Managing Sleep Problems

Sleep difficulties can be common following brain injury. The following blog offers some self-help tips for this area.

Establish a regular waking time

Establishing a regular sleep–wake pattern is very important, especially waking up at the same time each morning. The time that you wake helps to set (or synchronise) all of your body’s circadian rhythms. In fact, you should try not to vary the time of day that you get up by more than one hour, even across the weekends. In particular, avoid laying in bed until 12 noon on the weekend if you get up at 6 o’clock each weekday morning for work.

Establish a proper sleep environment

1. Comfort

The discomfort caused by a rumbling stomach, persistent aches and pains, or being too hot or cold, can prevent you from relaxing enough to fall asleep. Therefore, it is necessary that all your immediate needs have been met before you try to sleep. If you are hungry, have a light snack or a warm milk drink (caffeine-free) before you go to bed. If you are in pain, take a mild pain reliever. It is much easier to sleep if you are comfortable.

2. Noise

Noise during the night (such as traffic) is another common source of sleep disturbance. Even if you do not awaken and cannot remember the noises the next day, the noises can interfere with your normal sleep pattern. If you sleep in a place that tends to be noisy, try to shut out sound by closing windows and doors, wearing earplugs, or sound-proofing the room. Even if you think that you cannot fall sleep without a radio or television in the background, remember that this noise will disrupt your sleep during the night. A clock radio that will automatically turn itself off may be useful.

3. Light

A light room will make it more difficult for you to sleep. Therefore, if you have trouble sleeping, it will be helpful to darken the room before going to bed and to ensure that the morning light does not wake you up in the morning. If you have a tendency to oversleep, it may be helpful to allow the light to enter the bedroom in the morning.

Allow a wind-down time before sleep

Make sure that you stop work at least 30 minutes before you go to bed and do something different and non-stressful, such as reading, watching television, or listening to music.

Use your bed only for sleep

Your bedroom should only be used for sleep, and of course sexual activity (which may help you to sleep). Activities such as eating, working, watching television, reading, drinking, arguing, or discussing the days problems should be done elsewhere, because their associated arousal may interfere with you getting to sleep. These activities also make you associate your bed with wakefulness and alertness rather than drowsiness and sleep onset. It may be useful to remove all objects in your bedroom that are not associated with sleep.

Do not stay in bed when you are not asleep

If you have been having problems falling asleep, only go to bed when you are sleepy. If you do not fall asleep in about 10 minutes, get up and go to another room. Stay up until sleepy and only then return to your bed to sleep. If you return to bed and still cannot sleep, repeat the preceding instruction. Do this as often as is necessary to fall asleep in 10 minutes.

Coping with worry and anxiety

One of the most common causes of sleep disturbance is anxiety. Many people find it difficult to wind down when they climb into bed at night after a hectic day. Often this is the first chance they have had to think about things that are concerning them. People can find themselves lying in bed worrying about their problems when they would really rather be asleep. The feelings of tension and arousal that accompany these thoughts make it more difficult to fall asleep; therefore, these individuals also begin to worry about their sleeplessness as well as their other problems. They may end up tossing and turning well into the night. If you think you are having trouble sleeping because you are anxious about things that are happening in your life, there are two things you can do to improve your sleep.

1. Set aside time for problem solving during the day

Bed is not the place for thinking about things that distress you. If you do not normally find time during the day for thinking about things that are happening in your life then you need to set aside a time each day to do so. It should be a time when you are alone. Try to think of ways to resolve your problems. Usually this will require you to make decisions, some of which may be difficult because they concern important features of your life such as family and work. However, putting off stressful decisions only extends your feelings of anxiety. In most cases, the uncertainty that accompanies difficult decisions is much more stressful and unpleasant than living with the outcome of the decision once the decision is made. Talk to your health worker if you would like more information about useful problem solving techniques.

 

2. Learn to relax

Learning ways to relax can help sleep problems. There are many relaxation techniques. Here, we will give you a breathing relaxation technique from which you will benefit:

 

  • Breathe in slowly to the count of three seconds.
  • When you get to three, slowly breathe out to the count of three seconds.
  • Pause for three seconds before breathing in again
  • After five minutes or so, say the word ‘relax’ to yourself as you breathe out
  • Breathe in using your abdomen (not your chest) and through your nose
  • Practise five to ten minutes at night in a comfortable chair
  • Keep in mind that the benefits of relaxation will not occur unless you practise
  • Do not try hard to relax or to sleep; just carry out the exercise.

