Better Sleep

The following instructions are general and useful in dealing with transient sleep problems due to stress. If you have ongoing sleep problems it is important to consult with a health professional.

1. Sleep only as much as you need. A guide is that you feel refreshed during the following day. Don’t spend extra time in bed (eg “lying in”). Long times in bed can give greater opportunity for weakening the association between bed and sleep. For example lying in bed awake and bored, you may create an association between bed and lying awake bored, instead of may the association you want, bed and sleep. The psychological principle behind this is called stimulus control (Sharma & Andrade, 2012).

Another reason for NOT staying in bed trying to get more sleep is that if you do sleep you may then affect your capacity to sleep later at a normal time in line with a normal sleep pattern. This is consistent with what is known as sleep restriction principles (Spielman et al 1987).

For example if you normally get up at 7 am, but instead on one day have a long sleep in until 10 am. At your normal bed time of 12 pm you probably won’t feel sleepy, and may find yourself awake at 3 am. This is because the normal push for sleep, a lack of sleep, has been shifted by extra sleep. Restricting sleep during the day time helps maintain a good, consolidated pattern of sleep.

2. Get up at the same time each day, 7 days a week, no matter how little you slept (as much as is practical). This is a sleep restriction principle (Spielman et al 1987) and also aimed at better sleep by having a short time to sleep onset. It also has a basis in circadian rhythm (body clock) factors. In addition, it is supported by research in to lifestyle regularity, which has shown there was a significant correlation between higher levels of lifestyle regularity and fewer sleep problems (Monk, Reynolds, Buysse, DeGrazia, & Kupfer, 2003).

3. Exercise regularly. There are a number of studies showing that exercise assists with sleep , no matter what your age (Shapiro et al., 1981), (Brand, Beck, Gerber, Hatzinger, & Holsboer-Trachsler, 2009, 2010), (King, Oman, Brassington, Bliwise, & Haskell, 1997), (Li et al., 2004). It appears that exercise assists with sleep onset, and sleep efficiency. However, as a general rule exercise should NOT be performed within 3 hours of when you intend to go to bed. This is because it can potentially have an effect on arousal and raising core body temperature, which is tied to circadian rhythm factors that effect sleep. In contrast to this general rule there is research that supports that late night exercise in hours proceeding sleep does not disturb sleep quality 3 and that individual who exercise report better sleep regardless of the time that they exercised 4. Considering all of the above the answer to the question of, “when should I exercise”, is try and see what works.

4. Make your bedroom a place to sleep. Stimulus control principles (Sharma & Andrade, 2012) can be applied to help reinforce sleep. Simple changes including

  • A comfortable temperature (Excessively warm or cold sleep environments may disturb sleep).
  • A room free from light. Light is a cue for circadian rhythm (including artificial light).
  • A room free from noise (Noise that does not awaken you may still disturb the quality of your sleep, through creating unnecessary arousal).
  • Closing the door.
  • Being aware that the evening use of light-emitting eReaders has been shown to affect sleep, whereas reading a book has not 2. It might also be important to consider if phones, tv, or other screens are effecting your sleep.

5. Consider what you put into your body, and when.

Eat regular meals and do not go to bed hungry. Hunger may disturb sleep. Avoid greasy or “heavy” foods. A light snack at bedtime (especially carbohydrates and Protein) may help. 1

Avoid excessive liquids in the evening. It minimizes the need for night time trips to the bathroom

Caffeine products (coffee, tea, cola, V, Red Bull, chocolate). Caffeine causes an increase in arousal 5, which interferes with sleep onset, continuity and depth. It must be kept in mind that caffeine is a drug, and the effects of any drug vary between individuals. How caffeine affects an individual depends on many things including their size, weight, health, whether the person has tolerance, and the amount they have taken. Caffeine can also have a diuretic effect, possibly causing night time toilet trips. (Australian Drug Foundation, 2011a). The simplest measure is to stop caffeine use completely, however considering timing of use may also be an option depending on the individual.

