In this booklet we will attempt to address some of the common questions that people ask about sleep problems and how to deal with them, including:

• What are the different types of sleep problems?
• Why do we have problems sleeping?
• How much sleep do we need?
• Do electronic devices affect our sleep?
• What is the link between sleep and mental health?
• What help is available for sleep problems?

Different types of sleep problems

There are lots of different types of sleep problems.

Insomnia is the most common sleep disorder and will be the primary focus of this leaflet.

Insomnia – Trouble falling asleep or staying asleep

Sleep breathing disorders – Sleep disrupted by difficulty breathing when sleeping eg sleep apnoea

Sleep-related movement disorders – Abnormal movements that occur while falling asleep or during sleep. eg Restless legs syndrome (RLS)

Parasomnias Hypersomnias – These can include sleep walking, acting out your dreams, and night terrors

Circadian Rhythm Disorders – Excessive daytime sleepiness or excessive time spent sleeping eg narcolepsy. People with sleep apnoea can also experience hypersomnia

Sleep disorders where there is a mismatch between the body clock and the times a person wants to sleep. ie sleeping well but just at the ‘wrong times’

Insomnia

Insomnia is the most common sleep disorder. Symptoms of the disorder include:

• Difficulty falling asleep
• Waking up in the middle of the night or waking too early
• Being very sleepy during the day
• Not feeling refreshed
• Having difficulty concentrating the next day

Insomnia is sometimes divided into primary insomnia and secondary insomnia.

Primary – no clear underlying cause of insomnia

Secondary – related to an underlying cause

These causes include mental health disorders, chronic pain and sometimes also other sleep disorders (see previous page). However, sleep disorders are best viewed as separate conditions as they need specific treatments.

What causes insomnia?

The reasons why we experience sleep problems can be complex.

There are two psychological sleep processes that control your sleep: your body clock or circadian clock, and your sleep drive.

In insomnia there is also thought to be a third
process, high levels of arousal, known as hyperarousal.

Underlying these processes are factors such
as our genes, age and environment eg what’s going on around you, other health problems, the medication you take.

Example
Michelle, who is 20-years-old, has trouble getting to sleep until 2-3am. Why is this?

• she got up very late in the morning, so she has less sleep drive
• her body clock setting – young people’s body clocks make them sleepy later and wake up later
• she is stressed about exams or work – hyperarousal
• and her genes may be playing a part – her mum also has problems sleeping

As mentioned already, sometimes insomnia is associated with other sleep disorders and other conditions such as chronic pain and mental health problems eg depression, anxiety, ADHD.

How much sleep do we need?

How much sleep you need is difficult to determine. Your age and your genes have some influence, but other factors still remain unknown.

As a rough guide the National Sleep Foundation have produced a useful chart which can be seen on the next page.

As you can see there is a wide variation in amount of sleep that may be appropriate depending on your age.

Teenagers, children and infants generally need a lot more sleep. Following our teenage years, the sleep requirement generally remains steady but the pattern of how this sleep is attained may vary (e.g. napping as an older adult).

You can get an idea of how much sleep you need by filling in a sleep diary. Work out the number of hours you have slept each night and how you feel the next day to help determine the optimum number of hours for you.

Download free sleep diary template:

ncmh.info/sleep-diary

Recommended hours of sleep*

New Born	14-17
Infant	12-15
Toddler	11-14
Pre-school	10-13
School age	9-11
Teen	8-10
Young adult	7-8
Adult	7-9
Older Adult	7-8

*As recommended by the national Sleep foundation

How harmful is a lack of sleep?

In experiments where researchers deprived people of sleep for a short period of time, they found that participants generally experienced problems with concentration, attention and memory.
Long-term poor sleepers seem to partially adapt to sleeping less so short-term problems from not enough sleep are not always as obvious.

Insomnia has been associated with being overweight and with increased risk of diabetes, high blood pressure and heart disease.

However, we can’t say for sure whether these conditions definitely arise because of long-term effects of poor sleep due to the following reasons:

• Many people with insomnia are unaffected in these ways.
• The need for sleep varies so much between different people.
• Reported sleep is often not accurate (whether using sleep diaries or activity monitors).
• Links between sleep and other health problems often either share a common cause, such as genes that affect sleep and mental health, or the mental health problem and quality of sleep may have an effect on one another.

Sleep problems in young people

Sleep in young people is a particular issue as young people report higher levels of mental health issues as well as sleep problems.

Young people have a later shifted bodyclock and high levels of physiological and environmental stressors (eg puberty, school changes, exams, social contexts), which interfere with sleep processes.

They are also heavier users of electronic devices.

Use of these devices late at night can disturb sleep due to:

• light emitted from devices interfering with our body clocks – blue light filters can help but don’t stop all light stimulation.
• social communication keeping us alert late at night.

