A Mother’s Day Wish For Better Sleep

Image

This is my mom.  Please spend a moment and look upon her beautiful face.  Perhaps you may see some of the same qualities that I do:  the hopeful happiness in her smile, the joyful but fiery intensity in her eyes, the serene youthfulness in her gaze.  She looks so young and new here, new at adulthood, parenthood, American life.  But for me, her son, I also see wisdom, awareness, a vague sense of knowing, some ill-defined proficiency in everything she does, though she was much newer at this parenting thing when the photo was taken than I am now.  A lifetime of observing my mom’s way of being and burning love for her family gives me well-informed license to perceive these special qualities:  this unique perspective creates a sensation, and feeling you cannot know unless it’s your own mother you see looking back at you from that old, black-and-white photograph.

Mom had gone through a lot to get to where she was when my dad snapped this photo.  She had left her native country and a life of comfort and stability–a true rarity in Korea at the time–for a modest life with a young Japanese-born, American-trained professor of Korean descent, now living and teaching in Michigan.  An accomplished pianist and young scholar in her own right, she threw herself eagerly into the responsibilities of being a wife and parent, managing to earn a master’s degree in mathematics along the way.  Looking at her young, smiling face, one wonders if she had some inkling of the adventures to come:  all the soccer and baseball games, the world travel, the many times playing hostess to friends and her husband’s many colleagues and students, the maturation and graduation of her sons, the germination and success of her businesses.

She could not have known, however, about all the challenges that lay ahead.  Apart from the passing of my father–the most devastating event in the lives of everybody in my immediate family–the biggest challenge of them all was her diagnosis with Parkinson disease, which has over the past several years gradually robbed her of her agility, coordination, and ability to walk.

A neurologist by training, I have counseled many patients and families regarding the management of Parkinson disease over the years.  No clinical experience or medical training could compare, however, to the education I have received from helping a parent cope with this cruel disorder every day.  It has been a truly humbling experience, realizing the true personal effects of Parkinson’s as I have through my mother.  This knowledge now in hand and without dwelling on details, I am qualified to offer this one, non-doctorly piece of simple, universal advice:  never get Parkinson’s.  It blows.

Today’s entry pertains to sleep because Mom started having substantial insomnia–without a clear trigger–years prior to her diagnosis with Parkinson’s.  Parkinson disease is commonly associated with sleep disruption and it is not uncommon for the first symptoms of Parkinson’s to be very nonspecific, starting well prior to the onset of more specific symptoms (tremor, slowness of movements, and the like), so I wonder in retrospect if her difficulties sleeping represented the heralding problem of her particular disorder.  Her neurologist, a movement disorder specialist, is doing what she can to manage the insomnia, but Mom still struggles with her sleep from time to time.

Image

Last year I had the pleasure of introducing my mother to Michael J. Fox, whose public battle with early-onset Parkinson disease has been the inspiration for many public speaking events and several excellent, highly recommended books (which Mom and I have both read), including Lucky Man:  A Memoir and Always Looking Up:  The Adventures of an Incurable Optimist.  Mr. Fox told Mom, “You look great!”  It was wonderful for her to meet someone who has lived what she is living, someone who understands.  She smiled quietly in response, and in her expression I saw that same hope and determination she’s always had, qualities so relentlessly challenged in recent years by this crippling disorder.  I believe that that fight will always be there, despite the fatigue, because that’s who she is and who she will always be.  And my family and I will continue to be there for her, helping her fight.  When it comes to my mom, I took off my doctor’s hat long ago.  I’m just a son, a boy loving and trying to help his parent.  That’s all I can be now, and I think that’s what she needs most.

Today’s Mother’s Day.  Dang it, man.  Love your mom.  Remember her if she’s gone.  Squeeze her tight if she’s not.  Call her if she’s away.  Just don’t waste a second of her presence.  Moms are incredibly precious.  I know mine is.

Sleep Song #5: “Sleeping With the Television On” by Billy Joel

Recently I wrote about my early love for Billy Joel’s music:

https://sleephelpdesk.com/2013/03/29/what-a-young-billy-joel-fan-can-teach-us/

The year after my mom bought me his great album 52nd Street in 1979, Joel’s Glass Houses was released, and I managed to get my grubby musical little hands on that album as well, and as I had done with its predecessor, I played it over and over in our basement until everybody in the house was bloomin’ sick of it.

The second song on the the second side of the LP is a happy 3-minute track called “Sleeping With the Television On.”  Here it is, for your listening pleasure.

It occurs to me as I write this that younger readers may be genuinely puzzled by the prelude to the song:  years ago, before “24-hour news cycles” and hundreds of channels to choose from, network television stations “signed off” late at night, following the national anthem, and the viewer would then see snow or some focus pattern until the next morning, when the station would resume its programming.

Anyhow, though this song actually has little to do with sleep, I am nonetheless using it as an opportunity to bring up one point:  many people do sleep with the television on, specifically because of their insomnia.

