From Lutz U

Sleep Studies

Hey Pedram,

I know you’re ridiculously busy running your sleep clinic and finishing law school, and now I hear you’re having a novel published soon! I’m going to need to hear more about that.

I can’t help but think about that year we spent as exchange students in Leeds. I never would have guessed at the time that you’d turn into such an overachiever. I distinctly remember a conversation we had about how to make pasta: “So you have to boil the water first,” you kept saying. And now you’re a neurologist! It still blows my mind. I also remember that you had a lot of questions about how to do laundry. Maybe it’s just domestic stuff that trips you up.

Anyway, I’m not writing to bust your chops. I have some questions about sleep and since you are an expert on it, I figured I’d take them to you.

I’ve never been awesome at sleep. It’s always taken me at least thirty minutes to drift off, and I often wake in the middle of the night (or, lately, early in the morning) and remain in a half-sleep until it’s a reasonable hour to get up.

I’ve always attributed my sleep issues to a heightened fight-or-flight response. I’ve heard stories about people getting on BART, falling asleep, and missing their stop by several cities. I can’t fall asleep in public, so that would never happen to me. I did, however, once get stuck on a MUNI train because I thought there was one more stop, but it wasn’t a stop—it was the place they store the trains overnight. I had to press the emergency button to get someone to free me. But I was awake the entire time.

While being unable to fall asleep on trains may one day save my life, so far it hasn’t. And I must say I harbor a great deal of jealousy toward good sleepers, late sleepers, airplane sleepers, et al. When I flew to Australia, I took two sleeping pills, had more than one drink (who’s counting?) and stayed awake for the entire thirteen-hour flight. It was hell.

I know you deal with patients who have extreme cases of insomnia and hypersomnia. What are the inherent differences between these two kinds of people? If you do a brain scan, do you see red sticks of dynamite in the insomniacs and billowy clouds in the brains of over-sleepers?

Is there any way, besides meds, to turn one kind of person into the other? Also, you hear a lot these days about the negative side effects of prescription sleep aids. Are they only a short-term solution or can some people take them for years without permanent damage?

A few more questions. It’s recommended that people get seven to eight hours a sleep a night. But some people claim they can get away with four. Are they just liars and cokeheads, or are they really okay? And what happens to people with extreme insomnia who barely sleep at all? Long term, what does it do to them?

Also, online articles about getting a better night’s sleep put a lot of stock in preparation. Is it really true, for example, that turning off all electronic devices by five p.m. can help you fall asleep faster?

If you had to choose three pieces of advice to a person with mild to moderate insomnia, what would they be?

And, finally, what kind of sleeper are you?

Feel free to answer all, some, or none of my questions.

Cheers,
Lisa

Lisa!

As always, it's great to hear from you. But it always goes back to that pasta, doesn't it? Ha! Yes, I was never really good with that domestic stuff, and still am not. Let's put the pasta on simmer, though, so I can answer your questions.

Your questions are good, and I'll number them for simplicity's sake. First, a bit of history about insomnia. As you correctly note, it was indeed a mechanism by which the earliest human societies were able to protect themselves as hunters and gatherers. The threat of attacks from large animals (and other humans) was always imminent.

Sleep changed in medieval times, as people began sleeping in their own protected homes, and again with the onset of industrialization and the electric light. But if I’m going to answer your questions I’ll have to cut the history short. Here are my answers:

1. Yes, fMRI scans of the brain—which allow one to see which regions of the brain are active during certain activities—show that insomniacs have "mind-wandering" brains. That is, insomniacs have a much more difficult time "turning on" brain regions that are critical to a working-memory task and "turning off" regions that are irrelevant to the task. One study, conducted in August 2013 in UCSD's Psychiatry Department, compared the brains of 25 people who had primary insomnia with those of 25 good sleepers. Obviously, the study has its limitations, given the small sample size, but it does provide a glimpse into brain modulation due to lack of sleep.

At the other end of the spectrum, hypersomniacs have excessive daytime sleepiness and can fall asleep very quickly, especially during passive activities such as reading a book or watching a film. As you know, insomniacs hate these people. Passionately. In couples, although no studies have borne this out, one bed partner is often a sound sleeper and the other is an insomniac.

Hypersomnia can be linked to a variety of sleep disorders, most notably obstructive sleep apnea, narcolepsy, idiopathic hypersomnia, and clinical depression. Narcoleptics often experience sleep attacks and muscular weaknesses triggered by strong emotions (cataplexy). Furthermore, the brains of these individuals have diminished hypocretin, which regulates wakefulness and appetite. Idiopathic hypersomnia is a close cousin to narcolepsy, although individuals who suffer from it do not experience cataplexy or sleep attacks. They are extremely sleepy, but unlike their narcoleptic counterparts, show no evidence of diminished hypocretin.

2. Medications can only go so far. While there have not been any reports of significant long-term side effects of sleep medications in general, we know that they increase the probability of dependence and accidents, especially in the elderly.

