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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP Programme 5. - Sleep
RADIO 4
THURSDAY 27TH MARCH 2008
PRESENTER: BARBARA MYERS
CONTRIBUTORS: KEVIN MORGAN
PRODUCER: DEBORAHÌýCOHENÌý
NOT CHECKED AS BROADCAST
MYERS
Hello. It wasn't so very long ago that if you said you were not sleeping well at night the only thing your doctor might offer would be sleeping pills. Well they still have their part to play but they're not the best way of dealing with insomnia, which is our subject today. If you are having difficulty getting off to sleep or if you wake often or too early and if you're tired and irritable during the day you may benefit from some of the newer more psychological treatments on offer. Well to explain what these are and to answer your questions about dealing with sleeplessness I'm joined in the Check Up studio today by Professor Kevin Morgan, he is the director of the Clinical Sleep Research Unit. And you have taken the opportunity to call in droves, I may say so, let's get quickly on to the first caller who's in mid-Wales, she's Roma, she doesn't have trouble getting off to sleep but I think doesn't feel as though she's had a good night sleep, so what happens to you Roma?
ROMA
Yeah, that's it. Usually I manage to go to sleep okay but I wake up quite a lot of times in the night, sometimes to go to the loo or sometimes just I'm not quite sure why. And although I can usually get back to sleep, not too badly, quite often by listening to the World Service on the way, nearly I would say just about everyday I wake up and I feel as if I've hardly slept, I feel as if I sleep incredibly lightly, almost a fly walked across the room and I'd wake up.
MYERS
So it's the quality really of the sleep as much as anything and that feeling of not really having been deep down there and getting the refreshment. And I think we've had a lot of calls and e-mails which are indicating that that's what people are most concerned about. So let's find out from Professor Morgan what's going on here.
MORGAN
Roma, just out of interest, tell me how you feel in the afternoon, like now - sleepy, do you nap?
ROMA
Quite often I would feel that but I'm quite an energetic person, so I almost never would do that.
MORGAN
So you can manage to sustain attention, to cope with your day until the following bedtime as a rule?
ROMA
Yes I guess I sort of push through it, yeah.
MORGAN
Okay. There is a kind of sleep, it's called non-restorative sleep, and it's the kind of sleep that you seem to be describing quite well now, it's that feeling that you wake up and you don't really feel you've done the thing properly, you wake up and you feel I haven't had enough of this. If that's associated with feeling sleepy and lethargic during the day, feeling fatigued during the day, then you properly have an insomnia problem. If on the other hand it's an inconvenience waking up in the night and it's probably not doing you any favours waking up in the night, when you wake up feeling maybe a bit under the weather in the morning, but if you can sustain attention during the day, if you can manage to execute a day's routine before you go to bed then you probably have to look to managing the sleep you already have at night and maybe try to consolidate that a bit more. The second question I feel obliged to ask is what time do you go to bed?
ROMA
Very variable, possibly not early enough, ooh gosh, anywhere between kind of 10 and the early hours of the morning if I get busy doing something.
MORGAN
So how many hours sleep do you think have on average?
ROMA
Probably about six.
MORGAN
Okay, and here's the big question - how long do you think you spend in bed awake every night?
ROMA
It feels like a lot, it probably isn't as much as it feels like but it probably feels as if - if you added up all the bits I've been awake for an hour or two.
MORGAN
Well that's not an excessive amount of time to spend awake in bed, I mean it's not helpful and it certainly - I mean don't devalue your own subjective feelings of its impact upon you, that's quite important. But what I would suggest is that you regularise your time of going to bed but if you can manage to get off to sleep okay and you said earlier - you said maybe I don't go to bed early enough, I mean maybe you'd only be committing yourself to spending even longer awake in bed if you went to bed any earlier. Perhaps the issue here is somehow being able to predict that you're going to go to sleep and when you wake up in the night if you can get back to sleep then you've probably offset a growing problem here. I don't know how old you are Roma but this is one of those problems that if you don't sort of resign yourself to it now or address it now it's going to get worse.
