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Programme 3. - Insomnia
RADIO 4
THURSDAY 04/08/05 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
KEVIN MORGAN
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
MYERS
If you suffer from insomnia then you've probably tried everything to get a good night's sleep - lavender pillows to soothe you, milky drinks to guard against night starvation, opening the windows, closing the windows or moving into the spare bedroom. Actually it's not a bad idea to set the scene in whatever way suits you but this sleep hygiene, as it's called, is just one of a number of steps that you might need to take to get back into a good sleep pattern. Of course you could just give in to it, take a sleeping pill, there are 12 million of these prescriptions handed out every year. But according to my guest today taking a more psychological approach to insomnia is far more beneficial and he has the evidence to prove it. So it's a pleasure to welcome Professor Kevin Morgan from the University of Loughborough's Sleep Research Centre who's here today with me to take your calls and the number is 08700 100 444 or you can e-mail Check up at bbc.co.uk in the usual way.
We'll go to our first caller, he's Jack and he's in Greenwich. Jack, you've got insomnia I guess or else you wouldn't be ringing us, what's the precise problem for you?
JACK
Well the problem is like this: I usually go to sleep at about 12 o'clock, sleep for one hour and then I wake up, almost on the dot of 1 o'clock and it's impossible to go off to sleep again so I get up and I usually make a drink, sometimes a weak tea or sometimes an Ovaltine. Stay up for an hour listening to Radio 4 and then I go back to bed at about 2 o'clock and most times I can go to sleep for another two hours and then I wake up again. So I have this - then if I wake up again I do this - I repeat the activity - get up, have a short drink and go back to bed again. So on average I'm up twice during the night and I suppose because I'm retired I'm able to make up my sleep in the morning hours and my best sleeping period is from probably 5 o'clock till 10.
MYERS
Right I'm going to stop you there because at the point where you mentioned being retired and sleeping in till 10 Kevin Morgan raised his eyebrows - is that a bit of a clue there?
MORGAN
For me. Hello Jack. A quick back of the envelope calculation tells me you're spending - you're intending to spend about 10 hours every night in bed and you're retired which tells me that you're probably over 60 - over 65?
JACK
Yes I'm 72 actually.
MORGAN
I think people vary enormously in how much sleep they actually need but it's probable that you don't need much more than seven hours to seven and a half hours sleep each night. So you're already over-investing in your time in bed. I've got two things to suggest, the first is this that if you're finding that you can sleep in that 5 till 10 period in the morning then you have a healthy sleep need, it's possible that you're squandering it by going to bed a little bit too early. I think the very least you could do, and if this doesn't work then I strongly recommend that you go and seek professional help and discuss this with your doctor, but what I would suggest you do is start limiting how much time you spend in bed and I'd start by limiting it to at least seven hours and see what happens. I mean just go to be bed with the intention of sleeping, now you seem to be doing pretty much what we would recommend people to do if they don't go to sleep straightaway - if you're not asleep in half hour, get up and do something quiet. I'm not so sure drinking anything is a good idea because that means you've got to get up later to go to the bathroom. But at the very least if you can't go to sleep get up. But here's the important thing - if your alarm clock is set for say 7 or 8 o'clock in the morning, when it rings you get out of bed, fully intending to meet your day and you don't return to bed until your usual bedtime of - if it's midnight, then go back to bed at midnight. Now this might make you a little bit tired in the first week but tiredness is a valuable resource if you have a sleep problem.
MYERS
Now can I just interrupt if only to say that what you're saying sounds to me a little bit sort of paradoxical, you're saying - if you're not able to sleep, you're tired because you're not able to sleep, sleep less - that does seem slightly perverse and if people - I don't know they're going to say well I'm going to be exhausted in that case.
MORGAN
I'm not saying sleep less necessarily, I'm saying spend less time in bed. Now what Jack is doing is working up an exhaustion through the early part of the night, which he's then spending between 5 and 10 o'clock in the morning which tells me Jack's quite tired. Okay? Now whether or not he feels able to function during the day is something we haven't explored but what he can certainly benefit from is spending tiredness earlier on in the night, so that he doesn't have to go through this ritual of getting up, making drinks, going back to bed.