Benzodiazepine agents, such as temazepam, while usually more effective than non-benzodiazepines, such as Ambien and Lunesta, may actually promote lighter sleep and diminish deeper, or slow-wave, sleep. Over time, they can also lead to rebound anxiety (the return of symptoms when medication is discontinued).

Non-benzodiazepine hypnotics, on the other hand, carry less potential for chemical dependence, but they often cause memory and cognitive effects, morning sedation, and automatic behavior, including sleep-walking, sleep eating, and sleep driving, which occur as side effects of these agents and limit their use, especially in those who already have these predispositions. One promising new sleep agent, suvorexant, blocks the same receptors affecting narcolepsy, to try to simulate its symptoms. It has yet to be approved by the FDA.

Numerous studies have demonstrated that Cognitive Behavioral Therapy (CBT-I), in which individuals attempt to modulate their behavior and change the way they think about sleep, is a much better way to combat insomnia. CBT-I is now considered the first-line therapy for chronic insomnia. CBT-I includes a healthy dose of "sleep hygiene" techniques, such as going to bed only when one is sleepy, dimming the lights at night, using the bed only for sleep and sex, and so forth.

3. On to long and short sleepers. Although studies have shown that people who sleep between 6.5 and 7.5 hours per night live longer than those who sleep less than 6 or more than 8 hours, this probably has to do with factors other than sleep itself. However, studies have shown that shift workers who work at night and sleep during the day often have gastrointestinal and cardiac issues related to the unnatural period in which they sleep. So, I think the timing of sleep is more important than the number of hours.

Of course, there are people who need less or more sleep. Usually, one's hours of sleep are sufficient if one feels refreshed when he or she awakens in the morning. That would be my short answer, until good studies are done to tease out the other variables.

4. Your question about electronic devices is an interesting one, especially in this age of social networking. Yes, in general, one should not use electronic devices at least a couple of hours prior to going to bed. And, please, for God's sake, do not place your cell phone next to your bed for any reason. Not only will this provoke more anxiety about the fear of missing a call or failing to check your e-mail, but the light of the electronic device will also affect your suprachiasmatic nucleus, which can alter your circadian rhythm. Translation: Your brain will think it's time to wake up, even when it isn’t.

5. My three pieces of advice:

a) Never, ever place an alarm clock next to your bed. Place it somewhere in the bedroom where you’ll never look at it until you have fully awakened. The anxiety of looking at the clock at three a.m., for example, will only provoke more anxiety and prevent you from returning to sleep. Behaviorally, this is the worst thing you can do.

b) Be consistent about your wake-up hour. Although you may feel tired, your homeostatic drive will increase and allay your anxiety about falling asleep. Also, at least during the summer when the sun is out, make sure that you get, at a minimum, 30 minutes of natural sunlight and, with that, some exercise.

c) Retrain your brain to think that although sleep is important, it is not the end-all. Sure, you may not feel especially energetic or vibrant after only three hours of sleep, but you know that you can still function. Sleep is a natural process; putting too much thought into it can actually prevent you from sleeping. Psychologists sometimes use a technique called "paradoxical intention" to help allay the performance anxiety of falling asleep. Thus, the individual is told to try to stay awake as long as possible. When all else fails, remember that lack of sleep never killed anyone. Learn to let go!

6. What kind of sleeper am I? I'm not a perfect sleeper either, especially with everything that I have going on now. My sleep was really affected during my medical residency, when I was expected to get up at a moment's notice. But I recognize that I can modulate my behavior and cognition. I try to implement the techniques I've related to you in this e-mail, but I have my own moments of acute insomnia. If I can't fall asleep for any reason, I take a small dose of Ativan to help me fall asleep faster. This usually occurs once or twice a month. I also implement techniques such as deep-breathing exercises and calming mental imagery.

I hope this has helped, Lisa. Next time you're in L.A., you're invited to my place for some good pasta.

Cheers,
Pedram 

Pedram,

Wow, you’ve just given me a lot of information to sleep on. I might want to get back to you later on all of that. But I’m particularly intrigued by the association between difficulty turning on working memory and propensity for insomnia. I have a crap memory to begin with, but is it possible that by challenging my working memory (for example, memorizing a list of numbers and then repeating that list backwards), I could improve my sleep? I’ve lately been reading quite a bit on working memory as it has benefits to mood and impulse control.

I also really love the idea of “paradoxical intention.” I’m curious whether this could work with housekeeping. I’ll let you know.

Look forward to seeing you soon. But let’s eat out.

Best,
Lisa

Pedram Navab, a board-certified neurologist and sleep medicine specialist, is the medical director of a private sleep lab. His debut novel, Without Anesthesia, will be published in 2015 by Jaded Ibis Press. Pedram is currently writing an article on neuroimaging and its medical and legal implications in predicting criminality and sleep violence. He lives in Los Angeles.

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