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Sleeping
Problems
An NHS self help guide
www.cntw.nhs.uk/selfhelp
2
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Introduction 3
Understanding sleep and sleeping problems 3
How much sleep do we need?
4
Are there different sorts of sleep?
5
Are there other changes in sleep patterns?
6
What causes sleep problems?
6
What sort of sleep problem do you have?
8
Overcoming your sleep problem
9
Good sleep habits
15
Useful organisations
18
Useful books
19
References 20
Rate this guide
20
3
"I toss and turn for hours on end. No matter what I do, I just
can't seem to get off to sleep".
"I'm very restless through the night, often waking and not
able to get back to sleep".
"I wake up two or three hours before I need to get up and
just lie there trying to drop back off to sleep".
"I never feel like I've had a proper night's sleep. I sleep very
lightly and seem to drift in and out of sleep".
"I have no trouble sleeping. In fact I sleep way too much
but I still feel really tired"
These are all comments made by people who suffer from
different kinds of sleep problem.
This booklet aims to help you understand your sleep problem
and to learn some simple ways to sleep better. Although
hopefully some of the suggestions in this booklet may help, if
you remain concerned about your sleep you should talk to your
GP.
Understanding sleep and sleeping problems
Sleep problems are very common and are often referred to as
insomnia. One study in America found that only 5% of adults
reported never having trouble sleeping.
A recent study found that as many as 30% of the adult
population are affected by sleep problems. Sleep difficulties are
particularly common in women, children and those over 65. In
fact, roughly half of the elderly population complains of
insomnia. Therefore to have trouble sleeping at some point in
your life is quite normal.
4
How much sleep do we need?
People can become very distressed when they feel they are not
getting a good night's sleep, which can then make it harder to
get off to sleep.
But what is a normal amount of sleep? How much sleep do we
need?
The answer is that people vary greatly in their need for sleep.
There is a popular idea that we all need 7 to 8 hours sleep
every night. This is not true. Although for an adult 7-9 hours is
recommended, many studies have shown that people can
range between needing 6-10 hours a night. Also the amount of
sleep a person needs varies throughout their life. For example,
a newborn baby spends 14 to 17 hours sleeping per day. As
children grow older they require less sleep, possibly 11-14
hours as a toddler and maybe 8 to 10 hours as a teenager.
Older adults, aged 65 and over, usually need slightly less sleep,
but the recommendation is still around 7-8 hours.
Not only does the need for sleep vary from person to person,
and with age, it also varies depending on level of activity. For
example, if someone has retired from work, they may be less
active and therefore require less sleep. On the other hand, if
they have a young family and are constantly on the go, then
they may require quite a bit of sleep. Basically, if you awake
refreshed and get through the day without feeling tired then you
are probably getting the right amount of sleep for you.
5
Are there different sorts of sleep?
Sleep is not like a light bulb which is either on or off, but has
different stages, varying from light to deep sleep. There are two
main types of sleep. Broadly, sleep is divided into what is called
Rapid Eye Movement (REM) and non-REM (NREM) sleep.
REM sleep occurs several times during the night and is where
most dreaming is thought to take place. Non-REM sleep is
divided into three stages, each stage being a bit deeper, almost
like a staircase of sleep.
During the night whilst asleep, people go up and down this
staircase many times and in fact wake up several times. We
may not remember these brief wakening's but it is entirely
normal to wake about every 90 minutes or so.
On a typical night an adult who sleeps well will spend about
20% in REM sleep, 5% in Stage 1, 50% in Stage 2, and 25% in
stage 3.
As with the amount of sleep we need, the sort of sleep we have
changes as we get older. Sleep in older people tends to be
lighter, with more frequent wakening. This is normal and
nothing to worry about.
6
For a typical person aged 70, deep sleep takes up less than
10% of the night's sleep. Therefore, an older person may report
waking more times throughout the night.
In summary, sleep in older people does tend to be shorter and
more easily disturbed, but it should still be refreshing.
Are there other changes in sleep patterns?
Not only does our sleep become lighter with more wakenings as
we get older, but our pattern of when we sleep often changes
too. It becomes more likely that we go to bed sooner, wake up
earlier or drop off to sleep during the day, so our natural rhythm
of sleep can be disturbed.