MYERS
Jack, thank you very much, there's some interesting information there and I'm sure we'll add to it as we go through the programme because I know Kevin in this research work you've been doing you've been looking at almost a package - a sort of tool kit of psychological approaches and that sort of touches on this sleep restriction, maybe we can come on to some of the other aspects of this work that you're doing. Let's go though to another caller who's waiting patiently and it's Stephen Howells. Stephen is taking medication, doesn't want to take medication, I guess you'd approve of that, but where do we go from there, that's presumably the question is it Stephen? What other ideas have you got?
HOWELLS
Well I'd like to find some way of not using medication, that's my basic problem. But I only have a small dose of zopiclone, I think they're 30 milligrams, so I take a quarter and I've been doing that for probably - a quarter of a tablet a night - for probably more than a year. And if I don't take them then I tend to sleep - well down to a very shallow sleep but wake up very, very easily and probably don't - I don't go down into a deep sleep at all. If I take just a quarter of a tablet I can get off that edge and get down to sleep and probably sleep for five or six hours, even that doesn't seem to be enough sometimes. But I'd just like some alternative ideas. I've tried Tranquillity Tea, which does seem to help sometimes but it's very - not very tasty, to say the least. And also a herbal remedy I do try sometimes which is Quiet Life, which I think is a natural valerian and that does seem to help but it's very slow acting.
MYERS
Well let's see what the professor has to say, what's wrong with staying on sleeping tablets if they seem to do the trick, as they seem to do for Stephen?
MORGAN
The problem is that they actually stop working, that's the main problem, nothing more dramatic than that. The longer you take sleeping tablets the less impact they have on your sleep until they can, as in Stephen's case, have virtually no impact on the quality of his sleep at all. The problem arises when you start trying to stop taking your sleeping tablets and paradoxically that can actually generate an insomnia. Now I didn't get a clear idea from you Stephen whether your problem is getting off to sleep in the first place or whether it's staying asleep for the full length of the night.
HOWELLS
It's getting to sleep.
MORGAN
Okay.
HOWELLS
The tablets are still working, I've been taking them a long time but they do help me get to sleep but I'd like to stop obviously.
MORGAN
I'd ask you to reflect on whether or not your tablet - you're taking a very, very tiny dose, you're taking the kind of doses which if we were trying to withdraw somebody from sleeping tablets they'd be taking that kind of dose immediately before they stopped taking them altogether.
MYERS
So could it almost be a placebo effect?
MORGAN
Well what I'm coming to is that maybe you have - it's a kind of psychological crutch that makes you feel as if it's going to be of benefit. So there are two issues here. One of them is if you want to stop taking your tablets that's fine and you must discuss this with your doctor but then you must consider well what do you do, even if it is a psychological crutch, which it may not be, it may actually be a pharmacologically active dose in your case. Nevertheless, it still introduces the problem - what do you do when you withdraw your sleeping tablet. And if your problem is getting off to sleep then there are cognitive behaviour strategies that can help you to deal with the kinds of thoughts you might be having immediately before you go to sleep that can certainly help you.
MYERS
Is it worrying that might keep you awake?
MORGAN
Worrying can keep you awake but it's easy to overemphasise the value of worrying. Thinking in and of itself in an uncontrollable way will keep you awake at night, if your mind is active you cannot go to sleep.
MYERS
Is that you Stephen - an active mind?
HOWELLS
It certainly is, yes, it never stops.
MYERS
Never stops.
MORGAN
Then what I would suggest you do is go and discuss this with your doctor, what you're introducing here is the issue of withdrawing from that very small dose of zopiclone but what you also need is some therapeutic input that can help you deal with the kinds of thoughts you're having at night, technically the kind of input I'm thinking of is called cognitive behaviour therapy and it's widely available throughout the health service.
MYERS
And briefly what is that and how does it apply in this case because there must be many people out there who will certainly agree they worry, they think, their minds are racing, they're imagining things, they're turning things over in the mind - it's the only time in the day they have time to turn things over in the minds?
