Sleep Matters The impact of sleep on health and wellbeing Mental Health Awareness Week 2011 - Mental Health Foundation
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Sleep Matters
The impact of sleep
on health and wellbeing
Mental Health
Awareness Week 2011
Address
Mental Health Foundation
Sea Containers House
20 Upper Ground
London SE1 9QB
United Kingdom
Telephone
020 7803 1100
Email
info@mhf.org.uk
Website
www.HowDidYouSleep.org
£10
IBSN 978-1-906162-65-8
Registered charity number
England 801130
Scotland SC039714
© Mental Health Foundation 2011Contents 04 Executive summary
08 Introduction
12 Part 01 – Sleeping and sleep patterns
28 Part 02 – Poor sleep
48 Part 03 – Sleeping well
62 Conclusion
66 Useful resources
68 References
72 Appendix: Sleep diary
76 Acknowledgements
01‘The main facts in human life are five: E. M. Forster
Executive We spend approximately a Poor sleep over a sustained period
leads to a number of problems which
One of the most widely used and
successful therapies is Cognitive
– The new Public Health Outcomes
Framework should include a specific
Summary third of our lives asleep. Sleep
is an essential and involuntary are immediately recognisable, including Behavioural Therapy (CBT). This is outcome on reducing sleep problems
fatigue, sleepiness, poor concentration, useful even for people who have across the whole population.
process, without which we lapses in memory, and irritability. had insomnia for a long period of time. Sleep should also be reflected in
cannot function effectively. A full course of such a therapy with new national mental health outcome
It is as important to our Up to one third of the population may a sleep specialist is potentially costly, indicators, including improving
bodies as eating, drinking suffer from insomnia (lack of sleep and is most appropriate for people sleep for people who experience
and breathing, and is vital for or poor quality sleep). This can affect with severe sleep problems. Still, some significant sleep problems requiring
maintaining good mental and mood, energy and concentration levels, CBT principles can be appropriate specialist help.
our relationships, and our ability to stay and easily practiced for anyone who is
physical health. Sleeping helps awake and function during the day. experiencing a sleepless night. – The National Institute of Health
to repair and restore our brains, and Clinical Excellence (NICE)
not just our bodies. Sleep and health are strongly related, Key points: should develop guidance for the
poor sleep can increase the risk of – Sleeping poorly increases the risk of management of insomnia using
During sleep we can process having poor health, and poor health having poor mental health. In the same non-pharmacological therapies,
information, consolidate memories, can make it harder to sleep. Common way that healthy diet and exercise can to complement existing guidance
and undergo a number of maintenance mental health problems like anxiety help to improve our mental health, on using pharmacological therapies.
processes that help us to function and depression can often underpin so can sleep.
during the daytime. Sleep is crucial sleep problems. Where this is the case, – People with sleep problems should
to the health of individuals within the a combination approach to treating – There is no universal answer to be recognised within the Improving
UK and to the public health of the UK the mental health problem and sleep the question of how much sleep Access to Pyschological Therapies
population. problem in tandem is often the most a person needs. This varies from (IAPT) programme, especially
effective. person to person. What is important regarding access to Cognitive
We all need to make sure we get the is that people find out how much Behavioural Therapy (CBT). IAPT staff
right amount of sleep, and enough It is essential for us to better sleep they need and ensure that should be suitably trained on sleep
good quality sleep. There is no set understand the sleep process in they achieve this. issues.
amount of sleep that is appropriate order to ensure that we get a regular
for everyone; some people need more amount of good quality sleep. Sleepio, – The consequences of poor sleep – Further research should be carried
sleep than others. Our ability to sleep co-founded by Professor Colin Espie, should be taken seriously in out to establish the effectiveness
is controlled by how sleepy we feel and Director of the University of Glasgow healthcare, education, family life, of low cost, non-intrusive CBT-
our sleep pattern. How sleepy we feel Sleep Centre, is a new organisation and society at large. based interventions for sleep
relates to our drive to sleep. The sleep that is dedicated to raising awareness problems, such as self-help books
pattern relates to the regularity and of the importance of sleep. Sleepio We recommend that: and online courses.
timing of our sleep habits; if we have collected data from a large-scale, – The importance and benefits of
got into a pattern of sleeping at set national survey on sleep habits; some sleep for both mental and physical
times then we will be able to establish of these revealing new data appear health should be highlighted in
a better routine, and will find it easier throughout this report. national and local public health
to sleep at that time every day. campaigns, including in schools and
We can all benefit from improving the workplaces. New and easily accessible
Sleep is a more complex process than quality of our sleep. For many of us, it resources should be made available
many people realise, much of it is still may simply be a case of making small advising people on what they can do
a mystery to scientists. During sleep, lifestyle or attitude adjustments in themselves to improve their sleep.
the body goes through a variety of order to help us sleep better. For those
processes and sleep stages. Good with insomnia it is usually necessary – The Royal College of GPs should
quality sleep is likely to be the result to seek more specialist treatment. provide up to date, evidence-based
of spending enough time in all of the Sleep medication is commonly used, training and information for its
stages, including enough deep sleep but may have negative side effects and members on the importance
which helps us feel refreshed. is not recommended in the long-term. and benefits of sleep for physical
Psychological approaches are useful and mental health. GPs should also
for people with long-term insomnia have access to a diagnostic tool for
because they can encourage us use in recognising sleep problems
to establish good sleep patterns, in primary care settings.
and to develop a healthy, positive
mental outlook about sleep, as well
as dealing with worrying thoughts
towards sleeping.
