The constant bad news about Covid-19 and the fear that the virus with a serious sting in the tail could affect the people you love, is leading to anxiety and many sleepless nights for many of us. If you were a bad sleeper; the worries about the coronavirus could make the situation even worse. Adding to the pressure, are the stories in magazines and on the internet about a link between sleep deprivation and bad health including dementia. Biznews tracked down a South African born psychiatrist, Dr Hugh Selsick who runs the Insomnia Clinic in Bloomsbury in London to provide more clarity on insomnia and he shares valuable insights into some of the myths associated with sleep. Dr Selsick’s approach has been described as ‘remarkable’ by a fellow journalist, Simon Parkin from the Guardian. – Linda van Tilburg
I started studying BSC at Wits – doing physiology and then I moved into medicine – and during my first one or two years of medicine, I volunteered to be a subject in a sleep experiment. It was being run by Professor Helen Driver who, as she was wiring us up for this experiment, started talking to us about sleep and the different types of sleep and different sleep disorders and from that moment – I was just absolutely hooked and it was something that I realised I wanted to do for the rest of my life. So, I took a year out of medicine to do a postgrad degree in physiology and do some research with her after whichI had to figure out how to get into sleep and particularly – sleep medicine. The thing is – in most countries it’s not a speciality of its own. So, you have to go into it through either respiratory medicine or psychiatry or neurology and I really enjoyed psychiatry. It was the other area of medicine that fascinated me so I specialised in psychiatry but it was always with the intention of doing sleep because it’s such a huge part of our lives. We spend a third of our lives doing it, it’s incredibly mysterious – we don’t understand a huge amount about it – but we do know that it’s absolutely essential for well-being. When I finished my training I was lucky enough to find a place that was willing to try doing something new. The hospital of integrative medicine looks at holistic ways of treating patients and they wanted to open up an insomnia clinic and asked me and – I had no idea what I was doing when I started it – but, it’s something that’s just grown over the years.
Are you an insomniac?

I was – certainly in my first year at university – I had quite bad insomnia for quite a long time and it just miraculously resolved after many months (I’m very grateful it did – I have no idea why it did) and I did then have another bout of insomnia a few years ago but, at that point, I was working in the field – so I knew what I needed to do to treat this and managed to get it under control much more rapidly. So right now, I’m a very good sleeper and have been for a long time but I can really empathise with my patients because I’ve been there.
Obviously, coronavirus is not helping any of us. We’re not talking here just about stressful situations, we’re talking about crippling insomnia for people who have it their whole lives – it’s something far more serious than that.
Even the world’s greatest sleepers have bad patches. No one sleeps beautifully every single night and when something stressful or upsetting happens – it’s entirely appropriate to sleep badly – but what people with insomnia will say is, ‘well, I understand why I got the insomnia 10 years ago because I was going through a really difficult patch at work or whatever, but now all of that stuff is gone and everything in life is going well – I’m enjoying my job, I’m in a good relationship and yet I still can’t sleep’. And it’s something really pervasive because it makes people feel really awful all day, every day.
Yes and what probably makes you more stressed – people would say one bad night’s sleep increases your levels of the alzheimer protein which freaks them out even more.
Yes, actually a lot of that comes from perhaps a misunderstanding of the science. When you look at the big studies – the epidemiological studies where you look at large groups of people – what you see is actually that people with insomnia don’t die any younger than people without insomnia and you don’t really see increased rates of dementia or severe physical illness. So, one bad night’s sleep is of course stressful for the body but actually, what we suspect may happen with insomnia is that – because it is consistent – the body learns to adapt to it in a way that it doesn’t do if you’re just having a bad night here or there. So, if there’s one really important message to get out there it’s that insomnia doesn’t kill you – because I think that’s one of the things that perpetuates it. If you go to bed at night thinking, ‘if I don’t sleep – this is going to do me some serious damage’ then of course you’re not going to sleep. Actually realising that it doesn’t cause serious physical damage is really therapeutic. What it does do is have a huge impact on one’s quality of life and a big impact on mental health and, in particular, it’s a significant risk factor for depression. There’s been this recent book by Matthew Walker which I think is probably keeping me in business because he is very evangelical about the importance of sleep – which I think is good – and he says if you don’t sleep bad things will happen. But what people don’t realise is that he’s talking much more about sleep deprivation – not insomnia – and these are two completely different things. Sleep deprivation is where I’m not getting enough sleep because I’m sitting up late at night working or because my neighbours are keeping me awake so I just don’t have the opportunity to sleep, whereas insomnia is where I’m not getting enough sleep despite having adequate opportunity. These are completely different things – they lead to completely different outcomes. So unfortunately, we often use the terms interchangeably ( insomnia and sleep deprivation) but they are very different. Sleep deprivation does seem to have significant physical health consequences whereas insomnia doesn’t – but does tend to have more mental health consequences.
Are there other myths that you can bust for us – the hours we sleep? First of all, a lot of people say you’ve got to sleep the set amount of hours and that’s also what makes people stressed.
