Wellbeing Services - Get Some Sleep Booklet

Get to bed and get some sleep

Helping yourself to improve your sleep

By Jenny Cadman and Josie Bannon

It can be hard to ask for help with sleep problems, particularly at university when everyone else may look like they have no trouble sleeping. Well done in taking the first step towards tackling the problem.

This booklet is aimed at anyone who struggles with sleep problems. It includes a number of student examples to illustrate different ideas and techniques. All the techniques in the booklet are based on the Cognitive Behavioural Therapy approach.

CBT has a lot of research to show that it can be very helpful for a range of problems. You may be working through the booklet on your own or with the support of a practitioner from the Wellbeing Centre. It can also be helpful to talk to someone you trust such as a family member or a friend so you have their support as well.

If you are working with a practitioner it is likely you will have regular sessions where you can talk through how you have got on using the different techniques and any problems that may have arisen. You can talk together about how to solve these problems and progress with the techniques.

Tackling sleep problems can be a difficult and challenging process and there may be times where you feel as though you aren’t getting anywhere. Just remember that we all have good days and bad days so try not to let the bad days feel as though you have taken ‘two steps back’.

The idea of this booklet is to give you the information you need to help yourself to improve your sleep. This means that you need to have a go at all the techniques to find out which ones are the most helpful for you.

How much sleep do we need?

People differ in the amount of sleep they need, but generally we know 7-8 hours is the optimum amount. The type of sleep we get also changes throughout our lives. As we get older our sleep often becomes more fragmented and we spend less time in the deeper stages of sleep. People often say they get less sleep when in actual fact they are not happy with the quality rather than the quantity of their sleep.

The stages of sleep

Vividdreaming

Sleep contributes to a healthy immune system, and can also play a role in our feelings of hunger and fullness. When we’re sleep deprived, we may feel the need to eat more, which can lead to weight gain.

The one-third of our lives that we spend sleeping, far from being “unproductive,” plays a direct role in how full, energetic and successful the other two-thirds of our lives can be.

What happens when we sleep?

We all go through different stages of sleep during the nigh. On a typical night 75% of our sleep will be stages 1-4 and about 25% will be Rapid Eye Movement (REM) sleep.

Stage one

Stage one is where we are between being awake and falling asleep. During this stage it can feel as though we are daydreaming. We may experience a feeling that we are falling or have sudden muscle contractions. During stage one we are only lightly asleep and can be woken up easily.

Stage two

Stage two marks the onset of sleep. At this point we become disengaged from our environment, our body temperature begins to drop and our heart rate slows down.

Stage three and four

Stage three is a transitional stage from light to heavy sleep. Stage four is the deepest and most restorative stage of sleep. During stage 4 we are least likely to be woken up. At this point our blood pressure drops, our breathing becomes slower, and our muscles relax. This is the stage where all the bodies healing takes place, blood flow to the muscles is increased and tissues growth and repair occurs. Stage four is also important for restoring energy and feeling rested.

Stage five or rapid eye movement (REM)

REM takes up around 25% of the night. It first occurs about 90 minutes after falling asleep and recurs about every 90 minutes, getting longer later in the night. REM provides energy to the brain and body and supports daytime performance. During this stage the brain is active and dreams occur, our eyes dart back and forth, hence the name REM. Our body becomes immobile and relaxed, as muscles are turned off. In addition, levels of the hormone cortisol dip at bed time and increase over the night to promote alertness in morning. 1 2 & 4 3 5

What happens when we sleep?

Sleep is regulated by two body systems: sleep/wake homeostasis and the circadian biological clock.

When we have been awake for a long period of time, sleep/wake homeostasis tells us that a need for sleep is building up and that it is time to sleep. It also helps us maintain enough sleep throughout the night to make up for the hours of being awake. If this restorative process existed alone, it would mean that we would be most alert as our day was starting out, and that the longer we were awake, the more we would feel like sleeping. In this way, sleep/wake homeostasis creates a drive that balances sleep and wakefulness.

Our internal circadian biological clocks regulate the timing of periods of sleepiness and wakefulness throughout the day. The circadian rhythm dips and rises at different times of the day, so adults’ strongest sleep drive generally occurs between 2:00-4:00am and in the afternoon between 1:00-3:00pm, although there is some variation. The sleepiness we experience during these circadian dips will be less intense if we have had sufficient sleep, and more intense when we are sleep deprived. The circadian rhythm also causes us to feel more alert at certain points of the day, even if we have been awake for hours and our sleep/wake restorative process would otherwise make us feel more sleepy.