MORGAN
Generically cognitive behaviour therapy refers to a collection of therapeutic approaches that operate on the basic assumption that how we think about things and our style of thinking affects how we respond to them and how they affect us. Now in the case of going to sleep there's a very special way in which thinking works. In your particular case Stephen it sounds very much as if the act of thinking itself is prolonging the time it takes you to get to sleep. Now most of those can control whether or not we're thinking worried thoughts and whether or not we're thinking at all, we simply need to learn strategies for dealing with this. Cognitive therapy of the kind I'm thinking of actually can help you do your worrying at some other time during the day, nothing inherently wrong with worrying, providing you can draw a line under it and say right I'll stop here. It can help you to perhaps block the kinds of thoughts that are particularly unhelpful, the kind of exciting or depressing thoughts people can have. And it can help you challenge thoughts sometimes, it can help you say well look that's not a useful way to be thinking about anything, where's my evidence for that particular thought being true. And there's nothing worse than a dark room, a quiet room for exciting exactly the wrong kinds of thoughts.
MYERS
Now we've got an e-mail I just want to bring in here because Heather has written to us saying she's had insomnia for years, probably gets a decent night's sleep about two nights a week. This has been going on for a length of time, she's tried various remedies, sleeping pills, she's asking about these psychological therapies of which she's obviously read or heard and she's saying are they available on the NHS - so the sort of thing you've been talking about - cognitive behavioural therapy - does she or Stephen go to their doctor and get an appointment to see someone who will help with these thoughts to restructure how we think about things that perhaps is the reason that we're not able to get off to sleep or back to sleep?
MORGAN
Okay that's the usual query I can make a specific and a general point on the basis of that. The first thing is that if you look at the sleep patterns of many people with insomnia, the kind of pattern you've just described is not untypical, people sleep maybe okay for one maybe two nights and that's followed by and preceded by periods of turbulent poor quality sleep. Now in fact these so-called typical or good nights are in fact a consequence of sleeping badly, ultimately sleep is self-regulating and a period of sleepless exhaustion will eventually resolve itself in a period of what's called recovery sleep or exhaustion sleep.
MYERS
So even insomniacs get a good night sleep from time to time?
MORGAN
Episodically they can't predict it and it's not quite the way most of us would prefer to do our sleeping. But what it isn't is their typical sleep, it's a sleep you can only get if you're exhausted, okay. Now coming back to the issue of whether or not the kinds of cognitive behaviour therapies I've been describing are available on the health service, yes they are. And the main therapeutic group that is responsible for using cognitive behaviour therapies is clinical psychology, clinical psychologists are available through every general practice in the country. There are also specialist nurses and specialist therapists who are trained in cognitive behaviour therapy. Now here's the interesting thing - not all clinicians who practise cognitive behaviour therapy know that it has specific applications in sleep but it's fairly straightforward how their skills can be directed and translated into specific CBT I - for insomnia.
MYERS
Okay, and that's the research you've been involved in at Loughborough with cognitive behavioural therapy specifically for sleep problems and you do seem to have quite spectacular results - I think the claim is that within five hours you can cure something like 80% of insomniacs - is that quite right?
MORGAN
Nobody cures insomniacs, insomnia is something that you manage rather than cure. You certainly treat it successfully. In Loughborough, in common with other groups in the UK, there has to be said not many of us, what we've shown is that not only can a package of cognitive behaviour therapy substitute adequately for sleeping tablets and deliver long term benefits for a range of people of different ages and different backgrounds with sleep problems but we've also shown that these treatments can be delivered in routine general practice, in routine primary care settings. So there really is no reason now why we cannot within the health service organise things so that these treatments are available to everyone.
MYERS
Good news. Let's go to an anonymous caller who is in Kent, it's your turn. Hello? I'm not sure you are there anymore. Let's see who else is waiting to talk to us in that case. Lines are quite dead for the moment - that's fine. So let's talk a little bit more about the research and this ability to use these techniques, these psychological techniques. You mentioned, or I mentioned I think, that within five hours you can make a real difference, is this a five hour session we're talking about or is it five hours over five weeks?
MORGAN
The research evidence collectively shows that five hours of treatment, now these are usually delivered as, what we call, a package and the therapy sessions generally last 50 minutes to an hour and they begin with an introduction and they run over five separate episodes. Now what we aim to do is cumulatively build up resources - tricks, skills - that an individual can acquire, take away and practise themselves and it's that combination of instruction and therapeutic support that delivers benefits. So I suppose I have to say here that psychological treatments are not do-it-yourself treatments but they're treatments where the cooperation and the support of the patient themselves is critical.
