Category Archives: The Nature of Sleep

“What’s With This Big Body Jerk Out of My Sleep?”

Tell me if this has ever happened to you.

 

You’re lying on your couch one night, watching a movie. An hour into the show, you gradually start to drowse. Your eyes are getting heavy; it’s increasingly hard for you to concentrate. You want to keep watching, but finally you start to give in: your eyes are closing.  A familiar, dark, fuzzy, comfortable sensation enshrouds you, mixed with a vague feeling like you’re falling into some kind of void. There is a brief reverie; you are asleep. Then, shortly thereafter and out of nowhere, BOOM! There’s a sudden shock-like sensation and an abrupt awakening. Your entire body jerks violently, like someone sucker-punched you, but there is no pain. That singular jerk almost sends you off the couch. The person you’ve been watching the movie with looks over, wondering what the hell is wrong with you.

Sound familiar? Most (up to 70%) of us have had that experience at one time or another in our lives. This phenomenon is called a hypnic jerk, or sleep start. Much is not understood about why or how it occurs, but a hypnic jerk consists of a single, sudden simultaneous contraction of multiple body muscles, basically the manifestation of a full-body reflex occurring shortly upon entering light stages of non-REM sleep and resulting in a sudden arousal from sleep.

Hypnic jerks tend to happen more in the setting of sleep deprivation or irregular sleep schedules. I vividly recall that during my residency training days, I abruptly awakened with these jerks all the time, probably because of the frequent sleep deprivation to which I was subjected at the time. It drove me nuts. Now that I’m allowed to get my 8 hours per night most of the time, only rarely now do they occur.

There are several reasons why it’s worth writing about hypnic jerks. First, some people freak out about them. The jerks in and of themselves generally are benign and aren’t harmful per se. Secondly, some may wonder if the jerks indicate an underlying medical problem, such as epilepsy. A generalized convulsion that involves jerking movements of the entire body are usually associated with repetitive jerking instead of a solitary body jerk, and you would be unconscious during the seizure. Finally, if the hypnic jerks are frequent or bothersome, there is often something that can be done about them. If you’re chronically sleep deprived, do what you can to gradually increase your total sleep time per night; most adults require about 7.5 – 8 hours of sleep per night. Regulate your sleep schedules by awakening around the same time every morning, including between workdays and non-workdays. Consider tapering down things that can disrupt sleep, like caffeine or alcohol. Sometimes stress or particularly strenuous activities late at night may also increase the likelihood of having hypnic jerks, so relaxing prior to your bedtime may be helpful as well.

Have a great weekend, everyone!

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.

“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!

How Do You Make Time For Sleep?

 

A high school classmate of mine recently asked me about how to find time for sleeping.  This is a vitally important question that bears discussion.

You probably have heard phrases like “sleep is for sissies” or “I’ll sleep when I’m dead.”  Well, regardless of the motivations one may have for saying such things, the fact is that sleep is essential, and you function best if you get as much sleep as your body and brain need.  An important concept is that your body will somehow, eventually, force you to find the time to sleep.  To those who do not believe this (take it from me, there are some people who honestly do not), a simple experiment would be to stay awake, day and night, for as long as you can.  See how long you can stay awake before you eventually fall asleep.  There comes a point in which the urge to sleep becomes overwhelming and completely irresistible, forcing even the most sleep-deprived people and the most hardcore insomniacs to yield to its power.

A less dramatic example from everyday life is the concept of “sleeping in.”  Most everybody has slept in, such as on weekends, on occasion during their lives.  Unless there is some complicating circumstance like certain medical illnesses, medications, or substances (like alcohol or drugs), your body won’t let you sleep more than what it needs, so sleeping in is your body’s way of telling you that it’s needing more sleep on other nights than what you’re granting it.

The vast majority of adults require around 7.5 to 8 hours of sleep per night regularly to feel fully rested and awake during the day.  However, today’s American society often makes it difficult to get that much sleep every night.  Think about the challenges we face.  Many of us work hard, spending long hours working, networking, and commuting.  We play hard too, engaging in numerous activities that make us happy and fulfilled.  Our lifestyle has evolved based on a combination of individual drive and capabilities and the culture and expectations of the society in which we live.  There are many additional factors that also play roles, of course.  If you have children, for example, you know well the challenges of coordinating your life with your kids’ schooling and activities.  The availability of different activities and entertainment has also grown exponentially in the past several decades; choices of things to do to occupy your time have now become virtually limitless.  Finally, there is technology, that ubiquitous fun, instructive, helpful, time-sucking presence that virtually defines our modern lifestyle.