3. Get out of bed

If you find yourself unable to stop worrying about things when you are in bed, get up and do something that is distracting yet relaxing, like knitting, listening to music, or reading a book. You may even want to listen to a relaxation tape. Do not return to bed until you feel sleepy again. When you do go back to bed, if you find that you are still worried and sleepless, get out of bed again and do something relaxing (as above) until you are sleepy enough to return to bed once more. At first, you may find you need to get out of bed a number of times before you are finally able to fall asleep. The important thing is that you will learn to associate your bed with sleep and not with worry.

Avoid napping during the day

It is not uncommon for people who have had a particularly bad night’s sleep to feel sleepy the next day. This daytime sleepiness can make it very tempting for you to take a nap in the middle of the day or early afternoon. However, if you have insomnia and nap in the afternoon, you make it much more likely that you will have another night of poor sleep. This is because when it comes to time for bed you will be less tired and will need less sleep because you have slept during the day. You will probably take longer to fall asleep and you will awaken more frequently during the night. The next day you are likely to feel sleepy again and will be tempted to have another daytime nap.

As you can see, this pattern of napping soon becomes a vicious cycle that makes your original sleeping problem even worse. If you have insomnia, no matter how tired you are during the day, try to avoid daytime naps (unless you are doing shift work). Stick to regular sleep times by going to bed at the same time every night and waking up at the same time every morning. If you cannot get to sleep until later than your normal sleep time, do not sleep late the next morning — get up at your normal waking time. By following these instructions, you will help to ensure that your natural body rhythm works with you, helping you to sleep at the times you want to sleep.

Avoid caffeine

This drug is found in coffee, tea, cocoa, cola drinks, as well as some over the counter medications. Consuming caffeine before bedtime, or drinking too much caffeine during the day will increase feelings of energy and wakefulness and make it more difficult for you to fall asleep. Any caffeine consumed after about 4 pm will still have an effect by the time you go to bed.

 

Sometimes individuals get into a pattern of drinking too much caffeine during the day, sleeping badly at night time, and then consuming even larger quantities of caffeine the following day to help ward off sleepiness. Such behaviour sets up a vicious cycle, which is to be avoided wherever possible. Some helpful suggestions about caffeine are provided below:

  • limit caffeine intake
  • avoid drinking caffeine after about 4pm
  • avoid using caffeine as a means of staying awake.

Avoid nicotine

Nicotine stimulates the nervous system by releasing a hormone called ‘adrenaline’. Adrenaline acts to arouse the body and mind, making you alert and ready for action. Your body normally releases small doses of adrenaline throughout the day and large doses when you are faced with something challenging or threatening. Therefore, smoking prior to bedtime causes adrenaline to be released, thereby increasing energy and liveliness at the very time when you want to be relaxed and ready for sleep. If you are a smoker and you normally have trouble getting to sleep at night, it is best that you do not smoke for at least an hour before going to bed (preferably an hour and a half), since this is the length of time it takes for the stimulating effects of nicotine to wear off. Furthermore, if you wake up during the night and cannot go back to sleep, try not to smoke because the nicotine will make the sleeplessness worse.

Avoid excessive alcohol

A popular belief about alcohol is that alcohol will help you sleep if you are uptight and anxious. One or two glasses of wine or beer in the evening may help you to relax, but regularly having several drinks in the evening causes you to get much poorer sleep overall. As the alcohol in your system is broken down by your body, you tend to awaken more frequently and you spend less time in the deeper stages of sleep. If you drink regularly, you may find that you come to depend on the alcohol to reduce your anxiety and help you get to sleep. Not only will alcohol leave you feeling unrefreshed the next morning (because you are robbed of better quality sleep), but you are likely to have rebound anxiety which will last throughout the day and make it even more difficult to sleep at night. Alcohol is not the solution to sleeping problems so do not drink before you go to bed.

