The Woolcock Institute of Medical Research

Thank you to ABC Radio Sydney for letting us share the recording of this show. The show aired at the start of Sleep Awareness Week 2021. See our latest sleep news.

TRANSCRIPT

Emma Crowe: How'd you sleep last night? Pretty muggy at my place, so it was one of those nights where you're kicking the sheets off, then pulling them back on again, wriggling around.

I think there's a big difference though between having the occasional restless night and then having days and days at a stretch with interrupted or minimal sleep.

So how common is insomnia? And is this something that you're dealing with? What's worked for you?

Associate Professor Christopher Gordon is Research Associate at the Woolcock Institute of Medical Research, and joins us here on Weekends. Good morning Christopher.

Christopher Gordon: Good morning Emma how are you?

Emma: Great thanks. And how did you sleep last night?

Christopher: I slept well and I sleep well all the time.

Emma: All the time? Okay! Have you always slept well?

Christopher: I have actually. I've been fortunate. It doesn't mean that I haven't had bouts of insomnia at particular times of stress, like many people. But generally, people in the sleep community sleep well.

Emma: That's very interesting. So when people come to you and talk about not sleeping well, is it hard to muster the empathy for them having had your beautiful good night's sleep?

Christopher: It is, it is. Look what we do is we think of sleep as one of the three important factors in your life: diet, exercise and sleep. And that's the thing that often people don't get enough of.

Emma: Yeah that's right. They think that they can catch up later. It's a bit of a myth isn't it that you can really catch up, you do need your daily dose?

Christopher: You do. There is a little bit of evidence about what we call 'catch-up' sleep, which is some of your listeners have probably done on the weekend, but generally you do need a decent dose every night. A bit like the same with diet and exercise.

Insomnia

Emma: So let's go right to the beginning: what is insomnia? How do you define insomnia versus what I was talking about last night with just not a great sleep?

Christopher: So insomnia is a really complex disorder and we actually don't understand it fully. But what we do know is what you describe very elegantly. People that have chronic problems that go for at least three months, most nights of the week, that don't feel as though they're getting that restoration of what sleep does in the morning, is classified as chronic insomnia. But people will have insomnia symptoms commonly, and we know that about 30 percent of the population in the adults generally have insomnia symptoms throughout the year.

Emma: Do we know what causes [insomnia]?

Christopher: Most of the information is around an acute stressor: something that causes a change in your lifestyle. It could be the temperature. It could be things like pregnancy. Getting older is a problem as well unfortunately. Financial stress, emotional stress, relationship [stress]. All of those types of things tend to be triggers for sleep problems. Pandemics – good example.

The wired and tired brain

Emma: What about – this is a really interesting thing that I've noticed – worrying about the fact that you can't sleep? It can really exacerbate things can't it? Sort of lying there thinking about the fact that you're not sleeping, looking at the clock and knowing you've got to be up and on your game in four hours' time. That's exactly what you shouldn't be doing isn't it?

Christopher: It's a very common feature of insomnia. We refer to it as the 'wired and the tired brain'. So it's wired, it's going a million miles an hour, but you're actually tired at the same time. And ruminating and thinking about why you're not asleep is going to cause you not to sleep more. That's a really central aspect of the problem, and it's what we need to address when you give therapy to people.

Emma: We'll get onto that a little bit later because I know that cognitive behaviour therapy is one of the things you can do to help people.

So you've talked about some of the main stresses and you mentioned different ages. What part do hormones play here? You hear a lot of people in perimenopausal and menopausal women especially having a lot of trouble with insomnia.

Hormones and temperature

Christopher: We know that there is an increase in insomnia around menopause, and it's associated with hormonal changes. Temperature is a good example that you described in your introduction, that can make people feel hot, and then you're not going to sleep. You need a nice dark cool environment to be able to sleep well.

The interrelationship between hormones and sleep is very complex and we're still trying to untangle it. With insomnia, though, it can occur across any parts of the lifespan, but we know that it is common in that 40 year old 50 year old age group as well, and more with women than men.

