Matters The impact of sleep on health and wellbeing Mental Health Awareness Week 2011

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Contents 04 Executive summary 08 Introduction 12 Part 01 – Sleeping and sleep patterns 28 Part 02 – Poor sleep 48 Part 03 – Sleeping well 62 Conclusion 66 Useful resources 68 References 72 Appendix: Sleep diary 76 Acknowledgements

01 ‘The main facts in human life are five:

E. M. Forster Executive We spend approximately a Poor sleep over a sustained period One of the most widely used and – The new Public Health Outcomes third of our lives asleep. Sleep leads to a number of problems which successful therapies is Cognitive Framework should include a specific Summary are immediately recognisable, including Behavioural Therapy (CBT). This is outcome on reducing sleep problems is an essential and involuntary , sleepiness, poor concentration, useful even for people who have across the whole population. process, without which we lapses in memory, and irritability. had for a long period of time. Sleep should also be reflected in cannot function effectively. A full course of such a therapy with new national mental health outcome It is as important to our Up to one third of the population may a sleep specialist is potentially costly, indicators, including improving bodies as eating, drinking suffer from insomnia (lack of sleep and is most appropriate for people sleep for people who experience and breathing, and is vital for or poor quality sleep). This can affect with severe sleep problems. Still, some significant sleep problems requiring mood, energy and concentration levels, CBT principles can be appropriate specialist help. maintaining good mental and our relationships, and our ability to stay and easily practiced for anyone who is physical health. Sleeping helps awake and function during the day. experiencing a sleepless night. – The National Institute of Health to repair and restore our brains, and Clinical Excellence (NICE) not just our bodies. Sleep and health are strongly related, Key points: should develop guidance for the poor sleep can increase the risk of – Sleeping poorly increases the risk of management of insomnia using During sleep we can process having poor health, and poor health having poor mental health. In the same non-pharmacological therapies, information, consolidate memories, can make it harder to sleep. Common way that healthy diet and exercise can to complement existing guidance and undergo a number of maintenance mental health problems like anxiety help to improve our mental health, on using pharmacological therapies. processes that help us to function and depression can often underpin so can sleep. during the daytime. Sleep is crucial sleep problems. Where this is the case, – People with sleep problems should to the health of individuals within the a combination approach to treating – There is no universal answer to be recognised within the Improving UK and to the public health of the UK the mental health problem and sleep the question of how much sleep Access to Pyschological Therapies population. problem in tandem is often the most a person needs. This varies from (IAPT) programme, especially effective. person to person. What is important regarding access to Cognitive We all need to make sure we get the is that people find out how much Behavioural Therapy (CBT). IAPT staff right amount of sleep, and enough It is essential for us to better sleep they need and ensure that should be suitably trained on sleep good quality sleep. There is no set understand the sleep process in they achieve this. issues. amount of sleep that is appropriate order to ensure that we get a regular for everyone; some people need more amount of good quality sleep. Sleepio, – The consequences of poor sleep – Further research should be carried sleep than others. Our ability to sleep co-founded by Professor Colin Espie, should be taken seriously in out to establish the effectiveness is controlled by how sleepy we feel and Director of the University of Glasgow healthcare, education, family life, of low cost, non-intrusive CBT- our sleep pattern. How sleepy we feel Sleep Centre, is a new organisation and society at large. based interventions for sleep relates to our drive to sleep. The sleep that is dedicated to raising awareness problems, such as self-help books pattern relates to the regularity and of the importance of sleep. Sleepio We recommend that: and online courses. timing of our sleep habits; if we have collected data from a large-scale, – The importance and benefits of got into a pattern of sleeping at set national survey on sleep habits; some sleep for both mental and physical times then we will be able to establish of these revealing new data appear health should be highlighted in a better routine, and will find it easier throughout this report. national and local public health to sleep at that time every day. campaigns, including in schools and We can all benefit from improving the workplaces. New and easily accessible Sleep is a more complex process than quality of our sleep. For many of us, it resources should be made available many people realise, much of it is still may simply be a case of making small advising people on what they can do a mystery to scientists. During sleep, lifestyle or attitude adjustments in themselves to improve their sleep. the body goes through a variety of order to help us sleep better. For those processes and sleep stages. Good with insomnia it is usually necessary – The Royal College of GPs should quality sleep is likely to be the result to seek more specialist treatment. provide up to date, evidence-based of spending enough time in all of the Sleep medication is commonly used, training and information for its stages, including enough deep sleep but may have negative side effects and members on the importance which helps us feel refreshed. is not recommended in the long-term. and benefits of sleep for physical Psychological approaches are useful and mental health. GPs should also for people with long-term insomnia have access to a diagnostic tool for because they can encourage us use in recognising sleep problems to establish good sleep patterns, in primary care settings. and to develop a healthy, positive mental outlook about sleep, as well as dealing with worrying thoughts towards sleeping.

04 05 ‘Sleep is the best meditation.’ Dalai Lama Introduction We spend, on average, approximately a third In Part II, we review the literature on sleep problems of our life asleep. Along with eating, drinking and explain what can happen if we don’t sleep and breathing, sleeping is one of the pillars for properly. In Part III, we describe ways in which maintaining good mental and physical health. we can improve our sleep and explain possible Ultimately, we would die if we did not sleep. treatments for those who find achieving good quality sleep difficult. The primary focus of this Despite its obvious importance, sleep remains report is sleep and mental health; both how mental a mysterious realm that has fascinated us for health can affect our sleep, and how sleep can thousands of years. For example, in the Greek affect our mental health. pantheon sleep is represented by the winged god Hypnos, himself the son of Nyx, goddess of the The report includes primary data from the Great Night. Closely related to Hypnos were Thanatos British Sleep Survey, developed by Professor Colin (god of death) and Morpheus (god of ). Espie at the University of Glasgow in association As human beings, most of us cross the bridge with Sleepio Ltd. between the conscious to the unconscious on at least a daily basis. Yet, we seldom give a second The survey has been available online from March thought to the countless physiological and 2010, and aimed to take a snapshot of the UK’s psychological processes that occur within our sleep habits. By December 2010, there had been bodies and brains when we are deep in slumber. 6708 responses to the survey. This survey is still online: you can take part by visiting the Sleepio The aim of this report is to raise awareness about website, www.sleepio.com. the importance of sleep and its crucial role for our health, both physical and mental, just like diet and exercise. In Part I of this report, we provide information about sleep, why we need to sleep, and what happens during sleep.

08 09 ‘A good laugh and a long sleep are the best cures in the doctor’s book.’ Irish proverb Sleeping and Sleep Patterns

12 13 Sleep affects our ability to use What is Sleep? language, sustain attention, Sleep is often seen as time understand what we are reading, when the body is inactive. and summarise what we are In fact, the opposite is true. hearing03. If we compromise on Sleep is an active, essential our sleep, we compromise on our performance, our mood, and our and involuntary process, interpersonal relationships. Sleep without which we cannot has also been shown to protect function effectively. Sleep is the immune system04. not a lifestyle choice; just like breathing, eating or drinking, Animals have evolved to sleep it is a necessity. in many different ways. Dolphins can sleep using only one half of their Sleep is a complex process during brain at a time. Even hibernating which our body undertakes a number animals have been shown to of essential activities. It involves low temporarily cease hibernation, go to sleep (a different, active process), awareness of the outside world, relaxed 05 muscles, and a raised anabolic state then return to hibernation . Sleep which helps us to build and repair is an inconvenient, time consuming our bodies. process, but it is so essential that we have simply evolved to fit it into Primarily, sleep is for the brain, allowing our lives. it to recover and regenerate. During our sleep, the brain can process information, consolidate memory, and enable us to learn and function effectively during daytime01. This is why we are encouraged to get a good night’s sleep in the run up to a job interview or exam rather than staying awake all night to prepare. Whilst we sleep, our brain is not The first part of this report only strengthening memories but it is also reorganising them, picking out the emotional details and helping describes the sleep process us produce new insights and creative 02 in detail, providing information ideas . about how and why it is essential to maintain good quality sleep throughout our lives, and on the problems that can arise during sleep.

