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My Sleep Workbook is a personalised publication, one of a suite of workbooks, evaluation measures and other resources, in print and digital format. Core components are produced by Sustaincare Community Interest Company as

 and are linked to the SELF CARE LIBRARY (www.selfcare-library.info)

Š 2013 Sustaincare CIC, Exeter, England. All rights reserved. Other components are published with the agreement of their copyright owners and duly acknowledged. This series is published by Sustaincare CIC. However content and background resources remain the property of the copyright owners. This copyright, and the moral rights of all authors, are hereby protected by the publisher. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without permission in writing from the publisher at Notaries House, Chapel Street, Exeter, Devon, UK, EX1 1AJ. ISSN xxxxxxxxxx (beta only)

The authors and publisher have consulted independent authoritative sources and experienced practitioners to compile these materials. However knowledge and best practice in the health field are constantly changing. Each person and illness is also unique and no publication can anticipate every circumstance. There can be no guarantee that any written information is appropriate for every reader. The journal is ideally suited for use by individuals along with their health advisors. The latter should use their best professional judgment to guide the user, and both should defer to licensed medical practitioners for relevant diagnoses, prescriptions and other treatment plans. In the case of remedies or other products, users should read the label carefully for detailed information about safe use and in the case of natural products should choose responsible manufacturers with independently assured quality standards and safety monitoring procedures (for example registered herbal medicines in Europe, registered Therapeutic Goods in Australia or Natural Products in Canada). To the fullest extent of the law, neither the publisher nor the authors, contributors or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the materials herein.


What I can do with this book ... LEARN more about my sleep problem Work out what I WANT TO IMPROVE FIRST Work out my EASIEST and BEST first step - and do it Keep TRACK of this step with my diary MEASURE how I am doing on this step MOVE ON to the next step when I’m ready - if needed WORK THROUGH until I have a plan that works and to manage my sleep in the future

Check in with my doctor to be sure

Check in with my doctor / health professional when needed or arranged Get a new partnership with my doctor / health professional!

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My Sleep Workbook It’s three in the morning and you really need to go to sleep. You’ve tried everything you can think of and you still have bad nights. You need to sort this out – a proper plan. That is what this workbook is for. This is a compendium of the world’s best independent information, from experts who work with sleep problems. The information is turned into practical and natural steps that you can safely master at home. The aim is to turn you into your own sleep expert! The advice is based on both the best research evidence and on what many other people have found helpful. We will go through each exercise or remedy clearly so that you can check it off and if it does not work for you move on to the next step, until you find the approach that does. A really good way to make the changes that will bring longterm improvement is to record your progress. There are diary pages at the end of this book you can use as your personal sleep journal, either on-screen or as hard copy. With this you can check each approach by results. This is the best way to know what works and how well it works. The information is grounded in what independent experts know about sleep and how the body works. In particular we refer you to our major online resource, the SELF CARE LIBRARY, an evidence base for health care you can do yourself. Here we refer to the best published scientific papers so you can find out more about each approach. In this workbook we also refer you to relevant pages in independent online websites that we have found most helpful. All this should help you build your own sleep plan – one that makes sense to you.

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What we will cover in this workbook

About sleep and insomnia: page 4 Our best sources of information and further reading Why aren’t you sleeping? page 7 The main types of sleep problems and things that interfere with sleep – which apply to you? My Work Plan: page 15 Set out your own step-by-step plan for better sleep Steps towards better sleep 1) correcting interferences: page 18 Address things that may interfere with sleep - one by one 2) learning to sleep again: page 31 Work through different approaches that have helped people 3) sleep treatments: page 34 Medicines from the doctor or pharmacy Natural home remedies, classes and practitioners Your personal sleep journal: page 36 Set your goals and your sleep diary to check your progress Before we start ... If you are going to tackle your sleep problems yourself you should also know when to call for help. Sleep problems are occasionally signs of more serious underlying conditions. They can certainly make almost any medical condition worse. See more here. This workbook is designed to give you the tools to take back control of your problem but it cannot be a substitute for a personal assessment. It is your responsibility to yourself to get the best possible advice when you need it. This workbook should be used after you have seen your doctor or other health professional, and the medical implications of your sleep problems and possible treatments have been properly reviewed. If you have not had proper attention then do what you can to get it!

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About sleep and insomnia

What is sleep? Sleep provides an opportunity for the body to repair and rejuvenate itself. Animals deprived entirely of sleep lose all immune function and die in just a matter of weeks. Sleep is also known to play a critical role in brain development in infants and young children and reorganisation in adults too. The two main types of sleep are rapid-eye-movement (REM) sleep and non-rapid-eye-movement (NREM) sleep. These were identified by ‘EEG’ monitoring of brain waves:

Sleep starts by moving through 4 phases of NREM. Brain waves become slower and more synchronized, till in phase 4, the deepest stage, the brain waves become large and slow. This stage is referred to as "deep", "slow-wave" or delta sleep. Phase 4 is followed by a move back to REM sleep in a cycle lasting between one or two hours (longer as the night progresses). REM sleep, often called "active sleep," is marked by its characteristic small, fast brain waves and regular ‘alpha’ rhythm, as well as the rapid eye movements. REM sleep makes up 20-25% of total sleep in adults though 50% in babies. For sleep to be effective 15-25% should be spent in deep sleep.

