From telegraph.co.uk
By Dr. Alanna Hare
Dr Alanna Hare is a consultant in sleep and ventilation at Royal Brompton Hospital and president of the British Sleep Society, with more than 20 years’ experience in treating sleep-related issues. We asked her your questions about how to get a better night’s sleep and beat insomnia.
‘Why do I feel anxious and have intrusive thoughts if I wake up in the middle of the night?’
Claire*
Our brains are often racing with anxious thoughts, but it’s common to be so busy in the daytime that we don’t notice it. If you’re the type to crash into bed exhausted at the end of the day and sleep instantly, it’s no wonder that worrying, intrusive thoughts will crop up in the middle of the night when there’s nothing to take up your attention. Your anxious mind thinks that this is its time to shine and combs over those embarrassing moments from years ago that we’d rather forget.
It’s not unusual to then become anxious about being anxious, and to ruminate on being kept up all night when you need your rest. This can be incredibly distressing, and in the worst cases can cause insomnia and deepen anxieties you might already have bubbling under the surface throughout the day.
For my patients who struggle with this regularly, I recommend acceptance and commitment therapy, a practice that helps people to increase their psychological “flexibility” and find it easier to tolerate their thoughts and feelings. It’s a treatment that helps people to stay in the present moment. I’d recommend following this principle and trying to ground yourself in the present in some way.
A great way to do this is through progressive muscle relaxation: start by clenching your toes and releasing, moving slowly through your body, until you reach your head or have fallen asleep. This will take you out of your anxious thoughts for long enough to drift off to sleep.
‘I’m in my 70s and wake up at 3am every night feeling alert. How can I get back to sleep?’
Trevor*
Six in 10 of us in Britain wake up in the night unprompted and find it hard to get off to sleep again. In fact, we all briefly wake throughout the night, though we may not remember it, two or three times on average. Finding that your sleep is interrupted at the same time every night is common too, and often signals the beginnings and ends of your sleep cycles, dictated by your unique circadian rhythm.
Of course, waking up at night is only a big problem if you can’t get back to sleep again. If you find yourself wide awake at three in the morning, you’ll likely want to turn over and try to get right back to sleep, but that feeling of alertness you mention can sometimes mean that drifting off is hard to do.
Instead, get up and move to another part of your house, and do something relaxing for 20 to 30 minutes, until you naturally feel sleepy again. You could read a book, listen to some music, or even watch TV – anything but scrolling social media, more because it’s hard to put down than because of the blue light from your screen, which these days we believe is less disruptive to your sleep than was once thought.
It might sound counter-intuitive, but the longer you lie in bed, the more frustrated you’ll get and the more awake you’ll feel. Make your bed a space where only sleep happens and you’ll find it easier to sleep through the night over time.
‘How safe is it to take prescription sleeping pills from time to time? I usually don’t struggle to sleep, but I often wake up far too early and take about a quarter of a pill at 4am or 5am to get back to sleep again’
Stephen C.
Doctors prescribe sleeping pills for short-lived periods of insomnia, the sort you might have after a bereavement or the breakdown of a relationship, because we know that they’re effective. We call these the “z-drugs”: zolpidem and zopiclone are the ones licenced for use in the UK. More than a million people are prescribed them each year in Britain, and we know that they’re safe and effective when taken in the short term, for four weeks or less.
Regularly taking a full dose of z-drugs in the long term, rather than for an acute period, can increase your risk of falls and accidents. In my opinion, it’s unlikely that taking a quarter of a sleeping pill at four in the morning is doing much to your body (or indeed, sleep) at all, though I’d advise you to make your GP aware of what you’re doing.
You’re likely experiencing the good end of the placebo effect: you’ve conditioned yourself to switch off and relax after taking your quarter-pill, because you believe that it works. But is what you’re doing dangerous? At this dose, that is unlikely, but it would be far preferable to address the underlying issue and help you sleep without needing medication.
These pills aren’t effective for chronic insomnia, the sort that isn’t prompted by a recent event or that has gone on for more than a few weeks. For my patients struggling with this sleep problem, I always recommend a specific form of cognitive behavioural therapy, a talking therapy, that’s been adapted for insomnia, called CBTi. I trained in delivering this more than 10 years ago, and it’s very effective. It works to address the behavioural issues around insomnia and the thoughts that can drive it, by changing people’s beliefs around sleep and helping them sleep again naturally and reliably.
‘Why does alcohol affect my sleep so badly? Just one drink can keep me awake for hours. Is there anything I can do?’
