Is fear of insomnia like fear of flying?

 What are two major miseries of our well-off modern society?  Obesity and sleeplessness.  No surprise that they seem to be connected; looks like those who fail to get enough sleep are more likely to be overweight.

They’re connected in another way: for some folks, no matter what they try, nothing is effective.  Behavioral treatments usually fail, and drugs have serious side effects and often fail to work on top of that.  Pharmaceutical companies are working like mad to solve both woes. The company that does so will become very rich, if it’s not later sued for all profits plus penalties.

Although over-eating is sometimes connected to anxiety (people eat to soothe themselves),  this post is addressed to the anxiety people feel about insomnia. Those with long-standing cases talk about it frequently and find their lives are constricted by it.  Just as fear of flying causes people to avoid traveling,  so does insomnia.  Even occasional sufferers find sleep more elusive on vacation. Chronic insomniacs consider sleep issues before any other considerations.  Where will I sleep? What are the beds like?  How should I schedule flight times? What will I do in a strange hotel room if I can’t sleep?

But if travel were the only problem, insomniacs could stay home. And sometimes they do, missing out on special occasions with friends and family, avoiding professional opportunities, straining a marriage.

Sleep, unlike flying, however, is a necessity and occurs once every day–can’t get away from it. Sleepless individuals fear their problem during much of their waking time–which, for them is a lot of hours.  And they talk about it: I didn’t sleep at all last night (to quote my European-born grandmother, “I didn’t close mine eye.”).  I had a horrible night. I’m so tired I don’t know how I can make it through the day. I’m worried I won’t be able to….fill in your own blanks: take care of my kids, complete a work project, drive safely, or, in my case, see clients all day without yawning (Clients hate it when I yawn; they think they’re boring me.)

The dread of not sleeping becomes an obsession, and a boring one to the non-sufferers.  In the words of Kenneth Lichstein ,PhD,  director of the sleep research project in the psychology department University of Alabama at Tuscaloosa, “even before they lie down to sleep these worrisome thoughts are already there.”   Anxiety  is defined as a future anticipation of threat, as distinguished from fear, which is a fight or flight response in the face of something that’s occurring immediately.

 

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In her charming and self-aware book Wide Awake: a Memoir of Insomnia Patricia Morrisroe details the excessive, continuous, nagging worry  of the insomniac. She describes endless drug and therapist adventures, alternative treatments, and hotel rooms that she “sleeps’ in for under an hour, before dragging her drowsy husband to some other hoped-fore respite.  Her insomni-phobia seems to come from her mother, who complained about sleeplessness, requiring silence from the family during the day to make up for her nights. Morrisroe finally achieves peace after learning to meditate–a real challenge for her.

The more I listen to their worries, the clearer it seems that the treatment for insomnia, like that of other phobias,  needs a shot of Exposure-Response Prevention, where the patient is exposed to the fear (sleeplessness) and lives moment by moment in the experience until the fear subsides.  The classic example is fear of flying, with the patient is rides in an actual airplane, with the doors shut, of course, despite sweaty palms, rapid heart rate, and increasing anxiety. The physiology works like this:  the patient’s anxiety climbs, gets more intense, peaks, and then subsides.  Bingo! What was feared has been accomplished.

When the patient can tolerate the discomfort of insomnia–the future prediction of insomnia–she’s more than halfway there. It’s a bit like tough love, where the tough part is not sleeping and the love part is being OK with whatever happens.

I’ll offer more specific how-to’s in Part II. It this post gets much longer, it might cure insomnia by itself.

 

Are You Reading This After Midnight? More Thoughts on Insomnia

Up All Night” by Elizabeth Holbert, a  nice piece in the March 11 New Yorker, reprises the research of Matthew J. Wolf-Meyer, an anthropologist with an alternate model to our 11pm to 7am “ideal sleep schedule.”

In The Slumbering Masses” Wolf-Meyer looks at the recent history of sleeping patterns. Before electric lighting, folks went to bed shortly after sunset for Part I or the night. Four to five hours later, they awoke (like me, surprisingly) and enjoyed other activities. Ben Franklin supposedly used the middle of the night to read naked in a chair.  Eventually, they returned to bed for Part II, the “second sleep.”

The theory is that capitalism forced people to go to work at dawn and stay there til night, a schedule gradually modified to 9-5. With that external pressure, we obsess any time we’re awake in the night hours that we’ll be tired at work.  Sleep problems are, Wolf-Meyer thinks, the result of being forced to sleep when we’re not naturally designed to do so.