04 05‘Sleep is the best meditation.’ Dalai Lama
Introduction We spend, on average, approximately a third In Part II, we review the literature on sleep problems
of our life asleep. Along with eating, drinking and explain what can happen if we don’t sleep
and breathing, sleeping is one of the pillars for properly. In Part III, we describe ways in which
maintaining good mental and physical health. we can improve our sleep and explain possible
Ultimately, we would die if we did not sleep. treatments for those who find achieving good
quality sleep difficult. The primary focus of this
Despite its obvious importance, sleep remains report is sleep and mental health; both how mental
a mysterious realm that has fascinated us for health can affect our sleep, and how sleep can
thousands of years. For example, in the Greek affect our mental health.
pantheon sleep is represented by the winged god
Hypnos, himself the son of Nyx, goddess of the The report includes primary data from the Great
Night. Closely related to Hypnos were Thanatos British Sleep Survey, developed by Professor Colin
(god of death) and Morpheus (god of dreams). Espie at the University of Glasgow in association
As human beings, most of us cross the bridge with Sleepio Ltd.
between the conscious to the unconscious on at
least a daily basis. Yet, we seldom give a second The survey has been available online from March
thought to the countless physiological and 2010, and aimed to take a snapshot of the UK’s
psychological processes that occur within our sleep habits. By December 2010, there had been
bodies and brains when we are deep in slumber. 6708 responses to the survey. This survey is still
online: you can take part by visiting the Sleepio
The aim of this report is to raise awareness about website, www.sleepio.com.
the importance of sleep and its crucial role for
our health, both physical and mental, just like diet
and exercise. In Part I of this report, we provide
information about sleep, why we need to sleep, and
what happens during sleep.
08 09‘A good laugh and a long sleep are the best cures in the doctor’s book.’ Irish proverb
Sleeping and Sleep Patterns 12 13
What is Sleep? Sleep affects our ability to use
language, sustain attention,
Sleep is often seen as time understand what we are reading,
when the body is inactive. and summarise what we are
In fact, the opposite is true. hearing03. If we compromise on
Sleep is an active, essential our sleep, we compromise on our
and involuntary process, performance, our mood, and our
interpersonal relationships. Sleep
without which we cannot has also been shown to protect
function effectively. Sleep is the immune system04.
not a lifestyle choice; just like
breathing, eating or drinking, Animals have evolved to sleep
it is a necessity. in many different ways. Dolphins
can sleep using only one half of their
Sleep is a complex process during brain at a time. Even hibernating
which our body undertakes a number animals have been shown to
of essential activities. It involves low temporarily cease hibernation, go
awareness of the outside world, relaxed to sleep (a different, active05process),
muscles, and a raised anabolic state then return to hibernation . Sleep
which helps us to build and repair is an inconvenient, time consuming
our bodies. process, but it is so essential that
we have simply evolved to fit it into
Primarily, sleep is for the brain, allowing our lives.
it to recover and regenerate. During
our sleep, the brain can process
information, consolidate memory,
and enable us to learn and function
effectively during daytime01. This is
why we are encouraged to get a good
night’s sleep in the run up to a job
interview or exam rather than staying
awake all night to prepare.
The first part of this report Whilst we sleep, our brain is not
only strengthening memories but
describes the sleep process
it is also reorganising them, picking
out the emotional details and helping
us produce new insights and creative
in detail, providing information
ideas02.
about how and why it is
essential to maintain good
quality sleep throughout our
lives, and on the problems that
can arise during sleep.
14 15How Much Sleep? Sleep Patterns
We all need different amounts of sleep. Equally important as the total amount
Different species of animals require of sleep is the pattern of sleep. Babies
vastly different amounts, as shown in the and small children tend to sleep multiple
estimated average sleep times of several times across each 24 hour period, but
species06: as we mature into school years and into
adulthood we tend to sleep in one long
phase; daytime sleeping decreases and
the person instead tends to sleep
throughout the night.
Table 1 Still, it is important for us to gauge the A mechanism called the circadian It is possible to think of a “master
The sleep needs of various species amount of sleep that we need and to timer regulates the pattern of our clock” which regulates our circadian
ensure that we get the right amount. sleep and waking, and interacts rhythms. This clock is made up of a
Species Average total sleep There is no set amount of sleep that is with the sleep homeostat. Most group of nerve cells in our brain called
time per day (hours) appropriate for everyone. For example, living things have internal circadian the suprachiasmatic nucleus (SCN).
although Margaret Thatcher once said rhythms, meaning they are adapted The SCN controls the production of
Python 18 that she only needed five hours sleep to live in a cycle of day and night. melatonin, which is a hormone that
Tiger 15.8 a night when she was Prime Minister, makes us feel sleepy. During sleep,
Cat 12.1 this would have been unremarkable for The French geophysicist Jean- melatonin levels rise sharply. The
Chimpanzee 9.7 her if she was naturally a short sleeper. Jacques d’Ortous de Mairan was the SCN is located just above our optic
Sheep 3.8 Just as people may need different first to discover circadian rhythms in nerves, which send signals from
African elephant 3.3 size shoes they may need different an experiment with plants in 1729. the eyes to the brain. Therefore, the
Giraffe 1.9 amounts of sleep. It is vitally important Two centuries later, Dr. Nathaniel SCN receives information about the
to find out how much sleep we as Kleitman studied the effect of amount of light in the environment
In humans, the amount of individuals actually need, and to then circadian rhythms on human sleep through our eyes. When there is less
sleep a person needs depends recognise that it may be different from cycles09. These rhythms respond light, such as during night-time, it tells
upon their age. New born babies the amount of sleep that others need. primarily to light and darkness. The the brain to create more melatonin
tend to sleep for an average of cycle is actually slightly longer than (see Figure 1).
16–18 hours per day, which decreases Sleeping less than we need 24 hours10 11.
to about 13–14 hours after one year. as individuals has negative
Adolescents tend to require more consequences. Whilst awake, we
sleep than adults, possibly due to build up a sleep debt which can only Figure 1
the physiological changes that are be repaid through sleeping. This is Diagram of sleep homeostat and circadian timer
happening in the body during this regulated by a mechanism in the body (adapted model from Professor Derk-Jan Dijk,
period. called the sleep homeostat, which Surrey Sleep Research Centre)
controls our drive to sleep. If we have
As the person reaches adulthood they a greater sleep debt, then the sleep
tend to sleep 7–8 hours per day. Older homeostat indicates to us that we Performance whilst awake
adults tend to sleep roughly 6–7 hours need more sleep.
per day07, but take more frequent naps
throughout the day. The amount of In a healthy situation this debt is
time an average adult needs to sleep paid off night by night. However, the
debt can also build up and be repaid
varies from person to person, and can
range between 5 and 11 hours. gradually over a period of weeks or Sleep Wake Cycle
even months, for example, if we under-
sleep for several nights in a row then
we will need to repay the sleep debt in
the near future. Interestingly, for people
with bipolar disorder, the state of mania
Circadian Homeostat
is associated with decreased perceived
need for sleep08. However, despite this
perception, the person is still building
up a sleep debt which needs to be
repaid.
