# Motivation and emotion/Book/2013/Sleep and emotion

* Multimedia presentation (5 min)
O sleep! O gentle sleep!
Nature’s soft nurse, how have I frighted thee,
That thou no more wilt weigh my eyelids down
And steep my senses in forgetfulness?
Why rather, sleep, liest thou in smoky cribs,
Upon uneasy pallets stretching thee,
And hush’d with buzzing night-flies to thy slumber,
Than in the perfum’d chambers of the great,
Under the canopies of costly state,
And lull’d with sound of sweetest melody?
- 2 Henry IV (3.1.7-16)

## Overview

On average, adults spend about a third of their lives asleep (Glaze, 2004), and as shown in Table 2, the average amount of sleep required can vary significantly depending upon age. It is well established that regular sleep is an essential function for both physiological and psychological well-being (Smaldone, Honig & Byrne, 2007, Haack & Mullington, 2005), and it's when this regularity is disrupted that our physical and psychological health can be compromised.
According to the Diagnostic and Statistical Manual IV-TR, a disrupted sleep is one where it takes more than 30 minutes to fall asleep ("sleep initiation"), you regularly wake up during the night, or 30 minutes early ("sleep maintenance"), or upon awakening, you do not feel well rested ("non-restorative sleep") (American Psychiatric Association, 2000). This sleep disruption, often referred to as insomnia, can lead to significant difficulties in a person's daily life.
* Primary Insomnia
* The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month. (American Psychiatric Association, 2000)
Why does that matter?
A report by Deloitte Access Economics (2011) suggested a conservative estimate of 492,000 Australians who suffer from primary insomnia. Their costing of the economic impact of this for the country indicated approximately $10.9 Billion in health system, indirect (accidents, productivity, etc.) and human costs. The substantial costs associated with insomnia clearly illustrate a need to provide timely, effective and accessible treatment options to the affected population.
Research by Strine & Chapman (2005) further supports Deloitte's (2011) findings. Survey data from 79,625 respondents in the US phone-based study indicated that up to 25% of people have less than optimal amounts of sleep for 50% or more of the time. This research supported the findings of previous studies in that insufficient sleep is associated with poor health, psychiatric conditions, and social disability (Strine & Chapman, 2005). Though disturbing, these problems are not limited to the adult population.
In a Queensland survey of 3269 parents of "normal" 0-3 year olds, Armstrong, Quinn, & Dadds (2004) found that almost 30% reported that they had a problem with their child's sleep behaviour. Though this seemingly high percentage could indicate that there is a large potential for sleeping problems at this age, the subjective nature of the survey might also suggest that many parents need guidance on understanding what constitutes normal sleeping patterns.
Another study of adolescents and young adults (aged 12-20 years) estimated that insomnia symptoms could be found in 10-30% of the 107 respondents (Saarenpää-Heikkilä, Laippala, & Koivikko, 2000). This further indicates that the issues of insomnia are not limited to one particular group, and given the established impact that poor sleep can have, it is essential to further investigate how we can improve our sleep.
So where do emotions come in?
Consider the following:
| Case 1. Julia is a six year old girl who, two or three nights a week, awakens suddenly after about an hour with terrified screams. Her parents question her as to whether she has been dreaming, but she tells them she has no memory of it. It takes her some time to get back to sleep after these episodes. | Case 2. Max is an eleven year old boy who goes to bed at 9pm but can't seem to get to sleep until 1am. He is afraid to sleep in the dark, and so his parents leave a light on for him. At school he has difficulty paying attention and concentrating on his school work, and he is known to have a short temper and has conduct problems. He also takes methylphenidate each morning for his ADHD. |
(Adapted from Glaze, 2004)
Neither case appears to be uncommon, yet both suggest that there could be an emotional component at play within the apparent sleeping difficulties that warrants further investigation. They also demonstrate the wider effect that sleep difficulties can have, not just on those with the problem but for those supporting them and the wider community.
It therefore not the intent of this chapter to provide a how-to guide for falling asleep, but rather to establish an informative resource on bringing those emotional factors that may be affecting the sleep of you or your loved ones, back into balance.
With this in mind, here are some of the important questions we need to ask and answer regarding our sleeping habits:
* What are the emotional factors that affect sleep?
* What are the implications of an affected sleep?
* What control do we have over these factors?

