Contents
Chapter
1: Normal Sleep
Stages
of Sleep
Chapter 2 Normal variations
in sleep
Chapter 3 Poor sleep and
insomnia
Chapter 3 The consequences
of insomnia
Sleepiness
and fatigue
Problem
concentrating
Irritation
and moodiness
On
Becoming depressed
Coping
and everyday life
Insomnia
and its effects on the family
Effects
of insomnia on social life and working life
Is
insomnia doing me any harm
Chapter
3.1 Introduction to treatment
Chapter
5 assessing your insomnia
Chapter
6 Understanding sleep and insomnia
Chapter
7 Sleep hygiene and relaxation
Lifestyle
factors affecting sleep
Caffeine
Nicotine
Diet
Exercise
Pre
bedtime routine
Noise
Room
temperature
Body
temperature
Air
Quality
Lighting
Mattresses
and Pillows
Bed
time wind down
Learning
to relax
Chapter
8 Scheduling a new sleep pattern
Associating
bed and sleep
Napping
Amount
of sleep
Bedtime
Schedule
Chapter
9 Dealing with a racing mind
Types
of thought that may occupy
Dealing
with a racing mind
Thought
blocking
Imagery
Sleep
Scheduling
Give
up trying to sleep
Attentional
focus
Evaluation
Chapter 1: Normal Sleep
During sleep:
1.
Body tissue is repaired
2.
Growth hormone can be released.
3.
Proteins are laid down
4.
Selective hormones are released
Sleep can be measured by
1.
EEG
a.
Measures brain waves
2.
EMG
a.
Measure muscle tone
3.
EOG
a.
Measure eye movement
4.
A polysonograph uses all approaches
Stages of Sleep
We have our deepest sleep in the first third of our sleep.
1.
Stage W: Wakefulness
a.
Low amplitude high frequency, random EEG
2.
Stage 1 Sleep (lasts a couple of minutes)
a.
EEG waves slow down (theta waves)
b.
Muscle tone relaxes
c.
Rolling eye movement
3.
Stage 2 Sleep (overall 50-60% of sleep, first
stage quite short)
a.
Mixed EEG frequencies and amplitudes, but do see
K complexes (initially descending then ascending EEG wave), also get sleep
spindles, i.e. rapid bursts of high frequency waves
4.
Stage 3=deep sleep
a.
20-50%Slow wave sleep: Higher waves, more slowly
occurring.
5.
Stage 4=deep sleep
a.
Over 50% Slow wave sleep: Higher waves, more
slowly occurring.
6.
REM Sleep
a.
Light form of sleep, with EEG profile similar to
wakefulness
b.
EMG: loss of muscle tone
c.
EOG: rapid eye movement
SOL=Sleep onset latency, the time it takes to fall asleep
WTASO=Wake time after sleep onset, how much was the person
awake after falling asleep, before getting up
Sleep efficiency below 85% is considered a problem= total
sleep time\time in bed. Improving sleep efficiency rather than time asleep is
one of the keys to curing insomnia.
PsychoPhysilogical insomnia is insomnia that can be
objectively measured using a PSG
It is quite hard to estimate, time taken to sleep, time
spent asleep, so over estimation is common. PSG don’t always capture the
subjective feeling of sleep. For instance fast EEG waves or times that you get
wake up very briefly
Paradoxical insomnia: complaining of insomnia but actually
sleeping, according to the PSG
Chapter
2 Normal variations in sleep
Sleep
varies both across the night, and across the week. It also varies with age and
stage of development. It also varies person to person.
A
sleep hypnogram is an EEG pattern through the night.
Deeper
sleep dominates first half of night, lighter sleep in the second half. At the
end of each sleep cycle there is a period of REM. There is a progressive
fragmentation of sleep in the over 60s.
Definition
of insomnia=having 3 bad nights a week
Things
to help sleep
Routine
Things
that reduce sleep
Stress
Sleep
deprivation:
No
REM sleep=disorganisation of mental processes, such as perception, thinking,
learning and memory
Insomnia
isn’t sleep depravations, rather a sleep debt that the sleep homeostat seeks to
pay off.