Amber*
Unfortunately, alcohol is the enemy of sleep. Yes, it can help us get off to sleep more easily in the first place, with alcohol being a sedative drug. But your blood sugar drops as your body digests the drink you’ve had, making you wake up in the night, on top of your bladder demanding extra trips to the loo.
Drinking alcohol also makes it harder to get rapid eye movement (REM) sleep, the all-important stage of sleep that allows us to consolidate new memories from the day before and feel rested when we wake up. This can contribute to your hangover as much as your liver’s complaints about what it’s been fed.
Many people choose to take this on the chin, preferring to keep enjoying the social aspects of occasional drinking. While I’m not here to tell you to give it up entirely, as that is a very personal decision, I would advise drinking with as much moderation as you can if you’re concerned for your sleep or broader health. Ninety per cent of people who regularly drink in the evenings report having trouble sleeping.
An occasional glass of wine shouldn’t significantly disrupt your sleep, particularly if you have it well before bedtime. That said, if you do find that you’re kept awake by such a small amount, it might be that you’re more sensitive to alcohol than most, which is all to do with the activity of the enzymes that process alcohol in your body, something that is unique to everyone.
As with many sleep problems, there are powerful psychological factors at play here too. If you expect not to sleep well, because of alcohol or something else, then that’ll become a self-fulfilling prophecy. If you suspect this to be the problem, my advice is the same as for anyone struggling to put their thoughts down: get up and do something else when you wake in the night, or can’t sleep at bedtime, and only get back into bed when you can feel that you’re close to nodding off.
‘I’m 82 years old, and I’ve spent much of my life working on an airline. I lost my husband last June, and now I live alone, going to bed around midnight, falling asleep at 3am and then sleeping until midday, unless I need to get up earlier. Should I start setting an alarm to wake up earlier, or will this odd sleeping pattern pass naturally?’
Sarah*
If you’ve spent your life working in planes, you may be a long-term shift-worker. Sleep problems are common amongst people who work late shifts or night-shifts and we have a specific term for these issues: shift work pattern disorder, a sleep disorder that can cause either insomnia or excessive sleepiness. I have certainly seen people who still have this problem into their retirement.
It’s unlikely that your sleep pattern will move to more usual hours on its own, especially if you’ve only ever been able to sleep at 3am, even prior to your shift work. In this case you might actually have delayed phase sleep disorder, where your body clock is just set differently to most people’s. The treatment for this issue involves careful adjustments to your sleep timings with the help of a sleep specialist. You may be prescribed a dose of the sleep hormone melatonin at night, and bright light therapy in the morning, to set your body clock so that you can sleep earlier in the day.
One question you might like to ask yourself, however: how much of a problem is your current sleep situation posing for you? It sounds to me like you’re getting enough rest, though the three hours you spend in bed prior to falling asleep may be causing you stress. I’m more concerned about how sleeping to midday might affect your social life, given that you’ve suffered a bereavement and you now live alone. Older people report feeling more isolated on average. Getting up earlier may give you more time to touch base with friends and family to make sure that you’re getting enough contact with other people.
If you’d like to get up earlier, while preserving your enviable eight hours of rest, I’d recommend gradually shifting your bedtime backwards, by 15 to 30 minutes a day, and seeing whether you naturally wake earlier too. Get some bright light by going outside if you can in the earlier part of the day, and dim the lights as you prepare for bed. Avoid caffeine after lunchtime to help you drift off more easily at night. If these measures do not help, and this continues to trouble you, it might be time to seek professional help.
‘I have back pain and acid reflux, so I get conflicting advice about the best sleeping positions for my health. What should I do?’
Amina*
As a sleep expert, I’m frequently frustrated by how little doctors are taught about sleep. In my own days as a medical student at Cambridge in the 1990s, I wasn’t taught much about the topic, and little has changed since. This leaves patients with confused advice, and a gulf of information that it’s tempting to fill by seeking help online, where there’s less-than-trustworthy information.
In truth, each case of back pain is different, so I would avoid giving generic advice on the best position to sleep in for this problem. All I can say is that having a good supportive mattress is always important and will help you to sleep more easily.
Acid reflux is a simpler issue when it comes to protecting your sleep. Apart from treatment with medication, it can be helpful to raise the head of your bed, to prevent that acid from coming back up from your stomach. You can either use blocks or raise the front two legs on your bed if they’re adjustable. Then you can sleep in whichever position a professional tells you is best for your back pain. I’d recommend visiting a physiotherapist to find this out.