Light-Dark
Cycle
16 17Serotonin is another chemical that Sleep patterns vary greatly, some
affects sleep; produced by the animals are diurnal and tend to sleep
brain, insufficient levels of serotonin during the night time, and others are
are also related to mental health nocturnal and sleep mostly during
problems such as depression and the daytime. Within humans, each
anxiety. Levels of serotonin are person’s circadian timer is set slightly
highest in the brain when we are differently; some people function
awake and active, and the brain best in the mornings (larks), others
produces more serotonin when it best in the evenings (owls), many of
is lighter outside. This is why most us are somewhere in between.
people feel tired at night-time, and
why it is a good idea to turn off the Some people suffer from what is
lights when we are trying to sleep. known as circadian rhythm sleep
The immune system also influences disorder, which is an extreme end of
serotonin, and therefore influences this spectrum, but is often associated
sleep patterns12, which may explain with mental health problems. An
why we need to sleep more if we are extreme ‘owl’ may have delayed
feeling ill. sleep phase syndrome, tending to
fall asleep and wake up very late. An
As humans are mainly daytime extreme ‘lark’ may have advanced
animals, the period we choose to sleep phase syndrome, rising very
sleep is determined naturally by early in the morning but plagued
the level of light in the environment; with sleepiness in the evening. These
principally due to the setting and irregularities can become problems,
rising of the sun. But we can now depending upon what we are trying
manipulate light levels through the to do in life, although for some they
use of artificial lights, which means can prove to be an asset.
that we can continue activities long
into the evenings. People who work Similar effects are commonly seen
nightshifts may wish to reduce the in people whose sleep pattern is
level of light they are exposed to disrupted due to external factors,
during the daytime in order to sleep, such as working regular night shifts
and can do this through the use of (particularly after working regular
blackout curtains. day shifts in the weeks beforehand).
Another example is jetlag which
The story of the Copiapó mining is caused by travel between
accident in Chile in 2010 shows different time zones. Both shift
the importance of light for circadian work disorders and jetlag are very
rhythms. Miners’ sleep-wake common expressions of circadian
Humans are not designed
cycles were completely disrupted rhythm disorders. Humans are not
in the absence of sunlight. The designed to be awake during the
National Aeronautics and Space night and asleep during the day.
to be awake during the night.
Administration (NASA) consultants People who regularly work night
advised the miners to segregate their shifts are thought to be at a greater
space into working, sleeping, and risk of cancer14 and heart disease15.
People who regularly work
recreation areas. International flight crews are also at
elevated risk of cancer, possibly due
They used the lights on their helmets to repeated disruption of circadian
night shifts are thought to be
and the headlights on the mining rhythms.
trucks to create a communal ‘light’
area. The sleeping area was kept Disruption of sleep and circadian
at a greater risk of cancer and
dark, meaning that the miners could rhythms are also documented in
regulate the daylight cycle artificially people who suffer from bipolar
and maintain a regular pattern of disorder, although it is unclear
heart disease.
sleep. This is an extreme example, whether the circadian timer or sleep
but in fact, even moderate changes homeostat is responsible for the
in lighting can affect our internal underlying sleep disturbances16. It
circadian timers .
13
has been suggested that changes
in a person’s circadian rhythms can
act as a trigger for bipolar disorder17,
particularly mania18.
18 19‘The machinery is always going. Even when you sleep.’ Andy Warhol
The stages of sleep
In humans, sleep can be broadly divided
into non-rapid eye movement (non-REM)
sleep and rapid eye movement (REM) sleep.
We typically pass through four stages Non-REM stage one Non-REM stage two
of non-REM sleep before beginning The first of the five sleep stages is a Within a few minutes, the sleeper
REM sleep. In total, non-REM sleep form of light sleep, or non-REM stage may pass into another form of light
accounts for about 75–80% of total one sleep. This stage is essentially sleep known as stage two of non-
sleep in an average adult. the bridge between being awake REM sleep. The sleeper’s breathing
and sleep. pattern and heart rate slow down
This process is cyclical and during a and they become less aware of the
single night we may experience four Sleepers drift in and out of light sleep outside world. Eye movement stops
or five recurring cycles of non-REM and can be awakened easily. During and sleepers’ theta waves become
and REM sleep each lasting between this stage, the person may begin to even slower with the occasional
90–110 minutes. Only recently have breathe more slowly and evenly, the bursts of brain activity every minute
scientists begun to understand brain produces theta waves, which or so; these bursts of activity are
the process, especially since sleep are smaller and lower in frequency sometimes known as sleep spindles.
research has been aided by three than alpha waves. Muscle activity,
measurements: measured by the EMG, shows a Stage two non-REM sleep is also
slowing down of movement and the characterized by a type of brain
01 Brain wave activity using an sleeper may begin to twitch. wave activity known as a K-complex.
electroencephalogram (EEG), A K-complex is a high voltage of
which measures electrical activity
in the brain.
02 Muscle tone through an
These twitches are called hypnic jerks
and sometimes wake the sleeper,
particularly if the jerk is accompanied
The first of the EEG activity with a sharp downward
spike followed by a slower upward
component; it sometimes resembles
electromyogram (EMG).
03 Movement of the eye via
an electro-oculogram (EOG).
by the sensation of falling, which
many people experience from time
to time. Since individuals may have
five sleep stages a mountain. This stage accounts
for the largest part of human sleep
(45–50% of sleep in adults19) and is
Of these three, the EEG is the most
important in helping to differentiate
some knowledge of the world around
them, it is in this stage of sleep that
some people report out-of-body
is a form of light sometimes referred to as true sleep.
Like stage one sleep, stage two is
also considered relatively ‘light’ sleep
between the different sleep stages.