14 15 How Much Sleep? Sleep Patterns We all need different amounts of sleep. Equally important as the total amount Different species of animals require of sleep is the pattern of sleep. Babies vastly different amounts, as shown in the and small children tend to sleep multiple estimated average sleep times of several times across each 24 hour period, but species06: as we mature into school years and into adulthood we tend to sleep in one long phase; daytime sleeping decreases and the person instead tends to sleep throughout the night.

Table 1 Still, it is important for us to gauge the A mechanism called the circadian It is possible to think of a “master The sleep needs of various species amount of sleep that we need and to timer regulates the pattern of our clock” which regulates our circadian ensure that we get the right amount. sleep and waking, and interacts rhythms. This clock is made up of a Species Average total sleep There is no set amount of sleep that is with the sleep homeostat. Most group of nerve cells in our brain called time per day (hours) appropriate for everyone. For example, living things have internal circadian the suprachiasmatic nucleus (SCN). although Margaret Thatcher once said rhythms, meaning they are adapted The SCN controls the production of Python 18 that she only needed five hours sleep to live in a cycle of day and night. melatonin, which is a hormone that Tiger 15.8 a night when she was Prime Minister, makes us feel sleepy. During sleep, Cat 12.1 this would have been unremarkable for The French geophysicist Jean- melatonin levels rise sharply. The Chimpanzee 9.7 her if she was naturally a short sleeper. Jacques d’Ortous de Mairan was the SCN is located just above our optic Sheep 3.8 Just as people may need different first to discover circadian rhythms in nerves, which send signals from African elephant 3.3 size shoes they may need different an experiment with plants in 1729. the eyes to the brain. Therefore, the Giraffe 1.9 amounts of sleep. It is vitally important Two centuries later, Dr. Nathaniel SCN receives information about the to find out how much sleep we as Kleitman studied the effect of amount of light in the environment In humans, the amount of individuals actually need, and to then circadian rhythms on human sleep through our eyes. When there is less sleep a person needs depends recognise that it may be different from cycles09. These rhythms respond light, such as during night-time, it tells upon their age. New born babies the amount of sleep that others need. primarily to light and darkness. The the brain to create more melatonin tend to sleep for an average of cycle is actually slightly longer than (see Figure 1). 16–18 hours per day, which decreases Sleeping less than we need 24 hours10 11. to about 13–14 hours after one year. as individuals has negative Adolescents tend to require more consequences. Whilst awake, we sleep than adults, possibly due to build up a which can only Figure 1 the physiological changes that are be repaid through sleeping. This is Diagram of sleep homeostat and circadian timer happening in the body during this regulated by a mechanism in the body (adapted model from Professor Derk-Jan Dijk, period. called the sleep homeostat, which Surrey Sleep Research Centre) controls our drive to sleep. If we have As the person reaches adulthood they a greater sleep debt, then the sleep tend to sleep 7–8 hours per day. Older homeostat indicates to us that we Performance whilst awake adults tend to sleep roughly 6–7 hours need more sleep. per day07, but take more frequent throughout the day. The amount of In a healthy situation this debt is time an average adult needs to sleep paid off night by night. However, the varies from person to person, and can debt can also build up and be repaid range between 5 and 11 hours. gradually over a period of weeks or Sleep Wake Cycle even months, for example, if we under- sleep for several nights in a row then we will need to repay the sleep debt in the near future. Interestingly, for people with bipolar disorder, the state of mania is associated with decreased perceived Circadian Homeostat need for sleep08. However, despite this perception, the person is still building up a sleep debt which needs to be repaid. Light-Dark Cycle

16 17 Serotonin is another chemical that Sleep patterns vary greatly, some affects sleep; produced by the animals are diurnal and tend to sleep brain, insufficient levels of serotonin during the night time, and others are are also related to mental health nocturnal and sleep mostly during problems such as depression and the daytime. Within humans, each anxiety. Levels of serotonin are person’s circadian timer is set slightly highest in the brain when we are differently; some people function awake and active, and the brain best in the mornings (larks), others produces more serotonin when it best in the evenings (owls), many of is lighter outside. This is why most us are somewhere in between. people feel tired at night-time, and why it is a good idea to turn off the Some people suffer from what is lights when we are trying to sleep. known as circadian rhythm sleep The immune system also influences disorder, which is an extreme end of serotonin, and therefore influences this spectrum, but is often associated sleep patterns12, which may explain with mental health problems. An why we need to sleep more if we are extreme ‘owl’ may have delayed feeling ill. sleep phase syndrome, tending to fall asleep and wake up very late. An As humans are mainly daytime extreme ‘lark’ may have advanced animals, the period we choose to sleep phase syndrome, rising very sleep is determined naturally by early in the morning but plagued the level of light in the environment; with sleepiness in the evening. These principally due to the setting and irregularities can become problems, rising of the sun. But we can now depending upon what we are trying manipulate light levels through the to do in life, although for some they use of artificial lights, which means can prove to be an asset. that we can continue activities long into the evenings. People who work Similar effects are commonly seen nightshifts may wish to reduce the in people whose sleep pattern is level of light they are exposed to disrupted due to external factors, during the daytime in order to sleep, such as working regular night shifts and can do this through the use of (particularly after working regular blackout curtains. day shifts in the weeks beforehand). Another example is jetlag which The story of the Copiapó mining is caused by travel between accident in Chile in 2010 shows different time zones. Both shift the importance of light for circadian work disorders and jetlag are very rhythms. Miners’ sleep-wake common expressions of circadian cycles were completely disrupted rhythm disorders. Humans are not in the absence of sunlight. The designed to be awake during the National Aeronautics and Space night and asleep during the day. Humans are not designed Administration (NASA) consultants People who regularly work night advised the miners to segregate their shifts are thought to be at a greater space into working, sleeping, and risk of cancer14 and heart disease15. to be awake during the night. recreation areas. International flight crews are also at elevated risk of cancer, possibly due They used the lights on their helmets to repeated disruption of circadian People who regularly work and the headlights on the mining rhythms. trucks to create a communal ‘light’ area. The sleeping area was kept Disruption of sleep and circadian night shifts are thought to be dark, meaning that the miners could rhythms are also documented in regulate the daylight cycle artificially people who suffer from bipolar and maintain a regular pattern of disorder, although it is unclear at a greater risk of cancer and sleep. This is an extreme example, whether the circadian timer or sleep but in fact, even moderate changes homeostat is responsible for the in lighting can affect our internal underlying sleep disturbances16. It heart disease. circadian timers13. has been suggested that changes in a person’s circadian rhythms can act as a trigger for bipolar disorder17, particularly mania18.

18 19 ‘The machinery is always going. Even when you sleep.’ Andy Warhol The stages of sleep In humans, sleep can be broadly divided into non-rapid eye movement (non-REM) sleep and rapid eye movement (REM) sleep.

We typically pass through four stages Non-REM stage one Non-REM stage two of non-REM sleep before beginning The first of the five sleep stages is a Within a few minutes, the sleeper REM sleep. In total, non-REM sleep form of light sleep, or non-REM stage may pass into another form of light accounts for about 75–80% of total one sleep. This stage is essentially sleep known as stage two of non- sleep in an average adult. the bridge between being awake REM sleep. The sleeper’s breathing and sleep. pattern and heart rate slow down This process is cyclical and during a and they become less aware of the single night we may experience four Sleepers drift in and out of light sleep outside world. Eye movement stops or five recurring cycles of non-REM and can be awakened easily. During and sleepers’ theta waves become and REM sleep each lasting between this stage, the person may begin to even slower with the occasional 90–110 minutes. Only recently have breathe more slowly and evenly, the bursts of brain activity every minute scientists begun to understand brain produces theta waves, which or so; these bursts of activity are the process, especially since sleep are smaller and lower in frequency sometimes known as sleep spindles. research has been aided by three than alpha waves. Muscle activity, measurements: measured by the EMG, shows a Stage two non-REM sleep is also slowing down of movement and the characterized by a type of brain 01 Brain wave activity using an sleeper may begin to twitch. wave activity known as a K-complex. electroencephalogram (EEG), A K-complex is a high voltage of which measures electrical activity These twitches are called hypnic jerks EEG activity with a sharp downward in the brain. and sometimes wake the sleeper, spike followed by a slower upward 02 Muscle tone through an particularly if the jerk is accompanied The first of the component; it sometimes resembles electromyogram (EMG). by the sensation of falling, which a mountain. This stage accounts 03 Movement of the eye via many people experience from time for the largest part of human sleep an electro-oculogram (EOG). to time. Since individuals may have five sleep stages (45–50% of sleep in adults19) and is some knowledge of the world around sometimes referred to as true sleep. Of these three, the EEG is the most them, it is in this stage of sleep that Like stage one sleep, stage two is important in helping to differentiate some people report out-of-body is a form of light also considered relatively ‘light’ sleep between the different sleep stages. experiences. and if sleepers were to be woken up While awake, our brains display a during either of these stages they pattern of brainwaves known as sleep, or non-REM may deny that they had been asleep beta waves. Beta waves are high at all. in frequency, meaning they occur in quick succession, but they are low stage one sleep. in amplitude, meaning they are quite small. This stage is Whilst we are awake these waves do not follow a consistent pattern. This makes sense because when we are essentially the awake, our brains are often doing a number of different tasks, stimulating the brain in a variety of different ways. bridge between When we rest with our eyes closed, our brain wave activity slows down and becomes more synchronised, being awake these brain waves are known as alpha waves. and sleep.