The British Nutrition Foundation’s review of the benefits and risks of caffeine on mood, cognitive function, performance and hydration in 2008 concluded that that the range of caffeine intake that appeared to maximise benefit and minimise risk is between 1 to 8 cups of tea per day, or 0.3 to 4 cups of brewed coffee per day (equivalent to 38 to 400 mg per day).

Because tea and coffee can be brewed to different strengths, and products like V, Redbull and others have differing amounts of caffeine it may be advantageous to investigate the strength of what you are consuming as well as the timing of when you consume it.

In conclusion, if you want to consume caffeine, trying and observing what happens may be the way to establish if caffeine is influencing your sleep.

Alcohol , at all dosages, alcohol causes a shorter sleep onset, a more consolidated first half sleep and an increase in sleep disruption in the second half of sleep. (Ebrahim, Shapiro, Williams, & Fenwick, 2013). The second half of sleep is known as deep sleep and thought to be the most restorative. The simple instruction is avoid alcohol, especially in the evening.

Tobacco causes increased alertness and concentration (Australian Drug Foundation, 2011b) and has been shown to affect sleep architecture including a longer onset of sleep and a shift toward lighter stages of sleep. (Zhang, Samet, Caffo, & Punjabi, 2006)

Avoid sleeping pills except in exceptional circumstances, consult with your GP about it. In terms of long term use consider the following.

“Use of hypnotics 30 times per month is associated with a similar mortality hazard to smoking 1–2 packs of cigarettes per day” (p5) (Kripke, 2000). There may also be the risk of becoming dependent on sleeping pills to get you to sleep.

6. Manage your arousal (worry and stimulation). “Don’t take your problems to bed”. Stimulus control principles (Sharma & Andrade, 2012) include managing arousal that occurs through cognitive and relationship stressors. What you think affects your arousal level. Put simply, worrying may interfere with sleep onset and produce shallow sleep. Similarly, watching TV in bed, using laptops, iPads, smart phones and other equipment, may be stimulating and increase arousal. Managing your arousal also includes spending time winding down or relaxing before bed.

7. Do not try to fall asleep. Stimulus control principles indicate that there is too much opportunity for negative conditioning (making the problem worse), by trying to fall asleep. Going to bed when sleepy is the ideal. If you awaken in the middle of the night, once you realise you are awake (for 15 mins) get up, leave the bedroom, and do something different like reading a book. Don’t engage in stimulating activity. Don’t have lots of bright lights on (moderately bright light has been shown to shift circadian rhythm (Boivin, Duffy, Kronauer, & Czeisler, 1994; Wright, Hughes, Kronauer, Dijk, & Czeisler, 2001), and return to bed only when you are sleepy.

8. Don’t lie awake watching the clock. Put the clock under the bed or turn it so that you can’t see it. Clock watching may lead to increased arousal and experiences such as frustration, anger, and worry which interfere with sleep.

9. Avoid naps (generally). Staying awake during the day helps you to fall asleep at night. This is managing your normal drive for sleep, less sleep creates the drive for sleep. If you nap it makes it harder for you to fall asleep later in the day(Perlis et al., 2005), (Milner & Belicki, 2010). If Napping is hard to avoid or you have found it useful in the past, you can consider short naps of 20-30 minutes. However, avoid long naps, especially later than 3 pm as these are likely to affect your later attempts at sleep.

Insomnia

Reading this because you are not sleeping, having difficulty getting to sleep or back to sleep? Here are some ideas of managing transient insomnia. If your insomnia is ongoing for more than 3 nights per week for more than three weeks you should consult a health professional.

Some general ideas to follow to get back to sleep

Lie down only when sleepy and intending to go to sleep. Being sleepy is different to being fatigued (it is possible to be “tired and wired”). When you feel sleepy you yawn, your eyes want to close. This is different from being fatigued.

No other behaviour in the bedroom other than sleep and sex, eg don’t get up and study in your room.

