Sleep, glorious sleep


If you’ve had a new baby in your house, or been jet-lagged, worked shiftwork, or been worrying about a new job, you’ve probably had some time when your sleep pattern has really got out of sync. The feeling of not having had enough sleep is well-known to throw some of us right into depression, and sleep disturbances are one of the most common concerns of people experiencing chronic pain. It’s certainly much harder to cope with things when you feel you haven’t had enough sleep – and when it carries on, it can be very destructive, even fatal (albeit indirectly).

Sleep assessment must cover a wide range of factors that are known to influence sleep quality and quantity, and this post is an attempt to pull together and summarise those things that could be helpful to consider when talking with someone about getting better sleep.

Firstly, I ask the person about their sleep quality – do they feel like they wake up having had enough sleep, feeling refreshed. The number of hours sleep varies widely between individuals, so it’s not the number of hours of sleep that is important: it’s how refreshed the person feels that is. If they wake feeling OK, then there is little need to assess any further – and I often then ask the person why they think their sleep is a problem, if they feel fine. Usually their concerns are about the impression that if they’re not getting ‘8 hours sleep’, they are not getting enough. So a little education about the variability of sleep duration can go a long way. For some basic information, this link Healthy Sleep leads to a pdf brochure by the National Institute of Health in the US that describes basic sleep hygiene, and gives some guidance as to when a person might think about getting sleep assessed in more detail. You’ll be pleased to know this document doesn’t recommend medications!

Once I’ve established that the person is experiencing unrefreshing sleep, then it’s time to look at some basic routines. Sleep timing is dependent on various cues, one of which is the time we reduce stimulation from light, sound, and other activity. So it’s good to ask about what time the person goes to bed, what time they get off to sleep once they go to bed, what time they wake up, what time they get up, and whether they wake during the night. If they do wake during the night, it’s important to ask what they do then – especially how long they are awake for, whether they get out of bed, eat, drink, smoke, read etc. I also ask about whether the person has an alarm clock, and uses it!, and whether they sleep with another person and what that person’s routine is. At this time I also ask about napping during the day. Napping can reduce the requirement for night-time sleep, and although it’s helpful if you’re a shift-worker and needing temporary help to get through a day, it’s unhelpful in the long term because the sleep architecture can change, making achieving Stage 4 sleep more difficult.

A simple step toward normalising the sleep pattern is to ensure the person has a regular bedtime and bedtime routine, and a regular wake time and get up time. Erratic bedtimes and wake times maintain difficulties with sleep – and it’s at this time I talk about jet lag and how easily our sleep patterns alter to suit the time zone of the place we are visiting. This helps people understand that they can influence their own sleep patterns by simply changing stimulation levels and re-setting the body clock.

The next phase is to talk about sleep onset. How long does it take to get off to sleep? What does the person do as they go off to sleep? What are they thinking about? What’s happening with the temperature of the room, the light, the noise, and timing of medication.

Basic sleep hygiene deals with the need to make sure the bed is for sleep and sex only (and perhaps light reading as we wind down to go to sleep), but it’s not the place to worry, eat, watch TV, or have arguments! This is a behavioural strategy to ensure the connection between relaxing and being in bed remains intact. Keeping lighting in the room very low or the room completely dark is helpful. Turning off the TV, radio, iPod and any other stimulation will help the brain become less aroused. The temperature needs to gradually lower, but to a comfortable level, not too hot or too cold. Being hungry makes it difficult to sleep, but eating in bed and eating during the night can become habitual and re-set the metabolism. These factors are all related to the ‘body clock’ which is regulated via a paired area in the brain called the suprachiasmatic nucleii near the hypothalamus. This area responds to light via a series of neural pathways, to produce melatonin – more at night, less during the day. As a result, light is one of the most influential aspects of sleep regulation. Body temperature is also important – lower body temperature allows sleep, while higher body temperature is associated with wakefulness. Endocrine function and importantly urine production increases during the day, reducing during the night – as eating and drinking can re-set these hormonal patterns, making it more difficult to remain asleep at night. This Healthlink article is a simple description of circadian rhythms that can be used for patient education. Remember too, that medications have side effects, some of which promote sleep (eg tricyclic antidepressants), and the time these are taken can influence sleep onset. People may take medications meant to promote sleep too late in the evening ‘before bed’ – at 11.00, and find the speed of onset too gradual, and the hangover effect in the morning can be unhelpful especially when trying to change sleep patterns. Taking TCA’s earlier in the evening may be helpful – such as around 6.00pm, so that the effect is thorough by bedtime, and there is less of a hangover risk for morning waking.

