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SLEEP PROBLEMS
Introduction
Sleep is normal, something taken for granted most of the time, However, lack
of sleep, or insomnia, is a common and distressing symptom and often leads
people to consult their doctor. It may be due to ordinary, everyday causes, or
it may be a symptom of more serious underlying problems.
This article describes the common problems that people have with sleeping.
It gives simple guidelines as to how to improve sleep, and also advice as to
when to seek professional help in dealing with poor sleep.
Sleep patterns
While sleeping, we are not aware of the world around us. However, a lot of
things happen during sleep that are essential for good health. We sleep in
different ways at different times of the night. One of the most important of
these types of sleep is called Rapid Eye Movement (REM) sleep. It comes and
goes throughout the night, and takes up about one-fifth of our sleep time.
During REM sleep, the brain is particularly active, the eyes move quickly from
side to side, and we dream.
During the other type of sleep (non-REM sleep), the brain is inactive, but
there is a great deal of bodily activity. Hormones are released into the
bloodstream, and the body tissues are repaired after the wear and tear of the
previous day.
Sleep requirement
This depends mainly on age, but varies a lot between people of the same age.
Babies sleep for about 17 hours a day, but this reduces to 9 or 10 hours per
day for older children. Most adults need between 7 and 8 hours sleep each
night, less as they get older. There is a lot of difference between
individuals, and some people can manage on only three hours a night. The
elderly need less sleep and so often find their sleep at night is broken,
particularly if they take naps during the daytime.
Lack of sleep
No-one has died through lack of sleep. The occasional night without sleep
has very little effect on either physical or mental health. However, after
several sleepless nights, people find themselves dropping off to sleep during
the day. They find it more difficult to make decisions, and their mood may be
affected. This can be extremely dangerous if somebody is operating heavy
machinery or driving. Many deaths each year are caused by people falling asleep
at the wheel on motorways.
Sleep problems
Insomnia
People often complain that they are not getting enough sleep, or that their
sleep is not satisfying. Quite often, people actually sleep much more than they
imagine, short periods of being awake feeling much longer than they really are.
Sleeping too little is most commonly due to simple things that can be sorted
out without going to see a doctor (e.g. too much noise, uncomfortable
temperature or bed, irregular routines, or too little physical activity).
Eating too much may make it difficult to get off to sleep, eating too little
may lead to early waking. Cigarettes, alcohol, and drinks containing caffeine,
such as tea or coffee, also disturb sleep. Sleep is also affected by pain or a
high temperature.
However, if lack of sleep continues, it may be due to emotional problems,
difficulties in everyday life, or sometimes more serious psychological
problems. People with severe anxiety find it very difficult to get off to
sleep. In severe depression, people may wake early, or even in the middle of
the night, and then be unable to get back to sleep.
Drugs
Sleeping tablets have been used for many years, but we now know that they
are not a permanent answer. They tend to cause tiredness and irritability the
next day, and lose their effect quite quickly, so that people take increasing
doses, which may lead to addiction. The only place for sleeping tablets is
their use for short periods when someone is so distressed they cannot sleep.
Alcohol has similar effects to sleeping tablets and tranquillisers, and so
should be avoided. Slimming tablets make it hard to sleep, as do "street
drugs" like Ecstacy and amphetamines.
Self-help
The following are simple tips to help get a good night's rest:
- do not go without sleep for a long time; keep to a regular pattern of going
to sleep and waking up at the same time every day, whether tired or not
- make sure that the bed and bedroom are comfortable (not too hot, not too
cold, not too noisy)
- take moderate amounts of exercise (e.g. swimming or walking)
- cut down, or stop, drinking tea or coffee in the evening; try a milky drink
before going to bed
- do not drink a lot of alcohol; it may help to fall asleep, but will almost
certainly cause interrupted sleep through the night
- do not eat or drink a lot late at night; try to have the evening meal early
rather than late
- after a bad night, resist the temptation to sleep the next day; it will
make it harder to go to sleep the following night
- try to relax properly before going to bed; your doctor may be able to
recommend a helpful relaxation tape
- if troubled by something that cannot be immediately resolved, write it down
before going to bed and deal with it the next day
- if unable to sleep, do not lie in bed worrying about it; get up and do
something relaxing (e.g. reading, watching television, listening to quiet
music); after a while you should feel tired enough to go to bed again
If none of these approaches help, it may be necessary to see your doctor for
advice - either to talk over any problems that may be stopping you from
sleeping, or to ensure that the lack of sleep is not caused by a physical
illness, prescribed medicine, or emotional problem.
