Improving Your Sleep: Understanding the Stages and Benefits - Workshop by Ellie Johnson

1. Help yourself to a better night’s sleep A workshop on sleep Presented by: Ellie Johnson University of Sheffield Counselling Service (Part of the Healthy Campus initiative)

2. Sleep – an introduction • When we sleep well, we wake up feeling refreshed and alert for our daily activities. Sleep affects how we look, feel and perform on a daily basis, and can have a major impact on our overall quality of life. • To get the most out of our sleep, both quantity and quality are important. • If sleep is cut short, the body doesn’t have time to complete all of the phases needed for muscle repair, memory consolidation and release of hormones regulating growth and appetite. • Then we wake up less prepared to concentrate, make decisions, or engage fully in work and social activities.

3. Sleep problems • Sleep problems are very common. • Studies show that at least one third of the population are affected by sleep problems at some point in their lives. • Worrying about getting enough sleep makes things worse. • It is normal to wake briefly every night. How much sleep do we need? • People vary in their need for sleep. • Studies have shown that people range between needing 4 – 10 hours of sleep per night. • The amount of sleep a person needs changes throughout their life depending on age, circumstances and levels of activity.

4. Understanding sleep • Sleep takes place in different stages (at least 5 have been identified) • Broadly speaking, sleep can be divided into REM (Rapid eye movement) and NREM (non rapid eye movement) sleep. • Throughout a typical night, sleep occurs in a cycle that repeats itself about every 90 minutes. • This cycle is: N1 > N2> N3 > N4 > N3 > N2 V REM What role does each state and stage of sleep play? • We sleep in NREM sleep for 75% of the night • As we begin to fall asleep, we enter NREM sleep, which is composed of stages 1 – 4

5. Stages of NREM sleep Stage 1 • Between being awake and falling asleep • Light sleep Stage 2 • Onset of sleep • Becoming disengaged from surroundings • Breathing and heart rate are regular • Body temperature drops (so sleeping in a cool room is helpful) Stages 3 and 4 • Deepest and most restorative sleep • Blood pressure drops • Breathing becomes slower • Muscles are relaxed and blood supply to muscles increases • Tissue growth and repair occurs • Hormones are released • Energy is restored

6. REM sleep • We sleep in REM sleep for 25% of the night • REM sleep first occurs about 90 minutes after falling asleep and recurs about every 90 minutes, getting longer later in the night. REM sleep: • Provides energy to brain and the body • Supports daytime performance • The brain is active and dreams occur • Eyes dart back and forth • Body becomes immobile and relaxed, as muscles are turned off. In addition, levels of the hormone cortisol dip at bed time and increase over the night to promote alertness in the morning.

7. Pattern of NREM and REM sleep over an 8 hour period

8. Sleep problems • Insomnia – basically insomnia is sleeping too little. • Nightmares – may follow a traumatic event or be experienced by people suffering from stress, anxiety or depression. • Sleep walking and night terrors – brief episodes that are often caused by stress or a disturbance in your usual sleep pattern. • Sleep paralysis – the mind waking up briefly before the body does. • Hallucinations – During the period of falling asleep or waking up and may be brought on by a disturbed sleep pattern. • Narcolepsy – falling asleep frequently during the daytime, anywhere and at any time. • Sleep apnoea – may snore very loudly and sometimes stop breathing for short periods throughout the night. • RLS – restless leg syndrome.

9. Insomnia • The most common sleep problem is insomnia. • Common difficulties are: • Getting to sleep • Staying asleep • Waking too early • Poor quality sleep Insomnia can provide valuable clues about your mental health. If you fall asleep easily but wake up a couple of hours later, or sleep only fitfully, it may be a sign of anxiety. But if you wake up between 4am and 6am, it can be a sign of depression. • Pre-conditions of sleep • Broadly speaking, in the brain there are two centres involved in being asleep and awake: • The alertness centre which is dominant when we are awake. • The sleep centre which is dominant when we are asleep.

