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December 16, 2016
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Sleep: When it goes awry and what you can do about it

Sleep is like oxygen: It’s not really a big deal until you’re not getting any.

Although it’s common knowledge that getting sufficient sleep is important for maintaining good health, considerably less attention is paid to the fact that healthy sleep hygiene (i.e., behavioural habits that promote sleep) is crucial for getting a good night’s sleep. Sleep is an exceedingly complex subject and so my goal isn’t to comprehensively cover the subject here. However, I do hope to provide a basic introduction into the world of sleep, dispel some commonly held myths about sleep, and provide some general recommendations for how to maintain healthy sleep hygiene. Keep in mind however, that while these recommendations may help for some sleep difficulties, pinpointing the cause(s) of more complex sleep problems is a tricky process, and often requires an assessment and treatment plan through a specialist. If you’d like a basic assessment of sleep or more information about sleep, feel free to contact me.

Do I have a problem?

If you’re wondering whether you are getting insufficient sleep, you might look for the following two indicators. First, if you feel groggy (i.e., not refreshed) most mornings when you wake up and this grogginess does not subside within a few minutes of waking, you’re probably sleep deprived. Most of us, from time to time, feel a bit groggy when we wake up, but if that grogginess happens consistently and persists throughout the day, it’s probably a good time to intervene. Second, if you struggle to stay awake during the day you’re probably not getting enough sleep. Even when we are getting enough sleep, there are periods of the day when we will feel slightly less alert (I’ll say more on this later), but if you’re fatigued, and the urge to sleep is so strong that you nod off, that typically indicates that you are sleep deprived.

One criterion to ignore is whether you are getting the “recommended eight hours” of sleep. Saying everyone needs eight hours of sleep is like saying everyone needs to be six feet tall. Not everyone needs eight hours of sleep. Sleep requirements vary from person to person, from season to season, as a function of stress and illness, and across the lifespan, just to name a few factors. However many hours of sleep you need to avoid the symptoms listed above and to be alert and active during the day, then that’s how many hours of sleep you need.

What does a healthy sleep-wake cycle look like?

A healthy sleep-wake cycle (see Figure 1 below), as just noted, is generally defined as, or represented by, being alert and active during the day and getting uninterrupted sleep at night. With a healthy sleep-wake cycle, your need for sleep will be low in the morning and should increase gradually and consistently as the day progresses until you fall asleep at night. Napping during the day drastically lowers your body’s need for sleep, which often translates to difficulties falling asleep at night and staying asleep throughout the night. As I will note later, unless there is a safety concern such as falling asleep while driving, you should try to avoid napping during the day. Go for a walk, do jumping jacks – do whatever you need to do in order to tough it out until bedtime.

[As a side note, some people swear by napping during the day in order to maintain a stable and consistent sleep pattern. I agree that a stable, consistent sleep pattern is better than an unstable, inconsistent one, but based on my knowledge of healthy sleep architecture, I am highly skeptical of whether this is really healthy or optimal. By consistently napping, you’re conditioning yourself to fall asleep during day and awaken during the night, and that is bad news biologically and increases the probability of health problems down the road. Again, unless there are safety concerns or life circumstances absolutely don’t allow for sleeping throughout the night, don’t nap during the day.]

Figure 1. Typical daily rhythm of the sleep-wake cycle

Returning to the normal sleep-wake cycle, notice how “sleep need” is different than “sleep urge”, with the latter being our perceived desire to sleep. While sleep need is the biological drive that naturally increases gradually as the day progresses, in a healthy sleep-wake cycle, sleep urge can fluctuate during the day. Fro most people, the urge to sleep naturally decreases as the morning progresses, increases somewhat in the early afternoon (2pm-4pm), dips again in the late afternoon, and then increases throughout the evening. (This increase in sleep urge in the early afternoon is the basis for the recommendation of drinking your daily cup of coffee in the early afternoon – no later than 3pm – rather than in the morning.)