When you’re tossing and turning in bed for hours at a time, frustration inevitably develops, paradoxically making you feel more stimulated and awake.  This problem is compounded by a natural tendency to try to fall asleep, which rarely works, because you can’t force a biological function to occur just because you want it to, so the more you try to sleep, the more frustrated you get, and the worse the insomnia becomes.

At some point this can drive you completely nuts, and finally you arise from bed in disgust and go to the living room.  You turn on the TV and you lay down on the couch.  You’re now asleep instantly.

Why is that?  Because you’re no longer trying to sleep.  The TV also serves to distract you from the frustration, allowing your body’s natural impulses to become drowsy and fall asleep to take over unimpeded.

Sometimes this phenomenon leads people to believe that they need the TV to sleep, and that they are unable to sleep without it.  Trust me when I say that your body and brain do not biologically require a television set in front of you to generate sleep.  It can feel like they do, however, because, as I’ve mentioned in previous entries, we humans are creatures of habit.  We’re simply used to what we’re used to, and so over time sleeping without the television on after spending years sleeping in front of the TV seems foreign and abnormal.  To me, it’s reasonable to expect that if you managed to learn how to sleep well with the television on, you can learn how to sleep well without it as well.

Below you will see Joel’s lyrics for this great song.  Enjoy your weekend, everyone!

Sleeping With the Television On

(written by Billy Joel)

I’ve been watching you waltz all night Diane
Nobody’s found a way behind your defenses
They never notice the zap gun in your hand
Until you’re pointing it and stunning their senses
 
All night long, all night long
You’ll shoot ’em down because you’re waiting for somebody good to come on
But you’ll be sleeping with the television on
 
You say you’re looking for someone solid here
You can’t be bothered with those “just for the night” boys
Tonight unless you take some kind of chances dear
Tomorrow morning you’ll wake up with the white noise
 
All night long, all night long
You’re only standing there ’cause somebody once did somebody wrong
But you’ll be sleeping with the television on
 
Your eyes are saying talk to me, talk to me
But your attitude is “don’t waste my time”
Your eyes are saying talk to me, talk to me
But you won’t hear a word ’cause it just might be the same old line
 
This isn’t easy for me to say Diane
I know you don’t need anybody’s protection
I really wish I was less of a thinking man
And more a fool who’s not afraid of rejection
 
All night long, all night long
I’ll just be standing here ’cause I know I don’t have the guts to come on
And I’ll be sleeping with the television on
 
Your eyes are saying talk to me, talk to me
But my attitude is “boy, don’t waste your time”
Your eyes are saying talk to me, talk to me
But I won’t say a word ’cause it just might be somebody else’s same old line
 
All night long, all night long
We’ll just be standing here ’cause somebody might do somebody wrong
And we’ll be sleeping with the television on
Sleeping with the television on
Sleeping with the television on
Sleeping with the television on
Oh, sleeping with the television on

Does Your iPad Lead to Insomnia?

 

Our old, well-worn first-gen iPad has gotten a LOT of use over the years, and admittedly much of the use has been in bed at night.  I read quite a bit, and though I still prefer good old-fashioned paper print books (I’m always in the middle of 2 or 3), our iPad has also become a regular staple in my routine prior to turning off the lights for the night, primarily for e-mails and this blogsite adventure I started several months ago.  My wife and I have never had problems falling asleep as a result of iPad use, but many of my patients have found their insomnia improves with modifications in their habit of using electronic devices involving bright backlit screens in bed.

We’ve all experienced activities that cause us to end up going to sleep later than what we intended.  However, backlit electronic pads can contribute to difficulties falling asleep if used shortly prior to bedtime, and there are a couple reasons why.  First, the content of what you’re doing or reading can obviously play a role.  Whether it’s an exciting video or the discovery of the latest shoe sale on Zappos, anything that you’re exposed to that is visually or emotionally stimulating or is of emotional importance to you can create an alerting effect that delays the onset of drowsiness.  Second, and importantly, the light exposure from the backlit screen (particularly when full-color) can also have a stimulating effect.

 

Light tends to inhibit the release of melatonin in your brain.  There is a thin band of neurologic tissue–called the retinohypothalamic tract–that connects your eyeballs to the hypothalamus, the seat of your body block.  This tract is stimulated when the back of your eye–the retina (the cells of which are illustrated above)–are exposed to bright light, and the resulting signal to the brain leads to a sensation of wakefulness and alertness, the exact opposite of what you want when your goal is to fall asleep for the night.  This is why it’s important to avoid bright light late at night and to expose yourself to bright light early in the morning if you have insomnia.

The problem is that modern backlit e-readers are not only capable of emitting very bright multi-colored light, but also held very close to your eyes:  unlike your television set, which is across the room, your iPad is on your lap or held right in front of your face, bathing your retinas with light.

So here are some suggestions for you if you’re having difficulties falling asleep following backlit e-reader use at bedtime:

1.  Turn down the intensity or brightness of the screen.
2.  Try an e-reader without a backlit display, such as a basic Kindle.
3.  Call me old-fashioned, but you could always go back to paper books, and save your e-mail for tomorrow morning.
4.  Read in relatively dim light.
5.  In general, avoid intense light for about 1-2 hours prior to your projected bedtime.

