Episode 17 – Sleep.

The links to sleep hygiene resources can be found here:

Poor sleep is a sure sign, a common early warning, that we have lost balance in our lives. It is also a key area that can be responsible for lack of balance. It is a vicious cycle. If we don’t sleep well, we will feel anxious and bad, but feeling anxious and bad can stop us from sleeping.

Even if you don’t think that sleep is an issue for you, I would still recommend having a think about your sleeping habits, as invariably all of us have room for improvement across many aspects of our lives. Even if you don’t sleep badly, it is possible that you might be able to sleep better!

Sufficient good quality sleep is essential for good wellbeing, and if we don’t get adequate sleep we will struggle to be well. Sleep is not just being unconscious, it is an active process. It is during sleep that we lay down our memories, tidy up our minds, and prepare for the next day. It is during sleep that our bodies restore equilibrium, heal and repair. If we miss out on this active process our bodies and minds will not run as they should. I like to compare it to servicing a car, if you fail to properly clean and service your car over time it will start to run rough, and eventually break down altogether.

Because of this poor sleep does not just make us feel tired and sleepy. It has knock on effects throughout many aspects of our lives. It can lead to poor concentration and motivation. It can impair our immune systems and make us more susceptible to infections, illness and bad skin. It interferes with our hormone levels and balance. One example is the hormones Leptin and Ghrelin. Ghrelin is a hunger hormone, and high levels increase our appetite and make us eat more, whilst Leptin is the opposite, it is a satiety hormone, and increasing levels make us feel full and reduce our appetite. We know that during good quality sleep Leptin levels increase and Ghrelin levels fall. With sleep deprivation the opposite happens. What this means is that if we don’t sleep well we will constantly feel hungry and crave high energy foods. If we are not sleeping properly, we are at risk of becoming overweight, and it is extremely difficult to lose weight without good quality sleep. This is just a single example, there are literally thousands of processes and systems that can be affected by poor sleep.

For this reason, when we start to think about restoring balance in out lives sleep is always a good place to start. If you are not sleeping well, it will be difficult to feel well, regardless of what you do while you are awake.

Like everything in life there is a spectrum of sleep difficulties. Thinking about sleep is not just for insomniacs, all of us stand to benefit from improving our sleep. Sometimes people tell me they have no problem with sleep. They get a solid 8 hours a night, but are still feeling tired and unwell. Or they have the opposite problem of too much sleep – they are sleeping all the time. In this situation I suspect that there is still a problem with sleep. It is likely that they are getting poor quality sleep. We need to think about sleep quality as well as and quantity.

In recognising the importance of sleep we must be careful that we don’t create more anxiety around it. Anxiety and sleep are not friends. There is a danger that in learning about the huge benefits of good sleep, and the potential harm of not sleeping, we will create stress around sleep that stops us from getting to sleep. When it comes to sleep the viscous cycles are everywhere.

This is why I have taken so long to give any practical advice in this series. Remember, positive change must always start with out thoughts. If we are going to start making improvements in our lives we need to manage our minds.

When learning about sleep (and any other lifestyle advice) we need to practice seeing it as a positive step, as information that empowers us and gives us hope, rather than a damning judgment, highlighting our past, and possible future failings. These thoughts are just thoughts, and we can learn to change them and choose helpful ones.

If sleep anxiety is a problem for you I want you to practice your thought ladder. If you are lying awake thinking “I’ve tried all of Dr Bostocks advice and I’m still not sleeping – nothing is ever going to work – I’m never going to get better.” Try thinking, “I have had this problem for years, its not going to get better overnight” or “It is better to be doing something than nothing”. Try to work your way up to a target thought of something like – “I’m going to get my sleep sorted and I’m going to be OK”. A helpful step on the ladder for me is, “Even if I don’t fall asleep at all, if just lie here peacefully, my body will be getting some rest. I will get through tomorrow, and then I get another chance tomorrow night”. If you don’t have a clue what I’m talking about you should go back and listen to episode 11.

Despite all these vicious circles it is possible for us to have some influence on the quality of our sleep. There are practical things that we can do to promote healthy sleep. We call this sleep hygiene.

