avoiding sleep

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Sleep MattersThe impact of sleepon health and wellbeingMental HealthAwareness Week 2011

AddressMental Health Foundation

Sea Containers House20 Upper GroundLondon SE1 9QBUnited Kingdom

Telephone020 7803 [email protected]

10IBSN 978-1-906162-65-8RegisteredcharitynumberEngland801130ScotlandSC039714MentalHealthFoundation2011


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04 Executive summary08 Introduction12 Part 01 Sleeping and sleep patterns28 Part 02 Poor sleep48 Part 03 Sleeping well62 Conclusion66 Useful resources68 References72 Appendix: Sleep diary76 Acknowledgements

01

Contents


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The main facts in

human life are five:

E. M. Forster


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Sleep is the best

meditation.Dalai Lama


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0908

Introduction We spend, on average, approximately a thirdof our life asleep. Along with eating, drinkingand breathing, sleeping is one of the pillars formaintaining good mental and physical health.Ultimately, we would die if we did not sleep.

Despite its obvious importance, sleep remainsa mysterious realm that has fascinated us forthousands of years. For example, in the Greekpantheon sleep is represented by the winged godHypnos, himself the son of Nyx, goddess of theNight. Closely related to Hypnos were Thanatos(god of death) and Morpheus (god of dreams).As human beings, most of us cross the bridgebetween the conscious to the unconscious on atleast a daily basis. Yet, we seldom give a secondthought to the countless physiological andpsychological processes that occur within ourbodies and brains when we are deep in slumber.

The aim of this report is to raise awareness about

the importance of sleep and its crucial role forour health, both physical and mental, just like dietand exercise. In Part I of this report, we provideinformation about sleep, why we need to sleep, andwhat happens during sleep.

In Part II, we review the literature on sleep problemsand explain what can happen if we dont sleepproperly. In Part III, we describe ways in whichwe can improve our sleep and explain possibletreatments for those who nd achieving goodquality sleep dicult. The primary focus of thisreport is sleep and mental health; both how mentalhealth can aect our sleep, and how sleep canaect our mental health.

The report includes primary data from the GreatBritish Sleep Survey, developed by Professor ColinEspie at the University of Glasgow in associationwith Sleepio Ltd.

The survey has been available online from March2010, and aimed to take a snapshot of the UKssleep habits. By December 2010, there had been6708 responses to the survey. This survey is stillonline: you can take part by visiting the Sleepiowebsite, www.sleepio.com.


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A good laugh and

a long sleep arethe best cures in

the doctors book.Irish proverb


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Sleeping and

Sleep Patterns


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The rst part of this reportdescribes the sleep processin detail, providing informationabout how and why it isessential to maintain good

quality sleep throughout ourlives, and on the problems thatcan arise during sleep.

What is Sleep?Sleep is often seen as timewhen the body is inactive.In fact, the opposite is true.Sleep is an active, essentialand involuntary process,without which we cannotfunction eectively. Sleep isnot a lifestyle choice; just likebreathing, eating or drinking,it is a necessity.

Sleep is a complex process duringwhich our body undertakes a numberof essential activities. It involves lowawareness of the outside world, relaxedmuscles, and a raised anabolic statewhich helps us to build and repairour bodies.

Primarily, sleep is for the brain, allowingit to recover and regenerate. Duringour sleep, the brain can processinformation, consolidate memory,and enable us to learn and functioneectively during daytime01. This iswhy we are encouraged to get a goodnights sleep in the run up to a jobinterview or exam rather than stayingawake all night to prepare.

Whilst we sleep, our brain is notonly strengthening memories butit is also reorganising them, pickingout the emotional details and helpingus produce new insights and creativeideas02.

Sleep aects our ability to uselanguage, sustain attention,understand what we are reading,and summarise what we arehearing03. If we compromise onour sleep, we compromise on ourperformance, our mood, and ourinterpersonal relationships. Sleephas also been shown to protectthe immune system04.

Animals have evolved to sleepin many dierent ways. Dolphinscan sleep using only one half of theirbrain at a time. Even hibernatinganimals have been shown totemporarily cease hibernation, goto sleep (a dierent, active process),then return to hibernation05. Sleepis an inconvenient, time consumingprocess, but it is so essential thatwe have simply evolved to t it intoour lives.


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In humans, the amount ofsleep a person needs dependsupon their age. New born babiestend to sleep for an average of1618 hours per day, which decreasesto about 1314 hours after one year.Adolescents tend to require moresleep than adults, possibly due tothe physiological changes that arehappening in the body during thisperiod.

As the person reaches adulthood theytend to sleep 78 hours per day. Olderadults tend to sleep roughly 67 hoursper day07, but take more frequent napsthroughout the day. The amount of

time an average adult needs to sleepvaries from person to person, and canrange between 5 and 11 hours.

Still, it is important for us to gauge theamount of sleep that we need and toensure that we get the right amount.There is no set amount of sleep that isappropriate for everyone. For example,although Margaret Thatcher once saidthat she only needed ve hours sleepa night when she was Prime Minister,this would have been unremarkable forher if she was naturally a short sleeper.Just as people may need dierentsize shoes they may need dierentamounts of sleep. It is vitally importantto nd out how much sleep we as

individuals actually need, and to thenrecognise that it may be dierent fromthe amount of sleep that others need.

Sleeping less than we needas individuals has negativeconsequences. Whilst awake, webuild up a sleep debt which can onlybe repaid through sleeping. This isregulated by a mechanism in the bodycalled the sleep homeostat, whichcontrols our drive to sleep. If we havea greater sleep debt, then the sleephomeostat indicates to us that weneed more sleep.

In a healthy situation this debt ispaid o night by night. However, the

debt can also build up and be repaidgradually over a period of weeks oreven months, for example, if we under-sleep for several nights in a row thenwe will need to repay the sleep debt inthe near future. Interestingly, for peoplewith bipolar disorder, the state of maniais associated with decreased perceivedneed for sleep08. However, despite thisperception, the person is still buildingup a sleep debt which needs to berepaid.

Species

Python

Tiger

Cat

Chimpanzee

Sheep

African elephant

Girae

Average total sleeptime per day (hours)

18

15.8

12.1

9.7

3.8

3.3

1.9

Table 1The sleep needs of various species

A mechanism called the circadiantimer regulates the pattern of oursleep and waking, and interactswith the sleep homeostat. Mostliving things have internal circadianrhythms, meaning they are adaptedto live in a cycle of day and night.

The French geophysicist Jean-Jacques dOrtous de Mairan was therst to discover circadian rhythms inan experiment with plants in 1729.Two centuries later, Dr. NathanielKleitman studied the eect of

circadian rhythms on human sleepcycles09. These rhythms respondprimarily to light and darkness. Thecycle is actually slightly longer than24 hours10 11.

It is possible to think of a masterclock which regulates our circadianrhythms. This clock is made up of agroup of nerve cells in our brain calledthe suprachiasmatic nucleus (SCN).The SCN controls the production ofmelatonin, which is a hormone thatmakes us feel sleepy. During sleep,melatonin levels rise sharply. TheSCN is located just above our opticnerves, which send signals fromthe eyes to the brain. Therefore, theSCN receives information about theamount of light in the environment

through our eyes. When there is lesslight, such as during night-time, it tellsthe brain to create more melatonin(see Figure 1).

Light-DarkCycle

Sleep Wake Cycle

Performance whilst awake

Circadian Homeostat

Figure 1Diagram of sleep homeostat and circadian timer(adapted model from Professor Derk-Jan Dijk,Surrey Sleep Research Centre)

Sleep PatternsEqually important as the total amountof sleep is the pattern of sleep. Babiesand small children tend to sleep multipletimes across each 24 hour period, butas we mature into school years and intoadulthood we tend to sleep in one longphase; daytime sleeping decreases andthe person instead tends to sleepthroughout the night.