Sleeping
style
Some
people can sleep anywhere at any time, others are much more particular. Some
insomniacs can sleep much better in unfamiliar surroundings, maybe as they
associate their bed with not sleeping. Alternatively they maybe don’t
have any expectations of sleeping, so there is no stress around.
Owls
and Larks
An
owl is someone whose circadian rhythm is greater than 24 hours, so needs to use
social queues as to when they need sleep and when they need to wake. They tend
so sleep and rise later and these times may be erratic.
Larks
are people whose circadian rhythm is 24 hours long and they tend to sleep and
rise earlier, and more consistently.
Average
sleep
Young
adult 7.5-8.5
Adults=7-8
hours
Older
adult 6-6.5
Triggers
to poor sleep
Something
important on your mind=stress\anxiety
Sleeping
in unfamiliar environments
Something
upsetting has just happened
Poor
sleep is usually a temporary experience for people
Chapter
3 Poor sleep and insomnia
Insomnia
as disorder of initiation or maintenance of sleep. Some people sleep but don’t
find it restorative.
Criteria
Complaint
=initiation or maintenance of sleep
Frequency=3
or more nights
Severity=
over 30 mins to get to sleep or over 30 mins awake after onset
Duration=over
6 months
Effects=marked
distress
Clinical
cut off is .85, i.e. 15% of being in bed time is awake
Insomnia
sub types
Primary
insomnia is where you meet the above criteria, and there is no physical or
psychological cause of it, primary insomnia is also known as
psychophysiological insomnia. Paradoxical insomnia is where people state they don’t
sleep, but a PSG report suggests they do.
Physical
causes of sleep difficulties
Breathing
problems
Neurological
problems
Fever
Anything
that affects the immune system, heart disease, cancer
Any
other problems that can disturb sleep, i.e. pain, bladder needs
Psychological
causes of sleep difficulties
Anxiety
Depression
Stress
Substance
causes of sleep disorders
Drugs
legal and illegal
Alcohol
Cutting
down on sleeping pills.
If
there is a physical\psychological cause to insomnia then this means you have
secondary insomnia
Anxiety
about sleep can be a precipitating factor for insomnia. Sleeping earlier and
staying in bed later can also be a problem for insomnia, as this can reduce
sleep efficiency, and compound thoughts about I have a sleep problem and its
attendant anxiety.
One
common belief about sleep that can be dysfunctional is that how I feel in the
morning is a direct result of how I sleep. So that how I sleep will have a
bearing on how I feel the next day, which in turn puts pressure on sleep
performance, and these anxious thoughts then make it harder to sleep
Sleep
problems development
Sleep
problems can develop as you lose your automaticity of sleep, people start
paying attention to sleep then bringing intention to sleep in, i.e. plans to
sleep, then evaluating their success or failure. It is at this point that you
can end up with acute insomnia as this strategy provides anxiety about sleep.
If
you believe you are unable to sleep, then this is a source of danger, which
then provokes anxiety about sleep, which then prevents sleep
Treating
sleep disorders with sleeping pills can have problems. It is useful for short
term problems, but in the longer term, then tolerance builds up to the drug,
and you get rebound insomnia if you try to come off
Chapter
3 The consequences of insomnia
Whilst the problem of insomnia, is getting to and staying
asleep, lying in the dark at night hoping for either sleep to come or the
morning is an unpleasant experience. The unpleasant experience can lead to depressive
symptoms.
So insomnia is unpleasant in itself and has unpleasant
effects
Sleepiness and fatigue
Fatigue=numbing, depressing, losing energy and motivation
Sleepiness=wanting to fall asleep
You could not go 72 hours without sleep.
Problem concentrating
When we are alert we perceive, and we pay attention to that
which is important to us. When we are tired the reverse is true and we have
problems concentrating. This means it
takes us more effort, it is harder to pay attention to that which is important
to us. It also appears harder to retrieve things from memory. Now it could be
that both attention and memory retrieval
take the same amount of energy, but given we have less energy it feels more
onerous or that actually it takes more effort as we are tired.