Emma: So interesting what you're getting to there about temperature. I think people have this idea you're meant to be nice and warm and snug in bed. You're saying you need to be quite cool.

Talk to me about how cool, because then if you're too cold you wake up cold, and you need a doona on you.

Christopher: You do, and people from overseas have told me Australian houses are terribly insulated, so we've got all those problems.

Generally during summer, when it is hot and there's a lack of air conditioning, people do not sleep well. It's too hot. What you need to do is have a cooler room and a dark room, and not to do anything to raise your temperature before you go to bed. So, certainly, I don't want anyone running a marathon before they're going to bed. And also don't think about having a really hot shower before you go to bed. Maybe a bit more tepid, a bit cooler in temperature.

Temperature is really intricately related to sleep. We know that people do have changes in temperature, especially with insomnia, that can affect their sleep. So temperature regulation is really important to understand. The idea about maybe sticking a leg or an arm out from under the covers and the doonas. That's to actually regulate, to actually make you sleep better. But, yeah, not having a lot of coverage, not dressing too heavily is not the right thing to do.

Emma: Pretty hard for people sharing a bed then isn't it, you know. Is there a case for just going and sleeping somewhere else if you need to make it perfect for yourself?

Christopher: Well I don't want to get into relationship counselling Emma, but maybe not so much with cuddling if you've got someone that's very hot next to you, as well, and I'm talking in the temperature sense there.

Emma: Laughs

Christopher: In seriousness, temperature does affect people, but the relationship with bed partners and how people sleep, and how that plays out, is complex and we're still trying to fully understand that.

Sleep hygiene

Emma: You know, I think that people have been impacted differently. Some people it's led to a more simple life, for others it's increased anxiety, trying to get that good night's sleep.

Talk to me about what it does to you when you do try to pare back and focus on sleep.

I think you guys call this thing sleep hygiene, which I think is a funny term.

Christopher: We do. Sleep hygiene is the things that you should do when you're trying to go to sleep, and then if you can't sleep how to try to go back to sleep.

So obviously things like making sure there's not too much bright light before you're going to sleep. We're on our phones a lot more. Computers emit this blue light that actually sensitizes the system to keep you awake.

Making sure we're not eating too much.

Alcohol is a problem. It causes you to not only to not sleep as much but also affects your sleep quality.

Spicy foods. Foods that are going to be stimulating like caffeine. We shouldn't be having those.

And then the other thing, on the other end of the spectrum, when we get out of bed, we should be trying to get morning light. So natural sunlight helps, it helps with regulating our sleep wake cycles.

So all of those factors are really important. Unfortunately in our busy lifestyle, we tend not to do those as much as what we used to.

Emma: We have electricity to blame for a lot of this. You know, when you go camping you really notice how early you turn in, don't you? You get up earlier with the light, and it's such a different pattern.

We've got this artificial light that we can keep going as long as we need to. We've managed to extend the day to get all this extra stuff done.

So what about the artificial light in our own homes? Is there a type of light we should have in our environment that, you know, is worse for us in terms of sleep?

Christopher: Look, we actually don't know much about people's environments at home or what light they do [have].

I tend to think most people have less light at night. They use lamps, they use softer light, they may have the TV on, they may have their smartphone next to them, so they're getting that light emitted.

But certainly the invention of electric light has progressed humanity, but it has had a negative impact on our sleep. It tends to impact on our sleep quality. So whilst people mightn't necessarily be sleeping less, they actually say they don't have the same quality sleep, and that's an important factor in insomnia. People don't feel refreshed the next morning.

Emma: Dave's from Newport. Good morning Dave.

Dave (caller): Hello.

Emma: Hello. What did you want to tell us about?

Dave: Well I walk the dog every evening, and just one wine or beer with dinner. And when we go to bed we sometimes have a bit of horizontal folk dancing, which really helps.

Emma: Okay! Well we were just told not to get too hot before going to sleep Dave [laughs]. So maybe early in the evening and then time to cool down.