Happy reading, everyone!

Post-Traumatic Stress Disorder and Sleep: My Interview With Captain Ken LeBlanc

I want to tell you about my old and dear friend, Ken LeBlanc, a Captain in the United States Army. Ken and I went to high school together and have watched our lives and careers evolve in recent years.  He lives in and is stationed in Wiesbaden, Germany, near Frankfurt, and he works at US Army Headquarters for the G-34 Force Protection Directorate at Wiesbaden Army Airfield.  He is an Operations Officer.  His responsibilities include the entire Black Sea region of eastern Europe. He assesses and mitigates risk by developing site-specific guidelines for force protection and personnel safety, including counter-surveillance, stand-offs, and personnel access.  He develops travel guidelines, working with the DIA and Department of State for any individual and group travel to foreign lands. He has been deployed several times.  I consider Captain LeBlanc a hero, not only because of what he’s done for the benefit of our country, but also how he has handled the many intense experiences he has had as part of his military duties over the years.

Image

Ken tells me that he has had some genuine difficulties with his sleep since relocating to Germany.  Troubled by vivid dreams, he suffers from disrupted sleep, frequently awakening with a sensation of anxiety and in a cold sweat.

Ken has been diagnosed with post-traumatic stress disorder (PTSD).  He tells me that he’s not alone:  many of his colleagues have had similar symptoms upon returning from their deployment and have been diagnosed with PTSD, reflecting recent Veterans Administration reports that indicate that nearly 30% of VA patients who served in the Iraq and Afghanistan wars have been diagnosed with this disorder.  He also believes that PTSD is still under-recognized and under-treated in the military.

PTSD is commonly associated with sleep problems, often stemming from a combination of factors:  the self-protective mode of constantly being “on alert,” worry, physical symptoms (such as chronic pain) associated with previous trauma, and frequent nightmares which may or may not be directly related to previous traumatic experiences.  Chronic sleep-onset and sleep-maintenance insomnia and daytime fatigue are commonly observed in those suffering from PTSD.

Captain LeBlanc was kind enough to agree to describe some of his experiences with Sleep Help Desk from his home in Wiesbaden.

MC:  You’ve been in the military for many years, Ken; you’ve visited many countries and you’ve seen many things most Americans never will see. How does a soldier process all of the intense experiences such as the ones you’ve had?

KL:  If possible, by processing the good and bad with groups of others. The Army has many specific programs to help deal with and process activities and experiences. As an Officer I have a duty to help younger Soldiers with any issues that might arise from their combat- and noncombat-related experiences. Sometimes being far away from your family causes things to happen such as divorce and bankruptcy, and this can be as difficult to process as combat. As Soldiers one hopes that the foundation they have morally and psychologically helps them to diffuse critical events but being with like-minded others brings a support system unlike any other I have been involved with.

MC:  How do you perceive your experiences have affected your sleep?

KL:  Sleep is a critical and performance-altering behavior. I am an older Soldier who has witnessed many things younger Soldiers have not experienced and I’ve thought from the very beginning that this would be my personal asset. They aren’t, however, like good experiences (like the birth of a child or success at work), which do not replay in your head during times of attempted sleep. It might be thunder or loud noises or strange noises, but they all bring me back to unfavorable experiences. Dreams become more vivid and after awakening one goes through a litany of questions concerning that event. After a few months it gets a little better but when one least expects it one might dream of something as innocuous as a large crowd and begin to feel the anxiety that accompanies it. My military experiences cause many sleepless nights because after waking up (usually in a sweat) it becomes hard, if not impossible, to regain drowsiness and fall back to sleep.

MC:  So let’s talk more about your dreams, Ken.  How often and how intensely do your dreams relate to your current work or previous military experiences?

KL:  After returning stateside I had incredibly vivid dreams every night. I would wake up and go through them repeatedly. I would feel foolish for having them. Most of the time they relate directly to military experiences but after a while they lose that flavor and start to relate to difficult periods in my life. It feels as if it becomes a habit:  waking up to dredge over bad experiences no matter what the setting. I would normally not associate one with the other except that in prior times this never happened. The causality of combat and dream behavior is in my opinion directly linked.

MC:  What helps?

KL:  The honest truth is that alcohol and I have self-medicated many a night in order to fall asleep. This is not a good sleep, but it is the ability to get to sleep that one desires more than any other thing. Once in the habit it is very hard to break (thankfully I have recognized this as a direction I did not want to go and have stopped drinking as a habit). It affects performance at work and weight and psychological issues so this is not something I would recommend to anyone. I have also tried prescription medications. This is not a good alternative for me either as I still wake up, unknowingly, and re-medicate. I remember one night in particular, in which I woke up the next day to find that out of 30 prescription pills, some time during the night I had ingested 20 (and lived). This was my wake-up call and I stopped all medication thereafter. Now I read as long as I can before trying to sleep. It gets me to sleep but not for very long. I awaken again, usually in a sweat, and either get up for the day or lie in bed all night until a reasonable hour and then get up. I have tried many nights to stay awake for several days and then “reset” my body clock only to find I experience the same outcome as if I had gone to bed every night. It truly makes me wonder why I can function on such little sleep.

