Understanding sleep hygiene using psychological methods
- Why is sleep so important?
- Factors impacting on sleeping difficulties
- Medications and sleep
- Approaches to help with sleeping difficulties
- Useful resources and contact details
Authors: Victoria Partington-Smith and Joanne Veale, Assistant Psychologists at Livewell Southwest
It has been widely suggested that we spend about a third of our lives asleep. Sleep is vital. It is as important as eating, drinking, and breathing and helps us recover from mental and physical exertion.
Sleep and health are strongly linked. Sleep disturbances can affect mood, energy, and concentration levels, our relationships, and our ability to stay awake and function during the day.
Addressing sleep and sleep disorders as part of health treatment is very important and is often overlooked. Sometimes we can believe that having minimal sleep (3-5 hours) does not impact us. Therefore, it can be helpful to remind us of the importance of sleep.
Sleep improves mental health and enhances mood
Studies have found that a lack of sleep is related to mental health conditions like anxiety, bipolar disorder, and PTSD. A lack of sleep can make us feel low, irritable, and anxious, among many other things. It can also make us feel low in energy and decrease motivation to engage in daily activities, which can ultimately lead to social withdrawal and isolation.
Sleep empowers an effective immune system
Regular sleep boosts our body's defences, and studies have found that a lack of sleep can reduce the effectiveness of some vaccines.
Sleep can improve our physical health
A lack of sleep can cause an increase in blood pressure and stress hormones. It can also have a negative impact on cardiovascular health as it is linked to an increased risk of strokes, diabetes, and heart attacks.
Sleep heightens brain function
Our mind works better when we get good sleep, contributing to complex thinking, learning, memory, and decision-making.
Sleep problems are very common and affects us all in different ways. There is no "right" amount of sleep and this varies from person to person and across the life span. For example the effects of aging mean that as a person gets older, they do not sleep as deeply and may wake more frequently in the night to go to the toilet. To combat sleeping difficulties it is important to consider what factor(s) below may be contributing to disturbed sleep, finding the causes can help generate solutions. At the end of this booklet, we have included a formulation diagram which may be helpful for you to complete in order to try to understand how your sleeping difficulties have developed, what keeps them going and what can help.
Stress, worry and anxiety
If you are stressed and/or anxious, you may experience difficulties in both getting to sleep and maintaining a good night's sleep. This can cause both physiological and psychological consequences, including feeling physically tense and/or ruminating and worrying.
Worrying about not getting enough sleep can also become self-sabotaging and can often make the problem worse. The effects of worrying about sleep can lead to a cycle maintaining the initial problem, for example worry thoughts like "I'll be exhausted tomorrow" may cause someone to feel more anxious and tense, which in turns leads to more worrying.
Nightmares are dreams with "vivid and disturbing content" and usually cause us to wake abruptly during sleep. Nightmares can impact the quality of our sleep and you may experience difficulties in getting back to sleep following a nightmare. If you experience frequent nightmares, you may also struggle to fall asleep, due to fearing and/or expecting the nightmare. For this reason, you may find yourself avoiding, or putting off, going to sleep. This may not be obvious and you may not realise that you have been avoiding going to sleep, but it can be helpful to explore this with someone you know, a partner, a friend, family member or a professional. Information adapted from the Sleep Foundation
Our surroundings can make a big difference to how we sleep including a room that is too hot or too cold or a mattress that is too hard or too soft and whether a room is too noisy or light. All these factors may collectively or individually impact on both getting to sleep and maintaining a good night's sleep.
Disturbed sleep routine
This can be influenced by lifestyle factors such as smoking, and drinking alcohol. Having an established routine can be an effective way at reducing disturbed sleep. There may be a combination or singular cause(s) for disturbed sleep, but it is important to try and maintain a routine as much as possible and regular exercise can help tire us.
Over stimulation before bedtime
Using electronic devices such as mobile phones or iPads can greatly impact on our ability to fall asleep, this may also be due to playing video games. Using stimulants such as caffeine or nicotine can also impact on our ability to sleep. Stimulants can make it harder to get to sleep, it can cause you to sleep more lightly and wake up more during the night and it can also make you get up to use the toilet during the night.
Studies suggest that eating more saturated fat and more sugar throughout the day is linked with lighter and less restorative sleep. Other foods like lasagne, chocolate or ice cream can trigger acid reflux and contribute to difficulties in getting to sleep. There are other sleep related disorders which are linked to obesity. Excess body weight can contribute to sleep apnoea by causing increased pressure of the airways.
