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Sleep problems: some practical thoughts

 

Help, I can't get to sleep!

 

Homer is fearful as can't sleepWith relationship and other personal problems the first casualty is often our sleep: can’t get to sleep, keep waking up in the night, shallow sleep so don’t wake up refreshed and/or waking up far too early. Clearly, resolving personal matters is likely to help restore our usual sleeping pattern, but as a good night’s sleep is so central to how we feel we will take a practical look at what helps and what can hinder restorative sleep.

According to a Guardian article, one in ten of us in the UK is regularly taking a pill to get to sleep.  But what if these drugs are part of the problem and carry much greater health risks than we realise?  We will look at this too.  Let’s take a look at what disrupts sleep and what might help.

If you can’t get to sleep or wake up too early, it may be that one or more of these apply:

  • kept awake by young children
  • lots on your mind - with pressures at work, financial difficulties, relationship tensions and the like
  • staying up late to revise for exams
  • the arrival of a new baby
  • physical illness and perhaps intense pain
  • late night partying
  • lots of excitement, such as looking forward to a holiday, or falling in love!
  • a side-effect of various medications (including some of those for mental health)
  • high levels of stimulants (such as caffeine) in food and drinks during the day
  • the effects of childhood trauma
  • trauma in adult life (as with military combat)
  • working irregular shifts that include night working
  • hormonal changes such as the menopause
  • high levels of stress and/or distress

Pick and choose what works for you

Some people may appear to do all the “wrong” things, as it were, and still sleep as sound as a well-fed and contented baby. My concern here is for those who are regularly struggling to fall sleep and/or don’t sleep long enough to feel refreshed. These ideas (much of it common sense) are not offered as specific or clinical guidance but hopefully as a few helpful signposts along the way. Pick and choose what works for you.

Keeping to a sleep routine

Keeping to our usual going to bed and getting up times helps keep in time with our internal clock. But of course, in a real world this isn’t always that easy. Those with a tiny baby will inevitably have their sleep patterns completely disrupted - as you may know only too well! Not surprisingly many parents end up snatching some sleep during the day when the baby is having day time rests.

It is sometimes recommended that people try to get up at their usual time following a disturbed night to help maintain a sleep routine.  Some even discourage weekend lie-ins. I don’t think we need get over religious about this – what suits one person/family may not suit another.

Sleep and psychosis

Personal problems can lead to more extreme emotions and behaviours and lack of sleep can be a key issue. Refreshing and restorative sleep is often one of the first casualties when a person is going through a personal crisis. When deprived of sleep the situation can escalate and a person may experience confused or seemingly irrational thinking. For some people, severe lack of sleep can be a tipping point into psychosis.

Sleep deprivation is an ancient and contemporary form of torture that breaks down a person’s resistance. In this state a person’s ability to the think and act rationally is greatly diminished. Typically, a person may experience impaired memory, hallucinations, moodiness, paranoia, have irrational thoughts, and feel depressed and anxious.  It is therefore not surprising that people who have been struggling with sleep shortage over a period of days or weeks may show signs of these problems.  Unfortunately, all too often people then end up with a psychiatric diagnosis when really they are simply undergoing a period of intense stress and/or distress that is hampering their sleep. 

I am aware that the late Dr Loren Mosher, who was very concerned over the risks of antipsychotic drugs, did sometimes suggest the short-term use of an antihistamine like Benadryl to help a person sleep – with the intention of preventing the situation from escalating and reduce the need for antipsychotics.  However, even Benadryl, a generally well-tolerated drug, can in some instances lead to insomnia, nervousness, restlessness (see the patient information leaflet that comes with drug). 

Sleep and trauma - Flashbacks & nightmares

Those people (of all ages, including traumatised children and those who have been in military combat) who have experienced trauma may experience flashbacks during the day and night terrors during sleep.  These disturbances can be extreme and more detailed comment on this is beyond the scope of this particular article.