MYERS
Okay, let's move to another call, I'm very conscious of how many people are waiting to speak to us and hopefully there'll be more about the kind of pattern that you need to set for yourself and just what you can achieve. But Susan Selby is calling us from France with a particular problem and that's because you've got a teenage son Susan. We've all had teenage sons, or those of us who have know about trying to get them into bed and out of bed, what's the problem you're having with your boy?
SELBY
Hello there.
MYERS
Hi.
SELBY
Yes I have my 18 year old son and he cannot wake up, he has three alarms that go off simultaneously and I can hear them from my bedroom, which is downstairs, and they don't wake him up and you actually literally have to go in and shout above them. I have other children who don't have - other teenagers - who don't have a problem of getting up. But he just is - cannot wake up and I did hear that teenagers' body clocks don't work the same.
MYERS
So there may be an excuse, is that right - let's ask the professor, is that a well known phenomenon?
MORGAN
Susan hello. Why does this sound so familiar to me? You've hit upon two things: one of them is that you have one member of a family which otherwise seems to sleep fine and this one stands out and the other is this person doesn't seem to be arousable first thing in the morning when everybody else is aroused. Now the obvious question here is do you have problems getting your son to go to bed in the evening or does he have problems taking himself to bed in the evening?
SELBY
Well like a lot of teenagers and like my other children he goes into his room and he does his homework and I don't really see him but he doesn't go to bed. I know that he doesn't go to sleep until at least one o'clock in the morning, much like my other ones.
MYERS
I guess the question is really whether boys or teenage boys and girls, for that matter, need more sleep and so can we excuse them?
MORGAN
Teenagers require - teenagers require substantial amounts of sleep, there are two things going on here: one of them is for all kinds of internal hormonal reasons. They're actually finding it rather difficult to synchronise their sleep with the rest of the family. The other thing is that because they're teenagers for all kinds of psychological reasons they want to assert their control over their lives. Now one of the things that we know teenagers are particularly prone to is a condition called delayed sleep phase syndrome where if left to themselves they'll just shunt their sleep period further and further into the night.
MYERS
Is that a bad thing?
MORGAN
Well it's a very unhelpful thing if you've got to get up for school in the morning or if later in life you've got to get up for work in the morning.
MYERS
So as a parent then are we kind of well within our rights to try and establish reasonable sleeping patterns which will actually stand everyone in good stead?
MORGAN
I think in the interests of the child you have a parental obligation to put some pressure on reminding your children that they really ought - they perform better if they slept better.
MYERS
I mean is it ...
MORGAN
...and getting them out of bed in the morning.
MYERS
Indeed, I mean generally speaking is it our peril if we don't establish and keep good sleeping habits?
MORGAN
After puberty and after sort of late teenage years it becomes easier to regularise. But there are some particularly prone individuals - and the point made that this is one person in a family who otherwise sleep fine, this one particular prone individual will need special attention otherwise they will find themselves sleeping their mornings away for years.
MYERS
Susan I think the prof is saying get in there and get him up in the morning and good luck is what I would say. Let's move to another caller in Basildon in Essex and it's Edward. Hello Edward.
EDWARD
Hello.
MYERS
You've got a concern about a sleeping pills which I think you take.
EDWARD
Absolutely yes.
MYERS
So is there a problem?
EDWARD
Yes there is. I've just fairly recently discovered that I've been on a sleeping tablet which is addictive after apparently about four weeks and I've been on them three years. So the doctor has recommended that I try to get off of these, cold turkey if you like, on to Diazepam which is another addictive drug. And I hope I'm winning on that. I don't know. But I still get the most terrible vivid dreams during my night of very short sleep. I can go to sleep now for perhaps two hours, three hours and then after that it's just thinking aloud but trying to sleep.
MYERS
So actually it sounds as though - I don't know if you'd agree Professor - that this is obviously the right thing to try and do to get off these sleeping pills because they're not designed really for us to take over any really extended period are they?
MORGAN
They're not designed and they're not licensed to be taken continuously over these periods.
MYERS
So Edward's doing the right thing now to try and get off them but is being left with these rather vivid dreams and broken sleep - is that any surprise perhaps?