Okay you're saying this is working for you. So just the one drink, walk the dog, a bit of time with your partner?

Dave: That's right yeah.

Emma: Okay, so what do you reckon about that one?

Christopher: So what works for different people is the way to go. We have this expression in sleep research we say the bed is for two things only, and Dave has described both those aspects – sleep and then that other activity as well – and that generally people shouldn't be doing things like reading in bed, having a light on next to the bed. Taking the phone to bed, is a problem because it buzzes, it makes noises and it changes our sleep.

Having a wine or some alcohol is not too bad, but not too close to sleep. Certainly no more than what Dave said as well. And a little bit of gentle exercise in the evenings is fine, but making sure you've got that period that you're winding down before you're trying to go to sleep.

Conquer your phone

Emma: I mean the challenge with this whole no phone in bed or in the bedroom is a lot of people are using their phones as their alarm clocks. It's got the built-in alarm clock. I think we've all given up on the old alarm clocks that keep going out when there's a power outage, the time changes, they can't be bothered with the old clock radio.

What do you say to people who are using their phones as an alarm?

Christopher: If you've got insomnia, it is a problem, because people then are associating that with the bedroom, and they're not associating it with sleep. I've got the old digital clock radio and it's got a battery backup it works wonderfully as well.

Generally, it's not a great idea to take the phone to bed.

The other thing is people then have the urgency: I need to answer that email at two o'clock in the morning because the boss needs me to do that the next day. Guess what: you don't need to. I hope you don't get sacked with that advice.

Emma: No that's right. And I think people will often send the work email to make themselves feel better and they can sleep better. So they're "I've got to send that email. I'll send it now". It's 11 pm, but what they've done is you know it's gone on to the next person who now has to act on that email and now it's 1am and they're seeing it.

We all need to agree maybe just hold those emails in our draft box and send that email at business hours maybe.

Christopher: Or even more radical, just turn your phone off.

Emma: [laughs] Yeah just don't. That's right

The phone has a lot to answer for, because people expect to be able to contact people, don't they? You say "I didn't have my phone. I left my phone at home". People are like "But I was trying to call you". I'm like, "Yeah, I was out".

Christopher: So there's two aspects of the phone. One is the fact that you're talking and you're writing potentially for an email. But the other problem is the phone emits quite a lot of light and that's going to affect the circadian system, which is going to have an effect on your sleep.

It can really disrupt your sleep a lot more than what people think.

So turn it off. Don't feel so bad about turning your phone off.

Emma: Question here [from a listener]: do those blue light blocking glasses help at all?

Christopher: They do. That's what I was referring to before. I'm not necessarily suggesting take your phone to bed and then put your blue glasses on when you're reading, but it certainly will lower the amount of blue light, which won't sensitise the circadian system and then disrupt your sleep as much.

Sleep walking

Emma: Now I know that this is a bit out of your area of expertise, so maybe you just give a general response to this. Somebody's asking us what can be done to help my adult daughter whose sleep talking and walking is getting worse. She wakes tired. Her partner is disturbed. Last night she was on her way out of a window.

Christopher: Yeah that sounds pretty serious. I think the best advice for that is to see your GP about that as a matter of urgency, and then they can be referred on to a sleep clinic, something like the Woolcock Institute of Medical Research. We have expert clinicians in sleep, but also researchers as well, so they know the cutting-edge research of what can be done for people with problems.

Emma: That's right. And even people who are dealing with insomnia should go and seek their own professional help for their own situation of course. We can't give, you know, specific information here this morning.

Interesting she's talking about sleep walking, sleep talking. That's a little bit different to insomnia, because at least the person's asleep. The person who's walking and talking, they're actually asleep.

Christopher: The term we use is 'somnambulism'. I'm not an expert in that area. It's very complex. It is associated with children and adolescents as well. But as I said before you need to go and seek medical advice about that to see if there's treatments that are appropriate.

Emma: Especially if you're trying to go out a window. That does sound like time to go and get some help.

Melatonin

Emma: Here's another [listener] text. It says "Post menopause I've solved the last four years of a decline in good sleep by putting one milligram of melatonin under my tongue at sleep time".