Irregular sleep
Sometimes we have to stay awake when we would normally be asleep. If it
happens occasionally, we adjust quite easily. However, it is more difficult
when this disturbance of our sleep pattern continues (e.g. shift workers or
doctors working all night, nursing mothers). Such people often find themselves
sleeping at times when they ought to be awake. This is similar to jet lag,
where rapid travel between time zones means that you are awake when everybody
else is asleep.
A good way to readjust is to ensure that you wake at the same time every
morning, relatively early, with the help of an alarm, no matter what time you
have fallen asleep the previous night. You should not go to bed again before
about ten o'clock the next night, and will soon start to fall asleep naturally
at the right time.
Excessive sleep
Some people find that they fall asleep during the day despite wanting to
stay awake. The most common reason is lack of sleep at night. Some people fall
asleep as a way of escaping from the pressures of day to day life. However, if
this continues, it may be caused by a physical illness such as diabetes, viral
infections, or thyroid problems.
There are also two unusual conditions which make people sleep too much, as
outlined below.
Narcolepsy
This consists of sudden, uncontrollable attacks of sleepiness during the
day, sometimes in public. There is a sensation of not being able to move one's
body, and the sufferer may see or hear strange things as they are falling
asleep. Narcolepsy may sometimes be associated with sudden collapses due to
loss of muscle strength when the sufferer is angry, laughing, or excited.
Sleep apnoea
Loud snoring may be more of a problem for the person sharing the bed than
for the person snoring. However, sleep apnoea is a potentially serious
condition in which the loud snoring is associated with stopping breathing for
short periods of time during the night. Every time this happens, the person
wakes briefly, and understandably feels tired the following day. It is more
common in those who are overweight, and with increasing age.
Other sleep problems
Sleepwalking and night terrors
In this condition, a person apparently wakes from the deepest stage of sleep
and then does some quite complicated things (e.g. walking around or going up
and down stairs). This may land the individual in embarrassing (and
occasionally dangerous) situations. Unless woken at the time, the person
remembers nothing about it the next day.
Such episodes may be heralded by night terrors. In these, the individual
appears only half awake, is obviously frightened, but does not experience the
vivid ideas that characterise nightmares. Night terrors can also occur on their
own, without leading to sleep walking.
Guide sleepwalkers gently back to bed and do not wake them up. It may be
necessary to take precautions to protect the sleepwalker or others from injury
(e.g. locking doors and windows, and locking away any sharp objects like
tools). People with night terrors on their own often settle down to sleep again
without fully waking. Both these conditions are more common in children, but
about 1 in 20 adults experience night terrors at some stage, and 1 in 100
report sleepwalking.
Nightmares
Most of us have had frightening dreams or nightmares. They take place
usually during the later part of the night, when we have our most vivid and
memorable dreams. They do not normally cause problems unless they occur
regularly, which usually reflects emotional difficulties. Nightmares often
follow a traumatic event such as a bereavement, a disaster, or a violent
attack. Counselling may help.
Restless legs
Some people move around a lot while they sleep, and may jerk their legs to
such an extent that they stop their partner from sleeping. The simplest
solution is to put two single beds together instead of using a double.
Childhood sleeping problems
Most parents have had problems settling young children at night. If parents
get very tired themselves, they can find it hard to look after their child as
well as they would wish. Hence it is important that parents help young children
to learn how to sleep well.
During the first few months, most parents have to get up more than once
during the night. Young babies sleep and wake throughout the day and night.
Slowly, they learn the difference, and begin to do most of their sleeping at
night. Parents can help by getting into a regular daily routine for settling
their baby down to sleep. Babies settle more easily if they are put to sleep in
a quiet, darkened room which is warm and comfortable. Often they get drowsy
after a good feed, but will wake if they are windy, hungry, in pain or wet.
After the age of nine months, babies are able to keep themselves awake, so
this is a common time for sleep problems to start. Parents find that their
babies are often more wakeful if they are excited, over-tired or anxious.