While awake, our brains display a
pattern of brainwaves known as
experiences.
sleep, or non-REM and if sleepers were to be woken up
during either of these stages they
may deny that they had been asleep
beta waves. Beta waves are high
in frequency, meaning they occur in
quick succession, but they are low
stage one sleep. at all.
in amplitude, meaning they are quite
small. This stage is
Whilst we are awake these waves do
not follow a consistent pattern. This
makes sense because when we are
essentially the
awake, our brains are often doing a
number of different tasks, stimulating
the brain in a variety of different ways.
bridge between
When we rest with our eyes closed,
our brain wave activity slows down
and becomes more synchronised,
being awake
these brain waves are known as
alpha waves. and sleep.
22 23Non-REM stages three and four
Stages three and four are typically
Deep sleep is a very refreshing
type of sleep, and it is particularly
Dreaming The part of the brain involved in
emotions, sensations and memories
grouped together as the last stages important in helping the brain Dreams have been a subject becomes more active during REM
of non-REM sleep, also referred to as consolidate what it has learnt during of awe and inspiration for sleep. So the brain may attempt to
synchronised sleep. the day20. If awakened during these thousands of years, appearing make sense of this internal activity
stages, sleepers report feeling in the oldest works of literature, and the result is a dream27. Dreams
For these stages, sleepers pass from groggy and disoriented for several such as Epic of Gilgamesh may therefore be the result of signals
the theta waves of stages one and minutes. Illustration of the sleep (c.2200 B.C.), as well as in generated within our brains.
two to delta waves, the largest and stages is shown in Figure 2.
slowest brain waves. There is no real recent Hollywood blockbusters Another theory28 suggests that
distinction between stage three and Eventually, the sleeper will pass into such as Inception and Shutter dreams may help humans to
four except typically during stage REM sleep. This takes its name from Island (2010). Some people maintain sleep, by keeping the mind
three, sleep is comprised of less than the rapid eye movements that the are better at remembering occupied so that we don’t wake up.
50% delta waves, and in stage four sleeper displays, usually with their dreams than others, but most
more than 50% of the waves are eyes closed, as discovered in 1953 would agree that their dreams It suggests that dreams may
delta waves. Thus these stages are by Nathaniel Kleitman and Eugene entertain the brain so that other
often referred to as slow wave sleep Aserinsky. The frequency of one’s are meaningful to them. Many areas can rest and recover, and
or deep sleep. Sleepers’ breathing rapid eye movements is known people believe that dreams are without this kind of diversion, the
and heart rate are at their lowest as their REM density. a gateway for understanding brain would keep telling us to wake
levels, they breathe rhythmically our feelings, thoughts, up. However, these are merely
and their muscle activity decreases. During this stage, the brainwaves behaviours, motives and values. theories, and the exact reasons
are similar to when we are resting, why we dream are still uncertain.
although our breathing rate and The theoretical link between
blood pressure rise, all our voluntary dreaming and eye movements during What we do know is that dreams
muscles also become paralyzed and sleep was made as far back as in are associated with an abundance
our muscle tone becomes relaxed so 186824, and the explicit connection of a chemical called dopamine
that we cannot move our limbs. This between REM sleep and dreaming in the brain. Dopamine is a
Figure 2 is a relatively shallow stage of sleep; neurotransmitter (a chemical that
Brain waves during the stages of sleep was made almost a century later25.
the average person will have around It is possible that our eyes move transmits signals within the brain)
three to five episodes of REM sleep because we are following the images that helps to direct our attention to
Awake – eyes open/Alpha Waves per night, and the first period is likely important things in our environment.
of the dream in our sleep. Since we
to begin about 70–90 minutes after all experience REM sleep, we all have Both dreams and hallucinations
falling asleep. It is during this stage the potential to experience dreams. involve deregulation of dopamine
of sleep that we experience dreams. Still, the purpose and function production. It is thought that
Awake – eyes closed dreaming may be similar to some
of dreams remains unclear.
The amount of time spent in the of the symptoms of schizophrenia,
different sleep stages appears to There are many theories on the since they appear to have similar
relate to people’s mental health. meaning of dreams. Some scientists neurochemical backgrounds29.
Non-REM – Stage 1/Theta Waves Those who suffer from depression believe they serve no real purpose,
have been shown to have more REM while others believe they are Dreaming and REM sleep are also
sleep, enter this stage earlier, and integral to our mental, emotional, strongly related to major depression,
have increased REM density21. For and physical wellbeing. The most and people who suffer from this
Non-REM – Stage 2
people with schizophrenia, there can well-known theory comes from illness often display more frequent
be a delay in reaching deep sleep the Austrian neurologist Sigmund rapid eye movements than normal
Sleep Spindle K Complex and REM sleep22. Similarly, people - literally, people with depression
Freud who founded the school of
who suffer from anxiety may spend psychoanalytic thought. According dream more15. It actually appears
less time in deep sleep23. However, to Freud, dreams are subconscious as though getting too much REM
this is an area to be explored in future wishes26. He believed that the sleep can increase our vulnerability
research to provide more precise images, thoughts and emotions to depression. Interestingly, many
Non-REM – Stage 3 & 4/Slow Waves and Delta Waves
information. experienced in a dream were antidepressants aim to limit REM
attempts by our unconscious to sleep30.
resolve a conflict in waking life, and
that the process of dreaming allowed One night of sleep deprivation,
for an interaction between the particularly the deprivation of
unconscious and the conscious. REM sleep, may relieve depressive
REM
symptoms in the short term.
However, this cannot be
recommended as a treatment
for depression since individuals
become susceptible to symptoms
again once they have repaid their
sleep debt31 32. More importantly,
the negative consequences of
sleep deprivation can be far more
damaging.