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About sleep and insomnia

 Typically, when people are awakened from REM sleep, they report that they had been dreaming, often extremely vivid and sometimes bizarre dreams. In contrast, people report dreaming far less frequently when awakened from NREM sleep, although this is the time when night terrors can occur. During sleep some body functions slow down but others increase. In REM sleep many become more variable. The following activities increase during sleep: General: growth hormone, digestion, cell repair, protein synthesis, liver function REM sleep: brain activity, blood pressure, heart rate, regional blood flow (eg to genitalia)

Scan below with your smartphone QR reader to see the website

The following activities decrease during sleep: General: urine production REM sleep: body temperature NREM sleep: heart rate, blood pressure, brain activity and breathing, For more good quality information on the latest thinking about sleep go to the Harvard Healthy Sleep site.

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About sleep and insomnia

Scan below with your smartphone QR reader to see the website

Assess your sleep problems (do this yourself or with help) Have you checked out your sleep problems with your doctor? If you have had problems for more than a few months you should – to check for contributing medical problems. Have you also checked for reliable medical advice online? We recommend NHS Choices and their insomnia page. Do make sure as far as you can that other health problems do not apply to you. Take any such questions back to your doctor. Once you are ready to work on your sleep problems yourself and before you start you should also run though the pre-launch Self Care CHECKLIST (downloads as a pdf)

See the overview page in the Self Care Library

Further reading on sleep and sleep problems There are other expert resources and one useful smartphone app to help you better understand your sleep. Sleep Foundation: a good USA website for updated news and resources that is full of useful tips as well. You could also try the online Sleep profiler published by the BBC. Completing this helps you better to understand your sleep needs. For example are you a ‘lark’ or an ‘owl’ and what does that mean to how you get better sleep? App: try SLEEPBOT (free for iPhone and Android) to record and chart your overnight sleep sounds and activities! (see page15)

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Why aren’t you sleeping?

Main types of poor sleep 1

There are four main types of long-term sleep problems. To help you work out a recovery plan, we will number them. Please select each that applies to you. You may have more than one! For example Type 4 often comes with Type 2 or 3 (and can then make them worse). Type 1 can change to Type 2, especially if you have had to use a lot of sleeping prescriptions. Type 1: difficulty falling asleep (sleep onset insomnia) Type 2: awakening during the night with difficulty falling back to sleep (sleep maintenance insomnia), Type 3: early morning awakening (sleep offset insomnia) Type 4: poor quality sleep (non-restorative sleep).

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For more information go to the page numbered alongside each box.

                                                                                                              1

Czeisler CA et al. Harrison’s Principles of Internal Medicine” 15th ed. 2001: 155-163

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Why aren’t you sleeping?

Type 1: difficulty falling asleep (sleep onset insomnia) This is a common consequence of a stressful life, with many demands and distractions getting in the way of dropping off to sleep. The onset of sleep begins in the second stage of sleep. During the second stage of sleep (see page 4) your body temperature decreases, heart rate and breathing become regular and you become disconnected from your surroundings. If it takes longer than 30 minutes to fall asleep then you have this type of insomnia. I feel tired when I go to bed but can’t settle down for hours. It’s the same whatever time I go to bed: its like I cannot switch the film projector off!

If this is your type of sleep problem check any of the following common causes that apply to you. I drink caffeine, alcohol or take other stimulants or prescription medicines later in the day 21

I take physical activity late in the evening 20

I am often stressed, anxious, worried, or tense 22

A good way to approach this sort of sleep problem is with a stress management exercise. Later in this workbook we will look at things you can try especially in the afternoons and evenings to help you to settle better when you go to bed. beta edition – for review

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Why aren’t you sleeping?

There are some useful relaxation and breathing exercises that you can use just before bedtime. Check here or with your health professional for our guides to these.

Type 2: awakening during the night with difficulty falling back to sleep (sleep maintenance insomnia) This is a common pattern that can mean that you can be alert and restless for several hours in the middle of the night, typically from around 1am till 4am. No matter how tired I am I keep waking up in the middle of the night and cannot get back to sleep. I feel so much better after a good night’s sleep but the tireder I am it seems the harder it is to get one! There is an important point to make here. This sleep pattern was traditionally associated with conditions of depletion or low energy. Nowadays it may also be seen in people who have clinical depression. In other words, it has been associated with being run down rather than having too much energy! It is almost as though you need a certain amount of ‘battery charge’ to stay asleep and that when you are drained you might not be able to manage your sleep properly. It reminds us that sleep is actually a busy time for your body. It is time for repair, detoxifying and metabolic processing. Sleep is needed to give the body a chance to catch up with its housekeeping. It also means that sleeping pills might not be useful for this type of sleep problem. These medicines are usually sedatives, intended to reduce nervous activity – to help ‘knock you out’. If you are already run down these may even make the problem

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Why aren’t you sleeping?

worse. People have also noticed that this sort of sleep problem can occur after long-term use of sleeping pills for difficulty getting off to sleep. It seems to some sufferers that here is a vicious circle: you need sleep to recharge your batteries but they are too flat to allow you get enough sleep to do so. The more exhausted you feel after a broken night the harder it is to sleep through the next one! You end up in a long-term state of fatigue, low energy and often low mood. If this is your type of sleep problem check any of the following that also apply to you (see later pages for more things that might interfere).

