Insomnia and Mental Health
Editorial By Dustin Jasmer FNP
I am routinely asked about sleep. What is enough? What is the right kind of sleep? How do I know if I am getting enough? Why is it so important? Why does Dustin ask about sleep in nearly every followup appointment with me? I will answer all of these questions below:
The National Institute of Health recommend that adults get 7-8 uninterrupted hours of sleep nearly every night, teens need 9-10 hours of sleep, School aged children need at least 10, preschoolers get 11-12 and newborns get 16-18 hours of sleep. If you or your child aren't getting that, something is wrong. There are some people who do well with slightly less or need slightly more but there should not be huge variances. I am not a sleep expert and I don't claim to know everything about sleep but I have decided that I would devote a significant amount of time to researching this subject over the past few years and I have discovered quite a few interesting things.
How do I know if I get enough sleep? You can answer yes to the following three questions. If you can, then you are probably OK, if not then further workup is probably needed.
1. Am I getting the recommended amount for my age group?
2. Do I wake up rested?
3. Do I dream regularly? (more on this later)
Problems associated with Lack of Sleep according to multiple studies:
1. Daytime fatigue.
2. Memory Consolidation
3.Medical Issues: It has been shown in clinical trials and observational studies that lack of sleep or quality sleep can induce and/worsen: Early death, ADHD, depression, psychosis, stroke, elevated blood pressure, migraines, traffic accidents, heart disease, heart failure, irregular heart beats, high blood pressure, diabetes, low testosterone, decreased libido, erectile dysfunction, growth hormone deficiency, aging skin, impaired judgment, autoimmune disorders, respiratory illnesses, higher various cancer rates, suicidal thoughts, worsening of mania, depression, schizophrenia, OCD, Autism and various other mental health disorders.
4. Decreased ability to handle stress
5. Decreased optimism
6. Increased food consumption
7. Decreased levels of Growth Hormone, Testosterone, Estrogen and Progesterone
8. Higher levels of cortisol (stress hormone)
9. Unemployment
10. Work accidents (Chernobyl, Exxon Valdez are two notable sleep deprivation examples)
11. Driving performance which has been shown to have similar reaction times as alcohol consumption (increased motor accidents)
So I might have a problem with sleep, now what?
There are many problems that can cause sleep disruption and so no one treatment is appropriate for everyone. The one consistent answer is that everyone needs adequate sleep. The first key to treating sleep deprivation is finding the cause and eliminating or treating it.
Some of the most frequent causes of sleep disruption:
1. Schedules that interfere with IE. job, school, kids, care-giving role etc.
2. Having a partner who snores or has a sleep disorder.
3. Having improper sleep hygiene (more on this later)
4. Drugs, Nicotine, Caffeine and Alcohol taken too close to bedtime- This includes prescribed medications that have an ability to interfere with proper sleep. The list of prescribed drugs is extensive but there are hundreds of drugs that can interfere with proper sleep. The list includes many over the counter sleep aids and even commonly prescribed drugs for sleep such as Ambien, Xanax, Klonopin, Lunesta and even some vitamins such as B6, (commonly found in melatonin supplements) B12 and others.
5. Light- Having lights on, or watching anything that emits an electronic light can suppress melatonin production and sensitivity.
6. Sound- Having music with a beat or excessive instrumental music can disrupt sleep according to many studies. Also sleeping with the TV or radio on impairs adequate sleep maintenance.
7. Staying in bed for too long thinking about trying to go to sleep.
8. Acute stress events
9. Medical problems- Restless legs, Iron deficiency, Hypothyroidism, hyperthyroidism, GERD, Periodic Limb Movements, Asthma, Chronic Pain, Allergies, sinus problems, Sleep Apnea. Menopause, Andropause (low testosterone), menstrual variations.
10. Psychiatric Problems-Bipolar, Anxiety, OCD, Depression, ADHD, PTSD and Parasomnias such as night terrors, Periodic Limb Movement, sexsomnia, sleep talking or other.
11. Neurological Problems such as epilepsy, MS, Alzheimer’s and Parkinson’s can all cause sleep disruption.
Treatment of Sleep Disruption
Treatment of sleep disruption largely depends on what is causing it in the first place. Each cause can be treated differently and some treatments can worsen sleep if the diagnosis is wrong or if there are multiple factors affecting sleep.