22 23 Non-REM stages three and four Deep sleep is a very refreshing The part of the brain involved in Stages three and four are typically type of sleep, and it is particularly Dreaming emotions, sensations and memories grouped together as the last stages important in helping the brain Dreams have been a subject becomes more active during REM of non-REM sleep, also referred to as consolidate what it has learnt during of awe and inspiration for sleep. So the brain may attempt to synchronised sleep. the day20. If awakened during these thousands of years, appearing make sense of this internal activity stages, sleepers report feeling in the oldest works of literature, and the result is a dream27. Dreams For these stages, sleepers pass from groggy and disoriented for several such as Epic of Gilgamesh may therefore be the result of signals the theta waves of stages one and minutes. Illustration of the sleep generated within our brains. two to delta waves, the largest and stages is shown in Figure 2. (c.2200 B.C.), as well as in slowest brain waves. There is no real recent Hollywood blockbusters Another theory28 suggests that distinction between stage three and Eventually, the sleeper will pass into such as Inception and Shutter dreams may help humans to four except typically during stage REM sleep. This takes its name from Island (2010). Some people maintain sleep, by keeping the mind three, sleep is comprised of less than the rapid eye movements that the are better at remembering occupied so that we don’t wake up. 50% delta waves, and in stage four sleeper displays, usually with their dreams than others, but most more than 50% of the waves are eyes closed, as discovered in 1953 It suggests that dreams may delta waves. Thus these stages are by Nathaniel Kleitman and Eugene would agree that their dreams entertain the brain so that other often referred to as slow wave sleep Aserinsky. The frequency of one’s are meaningful to them. Many areas can rest and recover, and or deep sleep. Sleepers’ breathing rapid eye movements is known people believe that dreams are without this kind of diversion, the and heart rate are at their lowest as their REM density. a gateway for understanding brain would keep telling us to wake levels, they breathe rhythmically our feelings, thoughts, up. However, these are merely and their muscle activity decreases. During this stage, the brainwaves behaviours, motives and values. theories, and the exact reasons are similar to when we are resting, why we are still uncertain. although our breathing rate and The theoretical link between blood pressure rise, all our voluntary dreaming and eye movements during What we do know is that dreams muscles also become paralyzed and sleep was made as far back as in are associated with an abundance our muscle tone becomes relaxed so 186824, and the explicit connection of a chemical called that we cannot move our limbs. This in the brain. Dopamine is a Figure 2 between REM sleep and dreaming is a relatively shallow stage of sleep; 25 neurotransmitter (a chemical that Brain waves during the stages of sleep was made almost a century later . the average person will have around It is possible that our eyes move transmits signals within the brain) three to five episodes of REM sleep because we are following the images that helps to direct our attention to Awake – eyes open/Alpha Waves per night, and the first period is likely of the dream in our sleep. Since we important things in our environment. to begin about 70–90 minutes after all experience REM sleep, we all have Both dreams and hallucinations falling asleep. It is during this stage the potential to experience dreams. involve deregulation of dopamine of sleep that we experience dreams. Still, the purpose and function production. It is thought that Awake – eyes closed of dreams remains unclear. dreaming may be similar to some The amount of time spent in the of the symptoms of , different sleep stages appears to since they appear to have similar There are many theories on the 29 relate to people’s mental health. meaning of dreams. Some scientists neurochemical backgrounds . Non-REM – Stage 1/Theta Waves Those who suffer from depression believe they serve no real purpose, have been shown to have more REM while others believe they are Dreaming and REM sleep are also sleep, enter this stage earlier, and strongly related to major depression, 21 integral to our mental, emotional, have increased REM density . For and physical wellbeing. The most and people who suffer from this Non-REM – Stage 2 people with schizophrenia, there can well-known theory comes from illness often display more frequent be a delay in reaching deep sleep the Austrian neurologist Sigmund rapid eye movements than normal K Complex and REM sleep22. Similarly, people - literally, people with depression Freud who founded the school of 15 who suffer from anxiety may spend psychoanalytic thought. According dream more . It actually appears less time in deep sleep23. However, as though getting too much REM to Freud, dreams are subconscious this is an area to be explored in future wishes26. He believed that the sleep can increase our vulnerability research to provide more precise images, thoughts and emotions to depression. Interestingly, many Non-REM – Stage 3 & 4/Slow Waves and Delta Waves information. antidepressants aim to limit REM experienced in a dream were 30 attempts by our unconscious to sleep .

resolve a conflict in waking life, and that the process of dreaming allowed One night of , for an interaction between the particularly the deprivation of unconscious and the conscious. REM sleep, may relieve depressive REM symptoms in the short term. However, this cannot be recommended as a treatment for depression since individuals become susceptible to symptoms again once they have repaid their sleep debt31 32. More importantly, the negative consequences of sleep deprivation can be far more damaging. 24 25 ‘ Sleeplessness is a desert without vegetation or inhabitants.’ Jessamyn West Poor Sleep