‘I go to sleep around midnight and set my alarm for 7.30, but wake up around an hour before the alarm goes off. So I lose out on an hour’s sleep which is frustrating. I have blackout blinds so it isn’t the light. What can I do?’
Rochelle Poznanski, 51, accounts manager for a law firm
It sounds to me like you’re a lark – one of those people who naturally rises early in the morning. This can be inconvenient if you don’t have a reason to be up, but your current sleep schedule means that you’re only attaining six and a half hours of sleep per night, short of the seven we all need as a minimum to be healthy.
To sleep more, I’d recommend that you go to bed earlier. It won’t work if you suddenly try to hit the pillow at 10pm, however. Shift your bedtime forward by half an hour each week, until you hit a time that gives you enough sleep each night (for most adults, this is between seven to nine hours per night). Pairing this with some wind-down time half an hour before bed, with a book or some deep-breathing exercises, will make the process easier.
‘I have a good bedtime routine, a safe and comfortable place to sleep, I don’t drink alcohol or caffeinated drinks and I watch my weight. I have a demanding job and spend all day solving complex issues. I go to sleep around 10pm and always wake up between midnight and 1am. I’m then awake for around two to three hours before falling asleep again until I wake at 6am. Why does this happen?’
Carolyn Moss
From what you’ve described, it sounds like you have sleep maintenance insomnia, a kind of insomnia where getting to sleep isn’t a problem, but staying asleep is a struggle. This is a very common problem. Poor sleep hygiene is a major factor in why people develop this kind of insomnia, but it sounds to me like you’ve done everything you can to limit the issue by changing your lifestyle. If this has gone on for more than three nights a week for three months, then you would be diagnosed with chronic insomnia. The best treatment for this, again, is CBTi.
I’d recommend keeping a sleep diary, noting down when you’re awake so that you can see how much sleep you’re actually getting each night. Avoid spending time in the bed awake and don’t go to bed at night until you are feeling sleepy. Try to stick to getting up at the same time each day. Digital CBTi programmes can provide personalised advice which will help your sleep to repair itself.
‘I listen to a podcast every night to go to sleep and have done for over a decade. It’s the only thing I seem to be able to do to stop my busy mind and wind-down. I am aware however that it could be disturbing my sleep. How can I wean myself off the habit?’
Alana Grayson
According to one survey, from 2022, nearly half of us listen to podcasts, music or the radio to help us sleep. Having background noise can help to distract us from thoughts that might keep us awake, and over time this becomes an association, something that we need to get into “sleep mode”, like wearing pyjamas or having a duvet on the bed.
Unless you’re being interrupted in the night by unexpected sounds in the podcast of your choice, however, then I don’t think this habit should actually disrupt your sleep, or affect your sleep quality in any way. So feel free to keep lulling yourself to sleep with podcasts, unless your partner finds it difficult to deal with, or it’s restrictive when you’re away from home.
If this is the case, try using a technique called cognitive distraction, to keep difficult thoughts away without using a podcast. One method is to count back from 1000 in sevens, starting again when you lose track (this is like counting sheep for adults). You might find that this can replace your podcast as a way of lulling you to sleep.
‘What can I do about menopausal insomnia? I seem to have lost the knack of sleeping through the night and now wake up between 4 and 5 every morning, often dropping off just before my alarm goes off, then spend the day feeling so tired. The only reason I decided to try HRT was to see if it helped this but it hasn’t. The GP suggested melatonin but said I can only buy this abroad! What can I do?’
Louise*
Insomnia is a huge issue for women in menopause or perimenopause. It’s often a very pronounced symptom, and it’s poorly addressed. It’s right that HRT can help with menopausal insomnia if the issue is hot flushes, but if that isn’t the case, or if your form of HRT hasn’t helped with these, I would again recommend CBTi, which has been shown to be just as effective for menopausal insomnia as for any other kind of insomnia. Some forms of HRT are also more beneficial for menopausal insomnia than others. I’d advise that you ask your doctor or a menopause specialist about this.
Melatonin may help, though I wouldn’t recommend it as a first course of action. Melatonin is in fact licenced for over-55s in Britain, where a formal course of CBTi hasn’t been helpful. Otherwise, keeping your bedroom cool and having bedsheets and pyjamas made of natural fibres such as cotton or bamboo can be helpful, as can having a good bedtime routine with half an hour of wind-down time before you hit the pillow. Exercising regularly can also help to manage menopausal insomnia, especially weight-based strength training exercises, though you should avoid doing exercise just before bed as it can make hot flushes worse.
*Names have been changed
As told to Lauren Shirreff