Our bodies naturally release chemicals such as adrenaline, cortisol and noradrenalin (called epinephrine in US) to energise and alert us to face or flee our foe. But if the conflict persists or keeps on repeating, the cut off mechanisms in our brain can be hampered.  This can lead people to be hyper-vigilant and to live constantly on the edge – erupting at the slightest stress, distress, or provocation.  Not surprisingly, these tensions do not suddenly calm down at bed time.

Go to bed tense, wake up tense

The ancient Greek philosopher Heraclitus wisely recognised that day and night are one in that they seamlessly merge.  We are all aware that with regard to sleep, a rough night will likely disturb our following day (or days) – the one impacts upon the other.  Similarly, our day affects our night.

Stress, anxiety and tensions may tend to build up during the day and these can disturb our sleep.  It is therefore important to learn to put these to rest before we intend to sleep.  It is often assumed that sleep relaxes and refreshes us.  But in reality, if we go to bed fraught and tense we are likely to have a disturbed night and wake up tense.  It is not surprising that feeling stressed, distressed, tense and on edge can hinder sleep.  Stress tends to raise cortisol levels – preparing us for action and not rest and sleep.

Letting go of the days tensions

When we are alert and active our autonomic nervous system triggers various chemicals to boost our energy and activity – this is the sympathetic nervous system at work.  When we are resting and recouping the parasympathetic nervous system is operative.  It’s a bit like a lift: when the lift goes up, the counterbalance goes down.  Our aim is to have reduced stimulating chemicals buzzing around and those that help us relax and wind down for a restful sleep. There is within us a powerful force to keep us safe, raising levels of chemicals like cortisol to energise us.  Thus, we are unlikely to be able to enter a peaceful and restful slumber as long as we expect danger or distress.

There has been a growing interest in some types of meditation, yoga, tai chi, and mindfulness to reduce the days build up of stress, distress, and physiological tensions.  This is not surprising as these can help reduce stress and tension and help encourage parasympathetic responses.  Various studies have looked into this, such as here 10 (and discussed here 11).

Sleeping pills

sleeping pillsDrug companies spend many millions of dollars a year on promoting their drugs and a plethora of advertisements can easily lull the public into presuming that these drugs can be taken regularly without adverse consequences.  The fact that sleeping pills are widely used does not mean that they are as safe or as effective as we might hope.  Most drugs (if not all) carry risks, and we need to weigh any hoped for benefits against these risks. 

Some doctors are more vocal about the risks of sleeping pills. Dr Daniel Kripke (professor emeritus of psychiatry at the University of California San Diego with 35 years experience treating and researching sleep disorders) writes: “Sleeping pills are hazardous to your health and could cause death from cancer, heart disease, or other illnesses.” 3

A study published in BMJ Open 4 co-authored by Dr Kripke shows that even those people who took fewer than 18 sleeping pills per year had very significantly increased risk of dying sooner (3.6 times that of people who didn’t take sleeping pills). Those taking higher doses had an even greater chance of an earlier death – (the risk rose to 5.3 times for those taking over 132 pills per year).  The study summarises the key messages in this way:

  • Patients receiving prescriptions for zolpidem, temazepam and other hypnotics suffered over four times the mortality as the matched hypnotic-free control patients.
  • Even patients prescribed fewer than 18 hypnotic doses per year experienced increased mortality, with greater mortality associated with greater dosage prescribed.
  • Among patients prescribed hypnotics [sleeping pills], cancer incidence was increased for several specific types of cancer, with an overall cancer increase of 35% among those prescribed high doses.

For patients prescribed over 132 sleeping pills per year, there was a 35% increased risk of developing cancer within an average of 2.5 years. Now that is alarming.

In addition, studies by sleeping pill manufacturers show that these drugs can significantly increase the chance of becoming depressed.  The study is here 5.

There are numerous sleeping tablets (often referred to as hypnotics) on the market. These tend to be either barbiturates, benzodiazepines, sedative antihistamines or benzodiazepine agonists.  Some antidepressants, such as the tricyclic doxepin (branded as Silenor) are also used as sleeping tablets. In addition, melatonin (available over the counter in the US) is sometimes prescribed to help regulate the sleep-wake cycle. 