Irritation and moodiness
When we haven’t had enough sleep then our attention span is
short, and we have to make more effort to keep attention, therefore it takes
longer to do what we want to do, and then this irritates us, as we can’t
perform to our usual standards. We can
also get a nervy edginess, which can be the body’s way of trying to keep alert
when it hasn’t had enough sleep.
On Becoming depressed
Insomnia and depression seem reciprocal difficulties. We can’t
sleep as we ruminate and have had an unsatisfactory day, we wake tired and
listless, without the energy to have a meaningful day.
Coping and everyday life
Symptoms of insomnia are tiredness, mental slowing,
irritability, problems concentrating. The overall impact of this is that it
effects the type of things that we can do. Exactly what relation between sleep and day
time performance is hard to be exact but there does seem a relationship. Sleep
problems=decreased performance during day, increase unpleasant emotions=sleep
problems due to stress\anxiety\low feelings + anxiety about sleep.
Insomnia and its effects on the family
Insomnia can give a strong feeling of loneliness. People
with insomnia can also worry about the effect that it has on their partner,
therefore they can be worried about this as well, as their own worries about
their sleep.
Effects of insomnia on social life and working life
People with insomnia don’t feel at their best, tired,
irritable, poor concentration which affects their work and social life, which
in turn can add to depressive\anxious feelings.
Is insomnia doing me any harm
Insomnia can trigger depression and physical health problems
are more common in people with insomnia, as insomnia lowers an individual’s
ability to fight off infection.
Chapter 3.1 Introduction to treatment
Plan:
Chapter 5: Assess
Chapter 6 Review facts about sleep and insomnia
Chapter 7 Sleep hygiene
Chapter 8: implement new sleep patter
Chapter 9 Dealing with a racing mind
Each chapter needs a week
Chapter 5 assessing your insomnia
Start date 29/12/14
The aim here is to gather your personal sleep history
Aim of chapter: to provide you with the means to assess the
nature and severity of your sleep problem and its impact on your life. Then to
establish a goal
Assess your personal sleep history with:
Table 5.1 Your Personal Sleep History
Content Area
|
Starter Question
|
Further Questions
|
Pattern
|
What is the pattern of your
sleep on a typical night
|
How long does it take you to fall asleep?
How often do you wake up?
How long are you awake for during the night?
How much sleep do you get
How many nights each week are like this
|
Quality
|
How do you feel about the quality of your sleep?
|
Is it refreshing?
Is it enjoyable?
Is it restless?
How would you describe it in your own words?
|
Daytime effects
|
How does your night’s sleep affect your day?
|
Do you feel tired?
Do you feel sleepy?
Do you have problems concentrating? Do you feel irritable?
What do you think your insomnia does to your day?
When are the worst times of the day?
|
Impact on your life
|
How does your insomnia affect your quality of life?
|
What consequences does insomnia have for you?
What are you not able to do because of your insomnia?
How would things be different in your life if you overcame your
insomnia?
|
Development of sleep problems
|
Do you remember how and when your poor sleep started?
|
What were the events and circumstances then?
What were the important dates and times?
How has your sleep changed over time?
Has anything happened that has made it worse?
Has anything happened that has made it better?
|
Lifetime history of the sleep problem
|
Did you used to be a good sleeper?
|
How did you sleep as a child?
How did you sleep as a teenager?
How did you sleep as a young adult?
Were there previous episodes of poor sleep?
Dates and times?
Did these past episodes resolve? If so how?
|
Family history of sleep and sleep problems
|
Do other people in your family have problems sleeping
|
Do either of your parents have sleep difficulties (now or in the
past)?
What about brothers and sisters?
What about the extended family, including grandparents?
Does anyone have problems that are similar to your problems sleeping?
|
General health and medical history
|
Have you generally kept in good health?
|
Have you had any major illnesses?
Have any health problems been persistent ones?
Dates and times?
Have there been any recent changes in your health
|
History of psychological well being
|
Are you the kind of person who usually copes well?
|
Have you had any psychological problems?
Any problems with anxiety or depression or stress?
Dates and times?
|
Current and previous treatment for insomnia
|
Are you taking anything to help you sleep?
|
What (if any) medicines are you taking now to help you sleep?
