Changing thoughts to help us sleep better

Unfortunately, everyone has probably had sleep issues at some point in their lives. For some, it’s a nuisance, for others a - in some cases literal - nightmare. But could changing the way we think about sleep actually help us to sleep better? Paul Blenkiron thinks so. He's an NHS consultant psychiatrist and a member of the Royal College of Psychiatrists, and he spoke with Katie Haylor...

Paul - When I look back at a survey that was done back in 2010, which is the Great British Sleep survey, this showed that about a third of people have chronic insomnia, they've had difficulty sleeping for at least two years. Research shows that people physically get more problems with diabetes, obesity, high blood pressure if they don't sleep as much as they would like to or want to, and also there are mental health problems linked to sleep problems such as anxiety and depression or simply just not concentrating during the daytime.

Katie - Is it possible for you to summarise what kinds of issues people can have with sleep, because it's not just not getting enough is it?

Paul - That's right. Sleep could be too much, it could be too little, or it could be broken or just dissatisfied for people. Sleep really is part of our sleep/wake cycle and that's linked to stuff in the brain that controls our daily routine. So there's a group of cells in the brain, called the hypothalamus, produces this hormone called melatonin, this is a hormone that makes you sleepy and you produce more of this melatonin when it gets dark. So, of course, when it gets to the light times of the year, such as the summer, people sleep less, in the winter they sleep a bit more.

It’s sometimes people’s perception of sleep which is the problem rather than the actual amount. And people normally wake up during the night for one or two minutes a couple of times a night - so-called micro wakes - and we're normally not aware of those. But if you're bothered by your sleep, you’re going to pay more attention to those periods of waking up and, of course, that sets off this vicious cycle of worrying about your sleep.

Katie - At what point would a psychiatrist like yourself come into contact with people who are having sleep issues, because I'm guessing this goes a little bit beyond the sort of common sleep hygiene type routine stuff that people might be more familiar with?

Paul - Relatively few people with sleep problems will come to see a psychiatrist. I would tend to see people who had problems due to a mental health problem that was linked to sleep such as depression or anxiety, or some sort of stress. But a lot of GPs will see sleep problems quite commonly either leading to mental health problems or mental health problems leading to sleep. In depression, we know that people have poor sleep; they sleep too much or too little but, of course, if you're not sleeping already you become depressed. In that survey I talked about, 80% of people had low mood due to their sleep problems, 75% had poor concentration, and half had a relationship problem, so I think it's a bit of a chicken and egg situation. It can be difficult to disentangle those, even for somebody like me who sees quite a few people with this problem.

Katie - So, from a mental health perspective, are there particular elements of sleep that you would pay particular attention to?

Paul - There's quality and there's quantity. First of all dealing with quantity, we know that as you get older you need less sleep. New-born babies perhaps 18 hours, adults like you and me probably 7 to 8 hours for a good healthy night sleep, and even less as you get older. And, of course, Margaret Thatcher famously needed only four or five hours a night of sleep. So, I tend to look at people’s expectations of sleep as much as the content.

Katie - And could you just describe for us the various stages of sleep and what the brain's doing throughout the night?

Paul - We have two main types of sleep: slow wave sleep and REM sleep or rapid eye movement sleep. The REM sleep period last about 60 to 90 minutes at a time. They get more common as the night goes on and during those periods of time you're sleeping lighter than before and more likely to dream during those periods. People, if they're woken during slow wave sleep, tend to be really irritable, disoriented and confused, and in REM sleep if they’re are woken then they'll probably remember the dreams they've been having.

Katie - Is there any connection between the quality or quantity of dreams and mental well-being?

Paul - Well, this is a fascinating area and, of course, it was Sigmund Freud more than a hundred years ago who said that "our dreams are caused by unconscious impulses, unfulfilled wishes." I think there are few mental health professionals these days that would really interpret dreams in the same way. But we do know that people are bothered by dreams sometimes. If you’ve had a traumatic experience in your life you might get flashbacks or nightmares to that trauma and it might come out in the dream. But for most clinical people, I would say they're not really so concerned about the content unless the patient in front of them is concerned about it, they're more concerned about the overall quality of sleep, and dreams can be affected by mental health problems and by certain medications.

Katie - What can be done to help people who are suffering from bad sleep? What might you be doing as a psychiatrist?

Paul - First of all, address the cause of the sleep problem. Common sense tells you that if you've got a noisy room or your partner snores then that's the issue that should be dealt with. If there's some sort of heart problem that's keeping you awake or some sort of asthma, then get that treatment. So first of all deal with the cause where possible.

The second thing to do is to look at lifestyle changes, something that's called sleep hygiene. Even before people see me, I'm sure their GP will have given advice on avoiding caffeine and alcohol, using the bedroom just for sleep and little else, and generally making sure there's a regular routine.

When they get to see me I've got 2 interventions I could offer. Medication is one possibility, but a better, more long-term solution is to consider Cognitive Behavioural Therapy.

Katie - So this is actually changing the way people are thinking about sleep or the reasons why they're not sleeping, is that right?

Paul - That's a good summary. The B part first of all is about your behaviour, so often we might get people to keep sleep diary and, for example, if they’re only getting an average of 5 and a half hours sleep, we get them to go to bed a bit later than normal, maybe 1a.m. if they need to be up for 7 a.m. The key thing here is not to sleep in in the morning and to train yourself to get up after that 6 hour window for sleep to begin the day. That's the behavioural part of things.

The C is cognitive, which is how you change your view of sleep. We all know from sleep problems that when we're lying there in the middle of the night, these unhelpful thoughts keep going round our head - “I'm never going to sleep”, “everyone else is sleeping” and “I might go crazy if I don't get enough sleep”. And the idea of CBT is to encourage people to have more helpful and realistic thinking. So I might encourage people to train themselves to say in the middle of the night; this doesn't matter, I can function well enough without sleep; I'll sleep better tomorrow; I'll fall asleep when my body is ready.

The key thing, of course, is not to actually try and get to sleep because if you try really hard to push a thought out of your mind, back it comes again. So we practice a form of psychological adjustment called mindfulness. Letting your thoughts stay with you, being okay about that and being, so to speak, chilled out in bed, ready for sleep when it takes you.

Katie - How effective can this cognitive behavioural therapy be first of all, and also does having a pre-existing mental health condition just make things all the much more complicated when it comes to CBT?

Paul - Most CBT on the NHS is offered for other mental health conditions. So the National Institute for Health and Care Excellence recommends CBT for pretty much everything in mental health as being a good treatment, but it’s also useful for sleep problems on their own. It does complicate things when there are other problems present and we will treat depression and anxiety in other different ways. But CBT is still a useful intervention and in the right hands and if people actually do it, it can help at least three out of four people.

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