Melatonin - a natural sleeping pill

Melatonin, a natural body hormone, plays a key role in helping us to sleep.  A form of melatonin is sometimes prescribed by doctors to help with sleep difficulties. Although melatonin naturally occurs in the brain, it does not necessarily mean that taking extra melatonin is without any risk: the simplistic idea that “natural equals healthy” is not always a reliable test for safety.  Regarding the use of melatonin as a sleeping pill, Dr Kripke writes: “There is evidence that melatonin has a variety of minor side effects such as headache and nightmares, and some effects on the reproductive endocrine system … I think we need more long-term studies of melatonin safety…Today, nobody can be certain that any of the prescription sleeping pills (or melatonin) is safe for long-term use or even that they help sleep with long-term use (meaning several years).6” This science blogger discusses some of the possible pros and cons for the use of melatonin here.

Are sleeping pills effective?

It is interesting that people taking sleeping pills tend to think they are gaining more sleep than is actually the case – something of a feel good factor.  However, in most sleep laboratory studies, insomniacs only benefit from about just 20-40 minutes or even less (some reports 7 say as little as 12 minutes gain a night).  As with many drugs, people develop a tolerance to sleeping pills – so that this initial gain of the first few nights may then drop as the body compensates for the drug.  Thus, after a week or so, there may be no obvious gain in time asleep.  It is then possible to get caught into a dependency trap whereby a person may experience anxiety and insomnia as part of the withdrawal effects – and then conclude they must continue with the sleeping pills to treat this (drug-withdrawal induced) insomnia.

I guess a key factor is: do sleeping pills actually help people to be more alert and less washed out the following day?  This study casts doubt on their overall effectiveness: “The preponderance of evidence is that hypnotics impair performance, cognition and memory, increase the risk of automobile accidents and falls and promote unfavourable changes in personality. Due to tolerance, the sleep-promoting effects of hypnotics appear to be lost with chronic use 8” The bottom line is that sleeping pills reduce brain activity during the day and night – the effects of the tablets don’t simply cease once a person is awake.

It is known that sleeping pills can create a hangover effect that can make people feel sleepy, less alert, and with slower reaction times the following day. This is known to affect driving 9 (see FDA warning here also), and is one of numerous factors that can increase the likelihood of falls with the elderly.  The difficulty is that sleeping pills can reduce brain cell activity during the day as well as at night.

It is also possible to wake up feeling anxious and agitated as the effects of the sedating drug wear off - this is a sort of between dose withdrawal effect. As with many drug withdrawals, the effects tend to be the opposite to the purpose of the drug.

Whether or not the risks and limitations seem worth it, sleeping pills no more target the causes of insomnia than a painkiller targets a headache – both merely attempt to reduce symptoms.

Worrying about not sleeping doesn’t help

As lying in bed and being unable to sleep night-after-night is torturous, some sleep specialists suggest only going to bed when actually feel sleepy (thus avoiding lying in bed for hour after hour but unable to sleep).  It is suggested that people may fare better if they go to bed at the time they are falling asleep.  So if someone falls asleep at say 3am – why not go to bed at that time?  One can gradually extent the time in bed (perhaps by as little as 15 minutes a night) over days and weeks until a full night is reached.

Again, it’s a personal decision. Is it better to lie in bed anxious and frustrated at not sleeping – or to have various relaxing activities planned until really feeling sleepy and more certain of falling asleep? Without doubt, anxiety disturbs sleep.

Winding down

Having a regular winding down routine is a relaxing way to finish the day.  People develop all sorts of routines that seem to work best for them. A warm relaxing bath, a time of relaxation, writing down things you would like to remember to do the next day, listening to quiet music, playing a guitar, yoga, listening to the radio, thinking of the aspects of the day that you are pleased with, light reading – anything that doesn’t require too much energy or effort and does not make you feel too alert or tense.

