Insomnia

Understanding normal sleep

A normal night’s sleep has three main parts.

• Quiet sleep. This is divided into stages 1-4. Each stage becomes more 'deep'. Quiet sleep is sometimes called deep sleep.
• REM (Rapid Eye Movement) sleep. REM sleep is when the brain is very active, but the body is limp apart from the eyes which move rapidly. Most dreaming occurs during REM sleep.
• Short periods of waking for 1-2 minutes.

Each night, about 4-5 periods of quiet sleep alternate with 4-5 periods of REM sleep. In addition, several short periods of waking for 1-2 minutes occur about every two hours or so, but occur more frequently towards the end of the nights sleep. The graph below shows a typical normal pattern of sleep in a young adult.



Normally, you do not remember the times that you wake if they last less than two minutes. If you are distracted during the wakeful times (for example, a partner snoring, traffic noise, fear of being awake, etc), then the wakeful times tend to last longer, and you are more likely to remember them.

What is insomnia?

Insomnia means poor sleep. About 1 in 5 adults do not get as much sleep as they would like. Poor sleep can mean:

• Not being able to get off to sleep.
• Waking up too early.
• Waking for long periods in the night.
• Not feeling refreshed after a nights sleep.

If you have poor sleep, you may be tired in the daytime, have reduced concentration, become irritable, or just not function well.

What is a normal amount of sleep?
Different people need different amounts of sleep. Some people function well and are not tired during the day with just 3-4 hours sleep a night. Most people need more than this. To need 6-8 hours per night is average. Most people establish a pattern that is normal for them in their early adult life. However, as you become older it is normal to sleep less. Many people in their 70s sleep less than six hours per night.

So, everyone is different. What is important is that the amount of sleep that you get is sufficient for you, and that you usually feel refreshed and not sleepy during the daytime. Therefore, the strict medical definition of insomnia is "a persistent difficulty falling or staying asleep, leading to impairment of daytime functioning".

What are the causes of poor sleep ?

Poor sleep may develop for no apparent reason. However, there are a number of possible causes.

Concern about wakefulness

You may remember the normal times of being awake in the night. You may feel that to wake in the night is not normal, and worry about getting back off to sleep. You may 'clock watch', and check the time each time you wake up. This may make you irritated or anxious, and you are more likely to remember the times of wakefulness. You may then have an impression of having a bad night's sleep, even if the total amount of time asleep was normal.

Temporary problems

Poor sleep is often temporary. This may be because of stress, a work or family problem, jet-lag, a change of routine, a strange bed, etc. Poor sleep in these situations usually improves in time.

Anxiety or depression

You may find it difficult to switch off your anxieties about work, home or personal problems. Also, poor sleep is sometimes due to depression. Other symptoms of depression include: a low mood, lethargy, poor concentration, tearfulness, and persistent negative thoughts. Depression is common. Treatment of depression or anxiety often cures the poor sleep too.

Sleep apnoea

This sometimes occurs in obese people who snore, more commonly in obese men. In this condition the large airways narrow or collapse as you fall asleep. This not only causes snoring, but also reduces the amount of oxygen that gets to the lungs. This causes you to wake up to breathe properly. You may wake up many times each night which may result in daytime tiredness. (Note: most people who snore do not have sleep apnoea, and sleep well.)

Other illnesses

Various illnesses keep some people awake. For example, illness causing pain, breathlessness, leg cramps, indigestion, cough, itch, hot flushes, dementia, mental health problems, etc.

Stimulants

These can interfere with sleep. There are three common culprits.

• Alcohol - many people take an alcoholic drink to help sleep. Alcohol actually causes broken sleep and early morning wakefulness.
• Caffeine - which is in tea, coffee, some soft drinks such as cola, and even chocolate. It is also in some painkiller tablets and other drugs (check the ingredients on the drug packet). Caffeine is a stimulant and may cause poor sleep.
• Nicotine (from smoking) is a stimulant, and it would help not to smoke.

Street drugs

For example, ecstasy, cocaine, cannabis and amphetamines can affect sleep.

Prescribed drugs

Some drugs sometimes interfere with sleep. For example, diuretics ('water tablets'), some antidepressants, steroids, beta-blockers, some slimming tablets, painkillers containing caffeine, and some cold remedies containing Pseudoephedrine. Also, if you suddenly stop taking regular sleeping tablets or other sedative drugs, this can cause 'rebound' poor sleep.

Unrealistic expectations

Some people just need less sleep than others. If your sleep pattern has not changed, and you do not feel sleepy during the day, then you are probably getting enough sleep. Older people and people who do little exercise tend to need less sleep. Some people think they should be able to nap during the day - and sleep eight hours at night!

A vicious cycle

Whatever the initial cause, worry about poor sleep, and worry about feeling tired the next day, are common reasons for the problem to become worse.

What can I do to help improve poor sleep ?

This section will discuss three topics which often help to promote better sleep - understanding some facts, sleep hygiene, and further methods to combat insomnia. In effect, these can be used in a step-wise fashion. You need only go on to the next 'step' if the previous step is not very helpful, but each step requires a greater degree of effort.