And in the same way that wakefulness naturally fluctuates when we are awake in the day, sleepiness naturally fluctuates while we are asleep at night (see Figure 2 below). Waking during the night is not unusual or necessarily indicative of a problem, since most of us awaken during the night. When most people awaken during the night, they fall back asleep quickly and don’t remember being awake at all. Others awaken at the same time every night to use the washroom, immediately return to bed, and promptly fall asleep again with no difficulty. And all of us experience periods of paradoxical sleep multiple times every night (labelled “REM” in the figure; this is when we dream). During this phase of sleep, our brains are effectively “awake” while our bodies our physiologically paralyzed. So short periods of wakefulness during the night aren’t necessarily anything to worry about. However, if the awakening leads to being awake for an extended period and that interferes with daytime functioning, this may indicate a problem.

Another factor, which is very difficult to self-diagnose, is whether you don’t obtain deep, recuperative sleep (refer to stages 3 and 4 in the figure below). This could result because, unbeknownst to you, your sleep is being frequently interrupted during the night, possibly as a function of environmental factors (e.g., temperature changes, noises throughout the night, a restless spouse) or, more frequently, sleep apnea.

Figure 2. Stages of healthy sleep

Where did it all go wrong?

When we’re babies, most of us sleep like, well, babies! And from that point on, across the lifespan, most of us tend to naturally adopt healthy sleep habits. But life has a knack for interfering with routine and with healthy sleep habits. Having children, increased alcohol or substance (e.g., caffeine, marijuana) use, a new job with different or longer hours, a new romantic partner with different sleep habits, travel and jet lag, medical conditions (e.g., diabetes, neurological disorders), physical pain, or a traumatic event (e.g., motor vehicle accident) are all examples of life changes that can interfere with an otherwise normal and healthy sleep routine. Sometimes these wrinkles iron themselves out over time without needing to step in. Occasionally however, the sleep disruption persists, leading to more serious problems that require intervention. Before discussing how to intervene, I’ll first go over why it’s important to do so.

Effects of sleep deprivation: What happens when we don’t get enough sleep?

The negative effects of sleep deprivation are wide and far reaching. In the short term, acute sleep deprivation slows both our processing of information and our reaction times, thereby increasing our risk of accidents. Sleep loss also slows our rate of learning and makes us more forgetful. Not only do we process information more slowly when we’re tired, we actually process information differently. For example, a recent study demonstrated that when we are sleep deprived, even for a short period of time, we interpret emotionally neutral events as being emotionally negative. That means when we’re tired, we effectively colour our experience of normal everyday events, and not in a good way, making “mountains out of molehills”.

They’re not that big. Get some sleep.

In the medium to long run, the effects of sleep deprivation are more alarming. Chronic sleep deprivation increases symptoms of depression and anxiety, weakens memory, increases weight gain, kills sex drive, speeds up the aging of our skin, and increases our risk of heart disease, heart attack, heart failure, irregular heartbeat, high blood pressure, stroke, and diabetes. And this is only an executive summary. The list of negative effects goes on and on.

Interestingly, research suggests that even a single night of uninterrupted sleep can reduce daytime sleepiness and reverse many (but not all) of the cognitive performance deficits induced by acute and even chronic sleep deprivation. And although I’m generally reluctant to recommend medication as a first-line treatment for sleep problems, in some cases obtaining a short-term prescription (for a few days) for sleep can sometimes go a long way to minimize or even correct some of the above-listed effects of deprivation. Just be extremely cautious with usage of sleep medication, since long-term use frequently leads many people to become psychologically reliant and physiologically dependent on it in order to sleep. So if you choose to obtain medication, get detailed information about proper usage from the physician or psychiatrist prescribing it to you, use it for brief period only, and then reassess your situation. And, as always, don’t just rely on medication to do the heavy lifting; it’s best to manage these difficulties by learning and applying adaptive behavioural strategies. And on that note….