## What are the emotional factors that affect sleep?

There are a number of conceptual models of emotion, each of which contain factors that will generally fit into two categories: Positive and Negative Affect. One popular model described by Izard (1971), identifies 10 basic emotions of anger, disgust, distress, contempt, fear, guilt, interest, joy, shyness & surprise. Factors generally classed as positive would be joy and interest, whereas negative factors would include the emotions of anger and disgust. Emotions such as surprise or shyness could fit into either category depending on the situation. A summary of these categories can be found in Table 1.
Table 1 Emotions and their affective category
| Positive Affect | Negative Affect | Positive or Negative |
| Joy Interest | Anger Disgust Distress Contempt Fear Guilt | Surprise Shyness |

### Positive emotions

Research into the impact of positive affective emotions upon sleep is somewhat limited, as studies have generally focussed on pathological factors associated with negative affect. Steptoe, O'Donnell, Marmot, Wardle (2008), however, examined the bi-directional impact of positive moods on sleep in older adults with encouraging results. The study looked at 736 men and women, aged 58–72 years and asked them to self report on their mood at different times during the day. The results of their research identified that both eudaimonic well being and positive affect were associated with a good quality sleep.
Eudaimonic well-being - A state of purposeful engagement with life, realization of human potential and self-actualization (Steptoe, O'Donnell, Marmot, & Wardle, 2008)
More recently, a meta-study by Baglionia, Spiegelhaldera, Lombardob, Riemanna (2010) examined three studies which each looked at the effect of sleep on positive & negative affective states. Each of the studies found similar results - those who slept better showed an overall higher score for positive mood; those with sleeping difficulties scored poorly (2010). One interesting aspect to the findings was that good sleepers presented an increase of positive emotions when measured in the morning and the evening, however those who slept poorly showed a roughly stable pattern at both times (2010). These studies provide further evidence that a good quality sleep can improve the emotional state throughout the day.

### Negative emotions

On the subject of negative affective emotions, there is strong evidence to link these with poor quality sleep.
There is evidence to indicate that stress may be one of the more common precipitants of insomnia. Stress is a construct which can be multi-dimensional, and involves one or more of the negative emotional affective factors. A study by Healy et al. (1981) identified that 74% of poor sleepers recalled specific stressful events in their life during the year when their insomnia began. Among the major life stressors, the emotionally based factors of personal loss (i.e. grief) rated highly (1981). The significant percentage of poor sleep relating to negative emotions suggests that the emotional contribution to sleep disorders needs to be carefully considered.
Another study by Vollrath, Wicki & Angst (1989) identified negative emotional factors related to interpersonal relationship issues, diminished coping skills & low self-esteem being more common amongst participants suffering from insomnia. This study was particularly useful as it was performed longitudinally over the course of 7 years. In addition to highlighting the negative emotional contribution to insomnia, it also illustrated that sleep disruption may have a high likelihood of recurrence in the affected population.

### Sleep Quiz: Is your sleep affected?

Have you had trouble with your sleep in the last month? Take the quiz!
Did you score 1 or more in the quiz? If you have experienced these symptoms three times a week for a month or more you may fit the DSM-IV-TR criteria for primary insomnia. It would be advisable to consult a healthcare professional if this is the case!

## What are the implications of an affected sleep?

There have been a volume of studies on the implications of not having a sufficient amount of sleep.
In terms of health, several studies have shown significant health costs for those lacking in sleep. A study by Kripke et al (2002) showed a 100% increase in mortality for those who average less than six hours' sleep per night. Ayas et al (2003) also demonstrated that the risk of developing cardiovascular disease is increased by 1.8 times for those who average less than five hours' sleep per night.
In terms of emotions, research by Kruegar & Friedman (2009) had an interesting finding, in that those who sleep 8 hours have 12-35% increased risk of death compared with those who sleep 7 hours. To relate this to emotional health, it is hypothesised that the increase in mortality for those sleeping longer relates to the generally longer time spent attempting to sleep and poorer overall quality sleep by those suffering from insomnia. The study also found that among physiological and social factors, more emotional based aspects such as anxiety & depression had a strong association with poor quality sleep.
* A classic study on sleep disruption
* Have you ever had your sleep temporarily disrupted by external noise? The effects of even a small interruption can be profound, as Bonnet (1985) discovered. In a classic sleep-disruption study, participants were invited into a sleep lab for 5 days. Their baseline scores for mood, arithmetic & reaction times were taken on the first day, and then on consecutive days (1985). Over the course of the study, participants were temporarily awoken one minute after falling asleep, and then on the hour to perform simple cognitive operations. The results indicated not only that their scores for reaction time and arithmetic were dramatically impacted, but their mood scores for unhappiness and clear thinking were also significantly reduced (1985). Though the sample size was small (N=11), the significant findings suggest that disruption to sleep can have a profound impact upon psychological health.