Avoid sleeping pills

The use of sleeping pills (sedative hypnotics) for any length of time causes as many problems as it solves. While sedative hypnotics will help you fall asleep and will decrease your anxiety in the short term, these benefits will disappear in the long term if you continue to use the sedatives regularly. That is, you will begin to feel anxious and sleepless even though you are taking the pills. When this happens you will be tempted to take more sleeping pills since doing so will bring back the benefits of the drug. Unfortunately, however, these benefits will not be permanent either so that after a time you again experience the unwanted symptoms of anxiety and sleeplessness. The process that makes you less sensitive to the benefits of the drug over time is called tolerance. While sleeping pills are useful for overcoming temporary sleep loss, the development of tolerance means that these drugs do not provide a long-term solution to sleeping problems.

Continual use of sleeping pills also has the disadvantage that you will find it extremely difficult to give up the drugs because doing so will cause you to experience withdrawal effects. The levels of anxiety and sleeplessness that you experience after stopping the drug are likely to be greater than the anxiety and sleeplessness that made you start using the drug. Coming off sleeping pills can also cause you to have vivid dreams and nightmares. These dreams are often highly emotional and disturbing.

If you do not use sleeping pills, or use them only occasionally, take heed of these warnings and do not start using them regularly. If you do use sleeping pills every night to help you sleep, it is recommended that you talk to your family doctor about reducing your intake of sleeping pills over time until you can stop using the pills altogether. Your doctor can help you come off the sleeping pills slowly without causing too many unpleasant side effects. Do not stop taking your sleeping pills without first talking to your doctor.

Take a late snack

A light bedtime snack, such as a warm glass of milk or a banana, will help some people get to sleep. These foods are high in an amino acid called tryptophan, which is thought to be involved in the biochemical systems that induce and maintain sleep. If nothing else, the snack will prevent you from getting hungry during the night.

Don’t exercise before going to bed

Avoid exercise in the three hours before you go to bed, otherwise you may still be too aroused following the exercise to be able to fall asleep.

Coping with crying babies

Young babies need frequent feeding and nappy-changing, therefore they tend to wake up often during the night. Moreover, a baby’s sleep cycle is much shorter than an adult’s sleep cycle. A baby usually has a 50-minute sleep cycle and tends to have about two to four cycles per sleep period. Therefore, babies tend to awaken much more frequently than adults who have a 90 minute sleep cycle and experience about 5 to 6 cycles per sleep period.

If you have a young baby to look after, there are a number of things that may help to reduce the extent of the baby’s crying. When a baby cries during the night, he/she usually wants food, or to be comforted. Trying to discipline a young baby by yelling at or ignoring a baby does not usually work. Many parents find it better to give the baby plenty of cuddles and kisses so that the baby quietens down and goes back to sleep feeling safe and secure. Moreover, it may help if you alter the baby’s feeding time so that the baby is fed immediately before you go to bed rather than, say, two hours later. This way, you may not have to get up as often during the night. These suggestions do not always work, but take heart — babies do grow up and one day they will actually sleep undisturbed all night long!

Summary of good sleep habits

1.   Go to bed when you are sleepy and get up at the same time every morning. Do not sleep late in the mornings trying to make up for ‘lost sleep’ and, if you think you have insomnia, do not take naps during the day.

2.   Set aside time for problem solving during the day, not last thing at night. Identify any problems that are causing you to be anxious and try to resolve these problems by making decisions.

3.   Do not lie in bed worrying for long periods of time. If you cannot sleep, get out of bed and do something that is distracting yet relaxing, such as knitting or listening to music. (It will be important to plan appropriate activities in advance.) Return to bed only when you feel sleepy again.

4.   Do not use alcohol to help you sleep.

5.   If you experience insomnia, avoid drinking caffeinated drinks after about 4 pm and do not drink more than two cups of caffeinated drinks each day.

6.   Do not smoke for at least an hour (preferably an hour and a half) before going to bed.

7.   Avoid sleeping pills: they do not provide a long-term solution to sleeping problems.

8.   If you sleep in a noisy place, try to reduce noise levels by closing windows and doors and wearing ear-plugs.

9.   Ensure the room is dark and that the morning light does not filter in. If you have a tendency to oversleep, it may be helpful to let the morning light enter the bedroom.

10.  Getting to sleep when you are comfortable is much easier than getting to sleep when you are hungry, cold, in some kind of physical pain, or when you need to go to the toilet. Make sure all your immediate needs have been met before you go to bed.