What causes sleep problems?
There are a number of reasons why sleep problems can
develop.
1. Effects of ageing. As mentioned, when people get older they
tend to sleep less deeply and may also sleep less well at night.
Sometimes people will then tend to drop off to sleep during the
day which again reduces the need for sleep at night. This in
itself is not a problem, but often not sleeping at night becomes
a great cause for worry, frustration and concern, which in turn
leads to sleeping less well.
2. Medical reasons for disrupted sleep. There are many
health related reasons for poor sleep which may or may not
be to do with getting older.
Needing to go to the toilet at night. The need to go to the
toilet during the night occurs more in later life. About 60%
of women and about 70% of men, aged over 65 get out of
bed at least once a night to go to the toilet. This can also
happen for other reasons of course, such as pregnancy.
Getting out of bed at night isn't always a huge problem, but
can be frustrating if it is difficult to get back to sleep.
7
Many women report disturbed sleep around the
menopause, often related to hot flushes. Difficulty
sleeping often remains, and generally, post-menopausal
women are less satisfied with their sleep with as many as
61% reporting insomnia symptoms.
Another common medical reason for poor sleep is pain.
This again can be common in older age with joint
problems such as arthritis.
Other health problems can also affect sleep, for example
diabetes, high blood pressure and breathing difficulties.
Some medicines can interfere with sleep, so it is worth
checking with your doctor if you are on any tablets.
Depression and low mood can affect sleep. Disturbed
sleep is a common symptom of depression. It is quite
usual for a depressed person to wake up early in the
morning and be unable to get back to sleep, or
alternatively to have difficulty getting off to sleep.
Obstructive sleep apnoea is a treatable condition present
in around 5% of women and 10% of men most commonly
in middle age. People often don't know they have it, but if
someone snores and breathes loudly with pausing and
gasping, then sleep apnoea may be the problem. It is
more common in people who are overweight and in
people who smoke or drink alcohol. If severe your GP will
be able to refer you to a specialist.
Restless legs syndrome is present in about 5% of the
population and people with this have an urge to move
their legs and find it really hard to keep their legs still in
the last hour of the evening or getting into bed at night.
This can also be made worse by some medicines.
3. Stress, worry and anxiety. When someone is stressed and
anxious they may often find it hard to get off to sleep, with
their mind full of worries and their body tense.
8
4. Bereavement. The emotional upset of bereavement or other
trauma can affect sleep. Nightmares and upsetting memories
are common.
5. Surroundings. Our surroundings can make a big difference
to how we sleep. For example, a bedroom that is over hot or
over cold, a bed that is too hard or too soft, a room that is too
noisy or too light can all make a difference to how well
someone sleeps. Sleeping in a strange place can also affect
someone's sleep.
6. Disrupted sleep routine. People who work shifts which
change frequently often have disrupted sleep. This gets
worse with age and is affected by lifestyle factors such as
smoking and drinking alcohol.
Sometimes it may be a combination of a few different causes,
rather than just one thing. But it is helpful to know what is
causing your sleep problem, as this may help you find a
solution.
What sort of sleep problem do you have? Tick the
boxes that apply to you
Getting to sleep 
The most common sleep problem is trouble getting to sleep. For
some people it can take several hours to drop off to sleep, but
once they are asleep the quality of sleep is good.
Staying asleep 
The next most common problem is a disturbed sleep pattern,
with frequent waking in the middle of the night and difficulty
getting back to sleep.
Waking too early 
A third problem is waking earlier than is desired, again with
difficulty getting back to sleep.
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Poor quality sleep 
Some people report sleeping lightly, with restless, disturbed and
inconsistent sleep.
Sleeping too much 
Another common problem is when people find themselves
sleeping too much, often feeling sleepy or dozing during the
day.
You may have a mixture of these but knowing a bit more about
what sort of sleep problem you have can help when it comes to
trying to deal with it. Keeping a sleep diary to look for patterns
in your sleep can be very helpful.