In the mornings, with exposure to light, the part of the brain that controls the circadian rhythm sends signals to raise body temperature and produce hormones like cortisol. It also responds to light by delaying the release of other hormones like melatonin, which is associated with sleep onset and is procured when the eyes signal to this part of the brain that it is dark. Melatonin levels rise in the evening and stay elevated throughout the night, promoting sleep.

Circadian disruptions (e.g. jet lag) put us in conflict with our natural sleep patterns. The shift in time and light cues on the brain forces the body to alter its normal pattern to adjust. This can leave you feeling poorly and having more difficulty thinking and performing well. Because of this, it is important to keep a regular sleep schedule and allow plenty of time for quality sleep, allowing these two vital biological components – the sleep/ wake restorative process and the circadian rhythm – to help us perform at our best.

Myth busting – The facts about sleep

You can “cheat” on the amount of sleep you get.

Truth: Most adults need between 7 and 9 hours of sleep each night for optimum performance, health and safety. When we don’t get adequate sleep, we accumulate a sleep debt that can be difficult to “pay back” if it becomes too big.

Truth: The body rests during sleep, however, the brain remains active, gets “recharged,” and still controls many body functions including breathing. When we sleep, we typically drift between two sleep states, REM (rapid eye movement) and non-REM, in 90-minute cycles. Even in the deepest non-REM sleep, our minds can still process information. REM sleep is an active sleep where dreams occur, breathing and heart rate increase and become irregular, muscles relax and eyes move back and forth under the eyelids.

Insomnia is characterised by difficulty falling asleep.

During sleep, your brain rests.

Truth: Difficulty falling asleep is but one of four symptoms generally associated with insomnia. The others include waking up too early and not being able to fall back asleep, frequent awakenings, and waking up feeling unrefreshed.

Truth: Excessive daytime sleepiness is a condition in which an individual feels very drowsy during the day and has an urge to fall asleep when he/she should be fully alert and awake. The condition, which can occur even after getting enough nighttime sleep, can be a sign of an underlying medical condition or sleep disorder such as narcolepsy or sleep apnoea. These problems can often be treated, and symptoms should be discussed with a physician.

If you wake up in the middle of the night, it is best to lie in bed, count sheep, or toss and turn until you eventually fall back asleep.

Daytime sleepiness always means a person isn’t getting enough sleep.

Truth: Waking up in the middle of the night and not being able to go back to sleep is a symptom of insomnia. Relaxing imagery or thoughts may help to induce sleep more than counting sheep, which some research suggests may be more distracting than relaxing. Whichever technique is used, most experts agree that if you do not fall back asleep within 15-20 minutes, you should get out of bed, go to another room and engage in a relaxing activity such as listening to music or reading. Return to bed when you feel sleepy. Avoid watching the clock.

About sleep problems

Sleep problems are very common, around three in ten people will experience problems at point in their lives. Unfortunately this is an even higher rate among students. Coming to university may mean changes to environment, routines and noise levels all of which can affect sleep, not to mention any extra stress. Generally people have most problems getting to sleep. There can be many reasons for problems with sleep.

There are four main types of sleep problem:

1. Falling asleep

2. Staying asleep

3. Non-restorative / light sleep

4. Waking up too early

What causes sleep problems?

l Life events, e.g. relationship break up or bereavement

l Medical Problems, e.g. if you are in pain

l Depression or low mood

l Anxiety or stress

l Worrying

l Environment

l Some medications

l You may have a predisposition to sleep problems

l Disturbed routine (student life style)

Student examples...

Throughout the booklet we are going to be covering a number of ideas and techniques. Here are some examples of sleep problems that are often reported by students. We will use some of these examples to show how the techniques in the booklet can be applied.

Students’ sleep problems:

“I always wake up really early and can’t get back to sleep. It’s so annoying.” Sophie.

“It always seems like ages before I can get to sleep. I toss and turn for hours.” Clare.

“I often wake up a lot in the night and never feel refreshed when I wake up.”

Daniel.

What sleep problems do you experience?