However, there are a many useful calming apps which might be helpful to aid sleep.

Some encourage mindfulness and relaxation, such as Headspace and Insight Timer.

So if you are using electronic devices in the evening try switching to applications that can aid sleep before bedtime.

Sleep in mid-life and beyond

Sleep problems tend to increase again during mid-life and during older age.

This can often be due to a variety of biological changes as well as life stresses such as:

• changes in your body clock – as you get older, your body clock gradually changes to a morning pattern. This means feeling sleepier earlier and waking up earlier.
• hormonal changes due to menopause.
• conditions that disrupt sleep that are more likely to occur in mid-life such as sleep apnoea (symptoms include snoring), pain and prostate problems.

An online resource which provides detailed advice on managing insomnia during the menopause can be found here: tuck.com/menopause-insomnia/

The link between sleep and mental health

Sleep problems are common in people with mental health difficulties such as depression, anxiety, and ADHD, and they are often difficult to cope with.

It can be difficult to know how these are related – sometimes there is a common cause, such as genes that affect sleep and mental health.

And sometimes the relationship is two-way – the mental health condition worsens when the person is unable to sleep.
It is particularly important to properly deal with sleep problems if you have coexisting mental health difficulties and you should seek health professional advice or advice from a mental health charity.

The use of alcohol to aid sleep should be avoided as this can worsen mental health problems.

How to deal with sleep problems

You should see your doctor if you are having persistent problems with sleep (problems that have lasted more than one month) that are affecting your everyday life.

If your sleep problems are due to an underlying condition (e.g. menopause, thyroid problems), your GP will address that first.

Some people may have problems because they feel sleepy much earlier and wake much earlier than other people. Others feel sleepy much later and wake much later than most people.

If either of these sound familiar, your problems may be related to your body clock. Therapies such as bright light therapy and melatonin therapy may help.

If your sleep problems are linked to hyperarousal (eg stress) then stress reduction strategies, increased time unwinding before bedtime, mindfulness, and yoga may be helpful.

For most types of insomnia, Cognitive-behavioural Therapy for Insomnia (CBT-I) is the recommended treatment.

Cognitive-behavioural Therapy for Insomnia (CBT-I)

For some people insomnia can become chronic and last for months or more.

CBT-I primarily focuses on encouraging behaviour to improve sleep quality but also includes strategies to deal with thoughts that may be interfering with sleep problems (eg excessive worries about the consequences of poor sleep).

CBT-I aims to regulate your body clock, maximise your sleep drive and reduce hyperarousal by bedtime and during the night. It usually also includes sleep hygiene advice as well as muscle relaxation techniques.

CBT-I techniques include:

Improving your body clock and sleep drive

• Keep a regular sleep schedule – get up at the same time every day, even on weekends!
• Avoid naps during the day if possible – otherwise limit to less than 20 minutes and not after mid-afternoon.

Stimulus Control

• Only use your bedroom for sleep and sex – not for working or watching TV
• Only go to bed when sleepy.
• 15 minute rule – This technique ensures that you
  associate your bedroom with sleep, rather than lying awake at night. If you cannot get to sleep within 15 minutes, leave your bedroom then only return when you are sleepy. Make sure you just estimate 15 minutes, don’t clock watch!

Sleep restriction

This technique aims to maximise the amount of time you are asleep when in bed, your “sleep efficiency”. For example, someone who goes to sleep at 10PM, falls asleep immediately, and wakes up at 6AM has a sleep efficiency of 100%.

In the sleep restriction technique, you wake up at the same time each day and set your bedtime depending on the total hours you normally sleep (from your sleep diary).

Example

If you wake up at 7AM and your sleep diary indicates that the average time you slept over the previous week was 6 hours then your bedtime would initially be 1AM.

Over the following weeks, you gradually go to bed earlier while maintaining a sleep efficiency of 90%. Please note that a minimum time in bed of 4-6 hours is recommended.

If you have a condition such as untreated sleep apnoea, a seizure disorder (e.g. epilepsy) or bipolar disorder, you should only undergo sleep restriction therapy under the guidance of a health professional.

Useful resources

Books on managing sleep problems

Colin Espie – An Introduction to Coping with Insomnia and Sleep Problems (2nd Edition, 2017, Robinson, London)

Use a sleep diary

If you are concerned about your sleep, you may want to consider completing a sleep diary. This may help improve your sleep and flag up a health condition such a sleep apnoea. A sleep diary will also be a helpful reference if you seek medical advice. You can find a sleep diary template on our website

ncmh.info/sleep-diary

The Sleep Council

This website offers educational leaflets, 30-day sleep better plan, a useful sleep diary, and guides to solving different sleep problems.
sleepcouncil.org.uk

National Sleep Foundation

An American website, it offers lots of discussions around sleep issues, educational resources and a useful sleep diary for CBT-I sleepfoundation.org