Video script: sleep
GGC - 12 Week Pain Management Programme
This content is designed for the participants of the GGC Pain Management Programme.
Sleep problems and how to deal with them
In this talk I’m going to talk about some common sleep problems and some things we can use to deal with them. Many of the people we meet with chronic pain we meet tell us that as a result of their pain their sleep has become pretty disrupted and hopefully there will be something in this video that will be useful for you in terms of things that you can take away and apply, and try in the next few weeks to improve your sleep.
In this talk I’m going to try and answer the following questions;
Why do we sleep?
How much sleep do we need?
Is not sleeping dangerous?
I’m also going to mention a couple of quirks of sleep and use those to help you to better understand the nature of sleep so that you can use that understanding to improve your sleep.
Why do we sleep? The most obvious answer is to allow the body to rest and repair itself. However, we can rest without sleeping and this seems to allow most of the body’s necessary repairs to be carried out. There is one particular area of the body that requires sleep in order to operate effectively, and that is the brain. It seems that the brain requires sleep in order to make sure that what we’ve learned gets stored so that it can be easily retrieved later. Not sleeping seems to make learning harder.
So how much sleep do we need? The figure that you will hear the most is 7 to 9 hours. However, people vary in how much sleep they need in order to be able to function effectively. An additional problem is that we are very poor at working out how much sleep we’ve had and most people underestimate the number of hours that they managed to get. Who hasn’t heard their partner saying that they didn’t sleep a wink last night, but you remember being woken up by their snoring in the middle of the night?
Is not sleeping dangerous? The answer, unfortunately, can’t be a straightforward yes or no. Scientists generally believe that it is dangerous to not sleep at all. Although there haven’t been many experiments, there are stories of people becoming very ill, or having seizures, or going into comas when they have been completely denied sleep. At the same time, sleep problems are very common and, whilst there has been some research showing that sleeping less than 6 hours or sleeping more than ten hours are associated with poorer health in the long run. Again, this isn’t from experiments, but from just observing people, so it’s hard to tell whether the poor health is a consequence of poor sleep or that poor health is actually causing poor sleep. One thing that is clear is that worrying about not sleeping is counterproductive because it becomes just another thing that’s stimulating your brain and preventing you from sleeping. Generally, the more that you try to sleep, the less likely that you are to sleep. This is because sleep is a natural process and it is not under our control, although there are things you can do to set up the best conditions for sleep. There are various things you can do to not worry as much. It can help to bear in mind that you probably got some sleep, even if you can’t recall sleeping. It might also help to remember, and then remind yourself, that, even after a bad night, you probably coped better with the demands of the day than you expected to.
Another peculiarity is that we don’t necessarily get more and more sleepy the longer we are awake. If you don’t believe me, consider the following. Night shift workers tell us that, despite being awake for a long time; perhaps the whole of the day before their night shift and then awake throughout their night shift, they will get home, having been awake for 24 hours, but despite this they say that they are often wide awake and frustrated because they can’t sleep.
Why does this happen? This is because our ‘sleepiness’ and to a similar extent, how alert we feel, is largely determined by the daily rhythm of certain hormones. Some hormones make us feel sleepy and, if things are working normally, these hormones start to circulate a couple of hours before our normal bed-time and then they gradually build up as the evening and night wears on. Similarly, other hormones make us feel alert, and if you track the levels of these in the body, you usually see a spike in these around the time that we would normally be waking up. The levels of these hormones are largely determined by something that is called the “Body Clock”, or otherwise known as our “Circadian Rhythms”. The rise and fall of these hormones are usually strongly related to whether it is daytime, or if it’s night-time, but this rhythm can be easily disrupted.
You may have noticed this disruption yourself if you’ve ever gone to America or Australia and experienced jet lag. As an example, you can arrive at nightime in Orlando, or wherever, having been travelling all day and awake for hours, but find yourself unable to sleep, because your body is still on UK time, where the morning has just dawned. As you may have experienced yourself, jet lag tends not to last, and over a few days your sleep/wake cycle will get used to the different time zones and adjusts the release of those hormones to fit this new day/night cycle. This tells us something important. That is, that the sleep cycle isn’t fixed and can adapt and learn. Exposure to daylight is a major factor in this retraining of the sleep cycle and that is largely what happens when you are getting over jet lag. Our brains learn that day and night have shifted and it then alters the pattern of the cycle of these hormones to match it, so that we become sleepy at night time and alert during the day. Similar effects are seen in people who work night-shifts.
How do things go wrong and why are sleep problems so common when people develop chronic pain? Perhaps the most important thing is that pain disrupts normal routines, which in turn can throw these sleep and hormone cycles off balance. First off, there’s the obvious thing of pain interrupting sleep, either by making it hard to get off to sleep or by waking people up during the night or too early in the morning. If this becomes a regular occurrence, then problems can develop. There’s also the part that we can play in making problems worse. If you have had a disturbed night then it can be very tempting to try and ‘make up’ for the sleep that’s been lost by trying to sleep past the time that you would normally get up. If you are no longer working, perhaps because of pain, it can be easier to let your normal routines slip. Without the pressure of having to get up at a normal time to go to work, waking times can start to drift and this can have a knock on effect on bed times. When people are in pain, bed is often the place where they are most comfortable. Combine this with pain medicines that cause drowsiness, and it can be very easy for people to start having short naps. Some pain conditions also involve significant fatigue and this can make it easier to stick to a routine.
