We have become a 24-hour society where people can work, shop and exercise at all hours of the day or night. But just because we can, does that mean we should?
Humans evolved in a rhythmic world, with daily and seasonal variations in light, temperature, and food availability. In our modern world we can control all these environmental factors so they are the same throughout the year, but our body is still programmed for circadian variation. Cancer incidence increases when people live out of sync with natural rhythms, like those who do shift work.
Shift Workers at Increased Cancer Risk
Those people who work graveyard shift have an increased risk of breast cancer. This risk increases with the number of years graveyard shift has been done. Getting bright light at night suppresses our natural melatonin surge. Melatonin is a powerful anti-oxidant, protecting our cells from damage.
Shift workers also are at increased risk for:
•Elevated stress hormones
Cancer Causes Sleep Disruption
The sleep – cancer relationship goes both ways. For those people undergoing cancer treatment, sleep disruption can be a symptom. This can be a side-effect of chemotherapy, or of pain, or other factors.
The good news is that several studies have shown that sleep of cancer patients can be improved by doing Cognitive-Behavioral Therapy for Insomnia. Specifically, after treatment, cancer patients ended up sleeping a higher percentage of the time they were in bed, had improved mood, and decreased fatigue. Another study additionally found that the people had fewer nights on medication, and that the improvements were maintained for 12 months afterwards.
It was a pleasure to talk with journalist Sheila Cain about my approach to treating sleep disorders. The article is now published in Seattle magazine’s Top Doc issue (July).
My favorite excerpt is: “My primary care doctor gave me a printout of things to try, then told me to go home and do them,” Crocker said. “With Dr. Darley, we worked on a very individualized plan that was specific to me.”
The thing I love most is the way in which each person’s sleepless story is unique, even if each one is coming in for what appears to be the same ‘insomnia’ complaint. Taking the time in the first appointment to really understand how the sleep problem developed, how it impacts their quality of life, and the individual lifestyle makes all the difference in making an individual treatment plan that works.
Sometimes in an appointment a patient and I will have moments where we are communicating so clearly, heart to heart, and getting to the root of the sleeplessness. Those times I imagine if someone took a picture there’d be a big light bulb over both of us. Those break through moments make this work worth every effort.
Being unable to sleep can be very distressing, especially when it’s an acute episode. One analogy that works when I think about treating insomnia is that Curing Insomnia is Like Climbing a Mountain.
Think about going for a hike up a mountain to the scenic view from the peak. You look at the paths that lead to the top, and choose the one that’s best for you. Your choice is based on where you came from, your preferences (a long gradual climb, or a short steep one), and your other abilities or conditions. Once you choose your path you stick with it, knowing that if you switch to another path, that horizontal movement is not getting you any closer to the goal.
It’s helpful to think of curing insomnia in a similar way, that you look at the treatment options available to you, and choose the one that’s the best fit. Once you’ve selected the treatment you want, stick with it long enough for it to be effective. Sometimes when people are in an acute episode of insomnia it is tempting to try different treatments, each for a short time. What’s more effective is to give a reasonable trial of a treatment approach (several weeks or a month at least), before switching paths. Knowing that insomnia is cured one night at a time, bit by bit, just like climbing a mountain can help keep you calm and focused on the end goal.
Here’s to the view from the top, and the peaceful sleep at the end of the path!
So although I’m a sleep expert, unfortunately that doesn’t make me immune to the havoc that life events can wreak on sleep health. My usual healthy 8.3 hour average sleep which leaves me energetic and sharp all day has plummeted to a mere 6.5 hours over the last week. I’m not alarmed, as identifiable events are interfering with my sleep, and I know that once those settle down my sleep will easily bounce back. Today I’m feeling the effects of acute sleep deprivation, a perfect chance for a blog post.
During acute sleep deprivation, people can feel a variety of somatic symptoms, like stomach or head aches. Others may feel dizzy or have difficulty concentrating. And of course there are performance decrements which we’ve discussed previously, and health problems too.
For me, today, the sleep loss is making me feel slightly dizzy, ravenously hungry for sugar (which is more difficult to resist than usual), my eyes feel irritated, and I’ve been making errors like hitting the wrong elevator button, and feel I need to work extra hard to pay attention while driving. My temperature control also seems to be off.