How to improve your sleep: lifestyle habits

One way to improve sleep is to look at the things you could improve in your lifestyle. Below are some examples of different things that might influence your sleep.

Reduce alcohol

Alcohol interrupts the quality of sleep a person has and can cause more waking in the night. It can also lead to tiredness in the day.

Earlier dinners

Going to bed full up or hungry can interfere with sleep, and so it’s best to have an early dinner, and a light snack before bed if needed.

Reduce nicotine and caffeine

Nicotine and caffeine are both stimulants and can interfere with getting to sleep. Try to avoid them for up to 4-6 hours before going to bed.

Increase exercise

Physical activity is great for improving sleep, but try to avoid it for up to 4 hours before bed time.

Same routine

Getting up at the same time each day is one of the most important things you can do to improve your sleep, even if you haven’t slept much the night before!

GOOD SLEEP

I’m going to change:

The effect of caffeine

Caffeine is a stimulant. It can seriously interfere with sleep, it can temporarily make us feel more alert by blocking sleep-inducing chemicals in the brain and increasing adrenaline production. However, the more caffeine we have the more sleep chemicals are produced to combat the caffeine. This means we feel exhausted if we don’t have caffeine.

There is no nutritional need for caffeine in the diet. Moderate caffeine intake, however, is not associated with any recognized health risk. Three 8 oz. cups of coffee (250 milligrams of caffeine) per day is considered a moderate amount of caffeine. Six or more 8 oz. cups of coffee per day is considered excessive intake of caffeine.

Caffeine enters the bloodstream through the stomach and small intestine and can have a stimulating effect as soon as 15 minutes after it is consumed. Once in the body, the effects of caffeine will persist for several hours; it takes about 6 hours for one half of the caffeine to be eliminated. This means that if you are having problems with stress or sleep, you should avoid caffeine all together.

How caffeine works

l During the course of the day the chemical adenosine accumulates in the brain. This binds to receptors and slows down brain activity. The higher the level of adenosine, the more tired you will feel.

l Caffeine competes with adenosine and combines with the adenosine receptors. This stops the adenosine binding and temporarily stops you feeling tired.

l To compensate for this the body will create more receptors which means that you will need more caffeine to get the same effect, and when you don’t have it you will feel even more tired.

l Caffeine also increases adrenaline and dopamine.

How much caffeine is in what?

Here is a guideline of how much caffeine is in some different food and drinks. Try to work out how much caffeine you are currently consuming.

l One mug of instant coffee: 100mg

l One mug of filter coffee: 140mg

l One mug of tea: 75mg

l One can of cola: 40mg

l One 250ml can of energy drink: 80mg

l One 50g bar of plain (dark) chocolate: less than 25mg

l One 50g bar of milk chocolate: less than 10mg

How to improve your sleep: environmental factors

Another way to improve sleep is to look at what you might be able to change in your environment. Below are some examples of environmental factors that might influence your sleep.

What could you change in your bedroom that could help your sleep?

Low noise levels

Ear plugs can be good for blocking out noise.

Right temperature

If you’re too hot or too cold this will interfere with falling asleep. It is important to have the right duvet – the ‘tog’ will indicate how thick it is.

Improve air quality

Central heating can cause stuffiness and poor air quality which can make it harder to fall asleep.

Increase darkness

You can buy ‘black out’ curtains that block a lot of light, or an eye mask. If it’s light then your brain is getting the message that it’s day time and that you should be asleep.

Decrease any discomfort

‘Topper’ mattresses are good for improving the comfort of your bed, and they are usually quite cheap.

Avoid TV and computers before bed

Electronic screens are overly stimulating for the brain due to the visual stimulation. They can make it harder to fall asleep.

GOOD SLEEP

I’m going to change:

Get

bed

get

The importance of routine

It can be really difficult to get into a good routine when you’re a student, there may often be nights where you go out or staying up late with friends. Although going to bed at the same time each night can help, if you are unable to do this then a pre-bedtime routine can still help to improve your sleep. It can help to cue your brain/body to know that it is time to sleep and having wind-down time before bed can also help you to relax.

Before going to bed

l Try to go to bed at the same time each night

l Have the same routine an hour before going to bed

l The brain will start to know when it’s time to go to sleep

l Do the same thing each night an hour before bed

l Avoid anything stimulating (physically or mentally)

l This should be ‘wind-down time’

Clare’s example

Here’s an example of a 60 minute pre-bed routine:

23:00 Read a fiction book for half an hour.