You’ll see I’ve asked about thoughts and emotions while going to sleep. Long-term sleep disorder is often accompanied by feelings of anxiety, dread, and increased arousal levels as bedtime approaches because the bed is no longer associated with the feeling of relaxation and restoration. It can feel like a torture rack instead! Lying in bed awake, with the mind spinning or ruminating on negative thoughts like ‘how am I going to cope tomorrow if I don’t sleep?’, ‘I’m never going to get to sleep at this rate’, ‘I mustn’t move because my partner will wake up’ will serve to increase arousal and make it more difficult to get off to sleep.

Steps to reduce the association between bed and relaxing will help, but so is breaking any association between being awake and in bed, and worrying and being in bed. Strategies to promote relaxation include developing a bed-time ritual (cleaning teeth, getting into bed, reading a relaxing book, turning the light off, doing 10 deep breaths) can promote the relaxation response and reduce arousal. A relaxation tape, CD or even mp3 can be used also, in the short term. In the long term it’s more helpful to encourage self-regulation without an external source (partners complain about the noise of the relaxation through the headphones!).

Some techniques to stop negative rumination should be introduced if this is a problem. This can be as simple as the ’15-minute appointment with worry’ – saying to yourself throughout the day ‘I will not worry about this now, I’ll worry about it tonight when I have my worry appointment’, then worrying furiously for a complete 15 minutes from, say, 7.00 – 7.15pm. Most people can’t sustain 15 minutes of worry!! And the acts both of saying ‘I’ll worry about it later’ and writing down the worries can help reduce the emotional sting of the worries.
A further strategy can be to write a word with a neutral emotional impact such as the word ‘and’ over and over and over and over for one or two minutes can also interrupt the negative thoughts. This is helpful during the night, when it may be difficult to get back to sleep.

The strategy of getting out of bed after having been awake for more than 20 minutes, while hard to do (especially in winter!), is very effective at stopping the association between being in bed and being awake. The lights need to remain low, the stimulation from reading, eating, smoking etc needs to be limited, and once the person is ‘sleepy-tired’, they can go back to bed to sleep.

There are some other ways to help with sleep, but I’ll post these at a later date. In the meantime, these basic steps for assessing then managing sleep can be used.
Some good resources: MedLinePlus Sleep Disorders page
WebMD also has some great resources, mainly aimed at patients.
The NIH National Centre on Sleep Disorders has both patient and professional resources.

Ooops! Forgot to put in ‘How to Cope with Pain’ link to patient information tips on getting better sleep – How to get Better Sleep.

Another great place for information on all things psychological and this post on Pimping Insomnia from MindHacks.
Well, you can see there are many, many resources out there!! Must be a lot of insomniacs cruising the internet!
More will be posted tomorrow – so y’all come back now, OK?

4 comments

  1. l like the worry period, I use it often with GAD patients but have also found it useful for people having sleep disturbances. Takes some discipline but, like most things, with practice it can really help.

    One of my patients told me of a useful tip….peanut butter as a late night snack (obviously not too close to lying down)…she couldn’t take milk because of an intolerance..but peanut butter delivers the same effect as milk through tryptophan. I was skeptical but had others try this and find it to work.

  2. I hadn’t thought of peanut butter, but yes, it does have tryptophan, and if you like it (I don’t!!) it would be great!

    I’ve used the worry time myself – amazing how long 15 minutes can take to use up!

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