10. For the sleep centre to dominate over the alertness centre we need: • To be tired • To be calm and relaxed • Our brain should not be active • A quiet environment • A dark environment • To be at the right temperature • To be comfortable External stimuli (such as noise), thinking, worrying etc. will all activate the alertness centre in our brain and prevent us from sleeping.

11. What causes sleep problems? There are a great many reasons why we don’t sleep well. • Medical reasons – might cause disturbed sleep • Pain • Breathing problems such as asthma • Some medications can interfere with your sleep • Needing to go to the toilet in the night • Stress, anxiety and worry • This is one of the most common causes of sleep problems. Anxious thoughts and unresolved problems keep the alertness centre of the brain active. • Depression and low mood • Sleep disturbance is very common when someone is depressed. • Difficulties include getting off to sleep and/or waking up early. • The symptoms of depression are often the same or similar to the symptoms of sleep problems.

12. Surroundings • Our environment can make a big difference to whether we get a good night’s sleep. • Some people can sleep anywhere at anytime but most of us need to right conditions to fall asleep such as quiet, darkness, and the right temperature. • Disrupted sleep routine • If your work involves working shifts that affect the time you go to sleep, then you may have sleep problems to due your waking/sleeping routine being disturbed. • Sleeping pills and alcohol • Long term use can lead to dependency. • Sleeping pills lose their effectiveness when taken regularly. • Both can suppress certain stages of sleep and result in sleep which does not fulfil it’s physiological functions.

13. 5 Areas to exploreLooking at these 5 areas in your life will help you identify any sleep problems and may lead to getting a better night’s sleep. 1. Environment 2. Diet 3. Exercise 4. Thoughts 5. Behaviours

14. 1. Environment • Try and avoid bright lighting during the time before going to bed. • Make your bedroom a comfortable place to be in with a temperature ideally between 18°-22°C. • Cut out noise as much as possible, using earplugs if necessary. • Turn the lights out when you go to bed. • Make the bedroom dark using thick curtains or black-out blinds. • Have a comfortable mattress that is not too soft or too firm. Make sure your pillow/duvet etc are the right ones for you. • Use your bedroom only for sleep and sex (keep ‘”sleep stealers” out of the bedroom – avoid watching TV, using a computer or reading in bed).

15. 2. Diet • Avoid alcoholic beverages – may aid relaxation but disrupt sleep throughout the night and can prevent the deeper stages of sleep from occurring. • Cigarettes – have your last cigarette at least 4 hours before bedtime -smoking last thing at night can keep you awake as nicotine is a stimulant. • Try to finish your main meal at least 2-3 hours before your regular bedtime. • Avoid foods/drinks that contain caffeine or sugar (tea, coffee, coke, energy drinks) in the evening. • Increase good sources of the hormone melatonin. Because it comes from serotonin, which the body makes from tryptophan, eating tryptophan-rich foods will boost your melatonin and in turn help you sleep.

16. Do not go to bed hungry as this may lead to early waking • Try herbal drinks if thirsty. Those containing extracts of plants such as hops, passionflower and valerian are recommended to promote sleep. • Eat a light snack shortly before bed. • For this, avoid foods such as cured meats, mature cheeses, chocolate, pickles, and tomatoes. These contain tyrosine, from which your brain makes the stimulating reurotransmitters dopamine and norepinephrine. • If you suffer from RLS, extra magnesium, the B vitamins vitamin E and iron may help (from wholegrains, nuts, seeds and beans). • Try warm milk, ovaltine or horlicks as milk contains sleep-inducing tryptophan. Other foods rich in tryptophan are bananas, turkey, oats, corn, chicken, tuna, peanut butter, ginger and lettuce.

17. 3. Exercise • Exercise regularly during the day • However, do not exercise strenuously late at night – it is best not to exercise in the 3 hours before bedtime as this stimulates the body. • Just 20 minutes a day of aerobic exercise (a brisk walk, jogging, cycling, swimming dancing etc) can help us feel happier and sleep better. Two 10 minute slots are as good as a 20 minute session. • Regular daily exercise: • May help us get to sleep quicker. • Can increase the amount of sleep that we have per night. • Endorphins are released into our blood and have a positive effect on our mood. • Can increase confidence.

