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  • Writer's pictureHiro Saito

Sleep

On average, adults require 7-9 hours of sleep daily (Health Hub, 2019). Unfortunately, most Singaporeans are sleep-deprived (Lee, 2019). As insufficient sleep is associated with poorer general health and illnesses with higher mortality (Bjorvatn et al., 2007; Strine & Chapman, 2005), we provide recommendations to enhance one’s ease of sleep and sleep quality.


Mindfulness-Based Therapy for Insomnia (MBTI)


MBTI is a mindfulness intervention utilising behavioural techniques to help individuals with insomnia (Ong et al., 2014). It aims to increase one’s awareness of the mental and physical states that result in wakefulness and hyperarousal (Ong & Sholtes, 2010). For our recommendations, we will be adapting three components of MBTI that even individuals without insomnia can practice to enhance the ease of sleep and sleep quality. They should be practiced together for the best results.


MBTI reduces total wake time and insomnia severity (Ong et al., 2014). It also increases melatonin levels, a hormone that regulates the sleep-wake cycle, and reduces hyperarousal right before sleep and palpitations associated with anxiety and ruminations that inhibit sleep (Ong et al., 2014; Zeichner et al., 2017). These benefits appear to be sustainable in the long-run, as follow-up studies reflected high rates of treatment remission (Ong et al., 2014)


Technique 1 - Sleep Hygiene


In this psychoeducational behavioural intervention, individuals are encouraged to develop good sleep hygiene – i.e. healthy sleep habits. Sleep hygiene involves education on crucial personal and environmental factors that have either a positive or negative effect on sleep (Sharma & Andrade, 2012). Personal factors include developing a bedtime routine and health-related practices involving diets, exercise and substance use. On the other hand, environmental factors include a comfortable sleeping environment with the right temperature. Please refer to Annex A: Sleep Hygiene for a detailed list of tips.


Technique 2 - Sleep Restriction


Sleep restriction refers to reducing the amount of time spent in bed to more closely match the amount of time spent sleeping (Hood, Rogojanski & Moss, 2014). Sleep restriction was originally developed under Cognitive Behavioural Therapy for Insomnia but has more broadly been adapted into MBTI. Sleep restriction does not refer to reducing the number of hours spent sleeping, but refers to ensuring that the sleep quality or time spent in bed is more efficient. For a more detailed explanation on how to accurately conduct sleep restriction, please refer to Annex B: Sleep Restriction.


Technique 3 - Stimulus Control


Stimulus control therapy associates the bed as a place for only sleeping and weakens the bed as a cue for wakefulness (Turner & Ascher, 1979). The main aim of stimulus control therapy is to condition the brain to associate the bed as a place for sleeping and bring awareness to unwinding at the end of the day - which implies that the bed cannot be used as a place to engage in work. For a more detailed explanation on how to accurately practice stimulus control, please refer to Annex C: Stimulus Control.


Mindfulness-Based Stress Reduction (MBSR)


MBSR is a systematic patient-centred educational program focusing on mindfulness meditation to teach people how to take better care of themselves and live healthier and more adaptive lives (Jon Kabat-Zinn, 1996). MBSR programmes often happen over the course of 8 weeks to create the habit of meditation (Jon Kabat-Zinn, 1996).

Meditation stimulates the Vagus Nerve in our body, decreasing inflammation and increasing melatonin production (Wang, Zhai, Li, McCabe, Wang & Rong, 2015).

Having a higher level of melatonin has health promoting effects such as prolonging antioxidant activity and regulating body temperature, blood pressure and hormone levels (Tooley, Armstrong & Salients, 2017). Overall, MBSR has been shown to improve the quality of sleep.


Technique 4 - Meditation Before Sleeping


The method we adopted is as follows:


Step 1: Stay awake until 12am

Step 2: Be present in the moment and listen to the audio. Refer to Annex D for the audio link

Step 3: Go to sleep after the audio ends

Step 4: Record quality of sleep after waking


Melatonin signals to the body that it is time to rest and the melatonin productions levels are highest at 12am (Tooley et. al, 2017). As such, by increasing the production level of melatonin when it is at the highest, we should be able to get a higher quality of sleep. Additionally, based on personal experiences, meditation improves sleep even if we experience stressful events during the day as it was Week 11 when our group ran the experiment where we kept the time we spend on meditating to only right before we sleep.


Personal Observations


We employed the aforementioned mindfulness techniques and recorded our observations in a sleep diary for 10 days – 5 days without employing techniques and 5 days with techniques. Please refer to Annex E: Sleep Diary and Annex F: Personal Observations for more details on our experiences.


Time Taken to Fall Asleep: Each bar on the graph represents the sum of minutes over 5 nights. The group enjoyed an overall fall in the time taken to fall asleep post-mindfulness, with Jie Min enjoying the greatest reduction. She attributes this to the 5 minutes meditation exercise which helped to clear her mind and fall asleep faster. This overall trend can be explained via the successful adoption of the sleep techniques, as well as external factors such as multiple submissions on Week 11, which left the group feeling exhausted.


