Sleep Problems: A Help Guide

You do not have to suffer insomnia to have a sleep problem. In fact insomnia is only one of a range of issues that come under the umbrella of sleep problems.

A sleep problem is an ongoing difficulty getting enough sleep so that you feel able to function well during your waking hours.

Sleep problems are very common. A recent study shows up to one in three adults claim to have difficulties sleeping, with a greater incidence found in women, children, and the elderly. 

The main categories of sleep problems are as follows:

Getting to sleep: This is commonly known as 'insomnia'. It involves lying awake instead of sleeping. Or, your problem might be you can't sleep during the hours allotted but want to sleep during daytime hours instead.

Staying asleep: This can mean waking up one or several times during the night, having troubles falling back to sleep again, and/or waking up far earlier than desired.

Quality of sleep: Always feeling tired no matter how much you sleep, or tossing and turning often.

Schedule of sleep: Sometimes although you can sleep, it is at hours when everyone else is awake, which challenges your capacity to hold down a job or otherwise have a normal life.

Of course we all tend to sleep poorly during times of extreme stress, so if you suffer a few nights of missed sleep but then are back to normal, it is not a sign of a sleep problem.

The signs of a general sleep problem can include the following: 

• problems getting to sleep
• problems staying asleep
• sleeping, but only lightly
• persistent or frequent nightmares
• waking up in the night and not being able to get back to sleep
• waking up too early every morning then not being able to get back to sleep
• constant daytime fatigue and ongoing lack of energy
• repetitive activities like driving, watching tv, or reading see you nodding off
• feeling exhausted even when you sleep many hours every night
• a reliance on sleep aids like over the counter medication to get any sleep
• the need for naps daily
• overconsumption of caffeinated beverages simply to keep going
• problems concentrating or thinking clearly
• emotions that seem too 'at the surface' or overreactive and unstable
• slow physical and cognitive responses

The above symptoms include the signs of the most common sleep 'disorder', insomnia. Sometimes divided into difficulty falling asleep (sleep onset insomnia) and difficulty staying asleep (sleep maintenance insomnia), it is in general the inability to get enough sleep to feel rested during your waking hours.

There are other sleep disorders besides insomnia. They can have more marked symptoms and tend to be more genetic and brain-based then regular sleep problems, which tend to be stress and anxiety related. The main sleep disorders and their symptoms are as follows: 

Sleep apnea (involving issues with your upper airways, meaning when asleep you sporadically stop breathing and suddenly wake up) 

• often told you gasp or snore during the night
• wake up with a dry throat and chest pains

It's important if you suspect you have sleep apnea you seek help, as it can be life-threatening. It is, however, easily treatable with a mask that monitors airflow.

Restless leg syndrome (a recognised neurological condition connected to an imbalance of dopamine)

• a consistent urge to move your legs and arms even when at rest
• an unbearable tingling or itching sensation in your legs as you try to sleep
• waking up with muscle cramps

Narcolepsy (a disorder where the part of your brain that regulates sleep is dysfunctional, so you experience uncontrollable sleepiness in the daytime)

• unable to stay awake even during inopportune moments like when driving or at work
• starting to have dreams even before you are properly asleep
• often have vivid hallucinations or 'hear things' as you are falling asleep
• weak muscle coordination when you have strong emotional responses like anger or laughter

Idiopathic hypersomnia (excessive oversleeping or sleepiness with no explainable cause, different then narcolepsy)

• often sleep more than 10 hours at night and wake up feeling 'drunk' on sleep
• have good quality deep sleep (unlike narcolepsy) and yet still feel tired
• possible loss of appetite
• problems with remembering things and thinking clearly
• daytime naps don't feel refreshing (unlike with narcolepsy where they do)

Delayed sleep phase disorder (having an inner 'sleep clock' on a very different setting than those of others)

• can't fall asleep until at the earliest 2 a.m. no matter how hard you try (so not the same as 'being a night owl')
• sleep well when you do sleep, just at irregular and often unsocial hours
• if left to your own biological clock you develop a regular sleep pattern albeit not matching others
• you are possibly a teenager (although this disorder can carry over into adulthood)

Often, people think they have a sleep problem just because they don't sleep for eight hours a night.

It is simply not true that we all need eight hours sleep. There are not any hard and fast rules about sleep, other than that you can tell if you get enough by how refreshed and clear-minded you feel in the daytime. In general you require less sleep the older they get, with babies sleeping up to seventeen hours and an older person maybe needing less than six hours, but that also depends on how active one is. If you are sleeping few hours but feel energised in the day, you don't have a sleep problem.

It is also not true that just because stress has temporarily disrupted your sleep patterns that you now have a problem. If you are experiencing a challenging few weeks, such as starting a new job, or moving house, it's normal to have disturbed sleep temporarily. Try improving your sleep hygiene (see 'Treatment' section below for more on this) and see if your sleep goes back to normal before assuming you have an issue. A real sleep problem is ongoing, and diagnosis generally requires that it has persisted for at least a month. 

If you have a sleep 'disorder', it can be related to the way your brain works and might therefore be biological and genetic.

Or, your problems with sleep can be physical, related to another health condition you are unaware of, such as your hormones going through changes, or the effects of a medication you are taking.

