Sleep. We all need it. But some people find it really difficult to get a good night’s sleep. Over time, poor sleep can increase stress, anxiety and worry. In this article, sleep experts, Dr Debbie Spain and Dr Tasos Galanopoulos focus on the links between sleep and anxiety. They also outline useful tips for improving sleep.
Anxiety is an everyday experience. It typically functions as an internal alarm system to warn us of potential danger. In mild degrees, anxiety can have a protective effect. Sometimes, the alarm system can be overly sensitive, resulting in intense anxiety. This can lead to sleep/awake difficulties. In turn, sleep/awake difficulties can increase our vulnerability to feeling anxious during the day. This shows that anxiety and sleep can be linked – improving one can lead to improvements in the other.
It’s important to remember that a “good night’s sleep” refers to the overall amount of sleep we get, as well as the quality of sleep. The latter is mainly associated with the architecture of sleep – there are several cycles of sleep during the night, and these can be broken down into different sleep stages. Every sleep cycle lasts approximately 90 to 100 minutes, and includes light and deep sleep, as well as REM sleep which involves intense dreaming. Adequate completion of these stages and cycles, leads to “restorative sleep” and helps us to wake up feeling rested and refreshed.
How much is the right amount of sleep?
Generally, children need more sleep than adults. Adults need approximately 7- 9 hours of good quality sleep per night, but this varies from person to person. If you’re not sure how much sleep you need, you can fill in a sleep diary for a fortnight to gather information about your sleeping pattern and how rested you feel each morning. This can help you to work out how much sleep is the optimum amount for you. Keep in mind that when it comes to optimal sleep, timing is as important as duration. There is no “one size fits all” principle. For example, some of us are genetically programmed to function better later in the day (evening types or “night owls”), while others, feel at their best early in the morning (morning types or “morning larks”).
Why is my sleep disrupted?
Lots of factors can negatively affect quantity and quality of sleep. Some of the more common reasons include:
- Irregular working patterns or having no set bed time, as this means it’s more difficult to develop a regular and consistent sleep routine
- Staying up at night and going to bed during the day (also known as a reversed sleep pattern), as this affects our natural circadian rhythm
- Inconsistency between our biological chronotype (eveningness/morningness) and the imposed daily structure from work or family
- Drinking too much caffeine or energy drinks, as these are stimulants and partly designed to keep us awake or give us a bit of short-term energy
- Too much blue light close to bedtime (from electronic devices such as a TV, tablet, mobile phone or computer), as this can disrupt our circadian rhythm and make it harder to fall asleep
- Procrastinating about going to bed, despite feeling sleepy
- Stress and anxiety, as these can contribute to negative or racing thoughts, an unsettled feeling, and so it can be harder to relax and fall asleep
- Low mood, as this can contribute to sleeping too little or too much
What is “disrupted sleep”?
Our sleep can be disrupted in different ways. For example, we may:
- Have difficulty going to bed when we would like to or need to
- Struggle to get off to sleep and lie awake for longer than we would like
- Wake up several times in the night and find it difficult to get back to sleep quickly
- Wake up a lot earlier than we need to in the morning
- Sleep for a few hours but feel very tired and unrested in the morning
How can I improve my sleep quality and quantity?
Lots of strategies can help to improve sleep. These can be categorised into changes to the sleeping environment, changes to our behaviour, and changes to what and how we think. Most people find a combination of strategies help.
Making changes to our sleeping environment
Optimise your sleeping environment. We generally sleep better when we are comfortable. Consider:
- Is the room you sleep in the right temperature? Would it help to turn the heating off a bit earlier or later? Do you need a warmer or lighter duvet?
- Is the light / darkness of the room about right? Do you need thicker curtains, a dimmer light, or to move your bed so that it’s facing away from street lights?
- Is your bed cluttered with objects that make it hard to stretch out?
- Is your bed comfortable?
- Are the pillows comfortable?
- Are you distracted by sensory information, such as someone snoring, sounds from another room, light in the hallway? What could help to reduce these distractions?