23:30 Sort my bag out for the next day.

23:40 Have a wash, brush my teeth and get changed for bed.

23:50 Relaxation exercise for 5-10mins.

What could your routine be for the hour before you go to bed?

Relaxation

Relaxation is very important in order to help mood, memory, stress levels and sleep, although this is something that students sometimes find hard to justify. You may feel that you should be spending all of your time studying and feel too busy to relax. However, humans are not designed to be on the go throughout the waking day. It is important to have activities in your day-to-day routine that you find relaxing.

Daniel:

“When I play football I have no worries, I am totally absorbed in the game. I feel that it is my ‘time out’ from my uni work and other stresses. I also find listening to music relaxing.”

Types of relaxation:

What relaxing activities could you do?

Scheduling

When (what day and time):

Where:

With whom:

Relaxation exercises

It is really important to allow yourself time to ‘wind-down’ after each day. Otherwise your body and mind will still be active when you try and sleep. Without wind-down time you may end up lying in bed with loads of thoughts going through your head. On the next few pages are a number of techniques that you can use to help you to relax.

Focusing on the breath: The calming technique

When we feel stressed our breathing often changes. We tend to take quicker shallower breaths and take in more oxygen. This is all part of the fight or flight response. Over breathing (whilst not dangerous) can leave you feeling exhausted or “on edge”, and can make it difficult to fall asleep. Slowing down your breathing can help you to feel calmer and more relaxed.

1. Ensure that you are sitting on a comfortable chair or laying on a bed.

2. Take a breath in for 4 seconds (through the nose if possible).

3. Hold the breath for 2 seconds.

4. Release the breath taking 6 seconds (through the nose if possible) then pause slightly before breathing in again.

5. Practise, practise, practise!

Breathing tips:

When you are doing your breathing exercises, make sure that you are using a stomach breathing style rather than a chest breathing style. You can check this by placing one hand on your stomach and one hand on your chest. The hand on your stomach should rise when you breathe in.

www.cci.health.wa.gov.au

Positive Muscle Relaxation (PMR)

PMR can be a really helpful technique for reducing tension in the muscles. Often we don’t even realise when we are feeling tense. This tension can make it very difficult to sleep. PMR involves working through all the major muscles groups tensing and relaxing the muscles. It can also help us to tune into the feeling of tension so we can notice it happening at the time we become tense and then focus on relaxing the muscles. Try doing this in a quiet space to start with.

Progressive

Muscle Relaxation exercise:

1. Right hand and forearm. Make a fist with your right hand.

2. Right upper arm. Bring your right forearm up to your shoulder to “make a muscle”.

3. Left hand and forearm. Repeat as for right hand and forearm.

4. Left upper arm. Repeat as for right upper arm.

5. Forehead. Raise your eyebrows as high as they will go, as if you are surprised by something.

6. Eyes and cheeks. Squeeze your eyes tight shut.

7. Mouth and jaw. Open your mouth as wide as you can, as you might when you‘re yawning.

8. Neck. Be careful as you tense these muscles. Face forward and then pull your head back slowly, as though you are looking up to the ceiling.

9. Shoulders. Tense the muscles in your shoulders as you bring your shoulders up towards your ears.

10. Shoulder blades/back. Push your shoulder blades back, trying to almost touch them together, so that your chest is pushed forward.

11. Chest and stomach. Breathe in deeply, filling up your lungs and chest with air.

12. Hips and buttocks. Squeeze your buttock muscles.

13. Right upper leg. Tighten your right thigh.

14. Right lower leg. Do this slowly and carefully to avoid cramps. Pull your toes towards you to stretch the calf muscle.

15. Right foot. Curl your toes downwards.

16. Left upper leg. Repeat as for right upper leg.

17. Left lower leg. Repeat as for right lower leg.

18. Left foot. Repeat as for right foot.

Practice means progress. Only through practice can you become more aware of your muscles, how they respond with tension, and how you can relax them. Training your body to respond differently to stress is like any training –practising consistently is the key.

