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Every now and then, the ambience in our office is disturbed by a member of the public roaring with laughter in the corridor, whilst reading the 'Sleep Office' sign on our door. We prick our ears with a sense of familiarity, anticipating what is coming next. "Sleep Office. Ha ha! What do you think they do in there then, sleep?"
While the idea of sleeping on the job sounds amusing to some, to our patients, sleep at any time has often become a living nightmare. Night after night, for years or decades - stuck in a seemingly inescapable cycle of desperately wanting to sleep, yet spending much of the night exhausted and awake.
We call this insomnia, which is one of the many sleep disorders we deal with at our sleep clinic. To those who have never struggled with sleep, it is hard to understand the profound impact that sleep disorders have on a person’s life. While they may be seen as a nighttime problem, they have a significant impact - across the full 24-hour spectrum - on:
health
emotions
cognition
productivity
quality of life
You might call me biased, but I think that sleep is the ultimate occupation! Every other occupation is affected by how well we sleep, and similarly, sleep is affected by all our occupations.
At the Royal Surrey County Hospital (in the UK), we are a team of three Occupational Therapists, working within an outpatient National Health Service (NHS) sleep clinic to provide assessment and behavioural treatment for sleep disorders. While our respiratory nurse and physiotherapy colleagues provide the sleep disordered breathing service, our primary focus is on delivering treatment for insomnia. We also support patients with circadian rhythm disorders, concurrent insomnia and sleep apnoea (COMISA), nightmare disorder and parasomnias. Our patients range in age from 16-90 years and, unsurprisingly, many have complex medical or mental health issues in addition to their sleep disorder.
A day in the life...
Today, my day started with a remote clinic. Due to there only being a few NHS Insomnia services in the UK, many of our patients are not local and prefer remote treatment, to avoid long journeys.
My first patient was a 45-year-old lady who, for the last 10 years, has taken several hours to fall asleep and then woken for another hour or two overnight. At first assessment, she estimated sleeping around 5 hours on a good night and was feeling desperate. Despite describing herself as a naturally positive person, her life had become a battle. She felt exhausted all the time, had been pulled up for mistakes at work and her relationship with her husband was deteriorating - not helped by their recent 'sleep divorce' (separate bedrooms). We initiated cognitive behavioural therapy (CBT) for Insomnia, which is misleadingly named, as it is nothing like regular CBT. After only a few weeks, her sleep is improving.
CBT for Insomnia (CBT-I) is the recommended first line treatment for people with chronic insomnia - although sadly few services exist, which means that most sufferers are fobbed off with no help, or ineffective sleep hygiene. CBT-I has a robust evidence base, demonstrating efficacy in primary and co-morbid insomnia (references 1,2). It is a multi-component intervention, addressing cognitive and behavioural factors that perpetuate sleep disturbance. We deliver our programme in an innovative way, through a combination of treatment videos (which I created, after we were forced to close our service during covid-19) and one-to-one support (to tailor, troubleshoot and top-up video content).
While the principles of CBT-I are quite simple, in reality they can be challenging, both to deliver as a healthcare professional and to implement as a patient. For example, techniques such as sleep scheduling can be very daunting. This requires an already-sleep-deprived individual to sacrifice catch-up sleep, get up at a consistent time and temporarily reduce their overall time in bed, in order to increase sleep efficiency. Not surprisingly, occupational therapy coaching skills are extensively employed, including:
evaluating motivation
explaining rationale
instilling hope
compassionately acknowledging concerns
adapting guidance to overcome barriers or resistance
In spite of patients’ initial scepticism, CBT-I literally changes lives within a matter of weeks.
That was the case for my first patient. Only four weeks after first seeing me, she was surprised to find that she was falling asleep within 30 minutes - and getting back to sleep quickly during the night. Her average sleep duration had already increased to 6.5-7 hours a night. I explained the next steps and congratulated her on the positive spiral she was creating - where increased sleep consistency produces greater confidence, which in-turn promotes calm at bedtime and consequently promotes more sleep!
My next patient was a 62-year-old man, whom I was speaking to for the first time. He explained that his sleep had been poor for years; as is the case for many of our patients, his physical and mental health was suffering. After initially describing symptoms suggestive of insomnia, he flippantly disclosed violent dreams associated with thrashing around and dream-related movement. Further questioning revealed a history consistent with REM Behaviour Disorder (RBD). Sadly, around 70% of those with RBD develop Parkinson’s Disease within 12 years (reference 3). RBD is not something that can be treated behaviourally and a formal diagnosis requires a laboratory sleep study, which we do not have available at our hospital. So I inform the gentleman on good sleep practices, recommend safety measures to avoid injury overnight, advise the GP to remain vigilant to other prodromal Parkinson’s symptoms and refer him to a London clinic, for a formal diagnosis.
Other activities during the day include setting up a respiratory sleep study for a lady with insomnia - but whom I suspect has sleep apnoea too. Plus talking to a young woman with a severely delayed sleep rhythm (4am - 1pm) about light therapy. That and wading through an endless stream of admin, triaging referrals, attending a multidisciplinary (MDT) meeting and cursing the new electronic records system that isn’t cooperating...
As my day draws to an end, I am left utterly convinced that when we help our patients sleep, we help them live. If this article has inspired you to think more deeply about sleep, I would encourage you to start building your knowledge of sleep, through reading or training. From there, your most powerful tool is to ask your patients about their sleep.
In the words of Jane, a former patient and former insomniac: "Life feels so much brighter, better and happier when you’ve slept well!"
Struggling to sleep? Listen up!
This free 30-minute one-off podcast will provide insights and evidence-based techniques, to help you and your clients sleep better tonight!
If you are struggling to fall asleep or stay asleep, please listen in below.
Created by article author Louise Berger, the talk will cover:
How you are not alone and there is hope
What to do when you are having a few bad nights
The difference between a few bad nights and full-blown insomnia
How insomnia develops
The vicious cycle of trying too hard to sleep
The two systems that determine how well you sleep - sleep drive and hyper-arousal
The difference between being sleepy and tired
Practical ways to increase sleep drive, so you can fall (and stay) asleep more easily
Ways to reduce alertness and anxiety at bedtime and overnight
Why you don’t have to sleep 7-8 hours every night
Why your insomnia isn’t going to take you to an early grave
References
Trauer, J.M., Qian, M.Y., Doyle, J.S., Rajaratnam, S.M.W. and Cunnington, D. (2015) Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Annals of Internal Medicine. 163 (3): 191-204. doi: 10.7326/M14-2841.
Edinger, J.D., Arnedt, J.T., Bertisch, S.M. et al. (2021) Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. Journal of Clinical Sleep Medicine. 17 (2): 263-298.
Roguski, A., Rayment, D., Whone, A.L., Jones, M.W. and Rolinski, M. (2020) A neurologist's guide to REM sleep behavior disorder. Frontiers in Neurology. Jul 8; 11:610.
Berger, L. (2024) Say Goodnight to Insomnia Podcast. Royal Surrey NHS Foundation Trust: Occupational Therapy > Insomnia Clinic. Available online: https://www.royalsurrey.nhs.uk/saygoodnight. Accessed 15 February 2024.