MYERS
Okay, well I'm sorry we can't go to our anonymous caller again, who's taken the lines down with him or her, but we can go to a caller in London, Sylvia David - hello Sylvia.
DAVID
Hello.
MYERS
And your particular question on this theme - sleeplessness?
DAVID
My problem is similar to the first caller's. I go to sleep about 11 and then I wake up regularly about 12 o'clock and whereas one time I would go back to sleep by about 1, now I find it difficult to go back to sleep before 3 o'clock.
MYERS
And presumably you feel pretty grim for the rest of the day?
DAVID
Yes, yes I do, I need eight hours sleep a day.
MYERS
And I don't know if it's relevant, do you need less sleep anyway as you're getting older, I mean I'm not sure of your age group Sylvia ...
DAVID
I'm in my 70s, no I've always needed sort of eight hours, maybe sometimes less.
MYERS
But what you're getting is certainly not doing it even now. Okay. Kevin.
MORGAN
Yes if you're feeling groggy during the day Sylvia - is that the case?
DAVID
Yes.
MORGAN
Okay. Just tell what time is your alarm clock set for in the morning, what time do you get out if you've had one of these poor disturbed interrupt ...
DAVID
I don't have an alarm clock unless we're going somewhere. I normally - I will wake up about half past seven or 8 o'clock.
MORGAN
Okay. So it's not uncommon for sleep to change as we get older. There are three things that happen to our sleep as we age and these are - as far as we can tell they are normal and predictable - our sleep becomes shorter, it becomes lighter - we're more easily disturbed - and most importantly it becomes more fragmented, it tends to break up. Now part of the trick of dealing with our sleep in later life is dealing with the physiological break up of our sleep periods and in many respects this interrupted - this interruption in our sleep is a problem of getting back to sleep, okay? So many of us in mid-life and later experience waking in the middle of the night. Now the problem is how do we then deal with that, what do we do? Maybe we get up and go to the bathroom, maybe we just spontaneously wake up and wonder if there was a noise. But the trick is how do we then get back to sleep? Now there are a couple of options here, one of them is you can lie in bed and simply wait for sleep to return ...
DAVID
No, I couldn't do that.
MORGAN
Well that's good because if you lie in bed too long you just get frustrated and the frustration itself keeps you awake. So we have strategies that instruct people if you can't get to sleep and you want to get to sleep, get out of bed, go somewhere quiet, wait until you feel as if you're going to go to sleep, return to bed. What I wouldn't suggest is that you keep this up all night, although it does sound as if, in the later part of the night, you are going to sleep - is that right?
DAVID
As I said, I used to go off to at 1 o'clock but now I get up, I have perhaps milk and a sandwich or something, I have fast metabolism so I wonder also if food plays a part, and then I feel tired, I go back into bed but after five minutes I find I haven't gone to sleep so I get up again and read. And this carries on till about 3 o'clock.
MORGAN
Okay, and then after 3 o'clock you go to sleep?
DAVID
I go to sleep.
MORGAN
Okay, let me just deal with a few expectations here. One expectation you have is that you're going to sleep for eight hours, now I'm in no position Sylvia to say that you don't need eight hours sleep but I will reflect that of the many people I've ever spoken to in your age group few of them, few of them, experience eight hours sleep and it's been some years since many of them have. Okay, that's the first point. And the second is that if you're not asleep inside five minutes I mean you're doing quite well actually, I mean I'd give it 10 or 15 at least...
DAVID
Oh yes no I sometimes do, sometimes actually I do drop off but I wake up again and I'm back to where I started.
MYERS
Sylvia, can I pop in just to make a general point because I've got a lot of people waiting to speak to us and we haven't got very long in the programme? But can I ask Kevin whether the sort of discussion that you're having now with Sylvia is a kind of discussion that people should be having with their GP or with a therapist who can actually take them through what the right expectations are, just how many hours of sleep they're getting or not getting and how they deal with it, and that that is a way of addressing this and it's never too late to do that?
