Sleep. So, adequate sleep is necessary for healthy physical and psychological functioning.

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1 Sleep What is the function of sleep? Sleeping and waking are part of a normal 24 hour cycle which allows people to function efficiently and effectively, both physically and mentally. Our bodies require sleep in order to recover from physical exertion. We can think of sleep as a way of restoring and rejuvenating tired muscles and limbs and as a way of helping to refuel energy reserves for the next day. It is also thought that, during sleep, body tissues are restored at a faster rate. Thinking about how we function mentally and emotionally, research has shown that lack of sleep tends to result in fatigue and poor performance on tasks. For example, our reaction times will become slower. Not having enough of one particular stage of sleep, called rapid eye movement (R.E.M.) sleep, has been linked to increased irritability and emotional instability. Lack of R.E.M. sleep has also been shown to affect our mental functioning, particularly our memory and our ability to learn. So, adequate sleep is necessary for healthy physical and psychological functioning. What is a normal sleep pattern? It is too simple to say someone is either awake or asleep. Sleep is more like a car with the clutch disengaged with engine running compared to a car parked in the garage for the night. Sleep is an active process and there are distinct stages and cycles of sleep. There are four stages of increasingly deep sleep and a fifth stage known as R.E.M. sleep. It is in R.E.M. sleep that dreams commonly occur. These stages have characteristically different patterns of brain wave activity. The stages of sleep vary during the night and there are many differences between different people. However over the course of a typical night, four or five periods of R.E.M. sleep occur. How much sleep do we need? The amount of sleep needed varies from person to person, but it is generally believed that 7 to 8 hours is the average time for an adult. Some people can manage with less (as little as 5 hours) and others need more (anything up to 10 hours). 1

2 The amount of sleep needed for a good night also varies with age. For example, new-born babies sleep for around 18 hours, young children up to 12 hours, young adults sleep on average 7 to 8 hours and older adults sleep for even less time (about 6 hours on average). As people get older they have less deep sleep and more light sleep. So, there are many differences between individuals in the amount of sleep we need. The average adult needs at least 7 hours but the length of sleep at night we need decreases with age. Pain and sleep Many people who experience chronic pain also have sleeping difficulties. For some it will be difficulty getting off to sleep, for others it will be waking through the night. This needs to be taken seriously as a problem in its own right, because sleep loss will usually add to the various other difficulties that already occur as a result of pain. Lack of sleep can lead to exhaustion, poor concentration and irritability. Can anything be done? Having pain can certainly cause problems for getting to sleep and staying asleep throughout the night. But pain alone is rarely the only reason why sleep is disturbed. In fact, there are many reasons why people with pain have disturbed sleep. The good news is that these reasons can usually be dealt with and this can help to improve sleep. Because pain tends to cause sleeping difficulties, it is all the more important to reduce other factors that can affect sleep. It is important to help yourself to get the best sleep you can. With some work, sleep can be improved. What causes sleeping difficulties? It is helpful to consider just what your particular sleep problems are as well as exactly what factors are contributing to these problems. Consider the following questions;- If your sleep is disturbed, do you feel tired and drowsy as a result or, on the other hand, do you feel you have adjusted to it fairly well? Is your problem getting off to sleep? Is it that you keep waking up in the night and have difficulty getting back to sleep? Is it that you wake early 2

3 and cannot sleep again? Is it that, despite having slept, you do not feel you have slept well? Look at the below list of factors that can contribute to disturbed sleep. Put a tick against any and all of those factors that apply to you. It is only when we are clear about exactly what our sleep problems are and what is causing them that we can make the changes necessary to help us to better sleep. Factors contributing to sleep disturbance Which of these apply to you? Tick any that are part of your difficulties with sleep. Pain and discomfort in bed Movement in bed Lack of routine for getting to sleep Lack of routine when waking in the night Daytime and evening napping Active mind Worrying thoughts Emotional states, such as anxiety, stress and depression Reaction to sleep disturbance Unrealistic expectations about sleep Environmental factors, such as lighting, temperature and noise Activity and exercise patterns Partner disturbance Alcohol, caffeine, and food intake near intake near bedtime Over stimulation and sleep problems Over stimulation often plays an important role in causing sleep disturbance. If our bodies or minds are over stimulated or hyped up then sleeping can be difficult. For example, if you go straight to bed after exercising, it is very unlikely that you will go to sleep immediately. Our bodies need the opportunity to wind down in order to prepare for sleep. So, if your body is not relaxed, it will be more difficult to sleep. 3

