Marks Psychiatry

Shift work can have a dramatically negative impact on the quality of your sleep and ability to sleep. There is a diagnostic entity called Circadian Rhythm Sleep Disorder, formally called Sleep-Wake Schedule Disorder of which shift work type is a specific subtype. Circadian Rhythm Sleep Disorder occurs when a person has recurrent or persistent disrupted sleep patterns as a result of a mismatch between the person’s body clock (when we would naturally sleep) and our environmental demands (when we are supposed to sleep or be awake). So typically, people with this disorder will complain of being awake when they need to sleep or excessively tired or sleepy when they need to be awake.

Other subtypes of Circadian Rhythm Sleep Disorder include delayed sleep phase where the person habitually falls asleep late and awakens late. These individuals can feel stuck in a cycle of sleeping late and have trouble moving their sleep times earlier. The other subtype is caused by jet lag. This is most severe when individuals travel more than 8 time zones in 24 hours. Traveling eastward is usually more difficult than traveling westward because it is easier to delay sleep than to fall asleep earlier.

Back to the shift work subtype – in these cases, the person usually has normal circadian rhythm patterns, but the demand of switching back and forth between shifts disrupts the normal pattern of sleep. Even those who consistently work a night shift may have trouble because of the need to attend to personal or family responsibilities during the day. As a result, these people can not get adequate sleep during the day and fall asleep during their night shift.

What’s a person to do? The full answer to that is too long for this post, as it involves some behavioral adaptations. Provigil is a medication that is FDA approved for Shift Work Sleep Disorder to improve a person’s wakefulness on the job. But this is only half the answer as the second part is promoting sleep during the day. As tempting as it is to want to get things done during the day, it is equally important that a person treat the daytime as if it were night and shut everything down for a period so they may sleep.

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Sleep latency is the amount of time it takes to fall asleep. Normal is considered to be 15-25 minutes (some say 30minutes). I’ve had many people tell me with disappointment that it takes them 30 minutes to fall asleep and how they know people who can fall asleep instantaneously. They are surprised to hear that 30 minutes falls into the normal range.

In fact, a sleep latency of less than 5 minutes is considered to be a sign of sleep deprivation. So, if you can go into a dark room and fall asleep within 5 minutes – this isn’t necessarily a good thing and could mean you need more sleep.

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We don’t fully understand the mechanism of insomnia (defined as difficulty initiating or maintaining sleep). But some theorists believe untimely central nervous system arousal plays a large part. Our brains are always on, however when we think hard about something, our brain is more activated or aroused than when we are not consciously thinking about something (acting on autopilot). Caffeine to too close to bedtime can increase brain arousal as can bringing work home and doing stressful work before bed. We don’t know how long it takes for the mind to wind down after doing stressful work, but I compare it to lighting coals on the grill, getting them red hot then white, cooking your food, then having warm coals smolder long after you eaten your meal.

Unfortunately people can reinforce the nervous system arousal by getting into bed, watching the clock and worrying about how they are not falling asleep. This anxiety about the insomnia can produce more of a stimulating affect on the brain than the original stressful activity.

I usually talk with patients about their bedtime routine, emphasizing the need to have a wind down period before bed and a preparation period. So for example, think about what time you to be asleep. If this is 11pm, then you need to start preparing for bed around 10pm. Preparation can’t be finishing up those last stock trades or worse yet, getting off the treadmill. Preparation would be things like brushing your teeth, bathing (warm bath with dim lighting or relaxing shower), thinking about what clothes you will wear, etc. Because these activities are routine, your mind can rest and wind down. By 10:30 you could plan to be lying in bed with the expectation to be asleep within the next 30 minutes. Some people meditate or read a passage to help them fall asleep.

Leaving an hour in your evening to prepare for bed usually doesn’t happen. Usually what I see is a person will consider their bedtime to be 11pm, they calculate that if they go to bed by this time, they can get 7 hours of sleep. Then 10:50pm they are peeling away from the television and quickly jumping in the shower (or waiting until the morning), they slide into bed by 11:10 and watch the clock while they think about that intense Sopranos episode, which then leads to thinking about their boss and how their coworker is undermining them, etc. They may drift off to sleep by 11:45 – 12. There goes the 7 hours as the alarm is set for 6am.

Does this sound familiar? How do you prepare for bed? I welcome your input on what makes you fall asleep.

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I’ve frequently prescribed benzodiazepines (benzos) such as Klonopin and Ativan for patients with anxiety. For some patients who are particularly anxious in the evenings, taking the medication can help relax them to the point of falling asleep easier. I usually tell them it’s not a good long term solution for sleep and the most obvious was the habit forming potential and the need to resolve the sleep issue without the long term use of medications. However, another important reason is that benzos decrease slow wave sleep. As mentioned in a previous post, stages 3 and 4 are slow wave, or deep sleep and necessary for us to wake feeling rested. So a benzo can knock you out for several hours which can make you feel better in the short term, but in the long term you need adequate amounts of the deep sleep that you get in stages 3 and 4 to have healthy and restorative sleep.