24 25‘Sleeplessness is a desert without vegetation or inhabitants.’ Jessamyn West
Poor Sleep 28 29
Poor sleep relates not only to the total amount A person with insomnia may get
into a habit of sleeping in short shifts
Sleeping poorly increases the risk to
poor mental health, which is often
of sleep, but also to the quality of sleep and throughout the day, which then may neglected when aiming to improve
make it difficult for them to sleep at health and wellbeing. Insomnia is
the amount of time spent awake. Good quality bedtime. The problem with napping inextricably related to mental health.
sleep includes all of the aforementioned sleep like this is that the person only sleeps
for short periods of time. This means
Many of us will have experienced a
sleepless night due to worrying about
stages, with a significant amount of time that they are likely to get lots of light an upcoming event, such as an exam
sleep without ever passing through or a job interview.
spent in deep sleep. all the sleep stages. In particular,
they fail to achieve the essential A prolonged period of stress or
deep sleep necessary for restoration worry can also seriously affect our
of mind and body, and fail to recover ability to sleep. In a sample of roughly
their sleep debt. 20,000 young adults, lack of sufficient
Insomnia Sleep quality is of paramount
importance to our health. People sleep was linked to psychological
Most of us have experienced a who have slept poorly are likely to Sometimes insomnia can be related distress37, and a history of insomnia
sleepless night, which although suffer from fatigue, sleepiness during to physical health problems. Most has been shown to increase the
upsetting, is nothing to worry daytime, poor concentration, irritability, of us will have experienced an risk of developing depression38 39.
memory loss, depression, frustration, illness which has made it harder to Unsurprisingly, anxiety and depression
about since the sleep debt can sleep due to physical discomfort or are also common causes of chronic
be repaid over the course of the and a weakened immune system.
Fatigue – feeling weary and lacking irritation, such as a blocked nose or insomnia40. People who suffer from
next few nights. The inability in energy whilst awake – is the most sore throat. Some chronic conditions, depression may experience sleep
to fall or remain asleep over common problem associated with such as osteoporosis or diabetes, disturbances which disrupt the
a period of several nights is poor sleep. can drastically affect sleep in the long process of falling and staying asleep.
known as insomnia. term. Addressing physical health The sleeper may wake intermittently
This is different to sleepiness because problems could improve sleep quality. throughout the night, or wake early in
People with insomnia have poor quality it doesn’t necessarily increase the It may be possible also to address the the morning and be unable to sleep
sleep, may be unable to get enough likelihood of falling asleep. Signs of sleep problem alongside the health again41.
sleep, and may wake up for long sleepiness include yawning, muscle problem rather than just treating it as a
periods during the night, resulting in ache, and drifting off to sleep. symptom. Furthermore, insomnia is a common
fatigue during the daytime. Insomnia Furthermore, poor sleep can make us complaint in people who suffer
is a psychophysiological disorder, less receptive to positive emotions34 Our mental state is perhaps even more from schizophrenia42, and some
which means that it is a combination which in turn can make us feel important in allowing or preventing schizophrenia medications can
of our thoughts, behaviour, emotions miserable during the day, and may insomnia from developing from an profoundly affect a person’s ability
and physiology. Insomnia can be increase the likelihood of us developing acute into a chronic problem. This to maintain constant sleep43. People
acute (lasting less than a month), or it depression35. refers particularly to our thoughts and visiting sleep disorder clinics with the
may develop into a chronic, long-term attitudes about sleeping. For example, complaint of insomnia often have
condition. Evidence from experiments involving some of us, after suffering several another underlying mental health
rats suggests that in extreme cases, consecutive sleepless nights, may problem44. This type of insomnia is
Essentially, insomnia is associated with sleep deprivation may even be fatal36. become anxious that we have not had more difficult to treat since it involves
arousal of our mind and body. Typically Indeed, there is an extremely rare enough sleep. This type of thought treating the underlying problem as well
people complain of a racing mind genetic disorder called fatal familial process is likely to lead to thinking as the insomnia.
and get into a vicious cycle of poor insomnia, affecting around 100 about the problems associated with
sleep, concerns about poor sleep, and people worldwide. This usually begins not sleeping.
patterns of thoughts and behaviour between the ages of 35 and 60, and
that are unhelpful. This means that leads to death several months later. This can lead to anxious thoughts,
the normal operation of the sleep Poor sleep can also affect the which can then lead a person to see
debt and circadian mechanisms do circadian timing mechanism. Keeping themselves as failing to sleep well.
not work properly. The result of a series an irregular sleep pattern can make These thoughts perpetuate a negative
of sleepless nights can be serious. insomnia worse. People who suffer cycle, making it even more difficult
from insomnia are likely to feel the for the person to sleep. Many of us
Insomnia is by far the most common effects of sleep deprivation throughout may recognise this behaviour if we
sleep complaint in the general the daytime. have watched the clock during the
population. It is a massive public health night. This is a very common activity
problem, and the most commonly It may be tempting to catch up for people who suffer from insomnia,
reported mental health complaint in on sleep by ‘grazing’ at opportune where the clock starts to be used as a
the UK .33 moments across the day, but even gauge to monitor sleep performance.
though this temporarily recoups This pressure to perform in turn makes
a small amount of sleep debt, it more difficult to sleep.
unfortunately it also disrupts the
sleep pattern.
30 31The Great British Some caution should be used when
discussing the results of this survey,
Figure 5
Negative impact of poor sleep on daily life.
People with
Insomnia
Nearly 95% of respondents with
insomnia reported low energy levels
Sleep Survey: new since those who responded were (N=5328)
Good
Sleepers in their daily lives, considerably more
more likely to have taken an interest than twice the percentage for good
data on the impact in their own sleep, possibly because sleepers (just over 40%). This has a
of poor sleep
100
they had a problem with sleeping. range of mental and physical health
The sample therefore cannot be truly 90 implications, particularly with regard
The Great British Sleep Survey representative of the UK population. to an individual’s ability to take regular
80
was launched by Sleepio to exercise, which in itself is an effective
measure the sleep quality of theOnly 38% of survey respondents 70 way of reducing stress, anxiety and
UK population. By December (2522 people) were classified as ‘good 60 depression.
sleepers’, whilst 36% were classified
2010 there were 1870 as possibly having chronic insomnia 50
The impact of insomnia on energy
responses from men and 4838 (2414 people). Insomnia was slightly 40 levels indicated by the survey therefore
from women (total = 6708). more common in women (37%) than 30
has the potential to create a vicious
in men (32%), and 79% of those who cycle of deteriorating health: insomnia
20
The average age of respondents had insomnia reported having it for decreases an individual’s capacity
Percentage
was 40 years for men and 37 for at least two years. Other estimates
of insomnia have put the total figure
10 for exercise, negatively affecting their
mental wellbeing, in turn worsening
women. Average sleep scores at around 30% of adults, although 0
their insomnia.