Some of the common treatments that could employed:
1. Good Sleep Hygiene as outlined in the paragraph below.
2. Melatonin as a first line. This can be used for almost any person at nearly every age. There are studies showing that this is a potent antioxidant. It can help with growth hormone release (which helps heal damaged tissue and with insulin sensitivity), and it often helps with both sleep onset and sleep maintenance. For this reason it has been used intravenously with success in some NICU's after premature infants have had brain damage due to lack of oxygen. Many people have worries that it can suppress ones ability to produce melatonin but this does not appear to be true. Another worry commonly brought up by parents is that it may cause premature puberty. This is due to one obscure study in 1992 that demonstrated that juvenile rats given melatonin tended to hit full sexual maturity one month earlier than rats not given melatonin. It has never been shown in humans based on the research I have located. Melatonin is also critical in creation of several neurotransmitters. So far, I have never seen any study that advise against melatonin. Dose is highly dependent on the individual. I usually recommend 3-12 mg for children and up to 20 mg for adults although I have patients who take more and benefit from it. Avoid melatonin products which contain B6 as this can be stimulatory, especially at night.
3. Treatment of the Underlying issue- This can include starting with treating depression, bipolar, anxiety disorders, hormonal abnormality first and then moving on to sleep if still present. Often when this is addressed the sleep disruption self corrects. If there is a secondary sleep issue such as restless legs, sleep apnea, circadian rhythm disorder, night terrors or parasomnia this may need to be treated separately and possibly diagnosed by a sleep study.
4. Weight loss- Weight loss can help with sleep improvement but review the eating and exercise recommendations below in the sleep hygiene section. Some weight loss medications may worsen sleep.
5. Therapy with a licensed therapist- There are many different ways that a licensed therapist could help with sleep and should be discussed with a therapist. They may implement cognitive behavioral therapy, hypnosis or other options that should be discussed with a therapist.
6. Medications such as Ambien, Lunesta, Klonopin, Xanax and others can be used for a short period of time to help restore sleep cycles but should not be used for long periods. They have been shown to suppress REM on EEG studies and therefore prevent restful sleep. Many people report that they are able to stay asleep while on these medications but EEG sleep studies show that they decrease night time awakening but prevent the most restful types of sleep which are needed for people. Additionally there have been many reports of people who sleep walk, drive and even do chores around the house.
7. Medications such as Trazodone, Seroquel, Amitryptiline, Remeron, Lamictal, Gabapentin, Lyrica, Doxepin (silenor) bellsomra and others have shown to be beneficial in helping with sleep (with the exception of Lamictal which is generally non-sedating but does increase REM frequency).
8. Over the counter Medications/Herbals- Medications such as benadryl, Doxylamine, Pseudoephedrine and others tend to be sedating but do not assist in sleep maintenance or providing good quality sleep because they actually are stimulatory to parts of the brain that promote wakefulness. Valerian Root, Chamomile, lemon balm, catnip, passion flower and GABA at small doses all have research which show benefits with few side effects. L-Theanine has been shown in some clinical trials to be helpful with sleep associated with ADHD, especially in males. Kava Kava should be avoided as it can cause liver damage. Although 5-HTP may have some benefits in helping with depression, clinical trials have showed limited benefit with insomnia.
9. Hydrotherapy: Essentially a warm bath has been shown in some clinical trial to reduce insomnia
10. Meditation/self hypnosis: Clinical trials have shown benefits for Insomnia arising from various causes
11:Magnet Therapy: Although I am not familiar the specifics on how to implement this therapy, I must include it because some clinical trial have shown benefit and I don't know of any side effects unless there is a pacemaker, implanted metal device or vagal nerve stimulator present. Feel free to Google the “how to” on this.
12: Aromatherapy: Some clinical trials have shown usefulness with various oil preparations and these are generally considered safe for external use. Not all studies have shown benefit but this could be because it is hard to do placebo controls.
Dreams
Nobody knows for sure what the purpose for dreams why people dream but dreams are generally considered to be a functional process of emotional/working memory. Many people state: Everybody dreams but not everybody remembers their dreams. This is partially true.
