Sleeping Well

This helpful information is for anyone who has trouble with their sleep, or who lives with somebody who can’t sleep well. It includes both common problems with sleep, and some of the more unusual difficulties that people may have. There are some simple tips on how to sleep better, and some information to help you decide if you need professional help.

Introduction

We don’t usually need to think very much about our sleep – it’s just a part of life that we take for granted. When we can’t sleep, though, it can be a real problem. In fact, most of us will find it hard to sleep at some point in our lives. We have a word for it – insomnia. It’s often just for a short time, perhaps when we’re worried or excited. After a few days, things settle down and we get back to sleeping normally. However, we need sleep to keep our minds and bodies healthy. If we carry on sleeping badly, we start to notice the effects.

What is sleep?

Sleep is the regular period in every 24 hours when we are unconscious and unaware of our surroundings. There are two main types of sleep:
Rapid Eye Movement (REM) sleep
It comes and goes throughout the night, and makes up about one fifth of our sleep time. During REM sleep, our brain is very active, our muscles are very relaxed, our eyes move quickly from side to side and we dream.
Non-REM sleep
The brain is quiet, but the body may move around. Hormones are released into the bloodstream and our body repairs itself after the wear and tear of the day. There are 4 stages of non-REM sleep:
The muscles relax, the heart beats slower and body temperature falls – “pre-sleep”.
Light sleep – we can still be woken easily without feeling confused.
“Slow wave” sleep – our blood pressure falls, we may talk in our sleep or sleep walk.
Deep “slow wave” sleep – we become very hard to wake. If we are woken, we feel confused.

We move between REM and non-REM sleep about five times throughout the night, dreaming more as we get toward the morning.

During a normal night, we will also have short periods of waking. These last 1 or 2 minutes and happen every 2 hours or so. We aren’t usually aware of them. We are more likely to remember them if we feel anxious or there is something else going on – noises outside, our partner snoring etc.

How Much Sleep Do We Need?

This depends mainly on how old we are.

Babies sleep for about 17 hours each day.
Older children only need 9 or 10 hours a night.
Most adults need around 7-8 hours sleep each night.
Older people need the same amount of sleep, but will often only have one period of deep sleep during the night, usually in the first 3 or 4 hours, after which they wake more easily. We also tend to dream less as we get older.

There are also differences between people of the same age. Most of us need 7-8 hours a night, but some (a few) people can get by with only 3 hours a night. It’s not helpful to regularly sleep more than 7-8 hours each night.

The short periods of being awake feel much longer than they really are. So it’s easy to feel that we are not sleeping as much as we actually are.

What if I don’t sleep?

It’s easy to worry when you can’t sleep. The occasional night without sleep will make you feel tired the next day, but it won’t harm your physical or mental health.

However, after several sleepless nights, you will start to find that:

you are tired all the time
you drop off during the day
you find it difficult to concentrate
you find it hard to make decisions
you start to feel depressed.

This can be very dangerous if you are driving or operating heavy machinery. Many deaths are caused each year by people falling asleep at the wheel while driving.

Lack of sleep may also make us more vulnerable to high blood pressure, obesity and diabetes.

Sleep problems in adult life

Sleeping too little (Insomnia) You may feel that you aren’t getting enough sleep or that, even if you do get the hours, you don’t get a good night’s rest.

There are many everyday reasons for not sleeping well:

the bedroom may be too noisy, too hot or too cold
the bed may be uncomfortable or too small
you partner may have a different pattern of sleep from yourself
you may not have a regular routine, or may not be getting enough exercise
eating too much can make it difficult to get off to sleep
going to bed hungry can make you wake too early
cigarettes, alcohol and drinks containing caffeine, such as tea and coffee
illness, pain or a high temperature.

Some more serious causes include:

emotional problems
difficulties at work
anxiety and worry
depression – you may wake very early in the morning and not be able to get back to sleep
thinking over and over about day to day problems.

Can medication help?

People have used sleeping tablets for many years, but we now know that they:

don’t work for very long.
Leave you tired and irritable the next day.
lose their effect quite quickly, so you have to take more and more to get the same effect.
some people become addicted to them. The longer you take sleeping tablets, the more likely you are to become physically or psychologically dependent on them.
there are some newer sleeping tablets (Zolpidem, Zalpelon and Zopiclone), but these seem to have many of the same drawbacks as the older drugs, such as Nitrazepam, Temazepam and Diazepam.

Sleeping tablets should only be used for short periods (less than 2 weeks) – for instance if you are so distressed that you cannot sleep at all.

If you have been on sleeping tablets for a long time, it is best to cut down the dose slowly after discussing it with your doctor.

In some cases, antidepressant tablets may be helpful.

