How to cope with sleep problems
Explains insomnia and other sleep problems, giving practical suggestions for what you can do and where you can go for support.
About sleep problems
What is sleep?
Sleep is an essential part of life: you can relax while still awake, but the brain cannot shut down and rest unless you sleep. Sleep is therefore essential for good health, and any difficulties with sleep may be both a cause and a symptom of mental health problems.
The amount of sleep we need, and its pattern, changes with age. Small babies spend most of their time asleep; children need more sleep than adults, and small children need a nap during the day. Sleep patterns change again during adolescence. Most adults need about 7 or 8 hours sleep per night, although some people seem to need less, and some a bit more. Older people often go back to sleeping for shorter periods and have a nap during the day.
There are two main types of sleep: deep sleep and rapid eye movement (REM) sleep. Deep sleep is thought to be especially restorative for the brain. During REM sleep we dream, and this enables us to process things we have experienced during the day. We all need to experience periods of each type of sleep in cycles every night. Each sleep phase lasts about 90 minutes, but we normally sleep more deeply at the start of the night, and have more periods of REM sleep as we get closer to natural waking.
Sleep is also related to certain chemicals and processes occurring in your body.
Growth hormone is produced, throughout our lives, to grow and repair our bodies, and you will produce more growth hormone during deep sleep than at any other time of the day. Therefore, if you need extra growth hormone e.g. when you’re short of sleep, pregnant or when you’ve been exercising, you will take more deep sleep and stay asleep for longer. (Older people spend more time in light sleep.)
Sleep is influenced by melatonin, a hormone which regulates your responses to the day/night cycle, and by a brain chemical called orexin which promotes wakefulness. Sleep is also thought to be associated with the brain chemical serotonin, which is involved in regulating mood. Other brain chemicals, such as noradrenaline and dopamine are almost certainly involved too, but we do not know enough about the way they all interact.
Your sleep will be affected by your general metabolic rate, which is controlled by your thyroid gland. If you are feeling either very sluggish or, conversely, finding it very difficult to relax, you could ask your doctor to check your thyroid function; this is done with a simple blood test, and can be corrected if necessary with thyroid hormones or other medication.
Can lack of sleep harm me?
Losing a night's sleep once in a while won't cause you lasting damage. If you are going through a stressful time, such as starting a new job or taking exams, you can probably go for several nights with as little as two or three hours sleep a night. Once the pressure is off, you should be able to return to your normal sleeping pattern.
But some people develop more lasting problems, which can lead to fatigue during the day, and cause irritability and difficulty concentrating. If you are very short of sleep, your body may also take ‘microsleeps’ when you fall asleep very briefly during the day. This can be dangerous, especially if you are driving, operating machinery or doing other skilled or potentially dangerous tasks.
If you are a poor sleeper you may also develop more problems with your general health than a good sleeper, such as a less effective immune system; however, psychological changes are more common than physical problems. Both types of impairments can be reversed when you make up the sleep loss.
If you frequently go without sleep, or have many wakeful nights, you will build up a 'sleep debt', which you will eventually have to pay off. Sleep debt can affect your intelligence and control of movement, and can have a bad effect on your metabolism and hormones. If you are in the sleep-debt state, you are more likely to make mistakes or act irrationally.
Sometimes, lack of sleep contributes significantly to the development of serious mental health problems. Lack of sleep may be a cause of depression as well as a symptom, and a period of difficulty sleeping or inadequate sleep may predict an episode of mania in people with bipolar disorder, and may contribute to feelings of paranoia.
I feel exhausted. Do I have insomnia?
If you're feeling tired, irritable and having problems concentrating, you may automatically put it down to not getting enough sleep. However, studies have shown that people who believe that they have long-term insomnia may actually be getting only 40 minutes less sleep per night than other people. It’s easy to overestimate the length of time you spend lying awake at night. If you have been coping with sleeping difficulties and are confronted with additional stress, you may suddenly focus all your attention on your sleeping pattern. You may come to believe that all your problems stem from insomnia; however, tiredness and a sense of fatigue can have other causes such as stress, depression or certain health problems.
If you have a couple of disturbed nights, for whatever reason, it can make you more anxious about getting to sleep, or about whether you are having enough sleep. This worrying can make your sleeping problem worse.
What causes sleep problems?