How Much Sleep?We all need dierent amounts of sleep.Dierent species of animals requirevastly dierent amounts, as shown in theestimated average sleep times of severalspecies06:


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Serotonin is another chemical thataects sleep; produced by thebrain, insucient levels of serotoninare also related to mental healthproblems such as depression andanxiety. Levels of serotonin arehighest in the brain when we areawake and active, and the brainproduces more serotonin when itis lighter outside. This is why mostpeople feel tired at night-time, andwhy it is a good idea to turn o thelights when we are trying to sleep.The immune system also inuencesserotonin, and therefore inuences

sleep patterns12, which may explainwhy we need to sleep more if we arefeeling ill.

As humans are mainly daytimeanimals, the period we choose tosleep is determined naturally bythe level of light in the environment;principally due to the setting andrising of the sun. But we can nowmanipulate light levels through theuse of articial lights, which meansthat we can continue activities longinto the evenings. People who worknightshifts may wish to reduce thelevel of light they are exposed toduring the daytime in order to sleep,

and can do this through the use ofblackout curtains.

The story of the Copiap miningaccident in Chile in 2010 showsthe importance of light for circadianrhythms. Miners sleep-wakecycles were completely disruptedin the absence of sunlight. TheNational Aeronautics and SpaceAdministration (NASA) consultantsadvised the miners to segregate theirspace into working, sleeping, andrecreation areas.

They used the lights on their helmetsand the headlights on the miningtrucks to create a communal lightarea. The sleeping area was keptdark, meaning that the miners couldregulate the daylight cycle articiallyand maintain a regular pattern ofsleep. This is an extreme example,but in fact, even moderate changesin lighting can aect our internalcircadian timers13.

Sleep patterns vary greatly, someanimals are diurnal and tend to sleepduring the night time, and others arenocturnal and sleep mostly duringthe daytime. Within humans, eachpersons circadian timer is set slightlydierently; some people functionbest in the mornings (larks), othersbest in the evenings (owls), many ofus are somewhere in between.

Some people suer from what isknown as circadian rhythm sleepdisorder, which is an extreme end ofthis spectrum, but is often associated

with mental health problems. Anextreme owl may have delayedsleep phase syndrome, tending tofall asleep and wake up very late. Anextreme lark may have advancedsleep phase syndrome, rising veryearly in the morning but plaguedwith sleepiness in the evening. Theseirregularities can become problems,depending upon what we are tryingto do in life, although for some theycan prove to be an asset.

Similar eects are commonly seenin people whose sleep pattern isdisrupted due to external factors,such as working regular night shifts

(particularly after working regularday shifts in the weeks beforehand).Another example is jetlag whichis caused by travel betweendierent time zones. Both shiftwork disorders and jetlag are verycommon expressions of circadianrhythm disorders. Humans are notdesigned to be awake during thenight and asleep during the day.People who regularly work nightshifts are thought to be at a greaterrisk of cancer14 and heart disease15.International ight crews are also atelevated risk of cancer, possibly dueto repeated disruption of circadianrhythms.

Disruption of sleep and circadianrhythms are also documented inpeople who suer from bipolardisorder, although it is unclearwhether the circadian timer or sleephomeostat is responsible for theunderlying sleep disturbances16. Ithas been suggested that changesin a persons circadian rhythms canact as a trigger for bipolar disorder17,particularly mania18.

Humans are not designedto be awake during the night.People who regularly work

night shifts are thought to beat a greater risk of cancer andheart disease.


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The machinery

is always going.Even when you sleep.Andy Warhol


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We typically pass through four stagesof non-REM sleep before beginningREM sleep. In total, non-REM sleepaccounts for about 7580% of totalsleep in an average adult.

This process is cyclical and during asingle night we may experience fouror ve recurring cycles of non-REMand REM sleep each lasting between90110 minutes. Only recently havescientists begun to understandthe process, especially since sleepresearch has been aided by threemeasurements:

01 Brain wave activity using anelectroencephalogram (EEG),which measures electrical activity

in the brain.02 Muscle tone through anelectromyogram (EMG).

03 Movement of the eye viaan electro-oculogram (EOG).

Of these three, the EEG is the mostimportant in helping to dierentiatebetween the dierent sleep stages.While awake, our brains display apattern of brainwaves known asbeta waves. Beta waves are highin frequency, meaning they occur inquick succession, but they are lowin amplitude, meaning they are quitesmall.

Whilst we are awake these waves donot follow a consistent pattern. Thismakes sense because when we areawake, our brains are often doing anumber of dierent tasks, stimulatingthe brain in a variety of dierent ways.When we rest with our eyes closed,our brain wave activity slows downand becomes more synchronised,these brain waves are known asalpha waves.

Non-REM stage oneThe rst of the ve sleep stages is a

form of light sleep, or non-REM stageone sleep. This stage is essentiallythe bridge between being awakeand sleep.

Sleepers drift in and out of light sleepand can be awakened easily. Duringthis stage, the person may begin tobreathe more slowly and evenly, thebrain produces theta waves, whichare smaller and lower in frequencythan alpha waves. Muscle activity,measured by the EMG, shows aslowing down of movement and thesleeper may begin to twitch.

These twitches are called hypnic jerks

and sometimes wake the sleeper,particularly if the jerk is accompaniedby the sensation of falling, whichmany people experience from timeto time. Since individuals may havesome knowledge of the world aroundthem, it is in this stage of sleep thatsome people report out-of-bodyexperiences.

Non-REM stage twoWithin a few minutes, the sleepermay pass into another form of lightsleep known as stage two of non-REM sleep. The sleepers breathingpattern and heart rate slow downand they become less aware of theoutside world. Eye movement stopsand sleepers theta waves becomeeven slower with the occasionalbursts of brain activity every minuteor so; these bursts of activity aresometimes known as sleep spindles.

Stage two non-REM sleep is alsocharacterized by a type of brainwave activity known as a K-complex.A K-complex is a high voltage ofEEG activity with a sharp downward

spike followed by a slower upwardcomponent; it sometimes resemblesa mountain. This stage accountsfor the largest part of human sleep(4550% of sleep in adults19) and issometimes referred to as true sleep.Like stage one sleep, stage two isalso considered relatively light sleepand if sleepers were to be woken upduring either of these stages theymay deny that they had been asleepat all.

The stages of sleepIn humans, sleep can be broadly dividedinto non-rapid eye movement (non-REM)sleep and rapid eye movement (REM) sleep.

The rst of theve sleep stagesis a form of lightsleep, or non-REMstage one sleep.This stage is

essentially thebridge betweenbeing awakeand sleep.


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DreamingDreams have been a subjectof awe and inspiration forthousands of years, appearingin the oldest works of literature,such as Epic of Gilgamesh(c.2200 B.C.), as well as inrecent Hollywood blockbusterssuch as Inception and ShutterIsland (2010). Some peopleare better at rememberingdreams than others, but most

would agree that their dreamsare meaningful to them. Manypeople believe that dreams area gateway for understandingour feelings, thoughts,behaviours, motives and values.

The theoretical link betweendreaming and eye movements duringsleep was made as far back as in186824, and the explicit connectionbetween REM sleep and dreamingwas made almost a century later25.It is possible that our eyes movebecause we are following the imagesof the dream in our sleep. Since weall experience REM sleep, we all have

the potential to experience dreams.Still, the purpose and functionof dreams remains unclear.

There are many theories on themeaning of dreams. Some scientistsbelieve they serve no real purpose,while others believe they areintegral to our mental, emotional,and physical wellbeing. The mostwell-known theory comes fromthe Austrian neurologist SigmundFreud who founded the school ofpsychoanalytic thought. Accordingto Freud, dreams are subconsciouswishes26. He believed that theimages, thoughts and emotions

experienced in a dream wereattempts by our unconscious toresolve a conict in waking life, andthat the process of dreaming allowedfor an interaction between theunconscious and the conscious.

The part of the brain involved inemotions, sensations and memoriesbecomes more active during REMsleep. So the brain may attempt tomake sense of this internal activityand the result is a dream27. Dreamsmay therefore be the result of signalsgenerated within our brains.

Another theory28 suggests thatdreams may help humans tomaintain sleep, by keeping the mindoccupied so that we dont wake up.

It suggests that dreams may

entertain the brain so that otherareas can rest and recover, andwithout this kind of diversion, thebrain would keep telling us to wakeup. However, these are merelytheories, and the exact reasonswhy we dream are still uncertain.