Summary
Sleep problems are very common and affect people in different
ways. There is no "right" amount of sleep as this varies between
people and across the life-span. Sleep problems can occur for a
number of reasons: as a result of age; medical reasons;
emotional reasons; unhelpful surroundings; disrupted sleep
routines. There are different sorts of sleep problems. It is also
possible to think you have a sleep problem when in fact you are
still getting enough sleep but it is different from what you
expect.
Overcoming your sleep problem
One of the first steps in overcoming sleep difficulties is finding
out any possible causes and trying to look for solutions.
Is sleeping your main problem, or is there another problem
which may be causing you to have difficulty sleeping?
If there is another problem, is there anything you can do about
that problem?
10
Review these common reasons for insomnia and try to work out
which if any apply (please tick). There may be different
solutions for different problems.
Problem:
Worrying about not getting enough sleep - are you
expecting too much sleep and worrying about not getting
enough? Sometimes people lie in bed and worry about not
sleeping. As we have already mentioned, worrying about
not getting enough sleep makes matters worse. Thoughts
such as "I'll be exhausted tomorrow", "I'll never get to
sleep", "I must sleep, it's ruining my health", may run
through your mind. The effect of this is that you feel tense
and anxious and less likely to drop off to sleep, which in
turn leads to more worrying thoughts.
Solution:
Try to find ways to relax and clear your mind. You know
you will always fall asleep eventually. Lying calm and
relaxed in bed can be pleasant if your mind is cleared of
worrying thoughts about not getting enough sleep. Don't
keep looking to see what the time is. Try to put sleep out of
your mind. Have a daydream instead about something
pleasant such as somewhere you have enjoyed a relaxing
holiday. Bring the picture in to your mind as vividly as you
can, remembering all the sights, sounds and smells. You
can also focus on your breathing, breathing in deeply
through your nose, and making sure you have a nice long
out breath. Use your breathing as an anchor, so if your
thoughts wander off you simply bring your mind back by
focusing on your breathing. Deep muscle relaxation can
also be helpful. This can be done by gently tensing and
relaxing the main muscle groups in the body and focusing
your attention on the relaxed feeling as it begins to spread
through your body.
There are many free recordings available online of
relaxation techniques, as well as those that can be bought.
11
Problem:
Needing to go to the toilet in the night - are you up several
times in the night needing to empty your bladder?
Solution:
If you have to go to the toilet several times in the night,
there may be a medical reason for this and the solutions
will depend on what is causing the problem. Bladder
retraining can be useful, as can restricting caffeine intake
and fluid late at night, however medical advice should be
sought if this is a problem.
Problem:
Are you in a lot of pain and does this wake you up or stop
you getting off to sleep?
Solution:
Deep muscle relaxation can help with pain, as being tense
can make pain worse. It may be helpful to speak to your
GP about your pain as there may be a treatment that can
help.
Problem:
Loss and bereavement - have you experienced a loss or
bereavement recently?
Solution:
It is very common to have disturbed sleep following
bereavement. Try not to add to your difficulties by worrying
about not sleeping. Your sleep pattern should return to
normal in time. The relaxation techniques described in this
booklet may help. Talking about your feelings may also
help, either to a friend, counsellor or to your GP. A self
help booklet like this one for bereavement is available at
www.cntw.nhs.uk/selfhelp
12
Problem:
Anxiety, depression, stress - are you suffering from stress
at the moment? Or are you depressed or anxious? If so,
then your sleeping is probably affected. It may be that as
soon as your head hits the pillow your mind starts working
overtime thinking about problems such as work,
relationships and money worries.
Solution:
The following might help. If your mind starts to race try to
use the relaxation techniques described earlier, such as
focusing on a relaxing image or on your breathing. By
making your breathing deeper and slower, this can
decrease your heart rate which in turn reduces cortisol,
one of the hormones released when we are anxious. If you
notice your mind starting to worry again, try saying to
yourself 'I will deal with this tomorrow' and bring your focus
back to your breathing. Basically anxious, worrying
thoughts will keep us awake, and calming, happy thoughts
will help us sleep.
Jotting down a few things we are grateful for before
bedtime each night has been found to be helpful in getting
a good night's sleep. If worry is a big problem for you, it
may be helpful to set aside 30 minutes a day 'worry time'.