Relaxing ‘safe place’ imagery

The effect that mental images can have on our physiology is amazing. Just take a minute to imagine your favourite meal: how it would look, the aroma, the texture as you take the first mouthful and the delicious flavours. Now, what do you notice happening? Do you have increased saliva in your mouth, or a rumbling in you stomach? The images we have in our minds have a direct impact on how we feel and our physiology. With this in mind, practicing relaxing imagery exercises can be really helpful at calming the body and mind.

l Start by getting comfortable in a quiet place where you won’t be disturbed, and take a couple of minutes to focus on your breathing. Close your eyes, become aware of any tension in your body, and let that tension go with each out breath.

l Imagine a place where you can feel calm, peaceful and safe. It may be a place you’ve been to before, somewhere you’ve dreamed about going to, somewhere you’ve seen a picture of, or just a peaceful place you can create in your mind’s eye.

l Look around you in that place, notice the colours and shapes. What else do you notice?

l Now notice the sounds that are around you, or perhaps the silence. Listen for sounds that are far away and those nearer to you, those that are more noticeable, and those that are more subtle.

l Think about any smells you notice there.

l Then focus on any skin sensations – the earth beneath you or whatever is supporting you in that place, the temperature, any movement of air, anything else you can touch.

l Notice the pleasant physical sensations in your body whilst you enjoy this safe place.

l Now whilst you’re in your peaceful and safe place, you might choose to give it a name, whether one word or a phrase that you can use to bring that image back, anytime you need to.

l You can choose to linger there a while, just enjoying the peacefulness and serenity. You can leave whenever you want to, just by opening your eyes and being aware of where you are now, and bringing yourself back to alertness in the ‘here and now’.

The association between bed and sleep

Unconscious association is a powerful thing. The more two things occur together the stronger the association – this is the same with bed and sleep.

l Those who sleep well associate their bed with sleep.

l Those with sleep problems associate bed with being awake or feeling worried or anxious.

When you struggle to sleep you can get into a vicious cycle where you start to worry about not being able to sleep and to watch the clock (‘if I get to sleep now I’ll have 5, 4, 3,etc hours sleep) – this then means you associate bed with being awake, which then makes it harder to sleep which reinforces the worry about sleeping.

In bed awake worried about not sleeping.

Associate the bed with being awake rather than sleep.

In the next few pages we will look at ways to help you to improve this association and to break this cycle.

Four rules for better sleep

The association we have between our bed and sleep can make a big difference to how easily we fall asleep. If we often lie in bed worrying and struggle to get to sleep we might start to associate the bed with stress, rather than calmness and sleep. The longer we spend in bed awake, the weaker the association will be with sleep. Below are four different rules to strengthen the association between bed and sleep.

The bed is for sleep rule

Everything else (except sex) is banned! So no reading; working; talking on the phone; looking at the internet - nothing in bed but sleep. Sometimes this might be difficult due to the student lifestyle, but it’s worth doing if sleep is a problem.

The 20 minute rule

Healthy sleepers generally fall asleep within twenty minutes. If you are lying in bed unable to get to sleep for longer than this then the association between bed and wakefulness and anxiety is strengthened. If you’re not asleep within 20 minutes, get up, go into a different room if possible and do something relaxing until you feel sleepy again, then go back to bed.

The sleepy rule

Feeling tired and feeling sleepy are different. You can actually feel tired without feeling sleepy but you should only try and go to sleep when you feel sleepy. When you feel sleepy you might yawn a lot, have hot, heavy eyes that feel like they want to close and have heavy muscles.

The night time rule

Only sleep at night. Make sure not to nap in the day, no matter how much sleep you missed the night before. Napping in the day decreases the need to sleep at night and gets rid of the ‘sleepy’ feeling you need to fall asleep at night.

Sophie’s example of the association between bed and sleep

The problem

Sophie lives with four other people, she has her desk in her room and a kettle for tea. She often prefers to read Uni books and papers on her bed as it’s comfier than her desk. She also talks to friends and family on the phone whilst lying in bed. When she wakes up in the morning she can lie there for hours getting frustrated, before she finally gets up.

What Sophie did

Sophie made a comfy space on her floor to read her Uni books and papers and decided to talk to her friends and family down stairs in the living room; if her house mates were around she would go in the garden. She also started getting up in the morning when she woke up (using the 20 min rule), even though it was five o’clock. When she got up she found she did start to feel ‘sleepy’ again so went back to bed, she found that she was more likely to fall back asleep after getting up than if she was lying there getting frustrated.

