do (anyone try to lose weight, stop smoking, or cut down on alcohol lately?).
Insomnia patients tend to be slightly (or more than slightly) anxious, self-critical, high achievers, and you often need to be there simply as their biggest cheerleader.
If they are already on medications for their insomnia, leave the medications alone–at least at the beginning. Don’t give them something else to worry about.
If the patient has depression or anxiety, co-management with a psychiatrist is a must. Do not worry which came first–the sleep disorder or the mood disorder. Treating both gets both better faster, and better sleep helps keeps the mood disorder in check.
If they have struggled with insomnia for some time before going to a doctor, they are already using some coping mechanism. Introducing behavioral therapy disrupts this coping mechanism and may make them feel worse before it makes them feel better. This needs to be reviewed and warned at the outset.

And a parting (but not final) note about my insomnia patients: They are people sensitive to their internal and external environments, and may be quick to mingle their emotions with their intellectual and daily life. Frequently, they are artists, writers, musicians, and other creative souls. I thank them for their sensitivity, for what they create makes my life richer. Our job is not to change who people are, but to help them live with who they are.

Taking advantage of today’s technology, we developed SomnologyMobileDoc, an interactive, affordable mobile app that leads users to–and through–their sleep diagnoses and treatments, especially users with insomnia and obstructive sleep apnea.

How it works (brief version):

Users begin with the Sleep Questionnaires and, based on their answers, are led to their possible diagnoses. If user has Insomnia, they may follow 2 separate behavioral treatment program, starting with Stimulus Control Therapy and, if needed, followed by Sleep Restriction Therapy. Alternatively, users may access SCT and SRT directly from the Home Screen. The app contains a sleep log meter so our users do not have to carry around notebooks and graph paper.

Melissa S. Lim, MD, is the Medical Director and founder of Redwood Pulmonary Medical Associates. Dr. Lim is board certified in internal medicine, pulmonary diseases, and sleep medicine.