18. 4. Thoughts • Our thoughts and beliefs about sleep impact on our ability to sleep. • Worrying about not sleeping well increases tension in the body, making it less easy to get to sleep. The vicious cycle of worrying about sleep • Not sleeping well • Activation of Beliefs about sleep • I will never get enough sleep • I need 8 hours sleep a night to function well • Negative thoughts relating to the consequences of not sleeping well • I will be too tired to perform well at work tomorrow • I will have a really bad day • Anxiety • Muscles tense, increased heart rate, breathing quickens stomach ache etc.

19. Ways out of the vicious cycle The reason your mind worries is to help you stop making mistakes and to do things better. But sometimes it tries to do it’s job too well and worries too much and we experience unnecessary stress. There are two main ways out of the vicious cycle of negative thoughts. • Challenging our beliefs and thoughts about sleep If we can change our unhelpful and stressful beliefs about sleep, then we are less likely to get anxious when trying to sleep and sleep is more likely to happen. • Relaxation techniques If we can learn how to relax our mind and body, then we are less likely to feel anxious, and we will fall asleep more easily.

20. Common unhelpful beliefs about sleep: • We need 8 hours of sleep a night to function well the next day. • People’s sleep needs vary from needing 4 – 10 hours sleep a night. • The amount of sleep we need is affected by different factors such as our age, how much exercise we have had and our health. • We need the same amount of sleep every night • We tend to sleep less during the summer months than we do in the winter • Less during hot weather than in cold This is because as a species, we are much more used to a rhythm where the day begins at dawn and ends at dusk, our natural cycle being controlled by the hormone melatonin. This is interrupted by artificial lighting including candles.

21. All daytime impairments are due to inadequate sleep. • It is possible to function well after a bad night’s sleep as you often get more sleep than you think you did. Focusing on how tired you are helps to lower mood and impair concentration. • Everyone else sleeps better than me. • Sleep problems are very common – you are not unusual. • People vary in the amount and type of sleep they need. • Poor sleep will affect my health adversely. • No one has died from getting less than average sleep. • The body does not make up for lost sleep. When you start sleeping well, you don’t have to sleep extra each night to make up for what you have lost.

22. Relaxation • Relaxation helps promote sleep by relaxing the muscles and calming the mind. • Relaxation is a skill that can be learned. • There are many relaxation techniques and it is important to find a method which you enjoy. • Having short times of relaxation during the day will help i.e. going for a short walk, stretching after sitting for a long period, adopting a relaxed posture (drop your shoulders, sit back in your chair, relax parts of the body) and do a breathing relaxation. • Once you can tell the difference between tension and relaxation, you will be able to notice more quickly when you are getting tense. • Deal with your self-talk, particularly when you are ready to go to sleep. Give yourself permission to switch off “Now I am going to switch off – everything can wait till tomorrow!”

23. A few relaxation techniques • Progressive muscle relaxation • Work through the body, tensing and relaxing all the different muscles. Do this lying down. • Breathing • Use the breath as a focus to calm both mind and body. • Creative visualisation • Many people find that mentally imagining or visualising pleasant things is calming. Doing this sends positive messages to the brain. • Focusing on one subject at a time will filter out other distractions. • Use all of your senses and discover how to change your imagery to make it more calming. For example pastel colours, defocused images, and slowed motion are generally more calming. • Music • You can listen to soothing music whilst doing the above techniques. • Meditation • There are many different techniques that are not religious based.

24. 5. Behaviours • We need to try and change some of our unhelpful behaviours in order to break the vicious cycle of sleeping badly. Two things to keep in mind: • Creating patterns and behaviours that are conducive to sleep means that we are more likely to sleep better. • It is important to associate the bedroom with calm, relaxation and sleep. If we associate our bedroom with difficult emotions, frustration and not being able to sleep, this causes anxiety and we go to bed expecting not to sleep. This is a learned pattern called conditioned insomnia. People with conditioned insomnia often sleep better away from home.

