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Chronic insomnia — USMLE Step 3 MCQ

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HardAmbulatory Medicine / Primary CareChronic insomniaUSMLE Step 3

A patient in CBT-I has a fixed 6:30 am rise time but lies awake in bed for 45 minutes after nocturnal awakenings. Which instruction specifically applies stimulus control rather than sleep restriction or sleep-hygiene advice?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Leave bed during prolonged wakefulness, do a quiet activity elsewhere, return when sleepy, and keep the rise time fixed

The best answer is “Leave bed during prolonged wakefulness, do a quiet activity elsewhere, return when sleepy, and keep the rise time fixed”. Stimulus control rebuilds the bed-sleep association. Compressing the sleep window is sleep restriction, relaxation is a separate CBT-I component, and extending wakeful time in bed reinforces conditioned arousal.

Reference: VA/DoD 2025 Clinical Practice Guideline for Chronic Insomnia Disorder and Obstructive Sleep Apnea: https://www.healthquality.va.gov/guidelines/CD/insomnia/I-OSA-CPG_2025-Guideline_final_20250915.pdf