So how has the pharmaceutical community addressed this? Medications like Ambien, Sonata, and Lunesta have no effect on stage 3 and 4 sleep. In fact, in studies Sonata was shown to increase stages 3 and 4. Do these medications work? Well, for me anecdotally (meaning this is not a scientific study, but based on my practice experience with a limited population), I’ve had the most success with Ambien. I’ve had several patients complain of a bad aftertaste – a kind of metallic taste when taking Lunesta. Brushing their teeth forever didn’t help. BUT, everyone is different and I always tell people, what works for one person may not work for someone else.

Ambien has it’s own quirky side effect that is fairly rare and that is nighttime eating. For those who it affected, I was told they would wake up in the morning and notice plates in the sink or partially eaten food on plates and would not remember leaving their bed.

Despite this issue with Ambien, it’s probably better than taking a benzo for an extended period of time because it doesn’t affect your sleep architecture. But it is important to discuss this with your doctor as all medications have pros and cons and your doctor should prescribe something meets your needs.

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You may have heard this term used before, it refers to the different stages that make up our sleep. Understanding these stages of sleep help scientists and clinicians target treatments for insomnia.

Sleep is divided into two stages – Non-rapid eye movement (NREM) and Rapid eye movement (REM). NREM is further divided into four stages, numbered 1-4. Stage 1 is the drift off into drowsiness and it usually lasts about 5 -10 minutes. If you were awakened at this time, you’d probably feel like you never fell asleep.

In stage 2, brain waves slow and eye movements stop. You may observe some muscle twitching in someone in this stage of sleep. Stages 3 and 4 are deep sleep and brain activity will show slow delta waves. Stages 3 and 4 are responsible for the restorative effects of sleep and allowing us to wake feeling refreshed.

NREM sleep cycles throughout the night usually lasting 90-110 minutes for each cycle. This means usually 90 minutes after falling asleep, you enter REM sleep, which is when we dream. When we cycle through NREM, it goes Stage 1, 2, 3, 4, 3, 2, REM. Therefore, we enter into a lighter stage of sleep when we are dreaming. Our brain has heightened activity but our muscle groups are paralyzed. This paralysis is temporary and normal during this stage of sleep as it prevents us from acting out our dreams. Some disorders of sleep inhibit the muscle paralysis and the person can sleep walk or act out their dreams while their brain is still sleeping.

There are several REM periods throughout the night, the first one lasting about 10 minutes and each subsequent one getting longer. It is thought that the last REM period lasts about 1 hour. This means you can have several dreams throughout the night, but since the last one is the longest, it is this dreamtime that you are most likely to remember.

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This may seem like an obvious statement, but it’s not.  Our culture rewards hard work and often that comes at the expense of sleep.  Millions of people do not get enough sleep each night and it can have serious consequences to our physcial and mental health.  I’ll be doing a series of posts on sleep as I feel it is a very important, yet often undervalued component of our overal health.

Good sleep starts with good sleep hygeine.  What is sleep hygiene?  It is our rituals and behaviors that affect our sleep.  There are many things one can do to develop good sleep hygiene, a few suggestions are as follows:

• Have a consistent bedtime each night - our bodies work on a circadian rhythm and need to have regular sleep and waking times
• Wake up at the same time each day - even on weekends!  Our body clocks need to be reset each day as not everyone’s clock is on a 24 hour day.  So waking up at the same time each day can help maintain consistency.  If you do this routinely, and get enough rest, you should be able to wake up without an alarm clock.
• Avoid daytime naps - you can only sleep so many hours in a day.  If you get several hours during the day, you will have a harder time falling asleep at a set time.
• Exercise regularly - regular exercise promotes restful sleep.  But don’t exercise too close to bedtime or your body will have a hard time settling down.
• Avoid caffeine, alcohol and nicotine close to bedtime.  Although alcohol can make you sleepy and relaxed, it disrupts the quality of our sleep.
• Maintain a cool and quiet room.
• Avoid fluids too close to bedtime - if you drink a large beverage just before bed, you may be awakened in the night to go to the bathroom.  Even if you fall back to sleep, you still have interrupted sleep.

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A recent article in the Psychiatric News periodical discusses a survey that reveals a large number of women in the United States are sleep deprived.  There’s a quote saying “Americal women struggle to do it all…”  The women in the poll said they lacked the time to meet all of their obligations in addition to participating in extra leisurely activities.  Thirty percent said they were too weary to or busy to have sex.

You can see the article at Psychiatry Online Women Sleep Article

There are a number of trends documented with the study such as how many women used sleep aids and how 17% reported getting less than six hours.  The most significant finding to me was 25% of the women had been diagnosed with depression and 16% with an anxiety disorder.   This is not completely surprising as sleep is esential to mental well-being. However, these percentages are higher than the prevelance rates of depression and anxiety in the general population.  Are we depressed because we’re not sleeping or are we not sleeping because we’re depressed.

I would venture to say that the respondents in this survey were likely falling into the common pattern of sacrificing sleep for the sake of meeting family, financial and personal obligations.  The author ends by saying women need to make sleep a priority to set an example for their families.  This suggests becoming sleep deprived is a choice women make.  Unfortunately some are unable to sleep due to factors beyond their control (child interuptions, shift work, medical or psychiatric conditions, etc.).  If only they could choose to sleep.

Nevertheless, sleep is critical and affects our mental and physical functioning on a global scale.  More on sleep in future posts.

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