### How much sleep do we need?

Table 2
The amount of sleep required by different age groups
| Age | Hours sleep required |
| 0-3 Months (Newborns) | 16-20 Hours |
| 4-11 Months (Infants) | 14-16 Hours |
| 1-2 Years (Toddlers) | 13-16 Hours |
| 3-5 Years (Preschoolers) | 11-13 Hours |
| 6-12 Years (School-aged Children) | 10-11 Hours |
| 10-18 Years (Adolescents) | 8.5-9.25 Hours |
| 18+ Years (Adults) | 7-9 Hours |
| Note. Adapted from Childhood insomnia: why Chris can't sleep. by D. G. Glaze, 2004, Pediatric Clinics of North America, 51(1), 33-50. ||

## What control do we have over the emotions affecting our sleep?

Though this section primarily deals with self-help treatments to improve sleep quality, two commonly used intervention treatments are worth mentioning. These are cognitive behavioural therapy, and pharmacological intervention.
Cognitive Behavioural Therapy (CBT)
Cognitive Behavioural Therapy refers to a combination of various evidence-based behavioural techniques and deliberate changes to cognitive processes (Sharma & Andrade, 2012). It generally encompasses many of the below self-help approaches, such as stimulus control, sleep hygiene, sleep restriction & relaxation training, as well as cognitive therapy (2012). The form taken is generally adapted by a trained therapist to suit the circumstances of the individual, and is currently considered to be the treatment of choice when it comes to non-pharmacological intervention (Edinger & Means, 2005). Research by Edinger & Means (2005) compared the efficacy of CBT with singular forms of intervention such as relaxation or placebo therapy, and demonstrated that CBT had a significantly higher overall improvement as self reported by participants.
Pharmacological Intervention
Pharmacological intervention, also known as hypnotic or soporific intervention, involves the administration of sedative medication in order to reduce the time taken to fall asleep, and increase the likelihood of maintaining the sleep without awakening (Lahmeyer, Wilcox, Kann, & Leppik, 1997). An example of the efficacy of sleep-inducing medication can be found in a study by Lahmeyer, Wilcox, Kann & Leppik (1997). In the double blind study, researchers were able to show that medication proved immediately effective in reducing time taken to initiate sleep, and overall total sleep time when compared with the placebo group (1997). There were however some significant drawbacks in the medicated groups, including prolonged drowsiness, lethargy and dizziness in the hours following awakening, suggesting caution may be advisable due to the potent nature of the intervention.
CBT versus Pharmacological Intervention
A review of the available literature has shown that both forms of treatment are efficacious in alleviating symptoms of insomnia (Smith et al., 2002). Each has been shown to have benefits and associated costs. Appealing factors for pharmacological intervention are its relative low cost, availability, ease of use, and relatively instant results. However, major drawbacks such as drug dependency, tolerance, and withdrawal must be carefully considered prior to using pharmacology as a solution to insomnia (2002). CBT has been shown to have equally effective results to pharmacological intervention without the previously mentioned side-effects (2002). However, there are some major factor which may prove prohibitive for CBT to be used as the treatment of choice in medical intervention. Firstly, the standard course of CBT treatment generally runs for five weeks (2002), which proves costly when compared with medication. Secondly, there is often a latency period when commencing CBT treatment meaning that results are not always immediate, as would be expected with medication. Ultimately, if the need is a short term, acute result, medication may prove effective. However in the longer term, CBT would generally be more advisable due to the lower rate of side effects and better long-term outcomes.

### Sleep Treatment Table

The following table presents a list of potential self-help treatment options for insomnia, and scores them based upon the available evidence of their efficacy when treating emotionally-based sleeping issues.
Table 3
Treatment options for insomnia
| Treatment Type | Effect Size* |
| Progressive Muscle Relaxation | .81 |
| Stimulus Control Therapy | 1.16 |
| Sleep Restriction Therapy | .85 |
| Note. Adapted from Identifying effective psychological treatments for insomnia: a meta-analysis. by Murtagh & Greenwood, 1995, Journal of consulting and clinical psychology, 63(1), 79. *Cohen's d effect sizes: .2 Small; .5 Moderate; .8 Large. ||

### Progressive Muscle Relaxation

Progressive muscle relaxation, as the name suggests, is a form of therapy where the subject tenses and releases specific muscle groups in a systematic manner (McCallie, Blum, Hood, 2006). It is theorised that the combination of gently tiring the muscles and providing a single task on which the subject is able to concentrate, provides an effective manner with which to initiate the sleep process (2006). Progressive muscle relaxation is a therapy for which there is abundant evidence of its effectiveness in treating insomnia (Barrows & Jacobs, 2002). A literature review by the American academy of sleep medicine concluded that progressive muscle relaxation was one of three non-pharmacological treatments empirically supported as a treatment for chronic insomnia (morin, hauri & espie, 1999).
For an example script, See external links.