4 Almost everyone has had the experience at some time of not being able to sleep because their mind is overactive, particularly if our thoughts are of a worrying or unpleasant nature. So, if your mind is overactive or over stimulated, this is likely to interfere with your chances of sleeping. Some feelings, such as being upset, angry, anxious, frustrated, depressed or excited can produce increases in how active our bodies and minds are and can increase levels of stimulation. Changes in our bodies occur with emotions. For example our heart rate may increase, breathing may become faster and shallower and our muscles can become tense. So, strong feelings can make sleeping more difficult. A reasonably relaxed mind and body makes sleeping easier and more refreshing. Active mind Some people are in the habit, when they are in bed, of pondering the day s events (both what has been done and what has not been done) or planning ahead for the next day and forthcoming events. Indeed, some people look forward to the chance to think things through at the end of the day. Of course it is not always an enjoyable experience and not always easy to stop! Thinking in this way is usually mentally stimulating, whether it is enjoyable or not and hence can make sleeping difficult. In fact, some people find that their minds are in overdrive and can be full of fairly trivial and unimportant thoughts, flitting from one to another. Again, this is not helpful for sleeping because the mind can become over stimulated. Worrying Some people do their worrying at night and they can become preoccupied with upsetting, unpleasant or depressing thoughts. When this occurs, sleep is likely to be affected. People tend not to solve problems during the night, but instead seem to go over and over their various worries and problems. If you have not solved your worries during the day, whilst fully awake, what chance do you stand whilst half asleep and tired? Furthermore, worrying during the night will mean that you are more tired the next day and, because of this, less likely to sort things out when you are awake. Dealing with an active mind and worrying When people have an active mind at night, they often say that they try to stop thinking. This can be difficult and frustrating because the more you try not to think about something, the more you tend to think of it! It is extremely difficult to just switch your mind off. Instead, people find it more helpful to think of something 4

5 else. This is more relaxing and helps to distract the mind from bothersome thoughts. It varies from person to person, but one of the most common things that helps dealing with an active mind is thinking about something pleasant; remembering a holiday, imagining yourself on a beach, or any place that is relaxing for you, counting slowly and visualising something like a painting or a garden. Whatever you do, it should be something that is pleasant and relaxing for you. Be careful, however, that it doesn t stimulate your mind too much (so, nothing too busy or too exciting). The well known advice of counting sheep may not work for you but it does use some good ideas. Counting sheep is fairly boring and repetitive (so it is not over stimulating for the mind) and it also requires some concentration which helps to focus the mind. Counting sheep is something you can visualise and this can also make concentration and focusing your mind easier. It can help to have some pre-planned and familiar things to think of so that you do not have to spend time thinking about what to think about! In this way you can tune in straight away to relaxing and pleasing thoughts and images that will help you to sleep. There are also other ways of dealing with an active mind. This might involve focusing your attention on the radio, some music, an audio book, or by doing some breathing or relaxation exercises. Indeed, relaxation exercises can be particularly helpful for relaxing both your mind and your body and are also very useful ways of distracting the mind. Emotional states Emotional states such as anxiety, stress and depression are linked with sleep disturbance. Sleep disturbance may be as a result of these emotions and it may be necessary to seek other means of help with these feelings. People will use various means of help depending on the nature of their problem and the ways they have of coping with their problems. Often talking through problems with family, friends or with someone you can trust (e.g. G.P., health care professional or religious official) can be very helpful. Making practical or emotional changes may frequently be necessary to deal with such problems. Dealing with pain People with pain sometimes have a particular problem in that this pain sometimes feels like it s demanding your attention and can be very good at getting your attention particularly when you are not doing anything! Night time may be a real problem because there is a lack of distracting activities and at night, when the lights are off, you can be especially aware of pain. It is helpful to 5