11.  Regular exercise during the day or early evening can improve sleeping patterns. Try to avoid exercise late in the evening as this may make it more difficult for you to get to sleep (with the exception of sex, which may help you to sleep).

12.  By doing the same thing every night before you go to bed you can improve your chances of falling asleep quickly. It is a good idea to develop a short routine involving things like washing your face and cleaning your teeth, which you can easily perform before going to bed at night. A hot bath for 20 minutes may also be helpful.

13.  Be aware of things in the environment that may interfere with your sleep. For example, pets can disturb your sleep if they become active during the night or if they prevent you from moving freely in the bed. Moreover, digital clocks can be distracting if they glow or flash. It is often helpful to face the clock in the opposite direction.

 

 

Johnston & Mackenzie LLP

“We required a very specific report, as we needed to show that a particular brain injury fell within the specific terms of an insurance policy.  Dr Morrison and Alba Psychology fully understood the brief and produced an excellent report, on budget, which answered the precise question fully, and led to a successful outcome for our client.”

Wright, Johnston & Mackenzie LLP

Assessment of Capacity using Neuropsychological Measures

Given the prevalence of cognitive deficits within brain injury the range of deficits an individual can experience has an important influence on their ability to make decisions in relation to daily activity. For example, an individual experiencing executive dysfunction may experience problems with abstract thinking and emotional regulation, which has clear implications for limited ability to engage in complex decision making such as personal care or financial management.

Cognitive impairment may have an impact on the individual’s awareness and understanding of their current circumstances. Furthermore this may have an impact on ability to understand and engage with therapeutic interventions.

A range of legislation exists in the UK that can be used to manage difficulties arising from cognitive impairment. Given the geographical anomalies within the law systems of the UK separate legislation exists in England and Wales, and Scotland:

The Mental Capacity Act (England and Wales)

Adults with Incapacity (Scotland) Act 2000

Adult Support and Protection (Scotland) Act 2007

A range of guidance is available for each of the aforementioned acts which is summarised here in terms of assessment. It is suggested the following areas are considered within assessment based around the Adults with Incapacity (Scotland) Act 2000; Perception, understanding, logical thinking, memory, motivation, planning, reasoning, suggestibility, emotional disorder, thought disorder and communication problems. All of these are included in a comprehensive neuropsychological assessment. Further to this the following points are:

  • Make sure the capacity question is specific
  • Consider evidence of impaired judgement prior to admission
  • Use vignettes to support exploration of the particular decision to be made

If you have a client that requires a capacity assessment please contact Alba Psychology.

Managing negative thinking in depression

Depression and Thoughts

One of the effects of depression is to change the way you think. When people are depressed, they tend to think the worst about everything. This way of thinking adds to the depression, and makes you feel even worse. Like inactivity, thinking in a negative way actually becomes part of the problem.

Psychologists have identified a set of ‘errors’ people make in the way they think when they are depressed. Thinking becomes distorted, and acts to keep the depression going. Look at these examples and see if you recognise yourself.

  • You think about things in black and white terms. Things are either good or bad with nothing in between. If you try to do something, and part of it is not as good as usual, you tend to write it all off as ‘hopeless’ or ‘useless’ instead of saying it was somewhere in the middle
  • You ignore the positive aspects of an experience and concentrate on what you feel worst about
  • Mindreading – you think that you know what people are thinking, e.g. “She must think I’m a rotten person”. You then act on this, perhaps by avoiding seeing the person again
  • If something goes wrong once, you assume that it will always be as bad as this in the future
  • You use the word ‘should’ a lot. You say things like ‘I should have been able to do that’ or ‘I should have known that he wouldn’t enjoy that’. This makes it seem as if you are failing all the time
  • Whenever anything goes wrong, you assume that it is your fault. If something goes well, you put it down to luck or think it is just a fluke

How to change your thinking

When you feel especially bad, try asking yourself if your way of thinking is making the problem worse. Remember that depression makes you think the worst, and things may not be as bad as they seem.

Try writing down what you have been thinking when you feel especially bad. This may seem difficult at first, but is a good way of getting things into perspective. You do not have to show what you write to anyone else if you do not want to.

When you have an idea of what you are thinking, try asking yourself these questions:

  • Do I have any actual evidence for what I am thinking or is there evidence I might be mistaken?
  • Could there be another way of thinking about this? What would someone who is not depressed think?
  • If a friend was thinking this way, what would I say to them?

