Archive for the ‘Sleep Disorders’ Category

Sleep: Pay Me Now or Pay Me Later

When I help people with stress management I always start with sleep.  Good health habits along with stress management help protect us from the damage stress can cause.  Stress overload raises cortisol and weakens the immune system.  Stress interferes with sleep by raising levels of the brain’s modulators norepinephrine and serotonin.  The result can be insomnia and the inability to function effectively during the day.

The best way to ensure adequate stress management is to sleep well.  Most adults need seven to eight hours per night.  Teens need 8-9 hours and children need 9-10 hours of sleep.  Adequate sleep is probably the single most important habit for keeping the mind and body healthy.

This is not an easy habit to maintain for most people.  Constantly changing lifestyles make it hard to "turn the brain off" at night.  Access to the internet 24 hours a day, television, movie channels, and heavy work schedules all make sleeping seem like an inconvenience.  Sleep becomes expendable in order to have more time for all our more "stimulating" activities.  At the turn of the century, before easily affordable lighting was available the average adult slept nine hours per night.  The average adult now sleeps seven hours.  Leisure time has also decreased an average of ten hours per week in the last ten years.

Complicating the time crunch is the feeling of pressure that we all have to get more things done in a 24 hour period.  We feel pressure to monitor current events since everything is changing so quickly.  We crave more leisure time.  We also have to change schedules after early flights and late meetings.  Shift work makes it hard for many people to have control of consistent sleep schedules. Unfortunately, sleep does not respond well to control because you can’t "do sleep."

One study found that working mothers with young children still spend the same amount of time per day with them as do mothers that work at home, which is 4 1/2 hours.  The bad news is that they are doing it at the expense of 2 hours of leisure and 1 hour of sleep per day.  Our bodies adapted over thousands of years to a life of being outdoors and physically active all day.  There was no artificial light or high stimulation in the evening.  Now it’s 24-7.  Daylight regulates sleep through the body’s natural system, melatonin.  In today’s world, we are mostly indoors.  We have become like "cave dwellers" and our brains have no idea what time it is.  Without the regulation of daylight the brain goes on a natural cycle of 25 hours.  This causes a tendency to go to sleep one hour later every night.

New advances in medication give us the ability to control sleep.  Only a few medications provide normal sleep.  These include Sonata, Ambien, Gabitril, Neurontin, and Xyrem.  They allow normal stages of sleep to occur.

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The Effects of Stress Disorders on Sleep

DEPRESSION – Sleep disorders are both a risk factor for and a symptom of depressive disorders. A study of 373 adults showed that 60% of people being treated for depression also had insomnia. Depression causes delayed sleep onset and awakenings, especially early morning awakenings. REM occurs earlier and is more intense. Dreams are usually negative.
Stage 4 sleep is usually decreased the most by depression. This can inhibit the body’s ability to promote growth hormones and boost the immune system. Early morning awakenings, possibly caused by cortisol are common. Cortisol (stress hormone) is higher than normal during serious depression. Cortisol releasing hormone causes a decrease in stage 4 and increase in REM sleep.

BIPOLAR-MANIA – Mania usually creates a feeling of high energy and reduced need for sleep. Severe insomnia can result. Sleep is essential for the bipolar individual. It helps reduce the risk of a manic episode.

ANXIETY – Most anxiety disorders have related insomnia. Anxiety causes vigilance and an inability to “turn off the mind.” This results in problems going to sleep and also produces shallow sleep.

PANIC ATTACKS – Sleep related panic attacks can be found in up to 30% of those with the disorder. Night time panic attacks occur three hours after going to sleep. This is during stage 4 deep sleep when breathing becomes shallow and CO2 levels peak. Individuals with panic disorder are extremely sensitive to CO2.