The most common causes of insomnia are:
- physical disturbance such as noise, inappropriate light levels, physical discomfort
- drinking stimulating drinks such as coffee, or smoking, just before bedtime
- taking vigorous exercise just before bedtime
- eating a large meal close to bedtime
- shift work or jet lag
- taking naps in the daytime, especially if late in the day
- breathing conditions.
Some people also have ‘delayed sleep phase’, which means that their body clock is out of phase with society’s normal sleep/wake cycle, so that they have difficulty coordinating with other people.
If there is no obvious cause for your sleep problems, doctors may say you have ‘primary insomnia’.
You may have difficulty getting to sleep because the conditions are unsuitable – your room may be too hot or too cold, too noisy or too light. Or there may have been a sudden change in your circumstances, such as moving into a new home or staying in a hotel, for example. You may be sharing your bed with a new partner; sharing takes practice, and sleeping alone for a night or two if possible may help you to catch up with sleep while you adjust. Or you may have lost a long-term partner through bereavement or separation and have difficulty sleeping alone.
If the change is a spell in hospital, you may be feeling very anxious, too. Being in pain, of course, will inevitably inhibit sleep. Any illness can temporarily change your sleeping habits. There are also a number of illnesses that may directly cause insomnia, including thyroid problems and post-viral fatigue syndrome (myalgic encephalomyelitis, or ME).
Some prescription drugs can disturb sleep: if you take a diuretic, for example, you may need to get up in the night to go to the toilet; some antidepressants may help you sleep, while others may cause sleep disturbance – at least when you first start taking them. If you are taking prescription drugs and having problems sleeping, it's worth asking your GP or pharmacist about it. Sometimes, sleeping also becomes disturbed when you stop taking certain medicines, such as antidepressants, or minor tranquillisers.
Jet lag or shift-work can disrupt the internal body clock that tells you when to sleep and when to get up. If you have been awake all night, it may be difficult to get a good sleep starting in the morning, because your body temperature, adrenaline levels and general alertness are all increasing. Shift workers sometimes have to stop doing night work because of long-term fatigue.
Alcohol, nicotine and caffeine are all powerful drugs, which alter sleep. One cigarette may have a calming effect that promotes sleep, but as you smoke more, nicotine levels rise and act as a stimulant. Alcohol is also a sedative and makes you sleep, but when the amount of alcohol in the system drops, it can have the opposite effect, causing insomnia later on in the night. Long-term drinking can ruin natural sleeping patterns. Caffeine is a stimulant, and is present in tea and chocolate as well as coffee. Drinking a lot of caffeine-containing drinks during the day, as well as having them late at night, is likely to make it difficult to get to sleep and to stay asleep.
Sleeping problems are often connected to underlying emotional problems that are causing anxiety or depression. Somebody who is habitually very anxious may become afraid of falling asleep, because they fear they might die in their sleep. A depressed person, on the other hand, is more likely to wake in the early hours of the morning feeling panic-stricken or full of dread.
Any traumatic experience is likely to cause disturbed nights. Stressful events such as unemployment, bereavement or divorce frequently trigger bouts of insomnia.
Problems for older people
Although older people tend to sleep less, it can be easy to ignore the contribution of social factors, such as loneliness, poor living conditions, depression, or the effects of living in an institution, such as a nursing home or hospital. Insomnia can often be the result of not getting enough exercise, too, because people get less opportunity for physical activity as they get older.
Other sleep problems
What other sleep problems are there?
You may have nightmares if you are stressed, anxious or depressed, or if you are withdrawing from drugs, such as minor tranquillisers or antidepressants. They are sometimes caused as an adverse effect of medication. They are also common following a traumatic event.
Sleep walking and night terrors
These occur during deep sleep, and may be caused by stress, or when normal sleep patterns have been broken (when doing shift work, for instance). Both sleepwalking and night terrors are more common in children, who often grow out of them. It may be necessary to take precautions, such as installing stair gates and locking doors and windows.
During the dreaming (REM) phase of sleep, limb muscles are limp and effectively paralysed. This may protect us from harming ourselves during dreaming. If something suddenly disturbs you during this phase of sleep, your mind may wake up before your body does, and so, for a few seconds, you become aware of your inability to move or speak and may be unnerved by it. Usually, such episodes are very brief, ending when you become fully awake.
In a small number of people sleep paralysis does not occur and they may get up and act out their dreams or behave in strange or dangerous ways, including binge eating, or even attacking their partner, which they cannot remember when they wake up.
