The Art of Sleeping Well
Dr Curt Gray, psychiatrist, has written an article for Hearsay directed to the regrettably common issue of professionals – including barristers – suffering from sleep difficulty. Statistically, and anecdotally, the inability to sleep well is pervasive in the ranks of the bar. So much is a function, usually, of court or client deadlines, or expectations of superior advocacy, on the part of the barrister, the instructing solicitor and the court.
Helpfully Dr Gray takes us through the key issues and, importantly, potential solutions. For those bar members who wish to look further on this issue, the BAQ (private) CPD Library contains a recording of a presentation by Dr Gray, including a PowerPoint, on 22 March 2022. The Vice President Damien O’Brien QC chaired the presentation and gave insight by reference to his own experience with sleep deprivation. The editor attended the illuminating presentation and has slept better ever since, if only on account of better understanding of the issues.
It is sometimes said that sleep, diet, and exercise are the pillars of good health and well-being. Certainly, each has attracted its own comment within the popular press and the general population appears to have a thirst for information about these topics.
The American Academy of Sleep Medicine launched its “Sleep is Good Medicine” campaign in 2022, with a view to improving the sleep literacy of the general population. In trying to better understand sleep problems, Harvard Professor Charles Czeisler published an article that advised that sleep can be affected because of problems with duration, quality, or timing. This is a valuable perspective and a useful way to think about when we may experience sleep problems.
Whilst there are individual differences in sleep needs, it is generally accepted that adults require between seven and nine hours per night. It is not recommend that adults get less than six hours sleep per night, although this may be slightly modified (five hours) for adults older than 65 years.
The most important message is that sleep requirements cannot be sacrificed. The effects of doing so are manifest in almost all human physiological systems, and of course we are prone to be sleepy when sleep deprived, which is a risk for function at work and, for example, when driving. When sleep deprived we are more inclined to feel pain, to be hungry and gain weight, to experience negative mood states such as depression and irritability, to perceive situations negatively, and to struggle with solving complex problems. Clearly these are problematic for the busy time-poor legal professional.
Apart from sleep deprivation, there are a number of broad categories of sleep disorders. Hypersomnia (excessive sleepiness), parasomnias (abnormal events during sleep), and circadian rhythm disorders (sleep timing problems) may all be related to underlying problems and require evaluation. Anyone suffering these conditions should seek review from a GP, in the first instance, and perhaps even see a sleep physician for a more thorough assessment. This is, arguably, especially relevant in the case of hypersomnia, with common conditions or factors such as sleep apnoea and alcohol misuse prominent amongst the causative culprits.
The most common sleep disorder, however, is insomnia, which can be understood as difficulties getting off to sleep, maintaining sleep, or with respect to feeling refreshed upon waking, most of the time over a number of months. This may be associated with sleep deprivation and all its problems, but isn’t always. A negative and maladaptive response that associates the bed with wakefulness, not sleep, and frustration/worry become connected with the bed at bedtime. This can become a chronic pattern which perpetuates wakefulness in bed.
Insomnia can be associated with a range of health and psychosocial problems, and sequelae including absenteeism, decreased work productivity, alcohol and drug misuse, and mental health conditions such as depression. Some research indicates that a history of insomnia predisposes a sufferer to the later development of clinical depression, suggesting that insomnia is a harbinger of later mood problems. Recent research has also shown that treatment of the insomnia can be a preventative strategy regarding this link.
Clearly, an insomnia complaint is therefore not trivial, and whilst it is reasonable to seek help from a suitably qualified psychologist the presence of co-morbid depression may be best addressed, in the first instance, by a GP assessment.
Self-help strategies are of great benefit when it comes to sleep. Australia’s Sleep Health Foundation recommends a number of steps including keeping regular times for going to bed and getting up, relaxing for an hour before going to bed, avoiding going to bed on a full or empty stomach, minimizing sleep disrupting substances such as caffeine and alcohol (it may get you off to sleep but the subsequent sleep is of poor quality and not “deep”), keeping distracting things such as work and device screens out of the bedroom, keeping the bed and bedroom for sleep not entertainment purposes, getting some sunlight and exercise during the day, and avoiding napping. Clock–watching is also a bad habit because it merely increases alertness and anxiety about not getting enough sleep.
If these good habits are unhelpful it may be time to go further with formal engagement with a treatment provider as noted, but if not depressed or lacking the energy to do what you need to throughout the day consider some of the following strategies taken, in slightly modified form, from the American Academy of Sleep Medicine’s Brief Behavioural Treatment for Insomnia Provider Fact Sheet:
- Reduce time in bed to increase sleepiness. Stay up later and reduce total hours in bed. A typical starting point is limiting time in bed to just 6 hours per night. Once time to fall asleep is <30 minutes for 3-4 nights, time in bed can be extended by making bedtime gradually earlier.
- Set a fixed wake up time. Waking up at the same time (or earlier) and ideally exposing oneself to natural light is more important than having a fixed bedtime and helps reset the homeostatic sleep clock. Sleeping late or lingering in bed is deleterious to falling asleep well that night. Do not go to bed just because “it’s bedtime,” but rather when you are sleepy enough to fall asleep quickly, even if that means a short period of sleep that night.
- Reduce time spent awake in bed. Limit time in bed to sleep and intimate activity. Getting into bed for other purposes rehearses being awake in bed and sabotages sleep.
- Get out of bed if not asleep in 20 minutes and return to bed when you become sleepy.
A busy professional life can place enormous psychological pressure upon the practitioner, especially when one is inclined to set high standards for oneself and one’s performance. Sleep disturbance can readily develop and may be a “canary in the coal mine” regarding other underlying problems. Self-help strategies are of great value and there is also a lot of material available online for further assistance, but this is sometimes not enough. It is also critical that sleep and well-being is not sacrificed through self-denial. A robust mechanism to help you look after yourself is available through primary care services, so if the informal and self-help strategies don’t reap the well-being fruit you seek go see your GP.
Dr Curtis Gray – Bio
MB BS, FRANZCP, AFRACMA
Dr Curt Gray is an experienced adult psychiatrist with clinical interests in mood and anxiety disorders, trauma and stressor related disorders, the interplay between medical conditions/injuries and mental health, sleep disorders and their relationship to psychiatry, and medicolegal matters related to those areas. He is a foundation Accredited Member of the Faculties of Consultation-Liaison Psychiatry and Psychiatry of Old Age, and an Accredited Member of the Faculties of Psychotherapy and Adult Psychiatry, of the RANZCP. He holds appointments to the Mater Health Services Mater in Mind Consultation-Liaison Psychiatry Service, Mental Health Review Tribunal, and the Queensland QComp Medical Assessment Tribunal (MAT) where he is a Deputy Chair. He has served as Assisting Psychiatrist to the Mental Health Court of Queensland. He has been a Senior Staff Specialist in the Departments of Psychiatry at Brisbane’s Prince Charles Hospital, where he was the A/Clinical Director for 12 months, and the Gold Coast Hospital. Additionally, Dr Gray has served a 6 year term as a federal Examiner for the RANZCP Committee for Examinations. He is actively involved in civil medicolegal work at the request of solicitors, insurers, and other entities, where he takes pride in providing an independent, unbiased report that’s primary purpose is to assist a court (or decision maker). He is a member of the executive committee of the Medico-Legal Society of Queensland.