I am not going to go through all of these in detail here, but instead will give a rough overview, and highlight some key factors.

First off, how much sleep do we need? Well that is different for each person, but in general studies have shown that humans need between 7-9 hours / night. If you are regularly getting less than 7 hours, it is likely that you are not getting enough. If you are getting 8 hours a night, but still feel tired it may still not be enough and, like me, your system is more towards the 9 hour end. It might be worthwhile increasing your sleep and observing the effect. There is also such a thing as too much sleep. All of us have had the experience of lying in too long at the weekend and making ourselves feel unwell. As always it is all about balance. You will need to experiment to find out what is the right amount for you, and this may change with time. In general, the older we get the less sleep we tend to need.

It is important to note that this minimum of 7 hours is not the amount of time we are in bed, but the time we actually spend sleeping. Most of us do not fall asleep the minute we get into bed, and often we wake long before we get up. In addition, most people will wake up a few times times during the night. This does not necessarily mean you are not sleeping well, and is considered to be a normal part of sleep. Some people can get anxious about waking in the night, believing that a good night’s sleep means “sleeping solidly through”. This is not true, and waking up in the night is fine if we are able to “get back over”. What it does mean, though, is that when planning our sleep we need to consider a “sleep window”. This should be at least 30-45mins more than the number of hours of actual sleep we want. 8 hours of good quality sleep probably requires at least an 8 and a half hours in bed.

This concept of a sleep window brings us to an important step to improving our sleep habits; scheduling and routine. With everything in life, if we want to be successful, we need to make a plan. Unless we do things with intention the outcome will be unpredictable. If we need to get 8 hours sleep to be well we need to ensure that we provide ourselves with the opportunity to achieve this. That means thinking about what time we need to be up and ensuring that we are in bed early enough to make that possible. If we have to catch the train at 7 we need to go to bed before 10.

This may seem pretty obvious, and is hardly earth-shattering news, but the key here is priorities. For many of us the reason we don’t get as much sleep as we should is because we are busy. Often people work late, have long commutes and early starts. Sometimes there just aren’t enough hours in the day.

Sleep is often pretty low down in our list of priorities. It is one of the first things we sacrifice when our schedules start to fill up. We might sacrifice a few hours of sleep for the sake of fitting in work, the gym, socialising or time to unwind. Now I’m not saying you should never do this, and of course life is busy, but just be mindful of it. Humans are creatures of habit, and if we start to regularly sacrifice sleep for other aspects of our lives this can have far reaching consequences. Because of how crucial good sleep is to our wellbeing it is worth thinking carefully if you have prioritised it correctly. There is a big risk of a “false economy” and it may be that spending an extra hour checking emails when you could be sleeping comes at a higher price than you think. I would recommend making sleep one of your top priorities, as you may find it increases your efficiency and productivity throughout multiple aspects of your life.

If you have an I-phone it has a “bedtime” feature where you set the time you need to get up and your required sleep window, and it will warn you when it is time to get into bed. Before my iPhone died I used it a lot and found it really helpful.

The other side to the sleep window is the concept of routine. Because Humans are creatures of habit routine is important for forming good habits. You should try to go to bed at roughly the same time each evening and get up at roughly the same time in the morning. It can help if you can maintain this routine at the weekends as well as during the week. Most of us find that this happens naturally, and the weekend lie in until midday becomes a distant memory of our teenage years. Those of you with kids will understand how important routine is to sleep, and also, the importance of getting enough sleep.  “They are just over tired” is a valid explanation for all manner of distress. But as adults we forget or ignore what once seemed so obvious, even though the same rule applies. We think we can sacrifice sleep without consequence. Children are more susceptible to their natural rhythms, and as adults we learn to overcome our natural instincts, inclinations, and emotions. We can better tolerate being hungry, overtired, or delaying gratification. We are socialised to not have a meltdown or tantrum. But this does not mean that these things are no longer relevant to us and may remain an essential part of maintaining balance in our lives.

So, to get the full health benefits from our sleep, we all need between 7-9 hours a night, plus 45mins to make up our sleep window, and we should go to bed and get up at roughly the same time each day. That’s all very well, but what if you get into bed and then just lie awake looking at the ceiling?

