I’ve turned to the usual sources for help. Reading, chamomile tea, essential oils and a range of soothing sounds from phone apps – rain, waves, birds, religious chants, bedtime stories and relaxation and meditation guides.

The results have been uneven, and I’m hoping that an upcoming holiday will break this cycle of bad sleep and ease my bedtime anxiety.

Indeed, anxiety and sleep are bad bedfellows.

Anxiety impairs sleep, sleep deprivation increases anxiety, and when you then also start to fear not being able to fall asleep, it all becomes a vicious circle.

Psychologist Jetaime Muk at Sengkang General Hospital’s (SKH) department of psychology sees this all the time in her patients.

Most who seek help for insomnia face daily stresses that cause sleep problems.

“Then the anxiety about not sleeping, and not being able to function the next day, makes them feel even more stressed, and it becomes a perpetuating cycle,” she said.

Insomnia is the most common type of sleep disorder (others include obstructive sleep apnoea, restless legs syndrome and narcolepsy).

It is marked by dissatisfaction with sleep quality or quantity and includes difficulty falling asleep or staying asleep, or waking too early without the ability to go back to sleep.

These issues should occur at least three nights a week for at least three months to qualify as insomnia, said Dr Tang Chao Tian, a consultant at SKH’s department of psychiatry and the SingHealth Duke-NUS Sleep Centre.

The dissatisfaction should also be severe enough to cause significant distress or impair key areas of the person’s life.

A mental health study of over 6,000 Singapore residents in 2016 found that more than a quarter of respondents had poor sleep quality.

Sleep is critical to physical and mental health with many organs, ranging from the heart to the brain, being affected by it, said Dr Tang.

More alarmingly, he added, new research has shown an association between inadequate sleep and accelerated brain ageing.

A study found that even one night of sleep deprivation could result in a significant increase in a metabolic “waste product” of the brain called beta-amyloid in critical parts of the brain. Alzheimer’s disease is widely believed to be driven by the production and deposit of beta-amyloid.

Poor sleep quality has also been associated with increased signs of skin ageing, poorer skin barrier function and a lower satisfaction with appearance, Dr Tang said.

“One difficult aspect of ageing which may sometimes be overlooked in healthcare is the effects of ageing on our appearance, which can have an impact on one’s mental well-being,” he added.

The amount of sleep required changes as we age. The National Sleep Foundation in the United States recommends that newborns get 14 to 17 hours, young adults and adults seven to nine hours, and older adults seven to eight. These are general recommendations that do not account for an individual’s situation, he said.

Dr Tang also pointed out that while both sleep quality and quantity are essential for health, there is an emerging view that quality triumphs.

“If one is not sleep-deprived, there is increasing evidence that one should aim for good sleep quality rather than quantity.”

Many factors can affect sleep quality, ranging from physical and mental health conditions to lifestyle habits. Again, a factor may affect one person’s sleep but not another’s.

Genetic influences may have a role to play though the exact mechanisms remain unclear, he said. 

That said, insomnia disorder is more likely to occur in those with anxious temperaments, or those who have a tendency to repress their emotions or are exposed to major life events such as illness or just ongoing daily stress, said Dr Tang.

“Individuals who have immediate biological relatives with insomnia disorders are at a higher risk of developing this condition,” he added.

Behavioural therapy

Treatment for insomnia may involve psychological therapy such as Cognitive Behavioural Therapy for Insomnia, commonly known as CBT-I, or medication.

Dr Tang said two medications with an acceptable efficacy and safety profile are lemborexant, which acts in a targeted manner on receptors in the brain that have a role in wakefulness, and a particular prolonged-release formulation of melatonin.

It is also not uncommon for patients to be treated using “off-label” sedative medication, which is prescribed medication primarily used to treat other conditions, he said.

I don’t think my occasional sleeplessness warrants medication, so I sought Ms Muk’s advice on how she would go about helping a patient through CBT-I.

The majority of her patients with insomnia also suffer from other mental issues such as anxiety, depression, post-traumatic stress disorder or adjustment disorder.

CBT-I teaches them strategies to cope. It usually involves six to eight weekly sessions, though frequency depends on the severity of the insomnia and the patient’s progress.

Keep a sleep diary

To understand a patient’s concerns, Ms Muk will first ask them to keep a sleep diary for about two weeks.

This records what time they go to bed, when they fall asleep, how many times they wake up during the night and for how long, what time they wake up in the morning, and how alert they feel upon waking up and during the day.

From this, she calculates the person’s “sleep efficiency”, which is the total number of minutes spent sleeping divided by the total number of minutes spent in bed.

Based on a seven-day sleep diary I’d kept, my sleep efficiency was 72 per cent. I tend to go to bed early but can spend up to two hours on Google and social media before trying to sleep.

A good sleep efficiency is generally 85 per cent and higher.

“We don’t want patients to spend too much time lying in bed because the more you lie in bed, the more frustrating it’s going to be,” said Ms Muk. 

But if a person has no problem falling asleep after, say, an hour of Googling in bed, and feels fine with the amount of sleep he gets, there is no issue.

