About this leaflet
If you have trouble sleeping - or know someone who has - this
leaflet is for you. It covers common problems with sleep, as well
as some of the more unusual
problems that can happen. There are some simple tips
on how to sleep better, and how to decide if you need professional
help.
Introduction
You don't usually need to think very much about sleep. It's
just a part of life's routine, but most people do find it hard
to sleep at some point. There's even a word for it - insomnia. It's
often just for a short time, perhaps when you're worried or
excited. When things settle down, you get back to sleeping
normally. If you can't get back to sleeping well, it can be a real
problem because sleep keeps our minds and bodies healthy.
What is sleep?
Sleep is the regular period in every 24 hours when we are
unconscious and unaware of our surroundings. There are two main
types of sleep:
-
Rapid Eye Movement (REM) sleep
It comes and goes throughout the night, and makes up about one
fifth of our sleep. The brain is very active, our eyes move quickly
from side to side and we dream, but our muscles are very relaxed.
The brain is quiet, but the body may move around. Hormones are
released into the bloodstream and the body repairs itself after the
wear and tear of the day. There are 4 stages of non-REM sleep:
- The muscles relax, the heart beats slower and body temperature
falls - 'pre-sleep'.
- 'Light sleep' - you can still be woken easily without
feeling confused.
- 'Slow wave' sleep - our blood pressure falls, you may talk
in your sleep or sleep walk.
- 'Deep slow wave' sleep - you are very hard to wake. If somebody
does wake you, you feel confused.
We move between REM and non-REM sleep about 5 times
throughout the night, dreaming more towards the morning.
During a normal night, you will wake up for 1 or 2 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, your 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 also
tend to dream less as we get older.
There are also differences between people of the same age.
Most of us need 8 hours a night, but some (a few) people will
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 easily feel that you are not sleeping
as much as you are.
What if I don't sleep?
It's easy to worry when you can't sleep. The occasional
night without sleep will make you feel tired the next day, but it
won't harm your physical or mental health.
However, after several sleepless nights, you will start to
find that:
- you are tired all the time
- you drop off during the day
- you find it difficult to concentrate
- you find it hard to make decisions
- you start to feel depressed.
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.
Lack of sleep can make you more likely to get high
blood pressure, diabetes and be 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.
There are many everyday reasons for not 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.
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 are
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 stopping
you from sleeping. Your doctor can make sure that your
sleeplessness is not being caused by a physical illness, a
prescribed medicine, or emotional problems. There is some 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 anxious worrying - if you
can't get out of bed and do something instead of lying in bed
worrying.
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 legs, arms, shoulders, face and
neck.
Can medication help?
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 quite addictive. The longer you take sleeping tablets, the
more likely you are to become dependent on them.
There are some newer sleeping tablets (Zolpidem, Zalpelon 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.
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 and to stay awake
when you would normally be asleep. If you only have to do this
occasionally, it's quite easy to adjust. It is much more difficult
if you have to 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 are falling asleep during the day
at times when you want to stay awake. It's usually due to not
getting enough sleep at night.
If you find that you are still falling asleep in the daytime
even after a week or two of getting enough sleep, see your doctor.
Sometimes, a physical illness can be responsible - diabetes,
a viral infection, or a thyroid problem.
There are other conditions which make people sleep too
much:
Narcolepsy (daytime sleepiness)
This is an uncommon and so may be missed by doctors.
There are two main symptoms:
- You feel sleepy in the daytime, with sudden uncontrollable
attacks of sleepiness even when you are with other people.
- You suddenly lose control of your muscles and collapse when you
are angry, laughing or excited - this is called cataplexy. It will
sometimes get 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 narcolepsy has recently been found - a lack
of a substance called orexin, or hypocretin.
Treatment consists of taking regular exercise and having a
regular night time routine. If this simple approach does not work,
medication may help - an antidepressant or a drug which increases
wakefulness such as Modafinil. Antidepressants such as Clomipromine
or Fluoxetine can help cataplexy, along with a new medication
called Sodium Oxybate.
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 happens several times during the night. So, you feel tired
the next day, often with an irresistible urge to go to sleep. You
may also have a dry mouth and a headache when you wake up in the
morning.
