About one in five people has some difficulty with sleeping. However, there are many things you can do to help yourself. This page aims to show you some of them. For example, simple things like winding down before bedtime, avoiding certain foods and drinks, and a bedtime routine can help. Further ways to promote sleep in more difficult cases include relaxation techniques, regular exercise, and behavioural and cognitive therapies. Sleeping tablets are not the best way to help with sleep problems because you can get addicted to them, and they often stop working if you take them regularly.
Understanding normal sleep
A normal night's sleep has three main parts:
Each night, about 4-5 periods of quiet sleep alternate with 4-5 periods of REM sleep. In addition, several short periods of waking for 1-2 minutes occur about every two hours or so, but occur more frequently towards the end of the night's sleep.
Normally, you do not remember the times that you wake if they last less than two minutes. If you are distracted during the wakeful times (for example, a partner snoring, traffic noise, etc) then the wakeful times tend to last longer, and you are more likely to remember them.
What is insomnia?
Insomnia means poor sleep. About one in five adults does not get as much sleep as he or she would like. Poor sleep can mean:
If you have poor sleep, you may be tired in the daytime, have reduced concentration, become irritable, or just not function well.
What is a normal amount of sleep?
Different people need different amounts of sleep. Some people function well and are not tired during the day with just 3-4 hours' sleep a night. Most people need more than this. To need 6-8 hours per night is average. Most people establish a pattern that is normal for them in their early adult life. However, as you become older, it is normal to sleep less. Many people in their 70s sleep less than six hours per night.
So, everyone is different. What is important is that the amount of sleep that you get should be sufficient for you, and that you usually feel refreshed and not sleepy during the daytime. Therefore, the strict medical definition of insomnia is ... 'difficulty in getting to sleep, difficulty staying asleep, early wakening, or non-restorative sleep despite adequate time and opportunity to sleep, resulting in impaired daytime functioning, such as poor concentration, mood disturbance, and daytime tiredness'.
What are the causes of poor sleep?
Poor sleep may develop for no apparent reason. However, there are a number of possible causes which include the following:
Concern about wakefulness
You may remember the normal times of being awake in the night. You may feel that to wake in the night is not normal, and worry about getting back off to sleep. You may clock watch, and check the time each time you wake up. This may make you irritated or anxious, and you are more likely to remember the times of wakefulness. You may then have an impression of having a bad night's sleep, even when the total amount of time asleep was normal.
Poor sleep is often temporary. This may be because of stress, a work or family problem, jet-lag, a change of routine, a strange bed, etc. Poor sleep in these situations usually improves in time.
Anxiety or depression
You may find it difficult to switch off your anxieties about work, home or personal problems. Also, poor sleep is sometimes due to depression. Other symptoms of depression include: a low mood, lethargy, poor concentration, tearfulness, and persistent negative thoughts. Depression is common. Treatment of depression or anxiety often cures the poor sleep too.
This sometimes occurs in people who snore, most commonly in obese people. In this condition the large airways narrow or collapse as you fall asleep. This not only causes snoring, but also reduces the amount of oxygen that gets to the lungs. This causes you to wake up to breathe properly. You may wake up many times each night which may result in daytime tiredness. See separate leaflet called 'Sleep Apnoea' for details. Note: most people who snore do not have sleep apnoea, and do sleep well.
Various illnesses keep some people awake. For example, illness causing pain, leg cramps, breathlessness, indigestion, cough, itch, hot flushes, mental health problems, etc.
These can interfere with sleep. There are three common culprits.
For example, ecstasy, cocaine, cannabis and amfetamines can affect sleep.
Some medicines sometimes interfere with sleep. For example, diuretics ('water tablets'), some antidepressants, steroids, beta-blockers, some slimming tablets, painkillers containing caffeine, and some cold remedies containing pseudoephedrine. Also, if you suddenly stop taking regular sleeping tablets or other sedative medicines, this can cause rebound poor sleep.
Some people just need less sleep than others. If your sleep pattern has not changed, and you do not feel sleepy during the day, then you are probably getting enough sleep. Older people and people who do little exercise tend to need less sleep. Some people think they should be able to nap during the day - and sleep eight hours at night!
A vicious cycle
Whatever the initial cause, worry about poor sleep, and worry about feeling tired the next day, are common reasons for the problem to become worse.
Doctors sometimes classify poor sleep (insomnia) into the following categories:
What can I do to help improve poor sleep?
This section will discuss five topics which can help to promote better sleep - understanding some facts, sleep hygiene, relaxation techniques, daytime exercise, and cognitive and behavioural treatments. In effect, these can be used in a step-wise fashion. You need only go on to the next step if the previous step is not very helpful, but each step requires a greater degree of effort.