Time Spent in Bed: Most of the group had a slight reduction of time spent in bed due to sleep restriction. Juiee saw the most reduction in time spent in bed as prior to the adoption of sleep techniques, she had a habit of staying in bed for an hour after her alarm goes off. Under sleep restriction, the group was more disciplined with the time they went to and got out of bed, such as waking up when the alarm goes off.

Quality of Sleep: Each bar is the sum of 5 days of sleep quality ratings. The quality of sleep for Kenrick, Tammy and Juiee marginally improved, while Jie Min and Dyan enjoyed more significant improvement in sleep quality. Tammy and Dyan both believe this was largely due to adopting sleep hygiene tips. For instance, Dyan did not use digital devices an hour before bed in his room. Tammy on the other hand, established a bedtime routine that allowed her to relax before going to bed.


Evaluation


Overall, we found these tips useful in increasing the quality of sleep and enhancing the ease of sleep.


However, caution must be taken regarding the generalisability of our findings due to our small sample size of 5, as well as the use of convenience sampling which might lead to self-reporting bias. As our evaluation lasted 10 days, we are also unsure of the long-term effectiveness of our techniques. Further, existing research on MBTI and MBSR have been conducted on individuals with insomnia and breast cancer, reducing the generalisability of its findings (Ong et. al, 2014; Zeichner et. al, 2017).


Some future research considerations include testing the effectiveness of each individual technique and utilising a more generalisable sample reflecting the SOSS student population.

By Dyan See Toh Jun Wei, Kenrick Tan Guan Da, Low Jie Min, Malekar Juiee Bhalchandra, and Teo Yu Min Tammy


References


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Hood, H., Rogojanski, K., & Moss, J. (2014). Cognitive-Behavioral Therapy for Chronic Insomnia. Current Treatment Options in Neurology, 16(12), 1-9.


Health Hub. (2019). Sleep well, live better. Retrieved 9 October 2019, from https://www.healthhub.sg/programmes/117/goodsleep


Lee, J. (2019). Many Singaporeans are sleep-deprived due to fast pace, stress of living or sleep disorders. The Straits Times. Retrieved from https://www.straitstimes.com/lifestyle/many-singaporeans-are-sleep-deprived-due-to-fast-pace-stress-of-living-or-sleep-disorders


Ong, J. C., Manber, R., Segal, Z., Xia, Y., Shapiro, S., & Wyatt, J. K. (2014). A randomized controlled trial of mindfulness meditation for chronic insomnia. Sleep, 37(9), 1553–1563. doi:10.5665/sleep.4010


Ong, J., & Sholtes, D. (2010). A Mindfulness-Based Approach to the Treatment of Insomnia. Journal of Clinical Psychology, 66(11), 1175–1184. https://doi.org/10.1002/jclp.20736


Sharma, M. P., & Andrade, C. (2012). Behavioral interventions for insomnia: Theory and practice. Indian Journal of Psychiatry, 54(4), 359–366. https://doi.org/10.4103/0019-5545.104825


Strine, T. W., & Chapman, D. P. (2005). Associations of frequent sleep insufficiency with health-related quality of life and health behaviors. Sleep Medicine, 6(1), 23–27. https://doi.org/10.1016/j.sleep.2004.06.003


Tan, N. C., Tan, M. S., Hwang, S. W., Teo, C. C., Lee, Z. K. N., Soh, J. Y. J., … How, C. H. (2016). Sleep time and pattern of adult individuals in primary care in an Asian urbanized community. Medicine, 95(35). https://doi.org/10.1097/MD.0000000000004749


Turner, R., & Ascher, L. (1979). A within-subject analysis of stimulus control therapy with severe sleep-onset insomnia. Behaviour Research and Therapy, 17(2), 107-112.


Wang, S., Zhai, X., Li, S., McCabe, M. F., Wang, X., & Rong, P. (2015). Transcutaneous Vagus Nerve Stimulation Induces Tidal Melatonin Secretion and Has an Antidiabetic Effect in Zucker Fatty Rats. PLOS ONE, 10(4), e0124195. https://doi.org/10.1371/journal.pone.0124195


Yuen, A. W. C. & Sander, J. W. Can natural ways to stimulate the vagus nerve improve seizure control? Epilepsy & Behavior 67, 105–110 (2017). https://doi.org/10.1016/j.yebeh.2016.10.039


Zeichner, S. B., Zeichner, R. L., Gogineni, K., Shatil, S., & Ioachimescu, O. (2017). Cognitive Behavioral Therapy for Insomnia, Mindfulness, and Yoga in Patients With Breast Cancer with Sleep Disturbance: A Literature Review. Breast Cancer: Basic and Clinical Research. https://doi.org/10.1177/1178223417745564


Kabat-Zinn J. Mindfulness meditation. What it is, what it isn’t, and its role in health care and medicine In Haruki Y, Suzuki M (eds.). Comparative and psychological study on meditation. Delft: Eburon Publishers; 1996.

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