MC:  Is there anything that happens in your current work life that triggers a worsening of your sleep, other than jet lag from travel?

KL:  As a Soldier I always have different report times as the events I manage don’t stop to allow me to get some rest. At the risk of sounding cavalier, they are life-and-death situations and as a result I never really know when I will be able to shut work out completely and rest. This is true for all Soldiers, not just me. In what other career can something happening 10,000 miles away affect your daily life? Sometimes it’s just the Army philosophy of early to rise. My days have started as early as 0345 to 0900 and there usually isn’t a cut-and-dry schedule as to when that will be.

MC:  Ken, tell me about how your colleagues handle their own problems with sleep.

KL:  Honestly, alcohol is pretty prevalent. Some medicate with sleep aids; some try relaxation techniques. Most Soldiers diagnosed with any form of PTSD is prescribed some form of selective serotonin reuptake inhibitors (SSRIs). This helps many deal with what I would refer to as “sleep anxiety.” I can only speak for myself when I say going to bed is one of the hardest events of my day. I know I’m not going to sleep, or the sleep will be lousy, but I also know if I don’t try I’ll be worthless the next day.

My deepest thanks go to Captain LeBlanc for bringing attention to this important problem, and for his honorable and courageous work in securing and protecting our country.

Insomnia: It’s Okay to Hope

Last night Wichita State University fell to top-seeded Louisville in a valiantly fought Final Four semi-final NCAA men’s basketball tournament game in Atlanta.  As my blog followers know, I’m a Kansas Jayhawk first and foremost, but I grew up in Wichita and have strong ties to WSU.  My heart aches for the Wichita State Shockers, as it did last week when Kansas lost to Michigan.

Intermediate- to low-seeded teams are a rarity in the Final Four, and ninth-seeded WSU truly exceeded the expectations of many.  Few anticipated the Shockers to make it much past the second or third round of the tournament.  But as Wichita State continued to shock the nation with win after high-profile win, something beautiful started to germinate and grow in my native Wheat Country:  hope, hope that those wins will continue, all the way up to the end.  Could it be that this young mid-major squad, whose name sportscasters and game announcers can’t even pronounce properly (“Wishlata?”  “Stalkers?”  Seriously???), might possibly wrestle the national title from the vaunted blue bloods of college basketball?

 

The Merriam-Webster definition of hope:  “desire accompanied by expectation of or belief in fulfillment.”

Though the championship is now not to be this year for Wichita State, Shocker fans did not lose much by daring to hope.  Hope implies a transition from non-expectation to expectation.  Hope is also rooted in reality, arising from a personal interpretation of what is experienced, such as upsetting the top-seeded team in your tournament region.  Despite the inevitably profound disappointment when your team loses after having battled to within an arm’s length of the national title, there still lingers the warm feeling of what has been achieved, against all odds, and what therefore can be further achieved in the future.  The new expectation then morphs into a different belief system, and it is this new set of beliefs that generates optimism, a hopeful confidence that continues to build and grow as the years go by.

Nowhere in the realm of sleep medicine is one’s individual system of belief more important–and more responsible for great success or abject failure–than in the management of insomnia.  If you’ve had difficulties falling and staying asleep in your bed for years, you can gradually become conditioned to not sleep well there.  There is no longer the expectation that you will sleep well there due to years of experience to the contrary, so you begin to feeling you’re losing hope that you’ll sleep well again.

Therein lies the cognitive paradox pertaining to insomnia.  We all know that sleep is a necessary and required biological function, and that sleep must be achieved eventually and inevitably, because we must sleep no matter how bad our insomnia; as such, logically there is every reason to expect to sleep, every reason to hope.  However, previous experience sleeping badly enforces the idea that we won’t be able to sleep reliably well again, and this misconception is reinforced every time we try unsucessfully to achieve asleep–such as by counting sheep, listening to relaxation tapes, or what have you–and the resulting fear and frustration keep the hope from surfacing.

In a clinical scenario, a longstanding insomnia patient may respond to the physician’s suggestion, for example, with the knee-jerk exclamation, “But I’ve already tried that!”  I’ve heard that response once or twice in my career, sometimes loudly, even angrily.  But the thought process that generates that frustrated claim can be self-defeating.  First of all, by the time insomniacs feel compelled to visit me in my clinic, they’ve usually already been through a variety of physician-recommended or self-employed treatments or management programs.  Second, by the time they make it through my doors they usually have developed multiple specific reasons to have the insomnia.  Third, whatever was tried earlier probably wasn’t tried in the same context of what is being suggested now.  Finally, often what is “tried” in the first place is tried with the additional burden of performance anxiety:  that feeling of “this had better work,” which only compounds the frustration when what is tried doesn’t result in the achievement of sleep.  Despite all of this, however, hope exists:  were it not for hope, these folks would never have bothered to make an appointment.