A second, related explanation of the origin of insomnia nation comes from Rill Roennenber’s “Internal Time: Chronotypes, Social Jet Lag, and Why You’re So Tired.”  Our chronotype is our internal clock,  People tend to be either larks and owls. Larks, who naturally rise early, are well suited to a work schedule, while owls, the reverse, do well socializing at night. Each bird feels fatigued when engaging in activities at the opposite end of its wakefulness cycle.

Infants are natural larks, exhausting their parents, while teens are owls, likewise exhausting their parents.  Proposals for later starts to the high school day make inherent sense but have not been instituted.

These 2 theories help explain our insomnia but don’t make it disappear.  They may, however,  ease the fear of not sleeping by reframing the problem as situational rather than a disease.

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Sleep Deprivation and Depression–Everything You Don’t Expect

ECT, TMS, antidepressants, Ketamine–ever thought you’d heard of just about every way there is to treat depression?

Well here’s one I bet you haven’t heard of: Sleep deprivation. That’s right: doctors have found that depriving patients of sleep can ease their symptomatology–and can do so faster than antidepressants. Ann Wirz-Justice, Ph.D, of the Chronobiology and Sleep Laboratory at the Psychiatric University Clinic in Basel, Switzerland, found sleep deprivation to be effective in over half her patients, and in many different types of depression.

The person who first thought up depriving depressed people of sleep was one Dr. Gerald Vogel, professor of psychiatry at Emory University and director of their Sleep Research Disorder. He would go on to become a world-famous sleep researcher.

In 1975 he published an article in the Archives of General Psychiatry, “A review of REM sleep deprivation,” that concluded, “Controlled but unconfirmed work indicates that  endogenous, but not reactive, depressive patients are improved by REM sleep deprivation, a finding consistent with the animal behavioral consequences of the procedure and with the unique REM-depriving properties of efficacious antidepressant drugs.” [Endogenous depression has a biological rather than environmental cause, in contrast to reactive depression which is brought about by a stressful life event or something else in the patient’s environment.]

And that last little piece of the quote there is intriguing. One class of antidepressants is known for blocking REM sleep. Tricyclics were the cat’s meow until Prozac and its ilk (the SSRIs, or selective serotonin [watch for this particular neurotransmitter; it makes a comeback later on] re-uptake  inhibitors) came on the scene.

Interestingly, depriving people of sleep works on a variety of types of depression. For example, there’s extensive work on how efficacious it is in postpartum depression.  In 2001 researchers published an article with the telling title, “Sleep deprivation as a model experimental antidepressant treatment: Findings from functional brain imaging.” In it they concluded that if a depressed mother fails to sleep even half of the night, by the next morning her depression will have eased.  It sounds crazy, but the conclusion comes after over 1,700 sleepless mothers were observed in over 75 papers.

In yet another manifestation of the illness, those with bipolar depression react extremely well to sleep deprivation. In one study, 8 of 9 bipolar I subjects were quite responsive, and in a second experiment, researchers found that those with bipolar disorder were notably more responsive than those with unipolar disorder.

So what is it about failing to get some shut-eye that alleviate the suffering of a major illness?

Well, although humans are clearly different from rats or hamsters, the research of the results of sleep deprivation on these two species is still interesting. Male Wistar rats were subjected to 3, 6 or 12 hours total sleep deprivation. Not just your garden variety hamster but specifically the Djungarian hamster was allowed only 4 hours of sleep. In both cases researchers found that, as a result of the lack of sleep, seratonin levels in the brain increased. That might explain the mechanism that makes missing sleep heal the depressed.

(picture from freedigitalphotos.net)
(picture from freedigitalphotos.net)

So, you might ask, why doesn’t every psychiatrist merely order you to stay up all night watching old movies–or to have a 5-month old who’s teething and whom you’re still nursing? In fact, sleep deprivation is almost never just what the doctor orders.  The answer is simple and obvious enough: the benefits recede once you have recovery sleep.

So even if you drink caffeine, turn the AC down to 50 degrees, and watch scary movies until 4:00 A.M. on Monday and Tuesday, when you finally collapse on Wednesday and sleep 12 hours, the mood lift you got at the beginning of the week dissipates. You’re better off getting your serotonin boost from a good SSRI, which doesn’t stop working when you get a bit of shut-eye.

But it sure is something to keep in mind before the meds kick in.  A little sleep deprivation goes a long way.