Sleep Cycles
Dreams occur in REM sleep. To understand dreams you must understand REM vs Non-Rem sleep. There are five stages of sleep. There are four stages of NREM which are progressively deeper and REM (rapid eye movement) when the brain is actually dreaming. Neuroscientists have shown that the part of the brain responsible for making decisions/processing the environment is “off”. The limbic system is on fully. This explains why dreams are so closely related to emotion and not suppressed by the part of the brain that normally has that ability. When a person shuts their eyes and sleep starts, they enter stage 1 NREM, It gets deeper and deeper until it reaches stage 4 NREM. After reaching stage 4 of non-REM for a period of time: generally 30-90 minutes the brain wakes up slightly going from 4,3,2 and then enters the first REM cycle. REM doesn't typically occur until you have gone through this cycle. You will then have a REM cycle which you probably will dream but generally brief and much shorter in sleep deprived individuals. During this first stage, the REM cycle is very short and then the cycle enters back into stage 2,3 and 4 Non-REM. In sleep deprived individuals, the Non-REM is much longer and frequent than those getting adequate sleep, therefore dreaming is suppressed. This is thought to be the case due to the fact that Non-REM is essential for survival and REM is essential for processing emotional memory which the brain designates of secondary importance. The second Cycle of REM/Non-REM ratio will become shorter with progressively shorter Non-REM episodes later in the sleep cycle.
Why is understanding the REM/Non-REM cycle important to understanding dreams? People are unlikely to remember dreams during the initial REM cycles even IF they are occurring due to the shortness, infrequency and poor quality of the initial stages of sleep. Later in the sleep cycle dreams occur at much longer intervals and emotional processing becomes much more efficient. Have you ever noticed that on those days that you get to sleep that those are the days that you feel like you dreamt all night long? You can remember your dreams and they often have personal meaning to you.
Researchers have shown the dreaming regularly is a sign that sleep quality is efficient. It has been shown that longer REM cycles are associated with greater mental performance, lower depression rates, less mental/physical fatigue and memory consolidation.
I don't like dreaming
I often get questions from patients about a side effect of a new medication for sleep. One of the most common is: “My dreams are so Bizarre, Vivid or Violent”. I often tell people that as long as they are getting adequate rest that the dream quality will likely improve. When adequate REM has been suppressed for long periods of time a person may experience day time dreaming or “feeling like they are in a dream like state”. When it is restored to a healthy night balance, it seems like the brain processes as many emotions and important memories as possible. I explain this as an “Emotional Diarrhea” so to speak. The brain is very efficient at “Cleaning up” and it generally will get out what designates as the most important first. Quite often, dreams will become much more pleasant after prolonged periods of adequate sleep quality. Pretty soon you will stop having those dreams of being naked in front of your boss and you will start having dreams of unicorns and rainbows again.
What about recurrent Nightmares?
Nightmares are also a form the brain working through emotional information. Recurrent nightmares can be a sign of PTSD, anxiety (acute or chronic), grief or even a temporary stressor. I often have patients tell me that they hate their nightmares. Sometimes its a good idea to take medication to temporarily block the effects of nightmares (in the case of PTSD) but generally the best way to overcome a nightmare is to figure out “What” your brain is trying to tell you and work through that emotional issue, often with the help of a counselor.
Dream Meanings in General
I don't claim to be a dream analyst or specialist in this area in any sense of the word. I have had many conversations and researched dozens of scientific studies on the subject. After my research, I have come to some conclusions but they are not facts. My opinion is that dreams usually have some personal meaning to the individual. All persons, people and objects in the dream have something to do with the individual having them, not actually to do with the person they are about. They are a representation of what that individual, item or situation meant to them and the emotions that they associated with it. These components are often accompanied with something that their subconscious deems similar-Almost as a way as their brain saying “You have been through this situation before, you can handle this.” Dreams are highly abstract for most people. For example: I often have people tell me about dreams where someone is dying, they are dying or they are actually killing someone. Although distressing, I believe dreams like these CAN be seen as a positive. If you think about death, it is the ultimate change. Life ends. I believe that when a person dies in a dream it usually indicates that the concept or emotion that that person represents to the person is probably changing or has changed in some way. It is the brains way of processing that change emotionally and helping it consolidate into long term memory. The one exception would be if the dream is a re-experience of a traumatic death which has induced PTSD nightmares. I believe these dreams are the brains way of trying to cope with that severe trauma. Once again, I am not dream specialist but the one thing that the research has shown is that they are necessary for many important emotional/psychological processes. People should be having them and remembering them often except perhaps right after a trauma when it is highly distressing.
How do I know if I am getting enough sleep?
I tell my patients that there are three questions to ask yourself every day when you wake up and then you will know if you are sleeping adequately.