My job in this situation is that of both doctor and coach.  Hope is based on reality and fueled by knowledge.  Therefore, for my chronic insomnia patients, the first thing I do after collecting a history and performing a physical examination is sit and discuss at length why I think the insomnia is happening.  I make a list and outline all the probable reasons why the problem has started and continued.  I’ve found this helps them understand the reasons why subsequent recommendations are made, and why I believe that real improvements can actually be achieved, no matter how stubborn or prolonged the insomnia has been.

I believe that even the most hardcore insomniacs can use hope to their advantage.  I suggest that insomniacs choosing to visit a sleep specialist go in with an open mind, a willingness to absorb thoughtfully made recommendations and employ them with an expectation that they may well be helpful, though not necessarily immediately.  It’s hope that brings them to the clinic in the first place, so I recommend making the most of what they already have in them and allow themselves the willingness to believe that the sleep can get better.  If doctor and patient listen to each other openly, it just might.

An Early Mo(u)rning For Jayhawk Nation

 

As any student or alum of a blue blood basketball college–Duke, Kentucky, Indiana, North Carolina, Kansas–knows, summer, fall, and winter really serve but one purpose:  to prepare for March Madness, the NCAA Men’s Basketball Tournament.  During this time of year, late March to early April, 68 of the best men’s college basketball teams in the United States punch their cards to the “Big Dance,” in the hope of their one shining moment, a chance to be national champion.

I’m an 8-year Jayhawk, having gone to college and medical school at the University of Kansas.  I was a senior undergraduate when our basketball team–led by Danny Manning–claimed the national title in 1988.  It was truly an unforgettable experience:  the height of uncontrollable joy and complete elation, a party that lasted for three straight days and nights.  Differences and conflicts between people and between groups on campus simply evaporated as hundreds of thousands from Lawrence to Kansas City poured out of their homes, dorms, and workplaces to celebrate together, to hug and high-five perfect strangers, to be in the moment.  For weeks following that win over Billy Tubbs’ Oklahoma Sooners, a collective rapture unified us, making us whole in our exultation and the love for our school.  That intoxicating sensation transcended mere sports:  it was a pure happiness, the way you wanted things to be forever, the way you hoped your life would be like when you grew up, whatever it was your future held.  That feeling is perhaps what I would imagine being jacked up on crack or heroin must be like.  When you’re there, in that moment, you know that it’s unrealistic to expect such ecstasy to be sustainable, it’s so epic and so intense.  But you hope against hope that life could feel this way, if not forever, then at least again.  Some time again.

It is with this hope of recapturing that bliss that every year we Kansas Jayhawks look forward to our autumn ritual, Late Night in the Phog, to usher in the new men’s basketball season and all the hopes and expectations that go with it.  Long after graduation we look forward to watching every game, at Allen Fieldhouse, on television, or online, and cheering on our guys.  We watch the AP and USA Today polls every Monday morning for upward movement in our rankings.  We closely follow our main man, head coach Bill Self, as he clears a path for each year’s kids with grace and confidence.  And as Selection Sunday draws nearer and nearer, our heads fill with a heady mixture of excitement and anxiety, anticipating seeds, matchups, and karma in an annual quest for our holy grail:  the national title.  No matter what your station in life, no matter how happy you might be at home or at work, there is still that other happiness you crave, that sensation more powerful than any street drug.  Your team is the only key that opens the door to that happiness.

It is the proclivity of the Jayhawk to combine hope with expectation, at least an expectation to be a worthy contender, and with class.  But becoming national champion is hard.  Very hard.  And statistically unlikely.  So for us, when it comes to the final result of the national tournament, there are really only two options:  complete elation with a championship or utter devastation when our team falls short.  Since my senior year at KU, that complete elation happened once again, in 2008, thanks to Mario Chalmers and his now-legendary game-tying 3-pointer against the Memphis Tigers:

To witness a true Jayhawk championship court-stormin’, forward to 4:00 in this clip, again taken from Allen Fieldhouse:

And so it was that Jayhawk Nation went into the 2013 national tournament with its usual high hopes, Kansas the #1 seed in the south region.  When we lost in overtime to the Michigan Wolverines 48 hours ago in the Sweet Sixteen, it was full-on, crushing, world-coming-down heartbreak.  Without dwelling on details here, a healthy lead dissipated gradually during the final 3 minutes of regulation play, forcing us into overtime due in part to an incredible Michigan 3-pointer with seconds left, kind of a Mario Miracle in reverse.  We had been winning virtually all game long until the very end of regulation.  It’s tough to take, this idea that just one more point, one less missed opportunity, one more free throw, and the outcome could have been very different.  Jayhawkers around the country reeled in shock.  Only now am I starting to recover from it.

I’ve spent this past weekend nursing my emotional wounds and dealing with another transient but inevitable element of my own special method of mourning:  sleep maintenance insomnia.  I’ve been awakening around 4:30 a.m. for the past 2 days.  Yes, I’ve been following my own advice and getting out of bed to minimize the frustration.  The phenomenon of early-morning awakening is a very common clinical element in situational and characterologic depression.  I know me, and I’ve been through enough NCAA tournaments to know my tendencies:  I’m as blue as can be for 2-3 days after a tournament loss, and then life’s demands and thoughts of next year’s season gradually take over to help me climb out of my funk.  I can already feel that happening today, so I think tomorrow will be a better morning.

