For this World Sleep Day Journal special, we’re going to be discussing insomnia. Insomnia is a very common and debilitating sleep disorder which can mean you either struggle to fall asleep, find it difficult to stay asleep, or cause you to wake up early and not be able to get back to sleep. I would be remiss to not mention that - rather ironically - I’m feeling a little out of sorts today having suffered with middle of the night insomnia myself last night. After being awoken by the dog at 4am, I did that classic thing of allowing my to-do list to whir around my brain like a never-ending merry-go-round. You know that it’s pointless to keep spinning the thoughts around and around your head during the middle of the night when you can’t act upon them, but your brain tricks you into thinking that if you cover the anxious thought enough times somehow it will magically disappear by the morning…
We’ve recruited the help of Dr Allie Hare - a consultant in Sleep and Respiratory medicine - to give our community some advice for managing this common sleep disorder. Dr Allie Hare trained in cognitive behavioral therapy for insomnia at the University of Oxford and at Edinburgh and today she is the Secretary of the British Sleep Society. So really, you couldn’t be in better hands! Without further ado, let’s go into Dr Hare’s top five tips:
1. As tempting as it is, don’t stay in bed trying to go to sleep
The harder you try to sleep, the more awake you will become. Spending time in the bed awake (especially if that time involves you becoming anxious, frustrated and angry) only serves to create a vicious cycle of negative associations about bed: over time, you can become conditioned to be anxious and awake in the bed, instead of relaxed and sleepy. Instead, if you feel as though you are not relaxed and about to drop off, get up and do something else entirely for about 30-45 minutes (read a book, listen to music, watch your favourite TV show) and then return to bed. If you still feel wide awake, simply repeat the process. Although for the first few nights, you might feel as though you are out of bed more than you are in it, rest assured that you are extinguishing the learnt pattern that bed = wakefulness, and relearning that bed = sleep.
2. Avoid spending long periods of time in bed, trying to catch up on sleep
It is very common for individuals who are struggling with their sleep to go to bed earlier and/or stay in bed longer in the morning, especially after a couple of bad night’s sleep, trying to catch up on lost sleep. In fact, those of us who manage insomnia always recommend sticking to a fixed time to get out of bed, regardless of how the night has gone. We also recommend avoiding extending the time spent in bed trying to “catch up” on sleep. Generally, this doesn’t actually achieve anything in terms of you feeling much better, but what it does do is reduce your natural drive to sleep, as you lie there dozing in the late morning or early part of the night. As a result, you are less likely to sleep well the following night, and the cycle then repeats itself. Instead, pick the time you need to be out of bed on most days and then stick to that daily. Go to bed only when you are feeling sleepy and avoid extending your time in bed. That way, you are more likely to sleep reliably on a regular basis. As above, this won’t work immediately, so try to stick to a routine for at least 2 weeks, in order to give your body and brain time to adjust.
3. Quieten your busy mind with proven relaxation strategies
“Relaxing” is easier said than done when you can’t switch off and then start to worry about not sleeping. Fortunately, there are proven strategies to help you switch off. Cognitive distraction helps to manage the racing or “busy” mind which can arrive when you are getting to sleep or if you wake up during the night. It is really a more scientific and structured version of counting sheep! The strategies help to “fill your mind up” with something, in order to avoid negative thoughts about sleep or wakefulness becoming intrusive. Cognitive distraction also helps to reduce effortful sleep as it takes your mind away from trying to get to sleep.
Try counting backwards from 1000 in 7s. If you go wrong or get lost, simply start again. Very few people manage to get to zero! Or try a word association version: this is a little like the shopping game children sometimes play at school. Choose a category, for example, animals or types of food, then starting with the letter “A”, name an animal that begins with that letter. So, you might choose “Aardvark”. Aarvark ends in a “K”, so your next animal begins with a “K”. You might then go through: “Kingfisher, Rabbit, Tortoise, Elephant” and so on. An alternate version requires you to name all the animals beginning with the letter “A” that you can, followed by “B”, then “C”. You can use these strategies if you wake in the night or when you cannot fall asleep. If, whilst you are doing a practice, you feel that you are becoming more awake and/or sleep is not going to happen, simply go back to the first tip, get out of bed and do something else for half an hour.
4. Try Mindfulness
When you’re unable to sleep, the natural response is to do whatever you can to immediately fix it. We are conditioned to respond to problems like not sleeping, with action and “doing” something. But paradoxically, in the case of sleep, this effortful struggle to control what is not in fact under your control, can end up being the very reason why sleep continues to be elusive. Persistent efforts to sleep results in anxiety, frustration and worry, leading to emotional, cognitive and bodily tension, all of which results in a physical state that is not at all conducive to restful sleep and creates a vicious cycle which only perpetuates and worsens your insomnia. There is increasing evidence that incorporating mindfulness-based approaches can help improve self-awareness, reduce unhelpful thoughts about sleep, reduce stress and provide the opportunity for healthy sleep to return.
Mindfulness meditation is an approach aiming to enable us to pay attention to the present moment, letting go of preconceptions and judgements and thereby, fostering curiosity, openness and acceptance. It is not about ‘switching off’ the mind, but instead, ‘letting go’ of those things that we can’t change, in order to to develop patience, and bring a fresh perspective to our experiences. In a mindfulness approach to insomnia, thoughts about sleep are allowed to come and go without judgement or criticism. Rather, they’re accepted for what they are: just thoughts and feelings which aren’t right or wrong, but rather, should be welcomed and explored. The mind and body are seen as having the capacity to self-regulate and are trusted to balance the need for sleep if allowed to do so. Patience is cultivated through the understanding that this change in approach will not occur overnight but will take time as new characteristics of the mind are learned. Each night is treated as a separate entity, with no preconceptions or assumptions based on what happened that day or the night before, and labels such as “insomniac” are avoided, since they give the insomnia an unjustified power. There are a variety of online programmes which provide the opportunity to explore mindfulness meditations, but the key is that this approach requires regular practice. It takes time to learn these new attitudes or ways of thinking, and daily practice for 20-30 minutes is required for at least 6 weeks to develop the skill. Initially, practice should take place in the daytime, and then be used at night-time once you feel confident. There is good evidence that the more you practice, the more successful this approach is.
5. Get help!
If you have been struggling for more than a couple of months, despite the above strategies, and your poor sleep is affecting your mental or physical health, or your work, do talk to your doctor. Insomnia is very treatable and in fact, the most effective treatment, Cognitive Behavioural Therapy for Insomnia (CBTI) does not involve any drugs, instead working with your natural biology to help you return to healthy sleep. There are some great online resources for CBTI too: take a look at Sleepio, Sleep Station or Sleepful, if you would like to learn more. In addition, for women, insomnia can often present during the perimenopause or menopause. Whilst CBTI is also effective at this time, hormone therapy in the form of HRT can be effective as well, particularly if hot flashes or night sweats are contributing to poor sleep.
Dr Allie Hare is a consultant in Sleep and Respiratory medicine. She is the Secretary of the British Sleep Society and sits on the Board and Council of the British Thoracic Society, for whom she also chairs the British Education and Training Committee. She graduated from Selwyn College, University of Cambridge in 1999, and undertook postgraduate training at Imperial College London in 2002.
Dr Hare trained in cognitive behavioral therapy for insomnia at the University of Oxford and at Edinburgh. Her advice on sleep has been featured amongst others, in the Guardian, the Telegraph, the Robb Report, the Wall Street Journal, The Sunday Times and on the BBC. She speaks regularly in the corporate world on the importance of sleep for health, wellbeing and work productivity.