Welcome to the first session of the SLEEP programme. By now you should have finished your first week of sleep tracking and have hopefully sent back the Dreem Headband. If you haven’t already done so, or are unsure on how to send the device back, please check the instruction sheet (Introduction) or contact the research team on the email below to avoid delays to others starting on their SLEEP journey!

As we explained last week, it is important to continue monitoring your sleep with your sleep diary to start implementing positive change in your sleep routine as you progress in the programme. To prepare for your first therapist-guided session (session 3), it will be helpful to take a look at your sleep journal yourself and think about what aspects you would like to change.

This week we will discuss about the different stages of sleep and what happens in each stage, how sleep works (what sleep homeostasis and circadian rhythms are), and how this is related to time-in-bed restriction therapy, which is a fundamental part of the programme to be discussed in detail during your first therapist-guided session (session 3). We will then cover what factors play a key role in the development and continuation of sleep problems, finishing off the week by identifying some of the common obstacles to a good night sleep with an interactive exercise on sleep hygiene.

You might notice that weekly content has a lot of information in the form of psychoeducation. It’s important to note that the more we understand what causes sleep problems, and gain insights into our own particular sleep needs, the better equipped we’ll be to support optimal rest.

 

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Sleep and Insomnia

Sleep is an active biological process. It affects the body’s metabolism and immune system, and allows the body to repair, restore and heal itself.

Getting enough sleep helps you in: energy conservation, memory and learning, mood and emotion regulation, body restoration, and daytime alertness and concentration.

All of these functions are working together for one overall aim: optimal functioning of the body and mind. Therefore, to keep yourself functioning optimally both physical and mentally, it is important to prioritise and protect your sleep!

 

 

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What is insomnia?

Insomnia is defined as having trouble falling asleep, staying asleep, waking up many times at night or earlier than planned. Insomnia is a common problem that can be brief or long-lasting.

Brief, occasional Insomnia can be a normal and understandable response to situations, e.g., can’t sleep after hearing some exciting news, can’t sleep because an important job interview/work meeting is coming up.

However, if the insomnia is becoming persistent (e.g., >3 months) and seems to be taking on a life of its own, then we need to do something about it. In this case, it results in poor-quality sleep and a lack of feeling refreshed in the morning, which affects productivity and may increase distress.

Insomnia can lead to:

• Feelings of exhaustion
• Low motivation
• Difficulty concentrating
• Poor judgment
• Poor problem-solving ability
• Irritability
• Moodiness

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Sleep and Mental Health

If you are stressed or worried during the evening, you are more likely to struggle with falling asleep as your arousal levels will continue to be high when trying to fall asleep. This will then affect how you are feeling the next day as you will be unrested, and your worries and stress levels will most likely increase even further.

Most people report being irritable, if not downright unhappy, when they lack sleep. Over time, this continued pattern of poor sleep and increased stress could significantly impact your overall mood and daily functioning. Lack of sleep itself also puts your body under stress and may trigger the release of more adrenaline, cortisol, and other stress hormones during the day. These hormones keep your blood pressure from dipping during sleep, which might even increase your risk for heart diseases in severe cases.

Therefore, when it comes to our mental health, sleep helps us to feel more emotionally stable and increases our resilience to stress. Without sleep, our ability to think rationally and to regulate our emotions is compromised, potentially worsening the effects of an existing mental health disorder or increasing our risk of developing one.

Still, it’s important to realise that some degree of sleep disturbance every now and then is normal and that we have the capacity, for the most part, to manage during a period of poor sleep.

The link between mental health and sleep issues means that treating one issue often has a positive effect on the other.

 

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What is CBT-I?

Cognitive Behavioural Therapy for insomnia or CBTi in short, is an intervention for insomnia and is recommended over medication. As the name suggests, it is part cognitive, referring to what we think and part behavioural, referring to what we do. About 75% of people with chronic insomnia benefit from this intervention. The people who benefit most are, as you might expect, the ones who follow the programme closely.

Cognitive Behavioural Therapy or CBT is based on the idea that thoughts, behaviours, and feelings both emotional and physical are all interconnected, and we often experience these in a ‘vicious cycle’.

The SLEEP programme for the next 6 weeks will consist of cognitive, behavioural, and educational components. Educational modules will give you information about the connection between thoughts, behaviour and sleep. Behavioural modules will include training in relaxation techniques, stimulus control, and time-in-bed restriction to help you establish healthy sleeping habits and patterns. Cognitive modules will help you reflect on your thinking patterns and attempt to change some unhelpful thoughts that you may have and also affecting your sleep at night and performance during the day. Two sessions (3 and 6) will be therapis-guided, which means that a trained specialist will meet you during an online session and will help you restructure your sleep schedule.

Since you were enrolled in the SLEEP programme, that means that you probably have been having problems sleeping that could have been developed only recently or some time ago. For the programme to work, it will require some time and effort to re-train your body and mind so that you’ll be a good sleeper again. The procedures are highly structured and will require patience and effort. Six weeks is usually the fastest you can really learn and apply CBTi but it may take slightly longer, so stay with it! CBTi is powerful and helpful. During the first weeks of practice, some people may find it a little bit challenging, however, you should start experiencing significant improvement a few weeks into the programme.