1. Did I get my recommended amount of uninterrupted sleep per the NIH guidelines?
2. Do I feel rested?
3. Did I dream?
If you can answer yes to all of these questions then you PROBABLY are getting enough sleep. Too much is not necessarily a good thing either so remember not to over do it. If you are still unsure you can consider getting sleep monitoring apps for your smart phone. One I find useful is Sleepbot which monitors sound, movement and can even set an alarm within 30 minutes of waking to awaken you when it believes that you are likely to be in a REM cycle and not stage 2-4 when it is more jarring. Another good option would be purchasing a Fitbit, Garmin or the I-watch for Iphones.
Sleep Hygiene Recommendations taken from the University of Maryland Sleep Specialty Clinic
1. Establish a regular time for going to bed and getting up in the morning. Stick to this schedule even on weekends and during vacations.
2. Use the bed for sleep and sexual relations only, not for reading, watching television, or working. Excessive time in bed disrupts sleep.
3. Avoid naps, especially in the evening.
4. Exercise before dinner. A low point in energy occurs a few hours after exercise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness.
5. Taking a hot bath about 1.5 - 2 hours before bedtime may help you fall asleep more easily. (Taking a bath just before bed may increase alertness.)
6. Do something quiet and relaxing in the 30 minutes before bedtime. Reading, meditating, or a leisurely walk are all appropriate activities.
7. Keep the bedroom relatively cool and well ventilated.
8. Do not look at the clock. Obsessing over time will just make it more difficult to sleep.
9. Eat light meals, and schedule dinner 4 - 5 hours before bedtime. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.
10. Spend at least a half hour in daylight every day. The best time is early in the day.
11. Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.
12. Avoid stimulants such as caffeine or nicotine in the hours before sleep.
13. Avoid alcohol in the hours before bedtime. While alcohol may help you fall asleep quickly, it can cause you to awaken in the middle of the night.
14. If still awake after 15-20 minutes, go into another room, read or do a quiet activity using dim lighting until feeling very sleepy. (Don't watch television or use bright lights.)
15. If distracted by a sleeping bed partner, moving to the couch or a spare bed for a couple of nights might be helpful.
16. If a specific worry is keeping you awake, thinking of the problem in terms of images rather than in words may help you to fall asleep more quickly and to wake up with less anxiety.
Specific tips I recommend in addition to Sleep Hygiene
1. For those who cannot or will not get off their phones, there are settings to invert the screen at night or to make it not emit blue light after dusk which can activate automatically.
2. If you have you are a person that stays up worried about the day, or what you have to do the next day, write your thoughts on paper and then put the paper upside down on your bedside table. This allows your brain to stop processing the thoughts repetitively and have some finality to those thoughts at least until you wake up.
3. Get rid of noises that keep that keep the brain active including music, especially if it has a beat or loud instrumentals. Also turn off the TV. Its never a good idea to fall asleep watching TV, your brain will continue listening as you sleep and you will not sleep as deep.
4. White noise can be a good thing for many people. Turning on a fan or white noise generator that doesn't cause brain activation can drown out noises that cause you to wake up.
5. Don't have topics of discussion which are stressful right before bed with a significant other. This can cause periodic sleep interruption unless you are pretty sure that it will turn out positive.
6. Darken the windows and remove light sources as much as possible, even in children. If they are too scared to sleep in the dark try progressively using a darker and darker nightlight until it isn't needed. There are studies that show that enforced darkness at night can help with mood.
7. Massage/Touch therapy- Consider getting a massage or just cuddle with your loved one. This can be calming release endorphins and other neurohormones which can be beneficial for sleep.
8. Don't allow children to watch scary or violent films, especially before bed.
9. Don't try to talk your children out of the fact that there are monsters in the closet. They often know this is an irrational fear but anxiety takes over. Instead come up with a way to calm their fears about it such as a protective teddy bear. I have one parent who has even placed toy gun “booby traps” in the room and said that it would protect them from any intruders.
11. Don't talk to children about grades, discipline or major behavioral issues right before bed if possible. Try to do this earlier in the night if possible.
12. Have a nighttime ritual that is calming. Don't wrestle or rough house shortly before bed. Maybe read a story. I personally recommend telling your children several good things about themselves right as they go to bed. Every night before bed I ask my daughter to repeat “I am smart. I am kind. I am generous. I am hardworking. I am an advocate. I am brave. I can do anything I want in my life. I am loved. I am healthy. I am funny. I am patient. I concentrate well. I am safe. People like me.” I tell her to sleep well, that I love her, to have good dreams and that I look forward to seeing her in the morning. This is very calming to her and she often repeats these things about herself during the day.
13. Consider therapy, medications or alternative treatments if sleep continues to be an issue.