Sleep Problems

Sleeping Well


About this leaflet
If you have trouble sleeping - or know someone who has - this leaflet may be helpful. It covers common problems with sleep, as well as some more unusual problems. There are some simple tips on how to sleep better, and how to decide if you need professional help.
Introduction
We don't usually need to think very much about sleep. It's routine. Even so, most of us sometimes just can't sleep properly. We call it insomnia. It's usually just for a short time, perhaps when we're worried or excited. When things settle down, we start sleeping properly again. If you can't sleep properly, it can be a real problem because we all need sleep to keep healthy.
What happens during sleep?
When you sleep, you become unconscious and unaware of what's going on around you. As you sleep, you pass through different stages - and there are two main types:


Rapid Eye Movement (REM) sleep

This comes and goes throughout the night, and makes up about one fifth of your sleep. The brain is very active, eyes move quickly from side to side and you dream. Although your brain is active, your muscles are very relaxed.



Non-REM sleep

Your brain is quiet, but your body moves around while you sleep. Hormones are released into the bloodstream and your body repairs itself after the wear and tear of the day. There are 3 stages of non-REM sleep:

'Pre-sleep' - your muscles relax, your heart beats slower and your body temperature falls.
'Light sleep' - you can wake up easily without feeling confused.
'Slow wave' sleep - your blood pressure falls, you may talk or sleep walk and it's hard to wake up. If somebody does wake you, you feel confused.


You move between REM and non-REM sleep about 5 times during the night, dreaming more towards the morning.

On a normal night, most people wake up for one or two minutes every 2 hours or so. You aren't usually aware of these 'mini wakes', but may remember them if you feel anxious or there is something else going on - noises outside, a partner snoring etc.
How much sleep do we need?
This mainly depends on your age.


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


There are differences between people of the same age. Most will need 8 hours a night, but some (a few) people can get by with only 3 hours a night.

The short periods of being awake can feel much longer than they really are. So you can feel that you are not sleeping as much as you really are.
What happens if I don't sleep?
An occasional night without sleep will make you feel tired the next day, but it won't affect your health.

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

feel tired all the time
drop off during the day
find it difficult to concentrate
find it hard to make decisions
start to feel depressed
start to worry about not being able to sleep.


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

If it continues, lack of sleep can make you more likely to get:

high blood pressure
diabetes
overweight.

Sleep problems in adult life

Sleeping too little (Insomnia)

You may feel that you aren't getting enough sleep or that, even if you do get the hours, you just aren't getting a good night's rest.

Many everyday things can stop you from sleeping well:

the bedroom may be too noisy, too hot or too cold
the bed may be uncomfortable or too small
you don't have a regular sleep routine
you partner has a different pattern of sleep from you
you aren't getting enough exercise
you eat too late - and find it hard to get off to sleep
you go to bed hungry - and wake up too early
cigarettes, alcohol and drinks containing caffeine, such as tea and coffee
illness, pain or a high temperature.



More serious reasons include:

emotional problems
difficulties at work
anxiety and worry
depression - you wake very early and can't get back to sleep
thinking over and over about problems - usually without getting anywhere with them.
physical problems including:
heart disease, such as angina or heart failure
respiratory disease, such as chronic obstructive pulmonary disease or asthma
neurological disease, such as Alzheimer's or Parkinson's disease
hormone problems, such as an overactive thyroid
joint or muscle problems, such as fibromyalgia or arthritis
gastroinestonal disease, such as gastro-oesophageal reflux disease or irritable bowel syndrome
genital or urinary problems, such as incontinence or an enlarged prostate
long-term pain.
medications:
stopping tranquillisers and sleeping tablets
slimming tablets
melatonin - occasionally
many medications can do this - check with your doctor.

Helping yourself
Here are some simple tips that many people find helpful:

Do's

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



Don'ts

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


If you try these tips and you still can't sleep, go and see your doctor. You can talk over any problems that may be interfering with your sleep. Your doctor can check that your sleeplessness is not due to a physical illness, a prescribed medicine, or emotional problems. There is evidence that cognitive behavioural therapy can be helpful if you haven't been sleeping well for some time.
Psychological Treatments

Cognitive therapy is a way of changing unhelpful ways of thinking that can make you more anxious, and so stop you from sleeping.
Stimulus control helps you to:
strengthen the link of being in bed with sleeping - by only getting into bed when you feel tired, and only using your bed for sleep and sex
weaken the link of being in bed with doing things that are likely to keep you awake - like watching exciting TV programmes, doing work, or organising things
weaken the link of being in bed with worrying - if you can't sleep, instead of lying in bed worrying, you get up and do something for a while until you feel tired again.
Sleep restriction helps you to go to bed later. Too much time in bed can stop you from sleeping.
Progressive muscle relaxation helps you to relax your muscles deeply. One by one, you tense and then release the muscles of your body, working up from your feet to your legs, arms, shoulders, face and neck.