People sometimes have hallucinations as they are falling asleep or while they are waking up. These are not true hallucinations but are usually very brief and simple visions, and stop as soon as you become fully awake and aware. They aren't a sign that anything is wrong, but may occur, for example, when looking after a wakeful baby, or when sleep is similarly disrupted.
If you are experiencing extreme daytime sleepiness, this may be caused by a condition called narcolepsy. Symptoms include falling asleep frequently, throughout the day, and experiencing vivid images and voices as you drop off to sleep. While this is happening, you may twitch, your eyes may jerk and your muscles lose power so that they fall to the floor. You may also have hallucinations, which may last longer or be more elaborate than the brief hallucinations mentioned above. Sleep paralysis is also more common and longer lasting. (For more information see Useful contacts).
Sleep apnoea means that you stop breathing for short periods while you are asleep, and this causes disturbed and poor quality sleep. The short periods when you stop breathing, leave your body temporarily short of oxygen; you then wake briefly, as your body responds to this, by taking a large breath in. It can be dangerous if it is untreated, as you may fall asleep briefly during the day, while driving, operating machinery or doing other potentially dangerous activities. It may disrupt your work and other aspects of your life too. The condition is more common if you are overweight, and as you get older. You may need to go to a sleep laboratory for the diagnosis to be confirmed. (For more information see Useful contacts).
What can I do to help myself?
The key to feeling refreshed is having a regular pattern of sleep, rather than the number of hours of sleep you get. If you go to bed before you're really tired, and then sleep badly, you'll tend to stay in bed later in the morning, which will affect the next night's sleep, and so on. The following steps can help you establish a good pattern.
Establishing a routine
- Go to bed only when you feel tired enough to sleep. If you always take a long time to get to sleep, delay going to bed until the time when you normally fall asleep, and get up at your usual time. This should mean you spend less time in bed, but more of it asleep, and your sleep pattern should improve.
- Set the alarm at the same time each morning. Don't sleep in late to make up for a bad night. This will only make it harder to sleep the following night. You may need to follow this programme for several weeks, to establish a regular pattern.
- Don't watch television or use your computer in bed. These are waking activities.
- If you don't fall asleep within 20 minutes, get up and relax in another room. Do something soothing, such as listening to music, until you're tired enough to go back to bed. Repeat this process, if you are awake for long periods.
- Avoid taking a nap during the day. But if you are really overtired, taking a short nap after lunch can be beneficial; sometimes sleep promotes sleep.
- After a long flight, try to adjust to local time. However tired you feel, go to bed close to the local bedtime, and get up reasonably early the next morning. You should then quickly adjust to a new pattern.
- Check your sleeping arrangements. Is your bed and bedding comfortable? Do the temperature and light levels suit you? Is there enough fresh air in the room? If you are easily bothered by noise, try using earplugs.
- Set aside time during the early evening for reflecting on your day. Write down an action list to deal with any worries. This stops you lying awake worrying in bed later.
- Wind down close to bed time, avoiding any complicated work or activity.
- Listen to the radio quietly to distract you from any daytime concerns.
- Have a warm bath, to help you unwind.
- Practise a relaxation technique before you go to bed. Breathe slowly and deeply: breathe in on a count of seven, hold for four seconds and then out on a count of eleven.
- Consciously tense and relax your muscles, in turn; start with your toes and work up.
- Hop pillows, or a few drops of lavender oil in the bath or on your pillow, may help you relax.
- Herbal sleep remedies for which there is some evidence include valerian, passion flower, lemon balm and hops. Caution: take care if you take medication, as herbs may cause adverse effects or alter the effectiveness of the drug.
- A hot milky drink may encourage sleep.
- Don't try to force sleep, it will only make you feel more anxious. Try keeping your eyes open, instead, and as they start to close, tell yourself to resist. The more you try to stay awake, the sleepier you’ll become.
- Interrupt unwanted thoughts by repeating a soothing word (such as 'peace') over and over to yourself.
- Visualise a scene or landscape that has pleasant memories for you. If you wake during the night, go through your relaxation routine.
- Avoid caffeine: coffee, tea, cocoa and cola. Try herbal or decaffeinated drinks instead.
- Limit alcohol in the evening to one or two drinks, and avoid drinks that have disturbed your sleep in the past.
