Understanding normal sleep
A normal night’s sleep has three main parts:
- Quiet sleep. This is divided into stages 1-4. Each stage becomes more deep. Quiet sleep is sometimes called deep sleep.
- Rapid eye movement (REM) sleep. REM sleep occurs when the brain is very active, but the body is limp, apart from the eyes which move rapidly. Most dreaming occurs during REM sleep.
- Short periods of waking for 1-2 minutes.
Each night, about 4-5 periods of quiet sleep alternate with 4-5 periods of REM sleep. In addition, several short periods of waking for 1-2 minutes occur about every two hours or so, but occur more frequently towards the end of the night’s sleep.
Normally, one does not remember the times that one wakes if they last less than two minutes. If distracted during the wakeful times (for example, a partner snoring, traffic noise, etc) then the wakeful times tend to last longer, and one is more likely to remember them.
What is insomnia?
Insomnia means poor sleep. About one third of adults do not get as much sleep as they would like. 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.
Poor sleep leads to tiredness in the daytime, reduced concentration, being irritable, or just not able function well.
What is a normal amount of sleep?
Different people need different amounts of sleep. Some people function well and are not tired during the day with just 3-4 hours’ sleep a night. Most people need more than this. To need 6-9 hours per night is average. Most people establish a pattern that is normal for them in their early adult life. However, as one becomes older, it is normal to sleep less. For most people it takes less than thirty minutes to fall asleep.
So, everyone is different. What is important is that the amount of sleep should be sufficient so that one usually feels refreshed and not sleepy during the daytime. Therefore, the strict medical definition of insomnia is … ‘difficulty in getting to sleep, difficulty staying asleep, early wakening, or non-restorative sleep despite adequate time and opportunity to sleep, resulting in impaired daytime functioning, such as poor concentration, mood disturbance, and daytime tiredness’.
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
A person may remember the normal times of being awake in the night and feel that to wake in the night is not normal, and worry about getting back off to sleep. One may clock-watch, and check the time each time woken up. This may make one irritated or anxious and lead to an impression of having a bad night’s sleep, even when the total amount of time asleep was normal.
Poor sleep is often temporary. This may be because of stress, a work or family problem, jet lag, a change of routine, a new baby, a strange bed, etc. Poor sleep in these situations usually improves in time.
Stress, anxiety or depression
It may find it difficult to switch off anxieties about work, home or personal problems. Also, poor sleep is sometimes due to depression. Other symptoms of depression include a low mood, lethargy, poor concentration, tearfulness, and persistent negative thoughts. Depression is common. Treatment of depression or anxiety often cures the poor sleep too.
This sometimes occurs in people who snore, most commonly in obese people. In this condition the large airways narrow or collapse during sleep. This not only causes snoring, but also reduces the amount of oxygen that gets to the lungs. This causes one to wake up to breathe properly. Waking up up many times each night may result in daytime tiredness. Note: most people who snore do not have sleep apnoea, and do sleep well.
Various illnesses keep some people awake. For example, illness causing pain, leg cramps, breathlessness, indigestion, cough, itch, hot flushes, mental health problems, etc.
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 and early morning wakefulness.
- Caffeine – which 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 (from smoking) is a stimulant, and it would help not to smoke.
Street drugs (for example, ecstasy, cocaine, cannabis and amfetamines) can affect sleep.
Some medicines sometimes interfere with sleep. For example, ‘water tablets’ (diuretics), some antidepressants, steroids, beta-blockers, some slimming tablets, painkillers containing caffeine, and some cold remedies. Also, if regular sleeping tablets or other sedative medicines are stopped suddenly, this can cause rebound poor sleep.
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.
What can poor sleep be improved?
Understanding some facts
It is often helpful to understand that short periods of waking each night are normal. Some people are reassured about this and so do not become anxious when they find themselves awake in the night. Also, remember that worry about poor sleep can itself make things worse. Also, it is common to have a few bad nights if you have a period of stress, anxiety or worry. This is often just for a short time and a normal sleep pattern often resumes after a few days.
General tips for sleeping better (often called sleep hygiene)
The following are commonly advised to help promote sleep and are often all that is necessary:
- Reduce caffeine – do not have any food, medicines, or drinks that contain caffeine or other stimulants for six hours before bedtime (see above). Some people have found that cutting out caffeine completely through the day has helped.
- Do not smoke within six hours before bedtime.
- Do not drink alcohol within six hours before bedtime.
- Do not have a heavy meal just before bedtime (although a light snack may be helpful).
- Do not do any strenuous exercise within four hours of bedtime (but exercising earlier in the day is helpful).
- Body rhythms – try to get into a routine of wakefulness during the day, and sleepiness at night. The body becomes used to rhythms or routines. If a regular pattern is followed one is more likely to sleep well. Therefore:
- No matter how tired you are, do not sleep or nap during the day.
- It is best to go to bed only when sleepy-tired in the late evening.
- Switch the light out as soon as you get into bed.
- Always get up at the same time each day, seven days a week, however short the time asleep. Use an alarm to help with this. Resist the temptation to lie in – even after a poor night’s sleep. Do not use weekends to catch up on sleep, as this may upset the natural body rhythm that you have got used to in the week.
Regular daytime exercise can help feel more relaxed and tired at bedtime. This may help one to sleep better. (However, insomniacs one should not do exercise near to bedtime). However, ideally 30 minutes of moderate exercise on five or more days a week should help.
Behavioural and cognitive therapies
If you have severe persistent poor sleep, your doctor may refer you to a psychologist or other health professional for psychological treatments. These are various therapies which help re-train your brain and the way you feel, think or behave.
What about sleeping tablets?
Sleeping tablets are not usually advised
In the past, sleeping tablets were commonly prescribed. However, they have been shown to have problems, and are now not commonly prescribed.
Possible problems with sleeping tablets include:
- Drowsiness the next day. It may not be safe to drive or to operate machinery.
- Clumsiness and confusion in the night if one has to get up. Older people who take sleeping tablets have an increased risk of falling and breaking their hip.
- Tolerance to sleeping tablets may develop if taken regularly. This means that, in time, the usual dose has no effect. A higher dose is needed to help with sleep. In time, the higher dose then has no effect, and so on.
- Some people become dependent (addicted) on sleeping tablets, and have withdrawal symptoms if the tablets are stopped suddenly.
Sometimes a sleeping tablet is advised
If a sleeping tablet is prescribed, it is usually just a short course (a week or so) to get over a particularly bad patch. Sometimes a doctor will advise sleeping tablets to be taken on only two or three nights per week, rather than on every night. This prevents tolerance or dependence to the tablet from developing.