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What are the different stages of sleep?

VIDEO talar

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Sleep Homeostasis and Circadian Rhythms

We already learned about the importance of sleep quality and the different stages of sleep we go through as part of our biological clock. Let’s now look at the two key biological systems that are at the root of good sleep.

VIDEO – Sleep homeostasis talar - Edit for experimental part

In summary, there are 2 main systems regulating our sleep: Process S and Process C. Both processes work together, which lead to an ideal sleep window. When our sleep pressure is high (due to being awake for a long time) and our circadian drive for arousel (level of alertness) is the lowest, thats the moment we have the easiest time falling asleep.

However, both processes can be influenced and disregulated. Sleep is not only affected by what we do during the night, but also by what we do during the day. If we take a nap during the day, we "use" some sleep pressure already. Sleeping is very efficient in lowering the sleep pressure, which means that the sleep pressure will be much lower if we take a nap during the day. While there might be still enough sleep pressure at the start of the night to fall asleep (however, it might already be a bit more difficult), it will be very difficult to fall asleep again if you wake up during the night after you already used most of your sleep pressure since the sleep pressure is just too low.

The human circadian rhytm is a near 24-h rhythm influenced by several stimili called "zeitgebers", which help us synchronize to a day-night rhytm but can also destabelise and desynchronise our internal clock if we get exposed to those factors at the wrong time. Exposure to light is the most important one, but physical activity and regular food intake are other examples of factors influencing our circadian rhytm. A well-synchronised internal clock will benefit us as it helps to feel sleepy when it is time to go to sleep and feel alert when we need to be awake. It is possible to advance or delay our circadian rhythm by adapting the light exposure and other synchronizers. When you expose yourself to light in the morning (e.g. morning walk after sunrise), you are more likely to advance your rhythm. This could be useful to reduce or prevent jetlag. However, when you expose yourself to light late in the evening, you’re most likely delaying your rhythm. This is what happens during the weekend with many people, particularly late chronotypes. They stay up later than usual and delay their clock, resulting in a “social jetlag” the following Monday. Besides, the adaption to cues from the environment is limited to certain level. When the rhythm of the environmental cues changes to fast, the circadian clock does not have the time to adapt and a misalignment will occur. This also implies that adjusting our sleep takes time! You can not expect impressive results over one or 2 nights!

 

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The 3P Model – Start and continuation of sleep problems

Different factors can play a role in the initial development and continuation of sleep problems and insomnia. These are Predisposing factors, Precipitating factors and Perpetuating factors, and together are known as the 3P Model.

1. Predisposing factors are things that put people at an increased risk for insomnia. These are factors that make us more prone or “predisposed” to sleep problems, such as:

2. Precipitating factors are things that occur before and bring on or trigger a period of insomnia:

Insomnia that is a result of a stressful situation may go away on its own over time or when the factor causing stress is no longer present, but for some people insomnia continues even after things improve. So, although some factors may have started problems with insomnia, it is likely that the harmful habits you developed to cope with the insomnia are keeping the insomnia going long after the stressful situation has passed.

3. Perpetuating factors are common habits and behaviours which people adopt to cope with insomnia which in effect keep insomnia going over time such as irregular sleep schedule, doing activities in bed other than sleep or sex, sleeping in on the weekends, taking long naps in the afternoon.

Even if the precipitating factors (the things which triggered the insomnia in the first place) are kept under control, perpetuating factors can still make the sleep problem worse and prevent recovery. The longer you have had your sleep problem, the more likely it is that perpetuating factors are helping to maintain or worsen your insomnia symptoms.

One of the objectives of the SLEEP programme, therefore, is to help you minimise the influence perpetuating factors have on your sleep.

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True or False? (H5P add later)

Keeping a regular sleep schedule is important to not disturb our sleep-wake rhytm.

A regular sleep schedule reinforces our circadian rhytms and helps us to feel sleepy when it is time to go to sleep and feel alert when we need to be awake.

Feeling drowsy in the afternoon means you’re not getting enough good quality sleep.

Feeling a bit sleepy in the afternoon, particularly after a meal, is perfectly normal. This happens because of a natural dip in our circadian rhythm wake drive.

Good quality sleep means not waking up at all during the night.

Although some uninterrupted sleep is important, it’s normal to wake up for very brief periods of time during the night.

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Prepare yourself to go to bed: Start with a wind down

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Take home messages and tasks

• Waking up briefly in between certain sleep stages is normal, and you will easily fall back to sleep if you remain relaxed.
• Finding your personal sleep gate is an essential part of this programme that will allow you to get a good quality of sleep.
• Winding down in the evening and creating a strong association between the bedroom and sleep is essential for good quality sleep.
• Please make sure you continue completing your morning and evening sleep diary every day to help you in your sessions with the therapist and keeping a regular sleep schedule.

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If you have any questions or concerns relating to your participation in the study and/or completion of weekly platform content, or if you feel unwell or distressed while completing study related tasks, please email the research team at MAIL.