By the time people arrive at The Good Sleep Clinic they will all have been given advice on ‘sleep hygiene’ at some point in their journey. Either from their doctor, from books or online ‘top tips’. However, it can be confusing for people; how to put it into practice, how it works, how effective it is, and even what exactly it involves.
We have tried to clear up some of the myths and misunderstandings in our blog.
What is sleep hygiene?
Sleep hygiene is a collection of habits relating to your lifestyle, that support good sleep. People can be confused about what sleep hygiene actually is, and whether they have done it properly, because it is not a single intervention, there is no defined approach or universally agreed list. There are a huge variety of materials available, and they all differ in the advice they contain.
What the advice has in common is that it is based around an understanding of how sleep works. Our ability to fall asleep is regulated by two internal systems; Our internal body clock, also known as our circadian rhythm or Process C and our “sleep drive” which is the way our bodies build up a pressure to sleep during our waking time, this is known as Process S. These 2 processes work together and in healthy natural sleep they do not need any help.
Is sleep hygiene necessary to achieve good sleep?
No. For most of us, most of the time, sleep is a natural process. We do not need to do anything active to achieve it. However, we will all have experienced times when our sleep regulation is out of sync, and sleepless nights sometimes follow. When this happens, a really helpful first step is to look at our sleep hygiene and make sure there are no habits or practices that could be altered to improve the chances of good sleep.
Does sleep hygiene work?
The principles of sleep hygiene are often helpful for episodes of short-term sleep disturbance. Geoff had been working from home since March.
He loved his espresso machine and saw it as a real treat that he could have an extra coffee in the afternoon. He also took the opportunity to have longer lie-ins on the mornings that he did not have to start early. He often did not leave the house until much later in the day if at all.
He began to struggle with falling asleep at night. Geoff had disrupted Process S with his additional caffeine and Process C with the changes to his routine. In understanding this and correcting these factors he found that balance could be restored and he rediscovered good sleep.
However there is no one single piece of sleep advice that will help everyone, what is helpful will depend on your individual circumstances and routines.
Unfortunately sometimes short -term sleep disruption can take hold and last longer than a few weeks. This can develop into insomnia. When insomnia persists it is not necessarily due to poor sleep hygiene, but often a combination of factors including unhelpful thoughts and behaviours. This means that sleep hygiene measures may not be able to fix the problem. There is no evidence that sleep hygiene is an effective treatment for people suffering from insomnia.
How I discovered I was wrong about Sleep Hygiene
Here is my confession; up until 5 years ago and before my passion for sleep had really taken hold, I thought that sleep hygiene was the correct way to treat patients with insomnia. I am a dedicated GP, committed to giving the best possible advice to my patients. I understood that sleep medications could cause problems, side effects and have long term negative effects. I had an understanding of the physiological mechanisms that drive sleep and it made sense to me that I should offer insomnia patients advice on how to maximise their lifestyle in order to promote good sleep.
I did this in the best way I could within our short appointment times (often a brief chat with some written information.) This approach was helpful for some, however for others it was not effective. Many patients return to me frustrated with their ongoing lack of sleep, and I witnessed the awful impact that insomnia can have on people’s lives; feeling perpetually tired, struggling to cope with work or family, and feeling unable to thrive and enjoy life. Many patients simply didn’t return, thinking that the GP was not in a position to help them.
I assumed I must be “doing sleep hygiene wrong.” Why were my patients not improving? This inspired me to learn more about insomnia. What I learnt from expert clinicians, and from patients themselves was that sleep hygiene is not a treatment for insomnia. The clinical trials, national and international guidelines all describe that the most effective and longest lasting treatment for insomnia is a cognitive and behavioural sleep programme such as Cognitive Behavioural Therapy for Insomnia (CBT-I). This motivated me to train to deliver CBT-I and then Acceptance and Commitment Therapy for Insomnia and led us to set up The Good Sleep Clinic.
There are many options of how to access effective sleep programmes; books that teach the key strategies, digital programmes, and face to face individual programmes such as those that we deliver.
Should we be ignoring sleep hygiene advice?
No! Sleep hygiene advice is based in good scientific theory. It is correct to say that caffeine or alcohol can disturb sleep. It is correct to consider the temperature of your bedroom, your wind down time and screen time, and it is correct to say that having a routine and set waking up times can really help to maintain or improve your sleep. These are all important factors and similar advice usually forms part of a sleep treatment programme. But this advice alone is usually not sufficient to treat sleep problems that are more established such as insomnia. Sleep hygiene importantly does not address the other factors that keep insomnia going which is why alternative approaches are often needed (see our blog on insomnia to find out more.)
OK, so even if sleep hygiene does not necessarily help insomnia, can it cause any harm?
The negative consequences that we hear about at The Good Sleep Clinic include the frustration people feel when they are given the same advice each time they consult a clinician. People will often have tried most of the strategies before seeking help from their doctor, seeing it as a “last resort.” They can feel “fobbed off” when they are given the same advice and sleep tips that they are already aware of.
Sleep hygiene can also contribute to another problem experienced by people with insomnia; it can form a strict set of “rules” to abide by. It is not uncommon for a patient to arrive at The Good Sleep Clinic with more than 10 specific rituals that must be in place for them to fall asleep; The strategies are usually all sensible in themselves, but sleep problems often persist despite living a near-perfect sleep-generating lifestyle. Sustaining these efforts is rarely possible, and can limit the lives we lead, and for some people they can heighten anxiety and arousal which can actually worsen sleep.
What should I do to improve my sleep?
Many sleep hygiene strategies are useful for improving short-term sleep disturbance. You may find it useful to complete a sleep diary to understand more about what impacts on your own sleep, and the effect of any changes you make to your lifestyle.
Dr Zoe Schaedel