These components are inevitable and inescapable in our collective lives.  There are still only 24 hours in a day.  But because there is always so much going on and because we’re always so busy, there are times in which something’s gotta give, and often that thing is sleep.  As a result, many of us sacrifice sleep, getting 4, 5, 6 hours per night for nights on end.  The problem is, there are well-known shortterm and longterm consequences of missing out on sleep, ranging from depression to fall-asleep car crashes.

Most of us have the common-sense knowledge that daytime fatigue and sleepiness result from missing out on proper amounts of sleep.  The clinical consequences of chronic sleep deprivation and the concept of sleep debt will be topics of future blog entries.  The purpose of today’s entry, however, is to outline a program to help a chronically sleepy, sleep-deprived person make more time for sleep.  Here are some simple but important steps.

1.  Buy into the notion that you need your sleep.  You need to own this one to get more sleep; as with anything else in life, fixing a problem starts with understanding the problem and acknowledging  the need to change.  This concept will be a recurring theme here at the Sleep Help Desk.  There’s nothing you can do about your intrinsic sleep needs:  you need sleep, and without enough of it inevitable consequences arise, such as daytime sleepiness, health problems, and decreased work productivity.  You’re human; it’s not macho to sacrifice your sleep to prove to everybody that you can go longer and further than everybody else.  A pot of coffee per day may make you feel more alert temporarily, but it doesn’t address the underlying cause of chronic sleepiness.

2.  Regulate your sleep schedules.  I recommend awakening around the same time every day, regardless of whether or not you need to awaken for work or some other activity.  This helps you obey your body clock’s hardwired need for regularity, allows you to get more consistent, predictable amounts of sleep at night, and ultimately increases your levels of wakefulness and alertness during the day.  If you have frequently irregular sleep schedules, you can still experience daytime sleepiness even if you get proper total amounts of sleep most nights.

3.  Change your bedtime scheduling little by little.  My recommendation is to slowly, gradually go to bed earlier, such as by 10-15 minute increments every 2-3 days.  If you know you’re sleep-deprived, tonight go to bed 15 minutes earlier than your usual.  Continue to go to bed around that time for several days.  Then, go to bed 15 minutes earlier than that.  Repeat this until you eventually get your 8 hours of bedtime per night.  This way, your body clock will easily absorb the changes you’re making in your sleep scheduling (thus avoiding a “jet-lagging” effect); if you suddenly go to bed two hours earlier than you usually do, for example, insomnia may well result, even if you’re sleep-deprived.  More importantly, however, you are more likely to be able to adhere easily to the changes you’re making for yourself if the changes are slow, deliberate, and gradual.  Why is this important?  Because we humans are creatures of habit.  If you’re used to staying up until midnight watching the late-night talk shows, for example, when you know you need to awaken early for work, though you know you will be sleep-deprived, the tendency to still stay up late watching TV remains, simply out of habit.  It’s what feels familiar and normal to you.  Successfully making something new familiar takes time.

4.  Reprioritize your and your family’s evening activities.  I know this is hard.  It took me some time to achieve this myself.  But if you really scrutinize what you and your loved ones do after work or school, it often becomes apparent that there are periods of time that could be either spent doing more essential activities or resheduled to another time of the day or week to allow for more sleep.  Try sitting down with your family and drawing out a weekly activity chart to determine what activities are most important in the evening, what activities can be stopped or rescheduled, and what down time there really is for you and your family to wind down from your day and prepare for adequate sleep.

5.  Stick with it.  Like restarting smoking, falling off the wagon and regularly getting less sleep than your body needs can eventually feel “normal” again because it returns to your daily routine.  Avoid the temptation.  Keeping striving to allow yourself proper amounts of sleep.  Often the tiredness you feel when you are now used to feeling more awake and alert during the day may be incentive enough to keep getting proper amounts of sleep each night.

Our crazy modern world doesn’t allow us to get our 8 hours every single night.  I recognize that, being a fellow member of our society, there are times in which there is no choice but to be sleep deprived from time to time.  March Madness is usually such a time for me, depending on how deep the Jayhawks get in the NCAA tournament (hopefully going all the way this year!).  Your body is usually able to handle a night or two of sleep deprivation from time to time, and make up for the sleep at a later time with minimal consequence.  Chronic sleep deprivation is an entirely different matter, however.

So the pearl for today:  be good to yourself and give your body the sleep it needs and deserves.  You eat and drink to provide your body with nutrition; don’t deny yourself the amount of sleep your body needs.