MORGAN
This is a very good point and I certainly won't overemphasise the role of expectations in sleeplessness, most of us know how much sleep we need and we intuitively feel whether or not our sleep is poor quality and Sylvia would fit into that category I'm sure. But one of the weakest components of sleep management, however it's delivered, is assessment, we don't have a culture of assessing sleep and what can happen is that these reports get frozen in time, like Sylvia's, and what would be beneficial here is if we were to look at the sleep pattern over time. But I would come back to eight hours is a long time to be asleep, personally I can't remember the last time I had eight hours sleep myself, but that doesn't help Sylvia.
MYERS
Okay, well I hope what you have been able to say through the programme helps Sylvia and others. Let's see if we can quickly help Jean who's in Old Harlow. Jean gets - well - two and half hours a night, it says here, that doesn't sound very much at all, why is that Jean?
CORLETT
Hello. Forty years ago my daughter was born and I was an overanxious mother and lay awake listening for her thinking she might die in the middle of the night. And then the same happened with my son 18 months later and from then onwards I've been a very light sleeper, very sensitive to sound or light. My sleeping pattern has worsened over the years and I have my own bed and my own bedroom with darkened blinds, I go to bed about 10 o'clock and I'm awake by 12.30. I listen to the World Services and tapes and if lucky I will sleep again about 5.30 till 6.30. In the afternoon I have a 10 minute nap, I lie down for an hour but 10 minutes of that I go to sleep.
MYERS
You can't even get to sleep during your nap?
CORLETT
No.
MYERS
That is worrying. Okay I mean that's a disrupted pattern of sleep by anybody's standards and if it's been going on for 40 years I'm surprised you're able to be compos mentis enough to tell the story, that's sleep deprivation in a big style. Let me ask Kevin for some thoughts on that.
MORGAN
Jean hello.
CORLETT
Hello.
MORGAN
You allow me to make quite an interesting point here. One of the things that we've learned from research over the past 40 years is that there really are some people who seem to be, to use a term that we use in psychology, wired up to be poor sleepers, they simply happen to be light fragile sleepers and by and large these individuals may not know about it but events in their life sooner or later will unmask this propensity. And I've lost count of the number of late life or elderly women I've spoken to who can identify the onset of their insomnia as the birth of their first child, it's not uncommon. Now almost certainly - stick my neck out here - you're probably a constitutional light sleeper and you probably didn't recognise this until you had a baby. Babies disrupt sleep - more than half of all mothers of new babies have sleep problems because babies wake you up. If you happen to be a constitutional light sleeper, if you happen to have fragile sleep, if you happen to have a kind of turn of mind that makes you amplify anxieties then early parenting will exploit this. Now what you describe subsequently is the career of a poor sleeper. Looking at the times, again I've done a quick back of the envelope here, you're spending about eight and a half to nine hours in bed every night and then you're trying to get a nap in the afternoon. You're going to have to look after your sleep now because it's a resource for the future. So the first thing I'd suggest you do is start spending less time in bed, why don't you go to bed later?
CORLETT
If I go to bed later I don't get to sleep at all. I've tried this many times, I become overactive and I just cannot switch off at all.
MORGAN
Okay, in that case ...
CORLETT
I've been to a psychoanalyst for six months plus all the other therapies you can think of and I also asked my GP if I could be sent to Loughborough and could they help me and she said oh no I shouldn't think so.
MYERS
Well we're not going to solve this problem in the few seconds that we've got left in our programme but would you just like to make a point about whether a sleep centre would be a relevant place for someone with that sort of level of difficulty?
MORGAN
Part of our research effort has been to take the therapies onto primary care, into general practice, I think that's where people do their complaining and that's where they ought to find treatment for it. And I still think Jean could benefit from competently delivered cognitive behaviour therapy.
MYERS
Well that is all we have time for. Very many thanks to Professor Kevin Morgan, our expert today, and thank you very much for all your many calls and e-mails and I'm so sorry we didn't get to more than a small percentage of them but I hope that at least you found something useful and relevant in the calls that we have been able to answer there. If you'd like to hear the programme again you can do so, you can go online, you can go to the 大象传媒 website and follow the trail to Check Up. You can call our action line 0800 044 044, those calls are free and confidential. And please join me again if you will at the same time next week when we'll be taking your questions about essential tremor.
ENDS
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