Insomnia_ CBTI, Stimulus Control, Sleep Hygiene (Lecture 3)
本文由 ‘中国推动’ 学者、吉林大学医学院毛宗韬同学编辑整理
Welcome to another MeCram lecture! What we were talking about before was the general approach to somebody with insomnia, and the general approach was to look for diseases that could cause it. If that didn’t elucidate exactly what the cause was, then look for other things.
Specifically, sleep hygiene, stimulus control, which we’re now going to talk about, and then move on to behavioral therapy and medications. We said in the last lecture that medications are actually a lot lower down on the list than what I might think. So in this section, let’s talk about what sleep hygiene and stimulus control are. Here, I’ve got listed the category of sleep hygiene and stimulus control, specifically, the different components of sleep hygiene and stimulus control. They are actually different. So, let’s take this one step at a time.
First of all, sleep hygiene specifically is making sure that you are performing and doing the right things when you go to bed, which ensures that we don’t perpetuate some bad habits that could keep you up at night.
So the first thing is to sleep until rested and then get up. The key here is to get up. We do not want you to stay in bed after you’ve woken up. Some people wake up early and they stay in bed for another hour, which is not a good thing because what we’re doing is we’re associating the bedroom with being awake. We want you to associate sleeping with the bedroom. So sleep until rested and then get up. Get out of bed and do your activity.
You also want to keep a regular sleep schedule, which is to make sure that your circadian rhythm is in tune. It’s gonna be much easier if when it’s time to go to bed you are actually going to bed. So keeping a regular sleep schedule would be important. This can be broken with people who do, for instance, graveyard shifts or nocturnal shifts. So that can be a problem.
Number three: do not force sleep. There’s nothing worse than trying to go to sleep when your body doesn’t want to go to sleep. When your body doesn’t go to sleep, you become anxious; then you associate anxiety with the bedroom, and you get performance anxiety. Remember we called that psychophysiological insomnia. We don’t want that.
Next: exercise regularly, but make sure you don’t do it right before you go to bed. Make sure it’s at least four to five hours before you go to bed because while exercise is good, it can also limit your ability to go to sleep right afterwards.
Number five is pretty obvious: avoiding caffeinated drinks in the afternoon or evening. This is going to ramp you up and it’s going to make it more difficult for you to go to bed.
In a similar token, avoiding alcohol at bedtime. Now this may seem counterintuitive, because alcohol is a central nervous system depressant. However, you have to realize it may help someone go to sleep initially, but because it is so short acting, you’re going to get a rebound awakening maybe two, three, four hours later. So, you might find it in the middle of the night waking up because of alcohol.
You want to avoid smoking in the p.m. I would say avoid smoking altogether. This is for many different reasons, of course, but smoking causes edema of the airway and can exacerbate obstructive sleep apnea among other things.
Don’t go to bed hungry. We want to be satisfied when we go to bed. It’s much easier to fall asleep.
You want to adjust your bedroom environment. So make sure the room is a little bit cooler. Make sure that there is no light coming in. Make sure that you are soundproofed. Just take care of the obvious things that would prevent you from going to sleep. If you sleep with a dog or baby, these things may kick you and maybe wake you up without your even knowing it.
So just be sure that is taken care of, and then deal with your worries before bedtime. I would advise avoiding television or the news, especially the bad news. If you’ve got worries on your mind, you may want to write those things down on a pad and put it on your bedside, and say I’m going to deal with those things in the morning.
Sleep hygiene is one of the first things that we do in somebody who just can’t sleep. And it’s to make sure that we’re avoiding some of these perpetuating factors that could prevent them from going back to a regular sleep schedule.
Stimulus control is a little bit different. Stimulus control has to do with classical conditioning. You remember Pavlov’s dogs? Pavlov’s dogs were these creatures that Pavlov, the scientist, kept. He noticed that before feeding them, if you rang a bell, eventually got to the point where all he had to do was ring the bell, and they would salivate instead of when he put the food in front of them, they would start to salivate. And the reason is that the brain of the dogs associated the bell with dinner time.
In this situation with sleep, we want to associate correct things with the bedroom. We don’t want to associate non–sleep activity with the bedroom. Because if we do that, it’s going to dilute that stimulus control to cause us to go to sleep. So just like on sleep hygiene, we said sleep until rested and then get up. Congruently, we want to only go to bed when sleepy. So, if we go to bed when we’re not sleepy, we’re not going to sleep. Then we associate not being able to go to sleep, the anxiety associated with that, with the bedroom. So what I’m saying here is that, if you go to the bedroom and you can’t sleep, then get out of bed and go to another room in the house.
The other one is to use the bedroom for sleep and sex only. No television, no reading, no eating, no other activity in the bedroom. We don’t want to dilute the stimulus of the bedroom. Number three: get out of bed if not able to sleep in 20 minutes. This goes along with number one. So you would only return to the bed when you were sleepy and you need to repeat this as many times as necessary throughout the night. This is to ensure that your only associating sleep with the bedroom.
Number four is wake up at the same time each day use an alarm clock if necessary. Again, this is kind of congruent with keeping a regular sleep schedule. Finally, no napping. Napping in the afternoon is going to rejuvenate you, and it’s going to reduce your homeostatic drive to sleep when you get to nighttime.
So again, this is sleep hygiene stimulus control. These are the sort of things that we do for an insomnia patient on the initial intake after we’ve ruled out some obvious diseases that could cause the insomnia. Again, if you look at our approach for insomnia. The general approaches, we’re going to look for diseases. We’re going to do hygiene and stimulus.
这是睡眠卫生刺激控制。这些都是我们在排除了一些明显的可能导致失眠的疾病后为失眠症患者做的初步治疗。 再次说明，如果您考虑我们的失眠方法。 一般的方法，我们将寻找疾病。 我们将要进行卫生和刺激。
If that doesn’t work and your patient still has insomnia, then we would move on to the next step with just behavioral therapy and medication. Join us for the next lecture where we talked about behavioral therapy. Thanks for joining us.