4 Increasing sleep drive
One piece of advice about sleep is that you should go to bed at the same time each night and then get up at the same time every morning. However, if significant stretches of this time in bed are spent awake then the strategy becomes flawed. Increasing sleep drive, or the desire to sleep, may be a better strategy as you will see in Activity 1.
Activity 1 Sleep strategies
Timing: Allow 20 minutes
Listen to Audio 1, taken from a podcast where menopause doctor, Louise Newson, discusses strategies on how to get the best night’s sleep with sleep expert, Kathryn Pinkham. Then answer the following questions:
- Why may sleep hygiene measures be counterproductive?
- How can sleep drive be increased?
Download this audio clip.Audio player: Audio 1 You Are Feeling Sleeeepy: Kathryn Pinkham
Transcript: Audio 1 You Are Feeling Sleeeepy: Kathryn Pinkham and Dr Louise Newson
Dr Louise Newson
So talk us through because, I mean, I’ve read all sorts of things about sleep. Some I agree with, and some I don’t. But a lot of it seems to be about having a really good routine, a bedtime routine. But also a seven-day routine, so it’s not having the five days and lying in at the weekend. But I don’t know whether that’s true or not. So talk me through some really simple measures.
Kathryn Pinkham
So I guess it depends who we’re talking to. So if you are somebody who has a decent sleep pattern, simple changes that we would call sleep hygiene, so everybody’s heard of sleep hygiene. That’s kind of don’t drink too much coffee. Don’t drink too much alcohol. Make sure your room is comfortable. Those kind of things. And that’s all quite decent advice for somebody who already sleeps OK and just wants to be educated and healthy in as many ways as they can.
If you are somebody who is actually struggling to sleep well, so you can’t get good quality of sleep, and it’s really important to think of quality rather than quantity. So we’re talking about good quality sleep, not just how many hours. If you’re somebody who’s struggling to do that, then actually, sometimes focusing on sleep hygiene or routine and those kind of changes can actually make the problem worse.
Because if you imagine, you already can’t sleep well, and then you don’t drink any caffeine. You never go out in the evening. You have a two-hour wind down routine involving yoga, mindfulness, sleepy teas, every single thing that you’ve googled and you can buy. So a lot of the people that we see, their sleep hygiene is perfect. They’re doing absolutely everything right. But it’s actually creating so much anxiety because we’re trying so hard to do something that actually, the more we try and do, the worse it becomes.
Dr Louise Newson
And then it makes them feel worse in themselves. I suppose more like a failure because they’re not achieving what they should be with all this routine.
Kathryn Pinkham
Yeah, and they say, I’ve tried everything. I’ve done everything right, and I still can’t sleep. And so the very first thing that I do with everyone that I work with is help them to understand the model of how we develop insomnia. Because if we can understand how sometimes what we do is maintaining that problem, it can make it a lot clearer how we need to change. And so would it be helpful if actually I just talk you through that model that we have?
Dr Louise Newson
Please do. Yeah.
Kathryn Pinkham
So the way that poor sleep develops is that for whatever reason, we have a bad night. So it can be something massive and obvious like a divorce or a bereavement or a really stressful time. It can be something very minor, cough and cold, but a noise outside, or you may not even know. For whatever reason, you just have a couple of nights where you can’t sleep. Very quickly, what we start is, we’re very intolerant of bad sleep. So very quickly, what we would start to do is make changes to try and improve our sleep.
So for example, if I had three nights of bad sleep, I’d certainly be thinking about it by that fourth day. And the first thing I would do is probably go to bed earlier. So I’d think I need to get some sleep back. But actually, the problem with going to bed earlier is that one of the things that controls our sleep is our sleep drive. So if you imagine an elastic band, when you wake up in the morning, we start stretching this elastic band, it gets tighter and tighter and tighter as the day goes on.
The ideal scenario being that this elastic bands is as tight as it can possibly be. We’ve built up a huge appetite for sleep, and we’re going to get into bed, fall asleep quickly, and get a nice quality. So the first thing that we do to try and make sleep better is go to bed earlier. Straight away, what’s happening is our drive is not high enough. So we’re in bed early. We’re more likely to be awake because our drive wasn’t quite high enough. So we’re lying in bed awake.
