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Insomnia

Anxiety-2

Sleep and emotional health

About one in five people in the UK have some difficulty with sleeping. It is well-known that sleep problems can be a key sign of common mental health conditions. What many people may not realise is that the reverse is also true – sleep disorders can actually cause emotional ill-health.  There have been many studies conducted which suggest that better sleep results in better mood. Sleep is an active process that results from change in the balance of major neurotransmitters in the brain such as serotonin and dopamine. These chemicals are also closely related to mood and other emotions. Therefore, to maintain a good mood, it is important to make sure that you are getting the right amount of sleep, and making sure that this sleep is of good quality.

What is insomnia?

Sleep problems are often referred to as insomnia. Sleep difficulties are particularly common in women, children, and those over 65. In fact, roughly half of people over 65 complain of suffering with sleep difficulties. To have trouble sleeping at some point in your life is quite common. Poor sleep can mean:

  • Not being able to get off to sleep
  • Waking up too early
  • Waking for long periods in the night
  • Not feeling refreshed after a night’s sleep

If you have poor sleep, you may be tired in the daytime, have reduced concentration, become irritable, or just not function well.

What is a normal amount of sleep?

People can often become very distressed when they feel they are not getting a good night’s sleep, but it is important to remember that different people need different amounts of sleep. Some people function well and are not tired during the day with just three to four hours sleep a night, but most people need more than this. To need six to eight hours per night is average. Most people establish a pattern that is normal for them in their early adult life. However, as you become older, it is normal to sleep less. In fact, many people in their 70s sleep less than six hours per night.

Everyone is different. What is important is that the amount of sleep that you get should be sufficient for you, and that you usually feel refreshed and not sleepy during the daytime. Therefore, the strict medical definition of insomnia is “a combination of both dissatisfaction with sleep and a significant negative impact on daytime functioning. Dissatisfaction with sleep is further defined as difficulty initiating and/or maintaining sleep or non-restorative sleep, on at least three nights per week for at least 3 months, despite adequate opportunity to sleep”. (DSM-V-TR).

Are there different sorts of sleep?

People are not just either awake or asleep. Sleep has different stages, which vary from deep to light sleep. At least five different types of stages of sleep have been identified. Broadly, sleep has been divided into what is called REM (Rapid Eye Movement) and non-REM sleep.  REM sleep occurs several times during the night and is where most dreaming is thought to take place. Non-REM sleep is divided into four stages, each stage being a bit deeper. During the night whilst asleep, people move from stage to stage many times, and even wake up several times. On a typical night a young adult who sleeps well will spend about 5% feeling drowsy, 50% in Stage 2, 28% in deep sleep (3 or 4) and about 25% in REM sleep. As with the amount of sleep we require changes with age, so does the type of sleep we have. Insomnia is much more common in older people. Sleep in older people tends to be much lighter and broken, with more stage 1 and 2 sleep and more frequent wakening. For a typical person aged 70, deep sleep takes up less than 10% of the night’s sleep. Therefore an older person may report waking more times throughout the night. Although sleep in older people might therefore be shorter, more restless and more easily disturbed, it should still be refreshing. Other illnesses can disrupt sleep, such as menopausal hot flushes and urinary problems from infection or prostate disease causing night-time waking. It is important to remember that as we get older, not only does the amount and type of sleep we have change, but our pattern of sleep also changes. It becomes more likely that we drop off to sleep during the day, so our natural rhythm of sleep can be disturbed.

What are the causes of poor sleep?

Poor sleep may develop for no apparent reason. However, there are a number of possible causes which include the following:

Concern about wakefulness
You may feel that to wake in the night is not normal, and worry about getting back off to sleep. You may clock watch, and check the time each time you wake up. This may make you irritated or anxious, and you are more likely to remember the times of wakefulness. You may then have an impression of having a bad night’s sleep, even when the total amount of time asleep was normal.

Temporary problems
Poor sleep is often temporary. This may be because of stress, a work or family problem, jetlag,  a change of routine, a strange bed, etc. Poor sleep in these situations usually improves in time.

