Pillow Talk
Getting to grips with sleep & sleep hygiene
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©The Insomnia Clinic 2014
Introduction
There is nothing quite like a good night’s
sleep. In fact, it’s entirely essential to our
health and wellbeing, but sometimes it
can feel easier said than done. And we all
know the impact of losing a night’s sleep.
We get grumpy, we struggle to
concentrate, our reactions slow down and
generally the following day is a bit of a
slog. Some occasional sleep loss triggered by an event or change in
circumstances - is quite normal but when
sleep loss persists, usually for a period of a
month or more, then we would say that
person is suffering with insomnia.
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Insomnia affects a surprisingly large
number of people, in fact around 15 to 30
percent of us can expect to suffer with
insomnia at some point in our lives so you
can take some comfort from the fact that
you are not alone. More comforting still is
the thought that you can begin to help
yourself to a better night’s sleep, and over
the coming weeks we are going to be
working on a step by step, NHS
recommended approach to dealing with
your insomnia. We’ll be looking at the
behaviours that can lead to and worsen
insomnia and explore ways in which you
yourself can take steps to change those
behaviours and take control of your sleep.
©The Insomnia Clinic 2014
The Self-Management Approach
How Does It Work?
Cognitive Behavioural Therapy for
insomnia (CBT-i) is a step by step
programme designed to help you to take
personal control over your insomnia. By
identifying bad habits, understanding why
these habits can lead to a poor night’s
sleep, and through learning new skills that
will help you overcome your bad habits,
you can start to make a positive difference
to your sleep. This is a step-by-step plan
with regular check-in points and activities
to help with your progress.
How Successful is It?
Sadly, there’s no magic wand we can wave
that would suddenly cure your insomnia,
but research shows that this approach to
insomnia has a high success rate with up
to 80% of people who complete this type
of treatment, seeing an improvement,
often within just four weeks. If you speak
with your GP they will be able to reassure
you that CBT for insomnia is indeed the
NHS recommended approach for poor
sleep.
What About My Medication?
If you are suffering with insomnia, then
it’s very likely that you’ve already been
prescribed medication. Medication is very
useful to combat sleep loss in the short
term but is rarely effective as a long term
solution. Scientific studies have shown
that while the effects of medication are
faster, a CBT-i approach can produce
more permanent results. That said, if you
are taking medication then you must
never stop taking prescribed medication
without first consulting your GP.
Time to get down to business! So that we can be better prepared to start tackling your
sleeplessness, let’s first take a more detailed look at how sleep works.
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©The Insomnia Clinic 2014
The Structure of Sleep
Sleep has been a subject of fascination for scientists, philosophers and poets for thousands
of years and although the actual purpose of sleep is still very much up for debate, we do
know that sleep comes in four distinct stages:
Stage One
Ever had that odd falling sensation as you’re dropping off to sleep or kicked your leg out for no reason?
Welcome to stage one of sleep. At this point you’re in the lightest stage of sleep and still reasonably alert.
In fact, if somebody was to wake you during stage one it’s likely you wouldn’t think you were asleep at all.
This stage usually lasts for 5 – 10 minutes.
Stage Two
You are now falling into a true sleep. Your body temperature will drop and your heart rate will begin to
slow. Although you are now asleep it is still a fairly light sleep and you can still be woken easily. This stage
usually lasts for around 20 minutes.
Stages Three & Four
This is now the deepest part of your sleep. Your blood pressure drops, breathing will be slower and you are
much harder to wake. Your body is using this time to repair damaged tissue and release hormones.
Rapid Eye Movement (REM)
This occurs for about 25% of your sleep and is characterised by the rapid movements of the eyes under the
lids. Brain activity is very high and most of your dreaming occurs during this stage. Once REM sleep has
finished we go right back to stage one which is why it’s quite common to wake up, remember a dream and
then pop back off to sleep again.
The full sleep cycle takes around ninety minutes to complete, and in order to experience a
good night’s sleep we need a good mix of light and deep sleep.
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©The Insomnia Clinic 2014
What controls how well we sleep?
How well we are able to fall asleep is determined by four key factors:
Sleep Drive
Body Clock
In order to fall asleep quickly and sleep
well we need a strong ‘sleep drive’. Our
sleep drive works like an appetite, the
longer we haven’t slept for, the bigger
the appetite. So, if we are suffering
from difficulties with our sleep it is often
the case that our drive has become
weak and we are in bed at a time when
our drive is not high enough to sleep
well.