If you lay in bed and are still awake after fifteen minutes get up Do something quiet like read a magazine, have a cup of warm milk or herbal tea. Avoid stimulating activities and stimulants. Avoid turning all the lights on, use low lighting.

Go back to bed when you are feeling sleepy and try to go to sleep again. IF you are worried about not getting enough sleep remind yourself that more sleep is lost through worrying and only prolonged sleep disturbance is unhealthy. If you are still awake after 15 minutes, get up again and repeat the process (Perlis et al., 2005).

Myths surrounding sleep include the following: 6, 7

  • We all need 8 hours sleep.
  • Waking up during the night and light sleep is abnormal.
  • Successful people don’t need much sleep.
  • Early risers are hardworking and diligent/The early bird catches the worm/An hour before midnight is worth 2 after.
  • Naps are only for the lazy, babies, the sick or the elderly.
  • Insomnia must be a symptom of depression and people who wake in the early morning must have anxiety.
  • Research does not support any of these myths.

    Useful links

    Harvard school of medicine interactive explanation of Circadian Rhythm and sleep.

    References

    1 http://sleepfoundation.org/sleep-topics/food-and-sleep

    2 http://www.pnas.org/content/112/4/1232.full.pdf+html

    3 http://www.ncbi.nlm.nih.gov/pubmed/20673290

    4 http://sleepfoundation.org/sites/default/files/RPT336%20Summary%20of%20Findings%2002%2020%202013.pdf

    5 http://www.ncbi.nlm.nih.gov/pubmed/9586865

    6 http://www.webmd.com/sleep-disorders/features/7-myths-about-sleep

    7 http://psychcentral.com/lib/do-you-believe-these-10-sleep-myths/0006569

    Australian Drug Foundation. (2011a). Retrieved 21st May, 2013, from http://www.druginfo.adf.org.au/drug-facts/caffeine

    Australian Drug Foundation. (2011b). Tobacco facts Retrieved 21st May, 2013, from http://www.druginfo.adf.org.au/drug-facts/tobacco

    Boivin, D. B., Duffy, J. F., Kronauer, R. E., & Czeisler, C. A. (1994). Sensitivity of the human circadian pacemaker to moderately bright light. [Comparative Study Research Support, Non-U.S. Gov't Research Support, U.S. Gov't, Non-P.H.S. Research Support, U.S. Gov't, P.H.S.]. J Biol Rhythms, 9(3-4), 315-331.

    Borbely, A. A., & Achermann, P. (2005). Sleep Homeostasis and Models of Sleep Regulation. In Meir H. Kryger, T. Roth & William C. Dement (Eds.), Principles and practice of sleep medicine (4th ed.). Philadelphia, PA: Elsevier/Saunders

    Brand, S., Beck, J., Gerber, M., Hatzinger, M., & Holsboer-Trachsler, E. (2009). 'Football is good for your sleep': favorable sleep patterns and psychological functioning of adolescent male intense football players compared to controls. [Research Support, Non-U.S. Gov't]. J Health Psychol, 14(8), 1144-1155. doi: 10.1177/1359105309342602

    Ebrahim, I. O., Shapiro, C. M., Williams, A. J., & Fenwick, P. B. (2013). Alcohol and sleep I: effects on normal sleep. Alcohol Clin Exp Res, 37(4), 539-549. doi: 10.1111/acer.12006

    King, A. C., Oman, R. F., Brassington, G. S., Bliwise, D. L., & Haskell, W. L. (1997). Moderate-intensity exercise and self-rated quality of sleep in older adults. A randomized controlled trial. [Clinical Trial Randomized Controlled Trial Research Support, Non-U.S. Gov't Research Support, U.S. Gov't, P.H.S.]. JAMA, 277(1), 32-37.

    Krakow, Barry, & Zadra, Antonio. (2006). Clinical management of chronic nightmares: imagery rehearsal therapy. Behavioral Sleep Medicine, 4(1), 45-70.

