In yesterday’s Daily Mail, in the first part of an exclusive series about how to beat insomnia, renowned consultant neurologist and sleep expert Professor Guy Leschziner told how the pandemic has been driving another global health crisis: an epidemic of sleep problems.
He explained how the most extreme forms of insomnia can lead to depression, type 2 diabetes, heart trouble and even Alzheimer’s.
But it’s not all bad news. Today, in the second of his four-part series which continues in tomorrow’s Daily Mail, Prof Leschziner shares the latest research on techniques for dealing with sleeplessness, outlining an approach that holds the key to a better night’s sleep.
Over 15 years as a neurologist specialising in sleep, I’ve treated every disorder under the sun (or perhaps I should say moon).
I’ve helped people plagued by night-terrors that make them scared to go to bed, and teenagers who cannot wake up before early evening.
And yet, fascinating – and frustrating – as these rare cases can be, the one sleep disturbance everyone wants to discuss is insomnia: chronic trouble sleeping.
There’s no doubt that the pandemic has exacerbated this problem, with evidence that those who’ve caught Covid, and many who haven’t, have suffered sleep issues following the strain the pandemic has put on our minds and bodies.
There’s no doubt that the pandemic has exacerbated chronic trouble sleeping, with evidence that those who’ve caught Covid, and many who haven’t, have suffered sleep issues following the strain the pandemic has put on our minds and bodies (stock photo)
Although we are hopefully moving into a post-Covid era, more people than ever are having difficulty trying to re-establish refreshing and continuous sleep.
There is little else more demoralising, and lonely, or that saps away more at quality of life, than chronic sleeplessness.
Tossing and turning in the dead of night, it’s easy to become afraid. You may fear not falling asleep for yet another night, that you will feel terrible tomorrow, or worry that your insomnia is untreatable or harming your health.
Indeed, sleep deprivation can be a precursor to serious conditions: lowered immunity, heart problems, depression, type 2 diabetes and possibly even dementia.
But as I explained in the first part of this series I’ve devised exclusively for readers of the Daily Mail and The Mail on Sunday, the vast majority of insomnia sufferers are not at risk of these long-term dangers.
Insomnia can take many forms, and be miserable and stressful to battle with, but only a minority with the problem have the ‘risky’ sort (‘short sleep duration’ insomnia) that leads to serious health problems.
I’ve helped people plagued by night-terrors that make them scared to go to bed, and teenagers who cannot wake up before early evening. And yet, fascinating – and frustrating – as these rare cases can be, the one sleep disturbance everyone wants to discuss is insomnia: chronic trouble sleeping, writes Professor Guy Leschziner
Not only is their sleep severely curtailed (to under five hours a night), but they experience notable physical changes in their stress hormone levels and heart rate, for instance.
You won’t know if you suffer this type of insomnia unless monitored in a sleep lab but, based on scientific evidence, it’s clear that most people with insomnia don’t sleep as badly as they think.
Indeed, we’re not always good judges of our own sleep. It’s not uncommon for individuals, after a night observed in the sleep lab, to think they’ve had only a few minutes’ sleep across the whole night.
But looking at their brainwaves, I’ve seen that they’ve had more sleep than I did!
Drugs can lead to troubling withdrawal effects and anxiety
For most insomniacs, sleep might be broken and they may take time to nod off. But, still, they’re usually getting a decent amount of sleep, particularly the deeper stages of sleep.
We call this type of insomnia – sleeping normally despite feeling you’ve not slept a wink – paradoxical insomnia.
Once, this was considered to be primarily a psychological phenomenon but we’re beginning to understand there may be underlying neurological processes that explain it.
We know that we don’t necessarily achieve the same degree of sleep in the whole of the brain at the same time. It’s possible for parts of the brain to be wakeful while others are in very deep sleep. That occurs in conditions such as sleepwalking, for example.
So it could be that, in patients with paradoxical insomnia, some area of the brain responsible for awareness is not ‘switching off’ to the same extent as the rest of the brain, so they feel they were awake all night. There really is such thing as ‘half-asleep’ – or half-awake.
Other patients may take hours to drift off, or wake several times during the night and feel wretched.