What we do know is that dreamsare associated with an abundanceof a chemical called dopaminein the brain. Dopamine is aneurotransmitter (a chemical thattransmits signals within the brain)that helps to direct our attention toimportant things in our environment.Both dreams and hallucinations

involve deregulation of dopamineproduction. It is thought thatdreaming may be similar to someof the symptoms of schizophrenia,since they appear to have similarneurochemical backgrounds29.

Dreaming and REM sleep are alsostrongly related to major depression,and people who suer from thisillness often display more frequentrapid eye movements than normal- literally, people with depressiondream more15. It actually appearsas though getting too much REMsleep can increase our vulnerabilityto depression. Interestingly, manyantidepressants aim to limit REMsleep30.

One night of sleep deprivation,particularly the deprivation ofREM sleep, may relieve depressivesymptoms in the short term.However, this cannot berecommended as a treatmentfor depression since individualsbecome susceptible to symptomsagain once they have repaid theirsleep debt31 32. More importantly,the negative consequences ofsleep deprivation can be far moredamaging.

Non-REM stages three and fourStages three and four are typicallygrouped together as the last stagesof non-REM sleep, also referred to assynchronised sleep.

For these stages, sleepers pass fromthe theta waves of stages one andtwo to delta waves, the largest andslowest brain waves. There is no realdistinction between stage three andfour except typically during stagethree, sleep is comprised of less than50% delta waves, and in stage fourmore than 50% of the waves are

delta waves. Thus these stages areoften referred to as slow wave sleepor deep sleep. Sleepers breathingand heart rate are at their lowestlevels, they breathe rhythmicallyand their muscle activity decreases.

Deep sleep is a very refreshingtype of sleep, and it is particularlyimportant in helping the brainconsolidate what it has learnt duringthe day20. If awakened during thesestages, sleepers report feelinggroggy and disoriented for severalminutes. Illustration of the sleepstages is shown in Figure 2.

Eventually, the sleeper will pass intoREM sleep. This takes its name fromthe rapid eye movements that thesleeper displays, usually with theireyes closed, as discovered in 1953

by Nathaniel Kleitman and EugeneAserinsky. The frequency of onesrapid eye movements is knownas their REM density.

During this stage, the brainwavesare similar to when we are resting,although our breathing rate andblood pressure rise, all our voluntarymuscles also become paralyzed andour muscle tone becomes relaxed sothat we cannot move our limbs. Thisis a relatively shallow stage of sleep;the average person will have aroundthree to ve episodes of REM sleepper night, and the rst period is likelyto begin about 7090 minutes after

falling asleep. It is during this stageof sleep that we experience dreams.

The amount of time spent in thedierent sleep stages appears torelate to peoples mental health.Those who suer from depressionhave been shown to have more REMsleep, enter this stage earlier, andhave increased REM density21. Forpeople with schizophrenia, there canbe a delay in reaching deep sleepand REM sleep22. Similarly, peoplewho suer from anxiety may spendless time in deep sleep23. However,this is an area to be explored in futureresearch to provide more preciseinformation.

Figure 2Brain waves during the stages of sleep

Awake eyes open/Alpha Waves

Awake eyes closed

Non-REM Stage 1/Theta Waves

Non-REM Stage 2

Non-REM Stage 3 & 4/Slow Waves and Delta Waves

REM

Sleep Spindle K Complex


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Sleeplessness

is a desertwithout vegetation

or inhabitants.Jessamyn West


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Poor Sleep


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InsomniaMost of us have experienced asleepless night, which althoughupsetting, is nothing to worryabout since the sleep debt canbe repaid over the course of thenext few nights. The inabilityto fall or remain asleep overa period of several nights isknown as insomnia.

People with insomnia have poor qualitysleep, may be unable to get enoughsleep, and may wake up for longperiods during the night, resulting infatigue during the daytime. Insomniais a psychophysiological disorder,

which means that it is a combinationof our thoughts, behaviour, emotionsand physiology. Insomnia can beacute (lasting less than a month), or itmay develop into a chronic, long-termcondition.

Essentially, insomnia is associated witharousal of our mind and body. Typicallypeople complain of a racing mindand get into a vicious cycle of poorsleep, concerns about poor sleep, andpatterns of thoughts and behaviourthat are unhelpful. This means thatthe normal operation of the sleepdebt and circadian mechanisms donot work properly. The result of a series

of sleepless nights can be serious.Insomnia is by far the most commonsleep complaint in the generalpopulation. It is a massive public healthproblem, and the most commonlyreported mental health complaint inthe UK33.

Sleep quality is of paramountimportance to our health. Peoplewho have slept poorly are likely tosuer from fatigue, sleepiness duringdaytime, poor concentration, irritability,memory loss, depression, frustration,and a weakened immune system.Fatigue feeling weary and lackingin energy whilst awake is the mostcommon problem associated withpoor sleep.

This is dierent to sleepiness becauseit doesnt necessarily increase thelikelihood of falling asleep. Signs ofsleepiness include yawning, muscleache, and drifting o to sleep.Furthermore, poor sleep can make usless receptive to positive emotions34

which in turn can make us feelmiserable during the day, and mayincrease the likelihood of us developingdepression35.

Evidence from experiments involvingrats suggests that in extreme cases,sleep deprivation may even be fatal36.Indeed, there is an extremely raregenetic disorder called fatal familialinsomnia, aecting around 100people worldwide. This usually beginsbetween the ages of 35 and 60, andleads to death several months later.Poor sleep can also aect thecircadian timing mechanism. Keepingan irregular sleep pattern can makeinsomnia worse. People who suerfrom insomnia are likely to feel theeects of sleep deprivation throughoutthe daytime.

It may be tempting to catch upon sleep by grazing at opportunemoments across the day, but eventhough this temporarily recoupsa small amount of sleep debt,unfortunately it also disrupts thesleep pattern.

A person with insomnia may getinto a habit of sleeping in short shiftsthroughout the day, which then maymake it dicult for them to sleep atbedtime. The problem with nappinglike this is that the person only sleepsfor short periods of time. This meansthat they are likely to get lots of lightsleep without ever passing throughall the sleep stages. In particular,they fail to achieve the essentialdeep sleep necessary for restorationof mind and body, and fail to recovertheir sleep debt.

Sometimes insomnia can be relatedto physical health problems. Mostof us will have experienced anillness which has made it harder tosleep due to physical discomfort orirritation, such as a blocked nose orsore throat. Some chronic conditions,such as osteoporosis or diabetes,can drastically aect sleep in the longterm. Addressing physical healthproblems could improve sleep quality.It may be possible also to address thesleep problem alongside the healthproblem rather than just treating it as asymptom.

Our mental state is perhaps even more

important in allowing or preventinginsomnia from developing from anacute into a chronic problem. Thisrefers particularly to our thoughts andattitudes about sleeping. For example,some of us, after suering severalconsecutive sleepless nights, maybecome anxious that we have not hadenough sleep. This type of thoughtprocess is likely to lead to thinkingabout the problems associated withnot sleeping.

This can lead to anxious thoughts,which can then lead a person to seethemselves as failing to sleep well.These thoughts perpetuate a negativecycle, making it even more dicult

for the person to sleep. Many of usmay recognise this behaviour if wehave watched the clock during thenight. This is a very common activityfor people who suer from insomnia,where the clock starts to be used as agauge to monitor sleep performance.This pressure to perform in turn makesit more dicult to sleep.

Sleeping poorly increases the risk topoor mental health, which is oftenneglected when aiming to improvehealth and wellbeing. Insomnia isinextricably related to mental health.Many of us will have experienced asleepless night due to worrying aboutan upcoming event, such as an examor a job interview.

A prolonged period of stress orworry can also seriously aect ourability to sleep. In a sample of roughly20,000 young adults, lack of sucientsleep was linked to psychological

distress37, and a history of insomniahas been shown to increase therisk of developing depression38 39.Unsurprisingly, anxiety and depressionare also common causes of chronicinsomnia40. People who suer fromdepression may experience sleepdisturbances which disrupt theprocess of falling and staying asleep.The sleeper may wake intermittentlythroughout the night, or wake early inthe morning and be unable to sleepagain41.

