Behavioral Topics

Stimulus Control

Sleep Restriction

Stimulus Control

Stimulus control is when a specific stimulus, a thing or event, causes a predictable response.

Stimulus control is found commonly in daily life and each person has different things and events that cause a stimulus control connection with a predictable response.  Stimulus control can be connected to good and bad responses.
- Smelling coffee leads to feeling more awake.
- Sitting at a work desk causes attention and motivation to work.
- Sitting in a recliner chair causes relaxation.
- Seeing a lighter causes a craving for a cigarette.
- Hearing someone else open a drink or unwrap a candy causes a desire for a soda pop or candy bar.
- Hearing the music from the ice cream truck causes a craving for ice cream.
- Experiencing a pet peeve automatically makes us respond in a strong negative way.
- A baby is given a pacifier and automatically feels comforted.
- The environment of a party (the music, lights, crowd of people) causes the desire to smile, talk and dance.
- The environment of a library (quietness, rows of books, smell, lighting) causes people to want to whisper, be quiet and think of others.
- The environment of a kitchen (the smells, sounds, look) causes us to think about food.

Stimulus control is all around you. Stimulus control happens all through your day.

Stimulus control impacts wakefulness and sleep.

The sleep area should be a stimulus that causes the predictable response of being sleepy and falling asleep.

If you lay awake in bed for more than 20 minutes, you have lost this connection of the bed causing sleepiness and falling asleep. In fact, you may have created a new connection for the sleep area to be a stimulus that causes a feeling of being awake! The opposite of what a you want!

Stimulus control connections are created by positive and negative rewards and routine behavior. Stimulus control connections can be created and changed.

Dr. Bootzin wrote a paper in 1972 on stimulus control treatment for insomnia. He applied the principles of stimulus control to sleep. He showed in this first research paper on stimulus control treatment for insomnia that someone with insomnia could use behavior to create a positive stimulus control connection between the bed and sleep and in that way, improve sleep. In this 1972 paper the person with insomnia improved from waking up five times per night to zero times per night after two weeks of treatment. After that, the person woke up about once per night and was able to fall asleep. You remember from the topic on sleep information that waking up briefly through the night and easily falling back asleep is normal because we go through sleep cycles.

Source: Bootzin R.R., Stimulus control treatment for Insomnia. Proceedings, 80th Annual Convention, APA (1972) 395–396.

The rules Dr. Bootzin used are:

1.  Lie down intending to go to sleep ONLY when you are sleepy.
2.  Do NOT read or watch television in the bedroom.
3.  If you find yourself unable to fall asleep GET UP and go into another room. Stay up as long as you wish and then return to the bedroom to sleep.
4.  If you still cannot fall asleep, repeat Step 3.  Do this as often as is necessary throughout the night.

It can be stressful to get out of bed when you want to be sleeping but the goal is to work hard for a few weeks to months and change your brain connections to be a good sleeper for years.  If you are not falling asleep within 20 minutes or you cannot fall back asleep within 20 minutes after waking up in the middle of the night you need to get out of bed. You have to make a strong connection that the sleeping area is only for sleeping.  Don’t let your brain connect your sleeping area with being awake!

Sleep Stimulus Control WORKSHEET:

What is stimulus control?

What is an example of a stimulus control in your everyday life?

Do you have a strong association with your sleeping area and being sleepy and falling

Asleep right away?

Are you open to trying sleep stimulus control?

What are the steps of sleep stimulus control that Dr. Bootzin designed?

Sleep Restriction

Sleep restriction is another behavior to help improve insomnia. Like stimulus control, you may dread doing it but short-term sacrifice leads to long-term benefits.

Sleep restriction was described in 1983 in a research paper by Dr. Spielman, Dr. Saskin and Dr. Thorpy. In this paper, they showed that sleep restriction improved sleep efficiency from 68.9% to 88.3% and the total sleep time improved. This means that before treatment on average the sleepers were only sleeping about 70% of the total time they were lying in bed. After treatment on average the sleepers were sleeping about 90% of the total time they were lying in bed. They improved efficiency by 20% and slept more total time each night.

Source: Spielman AJ, Saskin P, Thorpy MJ. Sleep Restriction: A New Treatment of Insomnia. Sleep Res 1983; 12: 286.

Sleep restriction is important to efficient sleep so that you are asleep more of the time that you are in bed. Using sleep restriction helps you fall asleep faster and be awake less through the night. It seems odd that forcing yourself to sleep LESS for a period of time helps you sleep MORE in the long run but it really works! Doing sleep restriction for a few weeks helps you sleep better for months and years if you keep up the rest of the good sleep behaviors and thoughts.