Absolutely. That’s one of the first myths that we’ll bust with our patients – this myth of the eight hour sleep. It can actually be a very destructive myth for exactly the reason that you’ve mentioned – that if you don’t get it, you then get stressed about it. There’s a grain of truth to the myth – that the average amount of sleep that adults need is around seven or eight hours, but that’s an average. There’s going to be variability either side of that average. So, the first thing we really would advise people is just to stop worrying about the number of hours that you’re getting. Everybody needs a different amount, that amount changes through your lifespan, the amount that you sleep is going to be different from your partner. So, really judge your sleep by how you feel during the day – if you are feeling alert and rested most of the day, most days – then whatever sleep you’re getting at night is the right amount for you. And I stress most of the day, most days because nobody feels alert all day, every day. But if you’re alert and rested most of the day, most days – you’re getting enough sleep and it doesn’t matter whether that’s five hours or 10 hours.
Margaret Thatcher only slept three to four hours a night and she was okay with that and even Donald Trump’s bragging that he doesn’t sleep a lot (but he clearly needs more). What do you say about that?
There are people who just need less sleep. There are people who are constitutionally short sleepers and actually, one of the worst things that we can do is try and get them to sleep longer than they need to. If anything, the data actually suggests that sleeping longer is worse for you than sleeping shorter and that if you are someone who just needs five hours of sleep or four hours of sleep and you are trying to hit this mythical eight hours – it’s going to lead to frustration and anxiety and if anything, you might then develop and insomnia on top of your short sleep.
So there are really people like that out there?
Yes, absolutely. They are relatively rare – obviously there are more people who fall in that sort of six to nine hour range – but there are people who will fall outside that range and will need either much longer or much less.
What about all these other things? First of all, saying that you should keep digital technology out of the bedroom you should not read on your Kindle (which has a backlight), all the other ideas of creating this sanctuary that you associate with sleep – what about all those ideas that you read about?
So I think the first thing to say is; if you are currently a good sleeper – then frankly, you don’t need to change anything. If you are a good sleeper and you watch TV in bed and you sleep absolutely fine – then there’s no reason to take the TV out of the bedroom. But if you have insomnia – then yes, there’s really good evidence that actually separating your sleeping space and your waking space very clearly makes an enormous difference. So, we’re not particularly concerned about people (for example) using an E-reader or watching TV in the evening – in terms of the light. What’s more of an issue is where they’re doing it. If someone’s got insomnia – they should be reading, watching TV, listening to the radio, ironing, exercising, meditating (whatever it is they do) outside the bedroom and the bed should be preserved for sleep and intimacy and absolutely nothing else. This is because we create an association with spaces. If you associate your bed with frustration, anxiety, if it’s a place where you go to do battle every night and you always lose that battle – then the act of going to bed will actually make you anxious and frustrated and wake you up. Whereas if you keep the bed and ideally the bedroom for sleep and intimacy and nothing else then after a while (and it does take a while – it can take many weeks for this to start working) what will happen is that when you go into the bedroom and into bed – because you associate that place with sleep – it will make you sleepy and then make you fall asleep.
Can you take us through how you treat people?
So, the first thing that we do is to really make sure that we understand why they can’t sleep – because sometimes it’s not from insomnia. It might be from something like restless legs (where the person gets this horrible discomfort in their legs at night and that makes it difficult for them to sleep) or they may have some other sleep or medical disorder that’s driving it. So the first thing that we do is really get a good understanding of what that person’s condition is and why they’re not sleeping. And then, for the majority of our patients, we put them through a course of what’s called cognitive behaviour therapy for insomnia – which is a really well established, well researched, evidence- based treatment program that’s used worldwide – and our program involves five sessions. The first session is very much what we call psycho-education – explaining how insomnia develops, what the impact of insomnia is, giving them that information that the insomnia is not going to kill them but then, also helping them to understand what normal sleep looks like. Because if you’ve slept badly for a long time – you have this very idealised picture of normal sleep so it feels like it’s a really long way away so when you realise that normal sleepers wake up several times a night and have the odd bad night – normal sleep actually that doesn’t seem that far away. You realise that you’re perhaps closer to being a normal sleeper than you realise. We then spend two sessions really focusing on behavioural techniques – changing sleep habits to optimise sleep – and these techniques harness some very deep-seated psychological principles but they also utilise the body’s innate physiological sleep drives. We show people how to get the most out of that physical sleep drive. In sessions four and five we focus a lot more on the mental side of things – showing them ways of calming the mind down, dealing with anxieties or annoying thoughts at night.
Yes, that’s a big one. My friend asked me – I should ask you about that – she said she just can’t get her mind to switch off.
Yes, so there are several things that we would do about that. One is that separation of the sleeping and the waking space; if you’ve spent a long time in bed lying awake, thinking – the act of going to bed is going to make you wake up and start thinking, if you use your bed for sleep only – over time what happens is that going to bed actually shuts the mind down.