Stress, anxiety or depression
A common trigger for sleeping difficulties is stress and worry. Some people are particularly vulnerable because they are more likely to show a more extreme response to stress, such as people who are chronically ill or struggling with other difficult issues such as relationship problems. You may find it difficult to switch off your anxieties about work, home or personal problems. Also, poor sleep is sometimes due to depression. Other symptoms of depression include: low mood, lethargy, poor concentration, tearfulness, and persistent negative thoughts. Depression is common and treatment of depression or anxiety often results in improving the poor sleep too. Contact First Steps or consult with your GP if you suspect you may have an underlying mental health condition which is affecting the quality of your sleep.

Sleep apnoea
This sometimes occurs in people who snore, most commonly in obese people. In this condition the large airways narrow or collapse as you fall asleep. This not only causes snoring, but also reduces the amount of oxygen that gets to the lungs. This causes you to wake up to breathe properly. You may wake up many times each night which may result in daytime tiredness. Note: most people who snore do not have sleep apnoea, and do sleep well.

Other illnesses
Some illnesses can contribute in keeping people awake. For example, illness causing pain, leg cramps, breathlessness, indigestion, cough, itching, hot flushes, restless leg syndrome, etc. If other illnesses are causing you to have disturbed sleep, please consult with your GP for further advice.

Going to the loo
The need to go to the toilet occurs more in later life. About 60% of women and 75% of men get up to go to the toilet at least once in a night. Getting out of bed to go to the toilet isn’t a problem if you can get back to sleep afterwards, but can become problematic if this is something you are unable to do.

Stimulants
These can interfere with sleep. There are three common culprits:

  • Alcohol – many people take an alcoholic drink to help sleep. Alcohol actually causes broken sleep which is often of poor quality, and early morning wakefulness.
  • Caffeine – this is in tea, coffee, some soft drinks such as cola, and even chocolate. It is also in some painkiller tablets and other medicines (check the ingredients on the medicine packet). Caffeine is a stimulant and may cause poor sleep.
  • Nicotine, usually taken in from smoking cigarettes is also stimulant.

Street drugs
For example, ecstasy, cocaine, cannabis and amphetamines can affect sleep as they can affect the normal balance of chemicals in the body.

Prescribed medicines
Some medicines sometimes interfere with sleep. For example, diuretics (‘water tablets’), some antidepressants, steroids, beta-blockers, some slimming tablets, painkillers containing caffeine, and some cold remedies containing seudoephedrine. Also, if you suddenly stop taking regular sleeping tablets or other sedative medicines, this can cause rebound poor sleep.

Unrealistic expectations
Some people just need less sleep than others. If your sleep pattern has not changed, and you do not feel sleepy during the day, then you are probably getting enough sleep. Older people and people who do little exercise tend to need less sleep. Some people think they should be able to nap during the day – and sleep eight hours at night! The amount of sleep you require is completely dependent on you as an individual. If you are trying to match the amount of sleep you have with your partner or someone else, it may be that you simply require less sleep and are setting yourself unrealistic expectations.

A vicious cycle
Whatever the initial cause, worry about poor sleep, and worry about feeling tired the next day, are common reasons for the problem to become worse. Once triggered, you may worry excessively about the effect that inadequate sleep will have on you and so strive excessively hard to get to sleep, take daytime naps or sleep in late which can disrupt your natural sleep rhythm. Many people also turn to medicines or alcohol in the belief that this will help, however most just induce unnatural patterns of sleep. A vicious cycle of poor sleep and stress is quickly set up and persists after the initial trigger has passed.  Insomnia contributes to excessive daytime tiredness, which in turn may be responsible for accidents, recurrent infections (inadequate sleep has been show to suppress the immune system), poor concentration, irritability, work and relationship problems and a general inability to cope. In children it may be linked to poor growth.

Treatment of insomnia

Sleeping tablets may be prescribed for short-term use only, typically just for a couple of days, when a specific cause of insomnia has been identified, such as bereavement or jet lag. It is usually more helpful to address any underlying cause of the insomnia and attempt to restore a normal sleep pattern through changes in behaviour and lifestyle. CBT can help to identify problems and treat insomnia by addressing the difficulties common associated with sleeping difficulties:

  • Our environment
  • Our behaviour
  • Our thoughts