28 29 A person with insomnia may get Sleeping poorly increases the risk to Poor sleep relates not only to the total amount into a habit of sleeping in short shifts poor mental health, which is often of sleep, but also to the quality of sleep and throughout the day, which then may neglected when aiming to improve make it difficult for them to sleep at health and wellbeing. Insomnia is the amount of time spent awake. Good quality . The problem with napping inextricably related to mental health. like this is that the person only sleeps Many of us will have experienced a sleep includes all of the aforementioned sleep for short periods of time. This means sleepless night due to worrying about stages, with a significant amount of time that they are likely to get lots of light an upcoming event, such as an exam sleep without ever passing through or a job interview. spent in deep sleep. all the sleep stages. In particular, they fail to achieve the essential A prolonged period of stress or deep sleep necessary for restoration worry can also seriously affect our of mind and body, and fail to recover ability to sleep. In a sample of roughly Sleep quality is of paramount their sleep debt. 20,000 young adults, lack of sufficient Insomnia importance to our health. People sleep was linked to psychological Most of us have experienced a who have slept poorly are likely to Sometimes insomnia can be related distress37, and a history of insomnia suffer from fatigue, sleepiness during to physical health problems. Most has been shown to increase the sleepless night, which although 38 39 upsetting, is nothing to worry daytime, poor concentration, irritability, of us will have experienced an risk of developing depression . about since the sleep debt can memory loss, depression, frustration, illness which has made it harder to Unsurprisingly, anxiety and depression and a weakened immune system. sleep due to physical discomfort or are also common causes of chronic be repaid over the course of the Fatigue – feeling weary and lacking irritation, such as a blocked nose or insomnia40. People who suffer from next few nights. The inability in energy whilst awake – is the most sore throat. Some chronic conditions, depression may experience sleep to fall or remain asleep over common problem associated with such as osteoporosis or diabetes, disturbances which disrupt the a period of several nights is poor sleep. can drastically affect sleep in the long process of falling and staying asleep. known as insomnia. term. Addressing physical health The sleeper may wake intermittently This is different to sleepiness because problems could improve sleep quality. throughout the night, or wake early in it doesn’t necessarily increase the It may be possible also to address the the morning and be unable to sleep People with insomnia have poor quality 41 sleep, may be unable to get enough likelihood of falling asleep. Signs of sleep problem alongside the health again . sleep, and may wake up for long sleepiness include yawning, muscle problem rather than just treating it as a periods during the night, resulting in ache, and drifting off to sleep. symptom. Furthermore, insomnia is a common Furthermore, poor sleep can make us complaint in people who suffer fatigue during the daytime. Insomnia 42 is a psychophysiological disorder, less receptive to positive emotions34 Our mental state is perhaps even more from schizophrenia , and some which means that it is a combination which in turn can make us feel important in allowing or preventing schizophrenia medications can miserable during the day, and may insomnia from developing from an profoundly affect a person’s ability of our thoughts, behaviour, emotions 43 and physiology. Insomnia can be increase the likelihood of us developing acute into a chronic problem. This to maintain constant sleep . People acute (lasting less than a month), or it depression35. refers particularly to our thoughts and visiting clinics with the may develop into a chronic, long-term attitudes about sleeping. For example, complaint of insomnia often have condition. Evidence from experiments involving some of us, after suffering several another underlying mental health rats suggests that in extreme cases, consecutive sleepless nights, may problem44. This type of insomnia is Essentially, insomnia is associated with sleep deprivation may even be fatal36. become anxious that we have not had more difficult to treat since it involves arousal of our mind and body. Typically Indeed, there is an extremely rare enough sleep. This type of thought treating the underlying problem as well people complain of a racing mind genetic disorder called fatal familial process is likely to lead to thinking as the insomnia. and get into a vicious cycle of poor insomnia, affecting around 100 about the problems associated with sleep, concerns about poor sleep, and people worldwide. This usually begins not sleeping. patterns of thoughts and behaviour between the ages of 35 and 60, and that are unhelpful. This means that leads to death several months later. This can lead to anxious thoughts, the normal operation of the sleep Poor sleep can also affect the which can then lead a person to see debt and circadian mechanisms do circadian timing mechanism. Keeping themselves as failing to sleep well. not work properly. The result of a series an irregular sleep pattern can make These thoughts perpetuate a negative of sleepless nights can be serious. insomnia worse. People who suffer cycle, making it even more difficult from insomnia are likely to feel the for the person to sleep. Many of us Insomnia is by far the most common effects of sleep deprivation throughout may recognise this behaviour if we sleep complaint in the general the daytime. have watched the clock during the population. It is a massive public health night. This is a very common activity problem, and the most commonly It may be tempting to catch up for people who suffer from insomnia, reported mental health complaint in on sleep by ‘grazing’ at opportune where the clock starts to be used as a the UK33. moments across the day, but even gauge to monitor sleep performance. though this temporarily recoups This pressure to perform in turn makes a small amount of sleep debt, it more difficult to sleep. unfortunately it also disrupts the sleep pattern.

30 31 Some caution should be used when Figure 5 People with Nearly 95% of respondents with The Great British discussing the results of this survey, Negative impact of poor sleep on daily life. Insomnia insomnia reported low energy levels Good Sleep Survey: new since those who responded were (N=5328) Sleepers in their daily lives, considerably more more likely to have taken an interest than twice the percentage for good data on the impact in their own sleep, possibly because sleepers (just over 40%). This has a they had a problem with sleeping. 100 range of mental and physical health of poor sleep The sample therefore cannot be truly 90 implications, particularly with regard The Great British Sleep Survey representative of the UK population. to an individual’s ability to take regular 80 was launched by Sleepio to exercise, which in itself is an effective measure the sleep quality of the Only 38% of survey respondents 70 way of reducing stress, anxiety and (2522 people) were classified as ‘good 60 depression. UK population. By December sleepers’, whilst 36% were classified 2010 there were 1870 as possibly having chronic insomnia 50 The impact of insomnia on energy responses from men and 4838 (2414 people). Insomnia was slightly 40 levels indicated by the survey therefore from women (total = 6708). more common in women (37%) than has the potential to create a vicious in men (32%), and 79% of those who 30 cycle of deteriorating health: insomnia 20 The average age of respondents had insomnia reported having it for decreases an individual’s capacity at least two years. Other estimates 10 for exercise, negatively affecting their was 40 years for men and 37 for of insomnia have put the total figure mental wellbeing, in turn worsening

women. Average sleep scores Percentage 0 at around 30% of adults, although Mood Energy Relationships Staying Concentration Getting their insomnia. were calculated for each person rates depend upon the criteria used Awake Things Done based upon the answers that to define it45. Of the people reporting Aspects of Daily Life The survey data indicated that people gave to the survey, with insomnia in the survey, over 30% have Other data from the survey showed over 75% of people with insomnia a higher score representing had insomnia for 2–5 years, and over that insomnia had a negative effect experienced poor concentration, and 25% for over 11 years (Figure 4) on people’s mood, energy, nearly 70% reported difficulties in better sleep quality (0% = very concentration, personal relationships, ‘getting things done’. In both instances, poor, 100% = excellent). ability to stay awake during the day, and this is approximately three times more ability to carry out daily tasks (Figure 5). Figure 4 than the percentage for good sleepers. The results showed that men had This inability to concentrate and carry better sleep quality than women; the Duration of insomnia In comparison to good sleepers, over (N=6708) out tasks shows how the implications average sleep score was 61% for men four times as many respondents of poor sleep can affect wider society, and 57% for women. Unsurprisingly, with insomnia reported relationship for instance, in terms of impairing sleep was related to health; people 40 difficulties. The ability to maintain productivity in the workplace. who rated their physical health as ‘poor’ good relationships with friends, family had an average sleep score of 47%, 35 and partners is naturally important Overall, the data from the survey has significantly worse sleep than people to an individual’s personal happiness, demonstrated the extent to which who rated their health as ‘good’ (63%). 30 affecting their mood and, in the longer sleep influences people’s everyday The average sleep score tended to term, their susceptibility to depression. 25 lives, both in terms of physical and decrease with age, though there was More than 80% of respondents mental health. Factors adversely some inconsistency in the relationship 20 with insomnia said they regularly affected by insomnia, such as exercise, between age and sleep (see Figure 3). experienced low mood. This is more can create vicious cycles where 15 than three times the figure for good the impact of insomnia worsens an Figure 3 sleepers. Sustained low mood can lead individual’s capacity to tackle the Chart of average sleep score by age 10 to depression. problem. As such, the data illustrate the

(N=6708) 5 complexity of tackling sleep problems. Percentage Over 45% of respondents with Effective methods of breaking this 0 insomnia had difficulty staying awake cycle are detailed in Part III of this 0-3 3-6 6-12 1-2 2 -5 6-10 >-11 during daylight hours, compared Mnths Mnths Mnths Yrs Yrs Yrs Yrs report. 60 to just over 10% of good sleepers. Duration Although sleepiness is to be expected 50 in people with insomnia, it may 40 encourage the person to keep an irregular sleep pattern. This in turn 30 upsets the circadian rhythm and can 20 make the insomnia worse.

10

Average Sleep Score (Percent) Score Sleep Average 0 16-20 21-30 31-40 41-50 51-60 61+ Age Group

32 33 Oversleeping Although it is nowhere near and as commonly reported as There are also some conditions insomnia, sleeping too much such as hypersomnia and may also cause problems. narcolepsy in which a person Oversleeping has been linked suffers from extreme sleepiness to physical health problems such during the day. Sufferers of as diabetes46 and cardiovascular hypersomnia may complain disease47. Oversleeping can occur that they do not feel fully awake in some people who suffer from until several hours after getting depression, roughly 15–40% of whom oversleep48. up. People who suffer from narcolepsy may suffer from extreme sleepiness, often at inappropriate times in the form of sudden sleep attacks.

Cataplexy is also common in people with narcolepsy. This is defined by a sudden loss of muscle tone, which can often leave the sufferer paralysed for a short term. Both hypersomnia and narcolepsy are rare (estimated at 0.3% of the general population for hypersomnia and 0.045% for narcolepsy49); however, they can have severe consequences for a person’s daily life. They could be misconstrued as insomnia due to the extreme tiredness, but they are very different and should be treated Hypersomnia and narcolepsy as such. could be misconstrued as insomnia due to the extreme tiredness, but they are very different and should be treated as such.