There are a range of things we can try, and some things that we should avoid, in order to address this. Much of the advice may seem obvious, but again it is about priorities and being mindful. We may “know” these things, but nonetheless have got into habits that are causing poor sleep without even realising it.

For me the number one issue is Caffeine. Caffeine is one of the few remaining socially acceptable, even socially encouraged, mind altering drugs, that is in common use in our society. I wonder if in the future we will come to view caffeine in the way we now view nicotine, and to a lesser extend alcohol. Whist alcohol is fairly socially acceptable, it is not normally considered OK to drink 3-4 beers a day at work.

As always, I want to make it clear that this is NOT A MORAL ISSUE. I drink coffee,(actually I am drinking one whilst writing this) I drink alcohol, and very occasionally I also enjoy a cigarette. These things are not bad or evil, and we are not sinful for using them. It’s just that, as with everything, if we use them to excess, they can disrupt our balance and make us unhappy and unwell.

Caffeine is very frequently overused. We know that caffeine interferes with our normal sleep. Personally, I am extremely sensitive to caffeine. If I have a coffee after dinner I will lie awake for hours. I know this, and even so, occasionally I fancy a coffee, and then I lie awake beating myself up for being an idiot once again. I knew the advice, but I was not mindful of it, and did not prioritise it. Some people tell me caffeine has no effect on them. They can drink a double espresso right before bed and sleep like a log. But studies have shown that even for these people caffeine is disrupting sleep. Sleep is not just being unconscious or unaware, it is an active process. Brain wave tests demonstrate that even small amounts of caffeine prevent us from entering the restful, restorative stages of sleep. We may be unconscious, but we are not getting any of the benefits of healthy sleep, and may wake feeling exhausted, and lacking energy. To deal with this we might turn to caffeine for an extra boost. I told you, those vicious cycles are everywhere.

The other important thing to realise is that caffeine hangs around in the body much longer than people think. The half-life of caffeine is about 6 hours. What this means is that if you have a cup of coffee at 6 o clock in the evening, half of that coffee is still in your system at midnight, and a quarter of it will still be circulating through your brain at 6am the next morning.

There is also caffeine in tea, green tea, and even in decaffeinated tea and coffee, although in smaller quantitites. In addition to this caffeine is also a strong diuretic, it makes you pee! If getting up in the night to go to the toilet is contributing to your sleep disturbance caffeine will be making this worse.

Because of its long half-life my recommendation is to avoid caffeine altogether after midday, and as an absolute maximum after 2pm, and I would recommend limiting to 2 cups of tea or coffee a day. It is very easy to get a “slow creep” to gradually build up the amount of caffeine we are consuming, and sometimes without even realising it. If we take the time to count, often find we are drinking far more than we thought. This certainly happens to me, and I frequently have to take stock and consciously reduce it.

Now if you are currently drinking 5-6 cups of coffee and tea a day, I wouldn’t recommend just going cold turkey. If you do you are likely to suffer from withdrawal symptoms, such as headaches, which are not going to help you to feel well or sleep better. I would recommend weaning slowly over a few weeks. Start by cutting out the latest cup at night and work your way back. You can try alternating with decaffeinated tea and coffee, or fruit teas (be careful because some will have caffeine so read the label). Part of the habit is having the hot drink and it will be easier to cut down if you substitute with something else in this way.

The next thing we should try to avoid is alcohol. Many of us use alcohol to unwind or destress in the evening. But brain wave studies have demonstrated that alcohol has a similar effect on our quality of sleep as caffeine. It prevents us from entering the restorative phase of sleep. Most people will already know that after a night on the town we feel pretty drained the next day, even if we have slept longer than normal. This effect is present even with small amounts of alcohol, although we may be less aware of it. Like caffeine alcohol is also a diuretic and will increase the chance of you having to get up in the night to pee. We do clear alcohol from our system faster than caffeine. As a rough guide we metabolise approximately 1 unit an hour. So, 1 pint of beer will take 2 hours, 2 pints will take 4 hours and 4 pints in an evening will wipe out our entire sleep window. If you are having even a single drink most evening you could be missing out on the first few hours of quality sleep every night. Whilst I’m not saying you should never enjoy a drink after work, in general you should avoid alcohol right before bed.