Understanding some facts

It is often helpful to understand that short periods of waking each night are normal. Some people are reassured about this and so do not become anxious when they find themselves awake in the night. Also, remember that worry about poor sleep can itself make things worse. Also, it is common to have a few bad nights if you have a period of stress, anxiety or worry. This is often just for a short time and a normal sleep pattern often resumes after a few days.

General tips for sleeping better (often called 'Sleep Hygiene')

The following are commonly advised to help promote sleep and are often all that is necessary.

• Reduce caffeine - do not have any food, drugs, or drinks that contain caffeine or other stimulants for six hours before bed time (see above). Some people have found that cutting out caffeine completely through the entire day has helped.
• Do not smoke within six hours before bed time.
• Do not drink alcohol for a few hours before bed time.
• Do not have a heavy meal just before bed time (although a light snack may be helpful).
• Do not exercise within a few hours of bed time (but exercise earlier in the day is helpful).
• Body rhythms - try to get into a routine of wakefulness during the day, and sleepiness at night. The body becomes used to rhythms or routines. If you keep to a pattern, you are more likely to sleep well. Therefore:
• No matter how tired you are, do not sleep or nap during the day.
• It is best to go to bed only when sleepy-tired in the late evening.
• Switch the light out as soon as you get into bed.
• Always get up at the same time each day, seven days a week, however short the time asleep. Use an alarm to help with this. Resist the temptation to 'lie-in'. Do not use weekends to 'catch up' on sleep as this may upset the natural body rhythm that you have got used to in the week.
• The bedroom should be a quiet, relaxing place to sleep.
• It should not be too hot, cold, or noisy.
• Earplugs and eye shades may be useful if you are sleeping with a snoring or wakeful partner.
• Make sure the bedroom is dark with good curtains to stop early morning sunlight.
• Don't use the bedroom for activities such as work, eating or television.
• Consider changing your bed if it is old, or not comfortable.
• Hide your alarm clock under your bed. Many people will 'clock watch' and this does not help you to get off to sleep.
• Mood and atmosphere :- Try to relax and 'wind down' with a routine before going to bed. For example:
• A stroll followed by a bath, some reading, and a warm drink (without caffeine) may be relaxing in the late evening.
• Do not do anything that is mentally demanding within 90 minutes of going to bed - such as studying.
• Go to bed when sleepy-tired.
• Some people find playing soft music is helpful at bedtime. Try a player with a time switch that turns the music off after about 30 minutes.
• If you cannot get off to sleep after 20-30 minutes - then get up. Go into another room, and do something else such as reading or watching TV rather than brooding in bed. Go back to bed when sleepy. You can repeat this as often as necessary until you are asleep.

Further methods to combat insomnia

Three further ways that may help to promote sleep are: relaxation techniques exercise and sleep restriction.

Relaxation techniques

These aim to reduce your mental and physical arousal before going to bed. Relaxation techniques may help even if you are not anxious, but find it hard to get off to sleep. There are a number of techniques. For example, progressive muscular relaxation has been shown to help promote sleep. This technique consists of tensing and relaxing various muscle groups in sequence.

Your GP or a counselor may be able to recommend a tape or CD that takes you through deep breathing exercises, and other methods to help you relax.

Daytime exercise

Regular daytime exercise can help you to feel more relaxed and tired at bed time. (However, you should not do exercise near to bed time if you have insomnia.) If possible, do some exercise on most days. Even a walk in the afternoon or early evening is better than nothing. However, ideally, you should aim for at least 30 minutes of moderate exercise on five or more days a week.

Moderate exercise means that you get warm and slightly out of breath. You do not need to go to a gym! Brisk walking, jogging, cycling, climbing stairs, heavy DIY, heavy gardening, dancing, and heavy housework are all moderate-intensity physical exercises.

Sleep restriction

This is a treatment strategy that may be advised by your doctor. It is best done only under the supervision of a doctor or sleep specialist. Very briefly, the principle of this treatment is that you limit the time that you spend in bed at night. As things improve, the time in bed is then lengthened. An example of the way that this may be done in practice is as follows.

• First, you may be asked to find out how much you are actually sleeping each night. You can do this by keeping a sleep diary. (See separate leaflet called 'Sleep Diary'.)
• You may then be advised to restrict the amount of time that you spend in bed to the time that you actually sleep each night. For example, if you spend eight hours in bed each night but you sleep for only six hours, then your allowed time in bed would be six hours. So, in this example, say you normally go to bed at 11 pm, get to sleep at 1 am, and get up at 7 am. To restrict your time in bed to six hours you may be advised to go to bed at 1 am, but still get up at 7 am.
• You then make weekly adjustments to the allowed time in bed depending on the time spent asleep. (You need to keep on with the sleep diary.)
• When 90% of the time spent in bed is spent asleep, then the allowed time spent in bed is increased by 15 minutes by going to bed 15 minutes earlier. In the above example, you would then go to bed at a quarter to one.
• Adjustments are made each week until you are sleeping for a longer length most nights.