Cat naps

time for a cat napNodding off for around 10-15 minutes during the day leaves some people refreshed; hence, cat-naps are sometimes termed power-naps. Clearly a longer time may lead to being less tired and unable to sleep at night. A cat nap is not a siesta!

How much sleep do we need?

The amount of sleep needed varies with age and from person to person.  What matters is how much sleep you personally need to feel refreshed and energetic. One study 1 suggests that the “folk belief that we should sleep eight hours seems to be incorrect.”  Many people seem well on comparatively little sleep. It is also true that too much sleep can make us lethargic and feel more depressed. 

Is it natural to wake up in the night?

The historian professor Ekirch points out that the idea of going to bed for a full night’s sleep is relatively new.  The Psychiatric Times ran an interesting article on this a few years ago.  Prior to the Industrial Revolution it was usual to have two periods of sleep a night – with an hour or two break in between.  In this break some people would get up, do chores, and even pop out to visit friends – yes, in the middle of the night. So waking up mid-night is perhaps quite natural; but if our waking is because we are distressed by personal troubles, clearly we might want to face and hopefully resolve these matters.

Exercise

Its common sense isn’t it – without adequate exercise during the day we are likely to be less physically tired at night.  Exercise also helps relieve emotional tensions that build up during the day. Vigorous exercise too near to bed time can cause us to be more awake.

Simulating dawn and dusk

One way our brains know day from night is by light and darkness.  We have brain chemicals that respond to these: those to wake us up and those help us to fall asleep.  But in modern times we rarely get up at sunrise and settle down at dusk.  It may therefore be helpful to gradually dim the light intensity during the evening to signal to our brains that bed time is drawing close.  We tend to do this naturally to help settle babies and young children. Conversely, it is worth bearing in mind that plenty of daylight during the day is believed to help us feel more awake in the day but also to sleep better when night-time comes.

Some people struggle to fall asleep again should they have to get up briefly in the night. Having a low wattage light may reduce the chance of waking up too much and then having difficulty falling back off to sleep.

Difficulty falling asleep inevitably leads to difficulties waking up in the morning. A sunrise simulation lamp (usually with an alarm clock) may help our brains to get the idea that morning has arrived – though I realise it takes considerably more than this to nudge some people from a deep sleep.  These lights gently increase light intensity and encourage the production of brain chemicals to help get us moving.  Conversely, reducing morning light (i.e. thick curtains/blinds) in summer months could help prevent early waking.

Cortisol helps us to face the day

Toward dawn, the hormone melatonin (that helps us to sleep) shuts off as another hormone, cortisol, increases. Typically, levels of the hormone cortisol begin to rise several hours before we awaken - then there is a sharp increase around 30-40 minutes before we awake.  This is to help us get going and face the day. Lower amounts of cortisol are released periodically throughout the day to help keep us active.

Additional cortisol is released during the day to help us respond to stress, tensions, conflict and trauma.  But if these problems continue over time (and/or are exceptionally severe) cortisol levels may either remain at a high level, fall to a low level (hypocortisolism), and/or fail to rise and fall naturally.  These changes directly affect our ability to sleep. In fact, becoming alert at around 10pm when we might be winding down and thinking about sleep can be due to high cortisol at that time.  Perhaps you recognise this.

As high levels of cortisol in the blood can cause insomnia, it may be helpful to identify circumstances that can raise cortisol levels, such as: ongoing high levels of anxiety and stress (including work related stress), emotional distress, mild hypercortisolism (a rise in cortisol) during the last trimester of pregnancy 2, lack of sleep, caffeine (as this stimulates a huge increase in cortisol), alcohol, some antidepressants, traumatic memories, childhood adversity.

Beware of that late evening wake-up!

Sometimes feel tired in the evening and then around 10pm get a second wind and start to get alert? I get like this at times and can work until the early hours – but it does affect my sleep over the next few days.  Unless I have a deadline to reach, I really don’t think it’s a good idea and easily changes the sleep routine.