Another common culprit for insomnia is screen time. It is very tempting to scroll on our phones, use computers or watch TV late at night. Screens are especially harmful because of the blue light they emit. This light tricks the brain into thinking it is morning, making us more alert. It supresses the release of the sleep-inducing hormone melatonin. The general advice is to avoid screens for around 2 hours before bed. You can get glasses or Apps for your phone that are designed to filter out blue light, although I have never personally tried this, so I have no idea if it works.

The other problem with scrolling is that it is activating our minds when we should be winding down. Constantly having our phones with us means that we are always available and always switched on. Our work, family and social lives come with us into the bedroom. Your phone can ping just as you are switching out the light, and the next thing we find ourselves replying to a text or email, switching our minds back on and eating into our sleep window. Sometimes I think even the knowledge of having the phone next to you, that it might go off at any time can cause us to be restless. Recently I have self-imposed a blanket ban on taking my phone upstairs. I moved my charger into the kitchen and plug it in once I get home. I would really recommend trying this. It has made the Bedroom a much more peaceful place.

A frequent objection to this suggestion is needing the phone for an alarm clock. I made the same objection for several months before getting my act together. But you can buy a simple alarm clock for a few pounds, so it is not an excuse that would stand up in a court of law. What I ended up doing, and what I would really recommend to you, is to try a Sunrise alarm clock. These have a natural warm light that gradually brightens over half an hour to simulate a natural sunrise. The idea is that you wake up more naturally rather than being jolted awake in the middle of a sleep cycle.

It’s been amazing, especially during these dark winter months. When my alarm used to jerk me awake into pitch darkness, it felt like if I got out of bed I would actually die. It was a horrible start to the day. My dog, asleep on the end of my bed, would lift her head and look at me like “What the hell are you doing you idiot, it’s the middle of the night.” She would give a big sigh and snuggle down back to sleep. Dogs seem to know a thing or two about living well. With the Sunrise alarm I wake up much more naturally and feel ready for the day ahead.

Many versions also have a sunset feature, where the light gradually dims, providing an “unwinding time” preparing you for sleep. My older model doesn’t do this, but my sister absolutely loves this feature. I have a Lumie clock, because it turned out that my partner already had one in her attic. These are fairly expensive at around £75-£100, but there are plenty of cheaper versions available. If you use one of these it would be great if you could let me know how you get on with it, by dropping me an email or leaving a comment on my website or facebook page. It is always handy to have some inside information on good quality cost-effective alternatives.

Another objection I sometimes get to leaving the phone behind is not being able to use Apps designed to promote sleep. There are loads of different sleep Apps available, from bedtime stories for adults, to relaxing sounds, and guided mediations. Obviously if you have left your phone downstairs you won’t be able to use them. One solution might be to put your phone on aeroplane mode rather than leaving it behind. Personally, I have found the guided meditations for sleep on Headspace really helpful, especially the progressive muscle relaxion techniques, and this is something I would recommend trying.

Whilst we are on the topic, several people have openly admitted to me that they have not been doing their meditation. This is extremely naughty! I know I said I wouldn’t tell you what to do, and that not everything will be for everybody, but I really urge you to try to make meditation a regular daily habit, even if its just for 5 or 10 minutes. It honestly gets easier with practice, and for me is a key tool for this work. It serves as a daily reminder that we have control over our own minds. It reminds us that the world is peaceful, that humanity is wonderful, and provides a window into our spirituality. It checks us when we are getting swept up in our own heads, restoring purpose and intention to our daily lives. If you are listening to these podcasts out of order, I suggest going back and listening to episode 7, and thinking about making meditation a part of your daily routine.