**Important: Do not restrict your total sleep time to less than 5 hours. If you have any mental or medical health conditions talk to your healthcare provider about guidelines that may be specific to you. Sleep restriction may not be healthy if you have bipolar disorder, another sleep disorder, a seizure disorder, chronic pain or other health conditions or risk factors.

First, we will learn about sleep efficiency and then apply that to sleep restriction to improve sleep.

What is sleep efficiency? Sleep efficiency is the time you are asleep compared to the amount of time you are in bed. You can calculate this as a percentage by dividing the time you are asleep by the time you are in bed and then multiplying that by 100.

Time Asleep / Time in Bed x 100 = % Sleep Efficiency

We will use the same example throughout this explanation on sleep efficiency and sleep restriction.  Example:
Bedtime:  10 pm
Fall Asleep Time:  11 pm (it took 1 hour to fall asleep)
Awake:  2 am to 3 am (1 hour of being awake in the middle of the night)
Wake Up:  7 am (1 hour of lying awake in bed after waking up)
Out of Bed:  8 am

It took 1 hour to fall asleep, 1 hour of being awake in the middle of the night and 1 hour of being awake in the morning before getting out of bed. This is 3 hours of being in bed but not asleep and 7 hours of actually being asleep. The time asleep is 7 hours. The total time in bed is 10 hours.

The sleep efficiency calculation is: 7 hours Time Asleep / 10 hours Time In Bed x 100 = 70% Sleep Efficiency
(7 divided by 10, then multiplied by 100, equals 70%)

The sleep efficiency can be calculated for each night over the last 5 nights, added together and then divided by 5 to get the average sleep efficiency for 5 nights.

NOW … what should you do about that number? The guidelines for this sleep restriction are from a 1987 paper on treatment of insomnia by the Dr. Spielman, Lauren Caruso, M.S. and Dr. Glovinsky. The goal is to get sleep efficiency greater than 85% to 90% or higher. If your sleep efficiency is greater than 85% on average for two weeks then you do not need to do sleep restriction.

Step 1: Collect information about your personal sleep by recording a sleep diary for two weeks. Calculate the sleep efficiency and total time asleep each night.
Example: In this example it is the same every night - 70% sleep efficiency and 7 hours asleep each night.

Step 2: Set a personal wake-up time based on the needed time to get up for the day. The wake-up time should stay the same every day.
Example: 8 am wake up time each day

Step 3: Take an average of the total time in bed from the collected sleep diary information.
Example: Sleep efficiency 70%, 7 hours asleep each night

Step 4: RESTRICT the time in bed to the average time actually asleep. Count back from the set wake-up time to figure out the new bedtime.
Example: Wake up time set at 8 am. Restricted to 7 hours in bed each night. Counting back from 8 am that means the new bedtime is 1 am.

Step 5: Continue to record sleep diaries. Stay with the restricted time until the sleep efficiency is 90% or greater.

Step 6: Once the sleep efficiency is 90% or greater increase the time in bed by 15 minutes by setting the bedtime 15 minutes earlier.
Example: New bedtime 12:45 am instead of 1 am

Step 7: Do not change the new sleep schedule for 5 days. If the sleep efficiency continues to be 90% or greater add back 15 minutes every 5 days until the sleep efficiency drops lower than 90%.

Step 8: If sleep efficiency is between 85% and 90% do not change the sleep time, total time in bed.

Step 9: If sleep efficiency drops below 85% on average for the last 5 days then decrease the total time in bed by 15 minutes.

Source: Spielman A., Caruso L., Glovinsky P., A Behavioral Perspective on Insomnia Treatment. Sleep Disorders. 1987;10(4):541-553.

After weeks of this hard work you will have efficient sleep AND a set wake up time and set bed time. It is important to keep a set wake up time. This work also helped you experiment and find out what is the best total sleep time for you each night. Maybe you found out that you are well rested and have good sleep efficiency at 7 hours per night and you should not be in bed longer than that each night. Maybe you found out that you continued to have high sleep efficiency until you reached 9 hours of sleep each night and you need to plan for 9 hours of time in bed and asleep each night.

Sleep Restriction WORKSHEET:

What has your sleep efficiency been for the past two weeks?

What is the concept of how sleep restriction works?

Do you need to restrict your sleep to improve your sleep efficiency?

Do you have any health conditions that would limit how you use sleep restriction?

What is a good time to set as your wake-up time?

How many hours should you restrict your sleep to?