Happy Insomnia Awareness Day!: Insomnia, Defined

The American Academy of Sleep Medicine (AASM) has declared today, March 10, Insomnia Awareness Day this year.  The timing of this auspicious occasion is in keeping with the daylight savings time change from over the weekend.

We in sleep medicine circles call today “Black Monday,” the first workday following the one-hour time change each spring.  Our body clocks don’t like making changes in their sleep shifts, even if only by a mere hour; anyone who has experienced jet lag knows what I mean.  As you know, “springing forward” one hour means having to get up one hour earlier than what our body clocks are accustomed to and thus “prefer.”  For those who do not adjust their bedtime schedules accordingly, getting up to get to work, school, or appointments on Black Monday becomes all the more difficult.  At the same time, the mild dysregulation of sleep scheduling can also lead to insomnia, particularly if there is already baseline insomnia to begin with.

 

I’ve covered insomnia in previous posts, and I will go over it and its management in future posts too, because it is such a huge, prevalent clinical problem and growing public health concern.  For the purposes of today’s Insomnia Awareness Day post, however, I will concentrate simply on what insomnia means.

The definition of insomnia, as accepted by the AASM, is the “subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment.”  [Schutte-Rodin S; Broch L; Buysse D; Dorsey C; Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008;4(5):487-504].

As such, insomnia is by its very nature subjective, meaning that you can have insomnia no matter how much actual sleep you really get, and implying that the time spent awake in bed is bothersome.  Among the many impairments associated with insomnia are a feeling of unrefreshing sleep, low energy levels during the day, daytime sleepiness, emotional problems (like depression and anxiety), morning headaches, difficulties with memory and concentration, reduced work productivity, and a propensity toward industrial and motor vehicle accidents.

This definition is important.  You can have insomnia even if you get a full 8 hours of sleep each night (such as if you are spending 12 hours trying to sleep each night).  Conversely, 4 hours spent in bed spent awake each night casually watching television but not trying to sleep do not constitute insomnia.  Note also that the definition does not address potential causes, of which there are hundreds–causes can range from a can of Mountain Dew at 10 p.m. to one’s mental perception of dread and frustration associated with previous difficulties falling asleep.  The definition of insomnia also helps provide a rough roadmap to therapy.  My own practice philosophy for patients with chronic insomnia (i.e., insomnia that lasts for a month or longer) is to identify the underlying causes and to improve the insomnia by improving or resolving the problems causing it.

From a clinical perspective, chronic insomnia management can range from relatively straight-forward to extremely challenging.  Doctors that identify themselves as “physician sleep specialists” should have the expertise and willingness to handle cases of insomnia, including the tough ones.  Enlist their help should your insomnia become sufficiently problematic.  Help IS available.

Sleep well tonight, everyone.  Black Monday is almost at its end!

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Sleep Song #3: “Shiftwork” by Kenny Chesney and George Strait

One thing I’ve always loved about country music is the recurring theme of hard work. Like sweet tea, personal freedom, trucks and cutoff jeans, getting your hands dirty and proudly carrying out your duties for yourself and your family are major topics in country songs old and new. And boy, can I relate.

 

I can also relate well to the topic of this little nugget from Kenny Chesney (with a little help from “The King,” the great George Strait). Growing up I worked late washing hundreds of thousands of dishes at a restaurant, and as a medical postgraduate trainee I was expected to work not only night call but also “night float,” in which we worked all night for weeks on end.

According to the Bureau of Labor Statistics, roughly 15 million Americans work permanently at night or regularly rotate in and out of night shifts. That’s a lot of people. People work the night shift for all sorts of reasons: it often pays better, for example, or they may simply prefer the quieter work environment, or their professions or particular stations in life may leave them no choice. Regardless, many or most of these millions of people suffer from sleep problems directly or indirectly related to the timing of their work.

A primary sleep-related problem for shift workers is fatigue. The feeling of tiredness or drowsiness can be pervasive, and when experienced during work can lead to a host of negative consequences, ranging from substantially reduced productivity to major industrial accidents. Working at night can often lead to falling asleep on the job, reduced attention and concentration, and missed time from work.

Why are such problems so prevalent in night shift workers? The answer usually lies in the difference between their weekly activities and the way we are designed to sleep. Days off from work are precious to night shift workers like they are for everybody else. The problem is, on days off, most night shift workers want to be awake during the day, because that’s when family, home, social, and leisure activities take place for everybody else around them. As a result, they end up flipping their sleep schedules around abruptly, such that now they are staying awake during the day instead of sleeping during the day on their non-workdays.

Unfortunately, your brain isn’t quite that flexible. Your body clock “wants” regularity in its sleeping patterns–which the basis for the concept of “jet lag,” for example–and completely changing your bedtime schedules around by reverting suddenly back to a night-time sleep schedule on non-workdays often or even inevitably leads to sleepiness and reduced quantity and quality of sleep.

No matter how many years you’ve put in work at night, your body clock does not biologically adapt or accommodate for your work shifts if you regularly revert back to a night-time sleep schedule when you’re not working. Instead, you adapt subjectively, accepting a certain degree of fatigue as a regular component of your life, and/or inserting a nap here and there to make up for the reduced sleep, or breaking your sleep times up into 2 or 3 separate parts in a day.

There will be more to say about shift work in future posts, because it’s not only a potential medical problem, but also a major public policy issue. Bottom line: fatigue due to irregular sleep schedules stemming from night shift work is potentially dangerous, decreasing safety at work and putting people at risk.

On that grim note, enjoy Kenny’s song! The lyrics don’t delve directly into sleep issues associated with working the night shift, but the fatigue so many shift workers feel can certainly cause “’round-the-clock pain” and make you feel like a big ol’ pile of . . . shift work.

Have a great weekend, No Shoes Nation, shift worker or not!

Shiftwork
(written by Troy Jones)

Shift work, hard work, tired body
Blue collar shirt and a baseball cap
Union made

He’s hot, sweat drops, ’round the clock
Door never locks
And the noise never stops
Not all day
Work seven to three
Three to eleven
Eleven to seven

Shift work, tough work for the busy convenience store clerk
Two feet that hurt, going insane
She’s mad at some lad
Drove off and didn’t pay for his gas and he won’t be the last
‘Round-the-clock pain
Work seven to three
Three to eleven
Eleven to seven

I’m talkin’ about a bunch of shift work
A big ol’ pile of shift work
Seven to three
Three to eleven
Eleven to seven

Well I work shift work,
Ten years man, I hated that work
Then I made a break with the money I saved
It took me to the beach
To have a beer by the edge of the sea
And this ’round-the-clock place
I drank my money away
We partied
Seven to three
Three to eleven
Eleven to seven

I’m talkin’ about a bunch of shift work
A big ol’ pile of shift work
Seven to three
Three to eleven
Eleven to seven

Talking about a bunch of shift work
A big ol’ pile of shift work
Seven to three
Three to eleven
Eleven to seven

Seven to three
Three to eleven
Eleven to seven