Take a pencil and pad and write down everything that is
worrying you. Taking each problem in turn, ask yourself if
there is anything you can do to solve the problem? If no,
score the problem out and move on to the next problem. If
yes, write down every possible solution you can think of.
Choose the most helpful solution and write down all the
steps you are going to need to take. Write as much as you
can. Write down any obstacles and how you might tackle
them. Make a plan for when you are going to deal with the
problem.
Whenever you find yourself worrying, remind yourself to
save it till your next 'worry time'. Sometimes if worrying
13
thoughts pop in to your head at night just asking yourself 'is
there anything I can do about this?' No? Then let it go.
Yes? Jot it quickly down and tell yourself you will deal with
it tomorrow.
Self help booklets like this one for stress, depression and
anxiety are available at www.cntw.nhs.uk/selfhelp It may
be that you need treatment for your depression or anxiety.
Your GP will be able to advise.
Problem:
Do you suffer with restless legs syndrome?
Solution:
Mild restless legs syndrome that isn't linked to an
underlying health condition can be managed with just a few
lifestyle changes. For example, avoiding stimulants such
as caffeine, and decreasing alcohol in the evenings;
stopping smoking; taking regular daily exercise, but not just
before bedtime; and having good sleep habits as described
later in this booklet, can all help. Symptoms may be
relieved by: massaging your legs; taking a cool shower in
the evening; walking and stretching; distraction and
relaxation exercises. If symptoms are more severe,
medication may be needed and you should see your GP.
Restless legs caused by an underlying health condition
can often be cured by treating that condition. For example,
anaemia may cause restless legs, and this may be treated
by iron tablets. Restless legs syndrome can be made
worse by certain medications. If you think this is the case
do not stop taking the medication, but speak to your GP.
14
Problem:
Do you think you may have sleep apnoea? Do you snore
loudly, pausing and gasping frequently in the night? You
may not be aware of this if you sleep alone. But if you are
very tired during the day and seem to be sleeping okay or
possibly even too much, then sleep apnoea may be the
problem, particularly if you are overweight, male and over
the age of 40.
Solution:
Sleep apnoea is treatable. Lifestyle changes such as
losing excess weight, cutting down on alcohol and sleeping
on your side can help. Other medical treatments are
available. If you think this is a problem for you then see
your GP who can refer you to a sleep clinic for further help.
You may find that getting help in another area has a knock-on
effect on your sleeping. Your sleeping may well right itself if you
can solve some of your other problems. Even so, you may have
got into some "bad habits" which are not helping you get off to
sleep. Many people have bad sleep habits and may get away
with it for most of their life. Having a cigarette last thing at night
may not always affect sleep. Lying in bed reading for hours,
watching TV and drinking coffee may be fine for some people
some of the time.
However when a sleep problem starts, it is most helpful to try
and get rid of any bad sleep habits we may have built up over
the years. The following simple checklist of good sleep habits
may help.
15
Good sleep habits
Don't worry
- try not to worry about sleep - it may be that
you are getting enough, but it's just less than you expect.
Don't take naps during the day to catch up if you can help it,
this will affect your natural rhythm and only add to your
problem. Remember that the amount of sleep we get is an
individual thing and may change throughout our life.
Surroundings
- go through this basic check list and see
whether there are any simple changes you can make:
 Noise. Is your sleep disturbed by noise either in or outside
your room? Earplugs may help.
 Light. Is your room too light? Are electronic devices
emitting light? Blackout blinds or an eye-mask may help.
 Temperature of room (too hot, too cold?) Wearing socks,
electric blanket, hot water bottle, can all help.
 Is your partner keeping you awake? Earplugs or spare
room may help.
Food and drink
- anything that contains caffeine, taken near
to bedtime, will reduce the quality of sleep. Examples include
coffee, tea, hot chocolate and cola. Chocolate also contains
caffeine. It is best not to have any of these things within six
hours of bedtime. If you are having a bedtime drink try to
make sure it is decaffeinated. There is some evidence that
having a malty drink at bedtime can increase length of sleep
and reduce broken sleep.