I have already mentioned the kinds of things that we all do in response to sleepless nights but which can affect our normal night time routines, such as varying when we go to bed and when we get up, alongside taking naps during the day. If these patterns carry on for a while, they can have the effect of confusing our rhythms. This reveals something interesting about our body clock and that is, that it can learn. This is what happens when you travel long-distances. Initially the sleep system is confused. Suddenly, it’s dark outside, but you are wide awake. However, it soon learns that you are in a different routine and it adjusts itself. It may take a few days, but it will usually get there.
Our body and our sleep system can learn in another way, and that is through association. This is something that is fundamental to humans and animals: if you put two things together, often enough, our brains figure out that one thing predicts another. This learning can even affect biological processes. If you don’t believe me, look up Pavlov’s dogs, where dogs were trained to salivate whenever a bell rang. Something similar happens to sleep. When we are in a steady routine, our brains get used to certain things predicting sleep, because they either happen before sleep or at the time of sleep. One major predictor is our beds. In the normal run of things, whenever our brain sees our own bed, it usually means that it’s bedtime, so it is a good predictor of sleep and this causes things to happen in the body in order to make sleep easier. However, if you are in bed and awake, perhaps because you’ve woken in the night and you’re tossing and turning in bed trying to get back to sleep, you are weakening the association between bed and sleep.
Leading on from what I’ve just said, it should be obvious that routine is important. Having a good routine should help to train the sleep system to respond better over time. Likewise, if you nap during the day, your brain will likely wonder why it’s so light outside. The other, and perhaps the most important thing, is to not lie tossing and turning in bed whilst you are trying to get to sleep. By doing this you break the association between bed and sleep and building the association between bed and being awake. Taken all together, if you stay in bed whilst you’re awake and sleep during the day, bed and darkness become weaker at predicting sleep and your body won’t respond to these things in the way that it has done previously and won’t prepare you for sleep.
So, you should try and go to bed at the same time each evening and get up at roughly the same time each morning. This helps your brain to predict when it needs to deliver the hormones to make you sleepy and to make you alert. Similarly, you should avoid napping during the day, unless this is going to be a permanent change in your routine, but remember, if you nap during the day, it is likely that you will need less sleep at night, so that will have to be factored in. The other kind of thing that breaks this association is doing activities like watching TV, or messing around on computers, or phones or tablets. Again, this is building up unhelpful associations in our brain. Bed no longer predicts just sleep, but is also predicts movie watching, social media browsing and game playing – no wonder your brain doesn’t see bed and think sleep!
What do you do then, if you wake up in the night and can’t get back to sleep? The sleep experts all agree that you should get out of bed. Ideally, you should go into another room and do something quiet and boring and, hopefully, you should start to feel sleepy, and if you do, you can go back to bed and try to sleep. If sleep doesn’t come after fifteen to twenty minutes, you should get up again and repeat the cycle.
Sometimes people find that their sleep habits have gone completely to pot and, somehow, they’ve managed to turn night into day and vice versa. There are a number of ways to tackle this, and in some ways it is like jet lag. The tough way to tackle this is by limiting sleep during daylight hours and only allowing sleep during the night time hours, but also bear in mind the advice on not tossing and turning in bed. This will work, but it is likely to be uncomfortable and you may find it hard to stick too. A gentler approach is to gradually try and shift your body clock round, but this will likely take weeks, if not months. If you find yourself falling asleep too early in the day, and waking too early in the morning, then try staying up an extra fifteen minutes each night. Remember to set your alarm fifteen minutes later in the morning. Also remember to stick to the other bits of advice around routine and not being in bed when you are awake.
Similarly, if you find yourself not falling asleep until the middle of the night and lying in until midday, then do this process in reverse. Set you alarm clock for fifteen minutes earlier each day and try to go to bed fifteen minutes earlier each night. Eventually, your sleeping pattern should come round to the normal day/night cycle.
Of course, it isn’t just having a good routine that helps to lessen sleep problems. Even if you had the best habits in the world, if there is enough noise or light, for example, stimulating your senses, then you will likely wake up. So it also important to try and minimise those sources of stimulation as best you can. Try and cut out sources of light,: blackout blinds can help. Cutting out street noises can also help. Double glazing or heavy curtains will help a little. If your bedroom faces onto a road, you might, if it’s possible, think about moving your bedroom to the back of the house and away from street noise. Hunger is another thing that can wake people. Alight snack in the evening can help, but avoid eating too much, and avoid snacks that have a high sugar content.
There are lots of other things that can stimulate the senses. Caffeine has been long recognised as a stimulant that can interfere with sleep. Perhaps monitor and reduce your intake, and remember it’s not just coffee that contains caffeine, but also many fizzy drinks, as well as chocolate. Worries can be another source of stimulation. Your meditation practice can help, but another tip is to leave a pad and pen by the side of your bed so that you can leave a note for yourself and so avoid that “I must remember to check this or I must remember to say that” scenario which gets in the way of sleep. Alcohol can also interfere with sleep. Although it is a sedative, for various reasons it can cause people to sleep more lightly. Exercise, whilst normally a helpful thing, can keep you awake if you exercise too late into the evening. The same goes for housework or DIY. Being too hot or too cold can also wake us up, as well as needing the toilet. There are various things you can do to stop these waking you.
When we meet up next, I’d like you to have thought about which of the above factors might be interfering with you getting a good night’s sleep. Maybe, make a note of the suggestions we’ve made hear that you think you might be able to change. One final thought; changing one thing might not be enough to get you into good habits.