Secondly, we need our body clock to
understand what we want it to do. Just
like with a baby, we need to learn how
to sleep in one go at the right time.
Often, those with poor sleep have
‘unlearnt’ this skill and need to re- set
their body clock to a more suitable
routine.
Automatic Process
Strong Connection
The process of falling asleep is one
which should happen automatically,
without any conscious involvement
from ourselves. Interfering with that
process by actively trying to sleep,
prevents the process from happening.
The harder we try to sleep, the harder it
is to get to sleep.
And finally, to sleep well, we need to
associate our bed with sleep. It sounds
simple, but If you spend a lot of time
awake in bed, your subconscious will
start to associate your bed with other
activities. This will make your mind
more alert at bedtime, and less
prepared for sleep.
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©The Insomnia Clinic 2014
In addition, there are a number of lifestyle and medical factors which contribute to the loss
of sleep. This includes:
AGE
As we get older our sleep shortens and we experience less deep
sleep and more light sleep. This is perfectly normal but it does
make us easier to wake. For those of us that suffer with sleep
problems this can be a bit of a bind as dropping back off can be a
big ask. But hopefully we’re going to help with that!
Too much light, too much noise, feeling too hot or too cold – none
SLEEP
ENVIRONMENT
of these will help you get off to sleep. And as you return to the
lighter stages of sleep, these are the things that will wake you up in
the night as well.
If you’re having a hard time and your brain is working overtime,
STRESS OR
ANXIETY
then it can be pretty difficult to get off to sleep. It’s also just as
likely that your stress and worry can wake you up later during the
lighter stages of sleep.
Some medication comes with side effects which may affect your
MEDICATION
OR OTHER
SUBSTANCES
sleep patterns. If that happens it’s important to talk to your doctor.
You should never change your medication without first consulting
your GP. There are, however, other substances which you may be
taking recreationally that could also have a negative effect on your
sleep. Nicotine, caffeine, alcohol – all of these can affect your sleep.
As we’ve said, a small amount of sleep loss is normal and a bit later in this booklet we’ll be
looking at ways to minimise the impact these factors will have on your sleep. But first let’s
have a look at how we develop insomnia.
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©The Insomnia Clinic 2014
How does insomnia develop?
If a period of sleep loss becomes chronic and persists for a period of at least a month, then it
becomes Insomnia. Insomnia is identified by four key symptoms:
Problems getting
to sleep
Problems staying Waking too early
asleep
in the morning
and being unable
to get back to
sleep
Although we’re all different, research has
shown us that there is a distinct pattern to
how sleep loss becomes chronic and
insomnia develops. That pattern generally
follows three stages:
Firstly, a person may be more prone to
sleep difficulty than others. They may be a
naturally anxious person or struggle to
‘switch off’ at night. These factors would
predispose somebody to insomnia.
There is also usually something that
triggers an episode of insomnia. This
could be a period of emotional stress like
losing a loved one or going through a
divorce. It could be a sudden change in
the environment - for instance a building
site appearing nearby - or it could be as
simple as a cough and cold which disrupts
your sleep pattern. These are all things
that would lead most of us to lose some
sleep but when things don’t return to
normal, it can lead to insomnia.
As a result of the poor sleep, habits and
behaviours develop which are intended to
combat the effects of sleep loss but which
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Not feeling
refreshed in the
morning
end up making the problem worse. For
example, we might start sleeping during
the day, drink more tea or coffee to try
and stay alert or take over the counter
remedies and although these things can
help us in the short term they make it
more difficult to sleep at night as they
interfere with our normal sleep pattern.
We then start to spend more time in bed
in order to get more sleep and may even
try weird and wonderful techniques like
lavender on the pillow, lengthy relaxation
regimes or looking at our phones to kill
the time, all of which will interfere with
our ability to fall asleep. These actions,
intended to overcome the initial
sleeplessness, in actual fact have the
opposite effect, training our bodies not to
fall asleep, developing what we refer to as
Conditioned Insomnia.
The longer this goes on, the worse it
becomes.
©The Insomnia Clinic 2014
The vicious cycle of insomnia
Following the pattern of how insomnia develops and worsens, we can see how easy it is to
fall into a cycle of sleeplessness. And this is why insomnia is often referred to as a ‘Vicious
Cycle’. It is a continuous loop of negative events and it works as follows:
Activity
Think about the bad habits you may have slipped into to try and overcome
your sleeplessness and then fill out the habits section of Worksheet 1 at the
back of this booklet.
