To sleep or not to sleep – that is the question Blog by Dr. Sue Peacock Imagine it’s dark, it’s nearly 2am, and you still haven’t slept despite going to bed at 11pm. You toss and turn, count sheep, pull the bedcovers up, then throw them off, you look at the clock again and it’s only 5 minutes since you last looked, but it feels like forever! Your pain is getting worse and you have taken all your allocated medication, you’re tempted to take extra, but you would have to get up and it’s cold so you continue lying there, feeling frustrated and getting more and more wound up because you can’t sleep. Everyone in your house is asleep, your partner’s snoring is echoing through the whole house, you nudge them a bit, then a bit harder because you really want them to wake up and chat, because everyone in the whole world is sleeping except you! If this is you, read on! Why can’t I sleep? The top reasons people experiencing pain can’t sleep are: You notice your pain more as there are no other distractions at night.Your medication for pain or low mood makes you drowsy in the day so you sleep at irregular times.You are not in a regular routine, so your mind and body are confused about when it is time to rest.You worry about how your lack of sleep will affect you the next day.You are experiencing mood changes that create tension in your body.You are not comfortable in your bed or you are disturbed by sounds or light in your bedroom. Understanding the science of sleep Sleep varies throughout the night and varies from person to person! It is an active process with physical, mental and emotional components. Sleep is orderly and made up of different cycles which are repeated through the night as illustrated in Fig 1 below. Figure 1. – Sleep cycles In addition to these sleep cycles, sleep is also controlled by our circadian rhythm (body clock) and homeostasis, which control your levels of sleepiness and your need for sleep. A “normal” night’s sleep can be anywhere between 5 and 10 hours. It’s a myth that we all need 8 hours sleep – this is an average. We all have different sleep times. How much sleep you need will vary and depends on your age and your situation. Health issues that could arise from sleep deprivation It’s important to distinguish between sleep deprivation and insomnia. Sleep deprivation is a lack of opportunity to sleep i.e. in shift workers. Insomnia is difficulty sleeping despite opportunity. A lot of research looking at health issues is in people with sleep deprivation. The effects of sleepiness on mental health and our physical health are well documented. What is the optimum sleep routine? Bedtime routines are important as sleep is a learned behaviour; a bedtime routine is a repeated set of behaviours that prepare your body and mind for good sleep. Over time, our brain recognises these behaviours as a precursor to sleep, which makes it easier to sleep once you get into bed. Our ideal routine begins in the daytime, ensure that you drink plenty of water, exercise and manage your stress well and then go to bed and, more importantly, wake up at the same time each day. Clear your mind by writing in a journal/ notebook a few hours before bed, what went well, what didn’t go well, what can I do about it? Add a ‘to do’ list for the next day. This is important as it will stop your mind mulling over the day and worrying about tomorrow. Switch off screens and technology, partly to give ourselves a break between work and sleep, and partly reduce our exposure to blue light which disrupts the body’s circadian rhythm. Have a warm bath or shower, as the body temperature reduces, our bodies prepare to sleep. About 20 minutes before bed, start slowing the body and mind by dimming the lights, try reading, colouring, knitting, meditation or relaxation. It’s important to go to bed when sleepy tired (eye lids feel heavy, maybe yawning) rather than just go to bed because it’s 10.30pm and you think everyone goes to bed then. If you go to bed sleepy tired you are more likely to drop off to sleep more quickly. Changing our behaviour can feel daunting at times, so just try one of these suggestions at a time until they become second nature. What are the alternatives to sleeping pills? Many health care providers are reluctant to give out sleeping tablets because some people can become dependent upon them if used continuously for as little as 2 weeks. So here are some alternatives for you to try: Two of the most well-researched alternatives are camomile and passionflower tea. Also, one of the amino acids in green tea is thought to have a calming effect.Lavender: it’s often suggested that stimulating the senses at 10 min. intervals, 30 mins. before bed, will increase relaxation and you experience deeper sleep and more energy in the morning.Magnesium: this mineral is often called nature’s tranquilizer because of its calming properties and because it can help the body relax and unwind at the end of the day. You can eat it in foods such as kale, spinach, broccoli, nuts and seeds and pulses, which are great before bed.Studies have shown that magnesium taken through the skin can have an even more instant and calming effect on sleep than tablets. You can bathe in magnesium, use it in a foot soak, enriched body oil and/or moisturiser, allowing it to be absorbed through the skin.Morning light is important as it is most effective at setting our body clocks. If you can’t get outside, then sit by the window with your cup of tea in the morning.Stop worrying about sleep – to break the cycle, try going to bed an hour later and just allow yourself to rest, rather than worrying about not sleeping. Worrying arouses our flight/flight/freeze response which then prevents us from sleeping. Try thought stopping techniques such as saying the word ‘THE’ in your mind, over and over again.Various breathing exercises are very helpful, also relaxation, hypnosis, self- hypnosis or meditation.Cognitive Behaviour Therapy for Insomnia (CBT-I). Suggestions for a good night’s sleep The sleep-wake cycle, is directly influenced by behaviour. That means being exposed to too much light before bed or not getting enough light within an hour of waking, can impact one’s body clock. Remember that we feel, function and are healthiest when we work with our circadian rhythms and keep them in-line with the 24-hours, so establishing routines with eating, sleeping and exercising as best as possible maintains our rhythm and encourages health — emotional and physical. Check your basic sleep hygiene, look around your bedroom. Is it too hot/ too cold? Too light/ too dark? Is your bedroom cluttered? Make adjustments, as optimum sleep conditions are cool, dark and tidy. Consider reducing your caffeine intake and have a last coffee at least 4 hours before bed. People often don’t sleep because of sleep anxiety. They get caught in the vicious cycle, not sleeping, feeling anxious about not sleeping, so don’t sleep! It helps to change the way we think about our sleep rather than ‘I’m not going to get any sleep’, reframe this to ‘I will get some sleep’ as inevitably we do get some sleep. Relaxation will help, but it’s a skill, so will take some practice. It can be used effectively to reduce anxiety. Many people who experience sleep anxiety have other anxieties, so reducing or removing those will help sleep. Relaxation helps to focus your mind away from intrusive and worrying thoughts. Relaxation exercises can give you more of a sense of being in control – of your breathing, your muscles and your mind. Try this brief relaxation exercise: First look around and notice where you are.Then close your eyes and notice the sounds around you, whether that’s noisy neighbours, car doors shutting, horns honking outside, allow yourself to be there with the sounds.Take one deep breath to settle yourself.Then follow your breath, from the moment the air touches your nostrils as you inhale, feeling it fill up your chest and belly, and as it leaves your body as you exhale, noticing if the air feels warmer or colder.Repeat this for five deep breaths. Thought-blocking techniques are effective, working best with trivial information that just comes to mind, rather than more serious problems. It works by stopping other thoughts from getting in. When interrupting thoughts come to you in the middle of the night, start thought-blocking immediately before you are wide awake. Here’s how to stop those thoughts. Close your eyes and repeat the word ‘the’ slowly and calmly every 2 seconds in your head.‘Mouth’ the word rather than saying it out loud.Try to continue this for about 5 minutes (If you can). The word ‘the’ is meaningless and has no emotional effect. By repeating this word, it stops other thoughts getting into your mind, hence the term, thought-blocking. I hope that you find these strategies are helpful in improving your sleep – Sleep Well! How did you survive the hot nights during the recent heatwave in the UK? Share your tips with us on Facebook, Twitter or Instagram and be sure to follow us for more future blogs and content on RA.