were calculated for each person rates depend upon the criteria used Mood Energy Relationships Staying
Awake
Concentration Getting
Things Done
based upon the answers that to define it45. Of the people reporting Aspects of Daily Life
The survey data indicated that
people gave to the survey, with insomnia in the survey, over 30% have Other data from the survey showed over 75% of people with insomnia
had insomnia for 2–5 years, and over that insomnia had a negative effect experienced poor concentration, and
a higher score representing on people’s mood, energy,
better sleep quality (0% = very 25% for over 11 years (Figure 4) concentration, personal relationships,
nearly 70% reported difficulties in
‘getting things done’. In both instances,
poor, 100% = excellent). ability to stay awake during the day, and this is approximately three times more
ability to carry out daily tasks (Figure 5). than the percentage for good sleepers.
The results showed that men had Figure 4
Duration of insomnia This inability to concentrate and carry
better sleep quality than women; the In comparison to good sleepers, over out tasks shows how the implications
average sleep score was 61% for men (N=6708) four times as many respondents of poor sleep can affect wider society,
and 57% for women. Unsurprisingly, with insomnia reported relationship for instance, in terms of impairing
sleep was related to health; people 40
difficulties. The ability to maintain productivity in the workplace.
who rated their physical health as ‘poor’ good relationships with friends, family
had an average sleep score of 47%, 35 and partners is naturally important Overall, the data from the survey has
significantly worse sleep than people to an individual’s personal happiness, demonstrated the extent to which
who rated their health as ‘good’ (63%). 30 affecting their mood and, in the longer sleep influences people’s everyday
The average sleep score tended to term, their susceptibility to depression. lives, both in terms of physical and
25
decrease with age, though there was More than 80% of respondents mental health. Factors adversely
some inconsistency in the relationship 20 with insomnia said they regularly affected by insomnia, such as exercise,
between age and sleep (see Figure 3). experienced low mood. This is more can create vicious cycles where
15 than three times the figure for good the impact of insomnia worsens an
Figure 3 sleepers. Sustained low mood can lead individual’s capacity to tackle the
Percentage
Chart of average sleep score by age 10 to depression. problem. As such, the data illustrate the
(N=6708) 5 complexity of tackling sleep problems.
Over 45% of respondents with Effective methods of breaking this
0 insomnia had difficulty staying awake cycle are detailed in Part III of this
0-3 3-6 6-12 1-2
Mnths Mnths Mnths Yrs
2-5
Yrs
6-10
Yrs
>-11
Yrs
during daylight hours, compared report.
60
Duration
to just over 10% of good sleepers.
Although sleepiness is to be expected
50
Average Sleep Score (Percent)
in people with insomnia, it may
40 encourage the person to keep an
irregular sleep pattern. This in turn
30
upsets the circadian rhythm and can
20 make the insomnia worse.
10
0
16-20 21-30 31-40 41-50 51-60 61+
Age Group
32 33Oversleeping Hypersomnia
Although it is nowhere near
as commonly reported as
and narcolepsy
There are also some conditions
insomnia, sleeping too much such as hypersomnia and
may also cause problems. narcolepsy in which a person
Oversleeping has been linked suffers from extreme sleepiness
to physical health problems such during the day. Sufferers of
as diabetes46 and cardiovascular hypersomnia may complain
disease47. Oversleeping can occur that they do not feel fully awake
in some people who suffer from until several hours after getting
depression, roughly 15–40% of whom
oversleep48. up. People who suffer from
narcolepsy may suffer from
extreme sleepiness, often
at inappropriate times in the
form of sudden sleep attacks.
Cataplexy is also common in people
with narcolepsy. This is defined by a
sudden loss of muscle tone, which can
often leave the sufferer paralysed for
a short term.
Both hypersomnia and narcolepsy
are rare (estimated at 0.3% of the
general population for hypersomnia
and 0.045% for narcolepsy49); however,
they can have severe consequences
for a person’s daily life. They could
be misconstrued as insomnia due
Hypersomnia and narcolepsy to the extreme tiredness, but they
are very different and should be treated
as such.
could be misconstrued as
insomnia due to the extreme
tiredness, but they are very
different and should be treated
as such.
34 35‘All men, whilst they are awake, are in one common world: but each of them, when he is asleep, is in a world of his own.’ Plutarch
Problems that Snoring
Of all sleep problems, snoring
Sleep Apnoea
Snoring during REM sleep
happen whilst asleep may seem one of the more
innocuous. However,
it can cause problems for the
is often a sign of obstructive
sleep apnoea, a potentially
serious respiratory problem.
partners of snorers whose own While sleeping, an individual
As detailed earlier, sleeping is a complex process sleep quality may be affected. will experience pauses in
which involves the body going through a number Strictly speaking, snoring is a breathing or shallow breath.
respiratory problem heightened
of different stages. During the sleep cycle we when a person is sleeping, Sufferers may stop breathing for up to
can react in several different ways, and a number not a sleep problem in itself. minutes at a time, potentially starving
the brain of oxygen. Normal breathing
of problems can occur. These problems can impact
Snoring is very common, approximately usually resumes, with the individual
on our sleep quality. 37% of UK adults snore50. It is twice often making a loud snort or choking
sound causing the airway to unblock,
as common in males as females, waking the individual up and disrupting
although post-menopausal women
Some are very common, such as snoring. Others are more likely to snore than pre- their sleep. Obstructive sleep apnoea
occurs in approximately 3–7% of adult
are much rarer but can cause great problems for menopausal women. Partners may men and 2–5% of adult women.
find their own sleep disturbed and may It is more common in older people and
the sleeper. Abnormal movements or behaviour need to sleep in separate rooms. There in those who are overweight52. Both
that occur during sleep are sometimes called is a suggestion that after undergoing smoking and alcohol also increase the
surgery to stop snoring, sleep quality
parasomnias. Well-known parasomnias include of partners improves51. risk of developing it.