This CBT-i programme is aimed at breaking this cycle by overcoming the bad habits. You will
learn techniques and cognitive behavioural practices that help to regain control of your sleep
and we’re going to start by taking a look at your sleep hygiene.
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©The Insomnia Clinic 2014
Sleep hygiene
Just as a good oral hygiene or personal hygiene routine is important if we want to be clean and
healthy, a good sleep hygiene routine is important to getting a good night’s sleep. With good
sleep hygiene we can develop some good habits, overcome some bad ones and begin to break
the vicious cycle of insomnia. Although poor sleep hygiene itself is rarely a cause of insomnia, a
good sleep hygiene routine can be used as a bed for us to build on.
Good habits
Keep your bedroom comfortable.
Your bedroom needs to be well aired and of
a comfortable temperature when you go to
bed. There’s no ideal temperature for
everyone but a cool 16-18˚C with enough
blankets to keep warm is generally best.
Your bedroom should also be clean and tidy
and free from clutter and try to avoid
having your bedroom as a working office
and rather keep it as a place for resting.
Keep your bedroom for sleeping.
Your bedroom should have two uses,
sleeping and sex. Whist you are trying to fix
your sleep problem don’t use it for
watching TV or doing work or eating or
anything else. This will help you to
strengthen the relationship you have
between bed and sleeping. Don’t worry,
this isn’t forever, in time if you want to
watch a film in bed or read that’s no
problem, we just need to re-learn how to
sleep well again first.
Minimise noise and light in the
bedroom.
Both light and noise will limit your sleep
and while you may not be able to resolve
everything there are positive steps you can
take to limit the effect they have on your
sleep. Keep your windows closed if its noisy
outside and put up some blackout curtains
if you feel your room is getting light too
early. If your partner snores, then it’s a
good idea to ask them (nicely) to sleep in a
different room whilst you are trying to fix
your sleep. You will need to use an alarm
clock but try not to use one that ticks, but
at the same time you don’t want a digital
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clock that gives off too much bright light
either.
Make good use of light during the day.
Just as we need darkness to sleep, we need
the light to wake up. Our bodies are
‘programmed’ to use light and dark to tell
us when it’s time to sleep and when it’s
time to be awake so during the day try and
get as much light as you can. This will help
to regulate your natural body clock.
Try to keep regular schedules.
Further down the line we’re going to look at
how to calculate your ideal bedtime but for
now it’s a good idea to start keeping to a
schedule. And not just with bedtime either.
Mealtimes and exercise times and anything
else that you do regularly. This, again, will
help to regulate your body clock.
Screen time
In order to fall asleep our bodies naturally
develop a hormone called melatonin, the
sleepy hormone. Melatonin development is
controlled by light and dark so the blue light
which come from our phones, iPads and
laptops confuse our brains into thinking it is
still daytime which inhibits the development
of melatonin when we need it, making it
harder to drop off and sleep well. Try to keep
away from technology at least one hour
before bed. This new habit will also help your
mind to unwind and get ready to sleep as you
are less likely to see that stressful work email
or get engrossed in a social media debate!
Please note, television is fine as although it is
a blue light it is far enough away from our
eyes to not cause an issue.
©The Insomnia Clinic 2014
Bad habits
Caffeine before bedtime.
Caffeine is a stimulant and it will keep you
awake. If you’re struggling with sleep loss,
then this might feel like a positive during
the day but at night it becomes a problem.
The stimulating effects of caffeine can last
for many hours afterwards, so you should
stop drinking caffeine at least six hours
before bedtime. Caffeine can be useful
during the day if you are struggling to stay
awake and if it gives you the energy boost
you need during this programme of
treatment then go for it but just make
sure you are not drinking it later in the
afternoon/evening.
A little nightcap.
This might seem like a good idea, as the
sedative effect of alcohol may help you
drift off to sleep. Unfortunately, as the
effect wears off the body starts to
experience withdrawal which makes us
restless and can lead to night-time
waking. Try to avoid going to sleep under
the influence of alcohol as it will interfere
in the quality of sleep you do get leading
to greater daytime tiredness.
Smoking before bed.
One last cigarette before bedtime might
also seem like a good idea, especially if
you feel it relaxes you, however nicotine is
a stimulant. Also avoid smoking in the
night time if you are awake as although
this can be a way to pass the time in the
night, your body will get used to this
routine and start to wake up for this
nicotine fix.
Exercising before bedtime.
This also has a stimulant effect and
although it’s useful for overcoming some
of the issues - like stress or depression – It
can make it harder to get off to sleep,
strenuous exercise is best avoided within
2 hours of bedtime.