There are lots of things that wake me up in the night 18-20

I am really tired and fall asleep easily in the day 32

I am often depressed 23

Type 3: early morning awakening (sleep offset insomnia) Commonly known as late or terminal insomnia, this occurs when you wake up very early in the morning and are unable to fall back to sleep. You may fall asleep easily but awaken after four or five hours. In some cases, you may fall asleep just before your alarm rings! Some people with this pattern refer to themselves as ‘early risers.’ However, when it leads to daytime sleepiness, poor concentration and irritability it suggests there is a problem to treat.

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Why aren’t you sleeping?

Scan below with your smartphone QR reader to see the website

Lighter sleep is the norm during the second half of the night and some sleepers may be more sensitive to outside stimulation during the early morning hours. Sounds, lights and movements that would go undetected during deep sleep might awaken a person during lighter sleep cycles. In a few cases this pattern is linked to a shift in body clock that means that you fall asleep early in the evening and wake up early as a result. This is called advanced sleep phase syndrome and if there is enough sleep is only a problem if the timing is upsetting. The usual approach is gradually advancing sleep time over several weeks (chronotherapy) or bright light therapy started as darkness falls in the evening. If sleep offset is your type of sleep problem check any of the following specific factors that apply to you.

I wake easily early morning light and sounds (eg traffic) 19

I have discomfort or pain that gets worse from lying through the night 25

I wake up hungry 21

I take alcohol and prescription drugs the evening before 21

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Why aren’t you sleeping?

Type 4: poor quality sleep (non-restorative sleep). Sleep can be interrupted for all sorts of reasons as well as those we have outlined in previous pages. It will be important to check off any medical reasons for poor sleep. These include asthma and other breathing problems, heart and circulatory problems, diabetes, Parkinsonism, and psychological problems. It will be advisable at this point to look again at a reliable medical resource like our recommended NHS Choices insomnia page.

Things that can interfere with sleep In the following pages we will list common barriers to sleep. We start with external and lifestyle interferences. Please check all those that apply to you. If none apply move on to the next page.

Uncomfortable, cold or noisy bedroom 18-20

Snoring partner 20

Restless family members (eg children, spouse, elderly relatives) Caffeine consumption (coffee, tea, guarana and stimulant drinks eg. Red Bull) Alcohol and recreational drug consumption

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21

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Why aren’t you sleeping?

Next check off health or medical factors that we know can interfere with sleep. Please tick all those that apply to you. Prescription medicines 21

Anxiety 22

Low mood or depression 23

Pain 24

Sleep apnoea (for definition see page 24) 24

Urinary frequency at night 25

Restless leg syndrome (see page 27) 27

Severe itching or other irritation 28

Blocked nose or tight airways 28

Difficulty breathing when lying down 30

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Why aren’t you sleeping?

REVIEW Have you found any simple steps in the previous pages you could take to improve your sleep? These can apply even if the problem is complex. In the following pages we will help you set up a work plan, starting with the simplest steps. We will plan this like a research experiment. It is important that you try each step on its own so that you can know whether it is useful. You should do it properly and for long enough (at least a week in most cases). If you think that something helps, you can carry on with it and move on to the next step. If something does not help you may still wish to carry on if it is generally good for you – or stop it and try the next step. Go to my Work Plan on the next page

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My Work Plan Choosing steps towards managing my sleep First achievements It is always good to start with little steps you can safely do yourself (avoid ones involving prescriptions and other medical complications that need your doctor or other professional). From the boxes you have ticked on previous pages, and from reading the following yellow-coded pages choose the most practical step to start with. DO share this with family members who can support you. First step I can do for myself (and with members of my family?)

TAKE ONE STEP AT A TIME and give each one a week to show whether it helps. If you want to make sure you know whether your steps are making any difference you should start to keep a sleep diary. This will allow you spot patterns over the coming weeks and will also help if you need to share your plan with someone else. Use the diary pages at the back of this workbook and get more as necessary. The first step could become your first move along the road! However if you have tried this and it has not worked well enough and there are other simple steps you can take, note the next here, and others on the continuation sheet at the back of this workbook. If you have a smartphone consider using the free app SLEEPBOT to generate daily charts of your nights. Record your progress with an app?

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How did I do? Did my sleep improve a lot, a little or not at all? Next step I can do

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My Work Plan Sleep work If you have run out of effective simple steps or cannot find one that you have not tried before then it may be time to tackle something that requires more organisation. You can do this work yourself or with the support of members of your family. They may involve changes in your routines and timings at home and it will generally help to share these with anyone at home so they can be your cheer leaders. Look at following orange-coded pages for advice, and links to other resources, on how to re-work your sleep time most effectively. My sleep work - where should I focus? (see also next page)

Sleep treatments There is a range of treatments that can help with improving sleep. You may have tried out many already. Look at the redcoded pages to check whether there are any you have not already tried that seem relevant to you. Note that many prescribed or natural remedies have only short-term effect. Keep looking for long-term solutions. Getting help? If you have really tried all the things you can do yourself you may need to call on professional help. It is always best to start with your family doctor who can also review your whole medical background in helping you chart your course and avoid risks. There are clear concerns about sleeping pills taken for too long and your doctor will offer them only for shortterm use. There might be referral to a specialist health professional: cognitive-behavioural therapy (CBT) or similar treatments could be considered.