6 learn how to distract yourself mentally during times of inactivity and rest, and in such a way that will not be too stimulating, either physically or mentally. The suggestions made for dealing with an active mind are also helpful as a means of distraction from pain. Different types of activity that you can do with your eyes shut are very useful when you have pain. Breathing and relaxation techniques are particularly good, not only as forms of mental activity but also as a means of helping you relax both mentally and physically even with pain, and these techniques can be developed to suit you in different ways at different times. Being relaxed is important for sleep but can be difficult when you have pain. However this is all the more reason to help yourself relax as best you can. Reaction to sleep disturbance The more you try to sleep, the harder it can be. You may well become aware of the fact that you are not sleeping and so get more annoyed. This does not help. A vicious circle can start if you then become apprehensive and concerned about whether you are going to get to sleep as bed time approaches. Unpleasant memories of hours spent lying awake or tossing and turning can come to mind and the prospect that the same might happen again is not a pleasant one! In fact, feeling desperate to sleep and thinking of the effects of not sleeping may well reduce your chances of getting to sleep. This may sound easier said than done, but the answer is to stop thinking and worrying about not sleeping. As already said, it may be difficult to just not think. What can be more helpful is to distract your thoughts and do breathing and relaxation exercises. Allowing your mind to occupy itself in other ways than thinking about trying to sleep will usually help to make sleeping easier. Lack of routine Lack of routine at bed time and when you wake during the night can make getting to sleep and getting back to sleep more difficult. Lack of routine seems to be the most important factor in sleep disturbance. Your body needs a sleep pattern. It needs to know when to expect to get some sleep. For example, if you change the time of sleep, it will take time for your body to adjust. An example is what is known as Sunday night insomnia. Someone who has gone to bed late on Saturday night and slept in on Sunday morning may well find that they cannot get off to sleep at the usual time on Sunday night. It can take a couple of days to adjust to one night s disturbed sleep pattern. Jet lag is another good example of this. Varying the time that you go to sleep may well make sleeping more difficult. There can be a difference between bed time and the time you intend to sleep. Feeling sleepy does not always occur when you first go to bed. Signs that you 6

7 are ready for sleep can be lapses in concentration, yawning, eyes feeling heavy, and generally feeling tired. It is important to feel able to gauge when you feel ready for sleep. People often, although tired, delay bedtime in the hope of having a better night s sleep, but this is not helpful. Go to bed when you begin to feel drowsy. When you go to bed you may need to do something to unwind and settle to sleep. With the exception of sex, it is important that what you do in bed is not too stimulating and is routine for you. Most of us have some form of routine at bedtime. You may lock the doors, go upstairs, brush your teeth, get into bed, read a while and then put the light out and have the radio on quietly as you settle to sleep. Think about what you do at bedtime and decide on a good routine that will help you to unwind. What you need to pay most attention to is what to do when the lights are out if you do not sleep straight away. Lying in bed for long periods of time is not likely to be successful, especially when you have pain. Remember - when the lights are off you need to do something to help distract your attention away from any pain or discomfort you may have. You also need something that will help you relax mentally and physically, as this will help with your sleep. The golden rule for good sleep is to establish a regular routine If you don t get off to sleep quickly As a rule of thumb, if you are not asleep after about 20 minutes of intending to sleep, you will need to think about what to do. Don t just keep waiting to sleep. If you feel fairly sleepy, then do some mental distraction or relaxation and breathing. If you feel quite awake, then stop trying to go to sleep and work instead on helping yourself get ready to sleep again. You may need to get up and leave the bedroom. Bed should be associated with sleep and not lying awake. Have a routine for what you do when you get up. For example, this may be going having a drink (avoid stimulating drinks like tea or coffee) or sitting and reading for a while. Watch out that you don t get too involved in what you are doing. So set a time limit for how long you wait downstairs. Avoid over stimulating yourself. Instead, do something that is reasonably relaxing. Go back to bed before you feel too sleepy and, on going back to bed, follow some of your normal routines. Deep breathing and relaxation is a useful last step. If you are still awake, try again. Resting and relaxing as best you can is better than just hoping for sleep, and if you can t sleep, resting is the next best thing. Waking during the night It is quite common for some people who have pain being easily woken during the night. Whilst it may not be possible to stop waking up, other factors can affect how long you stay awake and these factors can be changed to improve sleep. 7