How do I clean up this mess? The basics of healthy sleep hygiene

Here are some basic tips for maximizing the probability of creating a healthy sleep-wake cycle.

1. Maintain a consistent wake time

Do your very best to wake up at the same time…every…single…morning (yes, on weekends too). The stability of your circadian rhythm (i.e., the collective biological processes that naturally repeat every 24 hours) is governed in large part by when you wake up in the morning. This means that the time at which you awake each day will strongly influence the time that your body is prepared to sleep each night. If your wake times are all over the map from one day to the next, so too will be the times when your body is prepared to sleep each night. And you don’t want that. So although maintaining both a consistent wake time and a consistent bed time are important for maintaining a healthy sleep-wake cycle and overall health, maintaining a consistent wake time is arguably more important than maintaining a consistent bedtime at night. So set your alarm for the same time every day and honour it.

2. Move away from the light!

For thousands of years, our sleep-wake cycle was governed by the natural light-dark cycle of the rising and setting of the sun. Each night when the sun sets and light decreases, our bodies respond to this darkness by releasing melatonin, which is a hormone tells our bodies that it is time to sleep. Enter modern life and its myriad light-emitting devices. Flat screen devices like TVs, desktop monitors, laptops, smartphones, and tablets all emit a form of light (i.e., blue light) that has a very short wavelength and effectively mimics daylight. This means that when we’re on our devices in the evenings, melatonin release is delayed, and our brains and bodies are fooled into thinking it’s the middle of the day. Unsurprisingly, when we shut off those devices and try to sleep, our biological system is highly activated and there we are, lying in bed yet wide awake. So I know this sounds crazy, but stash your devices in the evenings, at least two (ideally three) hours before you plan to be asleep. And remove the TV from the bedroom.

  • Note: Apps like f.lux for computers, Night Shift for iPhones, Twilight for Android, can help counteract these light effects, but I wouldn’t rely on them.

3. Condition your brain to associate your bed (and bedroom) with sleeping

You’re asking for trouble if you engage in any activity in bed other than sleep and sex. This is because your brain subtly but powerfully associates your activities with the locations in which you engage in those activities. So if you have a habit of lying in bed while simultaneously planning, solving problems, posting on social media, or anything that requires active thinking or learning, your brain is going to anticipate lying in bed with cognitive activity. This is not good. To change this you need to teach your brain to associate your bed with sleeping by (1) using your bed exclusively for sleep and (2) engaging in any activity that is NOT sleep away from your bed (and ideally outside your bedroom). Note that this also applies to mornings. So when you wake up, roll yourself out of bed before you kickstart your brain.

Notes:

  • If reading in bed (not on a light-emitting device) helps you fall sleep, go for it.
  • If for any reason, you can’t sleep and you begin tossing and turning…get out of bed! Go do something relaxing somewhere else, like on the couch. Once you become tired again, then return to your bed. To reiterate, don’t let your brain associate your bed with the experience of struggling to sleep.

4. Create and practice a consistent, relaxing evening routine

In the hours leading up to bedtime, you should be practicing a routine that communicates to your brain and your body that the time to sleep is approaching. This means engaging in specific and relaxing activities at set times, for example, having a bath at 8pm or brushing your teeth at 9:30pm. Mindfulness meditation, reading, painting or drawing, stretching, having a bath or shower, washing your face, brushing (and flossing! *nod to my dentist friends*) your teeth, spending time with family, are examples of activities that can help prepare you for sleep. Remember, it’s not obvious that this conditioning is happening over time because it happens implicitly (i.e., non-consciously). But humour the process, because it will help.

5. Don’t nap!

The message here is fairly straightforward: Unless there are safety risks of staying awake, try not to nap during the day. If you absolutely have to nap, keep it to less than 20 minutes. There is also some newer research suggesting that in older adults (65 years or older) that longer naps of up to one hour may improve cognitive functioning without interfering with sleep at night.