MORGAN
Well there are two issues here at least. One of them is that after three years not only do you perhaps have this problem of psychological dependence but almost certainly these tablets are not helping you to go to sleep, their clinical effect has probably diminished years before, ages before. So you have this problem of taking a drug regularly which if you stop taking it can create what's called a rebound insomnia, a new kind of insomnia that you get only from not taking a sleeping tablet that you're habituated to. But you also have this problem of taking a tablet that's not doing you any good in the long run. Now whether or not substituting another tablet for it is the perfect solution. There are alternatives to taking sleeping tablets and if you've been taking sleeping tablets for three years one thing that's sure is that you feel you have a sleep problem, this is a sleep problem which needs addressing.
MYERS
So what would be a good approach and it's not just obviously for Edward but for anyone who may have tried sleeping tablets and it's no longer appropriate to take them - they're not working and it's too far down the line anyway to be taking them - what are these more psychological approaches, I mentioned them in my introduction and I know it's something that you specialise in, so what could be good?
MORGAN
Well the evidence base tells us that cognitive behaviour therapy for insomnia is as effective in some cases, more effective, than taking a sleeping tablet chronically. That said it's not entirely accessible to everybody. Now the way in here is always through your general practitioner and it really can't be overemphasised that if you've been taking sleeping tablets for as long as this caller has been taking sleeping tablets you don't adjust any of the taking regime without first consulting your doctor, you certainly don't stop taking them and then decide what to do afterwards, you're only move in the relationship to what your doctor tells you.
MYERS
And in short if you are offered CBT what are we saying here?
MORGAN
Okay, cognitive behaviour therapy for insomnia will be - if it's delivered by a talking therapist in the practice you're looking at maybe five or six face to face sessions with an individual who will help you both to understand how your sleep works, will give you advice about what we call sleep hygiene - the dos and don'ts of trying to get the best out of your sleep. But at its core cognitive behaviour therapy is about changing how people behave in relation to their sleep and changing how they think in relation to their sleep. And it also addresses issues like how to avoid worrying about your sleep.
MYERS
Well it sounds as though it would be very helpful for a lot of people, I wonder if anyone will phone in having tried it and whether it has worked, perhaps we'll hear more about that. But let's go to another caller, we've got Paul who's waiting for us in Leicestershire, insomnia for many years. What's your question about that Paul, is this you personally, yes you're suffering?
PAUL
Yes it goes back a long way. In 1968 I was having sodium amytal but after many years of taking sleeping pills I read in a book if you can't sleep get up and enjoy it and that's what I try to do. But there's just one query. In these night time hours you tend to drink tea or coffee and I think this makes your sleeping problem worse, I would like that confirmed and what alternatives can be taken to avoid caffeine.
MYERS
I think Professor Morgan is about to confirm just what you suspect as a matter of fact.
MORGAN
Hello. Yeah there's a paradox here, a self contradiction, the problem with taking tea and coffee if you wake up in the night is two fold. Firstly, both of them contain caffeine, sometimes quite large amounts of caffeine, which in itself is a stimulant, it's a drug which will actually prevent you from going to sleep. The second thing is that both of them will make you want to go to the toilet in about an hour or so after consuming them, which if you succeed in getting to sleep is almost certainly going to wake you up later on. So waking up in the night and albeit enjoying life if you can but drinking tea and coffee as a way of passing the time when you wake up in the night if you expect to return to sleep is probably not a good idea, these are stimulant drugs.
MYERS
So that's definitive and that would include other things with caffeine, such as cocoa - people think that's great to go off ....
MORGAN
Anything that's brown and nice contains caffeine. Cola drinks contain caffeine, chocolate contains caffeine, cocoa contains caffeine.
MYERS
I like Paul's approach though which is at least try and enjoy your waking hours. I mean we've had a lot of e-mails with people clearly wandering around during the night. But how to find the right kind of activity that's not perhaps over stimulating, I mean are there some key tips here as to what you might do with those wakeful hours?