You are more likely to get sleep apnoea if you are:
- older
- overweight
- a smoker
- a heavy drinker
The problem is often noticed more by their partner than
by the sufferer. Treatment is usually simple - cutting down smoking
and drinking, losing weight, and sleeping in a different position.
If your apnoea is very bad, you may need to wear a Continuous
Positive Airway Pressure (CPAP) mask. This fits over your nose and
supplies high pressure air which keeps your 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
If 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 will remember
nothing about it the next day. Sleepwalking may sometimes happen
after a night terror. If you sleep badly, or for too little time,
you will be more likely to sleepwalk - so it's important to get
enough good sleep.
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 an emotional
upset. 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.
Sufferers usually first seek help in middle age, although they
may have had symptoms since childhood. It often runs in
families.
RLS usually occurs on its own. It can occasionally be caused
by a physical illness, such as iron and vitamin deficiencies,
diabetes or kidney problems. It can also happen in pregnancy.
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. 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.
Self-help organisations
The Sleep
Council
Freephone leaflet line: 0800 018 7923.
Promotes the benefits of sleeping well. Provides information
leaflets on sleep and beds.
Helps snorers and their sleeping partners worldwide.
Sleep Disorder
Clinics. There are a number of Sleep Disorder Clinics, but
referral to one of them should be made through your family doctor.
Patients cannot refer themselves.
Further reading
Get a better night's sleep (Positive Health Guides)
by Ian Oswald and Kirstine Adam
Sleep like a dream: the drug-free way, Rosemary
Nichol
Insomnia: Doctor I can't sleep by Adrian Williams
(Amberwood Publishing)
The Insomnia Kit: Practical advice for a good night's
sleep, Chris Idzikowski
Audio Tapes
Coping with Sleep Problems.
Two-cassette audio pack with advice and self help tips on how to
deal with sleep problems.
£13.99 (p&p inclusive). Available from the Booksales
Department, The Royal College of Psychiatrists. Tel: 020 7235 2351
ext. 146.
References
Vignatelli L, D'Alessandro R, Candelise L.
Antidepressant
drugs for narcolepsy.
Cochrane Database of Systematic
Reviews 2005, Issue 3. Art. No.: CD003724. DOI:
10.1002/14651858.CD003724.pub3
Sleep Disorders (1988) Williams R.L., Karacan I. & Moore
C.A. John Wiley & Sons ISBN 0471837210.
Over-the-counter medicines and the potential for unwanted
sleepiness in drivers: a review (2001) Horne, J.A. & Barrett,
P.R. Department of Transport: HMSO.
Valerian for insomnia: a systematic review (2000) Stevinson C.
& Ernst E. Sleep Medicine, 1: 91-99.
Behavioural and pharmacological therapies for late-life
insomniacs (1999) Norin C.M. et al JAMA, 281: 991-999.
Management of insomnia (1997) Kupfer D.J. & Reynolds C.F.
New England Journal of Medicine, 336: 341-346.
Impact of sleep debt on metabolic and endocrine function
(1999) Spiegel, K., Leproult, R & Van Cauter, E. The Lancet,
354, 1435-1439.
Guidance on the use of Zalpelon, Zolpidem and Zopiclone for
the short-term management of insomnia (2004) Technology Appraisal
17, National Institute for Clinical Excellence: London.
Guidelines on diagnosis and management of narcolepsy in adults
and children - Evidence-based guidelines for the UK with graded
recommendations (2002). Developed by an independent
multidisciplinary working party based on widespread consultation
with the medical community and patient representatives and a
thorough review of the published literature. Taylor Patten
Communications Ltd: Surrey.
Non-pharmacological interventions for insomnia: a
meta-analysis of treatment efficacy (1994) American Journal of
Psychiatry, 151, 1172-1180.
Produced by the RCPsych. Series Editor: Dr Philip Timms Expert
review: Dr A J Williams.
Editorial Board: Dr Martin Briscoe, Dr Ros Ramsay, Deborah Hart,
User & Carer input: The RCPsych Special Committee of Patients
and Carers.
© April 2009 Royal College of Psychiatrists.
Due for review: April 2011
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