8 Again having a routine for what to do when you have difficulty getting back to sleep is most important and what you do will depend on how awake you feel. Doing lots of things in the middle of the night is not a good idea. Remember to have a routine, to use relaxing activities and distraction, and to stay calm. Getting annoyed won t help. Routines If poor routine is contributing to your sleep problem, you will need to establish a new routine. You may need slightly different routines for different situations. For example, you might need one routine for going to bed, another routine for dealing with any times when you don t get to sleep quickly and another routine for if you wake during the night. Also you may need different routines for when you re sleeping at home and when you re sleeping in an unfamiliar bed (e.g. when on holiday). Whatever routine you come up with, people with pain or other physical discomfort have found it extremely helpful to make breathing and/or relaxation techniques the very last part of any routine. It may take a while before you feel any benefit from changes in your night time routine. To break bad habits you need to form new habits and you will need to be quite strict about any new routine to start with. Once it has been established you can be more flexible. It can be a good idea to write down your routine and agree it with any others who might be involved with or affected by it. Napping Naps contain more deep sleep (stages 3 and 4) than light sleep (stages 1 and 2), and this probably explains why, even with brief naps you can feel quite refreshed. If you do have a nap, however short, don t be surprised if you don t sleep too well at night. Napping is associated with lighter sleep and more awakening during the night. Afternoon and evening naps have more effect on a night s sleep than morning naps. If you are in the habit of napping at a regular time, for example after a meal, then you may need to do something else to break the habit. Make a plan of what you can do rather than having a nap (e.g. going for a walk, doing the dishes, reading the paper). If you want a good night s sleep, then having a nap may not be a good idea. 8

9 What conditions are you sleeping in? Most people give some thought to how comfortable their bed is. For example, it is a myth that if you suffer from back pain then you will definitely need a really hard mattress. Rather, you need a bed that is comfortable for you. Temperature is also important. It is harder to sleep if you are feeling too warm or too cold. Think about what you can do to make the temperature more comfortable; for example, opening or closing windows or doors, turning on or off the radiator, having heavier or lighter blankets or duvet, or wearing more or less clothing. Are there noises disturbing you that you could do something about? Some people are able to sleep when there is a little noise going on in the background and find it difficult to sleep when it is completely quiet. It is easier to get used to the regular ticking of a clock or passing traffic than sudden infrequent noises like a car door slamming or an alarm. Where possible, factors such as lighting, temperature and noise should be adjusted to suit you best and it is helpful to keep these conditions the same, or at least as similar as possible. Exercise and sleep There are strong links between having plenty of exercise and good sleeping. Physical health problems often lead people to take little exercise during the day. This may make sleeping more difficult. But, on the other hand, attempts to tire yourself out in order to sleep are not always guaranteed to be successful. Some form of exercise during the day can certainly help you sleep better. However, the timing of exercise is very important. Activity as part of your day time and early evening routine is advisable, as research suggests that exercise taken late in the evening tends to liven people up when it might be better to be winding down. So, taking a late walk or doing another form of physical exertion late in the day is unlikely to be helpful. Food and drink Going to bed after a large meal or when you are hungry is usually unhelpful. However bed time snacks, as long as they are light and part of your usual routine, are unlikely to cause sleep disturbance. Drinks with caffeine can make sleep more difficult. These include coffee, tea, chocolate and cola drinks. Caffeine is both a stimulant and a diuretic and research has shown that it can disturb sleep. Indeed, its effects can last for several hours after drinking it. The more caffeine that you have in the day, the more likely it is that it will affect your sleep. If you have drinks with caffeine and you have difficulties with sleep, then it may be worth cutting this down, 9

10 particularly in the evenings. Drinking decaffeinated tea or coffee is one alternative. Drinking water is another. Smoking cigarettes can also have an effect on sleep. This is because nicotine is also a stimulant and there is evidence that smokers have more difficulty getting to sleep than non-smokers. Some people use alcohol to help them relax. On the face of it, a late night drink may help you get off to sleep, hence the idea of a night-cap. However, there is some evidence that sleep that is affected by alcohol may be less restful and R.E.M. sleep may be decreased. If you have a night-cap and wake in the morning still feeling tired, it may be worth trying to do without it for a while and see if it helps. One obvious point to make about all kinds of drink is that too much fluid before bed time probably means that you have to get up in the night to go to the toilet! In Summary: things to remember Establish good routines around sleeping Be patient and don t try too hard to sleep Work on relaxing yourself both physically and mentally Use relaxation and breathing techniques Develop mental distraction techniques Avoid day time napping Don t anticipate a bad night. Expect the best, rather than the worst Avoid frustration and annoyance with not sleeping. Stay clam Have good eating, drinking and exercise habits Health Psychology Service April 2012 Compliments, comments, concerns or complaints? If you have any comments, concerns or complaints and you would like to speak to somebody about them please telephone Are we accessible to you? This publication is available on request in other formats (for example, large print, easy read, Braille or audio version) and languages. For free translation and/or other format please call extension 5587, or us communications@dchs.nhs.uk 10