Does alcohol assist or hinder sleep?

Some people swear by their favourite evening tipple.  It is true that alcohol has sedative qualities and can help put us to sleep - but as the alcohol level in our blood falls, people are prone to wake up.  This could mean waking up after just a few hours sleep (depending on how much has been drunk).  Furthermore, alcohol is known to interfere with the quality of sleep.

Caffeine hinders sleep

Caffeine is a stimulant (raising cortisol levels in the body) and is contained in coffee, high energy drinks, colas, tea, chocolate, some medications (including a number of painkillers), some chewing gums, some weight loss pills, some cough and cold remedies etc.  Fresh ground coffee usually contains more caffeine than instant coffee and plain chocolate more than milk chocolate. Decaffeinated coffee does contain caffeine, but at a lower level. 

People metabolise caffeine at different rates and there are numerous variables.  This means that some people will be more strongly affected by caffeine than others and the stimulant effects will last considerably longer.  Caffeine can affect us much longer than is often realised.  Avoiding caffeine for about 6 hours before going to sleep seems a fair guide even though some people may be fine after 4 or 5 hours.  The stimulant (and therefore sleep-restricting qualities) can last for 2 days or more if taking the antidepressant fluvoxamine (Luvox). 

Nicotine

Although people find smoking relaxing, nicotine is a stimulant with effects similar to those of caffeine.  Smokers who have sleep difficulties may wish to consider this as a possible factor.

What about TVs and PCs in the evening?

It has become usual for many people, including children, to have TVs in bedrooms. How parents ensure youngsters still have adequate sleep when a TV is such a temptation is for parents to decide.  In one sense, watching TV (depending on the subject matter) can be quite relaxing – but I think we need to bear in mind that TV images are very fast flickering images and some people may experience this as brain stimulating and potentially sleep inhibiting. 

Medications

A number of medications can affect sleep. Ritalin (methylphenidate) and other stimulant drugs - widely used to try and suppress lively and distracted children with so-called ADHD - are often implicated with insomnia. 

Some medications, including various painkillers, contain caffeine which is a stimulant/psychoactive drug and may therefore inhibit sleep.

Many (if not all) of the so-called newer SSRI antidepressants (serotonin selective re-uptake inhibitors) can cause insomnia and disturbed sleep.

Some antidepressants also raise noradrenaline (a neurotransmitter and a hormone) levels in the brain. The brain chemical noradrenaline (norepinephrine US) is rather like adrenalin in that levels are raised when we are feeling stressed or threatened.  It is also implicated in our sleep-wake cycle.  Antidepressants that raise noradrenalin levels are known as noradrenalin reuptake inhibitors (SNRIs) and are sometimes prescribed for Chronic Fatigue Syndrome to help reduce pain.  Some commonly used SNRIs are Cymbalta (duloxetine) and Efexor (venlafaxine).  As one of the functions of noradrenaline is to help us remain alert, those taking these and similar drugs may wish to check out with their doctor if these may be a factor for them in reduced sleep.  The tricyclic antidepressants also raise noradrenaline levels.

For those people taking a sedative (such as a benzodiazepine) or a sleeping pill, difficulty sleeping could be accentuated by the body having developed a tolerance to the drug and is producing a paradoxical effect.

Statins have been found to cause major sleep problems in a significant proportion of patients. Research indicates that Simvastatin is particularly associated with insomnia, nightmares and other sleep disorders. More here.

Drug withdrawal

Insomnia and disturbed sleep is associated with the withdrawal of numerous medications – especially with too rapid a withdrawal (depending on the drug).  This applies to most of the psychiatric drugs which are often more addictive (in the sense that they can be extremely difficult to stop taking and withdrawal can bring distressing adverse effects) than acknowledged by many prescribing physicians.