What do you what do you know about melatonin?

Christopher: Melatonin is the hormone that actually helps with getting us to sleep. It is released by a gland in the brain called the pineal gland. It works on the circadian system, and it has this beautiful cascade of getting people to sleep. The thing that gets it to be secreted is darkness, so that's why you don't want too much light. Darkness is the is the trigger for that.

Melatonin is used for things like jet lag. It also can be used for sleeping as well. It tends to have a different effect on different people, but certainly yes it can be very effective for some people.

Emma: You talked about temperature before, and that it's important not to get too hot. So what's with the warm milk: shouldn't it be cold milk?

Christopher: I think it's the fact that the milk can make you sleepy. There are some foods that tend to be more stimulating, and there's some foods that tend to have not so much a sedative, but certainly a sleepy effect as well, and milk can be classified as one of those. But again, it's what works for different people at different times.

The typical or ideal sleep pattern

Emma: We're talking about what you can do to fix things. Let's just start by describing what a typical or ideal sleep pattern should be through the night so that people can work out whether or not they might be heading into the territory of having a bit of a problem.

Christopher: What we tell people to do is to do behaviours before they go to sleep, to try to help with starting that sleep cascade, to getting good sleep.

So it's winding down period. You should start that at least 90 minutes out before you go to sleep. Not answering those emails we were talking about before. Not getting too much exercise, or eating, or alcohol. Then when you go to bed, go to bed in light clothing. Turn the light out. Have a dark room, so that's really important. There's a lot of light artificial light, so try to reduce that. Make it cool. We talk about 18 degrees, which sounds pretty cold, but we know that a cool environment is better.

Then when people fall asleep, they're actually in a very light sleep, and they can be roused very easily. Then you go through these cycles where it progressively gets deeper. We get most of our deep sleep early on and then we get REM sleep towards the latter half of the night.

When we wake up we tell people to try to get out of bed pretty early on. Don't hang around in bed because then you're associating the bed with not sleeping.

Emma: Okay that's what I'm going to have to work on. I do like loitering in the bed because, you know, once you get up you have to do everything. [Laughs]

Christopher: That's not my problem sorry, Emma. [Laughs]

Emma: You know a little lie in. Come on, how long? What do you mean, you wake up and just got to get up?

Christopher: It's about setting that nice sleep schedule that you asked about. You talked about camping and you talked about getting better sleep. That's what happens in the morning. The sun gets up and you get up. You're not going to lie in the sleeping bag in the tent if the sun's up. You're going to get up and do things.

Without trying to sound too dogmatic, don't spend too long. Certainly not loitering, or reading, or doing other activities where you could be doing them out of the bedroom.

Sleep and health

Emma: Fair enough. I mean, the serious side of this though is that the effects of poor sleep can be really debilitating. Describe how this can impact health short term and longer term.

Christopher: Insomnia is really bi-directionally associated, which means it can go both ways with mental health problems. Particularly anxiety and depression, and they're highly prevalent in the community across the lifespan.

So we know that sleep can have a really negative impact on your mental health, and also the other way around.

Insomnia in particular, without trying to scare your listeners too much, can have some serious health effects. We know it can affect the cardiovascular system. We know that it tends to exacerbate chronic diseases like diabetes and arthritis and other things.

So it's something that you should talk to your general practitioner about to see if you can improve your sleep.

Don't just live with insomnia. Insomnia is something that you shouldn't just cope with. You should actively try to get back to being a better sleeper.

What to do if you're lying awake?

Emma: For people who are struggling, I've heard – and this sounds counterintuitive to me as well – that if you are lying there awake you should just get up and do something else and then try to go back to sleep.

Is that still the right advice?

Christopher: Similar to that sleep hygiene advice, what we do is we talk about this 15 minute window. It's not exactly that, but if you're lying in bed and you're awake and you're not feeling as though you're going to fall back to sleep, get out of the bed. Get out of the bedroom. Restart that routine, light reading, something not too stimulating. And then when you feel sleepy, go back to it the bedroom.