One thing’s for sure, a lot of Jayhawks slept poorly this past weekend.  But here’s to a new morning, a new Late Night in the Phog, and a promising 2013-2014 season.  Looks like Kentucky will be the team to beat next year, but we will continue to cultivate our high hopes.  Go get ’em, Hawks!

 

What About Naps?

Thank you, everybody, for your recent inquiries.  I’m happy to help!

The other day I was asked about daytime naps:  “is it better to take a nap when you are feeling really tired that day or try to go to bed earlier instead and skip the nap?”  In order to best answer the question, it’s important to know what is causing you to want or need the nap in the first place.

 

The science of sleep regulation is quite complex.  Sleep intensity is mediated by what is called the homeostatic mechanism of sleep, the specifics of which are beyond the scope of this blog entry.  Simply stated, the principles of sleep homeostasis dictate that sleep deprivation results in a compensating increase in intensity and duration of sleep, and excessive sleep (such as related to a daytime nap) reduces the inclination for sleep.  Taking a nap during the day implies daytime sleepiness, so let’s explore why one may be sleepy during the day.

One of the most common causes of daytime sleepiness is simple sleep deprivation.  If you’re getting 5 hours of sleep per night, for example, when your body needs 8, then likely you will not need to take a nap during the day any longer if you then gradually increase your sleep time to 8 hours per night, because by satisfying your body’s natural sleep needs consistently you should eventually feel substantially more awake and alert throughout the day.

Another common cause of daytime sleepiness is insomnia.  If you get less sleep at night because you’re awake a lot in bed, an obvious consequence would be feeling fatigued and drowsy during the day.  The problem is that taking a nap during the day can cause or worsen insomnia, particularly if the nap is prolonged and/or taken in the mid-afternoon to early evening; you tend to get a “second wind” and feel more awake and alert later than what you desire, resulting in further sleeplessness at night.

Finally, you could be sleepy during the day due to a problem with the quality (as opposed to the quantity) of your sleep.  Numerous sleep disorders can cause substantial drowsiness during the day even if you get your 8 hours per night:  obstructive sleep apnea, upper airway resistance syndrome, periodic limb movement disorder, and narcolepsy to name a few.  A good general rule to follow:  if you regularly get 7-8 hours of sleep per night and you’re consistently struggling to stay awake during the day when 7-8 hours per night used to satisfy your sleep need in the past, and if the sleepiness can’t be explained by some other factor (like medications or alcohol), you may want to see a specialist like me.

OK, synthesizing this down, then, here are my personal primary clinical concerns about napping:

1.  If you nap because you’re sleep deprived, there is often residual sleepiness between the time you awaken in the morning and the time your nap starts.

2.  If you nap due to insomnia, a vicious cycle can develop:  the nap can cause or worsen the insomnia, which then reduces your nocturnal total sleep time, which then makes you feel more sleepy during the day, which then makes you want to nap more.  In extreme cases people’s bedtime schedules can be completely turned around due to this problem, such that they become essentially nocturnal, sleeping throughout much of the day and remaining awake all night.

3.  Taking a nap to sustain you for the rest of day may “mask” concerns for an occult sleep disorder.

Bottom line here:  if the nap doesn’t cause difficulties falling or staying asleep at night, and if you don’t have substantial daytime fatigue or sleepiness prior to the nap, and if you’re confident you know the reason why you need the nap in the first place (such as staying up too late the night before), then I think there’s probably not much of a problem with taking that nap.  However, if you find yourself unable to stay awake during much of the day, if you are substantially sleepy during the day despite getting proper amounts of sleep, or if you are having mounting insomnia in this setting, there should be further concern about what is happening.

I’ll add several additional points before Sleep Help Desk closes for today.  First, naps can be intentional (i.e., laying down with the intention of taking a nap) or unintentional (such as falling asleep by accident in front of the television).  Second, if you doze off on the couch at 10 p.m. before you go to bed, that’s still a nap!  That late-night nap can cause difficulties falling back to sleep once you do go to bed, so try to avoid dozing off in the evening until you’re in bed intending to sleep.  Finally, to answer the original question posed to me above, I suggest not going to bed too early if you choose to not take the nap.  If you go to bed way earlier than usual, you can still have insomnia even if you’re sleep deprived, because your body clock “wants” regularity nonetheless.  The idea is to gradually increase your total sleep time such that you reliably get proper amounts of sleep every night.

Trivia question:  who is the famous person napping in the photograph above?  Write me with your answer!

Cheers, everyone!  Keep your questions coming!

“Why Do I Wake Up at the Same Time Every Night?”

I’ve been asked recently by a friend why she finds herself awakening at 2 a.m. virtually every morning.

Many people have experienced this phenomenon, a tendency to awaken at least briefly around the same time every night. There may be many potential reasons for this, ranging from your pet to a need to urinate or a spouse coming to bed for sleep later than you. The expression of certain hormones in your brain throughout the night might play a role.  However, for many people, these brief awakenings may also be related to your brain’s natural rhythms for sleep.