Problems may follow a break in routine, such as a holiday. At this age it is
very common for babies to feel panic-stricken at being left suddenly alone at
night. Again, parents can help by having an organised bedtime routine, and by
going through exactly the same steps each night. This helps a baby to
understand what is going on, and to settle down gradually and calmly. When you
have said "good night", you can stay next door for a while, leaving
the door slightly open, so that your baby can hear you moving around. At this
age, babies find it comforting and reassuring to have a soft cuddly blanket or
teddy, and a dummy to suck on. Rocking or singing can also be helpful.
If, despite all your efforts to settle and reassure, the baby continues to
cry, do not leave him or her alone. This only reinforces the feelings of
abandonment and panic. It is important for babies to know that you are still
within reach if they need you. Pop in from time to time to calm and soothe, but
do not pick babies up, or they will get the idea that if they scream long
enough you will eventually give in and pick them up.
At least half the children between one and two years old make a terrible
fuss about going to bed. Some parents try to leave their toddler to cry, only
to give up in desperation after they have endured hours of screaming. Others
abandon the idea of sticking to a regular bedtime altogether. There is a middle
way that does not leave the child feeling abandoned and allows you to keep
control. This involves going through the usual bedtime routine, saying
"good night" and leaving the room. As soon as your child starts to
cry, go back into the room, repeat the last "good night", and leave
again. Do this every five minutes for as long as the crying lasts. But do not
take the child out of bed, and do not stay away for more than five minutes at a
time. It may take as much as a week for this to work, but it is worth it.
Nightmares
Most children occasionally have frightening dreams or nightmares, and
usually just need cuddling and reassurance to help them settle down to sleep
again. Recurring nightmares may be the result of severe stress or emotional
trauma. If your child suffers with nightmares, your family doctor will be able
to put you in touch with a specialist who can help.
Night terrors
Young children sometimes wake up suddenly, apparently in a panic, or in
terrible distress. If you ask, they cannot remember any dream, and do not
remember anything in the morning. Although night terrors seem very dramatic,
they respond to simple comfort and reassurance, and children grow out of them
quite quickly.
Bed-wetting
Most children are dry at night by the age of two, but it is not at all
uncommon for bed-wetting to continue well beyond this. One in ten children are
still wetting their beds at the age of five, and 1 in 50 adults still have this
problem. It often runs in the family and is much more common in boys.
Occasionally, bed-wetting may be a sign of illness, so it is worth asking your
doctor's advice about this.
If your child is healthy and old enough to understand, you may be able to
increase the number of dry nights by praising him after each dry night.
Punishment for wet nights is not helpful, and may actually make the situation
worse. If your child is not dry by the age of 6, you may want to ask the school
nurse or your family doctor for specialist help.
Help
Your health visitor is a fund of expert advice on practical child care. If
your child's sleep is a problem, then the health visitor will probably be able
to help to establish a successful bedtime routine and healthy sleep pattern.
Excellent practical advice is also available in many books on baby and child
care, some of which are listed below. If problems continue, your family doctor
may be able to help, and may suggest referral to a specialist.
Self-help organisations
For information on narcolepsy, send a large stamped addressed envelope
to:
The Narcolepsy Association
South Hall
High Street
Farningham
Kent
DA4 0DE
 01322 863056
Likewise, for information about sleep apnoea, send a large stamped addressed
envelope to:
The British Snoring and Sleep Apnoea Association
The Steps
How Lane
Chipstead
Surrey
CR5 3LT
01737 557997
There are a number of sleep disorder clinics, but referral to these clinics
should be made through your family doctor; patients cannot be self-referred.
Useful books
For more detailed discussion of the issues raised here, refer to:
- "Get A Better Night's Sleep" by Ian Oswald and Kirstine Adam,
published by Optima
- "Why We Sleep", by James Horne, published by Oxford University
Press
- "Sleep Like A Dream The Drug-Free Way", by Rosemary Nichol,
published by Sheldon Press
The leaflet entitled "Baby And Child.. From Birth to Five", by P
Leach, published by Penguin, is one of a series produced by the Royal College
of Psychiatrists entitled "Help is at Hand". The others in the series
are:
- "Anorexia And Bulimia"
- "Anxiety And Phobias"
- "Bereavement"
- "Depression"
- "Surviving Adolescence"
To obtain individual copies of any of the "Help Is At Hand"
leaflets, send a stamped addressed envelope to:
Royal College of Psychiatrists
17 Belgrave Square
London
SW1X 8PG
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