7 top tips for better sleep - epilepsy and insomnia
Dr Hugh Selsick is a consultant psychiatrist working in sleep medicine, based at the Royal London Hospital for Integrated Medicine. Here he talks about insomnia in people with epilepsy, and how a type of therapy, CBT-i, can be used to combat sleeping problems.
Insomnia is reported in 40 to 51 per cent of people with epilepsy. People with epilepsy are faced with a particular problem when it comes to sleep as sleep deprivation can trigger seizures - and seizures, either in the day or the night, can disrupt our chances of getting a good night's sleep. We are therefore faced with a chicken and egg situation as to what is the root of our sleeping problem - my suspicion is that it is a bi-directional thing and they both impact the other.
However, it is possible to treat insomnia, and it is possible to treat insomnia without medical intervention. There is a system called cognitive behavioural therapy for insomnia (CBT-i) which has dramatically improved symptoms for a vast majority of patients at my sleep clinic, even for those with epilepsy.
What is CBT-i?
Cognitive behavioural therapy (CBT) is a talking therapy that helps you manage problems by changing the way you think and behave. CBT-i is about changing the way you think about sleep and then addressing dysfunctional sleep habits and anxieties. However, because treatment can lead to a brief period where people sleep a bit less before they sleep more, and a reduction in sleep time can trigger seizures for some people with epilepsy, the therapy has to be taken at a slower pace and should always be managed by a healthcare professional. It is important that you consult your GP or neurologist before making any changes to your sleeping habits.
For people who have no trouble sleeping, after a while the act of going to bed makes them sleepy. By contrast, for people who suffer with insomnia, there is often an element of anxiety involved when they are going to bed: "am I going to sleep tonight?", "is my insomnia impacting my health in the long term?", "how am I going to feel tomorrow if I get no sleep again?". For these people, the act of going to bed actually wakes them up.
CBT-i looks at ways you can work to change this anxious relationship with bedtime, so that you can go to bed when you feel tired, and break the cycle of disrupted sleep.
Seven top tips for better sleep
1. Changing how we think about sleep
For people with insomnia, there is often anxiety around how insomnia may impact their long-term health. There is very little evidence to suggest that insomnia will shorten a person's life span, and for some people knowing that insomnia is not going to kill them can often reduce this anxiety considerably. Then there is the myth of the eight hour sleep. But the truth is that the amount of sleep that is right for us varies. We each need the amount of sleep that will allow us to feel alert most of the time, most days of the week. Even good sleepers occasionally have sleepless nights - no one is alert and lively all day every-day - it's about finding the amount of sleep that is right for you.
2. Sleep, sex and getting dressed
To help break the feeling of being awake whilst lying in bed, we have to separate our "awake" activities from our place of sleep. This means limiting time in the bedroom to only three things - sleep, sex and getting dressed. Anything outside of these activities is considered an awake activity, and carrying them out in the bedroom can reinforce the association of feeling awake whilst lying in bed. Keep any other activity outside of these three for outside of the bedroom.
3. Tea and temperature
... or indeed, any caffeinated drink. Our behavioural techniques in CBT-i begin with two golden rules:
- Make sure you have a cut off point for caffeine intake, ideally 1 or 2pm
- Keep your bedroom cool
It is a myth that a warm room is good for sleeping. At night your body wants to lose heat. The ideal temperature for your bedroom is 18 degrees centigrade. You should be warm under a duvet but a little nippy if you go to the bathroom. This enables you to regulate your body temperature and stop this interfering with a night's sleep.
4. Setting your alarm
People often think that a good night's sleep is dependent on keeping a constant bedtime but it is the time that you get up that is the regulator. It is the one thing you can absolutely control. So, get an alarm clock and set it for the same time every day, seven days a week, regardless of what time you go to bed.
Fatigue makes you sleepy. From the moment you wake up you start to accumulate sleepiness. You are filling up your sleep fuel tank. When it is full, you fall asleep.
If you sleep for five hours, you will be awake for 19 hours - that is 19 hours to refill your sleep fuel tank. If you wake at 7am, you will need to sleep again at 2am. If you wake at 9am, you will only be ready for sleep at 4am. If you get up at the same time every day, you will feel sleepy at the same time every night and that will make your sleep more regular. So the time that you get up is critical.
5. Our sleep fuel tank
It is important to jealously guard your sleep fuel by not sleeping during the day. This will only steal some of your sleep from the night. Try to avoid falling asleep by exposing yourself to bright light, getting fresh air, taking exercise, and, within limits, having some caffeine. Chewing gum is also efficient at keeping you awake - they give it to soldiers in the army to keep them awake when they are on duty.
6. Quality before quantity
With CBT-i, we look at improving quality of sleep before we look at quantity. But this comes with a warning for people with epilepsy. If sleep deprivation triggers your seizures, it is important that this is managed by an expert and is taken in easy steps.
We ask patients at the sleep clinic to work out the average amount of time they are asleep. This is then subtracted from their wake up time. We then say don't go to bed until that time. For example, if you sleep for 6 hours on average and your wake up time is 7am, you shouldn't go to bed before 1am. This greatly improves sleep quality. For people with epilepsy, it is important to achieve this by moving the bedtime later in very small steps, 15 minutes a week, rather than in one go. This takes longer but it is worth taking things slowly. As sleep improves, we gradually make the bedtime earlier to increase the sleep quantity as well.
7. Relaxation before bedtime
Progressive muscle relaxation is also helpful for everyone. This is a matter of working through the body, tensing muscles in turn for five seconds and then relaxing them. This can help to get the body and mind into a relaxed state and ready for sleep.
Does CBT-i work?
CBT-i is all about harnessing your innate sleep drive and 80 per cent of people who try it, say it works. Not everyone shows a complete recovery, but there is usually great improvement.
Sleep disorders are a huge risk factor for depression and that is ample reason to ask your doctor for a referral to a sleep clinic.