Furthermore, insomnia is a commoncomplaint in people who suerfrom schizophrenia42, and some

schizophrenia medications canprofoundly aect a persons abilityto maintain constant sleep43. Peoplevisiting sleep disorder clinics with thecomplaint of insomnia often haveanother underlying mental healthproblem44. This type of insomnia ismore dicult to treat since it involvestreating the underlying problem as wellas the insomnia.

Poor sleep relates not only to the total amountof sleep, but also to the quality of sleep andthe amount of time spent awake. Good qualitysleep includes all of the aforementioned sleepstages, with a signicant amount of timespent in deep sleep.


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The Great BritishSleep Survey: newdata on the impactof poor sleepThe Great British Sleep Surveywas launched by Sleepio tomeasure the sleep quality of theUK population. By December2010 there were 1870responses from men and 4838from women (total = 6708).

The average age of respondentswas 40 years for men and 37 forwomen. Average sleep scoreswere calculated for each personbased upon the answers thatpeople gave to the survey, witha higher score representingbetter sleep quality (0% = verypoor, 100% = excellent).

The results showed that men hadbetter sleep quality than women; theaverage sleep score was 61% for menand 57% for women. Unsurprisingly,sleep was related to health; peoplewho rated their physical health as poorhad an average sleep score of 47%,signicantly worse sleep than peoplewho rated their health as good (63%).The average sleep score tended todecrease with age, though there wassome inconsistency in the relationshipbetween age and sleep (seeFigure 3).

Other data from the survey showedthat insomnia had a negative eecton peoples mood, energy,concentration, personal relationships,ability to stay awake during the day, andability to carry out daily tasks (Figure 5).

In comparison to good sleepers, overfour times as many respondentswith insomnia reported relationshipdiculties. The ability to maintain

good relationships with friends, familyand partners is naturally importantto an individuals personal happiness,aecting their mood and, in the longerterm, their susceptibility to depression.More than 80% of respondentswith insomnia said they regularlyexperienced low mood. This is morethan three times the gure for goodsleepers. Sustained low mood can leadto depression.

Over 45% of respondents withinsomnia had diculty staying awakeduring daylight hours, comparedto just over 10% of good sleepers.Although sleepiness is to be expected

in people with insomnia, it mayencourage the person to keep anirregular sleep pattern. This in turnupsets the circadian rhythm and canmake the insomnia worse.

Figure 4Duration of insomnia(N=6708)

Duration

0-3Mnths

3-6Mnths

1-2Yrs

2-5Yrs

6-10Yrs

>-11Yrs

6-12Mnths

0

5

10

15

20

25

30

35

40

PercentageFigure 3

Chart of average sleep score by age(N=6708)

Age Group

10

0

20

30

40

50

60

16 -20 21- 30 31-40 41- 50 51- 60 61+AverageSleepScore(Percent)

People withInsomniaGoodSleepers

10

0

20

30

40

50

60

100

90

80

70

Mood Energy Relationships StayingAwake

Concentration GettingThings Done

Aspects of Daily Life

Percentage

Figure 5Negative impact of poor sleep on daily life.(N=5328)

Some caution should be used whendiscussing the results of this survey,since those who responded weremore likely to have taken an interestin their own sleep, possibly becausethey had a problem with sleeping.The sample therefore cannot be trulyrepresentative of the UK population.

Only 38% of survey respondents(2522 people) were classied as goodsleepers, whilst 36% were classiedas possibly having chronic insomnia(2414 people). Insomnia was slightlymore common in women (37%) than

in men (32%), and 79% of those whohad insomnia reported having it forat least two years. Other estimatesof insomnia have put the total gureat around 30% of adults, althoughrates depend upon the criteria usedto dene it45. Of the people reportinginsomnia in the survey, over 30% havehad insomnia for 25 years, and over25% for over 11 years (Figure 4)

Nearly 95% of respondents withinsomnia reported low energy levelsin their daily lives, considerably morethan twice the percentage for goodsleepers (just over 40%). This has arange of mental and physical healthimplications, particularly with regardto an individuals ability to take regularexercise, which in itself is an eectiveway of reducing stress, anxiety anddepression.

The impact of insomnia on energylevels indicated by the survey thereforehas the potential to create a vicious

cycle of deteriorating health: insomniadecreases an individuals capacityfor exercise, negatively aecting theirmental wellbeing, in turn worseningtheir insomnia.

The survey data indicated thatover 75% of people with insomniaexperienced poor concentration, andnearly 70% reported diculties ingetting things done. In both instances,this is approximately three times morethan the percentage for good sleepers.This inability to concentrate and carryout tasks shows how the implicationsof poor sleep can aect wider society,for instance, in terms of impairing

productivity in the workplace.Overall, the data from the survey hasdemonstrated the extent to whichsleep inuences peoples everydaylives, both in terms of physical andmental health. Factors adverselyaected by insomnia, such as exercise,can create vicious cycles wherethe impact of insomnia worsens anindividuals capacity to tackle theproblem. As such, the data illustrate thecomplexity of tackling sleep problems.Eective methods of breaking thiscycle are detailed in Part III of thisreport.


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OversleepingAlthough it is nowhere nearas commonly reported asinsomnia, sleeping too muchmay also cause problems.

Oversleeping has been linkedto physical health problems suchas diabetes46 and cardiovasculardisease47. Oversleeping can occurin some people who suer fromdepression, roughly 1540% of whomoversleep48.

Hypersomniaand narcolepsyThere are also some conditionssuch as hypersomnia andnarcolepsy in which a personsuers from extreme sleepinessduring the day. Suerers ofhypersomnia may complainthat they do not feel fully awakeuntil several hours after gettingup. People who suer fromnarcolepsy may suer from

extreme sleepiness, oftenat inappropriate times in theform of sudden sleep attacks.

Cataplexy is also common in peoplewith narcolepsy. This is dened by asudden loss of muscle tone, which canoften leave the suerer paralysed fora short term.

Both hypersomnia and narcolepsyare rare (estimated at 0.3% of thegeneral population for hypersomniaand 0.045% for narcolepsy49); however,they can have severe consequencesfor a persons daily life. They couldbe misconstrued as insomnia due

to the extreme tiredness, but theyare very dierent and should be treatedas such.Hypersomnia and narcolepsy

could be misconstrued asinsomnia due to the extremetiredness, but they are verydierent and should be treated

as such.


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All men, whilst they

are awake, are inone common world:

but each of them,when he is asleep,

is in a world of his own.Plutarch


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SnoringOf all sleep problems, snoringmay seem one of the moreinnocuous. However,it can cause problems for thepartners of snorers whose ownsleep quality may be aected.Strictly speaking, snoring is arespiratory problem heightenedwhen a person is sleeping,not a sleep problem in itself.Snoring is very common, approximately37% of UK adults snore50. It is twiceas common in males as females,although post-menopausal womenare more likely to snore than pre-menopausal women. Partners maynd their own sleep disturbed and mayneed to sleep in separate rooms. Thereis a suggestion that after undergoingsurgery to stop snoring, sleep qualityof partners improves51.

The snoring sound is producedthrough a partial obstruction in theairway, within which the organs thathelp us breathe vibrate. The musclesrelax at the base of the tongue and theuvula (the small eshy piece which

hangs at the back of the throat).The relaxation of muscle tone cancause the airway (composed ofnose, throat, mouth and windpipe)to become partially or completelyobstructed. Other possible causesthat can restrict airow can be jawproblems or nasal congestion.

A persons size and body shape canalso have an impact on whether theyare likely to snore. For instance, peoplewith shorter, wider necks are moreinclined to snore because the musclesaround their windpipe cannot supportthe tissue that surrounds it when theysleep. Alcohol also increases snoring,since it relaxes the tissue at the back ofthe throat causing it to collapse into theairway and vibrate more easily.

There are a number of treatmentsfor snoring, most of which rely onunblocking the breathing passage,such as nasal strips and sprays. Still,if snoring becomes a problem, then itis better to seek professional medicaladvice rst.