Sophie used rules one, two and three:

1. The bed is for sleep rule.

2. The twenty minute rule.

3. The sleepy rule.

How to improve your sleeping pattern

Often when people are having sleep problems their sleeping pattern becomes very irregular. People often spend a lot of time awake in bed, whether this is due to not being able to get to sleep, waking in the night or waking up early. Having a regular sleeping pattern is really important and this technique will help you to improve this.

The technique works by finding out how much time you currently spend asleep and initially only going to bed for this period of time. As you start to sleep through this period, you gradually increase the time that you’re in bed until you are able to sleep through the night.

Step 1 – work out what your sleep window is

When the amount of time you are spending in bed asleep is up to 90% you can increase your sleep window by 15 minutes. Use the equation on page 21 to work out what percentage of the time in bed you are asleep for. 1 2 3

First you need to work out the average amount of sleep you get a night (you may need to keep a sleep diary for a week to determine this). Then give yourself a set time for getting up, and for going to bed. Finally, subtract your average amount of sleep from your ‘getting up time’.

This is your sleep window.

Step 2 – only go to bed for this window

Whilst it might sound counter-intuitive, the next step is to only go to bed during this sleep window. So if your sleep window is five hours and you want to get up at 8:00am then you would go to bed at 3:00am.

Step 3 – increase your sleep window

The benefits of a tight sleep window

Although the sound of a sleep window probably sounds pretty horrible, there are a number of benefits to having a tight sleep window. Having a tight sleep window means that:

l Less time is spent frustrated in bed

l There is an improved association between bed and sleep

l There is increased ‘sleepiness’ when in bed

l Quality of sleep is improved

l More refreshing and uninterrupted sleep

l Ultimately it increases the amount of sleep you get

Clare’s example of using the sleep window to increase her sleep: Clare worked out that she was getting about four hours sleep a night. She would go to sleep at different times but aimed to be in bed by 12:30am. She was often still awake at 3:00 or 4:00am and she would have to get up around 7:00am. Using the sleep window described she decided that she was still going to get up at 7:00am which meant going to bed at 3:00am.

To start with she found that it still took her a while to get to sleep (70% sleep efficiency) and she felt worse for the first week. But after the next week she started to notice an improvement in her percentage of sleep efficiency. Due to the improvement she added 15 minutes to her ‘sleep window’ so started going to bed at 2:45am. After a few months she was going to bed at 1:00am and getting to sleep within twenty minutes. She was now getting around six hours sleep a night rather than four. Clare continued to adjust the time that she went to bed as the percentage of her sleep efficiency improved.

Your sleep efficiency

We have been talking about sleep efficiency for the last few pages. If you want to work out your percentage of sleep efficiency then use the equation below. Try to do this on an average night rather than a night where you have slept either better or worse than usual.

Average number of hours of sleep a night: What is the best time for you to get up:

Set time for going to bed (getting up time, subtract average hours of sleep a night):

You will need to calculate your percentage of sleep efficiency each night so you know when you can start adding to your bed time:

Total time you sleep (roughly).

Total time you spend in bed.

When your sleep efficiency is at 90% then you can add an extra 15 minutes to your going to bed time. (e.g. 3:00am becomes 2:45am). Review your sleep efficiency each week and add 15 minutes each time it reaches 90%.

Sleep diary

Use this sleep diary to make an accurate assessment of how much you sleep and other factors associated with your sleep. This will help you to identify patterns and areas for improving sleep hygiene. Also, many people who struggle with sleep difficulties make negative assumptions about their sleep (e.g. “I never sleep more than 5 hours a night”) and this worksheet can help you to check if this is really the case.

Rest score (0-5, 5 most rested)*

Hours slept

3 –felt somewhat rested when I woke up

6 hrs 40 mins

Woke up? (Number of times, how long awake) Once at 2am, back to sleep after 20 mins

Waking time 5:10am

Time to fall asleep (mins)

40 mins

Lights out (tie) 10:30pm

In-bed activities Read for 1 hour

Tension in bed (0-5, 5 most tense)

Day mood (0-5, 5 most tensae)

Day fatigue level (0-5, 5 most tensae)

4 –felt very tense when I went to bed

2 –not really down

3 –felt a bit tired today.

Pre-bed activity (what did you do?) Watched TV after dinner, 3 hours

Medication (day total & before bed) Nil

Caf - feine, alcohol, nicotine?