What about medication?

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

don't work for very long
make you tired and irritable the next day
lose their effect quite quickly, so you have to take more and more to get the same effect
are addictive. The longer you take sleeping tablets, the more likely you are to become dependent on them.

There are some newer sleeping tablets (Zolpidem, Zaleplon and Zopiclone), but these seem to have many of the same drawbacks as the older drugs, such as Nitrazepam, Temazepam and Diazepam.



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



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



In some cases, antidepressant tablets can be helpful.



Melatonin is a naturally occurring hormone that can help insomnia. At present, in the UK, it is only licensed for treating sleeplessness in those aged over 55. It should not be taken for more than 3 weeks, and should not be used if you have liver or kidney problems.



It can make you drowsy and, occasionally, can cause:

irritability
dizziness
migraines
constipation
stomach pain
weight gain.



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


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

Your may have to work at night, staying awake when you would normally be asleep. If you only have to do this occasionally, it's quite easy to adjust. It is much harder to cope with if you do it regularly. Shift workers, doctors and nurses working all night or nursing mothers may all find that they sleep at times when they ought to be awake. It's like jet lag where rapid travel between time zones means that you are awake when everybody else is asleep.


A good way to get back to normal is to make sure that you wake up quite early at the same time every morning - whatever time you fell asleep the night before. Use an alarm clock to help you. Make sure that you don't go to bed again before about 10 pm that night. If you do this for a few nights, you should soon start to fall asleep naturally at the right time.
Sleeping too much
You may find that you fall asleep during the day at times when you want to stay awake. This will usually be because you have not been getting enough sleep at night.

If you are still falling asleep in the daytime, even after a week or two of getting enough sleep, see your doctor. Physical illnesses such as diabetes, a viral infection, or a thyroid problem, can cause this sort of tiredness.

There are other conditions which make people sleep too much:

Narcolepsy (daytime sleepiness)
This is an uncommon problem, so it's easy for a doctor to miss it.

There are two main symptoms:

you feel sleepy in the daytime, with sudden uncontrollable attacks of sleepiness even when you are with other people
cataplexy - you suddenly lose control of your muscles and collapse when you are angry, laughing or excited. This sometimes gets better with age.


You may also find that you:

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


The cause for this has recently been found - a lack of a substance called orexin, or hypocretin.

Treatment consists of taking regular exercise and getting yourself into a regular night-time routine. If this simple approach does not work, medication may help. These include:

Modafinil which makes you more awake in the day-time
Antidepressants, such as Clomipramine or Fluoxetine, can help with cataplexy
Sodium Oxybate helps the day-time sleepiness and poor sleep at night.


Sleep Apnoea (interrupted sleep)

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


You are more likely to get sleep apnoea if you are:

older
overweight
a smoker
a heavy drinker.


The problem is often noticed by a partner. Treatment is usually simple - cut down smoking and drinking, lose weight, and sleep in a different position. If your apnoea is very bad, you may need to wear a Continuous Positive Airway Pressure (CPAP) mask. This blows high-pressure air into your nose which keeps the airway open.
Other problems with sleeping

At some point in their life, about 1 in 20 adults have night terrors, and 1 in 100 report that they sleep-walk. Both these conditions are more common in children.


Sleepwalking
When you sleepwalk, you appear (to other people) to wake from a deep sleep. You then get up and do things. These may be quite complicated, like walking around or going up and down stairs. This can land you in embarrassing (and occasionally dangerous) situations. Unless someone else wakes you up, you won't remember anything about it. Sleepwalking sometimes happens after a night terror (see below). If your sleep is broken or you aren't getting sleep, you are more likely to sleepwalk.

A sleepwalker should be guided gently back to bed and should not be woken up. You may need to take precautions to protect them or other people, such as locking doors and windows, or locking away sharp objects, like knives and tools.