The suggestion of replacing your phone with a sunrise alarm goes hand in hand with the more general advice of making your bedroom into a place of rest a relaxation. We should avoid doing anything in our beds other than sleeping, with maybe one or two exceptions – Personally, I sometimes like to have a cup of tea in bed at the weekends. The brain is quick to form associations, and if you work or watch TV in the bedroom, you will soon start to associate the bedroom as a place of activity rather, than a place to sleep. For this reason, it is also recommended that if you are unable to sleep you should not lie awake restlessly in bed. Instead you should get up, go downstairs, and read a book, or sit peacefully until you start to feel tired, and then return to bed. If you still can’t sleep you should repeat the process. Otherwise your brain can start to associate the bed as a place of restlessness and anxiety, and we may go to bed each night anxious that we are not going to sleep.

Even if as a result of this pattern you are awake for much of the night you should try to avoid napping during the day. By repeating this process, you may be able to reset your body clock and get your natural rhythm back.

I have mostly talked about things we should avoid, but there is plenty of great advice about positive steps we can take to promote good sleep, such as how much exercise we take, and when we take it, what we eat and when we eat it, making sure the environment in our bedroom is correct; is it dark, is it quiet, is it the temperature right, and do we have the right type of mattress. How we should unwind and relax at the end of the day, with a warm bath, relaxation techniques or meditation. I am not going to go into detail about all this advice here. There are lots of excellent resources that discuss sleep hygiene, and I recommend that you spend some time going through these for yourself. I will leave some links on my website and Facebook page.

In addition to this if sleep is a major problem for you, or if you are interested, I would recommend listening to the Podcast “Feel better, Live more”. If you have not come across this already, you should definitely take a look. It is a popular podcast hosted by TV doctor Dr Ranjan Chatterjee, in which he interviews experts across a wide range of health and wellbeing topics. It was Dr Chatterjee that first got me interested in progressive and lifestyle medicine, and it is well worth a listen. There are several very good episodes all about sleep, and I will post the links to these.

Once again, there is a western medicine shaped elephant in the room. Unfortunately, this time it’s an ugly beast. I am of course talking about sleeping pills. I have spent considerable amounts of time discussing with patients the prescription of sleeping tablets. People sometimes need a quick fix, or feel that they simply will never sleep without medication. There are essentially two types of sleeping pills, a class called benzodiazepines, such as Diazepam, (which is Valium) and “Z-drugs” such as zopiclone.

I don’t blame people for wanting these drugs, the reason they want them is because they seem to work. If you take them, you will become unconscious. But unfortunately, they are not the wonder drug we once thought they were. They are not really doing what they should be doing, and they have a lot of very unpleasant side effects. As a treatment for sleep disturbance they have probably caused a lot more harm than good.

The most important thing to understand is that there is a difference between sedation and sleep. As we have said sleep is an active process. If you take diazepam you will become unconscious, but you won’t be asleep. You will not be getting any of the multiple benefits of restful, good quality sleep. That is why people often feel groggy the next day rather than refreshed. What is worse is that they interfere with normal sleep rhythms and taking them will actively prevent you from ever being able to achieve healthy sleep. They are also extremely addictive. People crave them, become dependant on them, and feel unwell if they stop taking them. As with many addictive substances the more we take them, the more we need to achieve the same effect. We must keep increasing the dose in order to get any rest at all. As we take bigger doses unpleasant side effects start to appear, the most significant of which is respiratory suppression, which means that they stop people breathing. These are powerful drugs that we use to terminate epileptic seizures and sedate people for surgery. Using them to help us sleep is not normally a good idea, and I rarely prescribe them. As always, this is not a moral issue. Benzodiazepines are not the Devils work. I don’t want to be melodramatic about it, and if you have used sleeping tablets it’s not the end of the world. Things are never black or white and there are times when I do recommend them for very short term use, such as immediately following a traumatic event. But as a general rule sleeping pills impair rather than restore balance to our bodies and minds. They make us more unwell rather than better.

I don’t want to end on a negative note. Sleeping pills might not be the answer, but this does not mean there is no hope. You have a lot of homework this week. If you are not doing so already number 1 is to start doing some regular meditation. Number 2 is to be mindful of your sleep, both quantity and quality. Do you have an adequate sleep window, sleep environment and routine? Are you prioritising sleep? To help with this, you might want to take a more detailed look at some of the excellent resources out there about sleep, and have a listen to Feel Better, live more. I know that’s a lot, but last week all you had to do was look at pictures of baby animals. So go get on with it, and I will see you next time.