Now 6.5 hours of sleep nightly for 5 nights is not bad for many people. About 30% of American workers report getting less than 6 hours on work nights. What I wonder is whether people who are habitually sleep deprived get accustomed to the feelings of sleep debt, so that it becomes their normal? Granted I’m not a good person to say, both because I spend more time thinking about sleep than average, and because I’m usually well-rested, so can really notice the effects of sleep debt.
Today and the rest of the week I’ll keep my healthy sleep habits in place, and not worry about it, knowing my sleep will get back on track in a day or two. Until then, sugar anyone?
Many people ask me “Does a warm bath help sleep, or is that just a myth?” The research shows . . .
Yes, it seems to help somewhat. Medical research has investigated the impact of both baths and foot baths on sleep. One study in older people with sleep disturbance found that a 40 minute footbath at 41C decreased wakefulness in the second nonREM sleep period. Women undergoing chemotherapy for cancer have also found increased sleep quality with a warm footbath. Another study done in elderly insomniacs found that a full-body bath (immersed to the mid-chest) for 30 minutes at 40-41C did increase deep sleep, and caused people to experience a good night sleep. .
How does a warm bath improve sleep? Human body temperature is not constant, but varies with a consistent circadian rhythm. There is a slight dip in body temperature at approximately 1pm, and then a more significant drop in the evening hours. We get that sleepy feeling as our body temperature drops. The bath effectively raises our body temperature, and the subsequent drop helps sleep. The bath should be about 60-90 minutes before bedtime.
Of all the means you can use to improve your sleep, this one seems one of the most simple, with the least possible negative side effects. This is a good therapy to try first before using other, more invasive medicine.
In past posts we’ve talked about the impact alcohol can have on sleep, which is widely known. Nicotine also has an impact, which seems less well known by the public.
Studies show that nicotine changes sleep, so that it takes longer to fall asleep initially, people sleep a lower percentage of the time in bed, and REM sleep and total sleep time is decreased. None of these are effects we want!
According to the Centers for Disease Control “In 2010, 43.5 million adults (19.3%) in the United States were current smokers—21.5% of men and 17.3% of women.” So that’s about 1 in 5 people who are exposing themselves to nicotine, and suffering the consequences on their sleep.
If you are someone who struggles with sleep, and smokes, it may be worth the effort to stop smoking in order to improve your sleep, and reap all the other health benefits too. Many state health departments have ‘Stop Smoking’ helplines, and your primary care physician can assist you.
Many people talk to me about their difficulties sleeping, either difficulty falling asleep initially, or returning to sleep in the middle of the night, or in some cases waking up before they want to start the day.
One question that can be very helpful in this situation is “what woke you?” or “what prevented you from falling asleep?” Surprisingly often, there is a clear environmental disturbance that is interrupting sleep.
Here are some of the external sleep interruptions I’ve heard of over the years:
– a snoring, or moving, bedpartner who may have a sleep disorder of their own
– bedpartner who gets into bed later, or who gets up earlier, thus waking up the person experiencing insomnia
– dog’s collar jingling
– cat asking for attention by scratching on the bedroom door
– outdoor lights that turn off and on with movement (hate those!)
– children in the bed, snuggled right up against the patient who then is uncomfortable
– an appliance or toy that beeps
– the cell phone, often a problem when it is used as an alarm clock
. . . and the list could easily go on.
When you are working to improve your sleep, you first want to eliminate as many of these interruptions as possible. I recently was working with a woman struggling to sleep well, waking 2-4 times each night. When asked “what wakes you in the night” she identified that sometimes her husband’s snoring woke her. We dialed down into that a little more, and she estimated that his loud snoring is responsible for half of her wakings, and realized looking back on it that when he’s away she does sleep better. Another person, a mother, said that she’s often squished between her children during sleep, and has no sleep problem if she has the bed to herself.
When you are working to improve your sleep, a helpful first step is to see if any external factor is interrupting or preventing you from sleep. Systematically resolve those interruptions, and then re-assess. You may find that those interruptions you were tolerating are not so trivial!
In my office, people who are taking many sleep medications for long-term use often come in looking for alternatives. In naturopathic practice there is a place for medications in the ‘Therapeutic Order.’ In naturopathic medicine the ‘least force’ treatment is used which will be effective. For instance, behavioral medicine will be used for insomnia first. Of course, behavioral strategies may not work for each person, so then herbal or nutrient therapy may be used next, and then pharmaceuticals.