Over the counter medication You can buy several remedies at your chemist, without the need for a prescription. These products will often contain an anti-histamine, like you find in medicines for hay-fever, coughs and colds. These do work but they can make you sleepy well into the next morning. If you do use them, take the warnings seriously and don’t drive or operate heavy machinery the next day. Another problem is tolerance – as your body gets used to the substance, you need to take more and more to get the same effect. It is best not to take anti-histamines for a long time.

Herbal alternatives are usually based on a herb called Valerian. It probably works best if you take it nightly for 2-3 weeks or more. It doesn’t seem to work so well if you take it occasionally. As with the anti-histamines, you need to be careful about the effects lasting into the following morning. If you are taking any medication for your blood pressure (or any other sleeping tablets or tranquillisers), have a chat with your doctor before using an over the counter remedy.

Psychological Treatments A technique called cognitive behavioural therapy has been shown to be helpful. It involves looking at unhelpful ways of thinking that can make you more anxious, and so interfere with your sleep.

Things to avoid

Alcohol. Everybody knows that alcohol can help you to fall asleep. The problem is that you will usually wake up half-way through the night. If you drink alcohol regularly to help you sleep, you will find that you need to drink more and more to get the same effect. If you drink regularly and you stop drinking suddenly, you may find it hard to sleep for a week or two.
Slimming tablets make it hard to sleep, as do street drugs like Ecstasy, cocaine and amphetamines.

Helping yourself

Here are some simple tips that many people have found helpful.

Do’s…

Make sure that your bed and bedroom are comfortable – not too hot, not too cold, not too noisy.
Make sure that your mattress supports you properly. It should not be so firm that your hips and shoulders are under pressure or so soft that your body sags. Generally, you should replace your mattress every 10 years to get the best support and comfort.
Get some exercise. Don’t overdo it, but try some regular swimming or walking. The best time to exercise is in the daytime – particularly late afternoon or early evening. Exercising later than this may disturb your sleep.
Take some time to relax properly before going to bed. Some people find aromatherapy helpful.
If something is troubling you, and there is nothing you can do about it right away, try writing it down before going to bed and then tell yourself to deal with it tomorrow.
If you can’t sleep, get up and do something you find relaxing. Read, watch television or listen to quiet music. After a while you should feel tired enough to go to bed again.

Don’ts…

Don’t go without sleep for a long time – go to bed when you are tired and stick to a routine of getting up at the same time every day, whether you still feel tired or not.
Caffeine hangs around in your body for many hours after your last drink of tea or coffee. Stop drinking tea or coffee by mid-afternoon. If you want a hot drink in the evening, try something milky or herbal (but check there’s no caffeine in it).
Don’t drink a lot of alcohol. It may help you fall asleep, but you will almost certainly wake up during the night.
Don’t eat or drink a lot late at night. Try to have your supper early in the evening rather than late.
If you’ve had a bad night, don’t sleep in the next day – it will make it harder to get off to sleep the following night.

If you try these tips and you still can’t sleep, go and see your doctor. You can talk over any problems that may be stopping you from sleeping. Your doctor can make sure that your sleeplessness is not being caused by a physical illness, a prescribed medicine, or emotional problems. There is some evidence that cognitive behavioural therapy (see above), can be helpful if your sleeplessness has gone on for a long time.

Sleeping at the wrong time – Shift Work and Parenthood You may have to work at night and to stay awake when you would normally be asleep. If you only have to do this from time to time, it’s quite easy to adjust. It is much more difficult if you have to do this more often. Shift workers, doctors and nurses working all night, or nursing mothers may all have this problem. They find themselves sleeping at times when they ought to be awake. This is similar to jet lag, where rapid travel between time zones means that you find yourself awake when everybody else is asleep.

A good way to get back to normal is to make sure that you wake up quite early, at the same time every morning. It doesn’t matter how late you fell asleep the night before. Use an alarm clock to help you. Make sure that you don’t go to bed again before about 10 pm that night. If you do this for a few nights, you should soon start to fall asleep naturally at the right time.

Sleeping too much You may find that you often fall asleep during the day at times when you want to stay awake. The commonest reason is not getting enough sleep at night.

However, you may find that you are still falling asleep in the daytime even after a week or two of getting enough sleep at night. Sometimes, a physical illness can be responsible – diabetes, a viral infection, or a thyroid problem.

There are other conditions which make people sleep too much:

Narcolepsy (Daytime sleepiness) This is an uncommon condition that has often not been recognised by doctors.
There are two main symptoms:

you feel sleepy in the daytime, with sudden uncontrollable attacks of sleepiness even when you are with other people
you suddenly lose control of your muscles and collapse when you are angry, laughing or excited – this is called cataplexy.