Have a look at the examples of distorted thinking above, and see if you can recognise yourself in them.

If you can, write down some answers to these questions. Read over what you have written when you feel a bit better – were things as bad as you thought?

Trying to change the way you think is difficult at first, but if you can persevere, it will become easier.

Medication

Your doctor may have given you tablets to help with the depression. It is important that you follow the instructions carefully. It is possible to follow the advice given in this leaflet for tackling depression and take medication. Doing both will help you to recover more quickly.

Please contact Alba Psychology to discuss meeting with a Chartered Psychologist to offer treatment based on the principles above

Managing Depression

At Alba Psychology we regularly meet individuals who have difficulties with low mood or depression following a brain injury. People with depression or a related problem often feel as though they are the only person in the world suffering like this.  This in itself can be very distressing.  In fact, depression is very common and it can affect anyone.

Feeling fed up and a bit down is a normal part of life.  If something upsetting has happened to you then it is not unusual to feel this way and to not enjoy what is happening in your life.

Sometimes, a person’s mood may seem to drop for little or no obvious reason.  In some cases, low mood can worsen and begin to dominate someone’s life completely.  When someone feels very low for more than two weeks and feels like this day after day, week after week, this is called a depressive illness.  It affects the person’s mood and their thinking.  Their behaviour may start to change and they may experience a range of physical symptoms in their body.  Practical problems may start to build up in that person’s life.

Psychological Techniques

There are various ways of tackling your depression using psychological methods. The first step is to think about your activities and routine.

Activity

When people are depressed, they usually do less. Activities seem less enjoyable and take more effort. Sometimes people worry that if they do something they will make a mistake or do it badly. Unfortunately the less you do, the less you feel like doing. When you are not doing things you used to enjoy, you miss out on the pleasure they gave you. Also, doing less can make you feel less confident about things you used to be able to do without a second thought. Worries about being incapable of doing things creep in. This is likely to make you feel worse. There is now a vicious circle.

Breaking the vicious circle

Part of overcoming your depression is breaking this cycle of inactivity. This means gradually getting back to doing things you used to. At first this will seem very difficult, and you may predict that you will fail. If you find yourself thinking in this way, tell yourself that you can change your habits, but it will take time.

Becoming more active

The key to changing habits of inactivity is to work gradually You may have been less active for quite a while, so it is unrealistic to expect this to change overnight.

Set yourself daily targets for activity. At first you could try to do something for 10 minutes in the morning and 10 minutes in the afternoon.

Choose an activity that used to give you a sense of enjoyment or achievement, but don’t worry if you don’t find it enjoyable to begin with.

If you do manage some activity – congratulate yourself. Keep up the habit! Doing something is better than doing nothing.

Once you become more used to more activity, you can gradually increase the amount you are doing. Notice that being more active makes you feel more motivated to do things.

If you find your targets too difficult, think about what is holding you back.

Perhaps negative thoughts have crept in. You may have tried to do too much. Set yourself an easier target and try again.

Next week – how to manage negative thoughts in depression

Please do not hesitate to contact Alba Psychology if you feel you would like to discuss your own difficulties with low mood.

Alcohol Related Brain Damage – A relatively new problem?

Alcohol Related Brain Damage (ARBD) is a term used to refer to a range of conditions including Wernicke’s encephalopathy, and Korsakoff’s syndrome (Schmidt et al 2005).  What these conditions have in common is that they are all induced by chronic alcohol consumption resulting in some degree of brain damage and neuropsychological dysfunction

 There are a number of characteristics commonly associated with ARBD:

  • Confusion about time and place
  • Impaired attention and concentration
  • Difficulty learning new information
  • Problems with short-term memory
  • Confabulation (the fabrication of memories as a way of masking memory impairment)
  • Frontal lobe dysfunction (e.g. problems with planning, organising and regulating behaviour)
  • Physical problems such as ataxia (a gait disorder resulting in poor balance)
  • Depression, anxiety and irritability

Alcohol can cause damage to the brain (ARBD) through a number of mechanisms, including

  • Direct toxic effect on the brain
  • Prevents absorption of thiamine (vitamin B12) – an important brain nutrient
  • Poor nutrition & dehydration
  • Liver disease (hepatic encephalopathy)
  • Falls and accidents
  • Changes to metabolism and blood supply to the brain