Information from: St-Onge MP, Roberts A, Shechter A, Choudhury AR. Fiber and saturated fat are associated with sleep arousals and slow wave sleep. J Clin Sleep Med, 2016;12
Perimenopause/ menopause/ post menopause
More than half of premenopausal women sleep less than 7 hours a night, on average. From perimenopause to post menopause, women report the most sleeping problems. These include hot flushes, mood disorders, insomnia and sleep disordered breathing. Research has reported that as many as 61% of post-menopausal women report insomnia symptoms. Hormone replacement therapy may help relieve menopausal symptoms and this can be explored with your GP.
There are of course, medical reasons which can contribute to finding it difficult to get to sleep or cause you to wake in the night, some of which include:
Symptoms of sleep apnoea mainly occur when a person is asleep. The signs of this include: stopping and starting breathing, making gasping, snorting or choking noises, waking a lot and loud snoring. It may be helpful for a partner or someone stay with you to check if you are displaying symptoms of sleep apnoea. If this is the case we would encourage a person to contact their GP to discuss treatment options.
Back pain is the most common type of chronic pain and research has demonstrated that disturbed sleep will exacerbate chronic back pain and so a vicious cycle is maintained through pain disturbing sleep and then difficulty in sleep making the pain worse. It may be beneficial to seek advice from their GP about positions and ways to sleep to ease pain (other than medications), such as having pillow between legs, ensuring the mattress is appropriate and engaging in mindfulness.
Reference: Schrimpf M, Liegl G, Boeckle M, Leitner A, Geisler P, Pieh C. The effect of sleep deprivation on pain perception in healthy subjects: a meta-analysis. Sleep Med. 2015;16(11):1313-20.
Other medical reasons for sleep difficulties include:
- Restless leg syndrome
- Headaches and migraines
- Gastrointestinal problems, such as acid reflux, nausea or vomiting
- Neurodegenerative conditions such as Parkinson's disease and Alzheimer's disease
It's the middle of the night and you have been looking up to the ceiling for hours, over thinking and feeling restless. If this is a one off incident, you may feel ok the next night, but if this persistently happens, you may want something to help, and medications are often seen as the best available option. This is because there is a temptation for sleep aid and relief once we have experienced difficulties in getting to and/or maintaining a good night's sleep and wanting to have a quick fix of 'just being able get a good night's sleep'. This is because medications may offer us aid in sleeping but can often only be achieved if the medications are a 'one off' and there are a number of reasons why. Medication should be a last resort and additional ways of coping should be explored first.
Also known as sleeplessness, insomnia is a sleep disorder where people have trouble sleeping. They may have difficulty falling asleep, or staying asleep as long as desired. Insomnia is typically followed by daytime sleepiness, low energy, irritability and a depressed mood. From Google books-Psychological psychology
What causes insomnia?
Anxiety, stress and depression are some of the most common causes of chronic insomnia. Sleeping difficulties can also make anxiety, stress and depression symptoms worse. Other common and psychological causes
include anger, worry, grief and trauma. Insomnia is a significant concern that has prompted substantial amounts of treatment and management strategies. When an individual has sleeping difficulties, they may have used both prescribed and over the counter medications.
Sleep medication may help with insomnia in the short term, but it's important that all information is considered before seeking sleeping medications. Medication to aid sleep can be bought over the counter or prescribed and all medications have possible side effects.
Common side effects from sleep medications include:
- Prolonged drowsiness
- Trouble concentrating
- The next day
- Muscle aches
- Rebound insomnia
Complications of taking sleep medication
This occurs when the user's body becomes dependant on the medication to fall asleep. When a person stops taking them, they may find the insomnia returns, or rebounds, and can often be worse than before. It is therefore critical to consider all other possibilities before seeking medications.
When sleeping medications, such as benzodiazepines, are commonly used they may stop working. This is because a person builds a tolerance towards the medication. This means an individual is likely to require higher doses to get the same sleep induced-effect. However, the risks associated with higher doses include depressed breathing while a person sleeps, which may also be due to other medical disorders such as sleep apnoea.
Abuse of intended purpose
Sleeping medications are sedative in nature and for this very reason, a person may choose to abuse sleeping medications. An example is taking this medication when they face something in life that makes them feel particularly anxious. It may start with a plane journey but eventually be used just to go to the shops and so creates a dependency to take the sedative medications to get through.
Many people assume they won't become addicted to sleeping medications and can use them regularly. But as tolerance increases, as does the dosage and many people don't realise they have become dependent or possibility addicted to taking these sleeping medications until they are taken away. Once this happens, they may experience withdrawal symptoms. These include:
- Delirium and hallucination
- Increased heart rate
- Rebound insomnia
- Nausea and vomiting
Impaired activates like driving People may have enough medication in their bodies the next morning to impact on activates like driving.
Most sleep difficulties can be put into two categories; difficulties with falling asleep and difficulties staying asleep.