25. Creating helpful behaviours • Get up at the same time each morning. • Go to bed when you are feeling tired. • You may need to get up a little early to temporarily deprive yourself of sleep. Then gradually extend the length time you are in bed, once again. (For example, you might begin by getting up 15 minutes earlier every three days – while still going to bed at the same time – until eventually your mind-body “allows you” to get to sleep more quickly at night.) Can take a few weeks. • Don’t have long naps in the daytime or evening. • After a bad night, do have a power nap (5-10 minutes) once or twice a day or a short nap for up to half an hour as these improve cognitive function and can help you get through the day. • Create a relaxing routine and wind down before going to bed. • Don’t do anything that is mentally demanding within 60 minutes of going to bed.

26. Get up if you have not got to sleep after 20-30 minutes. Do something relaxing, boring or repetitive to help you feel sleepy. Then go back to bed again. • Do not reward the body for waking up with food, drink, cigarettes etc. • Decide bed is for nothing other than sleeping (and making love) so avoid eating, watching TV, telephoning, knitting, etc. • Avoid looking at the clock to see what time it is as this could set off anxious thoughts about not sleeping. • Have pen and paper at your bedside to use when thoughts come up that you do not want to forget. • If something is troubling you write it down before going to bed.

27. Problem solving technique • It is helpful to put things on paper when you are either lying in bed thinking about a problem or wake up with a problem going around in your mind. • Go to a different room. • Write down the problem/problems you are thinking about. • Brainstorm all the ways you could solve the problem/problems (don’t be practical at this stage). • Write down any obstacles that might get in the way of the solution and how you might resolve these. • Manage your ‘self talk’ – tell yourself calmly, softly and patiently that you have done all you can for now and will think about it again in the morning. (90% of what we worry about never happens and the 10% that does, we can deal with) • Choose the most helpful solution and write down the steps you will need to take to achieve it. • Negative thinking is just a bad habit . Use positive imagery and affirmations to help yourself feel better. • Relax and wind down until you are feeling sleepy again. Then go back to bed.

28. Allowing sleep to occur • Sleep comes naturally and effortlessly when we mentally and physically switch off. So trying to get to sleep is best approached as a passive process, rather like relaxation. You cannot force or make yourself go to sleep any more than you can force or make yourself relax. When you re-develop the habit of passively allowing sleep to occur, or not to occur, sleep is likely to occur more easily, because you are not mentally or physically striving. • Many of us get the physical-mental balance wrong. We engage in too much mental activity and too little physical exercise and relaxation. When we readdress this balance, the body becomes naturally tired and more ready for sleep. • Think about your daily schedule and the different activities that you do. Is there a balance between focus, concentrated activity and being able to switch off and relax? You may need to take some time to learn the art of winding down, letting go and switching off.

29. Summing up • Sleep problems are very common. • There are many things we can do to improve our sleep. Not everything will work for you. • Think about the things you have learned today and what applies to you. Which areas could you focus on to help improve your sleep? • Is your bedroom a good sleeping environment? • Check your diet – could any changes be helpful? • Are you getting enough physical exercise? • Any emotional or physical problems that might affect your sleep? Check them out with your GP. • Is worry or tension keeping you awake? Check out unhelpful beliefs and try relaxation techniques. • Are there unhelpful behaviours that you could modify? • Don’t overwhelm yourself by trying to make too many changes at once. Try 1 or 2 things at a time and see the effect.

30. Useful books and websites Books • Get a Better Night’s Sleep (Ian Oswald and Kirstine Adam, Optima) • Why We Sleep (James Horne, Oxford University Press) • Sleep Like a Dream the Drug-Free Way (Rosemary Nichol, Sheldon Press) • Sleep Really Well (Paul Caldwell, Robinson) • Seven days to a Perfect Night’s Sleep (Debra Gordon, St Martin’s Paperbacks) • No More Sleepless Nights (Peter Hauri and Shirley Linde, Wiley) CDs • www.innerchange.co.uk – Deep Relaxing Sleep by Kathy Stephenson • The Ultimate Guide to Relaxing Sleep Every Night by Glenn Harrold Websites • www.britishsleepfoundation.org.uk • www.british-sleep-society.org.uk Breathing Relaxation Podcast (top right of page) • www.shef.ac.uk/counselling/staff