Most of the antidepressants which are used to treat depression can initially cause insomnia (especially if taken at night). This is due to the stimulating or activating effect they have on the system. Antidepressants include the SSRI’s-Zoloft, Paxil, Prozac, Celexa, Lexapro and also Wellbutrin XL, Effexor XR, most Tricyclics, and MAOI’s.
Antidepressants that increase stage 4 sleep include Remeron, Serzone, Trazodone, and Elavil. They decrease REM. Most antidepressants should be started in the morning and switched to bedtime later, (dinner time with Effexor XR) if sluggishness begins to occur.
The Benzodiazepines (Xanax, Klonopin, Ativan) improve sleep continuity by promoting quick sleep onset and reducing night awakenings. However, they don’t give normal sleep because they decrease stage four sleep.

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The Stages of Sleep

There are two basic types of sleep:
Non-REM (NREM) sleep – This includes stages 1-4 of sleep.
Stage 1 is very light sleep, and stage 2 is transitional sleep.
Stages 3 and 4 are deep sleep. They occur in the first 3 hours of sleep. Stage 4 is the only restorative sleep phase. It increases energy in the brain cells, releases growth hormone, and builds the immune system.
Dream, REM sleep – mainly starts after 3 hours of sleep. Each 90 minute cycle has a higher percentage of REM sleep. Although the brain only weighs 3 pounds, it uses 25% of our O2. More O2 is used during REM than during waking hours. That is why sleeping 9 or more hours can make you feel mentally drained.
Studies show that learning takes place during sleep. We show more benefit of study/practice in the morning after good sleep.

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Behavioral Management of Sleep

Since you can’t “do sleep,” trying to force its onset will only cause the opposite to occur. Instead, try to shift focus away from sleep. Read, watch TV, focus on breathing, thumb through a magazine or book, or listen to soothing music. Shifting focus to activities that are non’stimulating to you, will relax the mind and body, and allow sleep.
Sleep Restriction – Limit time in bed to match actual time needed for sleep. Start with 5-6 hours only and increase by 30 minutes at a time only if sleeping most of the time when in bed.

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Breathing and Relaxation Training

Breathing Technique Steps:
Close your eyes and focus on breathing
Reduce tension by breathing out FIRST
Slowly, exhale by saying ‘s H H H H?
Next inhale and count “1 2 3 4”
Hold and count “1 2 3 4”
Slowly, exhale again, “1 2 3 4”

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What Medications Are Best for Good Sleep?

Sonata – 10mg is probably the mildest sleep med. Since it totally wears off in 5 hours, there is no a.m. grogginess. If there is ever an emergency during the night you should be able to function normally and have full recall (memory) in the a.m.
Ambien – 10mg is 2 1/2 times stronger than Sonata 10mg and lasts 7-8 hours. The main advantages are duration, depth of sleep, and lower cost. Disadvantages (mainly at full dose of 10mg) include possible a.m. hangover, and if an emergency occurs during the night, there may be some lack of awareness and memory for the events in the a.m.

LUNESTA-This comes in 2mg and 3mg sizes and usually provides 7-8 hours of sleep.  Studies show it is well tolerated, however, some individuals cannot take it because it causes an unpleasant taste. 
Provigil – This is a mild stimulant used to treat daytime sleepiness associated with narcolepsy, shift work sleep disorder, and obstructive sleep apnea/hyponea syndrome.
Neurontin and Xyrem – both of these medications also allow normal sleep to occur with normal dream sleep and increased Stage 4 sleep.

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Sleep: Did You Know?

  • MOOD is affected more by sleep deprivation than are cognitive skills or physical performance
  • A 45 minute nap can improve alertness for the next 6 hours … a 1 hour nap can improve alertness for 10 hours
  • Healthy sleep prepares the brain for the next day and renews mental balance
  • Laboratory rats deprived of sleep died in only 16 days
  • Inadequate sleep is probably the most common cause of irritability
  • Untreated insomnia can lead to a worsening of a sleep disorder and the onset of depression
  • Alcohol and OTC sleep aids DO NOT result in normal sleep
  • 33% of traffic accidents are caused by sleepiness
  • The invention of the light bulb by Thomas Edison marked the beginning of sleep loss and abnormal sleep rhythms
  • Negative effects on sleep can be measured even 16 hours after ingestion of 200mg of caffeine (which is 2 cups of coffee)