Naps

2 coffees, 1 beer, nothing after 4pm

2:00pm, 40mins Day / date Example: 23.05.24

Worrying and sleep

It can be very difficult to stop or control worries. Worries often happen in bed as you are not occupied at this point and they can stop you from getting to sleep. This in turn can weaken the association between bed and sleep and strengthen the association between bed and stress.

We are now going to look at a technique that you can use to help you to control your worries. This can feel difficult to do at first, but should become easier the more you practice it.

Worry time

l Whenever you notice a worry write it down (make a list)

l Give yourself a set amount of undisturbed time each day to go through your list of worries

l Separate practical worries (e.g. problems that you can do something about) from hypothetical worries (e.g. ‘What ifs’)

l Write an action for all practical worries (what; when; where and who?)

l Give yourself time to think about the hypothetical worries (not right before going to bed)

l Once the time is up you need to stop worrying and focus on something else

l You might want to screw the paper up

l Try and do something engaging and get a change of scenery

l Any worries that you have outside of your worry time; write them down and think e.g. “I will think about that tomorrow at 5:00. There is no need to worry about it now”

l When in bed, try to focus your attention on your breathing, in-out, in-out

l Notice when your mind wanders and bring your attention back to your breathing

Stress around not sleeping

Often when we are having sleep problems we start to worry about not sleeping. As you can see below this can then feed into the vicious cycle making it harder for you to sleep. Again, these unhelpful thoughts also weaken the association between bed and sleep.

Thoughts

I’m never going to sleep tonight.

Sleep

Go to bed feeling stressed; don’t sleep.

Physical feelings

Tense, stressed, on edge.

Challenging these thoughts can help to break this cycle and improve your sleep. When we are worrying our thinking often becomes more negative, it is important to identify our negative thoughts, then to take a step back and to look at the facts of the situation. This can help you to come up with a more helpful thought which can reduce your worry and help you to sleep better.

Thought:

Words that went through your mind and rating of how much you believe this thought (0–100%)

I’m going to be awake all night (70%)

Feeling:

Emotion experienced and rating of how bad it was (0–100%)

Revised Thought:

Words of new thought and rating of how much you believe this thought (0–100%)

Stressed, upset (80%). It is rare that I never sleep in the night; I will sleep sooner or later, generally I get around 4 hours a night at least (50%).

Feeling:

Emotion experienced and rating of how strong it was (0–100%)

Less stressed; more relaxed (30%).

Problems with tiredness that are unrelated to sleep

Tiredness is a problem that a lot of people report, particularly whilst studying at university. There are lots of reasons why we get tired:

Physical reasons

l Being overweight

l Being underweight

l Physical illness

l Not doing enough (getting unfit)

l Doing too much (physical or mental, if you push yourself when you’re tired you may find it harder to recover).

Psychological reasons

l Worries and Stress

l Depression

l Everyday difficulties, e.g. moving house.

l Emotional shock, e.g. a bereavement or break up.

l Expecting too much of yourself. Standards can be helpful, they give you direction, however if you expect too much of yourself you may find yourself repeatedly failing which is frustrating and exhausting.

Habit reasons

l Sleeping too much: It sounds odd, but this can make you tired.

l Activity: A ‘roller-coaster’ of too much activity followed by too much rest; if you do too much on a good day, you may overdo things and feel even more tired the next day.

l Staying up through the night: People who stay up in the night often find that they get tired easily. This is more likely if the times that they are awake are constantly being changed.

from Royal College of Psychiatrists.

Improving tiredness

Feeling tired can have a big impact on your life, it can effect our energy levels, concentration, ability to have fun and perform at our best. Sometimes simple things can help to improve this. We will now look at a few techniques to help you to reduce this.