Making changes to our behaviour
Reset your body clock
It’s ideal to stick to a consistent sleep/awake pattern. Make adjustments gradually to help your body get used to the new routine. Perhaps change the time you go to bed or get up in 15 minute increments, and practice this for a few days, before making another change. It can take a while to get into a new routine, so persevere.
Get up at the same time each day
It’s really important to get up around the same time each day. Although you might feel tired if you haven’t slept properly, this will help your body readjust to a new routine.
Expose yourself to blue-enriched light during daytime
Light is one of the main ways of regulating our body clock. Sleep experts often say “get the light right and soon, a regular sleep cycle will follow”. Immersing ourselves in an abundance of light when we wake up, is the best way to stimulate our brain and improve alertness first thing in the morning. During winter months or if your room lacks light, consider getting yourself a wake-up light. These lamps mimic the natural daylight. Even though it’s not exactly the same as being outside, the beneficial effects are proven to be very similar.
Limit screen time before bed
The opposite applies for the evening of course. Using electronic devices with blue light such as a TV, mobile phone or tablet, before bed, can make us feel a bit more alert and distract us from going to sleep. Try to avoid using these devices at least 30 minutes before going to bed.
Try to stay awake in the day
It can seem really appealing to have a nap during the day, but doing this can reinforce difficulties getting off to sleep at night. Our sleep/awake cycle is influenced by a process called “homeostatic drive”. To put it simply, the longer you remain awake during the day, the stronger your drive to go to sleep will be, later in the evening. So it’s crucial not to disrupt this process by taking a nap.
Get some sunshine
If you can, go outside during daylight hours every day. If you are shielding due to COVID-19 or the social distancing measures mean that a walk is not possible, perhaps stand outside your front door for a while if and when the sun is out. Sunshine is considered to help with boosting key hormones involved in better mood and sleep (serotonin and melatonin).
Avoid having caffeine after a certain time
Caffeine is found in tea, coffee, some energy drinks and dark chocolate. Try to switch from caffeinated to decaffeinated drinks from 3pm. If you are used to drinking several cups of caffeine every day, you might need to switch this in a gradual way to avoid the impact of caffeine withdrawal. Your GP or the Practice Nurse at your GP surgery can advise about how to do this.
Don’t eat too late at night, or foods that are rich
Eating within an hour or two of going to bed can make it harder to get to sleep, as our metabolism and digestive system are trying to process the food. This is especially the case after eating rich or fried foods. If you are hungry close to bedtime, eat something light and easy to digest, like a banana or some crackers.
Being active during the day means we use up energy and so feel more tired at night. Try to do some form of exercise during most days of the week. This can include going for a walk, or going for a slightly longer walk than usual. Avoid doing strenuous exercise, like a gym workout, before bed.
Avoid starting a new activity, unless it’s a relaxation activity, before bed
It’s really easy to get absorbed in a box set, video game or emails. Try to avoid starting a new episode of a programme / film or game before bed, especially if you find it difficult to switch these off once started.
Have a plan to limit procrastination
If you tend to procrastinate in the evening, focus on doing activities that are engaging but not so absorbing that it’s difficult to stop doing them. Consider setting alarms to go off 60 minutes and 30 minutes before bed, as a prompt. Make a note of tasks that you need to come back to the following day.
Try a relaxation strategy
Relaxation strategies can help with reducing high levels of general stress and anxiety during the day, and reduce anxiety and worry about sleep. General strategies to try in the evening include:
Having a bath
Reading a book or magazine
Listening to music
Calm place imagery exercises
Try a mindfulness exercise
Mindfulness is an approach that can help us to learn to refocus our attention on the present moment, and be less bothered by worries or negative thoughts that pop into our minds. Like relaxation strategies, mindfulness exercises can be useful for reducing general levels of stress and anxiety, and anxiety about sleep. There are lots of exercises to choose from. These often involve focusing on breathing, sensations in the body or on a specific task. This might mean a more cautious approach is needed for people who have sensory sensitivities. You can find out more about mindfulness exercises on the franticworld website.