- Get enough exercise. Fit people sleep better, on the whole, and if you haven't had any exercise during the day, it will be more difficult to sleep soundly. Consider going for a walk in the early evening; however, exercise too close to bed time will stimulate you and make it harder to relax for sleep. Yoga and meditation are also useful methods for combating stress.
- Eat only a light meal in the evening, and avoid snacks. If you need a snack late at night, protein foods which are digested slowly are better than sugary carbohydrates which will give you an energy boost just when you need to relax.
If you are feeling very stretched during the day, doing a stressful job and taking on too many responsibilities, you are unlikely to sleep well. Insomnia can be a symptom of other, more general difficulties, and you may need to look at your work-load, improve your assertiveness, or time-management and decision-making skills.
What professional help is available?
If you can't resolve your sleep problems on your own, it may be a good idea to see your GP, so that any potential medical causes can be diagnosed and treated. If you have depression or anxiety, these conditions should be treated.
Your GP may refer you for a talking treatment with a clinical psychologist who works with people experiencing sleep problems. Talking treatments have been shown to be effective for insomnia, especially cognitive behaviour therapy, which emphasises changing unhelpful habits (see Cognitive behaviour therapy). Treatment may involve keeping a sleep diary, recording information, such as the time it takes you to get to sleep, any anxious or repetitive thoughts, the number of times you wake up and for how long, and the number of anxiety dreams you are having, or foods and drinks you have consumed before a bad night.
If your sleep problems are caused by depression, anxiety, or other emotional problems, or if you are suffering from nightmares, you could consider talking to a counsellor or psychotherapist. Again, your GP may be able to refer you. (Also see Depression and Anxiety and panic attacks.)
If other techniques for improving sleep are unsuccessful, you may be given medication. There are no drugs that can be taken long term, however, and it is recommended that sleeping pills are used as a last resort and on a ‘one-off’ basis. This is because they become less effective when taken every night, and, at the same time, you may become dependent on them. They may also promote deep sleep rather than REM sleep, so that drug-induced sleep is not as restorative as natural sleep.
However, if you have got into a habit of not sleeping, taking a sleeping pill for a night or two may be enough to break this, stop you feeling anxious about whether you will sleep, and help you to get back to a natural sleeping pattern. Sleeping pills available on prescription include benzodiazepine tranquillisers (such as nitrazepam) and the ‘Z drugs’ – zaleplon, zolpidem and zopiclone.
Some antihistamines have the side effect of making you sleepy, so these are marketed, and may be bought over the counter, as sleeping pills. But, as with the prescription medicines, they should not be taken for more than a night or two and may also have other side effects.
Melatonin, the natural hormone which regulates your body’s response to the day/night cycle, has also been developed as a prescription sleeping pill for people aged 55 and over. If you have insomnia and depression you may be offered a tricyclic antidepressant, as some of these have the side effect of making you sleepy.
Other drugs that may be prescribed to promote sleep are some of the newer antipsychotics, such as olanzapine, which also cause drowsiness as a side effect.
For more information about medication, see
These are used to assess insomnia and other sleep problems, such as narcolepsy or apnoea, and involve spending several nights in a sleep laboratory, wired up to a polygraph machine that monitors your sleep. (It may be possible to use one in your own home.) As a result, people sometimes come to realise that they sleep far longer than they thought. Being observed and taken seriously may be therapeutic in itself, even if there is no cure at the end of it.
Battle Against Tranquillisers (BAT)
PO Box 658, Bristol BS99 1XP
tel. 0117 966 3629 or 0117 965 3463
Helps people withdraw from benzodiazepines and sleeping pills.
British Snoring and Sleep Apnoea Association
tel. 01737 245 638
Council for Information on Tranquillisers, Antidepressants, and Painkillers
helpline: 0151 932 0102
Information on adverse effects and withdrawal.
advice on coping with insomnia
tel. 0845 450 0394
Charity offering information and advice about narcolepsy.
Sleep Apnoea Trust Association
Support for people with sleep apnoea
Sponsored by the mattress industry; advice about getting a good night’s sleep, as well as choosing beds and mattresses.
Sleep Unit, St Thomas’ Hospital
tel. 020 7188 0839
Runs a London sleep clinic requiring a doctor’s referral.
The Welsh Sleep Apnoea Society
Information and helpline
To be revised 2013
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