Understanding some facts
It is often helpful to understand that short periods of waking each night are normal. Some people are reassured about this and so do not become anxious when they find themselves awake in the night. Also, remember that worry about poor sleep can itself make things worse. Also, it is common to have a few bad nights if you have a period of stress, anxiety or worry. This is often just for a short time and a normal sleep pattern often resumes after a few days.
General tips for sleeping better (often called sleep hygiene)
The following are commonly advised to help promote sleep and are often all that is necessary:
These aim to reduce your mental and physical arousal before going to bed. Relaxation techniques may help even if you are not anxious, but find it hard to get off to sleep. There are a number of techniques. For example, progressive muscular relaxation has been shown to help promote sleep. This technique consists of tensing and relaxing various muscle groups in sequence.
Your GP or a counsellor may be able to recommend a CD that takes you through deep breathing exercises, and other methods to help you relax.
Regular daytime exercise can help you to feel more relaxed and tired at bedtime. This may help you to sleep better. (However, you should not do exercise near to bedtime if you have insomnia.) If possible, do some exercise on most days. Even a walk in the afternoon or early evening is better than nothing. However, ideally, you should aim for at least 30 minutes of moderate exercise on five or more days a week.
Moderate exercise means that you get warm and slightly out of breath. You do not need to go to a gym! Brisk walking, jogging, cycling, climbing stairs, heavy DIY, heavy gardening, dancing, and heavy housework are all moderate-intensity physical exercises.
Although exercise to improve sleep is often thought of as common sense - there is some research evidence to back this up. One research study looked at some older people with primary insomnia. The study compared a group of people who embarked on a programme of moderate-intensity exercise to a group who did not exercise. After 16 weeks, on average, the exercise group had a significantly improved quality of sleep, a reduced time taken to fall to sleep, and an increased time spent asleep, compared with the group who did not do exercise.
Behavioural and cognitive therapies
If you have severe persistent poor sleep, your doctor may refer you to a psychologist or other health professional for behavioural and/or cognitive therapies. Research studies have found that there is a good chance that behavioural and cognitive therapies will improve sleep in adults with insomnia.
There are various types or therapy and they include the following:
Stimulus-control therapy This helps you to re-associate the bed and bedroom with sleep, and to re-establish a consistent sleep/wake pattern.
Sleep restriction therapy Very briefly, the principle of this treatment is that you limit the time that you spend in bed at night. As things improve, the time in bed is then lengthened. An example of the way that this may be done in practice is as follows:
Relaxation training This teaches you ways of reducing tension. For example, this may include the progressive muscle relaxation technique as described earlier, plus various other techniques described earlier.
Paradoxical intention This involves staying passively awake, avoiding any intention to fall asleep. Its use is limited to people who have trouble getting to sleep (but not maintaining sleep).
Biofeedback This provides visual or auditory feedback to help you control certain body functions (such as muscle tension).
Cognitive therapy Briefly, cognitive therapy is based on the idea that certain ways of thinking can trigger or fuel certain health problems, such as poor sleep. The therapist helps you to understand your thought patterns. In particular, to identify any harmful or unhelpful ideas or thoughts which you have that can contribute to you not sleeping well. The aim is then to change your ways of thinking and/or behaviour to avoid these ideas. Also, to help your thoughts to be more realistic and helpful. Cognitive therapy is often used in combination with a behavioural intervention (such as stimulus control, sleep restriction, or relaxation training); this is then called cognitive behavioural therapy (CBT).
What about sleeping tablets?
Sleeping tablets are not usually advised
The main types of sleeping tablets are in a class of medicines called benzodiazepines, or in a class of medicines called Z medicines. In the past, sleeping tablets were commonly prescribed. However, they have been shown to have problems, and are now not commonly prescribed.
Possible problems with sleeping tablets include:
Sometimes a sleeping tablet is advised
If a sleeping tablet is prescribed, it is usually just a short course (a week or so) to get over a particularly bad patch. Sometimes a doctor will advise sleeping tablets to be taken on only two or three nights per week, rather than on every night. This prevents tolerance or dependence to the tablet from developing.
Melatonin is, strictly speaking, not a sleeping tablet. Melatonin is a naturally occurring hormone made by the body. The level of melatonin in the body varies throughout the day. It is involved in helping to regulate the circadian rhythms (daily cycles) of various functions in the body. A melatonin supplement is sometimes advised in older people (more than 55 years of age) with persistent insomnia. The recommended duration of treatment is for three weeks only.
Valerian and other herbal remedies are not recommended
Herbal remedies are used by some people to help with sleep. For example, valerian. However, research studies have shown that there is very little evidence to show that they work. Therefore, they are not recommended.
A final note
See a doctor if you feel that illness or medication is causing poor sleep. Treating any underlying condition that is causing the problem, if possible, can help to promote sleep. In particular, depression and anxiety are common causes of poor sleep and can often be treated.