What have you taken in the past?
Dates and times?
Are you taking anything you have bought over the counter?
What sorts of things have you tried to do yourself to help you sleep?
What have you found that has worked and what hasn’t?
|
Use a sleep diary to quantify your sleep:
Week Beginning___________________________________
Measuring the pattern of your sleep
Day 1
|
Day 2
|
Day 3
|
Day 4
|
Day 5
|
Day 6
|
Day 7
|
|
1. What
time did you wake this morning
|
|||||||
2. What
time did you rise from bed this morning
|
|||||||
3. What
time did you go to bed last night
|
|||||||
4. What
time did you put the light out
|
|||||||
5. How
long did you take to fall asleep
|
|||||||
6. How
many times did you awake during night
|
|||||||
7. How
long were you awake during the night
|
|||||||
8. How
long did you sleep altogether
|
|||||||
9. How
much alcohol did you have last night
|
|||||||
10. How
many sleeping pills did you have
|
|||||||
Measuring the quality of your sleep
1.
How well rested do you feel this morning
|
0
|
1
|
2
|
3
|
4
|
Answer
=
|
Not at
all
|
Moderately
|
very
|
||||
2.
Was your quality
of sleep good
|
Answer
=
|
|||||
On the basis of doing your history and measuring your sleep
for a few weeks specify a SMART goal for your sleep
Chapter 6 Understanding sleep and insomnia
Aim: to remind you about normal sleep and sleep disorders
and their effects
1.
People need less sleep in later life?
a.
Babies need 18 hours, deep and REM sleep is a
larger proportion of sleep for younger than older people. Older people have
more broken sleep, and therefore have more sleep difficulties, they need less
deep\REM sleep conceivably as for the latter they are learning less new type of
tasks. However it is debatable if older people need less sleep, some argue many
of the signs that are taken as dementia are actually effects of insomnia. It is
certainly the case that older people have more sleep difficulties and lighter
sleep.
2.
We tend to sleep better as the night goes on
a.
Our deepest sleep is during the first couple of
hours and our lighter sleep during the second half of the night. We get the
biggest payback out of the early episodes of sleep
3.
We should try to make up for all our lost sleep
on the subsequent night
a.
Whilst we have a sleep debt if we don’t sleep
enough, we don’t need to repay all the next night. Whilst a regular incurred sleep debt causes
problems, we do adapt to less sleep on an infrequent basis. Often if you have
poor sleep one night then next night you have deeper, more restorative sleep.
4.
Dreaming a lot is usually a sign of emotional
upset
a.
We usually have 6 spells of dreaming during the
night. We dream in REM 80% of the time, and in NREM 15% of the time, so this is
not the case. It is possible we dream
more when we have things on our mind, drug withdrawal creates more dreams, and
a recurring nightmare can relate to an unpleasant experience.
5.
Sleep is important for our memory?
a.
In sleep our minds and our bodies are refreshed.
Without sleep acquiring new skills is harder, and new memories are harder. There
is not a direct correlation to how tired your body to how much sleep you need, or
to how much mental exertion you have made.
6.
The more sleep we can get the better we will
feel the next day?
a.
This is not the case. There is a normal
distribution for length people sleep, people who sleep more than this do not
feel any better generally than people who don’t. Oversleeping can increase
sleep inertia.
7.
Feeling irritable during the day probably means
our sleep is poor
a.
Irritability can be associated with insomnia but
it could be because we are so irritated that we couldn’t sleep, or the fact our
lives suck or… So being tired can lead to being irritated but annoyance of not
being able to sleep is likely to be a factor too
8.
Most adults sleep 7-8 hours a night?
a.
True but
some people are fine with less some need more
9.
There is no such thing as deep sleep?
a.
False, there are 1.5 hour sleep cycles and deep
sleep, or slow wave sleep is part of this cycle as is lighter sleep
10.
Daytime sleep may be an important sign of a
sleep disorder
a.
When people are sleepy they are also tired, but
the reverse is not true. So tiredness is when your body and mind feel heavy and
aren’t working that well, sleepy is when your eyelids are drooping and you can’t
keep them awake.
