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Wednesday, October 1, 2014
I am practising stimulus control for insomnia, and at times am not sure if I am sleeping or awake, espcially when I have to get up out of bed after 15-20 minutes of not sleeping. What could be the reason? Am I sleeping or too tired? I am not tossing and turning. I am not very alert either in those situations. Please advise.
Insomnia is a very common in modern society with an estimated 1/3 of Americans suffering from insomnia at any one point in time. Fortunately, the majority of cases are short-term and resolve within weeks, rarely requiring prolonged therapy. However, up to 20 million Americans complain of problems with chronic insomnia that may significantly effects their life, so you are not alone.
Insomnia has multiple underlying causes. Identifying the underlying factors that are contributing to insomnia is extremely important to ensure appropriate treatment. Factors affecting one’s ability to fall asleep at the start of the night, as you describe, are quite varied and may include one or more of the following;
- a poor sleep environment (i.e. the bedroom is too noisy, too bright or too warm)
- learned poor sleep habits (i.e. watching TV to fall asleep)
- excessive use of stimulants (both medications and common substances such as caffeine and nicotine)
- certain medications, stress or anxiety, pain, medical conditions that may make it uncomfortable or difficult to breathe well when lying down
- restless legs syndrome (an irresistible need to move the legs when awake at night)
- circadian rhythm disturbances (when the body’s biologic rhythms are out of synchrony or delayed)
Occasionally some individuals will not have any of these underlying causes contributing to their insomnia and their condition is often labeled as “idiopathic insomnia” or insomnia for which a cause can not be found.
The mainstay of insomnia treatment is cognitive-behavioral therapy. There is also role for sleep aids in some cases. Cognitive-behavioral therapy includes several interventions and techniques. One of the most effective interventions is a behavioral therapy called “stimulus control,” as you are practicing. In this intervention, the individual goes to bed only when sleepy. If unable to sleep within 15-20 minutes, the individual is instructed to get up and leave their bed or bedroom, and engage in relaxing activity such as reading. The individual is to return to bed only when sleepy. These steps should be repeated if the individual awakens spontaneously during the night after being asleep for some time.
There are other interventions that are useful in ensuring the success of the stimulus control therapy. These include regular wake up time, regular exercise, avoidance of caffeine close to bedtime, and maintaining relaxing noise free bedroom. Adherence to the stimulus control is very demanding. Sometimes, the individual is very tired but unable to go back to sleep. In this case it is difficult to get out of bed after 15-20 minutes of unsuccessful initiation of sleep. However, it is critical for the success of the therapy that the individual leaves the bed. The objective of the stimulus control therapy is to dissociate being in bed physically from being sleepless. That is, the main goal is to never be in bed awake beyond a normal period of time considered to be 15-20 minutes. Being awake in bed beyond that duration exacerbates insomnia.
It is common to experience several arousals per hour in normal individuals with or without insomnia. Only if these arousals exceed certain duration (usually minutes), we would remember them. Otherwise we have no recollection of the vast majority of arousals that we experience in our sleep. If someone experienced several awakenings in close succession, possibly 5-10 minute apart, this person may think that he or she was awake throughout the whole time. This accounts for a condition called “sleep state misperception” that is common in patient individuals with insomnia.
It is possible that you are awake for few minutes and as you were trying to decide if it is time to get up from bed per the instructions of stimulus control, you fell back to sleep. When you awaken next, a short while later, perhaps 10-15 minutes later, you recall that you were awake just a while ago, and you recall that you were thinking about getting up. You may then think that you were awake all along. This is a common occurrence whether you are practicing stimulus control or not. Therefore, I would not be too concerned.
I encourage you to continue what you are doing and follow the instructions. It would be helpful for you, however, to review your treatment with your sleep doctor to decide if any other intervention of modification is needed in your particular case. Some of these are listed in the website below.
Rami N Khayat, MD
Clinical Associate Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University