ARBD severity exists on a continuum from mild to severe and will differ greatly from person to person (as does the potential for recovery)

ARBD is not the same as having an intellectual disability or having a dementia, although there are some overlaps. It has been suggested that people affected by ARBD have needs more akin to adults of similar ages with acquired brain injury than to people with other dementias (e.g. Jacques & Anderson, 2002; Mental Welfare Commission, 2010).  The main reason for this is the recognition that other dementias are progressive in nature, whereas ARBD is not (assuming alcohol consumption stops).  In fact, a significant proportion of people with ARBD will make significant improvements with the right care and conditions, with the following predicted recovery rates:

  •  25% making a complete recovery
  • 25% making a significant recovery
  • 25% making a slight recovery
  • 25% making no recovery                      (Smith & Hillman, 1999)

This suggests that over half of those with ARBD will make a significant recovery.  However, this recovery will only take place if the person with ARBD sustains abstinence from alcohol and is given access to specialist rehabilitation interventions and neuropsychological assessment.

Apps for Brain Injury Rehab

Recovery from brain injury can take time. With the advances in modern technology there a number of apps for your smartphone that can assist with this process.

 Communication

 Individuals with brain injury may find it hard to communicate in early stages of recovery so it may help to use a simple “yes no” format. Apps such as Answers: YesNo for iOS and Quick Talk AAC for Android can help with a forced choice format. There are further communication aids that involve emotions such as Bla|Bla|Bla for iOS, which shows fun faces reacting to sound.

Cognitive Rehab

There’s an app to match nearly any cognitive rehab goal:

 iMazing andMatrix Game for visual problem solving

 Awesome Memory for short-term memory,

Skill Game for executive functioning.

Compensatory tools

The calendar reminder on any mobile phone is a useful function to assit with prompting. A number of apps build on this format by including photos and voices to associate to a particular task. See  Visual Schedule Planner ,  EZBuzz  and Voice Reminder for further info. Sticky Notes for iOS and the Desk Notes widget for Android are also great for making virtual notes.

 Carers

Virtual check in apps such as GPS-based  Community Sidekick  and Family GPS Tracker  can help a significant other know where a person is in terms of following a daily routine.

Obviously all of the aforementioned apps are not a substitute for a targeted rehab programme but can be helpful.

Dr. Fraser Morrison, Clinical Director, Alba Psychology

Finding Nemo – psychological assessment required?

Inaccurate media portrayal of memory problems or brain injury can be frustrating for those who are living with those problems on a daily basis. Typically a character in a film will experience a head trauma, say falling off a boat as in the case of Goldie Hawn in the 1987 film ‘Overboard’ and then undergo a complete personality changes. Goldie’s character in this film goes from being a ‘bad’ mother to a doting parent overnight. Whilst an individual’s personality can change following brain injury the blanket manner in which it is often described in the movie industry is often far removed from reality. They suffer very few problems managing everyday tasks, while managing to hold down new jobs and function socially with the marked change being in their personality.

Research published in the British Medical Journal by Dr Sallie Baxendale of the National Society for Epilepsy highlighted the unlikely truth that a cartoon about a fish with memory problems actually bore more relevance than those involving humans. She said: “Unlike most films in this genre, this amnesiac character retains his identity, has little retrograde amnesia and shows several of the severe everyday memory difficulties associated with the disorder.”

Being a father of two young children I must have seen this film numerous times. With each watch I still find the tale of Dory, the fish with memory problems, moving through her daily life and finding the strength of character to help a father find his lost son heartening. Despite her obvious difficulties in recalling names or knowing where she is, Dory manages to succeed and also be happy within herself. Something that is key to recovery from any brain injury. As Dory would say………….”Just keep swimming, swimming, swimming………”

Some advice from Dory

 Dr. Fraser Morrison, Clinical Director, Alba Psychology

Morisons LLP Solicitors

“The report provided by Alba Psychology was concise and well delivered. The most important factor was the quick turnaround following assessment which can be essential within a legal setting.”

Morisons LLP Solicitors, Edinburgh

Mr. L.

“Alba Psychology provided one-to-one therapy following my accident. The help I received was invaluable and helped me move towards recovery.”

Mr. L, private patient who had experienced brain injury