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Problems with sleep

Problems with sleep are common in Chronic Fatigue. Generally sleep feels unrefreshing, you wake up feeling as tired as you did before you went to bed. Sleep may have got "out of rhythm" too. Sometimes people have difficulty getting to sleep and, though tired, lie awake for hours trying to get to sleep. They often wake up throughout the night. During the day they feel so exhausted that they often fall asleep, or have got into a habit of taking naps.

Overall, you may feel that you are not sleeping enough, or that you are sleeping much more than you used to. Either way you are still feeling exhausted.
So what can be done? Let us look first at what kind of factors can keep sleep problems going, then how you can become aware of them and finally how you can begin to change them. Like other problems in CFS, change will be gradual and it will probably get worse before it gets better.

Lack of sleep - Irregular sleep
Oversleeping
Self help for Sleep
Establishing a consistent sleep pattern
Break the association of bed and restlessness
Fixing the routine
What to do about daytime sleep
Coping with oversleeping
Tips for better sleeping
Don't worry
Other websites related to sleep problems

Lack of sleep - Irregular sleep

Beginning at bedtime. You may find that you go to bed feeling tired, but cannot sleep. Not being able to sleep when you want to sleep, and feel you have to sleep, is generally very frustrating. This frustration increases bodily arousal which in turn makes it more difficult to sleep. At the same time, you may be worried about the effects of lack of sleep, or other worries from the day are going through your head. Somehow, this often seems to happen at bedtime, when we have nothing else to focus on. Similarly you may be much more aware of bodily aches and pains, and of generally feeling ill. All these factors - frustration, worry and increased awareness of symptoms - are going to work against "trying" to get to sleep.

Once asleep you may wake up several times. A very similar pattern often occurs. You wake up, cannot get back to sleep and the frustration, worry and awareness make you more wakeful. The middle of the night can be a particularly bleak time for many. Between 2 and 4 our bodies experience a kind of physiological dip. Any feelings of lowness will be greatly amplified.

Come morning and you wake but feel exhausted. You don't feel able to get up, so you lie in bed feeling awful.

When you do get into the day, you may find that you feel the need to sleep to catch up on the night before. Or you may greatly reduce your activity and rest a lot because you feel so exhausted. This seems only sensible, indeed the need to rest and\or sleep during the day may feel overwhelming. However the daytime sleep and rest will actually reduce your need to sleep so much at night and will reduce the quality of the sleep that you do have. So when it comes to bedtime again, the whole cycle starts over.

Another problem with daytime sleep, which you may have noticed, is that it can actually be very difficult to get going again after it. If we sleep for more than 20 minutes, we go into deep sleep. Coming out of deep sleep after an hour or two usually makes us very groggy. This in turn leads us to doing less, feeling worse and this in turn affects the quality of sleep at night.

The overall effects of this kind of cycle of disrupted, irregular poor quality sleep would be devastating, even to a well person they include:
  • Loss of energy and drive during the day
  • Lowered immune functioning
  • increased feelings of depression and anxiety
  • lowered tolerance\increased perception of pain
In CFS this can make a bad situation worse. It compounds the feelings of lack of control over ones life. The aim of this section is to allow you to take control of your sleep again. First though, let us look at the effects of excessive sleep.

Oversleeping

Now, oversleeping here means sleeping more than you used to prior to your illness. Studies have shown that the amount of sleep our bodies need is between 7.5 to 9 hours. Any less than that and we suffer the effects laid out in the last section. Equally importantly though, we can sleep too much. Sleep is like food. There is an optimum amount that our bodies need. If we regularly eat too much or too little, our bodies will suffer.
However, in CFS people often feel the need to sleep more than the norm. Often they will sleep solidly for 10-12 hours, but still awake feeling tired. This reinforces the feeling that they need that much sleep.
Again, there is a kind of vicious circle at work here. It has been shown that sleeping more than the average amount actually leads to feelings of daytime fatigue, impaired concentration and lack of energy and motivation. Having these kinds of feelings during the day will reinforce the belief that yet more sleep is needed, which will in turn lead to more of these kind of feelings.
At the same time, the body will be getting into the habit of sleeping more and the longer this persists, the harder that habit will be to break. Any attempt to sleep less will lead to increased tiredness, so the cycle will continue.
Again, once this kind of cycle is established, it can be very hard to break. Any change needs to be gradual and consistent. The first step is to become aware of what is happening.

Self help for Sleep

The first step is to become more aware of what your current sleep pattern and needs are like.