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My Work Plan It may be that you want to take further advice. Traditional and complementary approaches to sleep may help. A well-trained practitioner will look at your sleep problems in the context of your whole life story and will come up with a plan that is specific to you. This may include sleep routines and a range of simple exercises for you to do. Traditional approaches were often to focus more on ‘recharging your batteries’ with supportive techniques (rather than sedation), especially if you are restless through the night (see page 34-35). The Self Care Library points to research evidence for sleep benefit for psychological therapies, hypnosis and related interventions, and yoga and tai chi classes. After you have read the rest of this workbook come back to the box below and headline an overall strategy for your sleep plan. My REGULAR ‘sleep hygiene’ plan

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Steps towards better sleep: 1) correcting interferences

Interferences o Uncomfortable bed, too much heat or cold o Noisy bedrooms, snoring partner, restless family members It is important to sleep in a darkened, noise-free environment in a comfortable bed. Unfortunately this can sometimes be hard to find. If living accommodation is difficult this can be a major interference with sleep. Parents do stay alert to young children; carers can sometimes be on call all night. A noisy partner can seriously damage rest. There are still many things you can do to improve even the worst situation. Go through the list below and add any that seem relevant to your list of simple steps on Page 15. Improving sleep comfort o Start with your bedroom. Just before we fall asleep, our bodies need to lose heat. Getting hot can disrupt this process: it helps to have some ventilation and not to heat up the bedroom too much. o For the same reason it is wise to have the right bedclothes: natural fabrics often ‘breathe’ better than synthetics and stop you heating up so much. On the other hand we cool down particularly during REM sleep and without warm enough covering we can chill too much. Wear plenty of bedclothes if you do not feel warm enough. You do not need to be glamorous for this purpose! o One thing that could be keeping you awake is your bed. It should be comfortable and is worth spending time and money on to get right. Lie on the mattress for 20 minutes to test it before you buy it. Some people advocate orthopaedic mattresses, especially for bad backs, but these may be too hard for many. Memory foam mattresses often transform the sleeping experience and may be well worth the extra cost. Some of the leading manufacturers (eg Tempur) offer 30-60 day return policies which can be very helpful in beta edition – for review

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Steps towards better sleep: 1) correcting interferences

Scan below with your smartphone QR reader to see the website

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making your choice). The material used may also be important: for some foam and synthetic fibre mattresses may retain too much body heat and interrupt sleep. You can find out more about beds from the British Sleep Council, an industry body that provides good generic advice on this aspect of sleep The pillow can be almost as critical. It is important that you experiment with different types to be sure which is most comfortable. There is no single good pillow: you might prefer a thick, thin, soft or hard pillow – or again memory foam. Do not overlook the oldest pillow style of all – a small roll of material under the neck which holds the spine straight (and which is still used widely in modern Japan for example). A duvet is often more comfortable than constricting blankets and has remarkable insulating properties. If you can buy two duvets go for around 4.5 tog for summer and up to 13.5 for winter. If you keep the same duvet all year round go for a tog value around 10 as a medium range insulation. Wear ear plugs if there are other noises that can disturb your night. Some people find background music or natural sounds helpful – usually best when sleeping alone! Light is a major disrupter of sleep in some people. Even the light of an alarm clock can be enough to reduce melatonin levels that are needed for good sleep. Remove all light sources. Put heavy curtains or blinds in the window to reduce unnecessary light (and outside noise). Eye masks can be very helpful to blanket out sensory stimulation, even when light is not the main problem.

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Steps towards better sleep: 1) correcting interferences

 New research suggests that LED screens, found in modern TVs, laptops, tablets and smartphones emit a surprisingly strong suppressor of melatonin. This hormone is produced in the dark and helps you sleep. Using your computer or watching late-night TV can disrupt sleep. The effect might be even worse for those who do not spend much time outside. Coming in for the evening after bright daylight is a natural stimulant to melatonin. Working inside during the day and then on TV and computer screens into the evening can reduce this melatonin-enhancement and lead to poor sleep. Try stopping the use of these screens later in the evening to see if that helps. Reducing distractions o Consider a good baby monitor if you are afraid to settle in case you miss a cry from a child or sounds from a relative you are caring for: knowing that you can hear them easily may allow you to relax more. o Snoring is caused by the weight around the neck restricting your airway, making it difficult to get air into your lungs. Although a small amount of snoring is fine, heavy snoring can be a serious problem (see also Sleep apnoea on page 24). In the case of a snoring partner discuss openly your need for sleep, and one of you could spend at least part of the night in a spare bed or on a couch in another room. Sleep and cuddling need not mix! Exercise and sleep o Regular exercise is a great way of improving your sleep - but be careful not to exercise close to bed time as this produces stimulants that stop the brain from relaxing quickly. o However there's new evidence that hormones released during sexual activity can promote sleep.