MORGAN
Perhaps it would be useful here Barbara is we just first define what we mean by insomnia and that will help you to know what you can do with your waking hours. If we define insomnia as an inability to get enough sleep to deliver you rested and able to function effectively the next day then that discriminates between people with insomnia and people who are short sleepers, people who just don't need as much as sleep as everybody else but find it very inconvenient waking up earlier than everybody else and having nothing to do with that time. Now if you're a short sleeper there are all kinds of things you can do, one of them is go to bed a bit later so that you can move your sleep phase further forward and maybe capture some of the evening doing other things. But by and large people know if they have an insomnia problem because they feel wretched the next day, there's no getting away from this. So I would strongly recommend if you feel that you don't get enough quality sleep then if you wake up in the night you'd be better advised - by all means get out of your bed but don't engage in things that are exciting or stimulating, try and engage in things that are rather quiet, that would allow you to notice if you start feeling sleepy again, then you can return to bed with the expectation that maybe this time you'll fall asleep.
MYERS
A question from Liz Rennie coming up now, she's in Brighton, it's an interesting question, Liz over to you.
RENNIE
Thank you. My question is rather bizarre. I'm in late my seventies, I go to bed fairly early because I want to but I wake up at any time - any given time during the night - one o'clock, half past one, ten to two, ten past three - any particular time but I always wake up, I can't stay there because if I do I get panic attacks. So I get up and like the gentleman caller before me I make tea which is a nasty experience because it's the middle of the night, it's sort of dark, it's cold but I still do this as a sort of comfort thing. I go back to bed and sleep fitfully. I'm wondering is there any truth in the fact that if you position your - either your bed or your physical self from the - either with your head to the north or to the west that you'll get a better night's sleep? I mean we are physical beings and there is such a thing as the magnetic north which is physical and I just wondered if there was any truth in this and whether it would help or not. Needless to say my bed faces neither direction.
MORGAN
Point straight up perhaps. Liz, that's a very interesting question and there's a lot in there. I'll go straight to - I'll address the very last question you asked which is which way round you should orientate your bed. I'll answer it in two ways. Firstly, if you didn't have any problems with your sleep at all but you felt that every night you slept well because you oriented your bed north/south or east/west okay? Then I would say okay keep doing it, if it works for you that's fine. I think it's highly unlikely that arranging the orientation of your bed now is going to make much difference to your sleep, okay, I know of no evidence to support this.
MYERS
Well that's fairly clear but is there something you can say in general Kevin then about maybe what you can do in your bedroom, how to set the scene so that you can get the best night's sleep for you?
MORGAN
I mean Liz has also pointed out something that's really quite important here, I don't know how much time she's spending in her bed awake but I would imagine it's quite a long time. If you expect to spend a substantial amount of your time in bed awake then you'd be well advised to spend as little time in bed as possible. The idea of going to bed is to sleep and if you're spending 20, 30, 40% of your time in bed awake then you're really spending too much time in your bed. So the very first thing to do is try and restrict the amount of time you spend in your bed to be closer to the amount of time you realistically expect to be asleep.
MYERS
So when you find people doing all sorts of things, not only in their bedroom but in the bed and that can of course these days include eating, it can include watching television, certainly listening to the radio, reading, maybe playing games etc., is this all a bad thing?
MORGAN
It's not helpful, I mean we've got to be very careful here with the way we use language, it's not the same as saying that it's the fault of the person who can't go to sleep that they're doing these things. What we do know - all the evidence suggests - that if you do other things in your bedroom, if you use your bed primarily for going to sleep or for having sex then you will do yourself a favour if you can't go to sleep. So that the bottom line here is simply this: if you have problems going to sleep at night and you're spending long periods of time in your bed wide awake you'd be well advised not to spend so much time awake in bed and basically get out of the bedroom and do something quieter.
MYERS
And you mentioned it, I didn't, but what about sex, does it help you get off to sleep?
MORGAN
I mean it's one of the few physical activities that actually is followed by a feeling of sleepiness as opposed to simply a feeling of fatigue. So yeah this is one of the only exceptions but as for all those other things that people do in their bedrooms we find it relatively easy to clutter our bedroom up with the - with the apparatus of wakefulness if we expect not to go to sleep. And this really isn't a good idea. Good though the World Service is you're better off leaving your radio perhaps outside of the bedroom along with your television, your exercise bicycle and all the other things.