nightmares, teeth grinding, night terrors and Sufferers may find themselves
The snoring sound is produced
sleepwalking. Often these problems can be related through a partial obstruction in the
waking up sweaty, with a dry
mouth and a headache. The frequent
to the mental and physical health of the individual airway, within which the organs that waking throughout the night can
help us breathe vibrate. The muscles
that suffers from them. lead to insomnia, excessive fatigue
relax at the base of the tongue and the and sleepiness during the daytime.
uvula (the small fleshy piece which Undiagnosed obstructive sleep apnoea
hangs at the back of the throat). is associated with increased likelihood
of hypertension, cardiovascular
The relaxation of muscle tone can disease, stroke, sleepiness during
cause the airway (composed of the daytime, and motor vehicle
nose, throat, mouth and windpipe) accidents53. The most widely used
to become partially or completely treatment for obstructive sleep apnoea
obstructed. Other possible causes is positive airway pressure. The sleeper
that can restrict airflow can be jaw wears a special mask over the nose or
problems or nasal congestion. mouth during sleep, whilst a breathing
machine pumps a stream of air in
A person’s size and body shape can
also have an impact on whether they the nose or mouth through the mask.
are likely to snore. For instance, people
with shorter, wider necks are more
inclined to snore because the muscles
around their windpipe cannot support
the tissue that surrounds it when they
sleep. Alcohol also increases snoring,
since it relaxes the tissue at the back of
the throat causing it to collapse into the
airway and vibrate more easily.
There are a number of treatments
for snoring, most of which rely on
unblocking the breathing passage,
such as nasal strips and sprays. Still,
if snoring becomes a problem, then it
is better to seek professional medical
advice first.
38 39Case Study Nightmares Night Terrors
Many of us will have Night terrors are perhaps
K* is a 36 year old female from Bedfordshire, experienced a nightmare from the most disturbing type of
whose sleep cycle is out of synch. She goes time to time. This is defined parasomnia. Like sleepwalking
through periods of not sleeping very much, merely as an intense, frightening and sleep talking, they occur
dream that wakes the sleeper during deep sleep. They can
a couple of hours per night, to sleeping all the time, in the throes of panic. Usually be intense, frightening, and
sometimes up to 19 hours a day. During this period nightmares occur in the early severely disabling experiences.
of oversleeping, she has a strong desire to sleep morning and often they are A night terror is different to
during the day and stay up all night. In spite of influenced by frightening a nightmare since the latter
experiences that have occurred occurs during REM sleep and
such long periods of sleep, she doesn’t wake up during the day. can be recalled on waking.
feeling refreshed.
Recurrent nightmares are said to Most often night terrors begin and end
typically occur due to anxiety. People in childhood. It has been estimated that
She first remembers her sleep problems starting who suffer from post-traumatic stress 18% of children experience them59,
around the age of 13. She would wake up from disorder (PTSD) can experience but only 2.2% of the adult population55.
distressing dreams or nightmares Like sleep walking, night terrors are
a frightening experience feeling anxious but as a consequence of past traumas, more likely to occur under sleep-
ultimately unable to recall what it was she and may experience significant deprivation, after drinking alcohol,
was experiencing. Sometimes she would wake interruptions during REM sleep56. or during a period of stress.
up and find she was unable to move her body Occasionally, we may experience Upon experiencing a night terror,
or to scream out. As a result of the frequency an episode of sleep paralysis; this the sleeper will feel a deep sense
happens after waking suddenly from of fear and panic, their heart rate
of these experiences, she began to feel afraid to REM sleep, which often happens will rise, and they may begin sweating
go to sleep and eventually she got out of the habit following a nightmare. Our muscles are and screaming. There will often be
of sleeping properly. paralysed during REM sleep, but during very little, if any, recall of the details
of the event the following morning.
an episode of sleep paralysis they
remain paralysed for a short period
She now knows that these episodes are known as of time after waking. In old English Little is known about how to treat
people who experience persistent
night terrors and still continues to have them today folklore, sleep paralysis was said to
be due to supernatural forces sitting night terrors. However, more severe
in adulthood, though they come and go in phases. or pressing down upon the sleeper’s cases could be related to traumatic
chest (Figure 6). experiences, particularly in childhood.
If this is true, then evidence-based
Figure 6 treatments for trauma may help.
The Nightmare, Henry Fuseli (1781)
40 41Sleepwalking Teeth Grinding Case Study
Also known as bruxism, this
and sleep talking is characterised by grinding G*, 46, from Liverpool has had problems with
Sleepwalking (somnambulism)
and sleep talking (somniloquy)
one’s teeth, and is sometimes her sleep for the past 15 years. Initially they began
accompanied by clenching
are commonly reported of the jaw. It can occur during with trying to stay asleep. She’d wake up frequently
parasomnias. Both activities day or night. During the day, throughout the night after sleeping for 1 ½-2
occur during deep sleep
(stages 3 and 4), and are
it is often in reaction to certain hours, and on average she would sleep a total
feelings or events that may of 3-3 ½ hours a night. There was a time when
unrelated to dreaming, with occur. During sleep, however,
people rarely recalling them bruxism is characterised G* was a good sleeper. Sleep problems however,
upon waking. by automatic teeth grinding developed after back surgery following a 12 year
Sleepwalking most commonly occurs and rhythmic jaw muscle stretch of shift work. The pain associated from
contractions.
in children between the ages of five
and twelve years; 15% of children in
the surgery kept her awake at night and since then
this age group are said to walk in their In one study, 8.2% of the general she has had trouble maintaining a constant night
population were estimated to grind
sleep at least once57. It is much less
common in adults, occurring in about their teeth at least twice a week during of sleep.