It is important for us to explore what it is that is stopping us from falling or staying asleep. Is it the environment? Are you experiencing racing thoughts? Have you had difficulties with this before and, if so, has anything helped in the past (other than medication)?
Difficulties falling asleep
Take time to wind down
A regular bedtime routine allows our bodies and minds time to slow down and recognise that it is time for sleep. Try to take at least half an hour to play quiet music, take a bath/shower, or read a book before bed. Try to avoid checking your phone or watching TV.
Avoid stimulants such as caffeine and nicotine close to bedtime
This includes alcohol as it can disrupt sleep as our bodies begin to process it.
Avoid food that can be disruptive right before sleep
Heavy or rich foods, spicy dishes, citrus fruits, and carbonated drinks can cause indigestion for some people. When this occurs close to bedtime, it can lead to painful heartburn that disrupts sleep.
Make sure that the sleeping environment is pleasant
Mattress and pillows should be comfortable and the bedroom should be cool. Have you considered using blackout curtains, eye masks, ear plugs, "white noise" machines and other devices that make the environment more relaxing?
Limit day time naps to 30 minutes
If you have had a bad night's sleep, it makes sense that you might want to sleep during the day. However, sleeping during the day can make sleeping at night even more difficult. So you should try not to sleep during the day, however, if you need to then short 20-30 minute naps can help.
Add exercise to the day
Regular exercisers fall asleep faster and sleep more soundly. In fact, even a brisk walk can improve sleep among people with chronic insomnia. As little as 10 minutes of walking can improve sleep quality. You could try to go for a 10 minute walk during the day and see how it impacts your sleep.
Be exposed to natural light
This is particularly important if you spend most of your time indoors. Going outside, if you can, or opening the curtains to natural sunlight helps the body recognise that it is daytime. This can help promote an effective sleep-wake cycle.
Learning to quiet our minds can be a helpful skill for falling asleep at night. Try taking deep breaths and quietly focus on your inhale and exhale. There are also free apps that will help guide you, such as Headspace and Pzizz. These apps are free to download via the App store.
Put your to-dos or worries on paper
Instead of letting our minds race with all the things that we don't want to forget to do, write them down so your brain can relax and let go.
It may be helpful for you to try a "worry tree". This technique can help you to name your worry and judge whether it is a hypothetical or practical concern. Hypothetical worries are often start with "What if..." and can cause a great deal of anxiety when there is usually not much that can be done about it. Practical worries are concerns that relate to circumstances that you are experiencing. These are situations where something can usually be done about it. Constructing a plan of what to do, when and how can help ease anxiety around this worry.
Techniques to change focus of attention can include methods such as distraction, mindfulness and relaxation.
Tense and relax
Muscle relaxation can be very effective in soothing our minds and relaxing our bodies before sleep. It can help move our attention from our thoughts to our bodies which can provide some relief from rumination.
You could try this relaxation exercise in bed. It may be helpful to have a copy of the instructions to hand. These instructions have been written by Dr Maunder and Lorna Cameron and can be found in the Northumberland, Tyne and Wear NHS Foundation Trust Anxiety self-help guide.
Progressive Muscle Relaxation
It may be helpful to record yourself reading these instructions out loud.
Lie down, get comfortable, close your eyes. Concentrate on your breathing for a few minutes, breathing slowly and calmly: in two-three and out two-three. Say the words "calm" or "relax" to yourself as you breathe out. The relaxation exercise takes you through different muscle groups, teaching you firstly to tense, then relax.
Starting with your hands, clench one fist tightly. Think about the tension this produces in the muscles of your hand and forearm. Now do the same with the other hand.
Study the tension for a few seconds and then relax your hand. Notice the difference between the tension and the relaxation. You might feel a slight tingling, this is the relaxation beginning to develop. Now do the same with the other hand.
Each time you relax a group of muscles think how they feel when they're relaxed. Don't try too hard to relax, just let go of the tension. Allow your muscles to relax as much as you can. Think about the difference in the way they feel when they're relaxed and when they're tense. Now do the same for the other muscles of your body. Each time tense them for a few seconds and then relax. Study the way they feel and then let go of the tension in them.
It is useful to stick to the same order as you work through the muscle groups:
Clench fist, then relax.
Bend your elbows and tense your arms. Feel the tension, especially in your upper arms. Remember, do this for a few seconds and then relax.
Press your head back and roll it from side to side slowly. Feel how the tension moves. Then bring your head forward into a comfortable position.
There are several muscles here, but it is enough to think about your forehead and jaw. First lower your eyebrows in a frown. Relax your forehead. You can also raise your eyebrows, and then relax. Now, clench your jaw, notice the difference when you relax.
Take a deep breath, hold it for a few seconds, notice the tension, then relax. Let your breathing return to normal.
Tense your stomach muscles as tight as you can and relax.