MYERS
Okay. To Stockport in Cheshire and Ruth who's got a problem relating actually to her digestion, so how does that affect your sleeping Ruth?
RUTH
Well the last two years I've had to actually - it was suggested by a nurse - to acquire a recliner chair because I found that when I was lying in bed I would wake up after a couple of hours with pain and discomfort, so with the recliner chair I'm reclined about 140 degrees, so I'm not completely flat but you know I am in a very restful position.
MYERS
So that you don't get heartburn or indigestion.
RUTH
That's right yes. So I'm going to sleep in my chair, using the sleep hygiene sort of techniques, going to sleep between 9 and 10, sleeping maybe three to four hours and then I - when my digestion seems to have settled I get into bed but then I find I can only sleep two or three hours. So I am getting up because quite often it can be pain waking me up and even if it's not the pain my body seems to have got into that routine you know of waking at the similar time.
MYERS
Okay, so Ruth was advised to do this, what would you say - is she doing the right thing here?
MORGAN
This is - I mean Ruth's problem is generic in as much as there are a lot of people who have postural difficulties with their sleep, people with chronic health problems who for reasons of posture alone would find it difficult to simply - to lie flat and go to sleep like the majority. Ruth, one thing I'm inclined to ask you is where is your recliner - is it in your bedroom, is it in your sitting room?
RUTH
No it's in the sitting room.
MORGAN
So that you're in fact trying to go to sleep in two different locations?
RUTH
Yes.
MYERS
Would it be better just to raise the head of the bed so that you can be in bed and not have the problem of perhaps regurgitation, which a lot of people suffer from?
RUTH
I've tried that and I'm afraid it just - it just didn't help me.
MYERS
So Kevin is there a quick answer?
MORGAN
I did a quick back of the envelope here and it seems to me that you're getting about six or seven hours sleep in these two locations every night Ruth, is that right?
RUTH
No, no I wouldn't say that, I would say five hours maximum.
MORGAN
Okay. I would certainly experiment with ways of adjusting the position of your bed and if you have reflux or any of these problems maybe propping up the head of the bed might help. Or you might consider taking your recliner chair into your bedroom.
MYERS
Okay, so there are some good tips. But the point there being for other people perhaps who don't have exactly the same problem really it's about using your bed appropriately and not actually nodding off because a lot of people with or without health problems nod off in front of the telly, that doesn't really necessarily help then with your longer proper sleep pattern does it.
MORGAN
If you have a sleep problem - and this only applies to people with sleep problems - you've really got to look after sleepiness, you've got to preserve it, you've got to treat it like a precious resource. You mustn't squander it in chairs in front of televisions.
MYERS
Let's see if we can get another quick call before we have to finish. We've got Sheila, I hope she's there, and - Sheila, if you can hear me, I believe you get off to sleep alright but can't get back to sleep, your question then to our expert today very quickly.
SHEILA
Okay very quickly. I probably read from about three o'clock, I go to sleep easily, from about three o'clock I read for three or four hours then if - I have my husband obviously - and it's the breathing or snoring or anything like that we end up bed hopping between us. So that's a problem. I've got a couple of questions. Melatonin, it's available in America I believe, can I get tablets and can I be referred to a sleep clinic?
MYERS
Okay we're going to have to take a yes or no answer on both those - melatonin yes or no.
MORGAN
Not available.
MYERS
Okay. Sleep clinic, would that be of any help to Sheila?
MORGAN
Sleep clinics are pretty rare in this country and I think the real question here is how can I get access to help.
MYERS
So not really ideal because there's not going to be that available but we heard about some of the services that you can engage with through your doctor.
MORGAN
Your general practitioner.
MYERS
Thank you very much. Sorry to hurry at the end, we always have to, but thanks very much for all of you who rang and all of you who e-mailed and thanks for our expert today Dr Kevin Morgan. So if you missed anything of course you can listen again to the whole programme, you go to our website, you follow the prompts to Check Up. You can download the programme or speak to someone, you go to 0800 044 044. The last in the current series, we'll be back in June.
ENDS
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