34 35 ‘ All men, whilst they are awake, are in one common world: but each of them, when he is asleep, is in a world of his own.’ Plutarch Sleep Apnoea Problems that Of all sleep problems, snoring Snoring during REM sleep may seem one of the more is often a sign of obstructive innocuous. However, sleep apnoea, a potentially happen whilst asleep it can cause problems for the serious respiratory problem. partners of snorers whose own While sleeping, an individual As detailed earlier, sleeping is a complex process sleep quality may be affected. will experience pauses in which involves the body going through a number Strictly speaking, snoring is a breathing or shallow breath. respiratory problem heightened of different stages. During the we when a person is sleeping, Sufferers may stop breathing for up to can react in several different ways, and a number not a sleep problem in itself. minutes at a time, potentially starving of problems can occur. These problems can impact the brain of oxygen. Normal breathing Snoring is very common, approximately usually resumes, with the individual on our sleep quality. 50 often making a loud snort or choking 37% of UK adults snore . It is twice sound causing the airway to unblock, as common in males as females, waking the individual up and disrupting Some are very common, such as snoring. Others although post-menopausal women their sleep. Obstructive sleep apnoea are more likely to snore than pre- occurs in approximately 3–7% of adult are much rarer but can cause great problems for menopausal women. Partners may men and 2–5% of adult women. the sleeper. Abnormal movements or behaviour find their own sleep disturbed and may It is more common in older people and need to sleep in separate rooms. There in those who are overweight52. Both that occur during sleep are sometimes called is a suggestion that after undergoing smoking and alcohol also increase the surgery to stop snoring, sleep quality risk of developing it. . Well-known parasomnias include of partners improves51. , teeth grinding, night terrors and The snoring sound is produced Sufferers may find themselves . Often these problems can be related through a partial obstruction in the waking up sweaty, with a dry to the mental and physical health of the individual airway, within which the organs that mouth and a headache. The frequent help us breathe vibrate. The muscles waking throughout the night can that suffers from them. relax at the base of the tongue and the lead to insomnia, excessive fatigue uvula (the small fleshy piece which and sleepiness during the daytime. hangs at the back of the throat). Undiagnosed obstructive sleep apnoea is associated with increased likelihood The relaxation of muscle tone can of hypertension, cardiovascular cause the airway (composed of disease, stroke, sleepiness during the daytime, and motor vehicle nose, throat, mouth and windpipe) 53 to become partially or completely accidents . The most widely used obstructed. Other possible causes treatment for obstructive sleep apnoea that can restrict airflow can be jaw is positive airway pressure. The sleeper problems or nasal congestion. wears a special mask over the nose or mouth during sleep, whilst a breathing A person’s size and body shape can machine pumps a stream of air in also have an impact on whether they the nose or mouth through the mask. are likely to snore. For instance, people with shorter, wider necks are more inclined to snore because the muscles around their windpipe cannot support the tissue that surrounds it when they sleep. Alcohol also increases snoring, since it relaxes the tissue at the back of the throat causing it to collapse into the airway and vibrate more easily. There are a number of treatments for snoring, most of which rely on unblocking the breathing passage, such as nasal strips and sprays. Still, if snoring becomes a problem, then it is better to seek professional medical advice first.

38 39 Case Study Nightmares Night Terrors

Many of us will have Night terrors are perhaps K* is a 36 year old female from Bedfordshire, experienced a from the most disturbing type of whose sleep cycle is out of synch. She goes time to time. This is defined . Like sleepwalking through periods of not sleeping very much, merely as an intense, frightening and sleep talking, they occur dream that wakes the sleeper during deep sleep. They can a couple of hours per night, to sleeping all the time, in the throes of panic. Usually be intense, frightening, and sometimes up to 19 hours a day. During this period nightmares occur in the early severely disabling experiences. of oversleeping, she has a strong desire to sleep morning and often they are A is different to during the day and stay up all night. In spite of influenced by frightening a nightmare since the latter experiences that have occurred occurs during REM sleep and such long periods of sleep, she doesn’t wake up during the day. can be recalled on waking. feeling refreshed. Recurrent nightmares are said to Most often night terrors begin and end typically occur due to anxiety. People in childhood. It has been estimated that She first remembers her sleep problems starting who suffer from post-traumatic stress 18% of children experience them59, around the age of 13. She would wake up from disorder (PTSD) can experience but only 2.2% of the adult population55. distressing dreams or nightmares Like sleep walking, night terrors are a frightening experience feeling anxious but as a consequence of past traumas, more likely to occur under sleep- ultimately unable to recall what it was she and may experience significant deprivation, after drinking alcohol, was experiencing. Sometimes she would wake interruptions during REM sleep56. or during a period of stress. up and find she was unable to move her body Occasionally, we may experience Upon experiencing a night terror, or to scream out. As a result of the frequency an episode of ; this the sleeper will feel a deep sense happens after waking suddenly from of fear and panic, their heart rate of these experiences, she began to feel afraid to REM sleep, which often happens will rise, and they may begin sweating go to sleep and eventually she got out of the habit following a nightmare. Our muscles are and screaming. There will often be of sleeping properly. paralysed during REM sleep, but during very little, if any, recall of the details an episode of sleep paralysis they of the event the following morning. remain paralysed for a short period She now knows that these episodes are known as of time after waking. In old English Little is known about how to treat folklore, sleep paralysis was said to people who experience persistent night terrors and still continues to have them today be due to supernatural forces sitting night terrors. However, more severe in adulthood, though they come and go in phases. or pressing down upon the sleeper’s cases could be related to traumatic chest (Figure 6). experiences, particularly in childhood. If this is true, then evidence-based Figure 6 treatments for trauma may help. The Nightmare, Henry Fuseli (1781)

40 41 Sleepwalking Teeth Grinding Case Study Also known as , this and sleep talking is characterised by grinding G*, 46, from Liverpool has had problems with Sleepwalking (somnambulism) one’s teeth, and is sometimes her sleep for the past 15 years. Initially they began and sleep talking (somniloquy) accompanied by clenching are commonly reported of the jaw. It can occur during with trying to stay asleep. She’d wake up frequently parasomnias. Both activities day or night. During the day, throughout the night after sleeping for 1 ½-2 occur during deep sleep it is often in reaction to certain (stages 3 and 4), and are hours, and on average she would sleep a total feelings or events that may of 3-3 ½ hours a night. There was a time when unrelated to dreaming, with occur. During sleep, however, people rarely recalling them bruxism is characterised G* was a good sleeper. Sleep problems however, upon waking. by automatic teeth grinding developed after back surgery following a 12 year Sleepwalking most commonly occurs and rhythmic jaw muscle stretch of . The pain associated from in children between the ages of five contractions. the surgery kept her awake at night and since then and twelve years; 15% of children in this age group are said to walk in their In one study, 8.2% of the general she has had trouble maintaining a constant night sleep at least once57. It is much less population were estimated to grind of sleep. common in adults, occurring in about their teeth at least twice a week during 2–5% of the adult population58, the sleep, and 4.4% were reported to majority of whom began sleepwalking fulfil the criteria for a full diagnosis She has tried keeping good sleeping habits on when they were children. Sleep walking of bruxism. It was also found to be is more likely to occur when people more common in those who regularly recommendation from her doctor: she doesn’t have been sleep-deprived, drinking consume large amounts of , 54 keep a TV in the room, abstains from caffeine and alcohol, or under stress. alcohol and nicotine . Importantly, bruxism can be symptomatic of alcohol and adheres to a strict routine by going to Sleep talking occurs in about 4% of underlying stress and anxiety; one be at 11pm and getting up at 4am. No matter adults, though again more frequently study found that roughly 70% of sufferers attributed their teeth grinding what she’s tried though it doesn’t seem to make in children. This can range from 55 non-verbal utterances to eloquent to these causes . any difference. speeches, which occur several times during a night’s sleep. The speech may or may not be comprehensible to In the last 5 years, G* discovered she was listeners. Sleep talking rarely presents a serious problem. In fact, it is much sleepwalking. She’d find objects in strange places, more likely to be problematic for the such as the remote control in the bin, as well as partner if they are disturbed during the night on a regular basis. odd cooking experiments left out on the hob, such as cereal covered in washing up liquid. After finding Sleepwalking can become a problem when people run the risk of injury, herself outside her building, she went to see a either within the house or if they go sleep specialist fearful she might end up doing outdoors. Some sleepwalkers conduct activities during their sleep, such as more serious harmful behaviour. Unfortunately cleaning. It can also be associated she was told there was little they could do to help with bedwetting; it is not uncommon for people to urinate in closets and her, as they told her the sleepwalking problem was cupboards during a sleepwalking a symptom of her poor sleep pattern. episode. In extremely rare cases people conduct violent activities. In the UK, a man unknowingly strangled his wife while on a caravan holiday. He thought he was fighting off some assailants who he believed had broken into their caravan. He was acquitted on all charges on the grounds that he was not conscious and not in control of his actions.

