SLEEP: How it works and what can go wrong

SLEEP: How it works and what can go wrong ROEI PLAVES & CHRIS O’GRADY Health, Counselling & Disability Service Acknowledgements: Prof Leon Lack, Adel...
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SLEEP: How it works and what can go wrong ROEI PLAVES & CHRIS O’GRADY Health, Counselling & Disability Service

Acknowledgements: Prof Leon Lack, Adelaide Institute for Sleep Health, Repatriation General Hospital. Dr Jodie Harris, PhD.(Clin Psych), Clinical Psychologist Lauren Moulds, Provisional Psychologist

How is sleep measured? Polysomnography (PSG)

Electroencephalography (EEG)

What is Sleep?

What is Sleep?

What is Sleep?

What is Sleep?

Individual Variation in Normal Sleep

Sleep need 8 hours of solid sleep need myth - Short vs Long Sleepers

Body Clock Night owl vs Morning lark

! Most important ‒ Daytime Functioning

Chronic Insomnia •  Chronic inability to obtain adequate sleep. •  May constitute difficulties initiating sleep, maintaining sleep, early morning awakenings, fragmented light sleep.

•  Associated with daytime fatigue and distress. •  Is the most common sleep disorder affecting 5-15% of general population.

•  Difficulty initiating sleep is more prevalent in the younger population.

•  Difficulty maintaining sleep is more prevalent (10-20%) in older population.

The Cycle of Chronic Insomnia Trigger (i.e. stressor, baby, illness, change in routine)

Acute poor sleep

Behaviour: I.e. excessive time in bed, napping, medication use, “trying” to sleep

Thoughts: I.e. I cant get to sleep, how will I cope at work/ Uni?

INSOMNIA Body Sensations: I.e. Physical tenseness, alertness, fidgeting

Emotions: I.e. Frustrated, annoyed, anxious, depressed

Maintaining Factors Sleeping in following a poor nights sleep

Going to bed before “sleepy”

Extending bed period (i.e. spending 9-11 hours in bed)

Medication/ alcohol use

Sleeping in on the weekends to “Catch up”

Napping in the daytime

Introducing alternative activities into the bedroom

Excessive use of caffeine

Conditioned Insomnia • 

Learned or habitual chronic insomnia


In association with experiencing difficulty trying to fall asleep have been 1. the bed, 2. bedroom, 3. time of night, 4. intention of falling asleep, 5. turning out the lights, etc.


This has probably been a time of frustration, irritation, anxiety, etc. which lead to alertness and prolong time taken to fall asleep.


Through this association the bed, etc. have taken on the ability to produce alertness on its own, even without noticeable emotions.


This insomnia response has become an automatic, involuntary reaction.

Associations and Sleep

Fight or Flight Response •  Physiological arousal ‒  Stress response (adrenaline), caffeine, nicotine, activity

•  Psychological arousal ‒  Psychological stress, anxiety, fears, trying to sleep

“Trying” to sleep More we try to sleep – the harder it becomes because the more alert we are THE BEST THING WE CAN DO WITH SLEEP? LEAVE IT ALONE!

Sleep and unhelpful beliefs /assumptions


I must get 8 hours of sleep each night


If I don t get 8 hours of sleep, I will not cope tomorrow


The more sleep I get, the better I will feel


Awakenings are not normal


If I can t get sleep, I will get sick


The only way in which I can get a good night s sleep is with a sleeping tablet


How I feel upon awakening determines how I will feel for the rest of the day


I must turn off my mind in order to get to sleep


I have no control over my sleep (yet I try)


My sleep is broken

Worry and Frustration during the night: Effects on the following day



•  • 

Worry and frustration about being awake is usually greatest when attempting sleep and it then inhibits sleep Worry and frustration exhaust our emergency system ( fight or flight reaction to a threat) and produce fatigue the next day Reduced sleep alone produces greater sleepiness. Hyper-alertness (e.g.Caffeine) model of insomnia results in fatigue.

Sleep/wake Perception Total Sleep Time (TST) Perceived TST

Actual TST

Good Sleepers

7.2 hrs

7.1 hrs

Poor sleepers

3.5 hrs

5.5 hrs

Poor Sleepers honestly underestimate the amount of their sleep. Comparing their perceived sleep with normal 7-8 hours of solid sleep can be distressing!

Circadian Rhythm Disorders • 

The 24-hour Circadian (Circa=about, dian=a day) physical world (night/day) pervades our society and our bodies. •  Virtually every physiological, hormonal, biochemical, and behavioural measure taken over time shows a strong circadian rhythm. Circadian Rhythms are associated with problems in the following areas: •  Shift work •  Jet lag •  Insomnia –  Sleep onset insomnia (Delayed rhythms) –  Early morning awakening (Early rhythms)


Seasonal Affective Disorder (SAD)

Sleep Onset Insomnia can come from body clock mis-timing

•  •  • 

Our 24-hour (circadian) body-clock rhythm has a strong effect on when we are sleepy and alert. These times can be out-of-sync with our preferred sleep time. (eg. Shift work, jet-lag) Sleep onset insomnia, and difficulty waking in the morning Diagnosis- DELAYED SLEEP PHASE SYNDROME

Morning Bright Light Can be Therapeutic.

An early timed (advanced) circadian rhythm can cause early morning awakening insomnia

Diagnosis- ADVANCED SLEEP PHASE SYNDROME Can be treated with evening bright light therapy

Sleep Hygiene

(Hauri, 1977)

TIME IN BED sleep as much as needed to feel refreshed during the following day but not more. Reducing time in bed can solidify sleep; excessively long times in bed seem related to fragmented and shallow sleep.

REGULAR WAKE TIMES Regular wake time can strengthen circadian cycling and finally lead to regular times of sleep onset.

TRYING TO SLEEP can be counterproductive due to increased arousal levels.

TEMPERATURE an excessively warm room can disturb sleep (i.e. electric blankets).

Sleep Hygiene HUNGER EXERCISE can disturb sleep; a light snack A steady daily amount of at bedtime can help sleep exercise can deepen sleep in the long run (but occasional exercise will not directly influence sleep). CAFFEINE in the late afternoon/evening can disturb sleep, even in people who do not feel that it does (& NICOTINE).

ALCOHOL helps tense people fall asleep, but the ensuing sleep is then fragmented.

Sleep Hygiene cont. NAPPING long daytime naps can impact on the following night’s sleep. A short nap (10 mins) can alleviate daytime sleepiness without affecting sleep.

PRE-BED ACTIVITY activities that require a high level of concentration in bed or before bed are not recommended due to increased cognitive arousal, which is not conducive to sleep.

SLEEPING PILLS An occasional sleeping pill can be of benefit, but the chronic use of hypnotics is ineffective at most, and detrimental in some insomniacs.

BEDROOM CLOCK eliminating the bedroom clock can reduce arousal during the night from unwanted cognitive activity.

Conclusions • 

Sleep patterns are different from person to person.


The most important factor to assess your sleep is daytime functioning.


Sleep is affected by changes to our routine (study, work, weekends…)


Sleep is robust and usually ‘bounces back’.


Sleep hygiene principles can help restore your sleeping patterns.


Help is available if needed: sleep studies, medication, therapy…

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