Take a look at the sleep diary. As with the activity and rest in section 5, you will not change anything for a couple of weeks, merely keep a record of how things are at the moment. This will allow you to form a baseline for gradual change.

The sleep diary asks you to record the following:
  • What time you went to bed
  • What time you prepared for sleep - i.e. turned lights off and started trying to get to sleep.
  • What time you actually got to sleep
  • Number and length of times you woke up during the night
  • Time you woke up for the last time that night
  • Time you got out of bed
  • Number and length of daytime sleeps
  • How refreshed you felt on waking

  • The quality of your sleep that night.
Now this is a lot of information. However what it will allow you to do is:
  • calculate the average amount of time you sleep in each 24 hour period
  • calculate the amount of time you spend in bed in each 24 hour period
  • take a baseline measure of sleep quality to monitor improvement
In the next section, we will put this information to use.

Establishing a consistent sleep pattern

Now, the broad aim of this section is to take the average amount of sleep you have in 24 hours and condense it into one sleep period at night. For instance, you may currently be sleeping an average of 8 hours. 5 hours of this may be broken sleep in a period of 8 hours in bed at night. The rest is 3 hours worth of catnaps during the day. Your aim then would be to "squeeze" those eight hours into the night time slot. Easier said then done. What is the first step?

Break the association of bed and restlessness

We are creatures of habit. After a time, our bodies become used to particular rhythms and tend to repeat them. This is particularly true of sleep. If you are currently in the habit of spending periods of time in bed awake, yet tired and restless, you are maintaining a kind of habit, an association of bed and feeling restless. As pointed out in above, this cycle becomes self-perpetuating. The way to break this cycle is to use bed only for sleep. The only exception to this is sex.

Practically this is done as follows. Look at your sleep diary for the last two weeks. Look at the difference between when you went to bed and when you actually fell asleep. This is the first area you can change. It could be that you are in the habit of feeling tired in the evening, going to bed early yet not sleeping for a few hours. In so doing you are building up an association between bed and not sleeping. The way to change this is to go to bed much nearer your going to sleep time. If you are in the habit of resting, watching TV or reading in bed before sleep, do these in another room or, if this is not possible, in another place in your bedroom. Then go to bed when you are feeling sleepy.

If you are not asleep within half an hour at most get out of bed.

Sit quietly somewhere else and do something relaxing - listen to music, read a magazine. Go back to bed when you feel sleepy again.

This will help to do two things:
  • strengthen the association between bed and sleep
  • help to break the cycle of frustration and restlessness described above. Rather than lying for hours "trying to get to sleep", go and do something relaxing and distracting to take your mind of this frustration. Then go back to bed.
You should repeat this cycle as often as necessary.

The same goes for night time waking. If you wake up in the night and can't get back to sleep again after half an hour at most, do the same. Get up and do something relaxing, when you feel sleepy, go back to bed again. Repeat as necessary.

Now this may sound somewhat like hard work, and initially it probably will be. It will feel unnatural and strange. Persist. You are breaking an old habit and establishing a new one. It wont happen overnight. However if you persist you will be establishing a sleep routine that will eventually become automatic. Your hard work will pay off.

The same principle applies to the morning. Once you wake up for the last time, get up.

Fixing the routine

To make the routine more stable, the easiest first step is to stabilize your getting up time. Take the average getting up time from your sleep diary. Try and get up at this time every day. This will help further establish a natural rhythm of sleep. Again initially you will feel more tired during the day, but if you persist, your body will begin to adjust to a new habit of having a more regular and controlled sleep cycle.

What to do about daytime sleep

The long-term goal is not to have any. As mentioned above, daytime sleep perpetuates the cycle of poor sleep at night and daytime fatigue. However it can be a hard habit to break. If you are sleeping a lot during the day - more than a couple of hours, you may find it easier to gradually reduce it. Read section below on oversleeping.

Otherwise, the key is to substitute sleep with quality rest during the day. If you follow the instructions in section five above, the rest you are having during the day will fulfil the need that you currently meet with sleeping. Again this will not happen quickly. Be prepared to feel more tired initially. However as the quality of your night time sleep begins to improve, and that cycle becomes established as detailed above, the need for daytime sleep will diminish. Remember, persistence is the key.

Coping with oversleeping

The steps for this are the same as for the other changes in CFS.
  • Establish consistency and control
  • Make gradual changes.
The first step is to take the average amount you are sleeping from your sleep diary and stabilize it. if this includes daytime sleep, do the same. Make it for a fixed time at a fixed time. Stick to this routine until it begins to feel easier to maintain it.