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Steps towards better sleep: 1) correcting interferences

Physical interactions o Caffeine consumption o Alcohol and recreational drug consumption o Prescription medicines

Scan below with your smartphone QR reader to see the website

Caffeine stays in your system for many hours, but is active in your brain for only about an hour. However, having large amounts of caffeine in your system will disturb your sleep. Caffeine also makes symptoms of anxiety worse (see page...). The use of such stimulants should be reduced for most people in the second part of the day, especially coffee, tea, maté, guarana and cola drinks. Some sports and party drinks (eg Red Bull) also contain stimulating taurine. If you need to keep alert, try taking a short nap when you feel sleepy. Current research shows a 15-minute nap beats tiredness more effectively than a cup of coffee (see page 32) Alcohol intake should also be reduced. Although it can make you sleepy short term it is more likely to lead to restlessness later in the night. By relaxing the throat muscles it is also a major contributor to snoring and sleep apnoea, affecting both you and your partner. It can also worsen high blood pressure and make it more likely that you will have to get up in the night to pass water. See this page on alcohol’s effects on sleep. Some prescription medicines can interfere with sleep. It is important to tell your prescriber if you have noticed sleep disruption worsening with a prescription. It is often possible to change prescriptions to reduce this effect. Some people find that certain foods can be too stimulating. For example a diet high in sugars (foods with a ‘high glycaemic index’) can lead to volatile blood sugar levels. A quick rise in blood sugar after eating kicks into an insulin-induced low blood sugar response (‘reactive hypoglycaemia’) that can increase nervous tension. The best evening meal may be a combination of ‘low glycaemic’ foods with protein (protein provides tryptophan, which converts to calming serotonin). For links to the most reliable diet information check our Diet Workbook. beta edition – for review

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Steps towards better sleep: 1) correcting interferences

Anxiety Trying to sleep when worried is very difficult and anxiety is a particularly common symptom reported by doctors who are asked to treat insomnia. This is often associated with too much of the wrong sort of stress during the day (modern stresses are sometimes harder to manage than those our ancestors battled with – now we tend to sit on them and bottle them up rather than react physically to them and blast them out of the body). Anxiety can affect all phases of sleep, especially not getting off in the first place. More severe anxiety (or panic) attacks may abruptly wake you up in the middle of the night with heart racing (tachycardia) and breathlessness. There are well-tested relaxation techniques to help reduce anxiety that may be well suited to the evening and bedtime. o

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Taking moderate exercise late in the afternoon (eg walking some of the way from work) can work the day’s adrenaline out of the system. The aim should be to get breathless for 5-15 minutes. You should allow several hours before bedtime to recover. A warm bath and warm drink late in the evening are well-known relaxants. They also dilate the blood vessels in your extremities and help cool the body. Reading a book or listening to the radio last thing is more relaxing than TV, video or computer activities. Try various mental games that can help close down mental overactivity. For example counting your breaths backwards from 100; choosing categories of items (eg animals, plants, countries, capital cities) and working through the alphabet (Aardvark, Badger, C...) Try aromatic herbs like hop pillows or lavender oil. At least as effective as well-timed physical exercise is a good breathing and relaxation session in the evening. See our separate Relaxation, Breathing and Exercise Workbooks for guidance. A simple exercise is Progressive Relaxation where you start at one end of the body by clenching and relaxing in turn. beta edition – for review

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See also the Self Care Library page on stress and anxiety

Low mood or depression Insomnia is strongly connected with depression – with each being known to lead to the other. Scan below with your smartphone QR reader to see the website

Managing depression is a subject that deserves much more space than we have here. It also is a job that best involves others. The simple act of talking can be a critical step, reducing isolation and building communication. There are some ‘talking therapies’ like Cognitive Behavioural Therapy (CBT) that have been proved effective for both depression and sleep problems and can often be prescribed by your family doctor. There is good evidence also for groups that offer creative therapies: these may also be available on prescription or see here for further information for the UK. The role of physical activity in relieving depression is comparable to its benefit for anxiety (see previous page), and for sleeping may be best done later in the day but not too close to bedtime. Walking can be notably effective, alone and in groups, especially in nature (‘Green Gym’) or by water (‘Blue Gym’). There is clear evidence that proximity to outdoor areas relieves the incidence of depression. Some doctors may also prescribe to local ‘eco-therapy’ groups who offer gardening, farm or outdoor activities specifically to improve mental health.

See also the Self Care Library page on depression

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Steps towards better sleep: 1) correcting interferences

 Pain Discomfort of any sort is a very common cause of broken sleep. Reducing overnight pain to get enough sleep is a priority, as overall pain management will be compromised if one is also tired. For example overnight could be the best time to take pain-relief medicines if you are reluctant to use them more often. It may also be possible to use more sedative pain killers if you use them only at night time. Do talk to your doctor about this. Much disruptive overnight pain comes from sore muscles (myalgia), inflamed joints (arthritis) and various back problems. It seems in some cases that it is very difficult to find a comfortable lying position. This is a good opportunity to review your mattress and pillow (see page 19). Sometimes warm baths before bed can reduce muscle pain; other times it may lead to more joint pain as the night wears on. See also the Self Care Library pages on back, joint, muscle and head pain There are many pain management approaches that can be applied in discussion with relevant health professionals. Some health centres have access to pain clinics for coordinated pain management. These may include physical therapies and complementary approaches like acupuncture any of which can be tailored to the extra sleep problems.