11.
Sleep problems usually pass away quite quickly
a.
This is true but 10% of adults experience
persistent sleep problems and it can be 20% in the over 65 year olds
12.
Most people don’t cope well after a bad night’s
sleep
a.
Thoughts like I’m never going to sleep, or
without sleep I’m never going to sleep are exaggerated and make you more upset,
and both restrict the amount of sleep you get and reduce your mood in the
morning.
13.
Sleeping pills are addictive
a.
Sleeping pills can be useful for the short term,
but if we take them too long, when we stop it might make getting sleep harder.
Many types of sleeping pills change the type of sleep we get which isn’t as
good as natural sleep. Some sleeping pills are dependency forming
14.
Taking a nap should be avoided if at all
possible
a.
If you have persistent insomnia then a nap could
help, however if you are having difficulty getting to sleep, then a nap could
reduce your desire to sleep. Naps of more than 15 mins will affect your ability
to sleep
15.
Life changes can cause insomnia
a.
This can be true as it increases anxiety, but
then when the anxiety goes sleep returns, unless of course worry about sleep is
now a behaviour
16.
Some people can go without sleep
a.
This is false, you can stay up for a night, but
after that your performance reduces a lot. People who sleep less on average can
also be measured during the day at EEG levels that are comparable to light
sleep. They are sleepy but have just learnt how to cope
17.
Depression causes insomnia
a.
Insomnia is a symptom of depression, but
insomnia is a precursor and a good predictor of depression.
Establish your beliefs about sleep and your sleep and see
what the effect of these thoughts are
Chapter 7 Sleep hygiene and relaxation
Two parts of sleep hygiene:
1.
How lifestyle affects sleep
2.
Developing a good sleep routine
Aim of chapter:
To introduce a healthy and natural sleep patter without
having to use medication and to learn how to relax
Lifestyle factors affecting sleep
Caffeine
This is a stimulant that can last many hours it is a good
idea not to have any caffeine 4-6 hours before bedtime
Nicotine
This is a stimulant, so try to not sleep before going to bed
or if you wake up in the middle of the night
Diet
Hunger can cause wakefulness and sleeping on a full stomach
can cause wakefulness as our digestion interferes with sleep. Weight changes can have some effect on sleep,
too much weight loss over a short time can lead to short broken up sleep. Only
lose a pound or two a week.
Exercise
People who are physically fit have a better quality of
sleep, although exercise per se doesn’t promote good sleep. It could be that
exercise improves mood, reduces anxiety therefore improves sleep. However strenuous exercise before bedtime,
can make it harder to sleep as your heart is still pumping.
Pre bedtime routine
Noise
Noise is an enemy of sleep, although some find absolute
quiet disturbing. To help you can use a white noise generator, or gentle music,
or relaxation techniques or ear plugs. A noise also is more than its level,
people tend to be more affected by noises they think are rude, inconsiderate,
so you may want to look at your beliefs about noise that affects you and see
what the emotional outcome of your belief is.
Room temperature
Err on the colder side, but too hot or too cold can cause
sleep problems. Ideal temperature 18c
Body temperature
Poor sleepers have higher body temperatures than good
sleepers. Therefore don’t have a hot bath straight before bed, have one a
couple of hours before bed time.
Air Quality
A stuffy room causes uncomfortable sleep, so open the window
just before going to bed
Lighting
Natural light is a trigger to circadian rhythm. Ensure your room is dark
Mattresses and Pillows
People with insomnia sleep better in unfamiliar
environments, which could mean because they don’t have the insomniac associations
with the unfamiliar environment. It could be that the other bed suits them
more.
Bed time wind down
Start 60-90 minutes before bed time, stop stimulating
activities, but don’t be too inflexible as this will cause an anxiety if your
regime is broken.
Learning to relax
Being more relaxed helps you to sleep, so learn to relax,
via progressive muscle relaxation techniques and mindfulness to aid with sleep.
And
There are active and passive ways of relaxing
Active would be working out at the gym or doing a crossword
Passive would be PMR, mindfulness, listening to music.
