Sleeping Well
Mental
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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.
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.
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.
Helps snorers and their sleeping partners worldwide.
American website with information on sleep and sleep
disorders.
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
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/
This leaflet reflects the best available evidence available at
the time of writing.
© 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
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