Then what happens is the more, if you imagine for the next week or so, we’re still not sleeping well. We’re now spending more and more time in bed and more and more time in bed awake. So now, our bed is being associated with wakefulness rather than sleep. And the chances of you being able to remain positive and upbeat during that time awake in bed is pretty slim. So actually, this time, we’re now in bed feeling stressed, frustrated, certainly anybody in menopause, hot and bothered, panicky, and we’re relating our bed to that feeling.
So this is how the cycle of poor sleep starts that we spend too long in bed. We go to bed too early. We perhaps get up too late. We’re very anxious. We’re very stressed. We’re very hyper-vigilant about sleep, and we’re connecting all of that to our bed. So in the end, it becomes sort of a Pavlov’s dogs style situation, where actually, your bed becomes a cue for anxiety.
So people get into bed. They say I was absolutely chilled out and relaxed on the sofa, could have fallen asleep. Second I got into bed, my mind started racing. And that’s because they’ve learnt that behaviour. They’ve learnt to associate their bed with that problem. So in a kind of really long-winded way, I guess what I’m saying about routine is it is important, but it needs to be the right one. If it’s a routine that involves all the wrong stuff that leads up to poor sleep, then actually, we’re just sort of cementing the problem over and over again, night after night.
Dr Louise Newson
That’s really interesting, isn’t it? So what would you suggest for those people then who are trying with their routine? And like you say, because it’s very common, isn’t it, that you think, oh, I’ve had such a bad night’s sleep. I’m going to go to sleep early or go to bed early. And then you just lie there feeling a failure. So what do you suggest or how do you help these people?
Kathryn Pinkham
So the first thing I would say, whether your problem is falling asleep or staying asleep, whatever it is, the first thing you need to do is increase that sleep drive. So that drive to sleep, that appetite needs to be much stronger. So what I would say is work out how much sleep you’re getting on average. So if you’re in bed for about eight or nine hours, but you’re only getting about six hours of sleep or five hours of sleep, create a window of time in bed which more closely matches how much sleep you can actually get.
So for example, if you’re going to bed at 10:00, you’re getting out at 6:00, but you’re only getting about six hours of sleep. Instead, go to bed at midnight. So go to bed later. Set your alarm nice and early. Spend as little time in bed as you can. And what will happen is your drive is much higher. The more time out of bed, the more fresh air daylight those kind of things that we can do. Stay out of bed. The more tired you are and this sort of genuine sleepy tired, higher that drive is. You’ll fall asleep quickly. You’ll get a better quality of sleep. Your alarm goes off.
However badly you sleep, you try and get up at that alarm. And you keep that cycle going. So what you’re doing is building up a momentum of sleep deprivation almost. But saying to your body clock, this is your only window of time where you can sleep. This is the only period I want you to sleep in. Rather than saying, here’s an eight-nine hour window. Pick and choose in that when you want to sleep.
Dr Louise Newson
That would fit in with what I’ve read about weekends not having a lie in. Because a lot of people think, well I’ll catch up at the weekend. But if you’re saying, I love your elastic band analogy, you’re not going to have so much time to stretch it if you don’t get up till later on a Saturday or Sunday morning, for example.
Audio 1 You Are Feeling Sleeeepy: Kathryn Pinkham and Dr Louise Newson
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Comment
Ironically, the focus on creating an environment conducive to sleep can start to make an issue of sleep and actually create anxiety around the activity. Going to bed can become a trigger for anxiety, making the problem worse. Spending time awake in bed is a real problem and may be helped by increasing sleep drive rather than sleep quantity. This is done by working out how much sleep you need and ensuring that you are tired and ready to sleep when you go to bed rather than creating a comfortable environment and hoping it will happen. A loss of sleep during the week cannot be effectively compensated for by having lie-ins at the weekend unfortunately.
If you have tried several interventions to improve sleep but to no avail it is worth speaking to a healthcare professional so they can consider more focused treatments. Sleep quality is so closely linked to mental health and during the menopause 95% of women said they had experienced changes to their mood and emotions since their perimenopause and menopause (Newson, 2023). The most commonly reported symptoms were stress and anxiety and you will go on now to consider stress.