The challenge to improve sleeping is to improve your
lifestyle, improve your bedtime routine, but not try too hard, that you worry
and have anxiety about sleeping.
Chapter 8 Scheduling a new sleep pattern
Sleep scheduling uses stimulus control and sleep
restriction.
Associating bed and sleep
Your body can give sleep responses in response to a cue. So
you want to associate your bed with sleep, not with insomnia. Therefore adopt the 15 minute rule. If you
are awake for more than 15 minutes in your bed and you’re not having sex, then
get up and do something else, relaxing.
Napping
Avoid this unless you absolutely must if you are suffering
from insomnia
Amount of sleep
Establish the amount of sleep you need by measuring the
actual time that you sleep for 10 days and averaging it. Then go to sleep at
the time that would allow you to wake having had this amount of sleep.
Bedtime
You should go to bed when you are likely to fall asleep
straight away and sleep right through until your desire waking time. This is
when you are sleepy, not when you are tired, and not when its bedtime. This is
known as the threshold time. You should always go to bed after your threshold
time. The smallest you should set your sleep time is 5 hours.
Schedule
Create this sleep schedule based on your threshold time for
7 days a week, whilst you establish a pattern
Adjustments in schedule
When you are sleep efficiency is 90% or over then you can
flex your average sleep time you are aiming for by 15 minutes, repeat for 7
days and if you are still at 90% then you can repeat.
Chapter 9 Dealing with a racing mind
Types of thought that may occupy
1.
Replaying, Planning, Rehearing
2.
Problem solving
3.
Thinking about sleeping
4.
Monitoring your body
5.
Thinking about thinking
6.
Thinking about things that go bump in the night
a.
E.g. things happening outside you may be anxious
about
Dealing with a racing mind
1.
Analyse what type of thoughts you have that keep
you away
2.
Putting the day to rest
a.
Give yourself 20 minutes before bed time
b.
Knowing your thought proclivity then
i.
Replaying, planning, rehearsing
1.
Given the 20 mins do these activities, and if there’s
anything outstanding, plan to do tomorrow. If it feels too much and a stress,
decide on what the most important thing is
ii.
Problem solving
1.
As above
iii.
Thinking about sleeping
1.
Put these thoughts aside, or challenge them,
worrying about sleeping is going to stop you sleeping
iv.
Thinking about sleeping/your body
1.
As just above
v.
Thinking
about things that go bump in the night
1.
You may want to challenge these thoughts
Thought blocking
For trivial thoughts then mouth the but don’t say it every 2
seconds for up to 5 mins
Imagery
Complete a vivid, attractive image that you can immerse
yourself in. Practise this when conscious then when you go to bed repeat this
to engage with as opposed to sleep blocking thoughts
Sleep Scheduling
Stick to your sleep schedule
Give up trying to sleep
When you have sleep difficulties then first of all you pay
attention to i.e., i.e. sleep attention, you notice that it’s a problem.
Then you try to make sleep an intentional act and you then
start making effort. Trouble is with effort comes anxiety about sleep and
frustration if you don’t, both of which are counter productive
To give up trying to sleep then: lie in bed with your eyes
open, when you start drifting off to sleep hold your eyes open for another
minute
Think of wakefulness as an opportunity not a disaster.
Try as often as you can to be carefree about insomnia
Give up any concern about falling asleep, rather if you are
awake try to enjoy it without stimulating yourself, relaxation exercise, and
imagery
Attentional focus
Use humour and decatastrophise the situation, this weakens
your focus on the situation. The other way to loosen your attentional focus, is
to completely give up trying going to bed, so this would mean going to bed when
you are sleepy not because its bedtime,
If you are paying attention to your sleep, you may well
produce an attentional bias to signs of insomnia, which will magnify them. The
aim of this work is to draw your attention away from insomnia
You need to stop monitoring your sleep, paying attention to
it, so don’t watch the clock, monitor the light in the room, or the noise, rather you want to just relax and
sleep will come
Evaluation
Evaluate how you feel in the morning, and then look at all
the possibilities of why you feel like that, it may not all be about sleep.
Your beliefs that it is puts pressure and anxiety on the need to sleep which
again can be counter productive