42 43 REM Behaviour Sleep Related Disorder Motor Disorders This is a rare condition in which People with periodic limb people can be seen to ‘act out movement disorder may their dreams’. This parasomnia experience an intense or tends to begin later in life and prolonged set of hypnic jerks is more common in adults (involuntary twitches that occur over the age of 50, particularly between and in men. sleep), and may involuntarily twitch muscles, particularly Most people are unable to move during the legs, whilst sleeping. It REM sleep because their muscles are paralysed. However, people with occurs in approximately 3.9% REM behaviour disorder maintain of the general population some degree of muscle tone during and is slightly more common REM sleep. Therefore, the sleeper in women than men60. This is not paralysed and the muscles becomes a problem when stay partially active, sometimes with it disrupts the sleep of the violent results. People acting out their dreams during REM behaviour disorder sufferer or partner. can injure their partners, and it is not uncommon for couples to get into the The reasons for periodic limb habit of sleeping apart for this reason. movement disorder are unclear, Interestingly enough, this has also but it may be related to a disturbance been noticed in other species, such in circadian rhythms. Medication as dogs.65 can help, particularly those that reduce muscle function during sleep. A similar disorder is restless legs syndrome. Figures from the US estimate that it affects around 7% of the population61, increasing with age and being more common in women62. Sufferers experience unpleasant sensations in their legs, and thus feel irresistible urges to move them; they may only gain relief by walking or moving. Symptoms are said to occur typically in the evenings potentially leading to difficulties There is some evidence that in falling asleep. There is some evidence that both periodic limb movement disorder both periodic limb movement and restless legs syndrome can be side effects of antidepressants63. The large majority of sufferers of disorder and restless leg restless legs syndrome do respond to treatment. Mild cases may be treated by abstaining from caffeine syndrome can be side effects and alcohol. There is also some evidence that regular exercise during the day may reduce symptoms, though of antidepressants. further research is needed to confirm this64. Those who are more severely distressed by restless legs syndrome may experience relief with drugs that mimic the neurotransmitter dopamine in the brain.

44 45 ‘ A sleepless night is as long as a year.’ Chinese Proverb Sleeping Well

48 49 This section of the report Many people can benefit from improving describes ways in which we the quality of their sleep. The phrase sleep hygiene is often used to describe how can all improve the quality lifestyle and environmental factors can affect our sleep. Positive sleep hygiene of our sleep. may help to improve sleep quality, but is not enough to treat chronic insomnia.

As highlighted in Part II, sleep Caffeine, alcohol and nicotine Eating habits have the potential are all substances which to affect sleeping. It is important can impair sleep quality. not to go to sleep whilst feeling is crucial to the health of all hungry, so eating a light snack before Caffeine makes it harder to bedtime may be helpful. However, sleep because it stimulates eating large meals shortly before individuals. It is important the central nervous system, bedtime should be avoided, because increasing your heart rate and the body will spend time digesting adrenaline production, and before it can sleep. Some foods may to remember that poor sleep have sleep inducing properties; for also supressing melatonin example, rice and oats may contain production. It takes a long small amounts of melatonin, which has massive implications for time for the body to break increases the desire to sleep. Some down caffeine, so drinking foods, such as dairy products, contain during the day can the amino acid tryptophan which our health; it is in all of our affect sleep at night. is useful in manufacturing melatonin.

Alcohol can help people fall asleep, Other foods, such as those that interests to ensure that we but it also impairs sleep quality contain caffeine or large amounts during the second half of the night, of refined sugar, make sleeping and it is a diuretic which means that more difficult. A study in the Isle sleep better. we may need to wake in the night to of Wight examining the effects of go to the toilet, disrupting the sleep food additives on health, found that pattern. However, a rapid reduction preschool children who received in alcohol intake for someone who is additive-laden drinks were more a heavy drinker can lead to alcohol hyperactive than when they did not have drinks containing colours and withdrawal syndrome, which itself can 67 lead to insomnia. Alcohol can also preservatives . contribute to depressive mood, which in turn can contribute to insomnia. Nicotine may impair sleep, smokers take longer to enter sleep and have less total sleep time (approximately 14 minutes less per night) compared to those who have never smoked66. Reducing nicotine intake is unlikely to lead to immediate improvements in sleep, but the long term health benefits are likely to have implications for sleep quality.

50 51 Regular exercise may also help The environment of our bed and Some antidepressants do have a us sleep. One study in older adults can either help or hinder Sleep medication sedative effect, and research has showed improved sleep quality sleep; much depends on our own The most common and well shown that people who were treated with regular aerobic exercise68, preferences. The obvious factors known treatment for insomnia using a combination of sleeping such as jogging or cycling. are noise, light, temperature and is sleep-inducing medication, medication and antidepressants It may be that physical fitness ventilation. Most of us prefer to also known as hypnotics. showed greater improvements in with increased metabolism sleep in a quiet environment, as depressive symptoms than people is associated with better sleep anyone who has experienced living who used antidepressants only72 73. patterns. Also, exercise can help next door to noisy neighbours can The most common type of to improve mood and to reduce testify. Earplugs may be useful for hypnotic are a group of drugs However, the British Association anxiety, which can in turn improve blocking out external noise although called benzodiazepines, the for Psychopharmacology advises sleep in people with chronic they do tend to amplify the body’s most well-known of these against using antidepressants in insomnia69. Exercise can also help own internal noises which may be is diazepam (Valium) which the treatment of insomnia as there to reduce the symptoms distracting. is limited evidence indicating their of obstructive sleep apnoea70. is used to treat anxiety and efficacy in this application74. Too much light can inhibit sleep since has been around since the The timing of physical activity it affects melatonin levels; eye masks early 1960s. Similar drugs like It is difficult to gauge how many is important. Exercise earlier in may be helpful, although they can temazepam can be useful for prescriptions are written for the day is better for people who be uncomfortable for some. Room short term insomnia, but there hypnotics because many of these want to improve their chances temperature is important, neither is little evidence to suggest drugs are prescribed for problems of sleeping, since in the short term too cold nor too hot, although the that they are appropriate for that are not directly sleep-related. it increases the body’s adrenaline ideal room temperature will vary 71 Up to 40% of people with insomnia production, making it difficult from person to person. Ventilation chronic insomnia . may self-medicate with hypnotics to sleep. can be improved by opening the that are available without a window, although this is likely to Another commonly-used group prescription, and many people also alter the temperature and make of drugs developed more recently drink alcohol to aid sleep. the room noisier. It is important to are the benzodiazepine receptor feel comfortable in the bedroom agonists; sometimes these are called Hypnotics may be effective for short- environment, including selecting the ‘Z drugs’ since many of their names term acute insomnia, particularly right mattresses and . People begin with the letter ‘Z’ (zopiclone for conditions like . However, may need to experiment with all and zolpidem, for example). There they only act on the biological, these factors until they find the ideal are various other groups of drugs neurochemical factors to help us balance. that may potentially be prescribed sleep. Many people develop tolerance for insomnia; melatonin receptor to hypnotics and become physically Sleep hygiene practices, such as agonists aim to promote sleep by or psychologically dependent, or those mentioned above, may help increasing the amount of melatonin suffer withdrawal symptoms such people improve their sleep quality, in the body, antagonists aim as anxiety, depression and nausea. but there is little evidence to suggest to limit the hormone orexin which is Some types of hypnotic, such as that they help people who have related to being awake, and some benzodiazepines, can cause ‘rebound chronic insomnia, in which case more antihistamines and (rarely) opioids insomnia’, which is often worse than specific treatment is needed. It is can be used as sedatives. the original insomnia symptoms. important to consider whether the Use of sleep insomnia is caused by physical or Also, hypnotics can have a range mental health issues. However, more of side effects. The National Institute often than not it will be important to for Health and Clinical Excellence75, medication dates directly address sleep itself, and not suggest that hypnotics should only simply rely on treating the physical or be used after other measures have mental illness. been tried, and then only for short back thousands periods of time, such as 2–4 weeks of years; Hippocrates maximum. noted the sleep- inducing properties of opium in c.400 B.C.