Get up if you can’t sleep
If you are really struggling to sleep and have been lying awake for 20 – 30 minutes, get up and do a relaxing or enjoyable activity until you feel sleepy, like relaxation exercises, reading or a crossword. Avoid blue light if you can at this time, as this might make you feel more awake. Go back to bed when you are feeling sleepy.
Making changes to what and how we think
Distract yourself from racing thoughts or worries
People who have poor sleep often worry about it. They might feel worried about if and when they will fall asleep, how many hours of sleep they will get and if they will feel alert enough in the morning. These are really normal worries, and understandably make it harder to get to sleep. Try to distract yourself from worries and negative thoughts, by practising a relaxation or mindfulness technique. Alternatively, you can try to distract yourself by focusing on counting down from 100 in eights, or listing an animal or city for each letter of the alphabet.
Keep a notebook by your bed
If you are worrying, decide if this is something that you can solve in that moment. If you can, write down the plan. If you cannot solve this, write down the worry, and come back to it the next day.
Remove clocks or any devices that can aggravate your anxiety
When we wake up during the night, one of the first things we do is to check the time. Unfortunately, this habit is likely to exacerbate our apprehension, and trigger thoughts such as “I’ve lost another hour, I don’t have enough time left to sleep, I’ve failed again”. It might be helpful to put these devices in another room. If you start thinking or worrying about it, stick to the fact that you have already set your alarm, so you will wake up when it goes off.
Manage your expectations
Rome wasn’t built in a day and the same applies for our habitual sleep patterns. Don’t be too hard on yourself when you start trying new ways of managing your sleep and anxiety. For example, don’t expect to fall into a rest state right away when you set up a new bedtime. Allow yourself an hour or even more, to switch off and gradually relax. This will also help you to worry less whether these measures work or not.
Keep a sleep diary
As you're learning about your sleep patterns, it can be helpful to keep a sleep diary for two weeks. This can help with noticing different aspects of daytime and night time routines that are more or less problematic, and which strategies might be most relevant. However, it’s important to remember that this is just a tool to monitor your sleep/awake pattern rather than a detailed assessment. It’s okay if you forget to note something on the diary. Try not to be hard on yourself about this, as otherwise this can increase your anxiety about sleep.
Medication for sleep
A small proportion of people are prescribed medication by their GP to help with sleep. Decisions about whether medication is the appropriate choice to treat sleep problems, is a clinical decision and should be taken by your GP or another health professional, after a thorough and careful evaluation of your sleep related complaints. This includes identifying key parameters of your sleep history, medical and mental health history, and family and occupational/social background. The aim is to formulate a robust and holistic diagnostic outcome to inform discussion about treatment options and their anticipated benefit. Clinical experience shows that medication is not usually the first line treatment, and so, might be offered when other strategies (such as some of those above) have not been effective.
There are different types of medication available, depending on the underlying cause of sleep problems and the mechanisms which trigger and perpetuate these issues. Medication can be prescribed for a short period of time (e.g. up to one week), from time to time (i.e. only when needed and not every night), or to be taken every night for a longer period.
It’s important to take medication as intended. The effectiveness of this should be monitored regularly by the GP or another health professional. It’s also important to let them know about any side effects you might experience.
If you would like more information about evidence-based therapy for sleep, try the following:
Rachel Hillier and Michael Gradisar, Helping Your Child With Sleep Problems
Colin Espie, Overcoming Insomnia and Sleep Problems: A Self-help Guide Using Cognitive Behavioural Techniques
Sleepio is a six week online program based on cognitive and behavioural techniques. The program is available via the NHS in some parts of England.
Cognitive behavioural therapy is the most widely evidence-based approach for addressing problems with sleep in adults. This is available via the NHS across the UK. Referals from a GP are usually required. In England, Improving Access to Psychological Therapies (IAPT) services can accept self-referrals or referrals from the GP.
If you are thinking of contacting an independent (private) psychological therapist, it’s good to ask them if they have experience of working with autistic people, and if they know how to adapt what they do so that this best suits needs and preferences of autistic people.