Sleep apnoea Obstructive sleep apnoea is marked by interrupted breathing during sleep. The muscles and soft tissues in the throat relax and collapse to block the airway, often for 10 seconds or more. This usually happens during snoring, with a gagging noise, an awakening and a gasp for breath. As one has to be awake for at least 30 seconds to remember it, it is possible to wake from beta edition – for review

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 a seemingly good night and still feel sleepy, even though there can be as many as 100 episodes an hour. However your partner may be alarmed to hear you stopping breathing in the middle of a snore and is often the one to raise the alarm. There are health risks associated with apnoea: it is associated with high blood pressure and there are raised risks of heart attacks and stroke. It is found much more in those overweight and a large neck size is a good predictor of apnoea. It is important that if your partner notices the signs that you go and report it to your doctor. o The long-term priority with sleep apnoea is to lose weight: even a few pounds can make the difference. o Lying on your back will make this problem worse. Try sleeping in different positions if you can. The old trick of sewing a tennis ball to the back of your pyjamas still works. o Taking sleeping pills to combat snoring may only make it worse, as it can further relax your neck muscles. Sleeping pills are considered ineffective as a treatment for snoring. Get advice from your doctor if snoring is a significant problem for you. See also the Self Care Library page on Sleep apnoea

Urinary frequency at night Nocturia is defined as the need to get up more than once in the night to pass water. Clearly this could disrupt sleep. There are many causes and these do need medical review. Sometimes nocturia is caused by the production of more fluid (polyuria), for example: o Excess alcohol intake o Prescription diuretics and other medicines o Sleep apnoea beta edition – for review

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 o o o o

Diabetes Chronic kidney disease Heart failure and circulatory disease Hormonal disruption, especially in the elderly

It can also follow disruption of bladder urine control or reduced bladder capacity at night o Bladder irritability (see below) o Prostatic problems in men, most often benign prostatic hypertrophy (BPH) but other causes need to be excluded o Pregnancy o Urethritis or cystitis or related inflammation (eg. interstitial cystitis) o Central nervous damage or disease Bladder irritability is the most common. It is usually not due to serious disease but can be distressing. Doctors may prescribe anticholinergic drugs. There are however many things that can be done for oneself or with professional help: Lifestyle changes o Reduce caffeine and alcohol intake. o It is generally not safe or effective to cut back on fluid intake as this can concentrate the urine and lead to build up of irritant breakdown products. It usually helps to drink more at he beginning of the day and cut back progressively towards night. o Reducing overweight o Barley water is an old and often effective home remedy for reducing irritation from urine itself. It is made by drinking the milky water left after boiling pearl barley. Bladder training o Pelvic muscle training, relaxation techniques, scheduled voiding intervals with stepped increases, . and suppression of urge with distraction

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Steps towards better sleep: 1) correcting interferences

Restless leg syndrome ‘RLS’ includes unpleasant discomfort and restlessness in the legs at night. It is common, especially among those over 65 years and among women. It is associated with iron deficiency, pregnancy and kidney dialysis, smoking, obesity, high blood pressure, loud snoring, use of antidepressant drugs, diabetes and lack of exercise. The first priority in correcting RLS is to make sure that iron levels are sufficient. Iron levels in the brain affect dopamine metabolism and in one study three-quarters of people with RLS had decreased iron stores. Iron levels in the blood further drop by over half at night. Oral supplementation of iron has resulted in significant clinical improvement.. Other supplements and treatments have also shown to be helpful, including in clinical trials. o Folic acid o Magnesium (12.4 mmol/day = 301 mg/day) o Valerian (800mg/day of medicinal quality for 8 weeks) RLS is also common in pregnancy and with varicosed veins where there is pooling of blood in the legs, stretching of the vein walls and red blood cell aggregation. After treatment for superficial varicose veins the vast majority reported an immediate improvement in their restless legs. Conventional medical treatment for RLS focuses on drugs for the nervous system, especially dopaminergic agents. Many of these drugs are quite powerful and should be reserved for more severe cases. See also the Self Care Library page on RLS

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Steps towards better sleep: 1) correcting interferences

Severe itching or other irritation Dry skin or eczema/dermatitis are all typically associated with itching that is worst at night. It may be the increased warmth and lack of ventilation around the skin, and is also likely to reflect changes in hormone and immune function at night. The following steps may help to relieve night time irritation while steps are taken to improve the wider problems. o Keep the itchy skin well moisturized with E45 or other non-perfumed simple moisturizing cream. A petroleum gel can be applied under gloves or socks to hands and feet before bed. o Avoid long hot showers as these quickly strip your natural oils. Brief warm baths are better, perhaps with added oil (oleatum). o Avoid using soap for washing the affected areas: excellent alternatives that do not strip natural skin oils are oatmeal (make a muslin cloth bag, fill with oatmeal, add hot water and use as a scrub) or china clay/kaolin/Fuller’s earth (reconstitute the powdered clay with warm water, paste over the skin and rinse with lukewarm water). o Wear cotton or silk bedclothes rather than wool or synthetics; duvets rather than blankets, and in other ways try to reduce heat build-up around the skin. o Closely trim your nails or wear gloves to reduce skin damage through itching at night. o Use medication like hydrocortisone creams and antihistamines with great care and only briefly as they can easily be counterproductive. See your doctor for more advice. Blocked nose or tight airways We all get colds which can interfere with sleep for a few days. Longer-term congestion or difficulty breathing may be due to sensitivities of allergies to something in the air, especially in the bedroom. Some reactions are easy to spot, for example to pollen in season or to pets, and you should avoid exposure to these as much as possible (by keeping windows closed for outdoor irritants and keeping pets frequently washed and well beta edition – for review