So that associating the bedroom, and the bed itself, with sleep and nothing else, not reading, because I can't sleep overnight.

Emma: My mum had some great advice when I had small children. Two things. She told me that five hours' sleep was enough sleep, which I'm sure is not true. But when you believe it, you can feel less anxious about the sleep you're getting. So she said yeah five hours, anyone can get by a five hour sleep a day. That was one little mindset I took on.

The other one that I thought was so wise, was, you have to tell yourself that having a rest is like 95 percent as good as having a sleep. So you lie there and you and you think "I'm having a lovely, lovely rest. Isn't this so lovely, resting. What a treat that I can lie here and have a rest while the baby's sleeping". It took away the anxiety about my sleep when the baby sleeps.

But you're saying if you're not asleep, you should get out of bed. What's the role for the in-between bit where you're lying there and just trying to be very relaxed.

Christopher: That's perfectly reasonable as well. Young mothers in particular do have lots of disturbed sleep. And you talked about less sleep. And there are billions of people have done it, so we do cope with that. That can potentially bring on other problems longer term, but people are still having babies, people are being sleep deprived in that first year in particular, and then they cope.

The thing that I think your mum was talking about was not to catastrophise it. Not to make it the worst thing ever and to say I can cope with this. Because you do have to cope with it.

But if you've got insomnia, that's another story as well. That means that you've got a condition that's really affecting your sleep and affecting your daytime performance.

Emma: I see what you're saying. So if this works for you, if you can lie there and say I'm having a rest and then you fall back to sleep, you haven't got insomnia. Insomnia is really when you just can't sleep and it's going on and on and on.

Christopher: You have trouble going to sleep, staying asleep, or waking up, or maybe a combination all of those. And you're being affected during the day as well. So you mightn't necessarily be sleepy, but you're fatigued and you may be making more mistakes than what you think you're doing.

Hopefully the rounding of the zero for financial people is right and they're not making huge mistakes. But it also can lead to really serious problems. We know that car crashes serious accidents have been associated with insomnia and sleep deprivation. So it is a serious problem.

Cognitive behavioural therapy

Emma: Yes fatigue is huge. We've only got a minute or so left so can you tell us a little bit about cognitive behavioural therapy. How does that work in treating insomnia?

Christopher: With insomnia we know that currently lots of people go to their general practitioner and unfortunately they often end up with a sedative hypnotic medication.

The medication gets them to sleep, but it doesn't treat the problem. That's what cognitive behavioural therapy does.

What it often starts with is some behavioural therapy to try to re-establish that sleep schedule. And then the cognitive component works on some of those functional beliefs. In other words, why are you thinking you're sleeping so poorly and what's the problems trying to sort those out?

It's very effective. It can work in about 70 percent of cases, so it's something that people should look at. Sleep psychologists are experts in that, but you can talk again to your GP about where you might get therapy.

Emma: Here's a [listener] text: my phone is set not to alert me between 8:15pm and 6am. I use my phone alarm, but I'm not disturbed when I'm falling asleep.

There's a little bit of advice for getting the phone to work for you.

Christopher: Perfect compromise.

Emma: And here's another question: I have no problem getting to sleep, but I wake up every couple of hours, so never wake up refreshed. I wonder if being a single parent has meant that I'm always alert to the slightest noise. I have tried earplugs but too uncomfortable. Any suggestions?

That's from Catherine.

Christopher: Yeah that does sound like insomnia. It sounds like you've got some issues with thinking about your child and others as well.

That's something that you probably need to speak to an expert about. But other tips is, again, try to establish that sleep-wake schedule that we talked about, and see how that goes.

And one final thing about that, is when people have been having sleep problems for a long period of time, it's not going to take a day or two. It's going to take a while for that to be fixed. It's not like if you've got a few extra kilograms, you're not going to get them off in a day or two.

Emma: Thank you so much for joining us this morning. Really appreciate your time

Christopher: Thanks very much thank you pleasure to be here.