Recently a person came in who had been using a combination of four sleep medications over the last 10 years. He had been alternating the medications on his own schedule as they became ineffective, and to avoid the need to increase dosage. Here was his regimen:
Alprazolam (Xanax) at 4am at his early am wakening to get another 3 hours of sleep. Alprazolam is a benzodiazepine hypnotic. Side effects include an increase in depression. When stopping the medication rebound insomnia can occur. Most of the hypnotics should not be taken with alcohol.
Zolpidem (Ambien) or Eszopiclone (Lunesta) Both are non-benzodiazepine hypnotics. Ambien is long-lasting, and people should be sure to have a full 7-8 hours in bed after taking it. Lunesta is one of the few medications approved for use on long-term basis.
Clonazepam (Klonopin) which is a long-acting benzodiazepine.
Even with these medications he was having interrupted sleep and found his sleep to be unrestful.
Our approach was to first use behavioral strategies to make his sleep robust and restful. Once he was sleeping well, we designed a schedule in collaboration with his PCP to taper down off the medications slowly. In this way we were able to avoid rebound insomnia and other withdrawal symptoms.
So, if you are struggling with insomnia, use the ‘least force’ treatment strategy that will solve your sleep problem. If you are recommended a sleep prescription, find out how long that medication can be safely used, any drug interactions to be aware of, and the typical withdrawal symptoms.
Over the last newsletters we’ve talked about many behavioral skills and strategies to help ourselves sleep well naturally. Sometimes though, we do everything in our power to sleep well, but without success. At that time, other therapies are in order.
One of the options is supporting neurotransmitters with specific nutrients. Neurotransmitters are brain chemicals which help us sleep at times and be alert at others. Some of the ones we think of which promote sleep include serotonin, dopamine, GABA, histamine, glutamate, and norepinephrine.
In the clinic, neurotransmitter levels can be tested by doing urinary analysis. This test has been used by holistic physicians for the last 12 years.
When neurotransmitter levels are out of balance, the nutrients which are their building blocks can be used to increase their levels. These are primarily amino acids (parts of proteins) and the vitamins and minerals to help form the neurotransmitters. This can be a very effective treatment for people whose sleep hasn’t improved with other strategies.
Because this is a powerful therapy, it is not a treatment to try on your own. If you would like to try amino acid therapy for yourself, go to a licensed holistic healthcare provider. They will get a detailed history of your sleep problem and current medications, do testing as appropriate, then recommend the right combination of amino acids and other nutrients.
There are many ways a person could experience insomnia. It could be difficulty falling asleep at the beginning of the night, or being awake for an extended time in the middle of the night, or waking too early.
Whatever time it is, being awake in bed can often lead people to feel frustrated, angry or hopeless about their sleep. As you can imagine, these feelings do nothing to help a person fall asleep. Let’s talk about some strategies to use to help yourself fall asleep.
An ‘Over-active’ Mind
Frequently people tell me that their mind is going a mile a minute once they are awake in bed, that they have ‘buzz brain.’ In this situation, you want to establish boundaries with yourself that bedtime (from lights out to wake time) is not a time to think things through.
So first of all, schedule time 2-3 hours before bed to jot down the thoughts that arise at night, and put them to rest. Spend just 10 minutes on this, so you don’t get further entrenched in those thoughts. You can use any format that works for you – a To Do list, journal, problem and solution brainstorming list, calendar system, or any other format.
Second, if thoughts arise in the night, tell yourself that you already thought about it, and will have time tomorrow, now is time to rest. Putting your thoughts aside like this is a skill, and like all skills, you will get better the more you practice.
Follow this up with purposefully substituting thoughts that help put you to sleep. Some strategies are: a sleep promoting visualization (think dozing on the warm sand at the beach), or slow deep breaths, or repeating a prayer or mantra. For people who are also physically restless, doing progressive muscle relaxation starting with the feet can help still both the body and mind.
Almost everyone has difficulty sleeping occasionally, and these strategies can help quiet the mind and promote sleep. Establish with yourself that during your sleep time you are “off duty” from all types of thinking or planning. You will feel better for having a good nights sleep, and be better able to think things through well during the day.