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Steps towards better sleep: 1) correcting interferences

away from the bedroom). Other sensitivities, to mould spores, house mites, and other house dust particles, are harder to spot. All however will be relieved by a ‘deep clean’ of the bedroom: o Remove all dust traps like soft toys, books, knickknacks, cushions and as far as possible replace (or cover) carpets and heavy curtains with materials that you can wipe or easily clean. o Replace feather pillows and blankets with duvets and synthetic fillings and wash regularly o Cover your mattress with plastic covers and wipe weekly o Vacuum the room weekly (wear a face mask while doing this) o Consider a complete clear out of the room washing everything possible and attacking all corners and surfaces perhaps with hiring or acquiring a vacuum with allergy filters (to pick up mould spores and dust mites) o If the room is damp, hire or buy a dehumidifier, put on any central heating during the day and then ventilate during the night (unless there is damp and traffic outside) – this is a time when a cold aired bedroom may help. Check and replace filters on any airconditioning units regularly. There are things you can do to relieve symptoms at any time o Use inhalations with aromatic oils on a tissue on your pillow, in steam inhalations or in the room (Karvol have a number of products using oil of pine, cinnamon and menthol and Olbas oil is possibly a stronger option). Steam inhalations (adding just-boiled water to a bowl and inhaling under a towel) can be augmented by volatile oils as above or strewing the water with chamomile flowers (if not allergic to them) o Salt water drops or sprays can be very effective and are made at home by dissolving a ¼ teaspoon of salt in a cup of warm water and storing for no more than a week at a time in a closed bottle. The salt water can beta edition – for review

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Steps towards better sleep: 1) correcting interferences

o

be applied with a dropper into each nasal cavity while lying down or by a spray bulb or can (like used for misting plants) Decongestants based on pseudoephedrine, phenylephrine or dextromethorphan have short-term benefits in some cases but are also prone to a ‘rebound effect’ if used too often.

Difficulty breathing when lying down If you find you have to prop yourself up to breathe easily you must go and see your doctor. This usually points to difficulties with lung and/or heart functions and is not something to treat by yourself.

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Steps towards better sleep: 2) learning to sleep again

 Sleep hygiene This is a term used to describe good sleep habits. Sleep hygiene is associated with rules to regulate sleep patterns in a busy life. Importantly it works on the principle that many sleep problems are due to bad habits built up over a long period and that you need to rebuild better habits over weeks and months. Sleep hygiene focuses on the long-term objectives rather than individual poor nights. The most important sleep hygiene recommendation is to maintain a REGULAR SLEEP AND WAKE PATTERN every day. Required sleep time should be worked out for each person. It may need to be shorter (say 7 hours) if you are not sleeping well at night, relatively longer if you are dropping off to sleep in the day. Once worked out you should aim to stick with this through to the long term. In a sleep hygiene regime you should o go to bed at the same time each day o get up from bed at the same time each day (regular sleeping-in rarely helps) o use your bedroom only for sleep and sex (not as an office or media centre!) o avoid sharing your bed with children and pets o get up if you cannot stay asleep (see discussions on the next two pages) o avoid stimulating activities before bed (except sex which can help sleep) o get regular exercise but not too close to bed time o spend some daytime outdoors or in natural light (especially in the morning) to help generate melatonin o keep bedroom dark and temperatures comfortable o avoid clock watching or obsessing about each night. Sleep hygiene principles give us a framework for this workbook. Many tips in previous pages can best be built into your personal sleep plan. On page 17 and the Continuation Sheet at the end of this workbook there is an opportunity to sum these up.

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Steps towards better sleep: 2) learning to sleep again

When may napping help? One of the most difficult questions is whether a nap outside sleep time is helpful. Some sleep hygiene advice is against this. However in many cultures, particularly those in warmer climates, afternoon napping is commonplace and is built into daily routines. It is not uncommon for stores and government offices to close and for many activities to stop for an hour or two every afternoon. Afternoon naptime coincides with a dip in alertness, often during the warmest period of the day and after a mid-day meal. Naps for most people typically last between 30 and 60 minutes. Any longer and there is a risk of falling into deep sleep and having a difficult time waking. Following a nap, many people report feeling better able to stay awake and alert in the late afternoon and evening. This increased alertness typically causes people to go to bed later and generally to sleep less at night than people who do not take naps. According to some sleep experts who take all this into account, napping can be a good way for people who do not sleep well at night to catch up. It is possible to combine all the best advice as follows. Napping -­‐ for 10-30 minutes in the day may benefit; -­‐ may be disruptive if you have insomnia and strict sleep hygiene rules are the priority; -­‐ late at night is most likely to disrupt the night’s sleep Sleep segmentation There is a radical alternative approach to sleep planning that deserves attention in difficult insomnia cases. It is based on the realization that sleeping in solid blocks is not the only biological pattern and that there are many precedents for humans to sleep in separate shorter batches. There are approaches to insomnia that work on segmenting sleep into blocks. These are particularly appropriate for Type 2 Sleep Maintenance Insomnia (pages 9-10)

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Steps towards better sleep: 2) learning to sleep again

It may not be essential that you sleep in one solid block. Most animals in the wild sleep in short bouts (animal sleep patterns) and early humans probably did as well. It could be dangerous to sleep too deeply if you live outdoors! In the days before electric light it is was also quite common for Europeans to go to sleep at dusk and wake up for a break around midnight. After getting up, socializing, writing, or making love there would be a second block of sleep starting in the early hours. Prayer manuals from the late 15th Century offered special prayers for the hours in between sleeps (Tahajjud is the Arabic word for night prayer). The two separate blocks of sleep were sometimes referred to as ‘first’ and ‘second sleep’: this was not universally followed! Don Quixote followed nature, and being satisfied with his first sleep, did not solicit more. As for Sancho, he never wanted a second, for the first lasted him from night to morning." Miguel Cervantes, Don Quixote (1615)

Those who wake up in the wee hours may be reverting to an early pattern. One tactic might therefore be to work with this rather than fight it. There is a fascinating website that introduces segmented sleep and other polyphasic sleep patterns as well as the science behind them, This will make very interesting reading for anyone with long term sleep problems.