But in general, sleep problems are often environmental - caused by what else is going on in your life. When life becomes challenging, many of us tend to worry instead of sleep, and this anxiety can flood our bodies with cortisol that makes it even harder to relax and let go.

Common causes of sleep problems are thus as follows:

• stress and anxiety
• depression
• bereavement
• a new environment you aren't used to
• a new schedule (new job, new shifts, jet lag)
• poor sleep setup (bed, noise and light levels, etc)
• medication
• health issues (bladder troubles, chronic pain)
• hormonal problems
• mental health disorders (schizophrenia, bipolar disorder, PTSD)
• overuse of caffeine
• alcohol and drug use

Sometimes, stressing about sleep itself can end up being your sleep problem. A person might worry that because they aren't getting the apparently 'normal' eight hours sleep they have heard about there is something wrong with them, and this worry itself can lead to not sleeping at night. Age changes the amount of required sleep, and some people seem to just need less then others.

If your troubles with sleep are persistent and ongoing to the extent they are negatively affecting your work life and relationships, if you have had insomnia for four or more weeks, and/or if you have tried general sleep advice (such as that below) to no avail, then it's a good idea to see your GP.

Your GP can ask you a series of questions and possibly run different health checks to determine what might be at the root of your issues with sleep, and whether it might be a medical condition or related to another health condition.

*If you have any symptoms of a sleep disorder, like snoring and snorting in your sleep and waking up unable to breathe, or falling asleep during activities in the day like driving and putting yourself in constant danger, do see your GP as soon as possible.

Your GP will first talk to you about good sleep hygiene to see if there is a practical way to sort your sleeping problems. This might include:

• keeping a regular sleep schedule, even at the weekends
• giving enough hours to sleep
• making your bedroom a better sleep environment that is dark, quiet, and cool
• changing your mattress and discussing sleep routines with your partner
• taking electronic equipment out of your bedroom (their light disrupts sleep)
• making exercise a regular part of your routine
• not using electronics (tv, computer, ipad, phone) for a few hours before bed
• reducing or eliminating caffeine, alcohol, cigarettes, and any other stimulant

They might give you a short-term prescription for sleeping pills, but this is not a preferred treatment for sleeping problems in the UK and they are not recommended for use over the long-term.

If your insomnia appears anxiety and mood related they might refer you for Cognitive behavioural therapy (CBT) to help change thoughts and behaviours that are contributing to your inability to sleep.

Otherwise, if required or if a sleep disorder is suspected, your GP will refer you to a sleep specialist or to a sleep clinic.

Depression and anxiety are the most common psychological issues related to sleep problems. Sometimes it's hard to say which came first, as insomnia can also lead to anxiety and depression (although it has not yet been proven that lack of sleep directly causes insomnia, only that it increases the risk of depression).

Often, low moods and insomnia are an interlinked web, with, for example, a little bit of depression causing sleeplessness which leads to more depression and anxiety as it's harder to manage your moods when you are exhausted. It's therefore important to treat both the sleep problem and the anxiety and/or depression.

Other related psychological issues to sleep problems include:

• Post-tramautic stress disorder
• Anxiety
• Bipolar disorder
• Schizophrenia

Your GP or mental health professional can help you determine if one of these issues is behind your sleep problems.

Sleep is important for our cognitive functioning, mood regulation, and immune system. In the long term lack of sleep can leave you unable to function well at work and home, suffering mood swings and depression that can cause relationship problems, and constantly suffering low grade colds and flu as well as feeling worn out.

Lack of sleep can lead to premature aging. When you don't sleep enough, your body releases extra cortisol, which breaks down collagen and can lead to high blood pressure. And your body will also not release enough growth hormone, which is needed for muscle mass and bone strength.

Lack of sleep has also been linked to obesity. Research has found a link between sleeping and peptides, the chemical that regulates appetite in the body. If you don't sleep enough you might lose your proper body response that tells you when you are satiated, leaving you suseptible to overeating. 

Useful self-help books

Overcoming Insomnia and Sleep Problems: A Self Help Guide Using Cognitive Behavioural Techniques. Colin Espie (2006).

Say Goodnight to Insomnia: A Drug-Free Programme Developed at Harvard Medical School. Greg Jacobs (2009).

Relaxation and Stress Reduction Workbook. Davis and Eshelman (2008).

Useful websites

The NHS Better Sleep Pages

The NHS Guide to Sleep for Children and Teenagers 

NHS Scotland Guide to Sleep

The Sleep Council's Good Night Guide

Helpguide.org Sleep Pages

Counselling and Therapeutic Services and Organisations

There are many trained professionals who will be able to support you such as your GP, as well as counsellors and psychotherapists if your sleeping problem is anxiety and depression related. 

The NHS - it's  a good idea to see your GP and ask their advice for your sleep problem, if only to rule out any other medical problem that might be behind it. 

Counselling and psychotherapy clinics - if, like the majority of those who suffer sleep problems, you are not able to relax at night due to stress or depression, counselling or therapy can really help. Search through online directories for a mental health professional in your area. Harley Therapy is one such private practice in London, UK that can assist with anxiety and depression related insomnia. Most workplace insurances now cover visits to a therapist, enquire with human resources at your organisation.