To describe human sleep physiology as simply as I can, human sleep is very dynamic. We sleep in cycles, called ultradian cycles, in which lighter stages of non-REM (called stage N1 and N2) sleep are followed by deeper forms of non-REM (formerly called stage 3 and stage 4 sleep, but now called stage N3, or slow wave) sleep and then, to varying degrees, rapid eye movement (REM, stage R, or dream) sleep. In general, the amount of deep non-REM sleep we have per cycle is highest during the first one-third of the night’s sleep, and the amount of REM sleep we have per cycle gradually increases as the night progresses (which explains why we tend to remember our dreams most around, say, 4-6 a.m.). Exactly how and why we have been designed neurologically to sleep in this way are a mystery. A typical human adult’s ultradian cycle lasts for about 90-110 minutes. Generally it’s most difficult to awaken fully from N3 sleep, and it’s quite easy to awaken fully from REM sleep. This explains why you often feel very groggy if you’re awakened abruptly during the first 2-3 hours of sleep, but may find yourself awakening easily and quickly from a dream later at night.

The primary point I want to make with all this is that between these ultradian cycles, there are normally and naturally periods of arousal from sleep. There can be several of these brief arousals in a typical night.  In children, adolescents, and young adults, these arousals are generally very brief, perhaps lasting for only several seconds; these awakenings are not usually enough to remember, in part because younger people tend to have a lot of slow wave sleep), leaving you with the feeling that you are sleeping uninterrupted all night long, even though you have likely in reality aroused several times. Once you reach middle age, however, such as your 40’s and 50’s, the tendency to recall these arousals from sleep can gradually increase, and the duration of the typical arousal from sleep may gradually increase as well. This may explain why some people remember awakening, say, at 3:30 a.m. on the dot every night. Finally, when you become elderly, in your 70’s and 80’s, say, still more frequent awakenings may occur due to the naturally increased sleep disruption that occurs as your brain becomes more brittle with age.

Why is this all important? Because some people freak out over a spontaneous recalled arousal from sleep in the middle of the night, and this substantial concern or annoyance can generate enough worry or frustration to actually cause persistent wakefulness subsequent to that arousal, potentially triggering chronic insomnia.

Take-home point here: if there is a brief awakening around the same time most nights, and there is no specific symptom or problem that causes the awakening, and if there aren’t substantial problems falling back to sleep, and if there is minimal sleepiness during the day, my sense is that the awakening is probably not much to worry about. If there are substantial problems associated with the awakenings, however, it may be worthwhile to bring that to a doctor’s attention.

Have a great evening, everybody, and sleep well!

Insomnia . . . For Wichita State and Gonzaga

I am and always will be a Kansas Jayhawk.  But my first awareness of college basketball was thanks to Wichita State University, the very school whose team just advanced to the Sweet Sixteen of this year’s NCAA men’s national college basketball tournament by trouncing top-seeded and top-ranked Gonzaga last night.

Wichita State was an integral part of my childhood.  My dad was a professor there for decades, teaching criminology, editing the journal he founded, The International Journal of Comparative and Applied Criminal Justice, and solidifying his legacy in the field of administration of justice.  I also took math, literature, and computer science classes there in the summer while I was in high school.  And, importantly, WSU’s infamous basketball coach, Gene Smithson, lived three doors down from us.  Growing up, we looked up to him and the young men he coached–particularly Antoine Carr and Xavier McDaniel, who subsequently became nationally recognized professional basketball players.  Smithson popularized (and perhaps even invented) the term “MTXE”–“mental toughness, extra effort.”  I live by this phrase every day.

 

So I have to say I was very pleased with WSU’s win over the Bulldogs last night.  As a Kansas native now living in Washington state, I empathize with both teams and their fans.  Nobody with ties to either school slept very well last night.

Here’s the Wichita State Shocker in bed.  You just watched your team pull down the heretofore #1 ranked college basketball team in the country.  Only now that you’re in bed are you processing what this huge upset means for you and your fellow Wu-Shocks.  It’s pure rapture.  You’re in the Sweet Sixteen in a year of absolute mayhem in men’s college basketball.  There’s no clear, inarguable favorite to take the title like there was last year.  It’s anybody’s tournament; any team can win it all.  This year it might, just might, be the Shockers!  Your head is buzzing from all this emotion and mental racket.  You imagine the improbable run to the championship game, a buzzer-beating final shot that clinches the title, the ticker-tape parade down Douglas Street.  How are you gonna sleep with all that adrenalin running through your brain?

Here’s the Gonzaga Bulldog in bed.  You’ve become tired of the pundits and analysts saying that Gonzaga became #1 by default.  You’ve just heard Dick Vitale on ESPN predicting loudly that “the Shockers are gonna shock the nation.”  Sure, your school is in the West Coast Conference, but you’ve had some wins against quality non-conference teams this season, and going into the Big Dance you know the Bulldogs now have the chance to prove the nay-sayers wrong.  And then . . . crushing, unmitigated defeat–in the third round.  It’s like someone ran over your dog and then sped off.  You feel helpless and in despair, left with the bitter reality of the loss.  You go to bed truly in mourning, knowing the mourning will only continue upon awakening the next day.  How can you hope to sleep tonight, knowing that any temporary rest will bring only minimal reprieve and solace?