52 53 ‘ Sleeping is no mean art: for its sake one must stay awake all day.’ Friedrich Nietzsche Psychological approaches These approaches can be effective because they aim to challenge underlying thoughts and feelings about sleep76. Cognitive Behavioural Therapy (CBT) is the most effective treatment for chronic insomnia.

It has also been used to treat Thoughts and feelings about sleep An alternative way of approaching The link between our thoughts people with a range of mental play a large role in perpetuating this situation, which could be and the values we place on insomnia79. People with chronic recommended through the those thoughts is very important health problems such as insomnia often associate sleep use of CBT methods, might be: in overcoming insomnia. depression and anxiety, and and bedtime with a range of negative is part of the Improving Access thoughts and feelings. CBT aims 1 Fact Good sleepers treat sleep as an to Psychological Therapies to question the assumptions behind I’m not feeling very sleepy automatic process which happens (IAPT) agenda. It can be our thoughts, and to break the links right now when they go to bed. In other words, used alongside hypnotics between our thoughts and how we 2 Thought they do not spend time thinking feel about them, i.e., our emotions. I’m not sleepy now; but I usually get about sleep, or about how they need or without. An example of how our thoughts can some sleep during the night. Maybe to get to sleep80. In CBT, a technique A comprehensive CBT approach influence our emotions with regard I will feel sleepy soon. called paradoxical intention is used. for insomnia includes a variety of to sleep is as follows: 3 Consequence When a person is finding it difficult techniques, such as sleep hygiene I’m going to get out of bed to go to fall asleep, they may be advised regimes (as described previously), 1 Fact to the toilet and drink some water. to remain awake passively and to relaxation training, readjusting sleep I’m not feeling very sleepy I will return to bed in a few minutes give up trying to fall asleep. In doing patterns, and altering the thoughts right now when I feel more sleepy this, the person reduces the effort and behaviours that hinder people 2 Thought they spend on sleeping, whilst still from sleeping77 78 . It’s already 1:30 a.m., In appraising the situation more maintaining their commitment to I’m never going to get to sleep’ accurately and more positively, the improving their sleep practices. It is The importance of relaxation should 3 Emotion individual does not place undue precisely this absence of effort that not be taken for granted. People Everybody else is sleeping, pressure on themselves to get to helps good sleepers to sleep easily. with insomnia tend to find it hard to I’m no good at sleeping sleep, and is then more able to take relax naturally before going to bed. 4 Consequence practical steps to help them adjust The most challenging part of a CBT Relaxation training involves paying Continued lack of sleep to the process of going to sleep. If the programme for insomnia is sleep attention to breathing and ensuring person does not fall asleep, a positive scheduling. This involves keeping that muscles are not tensed up. Here the individual has thought way of thinking about the situation a strict discipline for going to bed People who have trouble sleeping about the fact in a particular way, could be: and getting up. The first part of this by generalising that they will never is stimulus control, which relates to should ‘wind down’ in the hour before 81 going to bed, possibly doing relaxing get any sleep all night. In fact, even 4 Thought thoughts and feelings about sleep . activities such as listening to music. people with insomnia sleep on most It doesn’t matter whether or not I This is based on the idea that people nights, but tend to underestimate the fall asleep. I can function well with respond to certain cues (stimuli) The act of relaxation does not always amount of sleep they have had upon little sleep. I will relax and not worry and behave in a certain way. In the come naturally and may require reflection the next day. Therefore about it. I will fall asleep when my case of insomnia, the problem is patience, discipline and practice. the statement “I’m never going to body is ready. that when the person thinks of ‘the Activities that some people consider get to sleep” is likely to be false. The bedroom’ they immediately begin relaxing may not be appropriate for individual places more emphasis on thinking about sleepless nights. others. For this reason it may be this thought than the fact itself. The The bedroom should be a place that helpful to have a tailored relaxation subsequent emotional consequence is associated with sleeping, not with programme developed by a CBT generalises further still from the sleepless nights. practitioner. original fact, and feeds back into a person’s thoughts about themselves, negatively affecting their ability to sleep.

56 57 Therefore it is better, if possible, to For example, if you get an average of Case Study watch TV, eat and do other activities five and a half hours sleep per night in another room. If you are in bed but but need to rise at 7:00 a.m. for work, T* is a GP from Scotland who has suffered not feeling sleepy then it is better to set the alarm for that time, and then get up, leave the room and engage go to bed at 1:00 a.m. every night. from bouts of depression. Because of his work in a relaxing activity elsewhere, This leaves a six hour window for your commitments, T often doesn’t get enough sleep, returning to bed only when you feel new sleep pattern to slot into. After a sleepy. One exception to this is sexual period of time, you may be successful though he always managed with “catch up” nights. activity. Spending long periods of in sleeping within that six hour This past autumn, T* found himself struggling time in bed without falling asleep window. The window can then be runs the risk of strengthening the gradually increased, so go to bed at to fall asleep. To remedy this he would get up association between the bed and 12:45 a.m. instead. Sleep restriction and watch TV downstairs until he felt sleepy. sleeplessness. This ultimately makes is perhaps the most challenging sleeping more difficult. At first it technique championed in CBT for After a few weeks, he was getting up and going may seem counterproductive to insomnia, and is difficult to practice back to bed all night, only being able to fall asleep get out of bed so often, but in the and maintain without the help of a long term it is helpful in controlling specialist practitioner. around 4 or 5am in the morning. our psychological associations and therefore improving the chances There is substantial evidence from of overcoming insomnia. numerous high quality clinical T*’s GP switched his antidepressant medication studies to show that CBT is effective to one that had sedative properties but in The other part of sleep scheduling for insomnia83 84 85 86. Furthermore, is sleep restriction82. This is also the scientific literature around CBT spite of increasing doses and the addition challenging. A person with insomnia and its effectiveness has been of a benzodiazepine hypnotic, T*’s sleep did has developed a sleep pattern that systematically reviewed or meta- is inappropriate for them. The aim of analysed nine times in the past 15 not improve. sleep restriction is to help establish years. Reports by the American new sleep patterns. Keeping a sleep Academy of have diary is the first step; this will help revealed that across 85 clinical After not much success with medication, to record the amount of time spent trials (and 4194 participants) CBT T* consulted a sleep specialist, who recommended sleeping per night (for an example was associated with improvement of a sleep diary please see the in 70% of cases87 88. he stay up until 3am, then retire to bed and wake Appendix). It is then necessary up at 10 a.m. It was the sleep specialist’s belief that to set a bedtime and a waking time This improvement is long lasting, based on the average amount of time and it is therefore useful to treat T* had upset his ‘body-clock’, his natural circadian spent asleep. chronic insomnia with CBT. NICE84 rhythm for sleep. At the same time T* began has recognised CBT as an effective treatment for insomnia, although reading a self-help book on insomnia which was there is no guidance specifically based upon CBT methods93. He discovered that written for this purpose. However, a full course can be intensive and part of the reason he may have formed his sleep may involve substantial amounts pattern was that it allowed him to have some CBT was of work and discipline. This may be off-putting for some people with time to himself, which normally he didn’t have insomnia; however, there is some in his busy day. associated with evidence to suggest that as few as four CBT sessions are effective improvement for simple cases of insomnia89. This realisation, combined with a tailored sleep Stepped care models of providing regime of gradually bringing forward his bedtime appropriate services have been meant he returned to a normal sleep pattern in 70% of cases. recommended to improve people’s sleep quality. These models involve within a few weeks. T* also made adjustments making simple interventions (e.g. to his daytime commitments and the stress booklets, internet) widely available, using trained therapists for cases he felt when going to bed disappeared. at an intermediate level, and involving T* has incorporated what he learnt from his own sleep specialist psychologists for the most complex cases90. Certainly, experience when dealing with patients who have it has been known for some time sleep problems. This includes using sleep diaries that people seem to prefer the idea of psychological therapies as well as providing general sleep education. to medication for insomnia91.