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Steps towards better sleep: 3) sleep treatments

Evidence-based approaches The SELF CARE LIBRARY has published research reviews of the following treatments for sleep problems Natural remedies that can be tried at home o Chamomile o Hops o Lavender o Melatonin o Passion flower o Valerian o Vitamin B and other supplements Classes and practitioners to consider looking out for o Acupuncture o Hypnosis, Autogenic Training and guided imagery o Massage o Psychological therapies o Tai chi o Yoga

Other traditional approaches

Check out the Herbal Hub sleep problems page for help on choosing reliable herbal options

Herbal strategies. o Traditional calming herbs can be taken throughout the day to prevent a buildup of tension or mental excitability that might result in sleep upsets. An additional dose is

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Steps towards better sleep: 3) sleep treatments

o

o

then recommended around 1 hour before bed. If the insomnia is not severe, then the herbs can be taken as a single dose before bed. Key herbs include valerian, kava, Zizyphus, hops, lemon balm, magnolia, lavender, passionflower, California poppy and chamomile. Restorative or ‘tonic’ remedies may be used by professional practitioners in sleep maintenance insomnia, non-restorative sleep or sleep problems associated with low mood, depression, chronic fatigue syndrome or fibromyalgia. These include ashwagandha, St John’s wort, skullcap, licorice, rehmannia, damiana, rhodiola and schisandra. Some traditional remedies may help when pain interferes with sleep. Willow bark is useful for pain associated with inflammation, whereas cramp bark, kava and wild yam will help to alleviate pain associated with abdominal cramps.

Magnesium Research has that low levels of magnesium in the body can be unsettling at night. Two doses of magnesium citrate per day with the last one at night may be helpful. Magnesium is also found in seeds, nuts and green leafy vegetables. Iron This is often deficient in people suffering restless leg syndrome (see page 27) and folic acid and magnesium supplementation have also been helpful here. Vitamin B complex Research has that low levels of magnesium in the body can be Supplementation with B vitamins has been found helpful in a range of conditions marked by fatigue and depletion and this may coincide with some chronic sleep problems.

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My SLEEP DIARY

Week ......

Monday My STEPS / changes eg diet / events

symptoms / scores?

Hours sleep

hrs

Insomnia score

best

1 2 3 4 5 6 7 8 9 10

worst

Fatigue score

best

1 2 3 4 5 6 7 8 9 10

worst

Other symptoms

Tuesday My STEPS / changes eg diet / events

symptoms / scores?

Hours sleep

hrs

Insomnia score

best

1 2 3 4 5 6 7 8 9 10

worst

Fatigue score

best

1 2 3 4 5 6 7 8 9 10

worst

Other symptoms

Wednesday My STEPS / changes eg diet / events Hours sleep

symptoms / scores? hrs

Insomnia score

best

1 2 3 4 5 6 7 8 9 10

worst

Fatigue score

best

1 2 3 4 5 6 7 8 9 10

worst

Other symptoms

Thursday My STEPS / changes eg diet / events

symptoms / scores?

Hours sleep

hrs

Insomnia score

best

1 2 3 4 5 6 7 8 9 10

worst

Fatigue score

best

1 2 3 4 5 6 7 8 9 10

worst

Other symptoms


My SLEEP DIARY

Week ......

Friday My STEPS / changes eg diet / events

symptoms / scores?

Hours sleep

hrs

Insomnia score

best

1 2 3 4 5 6 7 8 9 10

worst

Fatigue score

best

1 2 3 4 5 6 7 8 9 10

worst

Other symptoms

Saturday My STEPS / changes eg diet / events

symptoms / scores?

Hours sleep

hrs

Insomnia score

best

1 2 3 4 5 6 7 8 9 10

worst

Fatigue score

best

1 2 3 4 5 6 7 8 9 10

worst

Other symptoms

Sunday My STEPS / changes eg diet / events

symptoms / scores?

Hours sleep Insomnia score

best

1 2 3 4 5 6 7 8 9 10

worst

Fatigue score

best

1 2 3 4 5 6 7 8 9 10

worst

Other symptoms

WHOLE WEEK REVIEW My STEPS - what did I try this week? How did my scores change? Any other links spotted?

hrs


My Work Plan continuation sheet  Use this sheet to follow on from pages 16-17. Use the next page to extend your notes on your sleep hygiene plan. Next step I can do

How did I do? Did my sleep improve a lot, a little or not at all?

Next step I can do

How did I do? Did my sleep improve a lot, a little or not at all?

Next step I can do

How did I do? Did my sleep improve a lot, a little or not at all?


My Work Plan continuation sheet  Next step I can do

How did I do? Did my sleep improve a lot, a little or not at all?

Further notes on my Sleep Hygiene plan ....

It’s the end of first month now. How am I doing? How regular have I been at sticking to the regime? Do I need to check in with anyone?

Sleepworkbook beta  
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