Problems thathappen whilst asleepAs detailed earlier, sleeping is a complex processwhich involves the body going through a numberof dierent stages. During the sleep cycle wecan react in several dierent ways, and a numberof problems can occur. These problems can impact

on our sleep quality.

Some are very common, such as snoring. Othersare much rarer but can cause great problems forthe sleeper. Abnormal movements or behaviourthat occur during sleep are sometimes calledparasomnias. Well-known parasomnias includenightmares, teeth grinding, night terrors andsleepwalking. Often these problems can be relatedto the mental and physical health of the individualthat suers from them.

Sleep ApnoeaSnoring during REM sleepis often a sign of obstructivesleep apnoea, a potentiallyserious respiratory problem.While sleeping, an individualwill experience pauses inbreathing or shallow breath.

Suerers may stop breathing for up tominutes at a time, potentially starvingthe brain of oxygen. Normal breathingusually resumes, with the individual

often making a loud snort or chokingsound causing the airway to unblock,waking the individual up and disruptingtheir sleep. Obstructive sleep apnoeaoccurs in approximately 37% of adultmen and 25% of adult women.It is more common in older people andin those who are overweight52. Bothsmoking and alcohol also increase therisk of developing it.

Suerers may nd themselveswaking up sweaty, with a drymouth and a headache. The frequentwaking throughout the night canlead to insomnia, excessive fatigueand sleepiness during the daytime.Undiagnosed obstructive sleep apnoeais associated with increased likelihoodof hypertension, cardiovasculardisease, stroke, sleepiness duringthe daytime, and motor vehicleaccidents53. The most widely usedtreatment for obstructive sleep apnoeais positive airway pressure. The sleeperwears a special mask over the nose ormouth during sleep, whilst a breathingmachine pumps a stream of air inthe nose or mouth through the mask.


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NightmaresMany of us will haveexperienced a nightmare fromtime to time. This is denedas an intense, frighteningdream that wakes the sleeperin the throes of panic. Usuallynightmares occur in the earlymorning and often they areinuenced by frighteningexperiences that have occurredduring the day.

Recurrent nightmares are said totypically occur due to anxiety. Peoplewho suer from post-traumatic stressdisorder (PTSD) can experiencedistressing dreams or nightmaresas a consequence of past traumas,and may experience signicantinterruptions during REM sleep56.

Occasionally, we may experiencean episode of sleep paralysis; thishappens after waking suddenly fromREM sleep, which often happensfollowing a nightmare. Our muscles areparalysed during REM sleep, but duringan episode of sleep paralysis theyremain paralysed for a short periodof time after waking. In old Englishfolklore, sleep paralysis was said tobe due to supernatural forces sittingor pressing down upon the sleeperschest (Figure 6).

4140

Figure 6The Nightmare, Henry Fuseli (1781)

Night TerrorsNight terrors are perhapsthe most disturbing type ofparasomnia. Like sleepwalkingand sleep talking, they occurduring deep sleep. They canbe intense, frightening, andseverely disabling experiences.A night terror is dierent toa nightmare since the latteroccurs during REM sleep andcan be recalled on waking.

Most often night terrors begin and endin childhood. It has been estimated that18% of children experience them59,but only 2.2% of the adult population55.Like sleep walking, night terrors aremore likely to occur under sleep-deprivation, after drinking alcohol,or during a period of stress.

Upon experiencing a night terror,the sleeper will feel a deep senseof fear and panic, their heart ratewill rise, and they may begin sweatingand screaming. There will often bevery little, if any, recall of the detailsof the event the following morning.

Little is known about how to treatpeople who experience persistentnight terrors. However, more severecases could be related to traumaticexperiences, particularly in childhood.If this is true, then evidence-basedtreatments for trauma may help.

Case Study

K* is a 36 year old female from Bedfordshire,whose sleep cycle is out of synch. She goesthrough periods of not sleeping very much, merelya couple of hours per night, to sleeping all the time,sometimes up to 19 hours a day. During this periodof oversleeping, she has a strong desire to sleepduring the day and stay up all night. In spite ofsuch long periods of sleep, she doesnt wake up

feeling refreshed.She rst remembers her sleep problems startingaround the age of 13. She would wake up froma frightening experience feeling anxious butultimately unable to recall what it was shewas experiencing. Sometimes she would wakeup and nd she was unable to move her bodyor to scream out. As a result of the frequencyof these experiences, she began to feel afraid togo to sleep and eventually she got out of the habitof sleeping properly.

She now knows that these episodes are known asnight terrors and still continues to have them todayin adulthood, though they come and go in phases.


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Case Study

G*, 46, from Liverpool has had problems withher sleep for the past 15 years. Initially they beganwith trying to stay asleep. Shed wake up frequentlythroughout the night after sleeping for 1 -2hours, and on average she would sleep a totalof 3-3 hours a night. There was a time whenG* was a good sleeper. Sleep problems however,developed after back surgery following a 12 year

stretch of shift work. The pain associated fromthe surgery kept her awake at night and since thenshe has had trouble maintaining a constant nightof sleep.

She has tried keeping good sleeping habits onrecommendation from her doctor: she doesntkeep a TV in the room, abstains from caeine andalcohol and adheres to a strict routine by going tobe bed at 11pm and getting up at 4am. No matterwhat shes tried though it doesnt seem to makeany dierence.

In the last 5 years, G* discovered she wassleepwalking. Shed nd objects in strange places,such as the remote control in the bin, as well asodd cooking experiments left out on the hob, suchas cereal covered in washing up liquid. After ndingherself outside her building, she went to see asleep specialist fearful she might end up doingmore serious harmful behaviour. Unfortunatelyshe was told there was little they could do to helpher, as they told her the sleepwalking problem wasa symptom of her poor sleep pattern.

Sleepwalkingand sleep talkingSleepwalking (somnambulism)and sleep talking (somniloquy)are commonly reportedparasomnias. Both activitiesoccur during deep sleep(stages 3 and 4), and areunrelated to dreaming, withpeople rarely recalling themupon waking.

Sleepwalking most commonly occursin children between the ages of veand twelve years; 15% of children inthis age group are said to walk in theirsleep at least once57. It is much lesscommon in adults, occurring in about25% of the adult population58, themajority of whom began sleepwalkingwhen they were children. Sleep walkingis more likely to occur when peoplehave been sleep-deprived, drinkingalcohol, or under stress.

Sleep talking occurs in about 4% ofadults, though again more frequentlyin children. This can range fromnon-verbal utterances to eloquentspeeches, which occur several timesduring a nights sleep. The speechmay or may not be comprehensible tolisteners. Sleep talking rarely presentsa serious problem. In fact, it is muchmore likely to be problematic for thepartner if they are disturbed during thenight on a regular basis.

Sleepwalking can become a problemwhen people run the risk of injury,either within the house or if they gooutdoors. Some sleepwalkers conductactivities during their sleep, such ascleaning. It can also be associatedwith bedwetting; it is not uncommonfor people to urinate in closets andcupboards during a sleepwalking

episode.In extremely rare cases people conductviolent activities. In the UK, a manunknowingly strangled his wife while ona caravan holiday. He thought he wasghting o some assailants who hebelieved had broken into their caravan.He was acquitted on all charges on thegrounds that he was not consciousand not in control of his actions.

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Teeth GrindingAlso known as bruxism, thisis characterised by grindingones teeth, and is sometimesaccompanied by clenchingof the jaw. It can occur duringday or night. During the day,it is often in reaction to certainfeelings or events that mayoccur. During sleep, however,bruxism is characterisedby automatic teeth grindingand rhythmic jaw musclecontractions.

In one study, 8.2% of the generalpopulation were estimated to grindtheir teeth at least twice a week duringsleep, and 4.4% were reported tofull the criteria for a full diagnosisof bruxism. It was also found to bemore common in those who regularlyconsume large amounts of caeine,alcohol and nicotine54. Importantly,bruxism can be symptomatic ofunderlying stress and anxiety; onestudy found that roughly 70% ofsuerers attributed their teeth grindingto these causes55.