Cigarettes - smoking last thing at night can keep you awake
as nicotine is a stimulant. If you do smoke, try to have your
last cigarette at least four hours before bedtime. Nicotine
patches or chewing gum could also affect sleep.
Medicines and other drugs
- some drugs can affect sleep
because they are stimulants. If you are taking medicine it is
worth checking with your pharmacist or doctor. Examples are
certain drugs for asthma and for migraine. Sleeping tablets,
whilst they can help in the short term often cause sleep
16
problems as they interfere with the quality of sleep and can
alter sleep patterns. They should only be taken for short
periods. You can discuss this with your GP.
Alcohol
- whilst people often feel sleepy after drinking a lot
of alcohol, again the quality of sleep is affected. It is best to
avoid drinking large amounts of alcohol close to bedtime if
you are having sleep problems.
Consistency
- try to get a consistent timetable so that your
body knows where it is. Getting up at the same time each day
is much better during insomnia than trying to catch up on lost
sleep or going to bed early or napping at odd times during the
day. It is better to go to bed feeling sleepy rather than too
early in an attempt to try and catch up If you feel the need to
sleep in at weekends try to make it not more than an hour
later than usual.
Pre-sleep routine
- try to use the hour before going to bed
to unwind and prepare for sleep. Dim the lights, listen to
some calming music. It is helpful to get into a pattern.
Electronic devices
- avoid using electronic devices (TVs,
gaming machines and more importantly, tablets and
smartphones) in the hour before bedtime and in the bedroom.
Blue light emitting from these gadgets stimulates the brain
and inhibits melatonin production - the hormone that helps
you sleep.
Tiredness
- this may seem obvious but do not go to bed
until you feel sleepy.
Activity -
gradually increase your daytime activity and
exercise, but don't exercise too near to bedtime.
Get up
- if you have not fallen asleep within 20 minutes - get
up. Don't lie in bed feeling tense. Listen to relaxing music,
read a relaxing book or watch something boring on TV until
you feel sleepy. Some people find that having a warm milky
or malty drink can help.
17
Bed for sleep
- make sure your bed is associated with sleep.
For example, don't watch TV, eat, and talk on the telephone in
bed. The only exception to this is sex which can in fact help
with sleep.
These simple guidelines really can improve your sleep but they
take time. Please be patient, your hard work will pay off
although it can take many weeks to develop new sleep habits.
Summary
The simple rules outlined above can help improve your sleep.
The checklist below is a brief summary of some of the 'dos and
don'ts' for a good night's sleep
Do
Do get up at a regular time.
Do have a bedtime routine and wind down before bedtime.
Do get up if you are worrying, or are not asleep after 20
minutes, and do something relaxing.
Do exercise regularly, but not in the late evening.
Do remember that sleep changes throughout the life cycle
so try not to worry about lack of sleep.
Do make sure your bed and bedroom are comfortable, for
example, noise, temperature, light, etc.
Do check whether any medicines you are taking may be
affecting your sleep.
Don't
Don't worry about not getting enough sleep.
Don't lie in bed worrying about other problems.
Don't use your bed for things other than sleep and sex.
Don't eat or drink caffeine close to bedtime, and cut down
during the day.
Don't smoke close to bedtime.
Don't drink alcohol close to bedtime.
Don't go to bed until you feel sleepy.
Don't take naps during the day.
Don't stay in bed longer to catch up on lost sleep.
18
These techniques have been proven to help many people but
take time and hard work. If you feel you are making little
progress or the problem is getting worse then speak to your
GP. Your GP may be able to refer you to local services with
training in sleep disorders. In addition there are NHS and
commercial digital CBT packages (CBTi) for sleep available
which you can discuss with your GP.
Good luck and sleep well.
Useful organisations
Sleep Matters Insomnia Helpline
Tel: 020 8994 9874 (Monday - Friday, 6pm-8pm)
www.medicaladvisoryservice.org.uk
Medical Advisory Service, P.O. Box 3087, London, W4 4ZP
Provides telephone advice and resources concerning
sleeping problems.
The Sleep Council
Freephone leaflet line (non medical): 0800 018 7923
Email: info@sleepcouncil.org.uk
www.sleepcouncil.org.uk
Provides helpline, information and a wide range of resources
on improving sleep.