So should you get up when you start overthinking or your mind’s racing – should you rather get up and do something?
Absolutely. Rather than lying in bed at the mercy of your thoughts (if you’ve been in bed and it’s been about 15 -20 minutes) – get up, get out of the bedroom, go into the lounge, read a good book, listen to a podcast.
All the things you mentioned are not related to digital technology.
We actually say to our patients that if you want to go downstairs and watch TV – if that’s what’s going to help you relax and take your mind off your anxieties and help you to start to feel sleepy again – that’s absolutely fine. The evidence is that using screens at night is not as harmful as most people imagine – there may be some minor effects – but they’re not significant. And frankly, it’s almost impossible to avoid technology nowadays. This is the 21st century – we interact with the world through our screens – so if we say to patients, ‘don’t watch TV’ or ‘don’t use your phone at night’ or ‘don’t use your iPad’ – they’re not going to be able to do it (unless you’re a hermit), it’s just not possible.
What are your views on all these apps – like Calm and all that? Because I personally find that if I start listening to a story by Stephen Fry – I don’t fall asleep because I want to hear the story.
They may be helpful for some people but – by and large – a lot of them are not evidence based. And in addition, what we really want is for people to have everything that they need to sleep inside their own heads so that if they end up camping on top of a mountain with no cell phone reception and no whale noise machine and nothing else – that they’re still able to sleep. And that’s important, because actually – in order to be a good sleeper you have to have confidence in your sleep. And if you are reliant on external props you’re never going to develop that confidence.
It seems that it’s quite a process you take people through. This is not an instant cure. Do you think that’s the problem – that people are looking for an instant cure?
I think people would love an instant cure but actually, by the time we see most patients – they’ve had their insomnia for years or decades. And so they feel that if this takes me six months (in the context of my 20 years of insomnia) – that’s not that much. Some of the stuff we ask them to do is quite hard and it can be quite anxiety provoking and it can make you sleep a bit worse before you sleep better. So it does take a little bit of persistence and courage and the ability to stick with it for long enough for it to work and – what I always say is – the techniques that we teach are remarkably simple. We could probably 8 or 10 A4 pages give patients those techniques and say ‘here you go – that’s what you need to do to sleep well’. What we spend a lot of time in the therapy doing is really convincing them to do it for long enough for it to actually work – that’s that’s the real trick. One of the things we often hear from patients when they come back for their follow ups after the therapy and they’re sleeping much better is – ‘I honestly didn’t think this would work, I just really didn’t think it would work but I just did it because well – what else was I going to do, because my wife made me or whatever – and oh my gosh this works amazingly’. So the nice thing about this is you don’t have to believe that it works for it to work. You just have to do it and you just have to do it for long enough – and long enough could be several weeks for some people and for other people it may be several months. It works in a very high proportion of people so around 70 to 80 percent of people will get significantly better using these techniques. It’s going to be that 20 or 30 percent who don’t who may then need additional input – which might involve medication or it might involve, if they’re particularly anxious, dealing more with their daytime anxiety and so on.
What do you say to women who say, ‘that’s all very easy – you don’t sleep next to somebody that sounds like a bear or something growling at night’ – what do you say to women about that?
Yes well, it is remarkable – I can’t remember ever having a patient to say that their partner also has insomnia – it’s always that their partner sleeps like a log and they snore like mad. The first thing you would say is that snoring can be a sign of a sleep disorder – it can be a sign of sleep apnea, which is a very severe disorder as well. So, the first thing we say is for them to tell their bed partner that they need to go to the doctor and get that investigated. If there are noises that you can’t always control (and particularly if it comes from a partner), we might look to reframe it and say that there are lots of people who sleep next to people who snore and they sleep fine. So, snoring in itself is not a bar to sleeping – it’s about how you interpret that sound, what you make of that sound. I don’t know if you can hear in the background – my dog, who’s in the room with me here, is snoring – and that used to drive my wife around the bend (because we sleep in the same room as the dog) whereas, I really like the sound of the snoring because I like knowing that my dog is there. And it’s something that you can change. So, my wife now actually quite likes the sound of the dog snoring – she’s gone from being irritated to being amused. So, the stimulus hasn’t changed – but the way that you interpret it can change. And that’s the kind of work that we might do in those circumstances – to reframe this noise that’s coming from your partners (it may be something that makes you feel safe, that makes you know the person you love is next to you – that they’re nearby) and that can be helpful sometimes.
Are people coming in droves to your clinic because it seems that sleep is such a problem of our age?
Yes, we are incredibly busy and since we started the clinic around 10 – 11 years ago – we’ve just been continually expanding, increasing our staff numbers and the hours that we work and looking at ways of treating more patients with the same resources. Insomnia is a remarkably common condition – depending on which studies you look at. It probably affects around 5 to 10 percent of the adult population This is a huge number of people and makes it one of the most common conditions and unfortunately – it’s something which is perhaps not taken as seriously as it should be by the medical profession and by policymakers and, as a result, there aren’t very many places that will treat it.