Next, begin to make gradual reductions. It is best to begin with daytime sleep as this will improve your quality of daytime life. Say you are now regularly sleeping for an two hours during the day. Make a slight reduction of 15-30mins. Stick to this until you can achieve it fairly consistently. Then reduce again. You may find that the less you sleep the better you feel. As mentioned above, if we sleep for more than 20 minutes, we go into deep sleep. Waking up from this during the day leaves us feeling groggy and tired.

So, aim to reduce and eliminate daytime sleep first. Once you have done this, follow the same principles with reducing night time sleep. First establish a consistent getting up time. Once this is regularly achievable, gradually reduce it. Keep the reduction consistent until it feels easier. Then reduce again. Your aim is to sleep about the amount you slept prior to being ill. It is best to aim for an average of between 7.5 and 9 hours. Any more or less than this will have the effects described in 6.1 and 6.2 above.

Following the above instructions will help you establish a more regular and controlled sleep rhythm. Below are some further hints that can help with improving and overcoming sleep problems.

Tips for better sleeping

Some Do's and Don’ts.
  • Don't exercise too near bedtime; this will make it more difficult to sleep as you will be physiologically aroused.
  • Don't eat a large amount of food or drink lots of liquid close to bedtime.
  • Don't take stimulants - tea, coffee, nicotine (or reduce the latter) within 4-6 hours prior to bedtime.
  • Don't drink more than a couple of units of alcohol near to bedtime. Although this promotes initial drowsiness, it leads to night time waking later on. However, we have noticed that CFS sufferers rarely drink alcohol, so this is unlikely to be a problem.
  • Don't do anything too mentally or emotionally strenuous near to bedtime - work, argue, make major life choices etc. These will only make it more difficult to get to sleep. For hints on how to deal with these issues, see 6.4.2. below.
  • Do have a regular bedtime routine:
    Wind down in the hour prior to sleep with relaxing activities - bath, music, reading etc.
    develop a routine of "getting ready for bed" - locking up, brushing teeth, changing for bed etc. This will act as a trigger for your body to slip into sleep mode. Similarly when you get up in the morning, change into day clothes. This will signal to your body that you are in a different mode, even if you still feel tired.
    make sure your bed is as comfortable as possible, and the bedroom is not too hot or cold.
  • Remember: try to build the association between your bedroom and sleep. Try to avoid any other activities or rest, apart from sex, in your bedroom.

Don't worry

At least not now. It seems to be part of falling asleep that worries go through our head. There is nothing to think about, nothing to distract our attention, so problems, worries and embarrassments from the day tend to rise up, worries about what the next day will bring. This makes us more anxious and more aroused so it becomes more difficult to get to sleep and our head gets even busier. We may begin to worry about not getting to sleep and how we are going to feel the next day. We get more anxious... and so on.

So how do we stop worrying? Worrying tends to be the feeling we have when a problem is on top of us, rather than when we are on top of the problem. The key to stopping worry is to switch to the latter, i.e. getting on top of the problem.

Here’s how:
  • Set aside some worry time in the early evening, time when you decide to focus on what's come up during the day and anticipate what's coming up in the future.
  • Write down the main issues and loose ends. Now taking each problem in turn, think of as many solutions as you can to it. Don't censor yourself, write down anything that comes to mind that you think could help solve or overcome the problem.
  • Go through your solutions and pick the one you think is most achievable, the one you are going to try.
  • What is the first step of your solution? You don't need to solve everything now, just decide on a course of action, and the first stage of that action. Plan it. Agree a time with yourself when you are going to try out your first stage.
  • Stick to this plan, implement it. Spend part of your next worry time evaluating how it went - did it work? If not why not? Do you need to go back to the drawing board (step 3) or can your carry on to the next step.
Now when it comes to bedtime, and worries arise, tell yourself that you have the matter in hand. If new worries arise, or new angles on old ones, decide that you will deal with that tomorrow in your official worry time.

All this should help you feel more on top of your problems. Worry is, after all, what fills the gap between a problem and a solution. if you are taking steps to bridge that gap, you do not need to worry.


Author: Vincent Deary

Other websites related to sleep problems


Royal College of Psychiatrists: leaflets on sleep problems

MIND booklet related to insomnia and sleep improvement techniques

Helpguide, org. information on sleep disorders: types, diagnosis, risk factors, and prevention

BBC Science & Nature: sleep apnoea, snoring, insomnia, and restless leg syndrome

MEDLINEplus interactive tutorial on sleep disorders produced by the Patient Education Institute
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