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45

There is some evidence thatboth periodic limb movementdisorder and restless leg

syndrome can be side eectsof antidepressants.

Sleep RelatedMotor DisordersPeople with periodic limbmovement disorder mayexperience an intense orprolonged set of hypnic jerks(involuntary twitches that occurbetween wakefulness andsleep), and may involuntarilytwitch muscles, particularlythe legs, whilst sleeping. Itoccurs in approximately 3.9%

of the general populationand is slightly more commonin women than men60. Thisbecomes a problem whenit disrupts the sleep of thesuerer or partner.

The reasons for periodic limbmovement disorder are unclear,but it may be related to a disturbancein circadian rhythms. Medicationcan help, particularly those thatreduce muscle function duringsleep. A similar disorder is restlesslegs syndrome. Figures from the USestimate that it aects around 7%

of the population

61

, increasing withage and being more commonin women62. Suerers experienceunpleasant sensations in their legs,and thus feel irresistible urges tomove them; they may only gain reliefby walking or moving. Symptoms aresaid to occur typically in the eveningspotentially leading to dicultiesin falling asleep.

There is some evidence that bothperiodic limb movement disorderand restless legs syndrome canbe side eects of antidepressants63.The large majority of suerers ofrestless legs syndrome do respondto treatment. Mild cases may betreated by abstaining from caeineand alcohol. There is also someevidence that regular exercise duringthe day may reduce symptoms, thoughfurther research is needed to conrmthis64. Those who are more severelydistressed by restless legs syndromemay experience relief with drugs thatmimic the neurotransmitter dopaminein the brain.

REM BehaviourDisorderThis is a rare condition in whichpeople can be seen to act outtheir dreams. This parasomniatends to begin later in life andis more common in adultsover the age of 50, particularlyin men.

Most people are unable to move duringREM sleep because their musclesare paralysed. However, people withREM behaviour disorder maintainsome degree of muscle tone duringREM sleep. Therefore, the sleeperis not paralysed and the musclesstay partially active, sometimes withviolent results. People acting out theirdreams during REM behaviour disordercan injure their partners, and it is notuncommon for couples to get into thehabit of sleeping apart for this reason.Interestingly enough, this has alsobeen noticed in other species, suchas dogs.65

44


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A sleepless nightis as long as a year.Chinese Proverb


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Sleeping Well

4948

Thi ti f th t Sl h i


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This section of the reportdescribes ways in which wecan all improve the qualityof our sleep.

As highlighted in Part II, sleepis crucial to the health of allindividuals. It is importantto remember that poor sleephas massive implications forour health; it is in all of our

interests to ensure that wesleep better.

Caeine, alcohol and nicotineare all substances whichcan impair sleep quality.Caeine makes it harder tosleep because it stimulatesthe central nervous system,increasing your heart rate andadrenaline production, andalso supressing melatoninproduction. It takes a longtime for the body to breakdown caeine, so drinkingcoee during the day canaect sleep at night.

Alcohol can help people fall asleep,but it also impairs sleep qualityduring the second half of the night,and it is a diuretic which means thatwe may need to wake in the night togo to the toilet, disrupting the sleeppattern. However, a rapid reductionin alcohol intake for someone who isa heavy drinker can lead to alcoholwithdrawal syndrome, which itself canlead to insomnia. Alcohol can alsocontribute to depressive mood, whichin turn can contribute to insomnia.

Nicotine may impair sleep, smokerstake longer to enter sleep and have

less total sleep time (approximately14 minutes less per night) comparedto those who have never smoked66.Reducing nicotine intake is unlikelyto lead to immediate improvementsin sleep, but the long termhealth benets are likely to haveimplications for sleep quality.

Eating habits have the potentialto aect sleeping. It is importantnot to go to sleep whilst feelinghungry, so eating a light snack beforebedtime may be helpful. However,eating large meals shortly beforebedtime should be avoided, becausethe body will spend time digestingbefore it can sleep. Some foods mayhave sleep inducing properties; forexample, rice and oats may containsmall amounts of melatonin, whichincreases the desire to sleep. Somefoods, such as dairy products, containthe amino acid tryptophan whichis useful in manufacturing melatonin.

Other foods, such as those thatcontain caeine or large amountsof rened sugar, make sleepingmore dicult. A study in the Isleof Wight examining the eects offood additives on health, found thatpreschool children who receivedadditive-laden drinks were morehyperactive than when they did nothave drinks containing colours andpreservatives67.

Sleep hygieneMany people can benet from improvingthe quality of their sleep. The phrase sleephygiene is often used to describe howlifestyle and environmental factors canaect our sleep. Positive sleep hygienemay help to improve sleep quality, butis not enough to treat chronic insomnia.


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Regular exercise may also helpus sleep. One study in older adultsshowed improved sleep qualitywith regular aerobic exercise68,such as jogging or cycling.It may be that physical tnesswith increased metabolismis associated with better sleeppatterns. Also, exercise can helpto improve mood and to reduceanxiety, which can in turn improvesleep in people with chronicinsomnia69. Exercise can also helpto reduce the symptomsof obstructive sleep apnoea70.

The timing of physical activityis important. Exercise earlier inthe day is better for people whowant to improve their chancesof sleeping, since in the short termit increases the bodys adrenalineproduction, making it dicultto sleep.

The environment of our bed andbedroom can either help or hindersleep; much depends on our ownpreferences. The obvious factorsare noise, light, temperature andventilation. Most of us prefer tosleep in a quiet environment, asanyone who has experienced livingnext door to noisy neighbours cantestify. Earplugs may be useful forblocking out external noise althoughthey do tend to amplify the bodysown internal noises which may bedistracting.

Too much light can inhibit sleep sinceit aects melatonin levels; eye masksmay be helpful, although they canbe uncomfortable for some. Roomtemperature is important, neithertoo cold nor too hot, although theideal room temperature will varyfrom person to person. Ventilationcan be improved by opening thewindow, although this is likely toalter the temperature and makethe room noisier. It is important tofeel comfortable in the bedroomenvironment, including selecting theright mattresses and pillows. Peoplemay need to experiment with allthese factors until they nd the idealbalance.

Sleep hygiene practices, such asthose mentioned above, may helppeople improve their sleep quality,but there is little evidence to suggestthat they help people who havechronic insomnia, in which case morespecic treatment is needed. It isimportant to consider whether theinsomnia is caused by physical ormental health issues. However, moreoften than not it will be important todirectly address sleep itself, and notsimply rely on treating the physical ormental illness.

Sleep medicationThe most common and wellknown treatment for insomniais sleep-inducing medication,also known as hypnotics.

The most common type ofhypnotic are a group of drugscalled benzodiazepines, themost well-known of theseis diazepam (Valium) whichis used to treat anxiety andhas been around since theearly 1960s. Similar drugs liketemazepam can be useful forshort term insomnia, but thereis little evidence to suggestthat they are appropriate forchronic insomnia71.Another commonly-used groupof drugs developed more recentlyare the benzodiazepine receptoragonists; sometimes these are calledZ drugs since many of their namesbegin with the letter Z (zopicloneand zolpidem, for example). Thereare various other groups of drugsthat may potentially be prescribed

for insomnia; melatonin receptoragonists aim to promote sleep byincreasing the amount of melatoninin the body, orexin antagonists aimto limit the hormone orexin which isrelated to being awake, and someantihistamines and (rarely) opioidscan be used as sedatives.

Some antidepressants do have asedative eect, and research hasshown that people who were treatedusing a combination of sleepingmedication and antidepressantsshowed greater improvements indepressive symptoms than peoplewho used antidepressants only72 73.

However, the British Associationfor Psychopharmacology advisesagainst using antidepressants inthe treatment of insomnia as thereis limited evidence indicating theirecacy in this application74.

It is dicult to gauge how manyprescriptions are written forhypnotics because many of thesedrugs are prescribed for problemsthat are not directly sleep-related.Up to 40% of people with insomniamay self-medicate with hypnoticsthat are available without aprescription, and many people alsodrink alcohol to aid sleep.