Man, I’ve gone to bed both ways every late March and early April for years.  I know exactly how it feels.  And the fact is that all of us have, basketball fan or not, for one reason or another, throughout our lives.  Why?  Because we’re human.  We have emotions, hopes, dreams.  We put ourselves at risk emotionally by daring to hope in the face of adversity or unfavorable statistics.  When the risk pays off, the elation is something you will savor for the rest of your life.  But when you lose, well, that’s also something you remember forever.

It is part of the human condition for these emotional peaks and troughs to affect your sleep.  As such, everybody is susceptible to at least some occasional transient insomnia.  Usually the insomnia burns off as its trigger fades into the background of your life.  However, in some cases the sleeping problem can persist as dysregulation of bedtime schedules and mounting frustration over the insomnia set in and worsen.  It’s at this point that people start to schedule appointments to see guys like me.

Bottom line here:  anything you think about that is of emotional importance–whether good or bad–can cause at least transient insomnia.  Just ask Shocker and Bulldog fans.

I’m hoping that I won’t be going to bed tonight like the Zags did last night.  KU is playing Roy Williams and his Tarheels.  MTXE, baby, and Rock Chalk Jayhawk!

 

Turn That Alarm Clock Around!

Howdy all.  I hope you had a great weekend!

 

Tonight I write briefly about a habit many millions have adopted as an integral part of their night-time routines:  staring at the alarm clock.

When you awaken in the middle of the night, it’s a perfectly natural impulse to glimpse at your clock.  It seems important to know how much more time you have before it goes off, or how much sleep you’ve gotten, or how many more hours you get to spend in bed.  However, for those with insomnia, this “clock-watching” can easily compound the frustration that comes with being awake in the middle of the night when you don’t want to be.

Here’s the typical scenario.  You go to bed, hoping you’re going to fall asleep quickly.  After a struggle and some tossing and turning, you finally manage to trundle off to sleep.  Suddenly, it’s 2:07 a.m.  You turn your head to view the clock.  The red digital numbers glare starkly at you, offering you a silent challenge:  “OK, now you know; so what are you going to do with the information I just gave you?”  You feel the frustration already gnawing at you as that precious sensation of drowsiness starts to ebb, giving way to an unwelcome wakeful feeling arriving way too early.  You turn your head forward to stare now at the ceiling, hoping the sleepiness will somehow return, but it’s too late.  The wakefulness that inevitably accompanies your exasperation is firmly planted now, dancing about in your head derisively as you try with increasing desperation to achieve sleep again.  A half-hour crawls by . . . or was it fifteen minutes?  Maybe you should look at the clock again to find out:  there’s that meeting you have to be fresh for, you have to get up at 6 at the latest, and you need that sleep badly to be in top form later in the day.  Should you turn your head toward the clock again?  A couple seconds of existential struggle later, you satisfy your need.  It’s now 2:11 a.m.

Does all this sound familiar?  Sure it does.  It’s happened, in one form or another, to virtually all of us (myself included) during our lives.  That urge, that need to gaze repeatedly at the clock can easily and naturally become a habit, an insomniac ritual.  And for some this ritual can, over time, get completely out of control, with an increasing need to look at the clock all the time, every several minutes, sometimes even several times per minute.  How is this not going to make you completely cray-cray?  I’ve had insomnia patients who have purchased those special clocks that actually project the time in huge red numbers onto the ceiling, so they can watch each minute of sleeplessness tick slowly away every night.  I do not advise this.

There are two problems with habitual clock-watching:  it doesn’t help, and it can often make insomnia worse.

Think about it.  Watching the clock doesn’t make the time go any faster; it doesn’t make you fall asleep any faster.  It only frustrates you, because every time you gaze at the clock you add a little bit more pressure upon yourself to perform, to achieve the sleep you so desperately want.  And the more frequently you watch the clock, the more the aggravation mounts.  You may not even be aware consciously of the frustration, but it’s there, creating more and more mental stimulation and making you feel increasingly awake and alert, at precisely the worst time of your diurnal cycle.

My advice to habitual clock-watchers:  turn the clock around.  If the alarm clock is working properly and if the wake-up time is set properly (you should check these prior to your bedtime), it will awaken you when it’s supposed to.  Get a second alarm clock that is battery-powered if you’re concerned about a power outage preventing you from awakening at the right time.  Your clock doesn’t care if you’re staring at it all night or not.  It’ll go off when it does.  Trust it to do that for you.  If you can free yourself from the psychic need to look and to try to control time when you can’t, you will only help yourself and increase the likelihood of eventually freeing yourself from the bondage of insomnia.

OK, folks, I am going to take a little breather from writing for several days.  I will be back at it in full force before long, however.  Sleep well, everybody!