Squeeze your buttocks together, and relax.
Straighten your legs and bend your feet towards your face. Finish by wiggling your toes.
Remember relaxation is a skill like any other and takes time to learn.
Tips if you wake up in the night and struggle to get back to sleep
If you wake during the night, it is important to not turn the light on (light = daytime as far as the brain is concerned).
You should try to not get up and do active things. Try to remain as inactive and unstimulated as possible.
If you are worrying about things, try to write your concerns down on a piece of paper. The act of writing them down can help soothe our minds as we have "transferred" our concerns to paper.
If you wake because to a nightmare, you could try to use the relaxation exercise mentioned above and remind yourself that it was a dream. Writing about the nightmare and changing the ending so that it is no longer threatening can also help (South Eastern Centre Against Sexual Assault & Family Violence).
Sometimes, people may find it helpful to talk about their nightmare. If you live alone, or feel unable to talk about it with a loved one, the helplines for Mental Health Matters and the Samaritans may be useful. These can be found in section 5 of this document.
You should try to not to look at your clock and count how many hours you have left before you need to wake up. We all have probably done this! This can be unproductive as it can lead us to feeling anxious, frustrated or even angry which can further prevent us from falling back to sleep.
Don't lie in bed awake
If you can't fall asleep for more than 20 minutes, get out of bed, keeping the lights low, and do something relaxing. Try to avoid using screens as screen lights can signal to our brains that it is time to wake up. When you feel more relaxed, try returning to bed.
Above all, if you do wake in the night and find yourself getting frustrated, try to remember the importance of self-compassion. This happens to everyone sometimes!
A note about the Coronavirus:
Recently, we have all found ourselves in unprecedented times. With the "lockdown" and current restrictions imposed on us, we are in a period of uncertainty which can, understandably, increase feelings of anxiety. This can impact various areas of our wellbeing, including sleep.
We have been asked to stay indoors so we haven't been able to get as much exercise and exposure to light, which are two very important factors in sleep. While it is important that we follow the guidelines that have been outlined by the government, we can try to reduce the impact of coronavirus on our sleep using the techniques listed above and in the following ways:
- Restrict time spent watching or listening to the news.
- Utilise the time we are allowed outside and going for a walk if you can. If this feels overwhelming, then sitting in the garden or on a bench somewhere could also be helpful
- Try to keep in contact with family or friends via the telephone or other virtual means
The aim of this guide is to explore on an individual basis what your identified sleep difficulties are and try to improve them using practical and psychological methods. There are no right or wrong answers. This can be filled in on your own, with a partner, friend and/or professional.
What made me vulnerable in the first place?
This questions aims to explore what factors have contributed to a sleep disturbance. This may include both physical and mental health related illnesses. For example, in you have anxiety and you often worry and ruminate, you may experience difficulties in both getting to sleep and maintaining sleep as you mind is occupied. Someone else, however, may a have chronic back pain and cannot get comfortable in bed. This again may impact on getting to sleep and waking in the night due to the pain.
Triggers for most recent episode
This section of the formation looks at identifying your specific triggers to a disturbed night sleep. This can include stress from changes in your life, e.g. moving house, getting a new job. It can also include anniversaries that may impact on your mood and can vary from person to person.
The identified sleep problem
This section looks at what specific difficulties you experience with your sleep. Are you struggling to fall asleep or stay asleep or both. Do you experience night terrors and feel this may be contributing to difficulties in falling asleep and/or maintaining a good night's sleep.
Factors that keep this problem going
This section of the formulation aims at identifying what factors might be maintaining your sleep difficulties. For prompts to fill in this section, please refer to section 2 - factors impacting on sleeping difficulties.
What have I tried to limit this problem and what can I come back to?
This section aims to identify any methods that you have used in the past or have identified within this booklet that may be helpful to combat your sleeping difficulty/ difficulties. This can include reducing substances such as nicotine and caffeine and/or the use of technology that keeps you awake, e.g. screen time. Please refer to section four for prompts.
- Sleep Matters Insomnia Helpline
Phone: 0208 9949874 (Monday- Friday, 6pm-8pm)
- The Sleep Council
Phone: 0800 0187923
- NHS webpage: Every Mind Matters- Dealing With Sleep Disorders
- Mental Health Matters
Phone: 0300 3230101
Phone: 01752 116123
- Get Self Help. Worry Tree.
- L, D.S.W.E., Dr Razeena Karim (2018). Psychological Psychology
- Maunder, L., & Cameron., L. (2016). Anxiety An NHS self help guide. Northumberland, Tyne and Wear NHS Foundation Trust NHS. Sleep Apnoea
- The Sleep Foundation. Menopause and Sleep.
- The Sleep Foundation. Sleep Hygiene.
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