Big meals at bedtime.
If your body is digesting a big meal, then
it's likely to keep you awake and so it's
best to leave plenty of time between
dinner and bedtime. The general rule is
don’t go to bed too hungry or too full.
There is very little evidence to show that
eating a particular type of food will
improve your sleep, a regular balanced
diet should provide everything you need.
Activity
Using Worksheet 2 complete your sleep hygiene checklist for your own home
and routine, taking note of any bad habits and how you can overcome them.
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The sleep diary
To properly begin the programme, we need to understand more about your own personal
sleep behaviour. Introducing the Sleep Diary. The Sleep Diary will help you monitor your
progress throughout the programme and see how far you’ve come and where your areas of
focus should be. It will also help us to identify any triggers to poor sleep as well as any cycles
or patterns which may be emerging.
Over the next seven days, fill out the sleep diary (Worksheet 3) before continuing reading
the materials. The best time to fill out the diary is when you wake up each day, but please
don’t clock watch when you do this; an estimation is fine.
Summary
So, we've looked at the pattern of sleep and some of the things that cause us to break this
pattern and develop insomnia. You should also have a basic understanding of sleep hygiene
and be able to make any changes necessary with your lifestyle.
In the next session we'll be taking what we've learned already and building on it to try and
overcome some of the bad habits and begin to develop a healthier sleep routine.
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©The Insomnia Clinic 2014
Some basic points to remember:
•
Sleep follows a continuous pattern of light to deep sleep. It is during the light
stages that you are most likely to wake up
•
Sleep disruption is common among adults but when the problem becomes chronic
we develop insomnia
•
Insomnia follows a negative cycle. Breaking that cycle is how we start to overcome
insomnia
•
Poor sleep hygiene is rarely the cause of insomnia but good sleep hygiene can give
us a starting point to begin overcoming the bad habits that keep the cycle going
•
Download your sleep diary and fill in for the next 7 days
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Worksheet 1: Vicious Cycle of Insomnia
Please complete the below diagram with any habits you have picked up to try and combat
the effects of sleeplessness. Some examples might include Sleeping during the day, drinking
excessive amounts of caffeine or spending a long time in bed trying to get to sleep.
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©The Insomnia Clinic 2014
Worksheet 2 – Sleep Hygiene Checklist
Use this sheet to keep on top of your sleep hygiene and identify areas that you may need to
change.
What is the temperature of your bedroom? Is it right for you and comfortable?
Have you removed everything from your bedroom that is not associated with sleeping?
Is the bedroom getting light too early? If so consider black out blinds.
Have you removed as much noise as possible from your room? This includes ticking
clocks, snoring partners and vibrating phones.
Are the windows closed to minimise external noise?
Have you been getting as much light as you can during the day?
Are you keeping the same schedule every day? Are your bedtimes, mealtimes and other
regular activities taking place at around the same time each day?
Are you avoiding caffeine at least 6 hours before bedtime?
Are you cutting back on your alcohol before bed?
Are you avoiding smoking before bedtime and during the night time hours?
Are you avoiding exercise at least 2 hours before bedtime?
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©The Insomnia Clinic 2014
Worksheet 3 – Sleep Diary
Please fill out this diary each morning, beginning on the morning of Day 1.
Day 1
What time did you
go to bed last night?
After settling down,
how long did it take
you to fall asleep?
After falling asleep,
for how long were
you awake in the
night (in total)
At what time did
you wake up this
morning?
How long after
waking did you get
out of bed?
From first going to
bed to getting up
this morning how
long did you spend
in bed?
In total how long did
you sleep for last
night? (In hours)
How would you rate
the quality of your
sleep last night?
1
2
Very Poor
3
10:45pm
Day 2
11:40pm
Day 3
11:30pm
Day 4
12:01am
10 mins
20 mins
30 mins
10 mins
30 mins
15 mins
1h
20 mins
7:15am
7:30am
6am
30 mins
15 mins
8h30m
Day 5
12:50am
Day 6
1:50am
Day 7
11:45pm
15 mins
15 mins
30 mins
1h10m
10 mins
15 mins
7:30am
6:35am
8:55am
6:45am
30 mins
straight away
straight away
15 mins
45 mins
8h
8h
7h30m
5h40m
7h
8h
7h30m
7h30m
6h30m
7h
4h30m
6h30m
6h30m
3
4
2
4
4
2
3
4
5
Very Good
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©The Insomnia Clinic 2014