SLEEP AND ALCOHOL An individual that can drink one glass of alcohol and show no impairment when rested can become … An individual that creates “fatal fatigue” with only one glass of alcohol when sleep deprived

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Insomnia Phobia

“Insomnia phobia” is a phrase I use to describe the fear of not being able to fall asleep.
Fear has an alerting effect and wakes you up! Telling yourself, “don’t worry about it!”, won’t help if you don’t have the confidence that you will get enough sleep. Cognitive therapy can help. Having a sleeping pill nearby to take if needed is also a way to help eliminate the fear. Even if you don’t use the medication, it allays anxiety, allowing you to lightly focus on something else as you drift off.

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Take 2 Benadryl and call me in the morning …

Last week, a rep from a pharmaceutical company that manufacture a sleep medication was in my office.  He said, “You have a unique practice because you see a lot of patients with sleep problems.” I said, “WRONG! I see the same patients that all psychiatrists and primary care doctors see. The problem is most patients that have sleep problems don’t mention it to their doctors, and unfortunately, most doctors don’t ask.”

I believe all patients need to be screened for all common, treatable problems every visit.

Sleep is the first thing I ask about on my screening questionnaire. Two days ago I was seeing a patient who happened to be the wife of a primary care physician. She told me recently her internist put her on Prozac for anxiety and depression. She immediately developed a significant sleep problem as a side effect. She asked him for a prescription for Ambien. He told her he didn’t prescribe Ambien because it is “highly addictive,” but she could take Benadryl. (See previous discussion on “pre-extraction disorder” P.E.D.) There are several problems with her internist’s response. First, Ambien isn’t addictive at all. An occasional patient will develop a mild physical dependence after several months of nightly use, but physical dependence is a physiologic adaptation and has “nothing to do with addiction.” This is not just my opinion but that of Dr. Robert DuPont, the first director of the National Institute on Drug Abuse. Fifteen percent of patients taking Ambien for one year every night will have one to two nights rebound insomnia if they stop it abruptly. This is hardly addiction.

Addiction is compulsive use or behavior in spite of negative consequences.

The second problem with her internist’s recommendation is that Benadryl is a horrible sleep medicine. There’s no scientific evidence that it’s effective. It doesn’t provide normal sleep (Stage IV deep sleep and dream sleep), and it frequently leaves you with a hangover. Other than that, it was a great idea. The third, and most important problem with his recommendation was that his ignorance with regards to the importance of a good night sleep.  The effect of sleep loss was studied in healthy young men awakened after 5 hours of sleep.  After just one night, they showed decreased concentration, marked irritability and increased levels of cortisol, a stress hormone that suppresses normal immune function and contributes to abdominal weight gain.

I consider good sleep (7-8 hours) the most important part of stress management.

Longevity studies show that too much sleep is actually worse than not enough. In the short term, excess sleep drains mental energy. A national survey found that 10% of people have a chronic nightly sleep problem, but 2/3 of the adult population has at least occasional sleep problems.  The good news is that we have effective, safe medications that provide normal sleep and are totally out of your system in 5-8 hours.  The bad news is many doctors are afraid to prescribe them and most people don’t have access to them. 

I think every home needs to have Tylenol and a good sleep medicine on hand.

Most people need to have a good sleep medicine (Ambien, Sonata, Lunesta).  We weren’t made for this world. We adapted from 1000’s of years in a world where we were outside and physically active all day.  The bright sunlight regulated our sleep, energy, and metabolism. Whereas, now most people are mainly indoors and sedentary. Life use to be hard but simple.  Now, it’s extremely complex and changing at an exponential rate, but we still have the old adaptive mechanisms.  We respond to mental stress with the same flight or fight mentality, but these aren’t appropriate responses to today’s stress.  It’s like driving your car hard all day but not putting it in gear.  It’s not good for your car, and it’s not good for our bodies. We end up hyper aroused, can’t relax and have problems sleeping.  We need a new stress management technology, but right now, the best we can do is great medicines.  It’s just a shame that most people either don’t know about them or can’t get them because our medical system is broken and most doctors just don’t get it.

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