Hypnotics may be eective for short-term acute insomnia, particularlyfor conditions like jet lag. However,they only act on the biological,neurochemical factors to help ussleep. Many people develop toleranceto hypnotics and become physicallyor psychologically dependent, orsuer withdrawal symptoms suchas anxiety, depression and nausea.Some types of hypnotic, such asbenzodiazepines, can cause reboundinsomnia, which is often worse thanthe original insomnia symptoms.

Also, hypnotics can have a rangeof side eects. The National Institutefor Health and Clinical Excellence75,suggest that hypnotics should onlybe used after other measures havebeen tried, and then only for shortperiods of time, such as 24 weeksmaximum.

Use of sleepmedication datesback thousands

of years; Hippocratesnoted the sleep-inducing propertiesof opium in c.400 B.C.


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Sleeping isno mean art:

for its sake one muststay awake all day.Friedrich Nietzsche

P h l i l h


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5756

It has also been used to treatpeople with a range of mentalhealth problems such asdepression and anxiety, andis part of the Improving Accessto Psychological Therapies(IAPT) agenda. It can beused alongside hypnoticsor without.

A comprehensive CBT approachfor insomnia includes a variety oftechniques, such as sleep hygieneregimes (as described previously),relaxation training, readjusting sleeppatterns, and altering the thoughtsand behaviours that hinder peoplefrom sleeping77 78 .

The importance of relaxation shouldnot be taken for granted. Peoplewith insomnia tend to nd it hard torelax naturally before going to bed.Relaxation training involves payingattention to breathing and ensuringthat muscles are not tensed up.People who have trouble sleepingshould wind down in the hour beforegoing to bed, possibly doing relaxingactivities such as listening to music.

The act of relaxation does not alwayscome naturally and may requirepatience, discipline and practice.Activities that some people consider

relaxing may not be appropriate forothers. For this reason it may behelpful to have a tailored relaxationprogramme developed by a CBTpractitioner.

Thoughts and feelings about sleepplay a large role in perpetuating

insomnia79. People with chronicinsomnia often associate sleepand bedtime with a range of negativethoughts and feelings. CBT aimsto question the assumptions behindour thoughts, and to break the linksbetween our thoughts and how wefeel about them, i.e., our emotions.An example of how our thoughts caninuence our emotions with regardto sleep is as follows:

1 FactIm not feeling very sleepyright now

2 ThoughtIts already 1:30 a.m.,

Im never going to get to sleep3 EmotionEverybody else is sleeping,Im no good at sleeping

4 ConsequenceContinued lack of sleep

Here the individual has thoughtabout the fact in a particular way,by generalising that they will neverget any sleep all night. In fact, evenpeople with insomnia sleep on mostnights, but tend to underestimate theamount of sleep they have had uponreection the next day. Thereforethe statement Im never going toget to sleep is likely to be false. Theindividual places more emphasis on

this thought than the fact itself. Thesubsequent emotional consequencegeneralises further still from theoriginal fact, and feeds back into apersons thoughts about themselves,negatively aecting their ability tosleep.

An alternative way of approachingthis situation, which could be

recommended through theuse of CBT methods, might be:

1 FactIm not feeling very sleepyright now

2 ThoughtIm not sleepy now; but I usually getsome sleep during the night. MaybeI will feel sleepy soon.

3 ConsequenceIm going to get out of bed to goto the toilet and drink some water.I will return to bed in a few minuteswhen I feel more sleepy

In appraising the situation more

accurately and more positively, theindividual does not place unduepressure on themselves to get tosleep, and is then more able to takepractical steps to help them adjustto the process of going to sleep. If theperson does not fall asleep, a positiveway of thinking about the situationcould be:

4 ThoughtIt doesnt matter whether or not Ifall asleep. I can function well withlittle sleep. I will relax and not worryabout it. I will fall asleep when mybody is ready.

The link between our thoughtsand the values we place on

those thoughts is very importantin overcoming insomnia.

Good sleepers treat sleep as anautomatic process which happenswhen they go to bed. In other words,they do not spend time thinkingabout sleep, or about how they needto get to sleep80. In CBT, a techniquecalled paradoxical intention is used.When a person is nding it dicultto fall asleep, they may be advisedto remain awake passively and togive up trying to fall asleep. In doingthis, the person reduces the eortthey spend on sleeping, whilst stillmaintaining their commitment to

improving their sleep practices. It isprecisely this absence of eort thathelps good sleepers to sleep easily.

The most challenging part of a CBTprogramme for insomnia is sleepscheduling. This involves keepinga strict discipline for going to bedand getting up. The rst part of thisis stimulus control, which relates tothoughts and feelings about sleep81.This is based on the idea that peoplerespond to certain cues (stimuli)and behave in a certain way. In thecase of insomnia, the problem isthat when the person thinks of thebedroom they immediately beginthinking about sleepless nights.

The bedroom should be a place thatis associated with sleeping, not withsleepless nights.

Psychological approachesThese approaches can be eective becausethey aim to challenge underlying thoughtsand feelings about sleep76. CognitiveBehavioural Therapy (CBT) is the mosteective treatment for chronic insomnia.

Therefore it is better if possible to For example if you get an average of CaseStudy


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5958

Therefore it is better, if possible, towatch TV, eat and do other activitiesin another room. If you are in bed butnot feeling sleepy then it is better toget up, leave the room and engagein a relaxing activity elsewhere,returning to bed only when you feelsleepy. One exception to this is sexualactivity. Spending long periods oftime in bed without falling asleepruns the risk of strengthening theassociation between the bed andsleeplessness. This ultimately makessleeping more dicult. At rst itmay seem counterproductive to

get out of bed so often, but in thelong term it is helpful in controllingour psychological associations andtherefore improving the chancesof overcoming insomnia.

The other part of sleep schedulingis sleep restriction82. This is alsochallenging. A person with insomniahas developed a sleep pattern thatis inappropriate for them. The aim ofsleep restriction is to help establishnew sleep patterns. Keeping a sleepdiary is the rst step; this will helpto record the amount of time spentsleeping per night (for an exampleof a sleep diary please see theAppendix). It is then necessaryto set a bedtime and a waking timebased on the average amount of timespent asleep.

For example, if you get an average ofve and a half hours sleep per nightbut need to rise at 7:00 a.m. for work,set the alarm for that time, and thengo to bed at 1:00 a.m. every night.This leaves a six hour window for yournew sleep pattern to slot into. After aperiod of time, you may be successfulin sleeping within that six hourwindow. The window can then begradually increased, so go to bed at12:45 a.m. instead. Sleep restrictionis perhaps the most challengingtechnique championed in CBT forinsomnia, and is dicult to practice

and maintain without the help of aspecialist practitioner.

There is substantial evidence fromnumerous high quality clinicalstudies to show that CBT is eectivefor insomnia83 84 85 86. Furthermore,the scientic literature around CBTand its eectiveness has beensystematically reviewed or meta-analysed nine times in the past 15years. Reports by the AmericanAcademy of Sleep Medicine haverevealed that across 85 clinicaltrials (and 4194 participants) CBTwas associated with improvementin 70% of cases87 88.

This improvement is long lasting,and it is therefore useful to treatchronic insomnia with CBT. NICE84has recognised CBT as an eectivetreatment for insomnia, althoughthere is no guidance specicallywritten for this purpose. However,a full course can be intensive andmay involve substantial amountsof work and discipline. This maybe o-putting for some people withinsomnia; however, there is someevidence to suggest that as fewas four CBT sessions are eectivefor simple cases of insomnia89.

Stepped care models of providing

appropriate services have beenrecommended to improve peoplessleep quality. These models involvemaking simple interventions (e.g.booklets, internet) widely available,using trained therapists for casesat an intermediate level, and involvingsleep specialist psychologists forthe most complex cases90. Certainly,it has been known for some timethat people seem to prefer theidea of psychological therapiesto medication for insomnia91.

Case Study

T* is a GP from Scotland who has sueredfrom bouts of depression. Because of his workcommitments, T often doesnt get enough sleep,though he always managed with catch up nights.This past autumn, T* found himself strugglingto fall asleep. To remedy this he would get upand watch TV downstairs until he felt sleepy.After a few weeks, he was getting up and goingback to bed all night, only being able to fall asleeparound 4 or 5am in the morning.