2–5% of the adult population58, the sleep, and 4.4% were reported to
fulfil the criteria for a full diagnosis
majority of whom began sleepwalking
when they were children. Sleep walking of bruxism. It was also found to be She has tried keeping good sleeping habits on
is more likely to occur when people more common in those who regularly recommendation from her doctor: she doesn’t
consume large amounts of caffeine,
have been sleep-deprived, drinking
alcohol, or under stress. alcohol and nicotine54. Importantly, keep a TV in the room, abstains from caffeine and
bruxism can be symptomatic of alcohol and adheres to a strict routine by going to
underlying stress and anxiety; one
Sleep talking occurs in about 4% of
adults, though again more frequently study found that roughly 70% of be bed at 11pm and getting up at 4am. No matter
in children. This can range from sufferers attributed their teeth grinding what she’s tried though it doesn’t seem to make
to these causes55.
non-verbal utterances to eloquent
speeches, which occur several times
any difference.
during a night’s sleep. The speech
may or may not be comprehensible to
listeners. Sleep talking rarely presents
In the last 5 years, G* discovered she was
a serious problem. In fact, it is much sleepwalking. She’d find objects in strange places,
more likely to be problematic for the
partner if they are disturbed during the
such as the remote control in the bin, as well as
night on a regular basis. odd cooking experiments left out on the hob, such
Sleepwalking can become a problem
as cereal covered in washing up liquid. After finding
when people run the risk of injury, herself outside her building, she went to see a
either within the house or if they go
outdoors. Some sleepwalkers conduct
sleep specialist fearful she might end up doing
activities during their sleep, such as more serious harmful behaviour. Unfortunately
cleaning. It can also be associated
with bedwetting; it is not uncommon
she was told there was little they could do to help
for people to urinate in closets and her, as they told her the sleepwalking problem was
cupboards during a sleepwalking
episode.
a symptom of her poor sleep pattern.
In extremely rare cases people conduct
violent activities. In the UK, a man
unknowingly strangled his wife while on
a caravan holiday. He thought he was
fighting off some assailants who he
believed had broken into their caravan.
He was acquitted on all charges on the
grounds that he was not conscious
and not in control of his actions.
42 43REM Behaviour Sleep Related
Disorder Motor Disorders
This is a rare condition in which People with periodic limb
people can be seen to ‘act out movement disorder may
their dreams’. This parasomnia experience an intense or
tends to begin later in life and prolonged set of hypnic jerks
is more common in adults (involuntary twitches that occur
over the age of 50, particularly between wakefulness and
in men. sleep), and may involuntarily
twitch muscles, particularly
Most people are unable to move during the legs, whilst sleeping. It
REM sleep because their muscles
are paralysed. However, people with occurs in approximately 3.9%
REM behaviour disorder maintain of the general population
some degree of muscle tone during and is slightly more common
REM sleep. Therefore, the sleeper in women than men60. This
is not paralysed and the muscles becomes a problem when
stay partially active, sometimes with it disrupts the sleep of the
violent results. People acting out their
dreams during REM behaviour disorder sufferer or partner.
can injure their partners, and it is not
uncommon for couples to get into the The reasons for periodic limb
habit of sleeping apart for this reason. movement disorder are unclear,
Interestingly enough, this has also but it may be related to a disturbance
been noticed in other species, such in circadian rhythms. Medication
as dogs.65 can help, particularly those that
reduce muscle function during
sleep. A similar disorder is restless
legs syndrome. Figures from the US
estimate that it affects around 7%
of the population61, increasing with
age and being more common
in women62. Sufferers experience
unpleasant sensations in their legs,
and thus feel irresistible urges to
move them; they may only gain relief
by walking or moving. Symptoms are
said to occur typically in the evenings
There is some evidence that potentially leading to difficulties
in falling asleep.
both periodic limb movement There is some evidence that both
periodic limb movement disorder
and restless legs syndrome can
disorder and restless leg be side effects of antidepressants63.
The large majority of sufferers of
restless legs syndrome do respond
syndrome can be side effects to treatment. Mild cases may be
treated by abstaining from caffeine
and alcohol. There is also some
of antidepressants. evidence that regular exercise during
the day may reduce symptoms, though
further research is needed to confirm
this64. Those who are more severely
distressed by restless legs syndrome
may experience relief with drugs that
mimic the neurotransmitter dopamine
in the brain.
44 45‘A sleepless night is as long as a year.’ Chinese Proverb
Sleeping Well 48 49
This section of the report Sleep hygiene
Many people can benefit from improving
describes ways in which we the quality of their sleep. The phrase sleep
hygiene is often used to describe how
can all improve the quality lifestyle and environmental factors can
affect our sleep. Positive sleep hygiene
of our sleep. may help to improve sleep quality, but
is not enough to treat chronic insomnia.
As highlighted in Part II, sleep Caffeine, alcohol and nicotine Eating habits have the potential
is crucial to the health of all are all substances which to affect sleeping. It is important
can impair sleep quality. not to go to sleep whilst feeling
hungry, so eating a light snack before
Caffeine makes it harder to
individuals. It is important
bedtime may be helpful. However,
sleep because it stimulates eating large meals shortly before
the central nervous system, bedtime should be avoided, because
to remember that poor sleep
increasing your heart rate and the body will spend time digesting
adrenaline production, and before it can sleep. Some foods may
also supressing melatonin have sleep inducing properties; for
has massive implications for
example, rice and oats may contain
production. It takes a long small amounts of melatonin, which
time for the body to break increases the desire to sleep. Some
down caffeine, so drinking
our health; it is in all of our
foods, such as dairy products, contain
coffee during the day can the amino acid tryptophan which
affect sleep at night. is useful in manufacturing melatonin.
interests to ensure that we Alcohol can help people fall asleep,
but it also impairs sleep quality
Other foods, such as those that
contain caffeine or large amounts
sleep better. during the second half of the night, of refined sugar, make sleeping
and it is a diuretic which means that more difficult. A study in the Isle
we may need to wake in the night to of Wight examining the effects of
go to the toilet, disrupting the sleep food additives on health, found that
pattern. However, a rapid reduction preschool children who received
in alcohol intake for someone who is additive-laden drinks were more
a heavy drinker can lead to alcohol hyperactive than when they did not
withdrawal syndrome, which itself can have drinks containing colours and
lead to insomnia. Alcohol can also preservatives67.
contribute to depressive mood, which
in turn can contribute to insomnia.
Nicotine may impair sleep, smokers
take longer to enter sleep and have
less total sleep time (approximately
14 minutes less per night) compared
to those who have never smoked66.
Reducing nicotine intake is unlikely
to lead to immediate improvements
in sleep, but the long term
health benefits are likely to have
implications for sleep quality.
50 51You can also read