### Stimulus Control Therapy

* The power of power naps
* Research has shown that short naps can have a positive effect on one's mood. In a study by Kaida, Takahashi, & Otsuka, (2007), two groups of participants self rated their mood before and after a 30-minute nap or in a natural bright light condition. In both conditions participants reported an improvement in positive mood, which had three aspects of pleasantness, relaxation and satisfaction. Interestingly, the natural bright light condition improved only the pleasantness rating, whereas the short nap improved ratings on all three scales. Be wary of oversleeping though - there is evidence to suggest that longer or irregular naps can reduce affective states (Kaida, Ogawa, Matsuura, Takahashi, Hori, 2006).
Stimulus control therapy is based upon the theory that bad habits such as being in bed when not tired, and performing non-sleep related activities in bed perpetuate insomnia (Sharma & Andrade, 2012). It is closely related to sleep hygiene, which is the term term used to describe a set of behaviours, changes to the environment, or other sleep-related factors that can be adjusted to assist with achieving an maintaining sleep (Stepanski & Wyatt 2003). Research by Riedel et al. (1998) has shown stimulus control therapy to be a highly effective single treatment, and is recommended as a standard for treatment of chronic insomnia (Sharma & Andrade, 2012).
* Tips for improving your sleep hygiene
* Sleep only as much as you need to feel refreshed the next day
* Establish a set, regular routine of sleeping and waking
* -Explore bedtime rituals such as a hot bath or soothing music.
* Ensure the room is sleep conducive (temperature, darkened, comfortable)
* Use your bedroom only for sleep and sex
* Exercise regularly
* - Exercising during the late afternoon or early evening may assist further
* Remove the influences of external noise where possible
* Have a light snack prior to bed if hunger disturbs your sleep (no large meals)
* Try to avoid the use of hypnotics long term (sleeping pills)
* Avoid caffeine, nicotine and alcohol
* Don't try to force yourself to sleep
* Consider having a nap during the day
* Adapted from Stepanski & Wyatt (2003).
How good is your sleep hygiene? Find the test in See external links.

### Sleep Restriction Therapy

Sleep restriction is a behavioural technique which involves a systemic, controlled, sleep deprivation in order to identify the ideal sleep requirements of the subject (Spielman, Saskin, & Thorpy, 1987). The process begins by calculating how much time the subject spends sleeping versus the total time spent in bed. The difference is known as the subject's "sleep window", and becomes the maximum amount of time they are allowed to sleep in bed, with the aim to attain a rate of 85% of time spent sleeping whilst in bed (Sharma & Andrade, 2012). To further assist with normalising the subject's sleeping patterns, the procedure requires a consistent bedtime and wake time, with the aim of re-training normal circadian rhythms.
A study by Friedman, Bliwise, Yesavage & Salom (1991) showed the efficacy of this form of treatment in elderly subjects. Two groups were given treatments of Sleep Restriction Therapy (N=10) and Relaxation therapy (N=12), and were asked to report on their sleep efficacy twice daily for six weeks to monitor their progress. Whilst both groups showed significant improvement in their follow-ups, improvement in the sleep restriction therapy group was approximately twice that of the relaxation therapy group. The results suggest that Sleep Restriction Therapy has the potential to be a useful and cost effective method of insomnia treatment.
For a sleep restriction guide, See external links.

## Summary

Sleep is recognised as an essential function for physical and psychological well being, and when reviewing the research, it becomes clear that the emotional aspect of this is a very important factor.
This chapter has provided an overview of the facets of emotion that have an effect on sleep, the potential implications when sleep is affected, and finally, offered some practical guidance on how to improve the quality of your sleep.
Some helpful practices you can adopt to improve the quality of your life through a better nights sleep are:
* Seek help from a qualified mental health professional
* Improve your Sleep Hygiene
* Investigate muscle relaxation and sleep restriction as low-cost options
Poor quality sleep can prove extremely detrimental to your health, but with the right tools and guidance, the secret to a good night's sleep can be yours!