Night terrors can happen on their own, without sleepwalking. Like a sleepwalker, a person with night terrors will appear to wake suddenly from a deep sleep. They look half-awake and very frightened, but will usually settle back to sleep without waking up completely. All you can do is sit with them until they fall asleep again.

Night terrors are different from vivid dreams or nightmares as people don't seem to remember anything about them the next morning.

Nightmares
Most of us have had frightening dreams or nightmares. They usually happen during the later part of the night, when we have our most vivid and memorable dreams. They don't usually cause problems unless they happen regularly, perhaps because of emotional distress. Nightmares often follow a distressing or life-threatening event such as a death, a disaster, an accident or a violent attack. Counselling may be helpful.

Restless Legs Syndrome (RLS)

You feel you have to move your legs (but also, sometimes, other parts of the body).
You may have uncomfortable, painful or burning feelings in your legs.
These feelings only bother you when you are resting.
They are generally worse at night.
Walking or stretching helps, but only for as long as you carry on doing it.
You may not be able to sit still in the daytime or sleep properly.


People usually first ask for help with this in middle age, even though they may have had symptoms since childhood. It often runs in families.

RLS usually occurs on its own. Pregnancy or a physical illness (iron and vitamin deficiencies, diabetes or kidney problems) can occasionally be responsible.

If it is not caused by another physical illness, treatment depends on how bad it is. In mild RLS, the symptoms can usually be controlled by simple steps designed to help you sleep better (see above 'Helping yourself'). In more severe RLS, medications may help. These include medications used in Parkinson's disease, anti-epileptic medications, benzodiazepine tranquillisers and pain-killers.

If simple measures do not help, you can be referred to a sleep or movement disorders specialist.


Autism

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

Sleep Problems

REM Sleep Behaviour Disorder (RBD)

A person will start thrashing about during REM or dream sleep, as though responding to a dream. They may punch, kick, shout, or jump out of bed. Quite often, the person will wake and be able to remember the dream that prompted their physical reactions. Someone sharing the same bed can be disturbed and, sometimes, injured.



The problem seems to be that, unlike normal REM sleep where the muscles are relaxed, in RBD they are not. It can happen on its own or it can be a symptom of a neurological illness, so it's best to be assessed by a specialist.
Self-help organisations
The Sleep Council
Promotes the benefits of sleeping well. Provides information leaflets on sleep and beds.

British Snoring and Sleep Apnoea Association
Helps snorers and their sleeping partners worldwide.

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

Narcolepsy Association UK (UKAN)
Tel: 0845 450 0394; email:info@narcolepsy.org.uk
Promotes the interests of people with narcolepsy and encourages better understanding of the illness.

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

Get a better night's sleep by Ian Oswald and Kristin Adam
Sleep like a dream: the drug-free way by Rosemary Nichol
Baby and Child: From Birth to Five by Penelope Leach
Insomnia: Doctor I can't sleep by Adrian Williams

References

British Association of Psychopharmacology consensus statementon evidence-based treatmenr of insomnia, parasomnias and circadian rhythms disorder (2010) Journal of Psychopharmacology


National Institute for Health and Clinical Excellence (2011): Insomnia - newer hypnotic drugs: Zaleplon, zolpidem and zopiclone for the management of insomnia



National Institute for Health and Clinical Excellence (2011): Sleep apnoea - continuous positive airway pressure (CPA)



Falloon K, Arroll B, Elley CR, and Fernando A (2011) The assessment and management of insomnia in primary care, British Medical Journal, 342, 1251-1255.



Johanssen K et al (2011): Longer term effects of very low energy diet on obstructive sleep apnoea in a cohort derived from a randomised controlled trial: prospective observational follow-up study. British Medical Journal, 342, 1248.

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This leaflet was produced by the Royal College of Psychiatrists' Public Education Editorial Board.

Series Editor: Dr Philip Timms

Expert review: Professor A J Williams, Lane-Fox Respiratory Unit and Sleep Disorder Centre, St Thomas' Hospital, London.







© Ilustration by Lo Cole: www.locole.co.uk/



© The Royal College of Psychiatrists. Updated: June 2011. This leaflet is due for review in June 2013. This leaflet may be downloaded, printed out, photocopied and distributed free of charge as long as the Royal College of Psychiatrists is properly credited and no profit is gained from its use. Permission to reproduce it in any other way must be obtained from the Head of Publications. The College does not allow reposting of its leaflets on other sites, but allows them to be linked to directly.



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Sleep Problems