    Kripke, D. F. (2000). Chronic hypnotic use: deadly risks, doubtful benefit. SLEEP MEDICINE REVIEWS, 4(1), 5-20.

    Kripke, D. F., Garfinkel, L., Wingard, D. L., Klauber, M. R., & Marler, M. R. (2002). Mortality associated with sleep duration and insomnia. Archives Of General Psychiatry, 59(2), 131-136.

    Kryger, Meir H., Roth, T., & Dement, William C. (2005). Principles and practice of sleep medicine / [edited by] Meir H. Kryger, Thomas Roth, William C. Dement: Philadelphia, PA : Elsevier/Saunders, c2005. 4th ed.

    Li, F., Fisher, K. J., Harmer, P., Irbe, D., Tearse, R. G., & Weimer, C. (2004). Tai chi and self-rated quality of sleep and daytime sleepiness in older adults: a randomized controlled trial. [Clinical Trial Randomized Controlled Trial Research Support, U.S. Gov't, P.H.S.]. J Am Geriatr Soc, 52(6), 892-900. doi: 10.1111/j.1532-5415.2004.52255.x

    Milner, Catherine E., & Belicki, Kathryn. (2010). Assessment and Treatment of Insomnia in Adults: A Guide for Clinicians. [Article]. Journal of Counseling & Development, 88(2), 236.

    Monk, Timothy H., Reynolds, Charles F., Buysse, Daniel J., DeGrazia, Jean M., & Kupfer, David J. (2003). The Relationship Between Lifestyle Regularity and Subjective Sleep Quality. Chronobiology International, 20(1), 97-107. doi: doi:10.1081/CBI-120017812

    Perlis, M.L., Smith, M.T., Benson-Jungquist, C. , & Posner, D.A. (2005). Cognitive Behavioral Treatment of Insomnia A Session-by-Session Guide. New York: Springer.

    Ruxton, C. H. S. (2008). The impact of caffeine on mood, cognitive function, performance and hydration: a review of benefits and risks. Nutrition Bulletin, 33(1), 15-25. doi: 10.1111/j.1467-3010.2007.00665.x

    Sleep Health Foundation. (2011). Ten Tips for a Good Night’s Sleep. Retrieved from www.sleephealthfoundation.org.au website: http://www.sleephealthfoundation.org.au/files/pdfs/facts/Tips%20for%20a%20Good%20Night%27s%20Sleep.pdf

    Shapiro, C. M., Bortz, R., Mitchell, D., Bartel, P., & Jooste, P. (1981). Slow-wave sleep: a recovery period after exercise. [Research Support, Non-U.S. Gov't]. Science, 214(4526), 1253-1254.

    Sharma, Mahendra P., & Andrade, Chittaranjan. (2012). Behavioral interventions for insomnia: Theory and practice. [Article]. Indian Journal of Psychiatry, 54(4), 359-366. doi: 10.4103/0019-5545.104825

    Spielman, A. J., Saskin, P., & Thorpy, M. J. (1987). Treatment of chronic insomnia by restriction of time in bed. Sleep, 10(1), 45-56.

    Wright, K. P., Jr., Hughes, R. J., Kronauer, R. E., Dijk, D. J., & Czeisler, C. A. (2001). Intrinsic near-24-h pacemaker period determines limits of circadian entrainment to a weak synchronizer in humans. [Research Support, Non-U.S. Gov't Research Support, U.S. Gov't, Non-P.H.S. Research Support, U.S. Gov't, P.H.S.]. Proc Natl Acad Sci U S A, 98(24), 14027-14032. doi: 10.1073/pnas.201530198

    Zhang, L., Samet, J., Caffo, B., & Punjabi, N. M. (2006). Cigarette smoking and nocturnal sleep architecture. [Multicenter Study Research Support, N.I.H., Extramural]. Am J Epidemiol, 164(6), 529-537. doi: 10.1093/aje/kwj231