Foods that help or hinder sleep (including herbs)

People sometimes ask if particular foods help us fall asleep.  It is sometimes suggested that foods that contain the amino acid tryptophan can help us fall asleep. Tryptophan is converted by the body into serotonin and also melatonin.  It makes sense to eat some carbohydrate a while before eating foods containing tryptophan as carbohydrate is necessary to help transport the tryptophan – and carbohydrates take longer to metabolise.  I will leave you to do an internet hunt for foods that might help with sleep.  You will find all sorts of suggestions including: a bowl of cereal and milk, yogurt and crackers, bread and cheese, a lettuce sandwich, kiwi fruits, bananas, milk, almonds, cherries, oats … Not all at once I might add! Do they really help? I’ll leave you to decide.

Tyramine (derived from tyrosine) is an amino acid found in some foods such as dried sausages like pepperoni, salami, bacon, smoked meats, aged and mature cheeses, Marmite, soy sauce, some beers and some red wines (in particular chianti-type wines).  Tyramine/tyrosine stimulates the release of adrenalin (epinephrine US) and also noradrenaline – so this could be yet another sleep disturber for some people if taken as part of an evening snack.

A high sugar diet (and high in refined carbohydrates too) can lead to energy and mood fluctuations. Clearly spiked blood sugar levels are not conducive to rest and sleep. A person with ongoing sleep problems who has a high sugar and high refined carbohydrate (including white flour in bread, pastries and pasta) diet may wish to take professional dietary advice to help balance blood sugar levels.

Many people find that camomile (tea) helps them relax and fall asleep. A study 12 on rats showed that it had an effect similar to benzodiazepines (like valium) in helping them fall asleep. I think it helps people too!

Children and sleep

Routines are very important in a child’s life and I respect that families develop their own ways of settling children down for sleep. If the parent is relaxed and calm the child is also more likely to be able to settle down for sleep.  In evolutionary terms, it is very recent that young children and babies are not with close their mother while sleeping. The personal bedroom is a relatively modern idea. With this in mind it seems to me most natural for a youngster to find it difficult to settle alone at night and to cry when waking in the night. 

Beware, drug companies have a vested interest in convincing us we have sleep problems

Drug companies are keen to promote the idea that many of us have sleep problems and extending the boundaries of what is and is not problem sleep is big business. Drug companies invest heavily into studies that have serious conflicts of interest and which ultimately promote their wares.

References - Bibliography - Further reading

1 Kripke, D. et al. (2011) Mortality related to actigraphic long and short sleep. Sleep Med. Jan;12(1):28-33. Abstract here.

2 Chrousos, G. (1995) The hypothalamic-pituitary-adrenal axis and immune-mediated inflammation. Seminars in medicine of the Beth Israel Hospital, Boston Vol. 332 No. 20 1995 p. 1359

3 Kripke, D. (Revised Feb 2012) The Dark Side of Sleeping Pills. Available here.

4 Kripke, D. et al. (2012) Hypnotics' association with mortality or cancer: a matched cohort study. BMJ Open 2012;2:e000850  doi:10.1136/bmjopen-2012-000850

5 Kripke, D. (2007) Greater incidence of depression with hypnotic use than with placebo. BMC Psychiatry 2007, 7:42. Available here.

6 Kripke, D. (Revised Feb 2012) The Dark Side of Sleeping Pills. Chapter 6available here.

7 The Guardian 20 August 2012 here.

8 Kripke, D. (2004) Chronic hypnotic use: deadly risks, doubtful benefit. Sleep Med Rev. 2000 Feb;4(1):5-20. Abstract here.

9 BMJ (1982) Effect of two hypnotic drugs on actual driving performance next morning. Br Med J (Clin Res Ed) 1982;285:852. Available here.

10 Streeter, C. et al. (2012) Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Medical Hypotheses Volume 78, Issue 5 , Pages 571-579. Abstract here.

11 Science Daily. March 06 2012. Yoga Helps Ease Stress Related Medical and Psychological Conditions, Study Suggests. Available here.

12 Shinomiya, K. et al. (2005) Hypnotic activities of chamomile and passiflora extracts in sleep-disturbed rats. Biol Pharm Bull. 2005 May;28(5):808-10. Abstract here.