Exercise/Physical activity

Exercise can feel like the last thing you want to do when you’re feeling tired, but it can really help to increase our energy. It gets the blood pumping through our bodies, oxygen is delivered to our muscles and endorphins are released which improves how we feel.

l Start with a little bit each day then gradually build up to half an hour a day

l If you feel more tired after this then reduce the amount you’re exercising to start with

l You should build it up to a point where you start to feel a bit out of breath

l Walking is a good form of exercise

l Being outside and with other people also helps

Plan your day and week

l Try to make sure that you don’t have any really hectic, tiring days

l Organise it so that you do a little every day

l If you cram everything into one day, you may be too exhausted to do anything for the rest of the week

l Try to do important activities when you think you will have the most energy

Improving tiredness: Diet

The best way to eat if you want to banish tiredness is to have a healthy, balanced diet that contains foods from the four main food groups in the right proportions. The four food groups are:

l potatoes, bread, rice, pasta and other starchy foods

l fruit and vegetables

l milk and dairy foods

l meat, fish, eggs, beans and other non-dairy sources of protein

Other important things to aim for...

Eat at regular intervals - If you eat at regular times, your body knows when your next meal is coming and learns to manage feelings of hunger and sustain your energy levels. Try to eat three meals a day and limit snacks – especially high-fat ones – between meals.

Breakfast boosts your energy - Breakfast gives you the energy you need to face the day. Despite this, up to one third of us regularly skip breakfast, according to the British Dietetic Association.

Go for healthier options, such as porridge with fruit; vegetable omelette or wholemeal toast.

If you can’t face eating as soon as you get up, take a high-fibre snack to eat on the run, rather than snacking on high-sugar or high-fat foods.

Aim for five a day for more vitality - Most people in the UK eat too much fat, sugar and salt, and not enough fruit and vegetables.

Fruit and vegetables are good sources of vitamins, minerals and fibre, essential nutrients that your body needs in order to work properly. Try to incorporate at least five portions of a variety of fruit and veg into your daily diet. They can be fresh, frozen, tinned, dried or juiced to count.

Improving tiredness: Diet continued

Slow-burning starches give sustained energy - Starchy foods (also called carbohydrates) such as potatoes, bread, cereals and pasta are an important part of a healthy diet. They’re a good source of energy and the main source of a range of nutrients in our diet. Starchy foods should make up about a third of everything you eat. But there are different types of starch. Where possible, go for slow-burning whole grain or wholemeal varieties, as they provide energy gradually.

Sugar steals your stamina - Adults and children in the UK generally eat too much sugar. Sugar gives you a rush of energy, but this wears off quickly.

Cutting out all sugar is virtually impossible. There are natural sugars in lots of foods, including fruit and veg, and you don’t need to avoid these. But it’s a good idea to cut down on foods with lots of added sugar, such as sweets, cakes, biscuits, non-diet fizzy drinks and chocolates.

Iron-rich foods prevent fatigue - Two out of five (42%) teenagers and one in three (33%) of 19-24 year olds have low iron stores, according to the National Diet and Nutrition Survey. Being low on iron can make you feel tired and look pale.

While red meats, green vegetables and fortified foods such as breakfast cereals are good sources of iron, the important thing is to eat a range of foods to get enough iron.

Soft drinks boost zest levels - Watch your intake of alcohol. It can dehydrate you, which will make you feel tired. Make sure you stay hydrated in general by drinking six to eight glasses of water a day.

Eat enough to pack a punch - Make sure you eat the right amount for your activity level. The average man needs around 2,500 calories a day, and the average woman needs 2,000 calories. But remember, we all overestimate how active we are.

www.nhs.uk/live-well/eat-well/food-types/how-does-sugar-in-our-diet-affect-our-health

Action plan for improving sleep

Well done on getting to the end of the Improving Sleep Workbook! It can be helpful to look back over the techniques you have learnt and to think about what has been the most helpful. This can help you to make a plan for how you will improve your sleep.

What have you learnt?

What techniques are most relevant to you?

What techniques are you going to use?

What changes are you going to make?

A final note...

Well done for taking the first steps to improve your sleep! It can be helpful to schedule in a Wellbeing day a month where you can focus on you! Where you can have a look back through this booklet to refresh your self on the different techniques that were helpful. If you schedule it in you’ll be more likely to do it, these things can easily get lost or forgotten about otherwise.

Coping tips - You might feel as though you’re still not where you want to be in terms of your sleep. This is completely normal, remember that it can take time for these techniques to work. Cognitive Behavioural Therapy is more effective the more you use it – like a muscle. If you found that they have made any difference at all even if it’s small this is encouraging, just keep up the good work and as time goes on you will notice more improvements.

Jenny Cadman and Josie Bannon (Psychological Wellbeing Practitioners)

Wellbeing

Centre

University of Exeter