But one relatively safe, temporary option to deal with insomnia is melatonin, a man-made version of the ‘sleepy’ hormone that occurs naturally in the brain to help control sleep patterns. The body produces melatonin just after it gets dark and continues through the night (stock photo)
Even so, they spend enough time asleep to enjoy an adequate amount of deep, slow-wave sleep – thought to be where the majority of the restorative processes for brain and body occur.
So it’s only people whose sleep is truly curtailed who’ll experience the physical consequences of poor sleep, with their nervous system on high alert, flooding their systems with hormones and chemical messengers.
While almost all insomniacs will have an over-active mind at night and experience the emotional consequences of poor sleep – which can include low mood, anxiety and irritability – most won’t experience any of these markers of physiological stress.
Even the daytime cognitive performance of people with ‘normal’ insomnia is more like that of people who say they have no trouble sleeping than those with short-sleep duration insomnia.
Hormone tablet that may help sleep for a while
Drugs are never my first port of call and should never be relied on as a solution for insomnia.
Indeed, no crutch – not even herbal tea – can be the answer. The key is a change in behaviour or how you think about sleep.
But one relatively safe, temporary option is melatonin, a man-made version of the ‘sleepy’ hormone that occurs naturally in the brain to help control sleep patterns. The body produces melatonin just after it gets dark and continues through the night.
Tablets can add to your body’s natural supply of the hormone to help you get to sleep and stay asleep. Melatonin is sold freely over the counter in the US and elsewhere, but is only available on prescription in the UK to help treat insomnia for up to 13 weeks in individuals over the age of 55.
The side effects may include nausea, headache and night sweats – but it doesn’t lead to the dependence and other serious issues seen with some other sleeping pills.
On its own, like other medications, it is not the long-term solution for insomnia but it may help a little alongside other non-drug-based strategies.
There is no way of knowing for sure if you’re one of those ‘at-risk’ insomniacs without undergoing clinical observation but, in some respects, it’s academic because everyone with any type of insomnia will be suffering and will want to address it.
It means that, for the majority of insomniacs, worries about their long-term health should not be added to existing anxiety about poor sleep.
One key step to tackling a sleep problem is to identify potential ‘saboteurs’ that could be undermining your sleep without you realising it.
For example, exercising in the evening or working in bed can make sleep more of a challenge, and I’ll look at this in tomorrow’s Daily Mail.
But first, I want to explain why one of my six rules for better sleep is to avoid the quick-fix solution.
Sleeping pills are not usually the answer. When people reach my clinic, they’re often willing to try anything – and the quicker the fix, the better it sounds to anyone desperate for rest.
That is partly why strategies for treating insomnia have focused on medication. But drugs are not often the solution and prescribing sleeping pills can create more problems than it solves.
Benzodiazepines, a form of sedative, hit the market in the early 1960s, rapidly becoming the staple treatment for insomnia and anxiety, popped in vast amounts (especially in the US).
Over recent decades, however, the dangers of ‘benzos’ have become apparent, as have the risks of the related but newer ‘Z’ drugs, or hypnotics, such as zolpidem and zopiclone.
Despite being initially hailed as reducing some of the risks of benzos, they did not do so entirely.
The potential risks of both groups of pills include morning drowsiness or ‘hangover’, traffic accidents, falls and fractures, and they can also trigger sleepwalking (it’s thought by extending deep sleep).
Importantly, they can lead to dependency and troubling withdrawal effects, such as a return of sleep problems and feelings of anxiety, with ever-increasing doses required to achieve the same effect on sleep.
Most alarmingly, there’s growing evidence these drugs are associated with cognitive decline, or risk of dementia.
The association between poor sleep and Alzheimer’s has yet to be fully understood. We know there may also be a link between lack of sleep and dementia, so there is a balance to be struck.
But whatever the case, concerns about this and other side effects of medication have prompted a change in how we treat insomnia.
While I’m not wholly against drugs – for some there may be no option – they have serious limitations and some evidence suggests they give you only an extra half an hour or so of sleep a night anyway.
Exercising late or working in bed make nodding off challenging
I strongly believe sleeping pills should not be used as a first-line treatment for anyone with insomnia, unless there’s a clear and short-lived reason why they’re not sleeping.
For example, if somebody has been unable to sleep for several nights because of a recent bereavement, then giving them a week-long prescription to offer relief might be reasonable.
But the primary aim should always be re-establishing healthy sleep patterns, not staying on drugs long-term. Drugs themselves do not address the underlying issues.