6. Minimize the impact of night time awakenings

If you tend to wake during the night to use the washroom, then try to make this as efficient as possible. Consider installing a soft nightlight for navigation so you don’t have to turn on any bright lights, and clear any obstacles from the path between your bed and the washroom. When you awake, try to stay as sleepy as possible. Open your eyes just enough to safely find your way to the washroom and back. Try to enjoy and maintain the feeling of sleepiness as you gently crawl back into bed, and try to get back into bed as quickly as possible without rushing yourself.

7. Sleep restriction

If you’re struggling to sleep, try to stay up as late as you can and don’t get into bed until you can’t keep your eyes open any longer. This recommendation to stay up as late as possible when you’re already sleep deprived is one of the weirdest recommendations we give for sleep problems, but paradoxically it often works. It does this by capitalizing on the fact that many people who have been struggling with sleep for some time often end up “trying” to sleep. In other words, they end up battling with sleep in an attempt to get to sleep. By making the simple shift to fighting to stay awake, sleep often results.

  • Note: If you attempt sleep restriction, then regardless of when you fall asleep, maintain your regular wake time. Don’t sleep in and don’t nap during the day (unless it’s unsafe to stay awake), as this will cause further disruption to your sleep-wake cycle. Stick to this routine and things will gradually settle in over the days and weeks ahead.

8. Don’t try so hard

Oscar Wilde famously said: “Life is too important to be taken seriously”, and the same could be said for sleep. If you’ve been struggling to get enough sleep, it can feel like a monstrous problem. It may even feel as though you’ve “forgotten” how to sleep. I can assure you, you haven’t forgotten how to sleep. All animals, including humans, instinctively know how to sleep. No animal goes to “sleep school” to learn how to sleep, nor does any animal have to try in order to sleep. Sleep is an instinctual process that will naturally happen if you just get out of the way. So although it may seem difficult to do, try not to make a big deal about it.

So when you’re lying in bed, if you find yourself ruminating about the possibility of another sleepless night, or you’re crunching the numbers trying to determine how few hours you’re going to get, or how tomorrow is going to be a total disaster if you don’t get any sleep, just gently remind yourself to relax and let go of those thoughts (mindfulness training can help with this; see my blog on mindfulness here). Instead, focus on how good your bed feels, or how quiet the room is…or if there are noises, how unique and interesting the soundscape is. Maybe think about the next vacation you’re planning, or revisit the sights, sounds, and smells of that beach you went to few years ago. Enjoy your thoughts and memories and your body and brain will know what to do. Let them do their thing and next thing you know it will be morning.

 

Two final notes:

  • Sleep apnea. Sleep apnea is an incredibly common problem, more common than most people realize (read more about it here). If you believe you’re sleeping a sufficient number of hours each night but are still tired throughout the day, this may be a problem for you. An assessment for sleep apnea through a sleep lab can be arranged through your family physician.
  • Managing nightmares. If you struggle with frequent nightmares, it’s a good idea to have something on your bedside table that helps you “ground” or reorient yourself when you wake up. Some people use photos of family members or pets, familiar objects, or handwritten notes. Smells are incredibly powerful and useful tool for reorienting. Try using essential oils, soaps, aromatherapy, or anything else that smells soothing or pleasant to you. Keeping in a bowl a cool, damp facecloth that you can place on your face after a nightmare can help as well. Nightmares are quite normal after experiencing a traumatic event; if they persist for longer than a month, it’s a good time to seek therapy.

As always, take care of yourselves and each other…and happy sleeping!

Caelin

 

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Image credits:

Figure 1: http://www.knowabouthealth.com/groundbreaking-results-on-biological-clock-to-cure-jet-lag/

Figure 2: http://www.centerforsoundsleep.com/sleep-disorders/stages-of-sleep/

Mountains: http://kingofwallpapers.com/mountains.html

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