 

Knitting up “the raveled sleave of care”: Sleep and Bipolar Disorder

Sleep.

I, for one, am a huge fan. I love that feeling of drifting off, right before my consciousness checks out, and I adore that well-rested feeling I have when I first open my eyes after a productively-slept night. [Those nights are becoming fewer and farther between as I age, but that’s just another one of those little amusements that come from slowly leaving behind those days when anyone would call me “young lady”–except for my ancient Uncle Herbie, who calls any woman under 92 a “young lady,” so I can’t really count him–can I? My mother, with another of her pearls, used to say that getting old is lousy–but it’s better than the alternative, and, as always, mother knows best.]

Sleep disregulation is one of the hallmarks of mood disorders, and, if it’s on the side of the inability to sleep, often one of its tortures.

I can recall the days–oh-so-fondly–when sleep came–early and often, like Chicagoans vote. Then, of course, the key was fighting it. Remember those college nights of coffee and No-Doz? I do–and somehow I was always asleep by 3:30 anyway, head on the book on my desk, still holding the M&Ms that were a pre-requisite for any all-nighter.

As appealing as it sounded then to just rev your motor and go, reduced need for sleep is actually bad news. For a person with bipolar disorder, it’s often one of the first signs of impending trouble, as not needing your shut-eye is a hallmark of mania.

And that seems clear enough–you can’t rest, you know you’re speeding up. But what is fascinating is that current research seems to indicate that the reverse is true, as well. That means that simply not sleeping over a period of time can actually help precipitate a manic episode.

 

In another one of those scientific article titles that I love due to their profoundly uncreative nature, Colombo et al, in the 1999 volume of Psychiatry Research entitled (here we go) “Rate of switch from depression into mania after therapeutic sleep deprivation in bipolar depression” (pretty great, right? You might have some idea of what’s coming now, no?) actually found that a small but significant percentage of bipolar people, when treated to a night of total sleep deprivation, switched into a manic episode.

It’s pretty fascinating.

In an article entitled “Sleep and circadian rhythms in bipolar disorder: Seeking synchrony, harmony, and regulation” in the July 2008 issue of The American Journal of Psychiatry, Allison Harvey studied the impact of disordered mood on sleep–and, interestingly enough, the impact of sleep on disordered mood. Her model suggests that individuals with bipolar have “a bidirectional relationship between daytime affect regulation and nighttime sleep such that an escalating vicious circle of disturbance in affect regulation during the day interferes with nighttime sleep/circadian functioning, and the effects of sleep deprivation contribute to difficulty in affect regulation the following day.”

Great, right? So now what?

Well, here’s where those with bipolar need to be really proactive about taking the sleep matter into their own hands.

As always sleep hygiene [and I love that phrase, it makes me think of those great those fifth-grade hygiene classes, with all the embarrassed 10-year-olds looking anywhere but at the opposite sex–or their friends–but now everyone is slightly drowsy] becomes vital. My guess is that you’ve heard it all before–but now really stick to it. You know–use your bedroom only for sleeping, no napping, get out of bed if you can’t sleep for more than 20 minutes, no TV in bed, make sure you get enough exposure to natural light, shut down the computer 2 hours before sleep–the whole shebang.

And then there are the “when-all-that-fails” ideas:

1. Under your doctor’s careful watch you might try melatonin, which has some research showing it can help sleep during a hypomanic episode.

2. There’s something called “dark therapy” which is cautiously being recommended for those tending toward mania with difficulty sleeping. It exposes the person to complete darkness for an extended period of time, hoping that this will help reset the body’s sleep/wake cycle. [See “Bipolar Disorder, Light, and Darkness: Treatment Implications” for a detailed description.]

3. If your doctor sees it as useful, there are a variety of sedating medications used for difficulty sleeping, especially, in an impending manic phase, benzodiazepines, anti-histamines, and sedating anti-depressants.

4. And there’s a new approach, unique to bipolar patients, called Interpersonal and Social Rhythm Therapy (IPSRT). It’s a therapy that works to help patients maintain regularity in routines–including sleep patterns–and claims to be having some pretty good results, when used in conjunction with psychopharmocology.

The Bard himself recognized that sleep is what “knits up the ravelled sleeve of care,” it is “balm of hurt minds, great nature’s second course, chief nourisher in life’s feast.”

Without it we all start to come unravelled–when the bipolar-disordered person lacks it, she is set on a dangerous course.

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