That’s why the gold-standard treatment for insomnia, now widely accepted, is a form of therapy known as cognitive behavioural therapy for insomnia (CBTi).
This uses behavioural techniques to reprogramme the brains of people with insomnia. Its beauty is that once a course of treatment is completed, the effects are long-lived. Whereas with a pill, it’s likely the insomnia will return once the medication is withdrawn.
So how does CBTi work? Primarily through conditioning. If you have no problems with sleep, you associate your bedroom with that comforting sensation of putting your head on the pillow and drifting off.
But for the insomniac, the conditioned response – the dread of those countless nights of anxiety – can mean that just being in the room arouses anxiety.
Breaking down this negative conditioned response and rebuilding positive sleep connotations lies at the core of CBTi. The trick is to re-establish the bed as a haven. This is done using a number of strategies – stimulus control, sleep restriction, relaxation training and the cognitive therapy after which it is named.
Set aside time to write down worries and put the day to bed
We begin by doing things during the day that facilitate sleep later, including setting regular wake and sleep times, restricting light exposure in the evening and not eating late at night or consuming caffeine. (For more details on the steps involved, see tomorrow’s Mail.)
We then move on to ‘stimulus control’, aiming to restore the connection in your mind between bed and sleep.
This means using the bedroom only for sleep (getting dressed in the morning and having sex are also permitted, but no TV, Twitter, or reading work emails). And you mustn’t nap during the day as this could diminish your body’s desire for sleep at night.
At night, if you haven’t drifted off within 15 minutes, you must get out of bed and go to a different room, only returning when you feel sleepy. This is to prevent you spending hours in bed awake and unsettled.
The next step, sleep restriction, further limits the amount of time spent in bed to the actual time spent sleeping (see report on previous page).
In addition, a CBTi programme is likely to teach physical and mental techniques to reduce hyper-arousal when you’re lying in bed, such as meditation or progressive muscular relaxation (where you tense a group of muscles in a certain order as you breathe in, relaxing them as you breathe out).
Finally, there’s cognitive ‘talking’ therapy. This is unique to each patient and unearths their own feelings and myths around sleep, helping them to reframe their outlook.
Techniques, including setting aside time to write down worries and possible solutions, are encouraged as a way of ‘putting the day to bed’ before entering the bedroom.
Such a programme, undertaken over six weeks using either an online programme or face- to-face therapy, helps 60 to 80 per cent of patients.
Multiple studies show it to be as effective – if not more so – as most drug treatments, longer-lasting and with none of the dramatic side effects.
Your GP can refer you for face- to-face CBTi sessions, which are often given in groups, or for online programmes. Sleep therapy is also available privately.
Sleep deprivation can reset the brain
Restricting the amount of time spent in bed might sound counter-intuitive.
However, many people with insomnia spend more time in bed to compensate for their poor sleep, to give themselves more ‘chance’ to fall asleep.
Yet this merely increases their time in bed not sleeping, thus strengthening their negative thinking about being in bed or their conditioned response to bed.
By limiting time in bed to about five hours a night (the amount depends on the individual) for a couple of weeks during CBTi, the theory is that we end up strengthening the brain’s drive to sleep while in the bed.
Of course, this isn’t easy. Things often have to get worse before they get better during this element and other parts of CBTi.
At its most extreme, there is an experimental, if brutal, treatment in Australia called intensive sleep retraining.
Patients are asked to spend no longer than five hours in bed the night before going to a sleep laboratory for a 24-hour treatment. They are permitted to try to fall asleep at night, every 30 minutes, with electrodes attached to their scalp.
If they haven’t dropped off after 20 minutes, they are asked to get up.
Alternatively, if they are able to fall asleep, they’re woken again after three consecutive minutes of sleep. In all, they will have had 48 opportunities to fall asleep in 24 hours: the theory is they’ll be so sleep-deprived they will fall asleep as soon as allowed, re-establishing a conditioned response between bed and the relief of sleep.
Results from trials have been impressive. The short, sharp shock rapidly reconditions the response to getting into bed and results in quick improvements in sleep.
This technique is not yet used routinely in clinical practice and is not appropriate for everyone but it shows that retraining the brain to associate bed with sleep is fundamental to dealing with insomnia.