“If you feel refreshed, you’re functioning, not yawning, not tired throughout the day and feel like the sleep is sufficient, then it might really be enough. There’s no magical number that we’re trying to hit,” she said.

Most patients with insomnia, however, lie awake feeling increasingly anxious.

Relax, relax

Patients are taught relaxation techniques to put them in a better frame of mind to sleep.

Ms Muk has two go-to methods.

The first is “4-7-8 deep breathing”. It works like this:

Take a deep breath out.

Inhale for four seconds through the nose.

Hold the breath for seven seconds.

Exhale for eight seconds through the mouth.

Do three cycles of this.

“It’s a very intentional breath work that activates your parasympathetic nervous system and induces a relaxation response which counters the stress and arousal state,” she says.

“Your heart rate and breathing will start to slow down and your muscles don’t get so tensed up. This relaxation state will make sleep more successful.”

Patients should practise 4-7-8 breathing at least twice a day, especially when feeling stressed, so they build the good habit of relaxing.

Another technique she teaches is “leaves on a stream” which helps patients cope with thoughts that get in the way of sleep. It works like this:

Sit comfortably with both feet on the ground to give you the sense of being supported.

Close your eyes or gaze at a spot.

Take a few deep breaths and imagine yourself sitting beside a beautiful stream.

Notice the sound of the water flowing gently past.

Imagine leaves floating on the water, one leaf after another.

Take each thought that comes to your mind and place it on a leaf and let it float by. It can be a good thought, a bad thought, or a completely random one.

If your brain tells you that what you’re doing is silly, take that thought and place it on the leaf. If no thoughts pop up, just watch the stream and the leaves floating by.

Don’t be in a rush to get rid of the thoughts.

When you feel calm, bring your attention to your breath, gently open your eyes and draw your attention back to the room.

This exercise helps you draw a distance from your thoughts and be less entangled in them. This should elicit a sensation of relaxation that will aid sleep.

Reframe your narrative

A key part of CBT-I sessions involves psychoeducation to target maladaptive – irrational – beliefs about sleep.

“Sometimes, patients come in with worries about the consequences of poor sleep,” said Ms Muk. “They will say, ‘I’m never going to make it through the day’ or ‘I didn’t get my eight hours and it’s going to be a terrible day, I’ll make mistakes at work’.”

In cognitive restructuring, she guides them to find evidence against such thoughts.

The patient might realise that, yes, he woke up feeling groggy after not sleeping well, but that he usually feels better after a meal. Or that there have been days when he functioned well with little sleep, and also days he had made mistakes after a good night’s rest.

“Once you are able to find evidence against the thought, that’s when we’re going to try to come up with a more balanced thought that sits a little bit more neutrally within yourself,” said Ms Muk.

Patients keep a “cognitive thought diary” to record situations that trigger a strong emotional response, their automatic thoughts and assumptions about them, and to rate their emotions.

They then challenge those thoughts and reframe them with something more balanced.

“People will sometimes start to report that they are not as anxious as before,” she said. “Whereas they might have rated themselves 100 per cent frustrated about something at the start, it might be 80 per cent after restructuring these thoughts.”

Beware sleep hygiene

Beyond relaxation techniques and cognitive restructuring, Ms Muk emphasises sleep hygiene.

This refers to habits that help promote restful sleep. They include establishing a routine of going to bed and waking up at the same time every day to regulate your internal clock, ensuring a calming sleep environment, and avoiding caffeine close to bedtime.

“The aim is to get patients to create a strong association between the bed and sleep. You should use the bed only for sleep and sex,” she said.

If patients still can’t sleep after 20 minutes of trying, she suggests they get out of bed to do something to induce relaxation. Light reading or listening to instrumental music or nature sounds are advised, until they feel tired and then go back to bed.

“But don’t watch TV,” she added. The lights from electronic devices are stimulating.

The hardest habit for most people to adopt is to stay away from their mobile phone before bedtime.

She noted that it is not just the activities on the phone that keep people awake, but also how it tells time. “When you wake up and check your phone and find that it’s 2am, what’s your immediate thought? You feel stressed, right?” That’s not helpful for going back to sleep.

Still, there will be others for whom using the phone in bed doesn’t impede sleep, so this is not an issue for them.

Sleep apps can be beneficial as they can create a calm and conducive environment with relaxation and mindfulness exercises, stories and sounds, she said.

But she cautioned against being overly dependent on such apps, which may lead to anxiety about sleeping without them.

Over-tracking sleep patterns can also be counter-productive. “Patients can get so caught up on the sleep data that any slight change leads to increased anxiety and unhelpful thoughts about sleep.”

And if one really, really, can’t sleep?

Just stay awake and don’t stress about it, she advised.

“Once we lose that stress and expectation of the need to fall asleep, that in itself relaxes you, and sleep may just naturally come,” she assured.

While I may never be able to recreate those rainy nights as a child, I feel better now that I have new tools to lull me to sleep.

Source: The Straits Times © SPH Media Limited. Permission required for reproduction.