T*s GP switched his antidepressant medicationto one that had sedative properties but inspite of increasing doses and the additionof a benzodiazepine hypnotic, T*s sleep didnot improve.

After not much success with medication,T* consulted a sleep specialist, who recommendedhe stay up until 3am, then retire to bed and wake

up at 10 a.m. It was the sleep specialists belief thatT* had upset his body-clock, his natural circadianrhythm for sleep. At the same time T* beganreading a self-help book on insomnia which wasbased upon CBT methods93. He discovered thatpart of the reason he may have formed his sleeppattern was that it allowed him to have sometime to himself, which normally he didnt havein his busy day.

This realisation, combined with a tailored sleepregime of gradually bringing forward his bedtime

meant he returned to a normal sleep patternwithin a few weeks. T* also made adjustmentsto his daytime commitments and the stresshe felt when going to bed disappeared.T* has incorporated what he learnt from his ownexperience when dealing with patients who havesleep problems. This includes using sleep diariesas well as providing general sleep education.

CBT wasassociated withimprovement

in 70% of cases.

Sl i th ld


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Sleep is the golden

chain that tieshealth and our

bodies together.Thomas Dekker

Sleep is a much more complex process than many The majority of people who are suering poorConclusion


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6362

Sleep is a much more complex process than manypeople realise, but it is crucial to the health of us all.It is not merely an inconvenience on busy wakinglives. The link between sleep and health is two way.

The Great British Sleep Survey data indicatethe extent to which poor sleep can negativelyimpact on peoples daily lives, with inevitableconsequences for mental health. People whoare suering the eects of low mood, who have

less energy to take exercise, or are experiencingdiculty in personal relationships are morelikely to develop mental health problems.The consequences of chronic insomnia shouldtherefore be treated with these risks in mind.

Furthermore, poor sleep and insomnia are notalways treated in accordance with the bestcurrent knowledge. In clinical practice, medicationis more commonly prescribed for insomnia thanCBT, although CBT is more eective in the longterm. CBT is sometimes seen as dicult to accessdue to its relatively high cost and because of thelack of trained therapists available.

The IAPT programme may have the potential toaddress some of this need, if sta members aresuciently trained to recognise and work withsleep problems. Current NICE guidance on thetreatment of insomnia mentions the importance ofpsychological approaches, but the benets of suchapproaches have not yet been expanded uponsuciently.

The amount of evidence for CBT in the treatmentof insomnia makes it dicult to ignore. It wouldappear that tting such therapies into clinicalpractice relies upon employing a stepped careapproach. Only the most severe cases of chronicinsomnia need to be treated by a specialist sleeppractitioner.

The majority of people who are suering poorsleep might benet from simple, non-intrusivemethods such as a guided self-help book orcourse delivered over the internet. These kinds ofinterventions should be based upon the principlesof CBT, but would be far more ecient in terms ofhealth spending. There is already some evidencein favour of using simple, self-guided therapies totreat sleep problems92.

If a person with poor sleep nds such therapiesto be ineective, then primary care workers suchas nurses or GPs should be able to give evidence-based guidance on how to improve sleep. Beyondthis, graduate psychologists may be able to oershort CBT courses in an individual or group setting,and clinical psychologists might review morecomplex cases where there is an underlying mentalhealth problem to be treated. There are severalstages that can be tried before enlisting the help ofa specialist sleep practitioner.

Poor sleep is a public health problem and needs tobe taken seriously. It needs to be recognised withinhealthcare, education, and society at large. Forsociety, it is vitally important that sleep is seen asa public health issue, much like diet and exercise.Sleep needs to be an issue on any public healthagenda. If this does not happen, a great numberof people will suer the consequences, withoutreason.

Conclusion

Sleeping poorly increases the risk of havingKey points We The importance and benets of sleep for


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Sleeping poorly increases the risk of havingpoor mental health. In the same way that healthydiet and exercise can help to improve our mentalhealth, so can sleep.

There is no universal answer to the questionof how much sleep a person needs. This variesfrom person to person. What is important is thatpeople nd out how much sleep they need andensure that they achieve this.

The consequences of poor sleep should be takenseriously in healthcare, education, family life,and society at large.

Key points Werecommendthat

The importance and benets of sleep forboth mental and physical health shouldbe highlighted in national and local publichealth campaigns, including in schoolsand workplaces. New and easily accessibleresources should be made available advisingpeople what they can do themselves toimprove their sleep.

The Royal College of GPs should provide

up to date, evidence-based training andinformation for its members on the importanceand benets of sleep for physical and mentalhealth. GPs should also have access to adiagnostic tool for use in recognising sleepproblems in primary care settings.

The new Public Health Outcomes Frameworkshould include a specic outcome on reducingsleep problems across the whole population.Sleep should also be reected in new nationalmental health outcome indicators, including

improving sleep for people who experiencesignicant sleep problems requiring specialisthelp.

The National Institute of Health and ClinicalExcellence (NICE) should develop guidancefor the management of insomnia using non-pharmacological therapies, to complementexisting guidance on using pharmacologicaltherapies.

People with sleep problems should be

recognised within the IAPT programme,especially regarding access to CognitiveBehavioural Therapy (CBT). IAPT sta shouldbe suitably trained on sleep issues.

Further research should be carried out toestablish the eectiveness of low cost, non-intrusive CBT-based interventions for sleepproblems, such as self-help booksand online courses.


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M h ld f t


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Man should forget

his anger beforehe lies down to sleep.Gandhi

Appendix: Sleep Diary This sleep diary has enough space for


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Appendix: Sleep DiaryWorking out the reasons why you mighthave problems sleeping can be dicult.Keeping a sleep diary, like the one on the nextpage, can help you keep track of when youslept well or poorly, and the possible reasonswhy that happened.To complete the sleep diary, simply

read the questions opposite and answerthem in the appropriate space in the table.For instance, the answer to question A willbe put in column A of the table next to thedate of the sleep concerned. An exampleis provided on the rst line of the table.

This sleep diary has enough space forup to a week. Once you have completedit, you can download and print a new copyfrom our website: www.HowDidYouSleep.orgQuestions for sleep diary:A How did you sleep last night?B What time did you go to bed?C Approximately how long did it take

you to get to sleep?D How many times did you wakeup during the night?

E What time did you wake up?F How long did you sleep for in total?G What did you consume (if anything)

within four hours of going to bed(e.g. cup of tea/coee/ milky drink,glass of wine/beer, sleeping pills,dinner) and how long before beddid you consume it?

H What was the temperature outsideand in your bedroom?

I What light sources were there whenyou went to sleep?

J How much noise was there whenyou went to sleep?

K What activities did you undertakebefore you went to sleep?

L Any other comments?M How well did you feel throughout

the next day (1= awful, 5= average,10= perfect)? Include a descriptionif appropriate (e.g. drowsy, grumpy,spaced out)?

Remember, this diaryis your personal recordof how well you sleptand why, so be honest!

Date A B C E F G H I J K L MD


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How you slept?

E.g 4th May 7/10Quite Well

Bedtime

11pm

Timetosleep

30mins

Wakeup inmorn

7am

Totalsleep

7hrs 50

Food and drink

Heavy dinner with glassof wine at 7pm, herbal teaat 10pm

Temperature

About 15 outside,window closed, felt a bithot

Light

Slight moonlight undercurtain

Noise

None

Activity before bed

Read book for 20 mins

Notes

Missed usual walk atlunch today

How did you feel?

8/10,Bit sleepy on bus to work

Wake in night?

Once about 2am for10 mins (went to loo)


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AcknowledgementsThis report was written by Dr. DanRobotham, Lauren Chakkalackaland Dr. Eva Cyhlarova.

Others who contributed to this workinclude: Professor Colin Espie, Directorof the University of Glasgow SleepCentre and Sleepio Ltd, Peter Hamesof Sleepio Ltd, Dr. Andrew McCulloch,Simon Lawton-Smith, Alistair Martin,Simon Loveland, Kirsten Morgan,Siobhan Trim and Kate Wilson.


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avoiding sleep

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