58 59 ‘Sleep is the golden chain that ties health and our bodies together.’ Thomas Dekker Conclusion Sleep is a much more complex process than many The majority of people who are suffering poor people realise, but it is crucial to the health of us all. sleep might benefit from simple, non-intrusive It is not merely an inconvenience on busy waking methods such as a guided self-help book or lives. The link between sleep and health is two way. course delivered over the internet. These kinds of interventions should be based upon the principles The Great British Sleep Survey data indicate of CBT, but would be far more efficient in terms of the extent to which poor sleep can negatively health spending. There is already some evidence impact on people’s daily lives, with inevitable in favour of using simple, self-guided therapies to consequences for mental health. People who treat sleep problems92. are suffering the effects of low mood, who have less energy to take exercise, or are experiencing If a person with poor sleep finds such therapies difficulty in personal relationships are more to be ineffective, then primary care workers such likely to develop mental health problems. as nurses or GPs should be able to give evidence- The consequences of chronic insomnia should based guidance on how to improve sleep. Beyond therefore be treated with these risks in mind. this, graduate psychologists may be able to offer short CBT courses in an individual or group setting, Furthermore, poor sleep and insomnia are not and clinical psychologists might review more always treated in accordance with the best complex cases where there is an underlying mental current knowledge. In clinical practice, medication health problem to be treated. There are several is more commonly prescribed for insomnia than stages that can be tried before enlisting the help of CBT, although CBT is more effective in the long a specialist sleep practitioner. term. CBT is sometimes seen as difficult to access due to its relatively high cost and because of the Poor sleep is a public health problem and needs to lack of trained therapists available. be taken seriously. It needs to be recognised within healthcare, education, and society at large. For The IAPT programme may have the potential to society, it is vitally important that sleep is seen as address some of this need, if staff members are a public health issue, much like diet and exercise. sufficiently trained to recognise and work with Sleep needs to be an issue on any public health sleep problems. Current NICE guidance on the agenda. If this does not happen, a great number treatment of insomnia mentions the importance of of people will suffer the consequences, without psychological approaches, but the benefits of such reason. approaches have not yet been expanded upon sufficiently. The amount of evidence for CBT in the treatment of insomnia makes it difficult to ignore. It would appear that fitting such therapies into clinical practice relies upon employing a stepped care approach. Only the most severe cases of chronic insomnia need to be treated by a specialist sleep practitioner.

62 63 Key points – Sleeping poorly increases the risk of having We – The importance and benefits of sleep for poor mental health. In the same way that healthy recommend both mental and physical health should diet and exercise can help to improve our mental that be highlighted in national and local public health, so can sleep. health campaigns, including in schools and workplaces. New and easily accessible – There is no universal answer to the question resources should be made available advising of how much sleep a person needs. This varies people what they can do themselves to from person to person. What is important is that improve their sleep. people find out how much sleep they need and ensure that they achieve this. – The Royal College of GPs should provide up to date, evidence-based training and – The consequences of poor sleep should be taken information for its members on the importance seriously in healthcare, education, family life, and benefits of sleep for physical and mental and society at large. health. GPs should also have access to a diagnostic tool for use in recognising sleep problems in primary care settings. – The new Public Health Outcomes Framework should include a specific outcome on reducing sleep problems across the whole population. Sleep should also be reflected in new national mental health outcome indicators, including improving sleep for people who experience significant sleep problems requiring specialist help. – The National Institute of Health and Clinical Excellence (NICE) should develop guidance for the management of insomnia using non- pharmacological therapies, to complement existing guidance on using pharmacological therapies. – People with sleep problems should be recognised within the IAPT programme, especially regarding access to Cognitive Behavioural Therapy (CBT). IAPT staff should be suitably trained on sleep issues. – Further research should be carried out to establish the effectiveness of low cost, non- intrusive CBT-based interventions for sleep problems, such as self-help books and online courses. 64 65 Useful Sleepio Self-help Espie CA (2006) Overcoming Insomnia and Sleep resources Sleepio is a new organisation dedicated to information Problems: A Self-Help Guide Using Cognitive helping people sleep better. The Sleepio website Behavioral Techniques. London: Constable & includes info about various sleep problems Robinson Ltd (Paperback). and your chance to take part in the Great British Sleep Survey! Espie CA (2011) An Introduction to Coping with Website: www.sleepio.com Sleep Problems. London: Constable & Robinson E-mail: [email protected] Ltd (Booklet).

Glovinsky P, Spielman A (2006) The Insomnia Mental Health Foundation Answer: A Personalized Program for Identifying The Mental Health Foundation promotes and Overcoming the Three Types of Insomnia. the impact of sleep on our mental health. Perigee Trade. Website: www.mentalhealth.org.uk E-mail: [email protected] Phone: 020 7803 1100

British Sleep Society The British Sleep Society is a charity for medical, scientific and healthcare workers dealing with sleeping disorders in the UK. Website: www.sleeping.org.uk E-mail: [email protected]

British Snoring and Sleep Apnoea Association

The British Snoring and Sleep Apnoea Association is a not-for-profit organisation dedicated to helping snorers and their bed partners improve their sleep. Website: www.britishsnoring.co.uk E-mail: [email protected] Phone: 01737 245638

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68 69 ‘ Man should forget his anger before he lies down to sleep.’ Gandhi Appendix: Sleep Diary This sleep diary has enough space for Working out the reasons why you might up to a week. Once you have completed have problems sleeping can be difficult. it, you can download and print a new copy Keeping a sleep diary, like the one on the next from our website: www.HowDidYouSleep.org page, can help you keep track of when you slept well or poorly, and the possible reasons Questions for sleep diary: why that happened. A How did you sleep last night? B What time did you go to bed? To complete the sleep diary, simply C Approximately how long did it take read the questions opposite and answer you to get to sleep? them in the appropriate space in the table. D How many times did you wake For instance, the answer to question A will up during the night? be put in column A of the table next to the E What time did you wake up? date of the sleep concerned. An example F How long did you sleep for in total? is provided on the first line of the table. G What did you consume (if anything) within four hours of going to bed (e.g. cup of tea/coffee/ milky drink, glass of wine/beer, sleeping pills, dinner) and how long before bed did you consume it? H What was the temperature outside Remember, this diary and in your bedroom? is your personal record I What light sources were there when you went to sleep? of how well you slept J How much noise was there when you went to sleep? and why, so be honest! K What activities did you undertake before 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 description if appropriate (e.g. drowsy, grumpy, spaced out)?

72 73 Date A B C D E F G H I J K L M How you slept? Bed Time Wake in night? Wake Total Food and drink Temperature Light Noise Activity before bed Notes How did you feel? time to up in sleep sleep morn

E.g 4th May 7/10 11pm 30 Once about 2am for 7am 7hrs 50 Heavy dinner with glass About 15° outside, Slight moonlight under None Read book for 20 mins Missed usual walk at 8/10, Quite Well mins 10 mins (went to loo) of wine at 7pm, herbal tea window closed, felt a bit curtain lunch today Bit sleepy on bus to work at 10pm hot Acknowledgements This report was written by Dr. Dan Robotham, Lauren Chakkalackal and Dr. Eva Cyhlarova. Others who contributed to this work include: Professor Colin Espie, Director of the University of Glasgow Sleep Centre and Sleepio Ltd, Peter Hames of Sleepio Ltd, Dr. Andrew McCulloch, Simon Lawton-Smith, Alistair Martin, Simon Loveland, Kirsten Morgan, Siobhan Trim and Kate Wilson.

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