Healthwatch
www.healthwatch.co.uk
Healthwatch England is the independent consumer champion
for health and social care in England. Working with local
Healthwatch networks, we ensure that the voices of
consumers and those who use services reach the ears of the
decision makers.
Mental Health Matters
Tel: 0191 516 3500
Email: info@mhm.org.uk
www.mhm.org.uk
A national organisation which provides support and
information on employment, housing, community support and
psychological services.
19
Mind Infoline
Tel: 0300 123 3393
Email: info@mind.org.uk
www.mind.org.uk
Provides information on a range of topics including types of
mental distress, where to get help, drug and alternative
treatments and advocacy. Also provides details of help and
support for people in their own area.
Helpline available Mon - Fri, 9am - 6pm.
The NHS website
www.nhs.uk
Information about conditions, treatments, local services and
healthy lives.
Useful books
The insomnia kit: practical advice for a good night's
sleep
Chris Idzikowski
NewLeaf 1999
Contains illustrated book, 28-day sleep assessment diary and
60 minute audio tape with relaxation exercises.
An Introduction to Coping with Insomnia and Sleep
Problems (2nd edition) (An Introduction to Coping
series)
Colin A. Espie
Robinson 2017
Explains the causes of insomnia and why it is so difficult to
break bad habits. This updated edition gives you clinically
proven cognitive behavioural therapy (CBT) techniques for
improving the quality of your sleep.
Why we sleep: the new science of sleep and dreams
Matthew Walker
London Penguin 2017
This book explores twenty years of cutting-edge research to
solve the mystery of why sleep matters. It explains really
happens during REM sleep to how caffeine and alcohol affect
sleep and why our sleep patterns change across a lifetime.
20
How to beat insomnia and sleep problems: One step at a
time
Kirstie Anderson
Little, Brown 2018
A self help guide with sleep diaries.
The perfect resource for helping you beat insomnia and sleep
problems, either by yourself or in conjunction with the support
of an IAPT service. Written in a friendly, engaging and
jargon-free style. This book will help you to understand your
sleep cycle, and learn techniques to get back to a better
night's sleep.
The One-week Insomnia Cure: Learn to Solve Your Sleep
Problems
Professor Jason Ellis
Vermilion 2017
The Insomnia Cure provides a fast and long-lasting approach
to identifying and managing insomnia and other sleep
disorders. Find out how to understand and assess your sleep
problem, cure insomnia in one week and manage sleep
apnoea, snoring, restless legs and much more.
The Sleep Book: How to Sleep Well Every Night
Dr Guy Meadows
Orion 2014
Using a blend of mindfulness and new ACT therapy
techniques, Dr Guy shares his unique five-week plan to cure
your sleep problem whether it's a few restless nights or a
lifetime of insomnia.
References
A full list of references is available on request by emailing
pic@cntw.nhs.uk
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Share your thoughts with other people and let them know what
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• Abuse
• Alcohol and You
• Anxiety
• Bereavement
• Controlling Anger
• Depression and Low Mood
• Depression and Low Mood - a guide for partners
• Domestic Abuse
• Eating Disorders
• Food for Thought
• Health Anxiety
• Hearing Voices and Disturbing Beliefs
• Obsessions and Compulsions
• Panic
• Post Traumatic Stress
• Postnatal Depression
• Self Harm
• Social Anxiety
• Sleeping Problems
• Stress
• Plus 3 guides for prisoners
• Anxiety
• Depression and Low Mood
• Post Traumatic Stress
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Published by Cumbria, Northumberland, Tyne and Wear NHS
Foundation Trust
2020 Copyright PIC/101/0220 February 2020 V4
Review date 2023
Written by Dr Lesley Maunder and Lorna Cameron, Consultant
Clinical Psychologists.
Many thanks to local voluntary sector groups, service users and
healthcare staff who have contributed to the review of this guide.
In addition we would like to thank Dr Kirstie Anderson, Consultant
Neurologist, and colleagues from the Regional Sleep Service, The
Newcastle upon Tyne Hospitals NHS Foundation Trust for their
helpful comments.
www.cntw.nhs.uk @cntwnhs CNTWNHS
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