You may also find that you:

can’t speak or move when falling asleep or waking up – (Sleep Paralysis)
hear odd sounds or see dream-like images (Hallucinations)
“run on auto-pilot” – you have done things, but can’t remember doing them, as if you had been asleep
wake with hot flushes during the night.

The cause for this has recently been found – a lack of a substance called orexin, or hypocretin. In sleep apnoea you may have excessive daytime sleepiness and this may be confused with Narcolepsy. If the diagnosis is unclear, then some tests may be required (Polysomnography or a Multiple sleep latency test ).

Treatment consists of taking regular exercise and having a regular night time routine. Depending on the pattern of your symptoms, medication may be helpful – e.g. a drug which increases wakefulness, such as Modafinil, or an antidepressant (particularly for prominent cataplexy).

If you continue to fall asleep in the daytime, it’s likely that you are either not getting enough sleep or exercise, or that you are not getting the right treatment. You should let other people know that it’s OK to wake you.

Sleep Apnoea (Interrupted Sleep)

You snore loudly and stop breathing for short periods during the night. This happens because the upper part of your airway closes.
Every time you stop breathing, you wake suddenly and your body or arms and legs may jerk.
You are awake just for a short time before falling off to sleep again.
This often happens several times during the night. So, you feel tired the next day, often with an irresistible urge to go to sleep. You may also have a dry mouth and a headache when you wake up in the morning.

It is more common in:

older people
the overweight
smokers
those who drink a lot of alcohol.

Sometimes, the problem is noticed more by their partner than by the sufferer. Treatment usually involves correcting the parts of your lifestyle that may be making the problem worse – cutting down smoking and drinking, losing weight, and sleeping in a different position. If your apnoea is very bad, it may be necessary to wear a Continuous Positive Airway Pressure (CPAP) mask. This fits over your nose and supplies high pressure air to keep your airway open.

Autism

Some people with autism do not seem to realise that night time is for sleeping, and may be up and about when everyone else wants to sleep. This will usually need the help of a specialist.

Self-help organisations
The Sleep Council Ttel: 01756 791089 Promotes the benefits of sleeping well. Provides information leaflets on sleep and beds.

National Sleep Foundation American website with information on sleep and sleep disorders

Narcolepsy Association UK (UKAN) Tel: 0845 4500 394; email:info@narcolepsy.org.uk Promotes the interests of people with narcolepsy and encourages better understanding of the illness.

Sleep Disorder Clinics. There are a number of Sleep Disorder Clinics, but referral to one of them should be made through your family doctor. Patients cannot refer themselves

Useful reading

Get a better night’s sleep (Positive Health Guides) by Ian Oswald and Kirstine Adam (Optima).
Insomnia: Doctor I can’t sleep by Adrian Williams (Amberwood Publishing).

Audio Tapes

Coping with Sleep Problems. Coping with Sleep Problems. Two-cassette audio pack with advice and self help tips on how to deal with sleep problems. £13.99 (p&p inclusive). Available from the Booksales Department, The Royal College of Psychiatrists. Tel: 020 7235 2351 ext. 146.

References

Vignatelli L, D’Alessandro R, Candelise L. Antidepressant drugs for narcolepsy. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD003724. DOI: 10.1002/14651858.CD003724.pub3

Managing excessive daytime sleepiness in adults. Drug and Therapeutics Bulletin 2004;42:52-56; doi:10.1136/dtb.2004.42752

Sleep Disorders (1988) Williams R.L., Karacan I. & Moore C.A. John Wiley & Sons ISBN 0471837210.

Over-the-counter medicines and the potential for unwanted sleepiness in drivers: a review (2001) Horne, J.A. & Barrett, P.R. Department of Transport: HMSO.

Valerian for insomnia: a systematic review (2000) Stevinson C. & Ernst E. Sleep Medicine, 1: 91-99.
Behavioural and pharmacological therapies for late-life insomniacs (1999) Norin C.M. et al JAMA, 281: 991-999.

Management of insomnia (1997) Kupfer D.J. & Reynolds C.F. New England Journal of Medicine, 336: 341-346.

Impact of sleep debt on metabolic and endocrine function (1999) Spiegel, K., Leproult, R & Van Cauter, E. The Lancet, 354, 1435-1439.

Guidance on the use of Zalpelon, Zolpidem and Zopiclone for the short-term management of insomnia (2004) Technology Appraisal 17, National Institute for Clinical Excellence: London.

Non-pharmacological interventions for insomnia: a meta-analysis of treatment efficacy (1994) American Journal of Psychiatry, 151, 1172-1180.

Produced by the RCPsych. Series Editor: Dr Philip Timms, Expert review: Dr A J Williams, Editorial Board: Dr Martin Briscoe, Dr Ros Ramsay, Deborah Hart, User & Carer input: The RCPsych Special Committee of Patients and Carers. © Cartoons by Mel Calman. © S. and C. Calman.