Thursday, February 22, 2007

In Dreams


Dr Dork has been thinking about his own history of challenges with Hypnos in light of some recent discussions such as this.


Sleep difficulties are rarely not a major component of depression - indeed, of most if not all psychiatric illness, it could be argued. The classic problem in depression being early morning wakening, considered one of the core physiological shift symptoms.

In the hour before the dawn,
When darkest thought is often born.
It seems to me my head is shorn
And that I sleep on frigid steel.

It's not fun to await the day, when your mood, your perspective, your world... are all bottoming out together in the diurnal trough.

Dr Dork has previously suffered from what is nowadays termed PTSD, as well as wrestling with the Black Dog since a young whippersnapper. He has run the full gamut of sleep dysfunction at one time or another.

Dr Dork also often advises his patients on improving sleep.

If there is a physical cause, such as pain or obstructive sleep apnoea, it needs to be treated.

Sedatives - anxiolytics and hypnotics - are, to Dr Dorks mind, best avoided if possible. Used briefly if necessary. They are only ever a short-term bandaid solution, and can exacerbate the problem(s) in the longer term.

Benzodiazepines are addictive. They also have a depressant effect on the CNS. Even a 'pure hypnotic' like zolpidem is at the very least psychologically habit forming.



Persistent insomnia is enervating. Exhausting.

The first goal is to treat the cause, whatever it may be, if it is identifiable.

The second goal is to promote sleep hygiene. This is not referring to clean pyjamas. In summary, this entails several principles, which the Dork endeavours to practice as well as preach, including:

1. Get a routine and stick to it. Always get up at the same time. As much as possible turn in at the same time.

2. Maintain a comfortable sleep environment. Not too hot, not too cold. Quiet. Dark. Wear earplugs if you have to.

3. Your bed is for two things. One of these is sleep. The other is not eating, reading, or watching television.

4. Limit caffeine. The half-life of caffeine is at least a few hours. Dr Dork religiously avoids caffeine after 3pm. Or maybe 4pm.

5. Alcohol. Many think alcohol helps them sleep. This is bollocks. It can induce sleep initiation, but stops you entering the 4th/dreaming phase of sleep, and leads to less restful, poor quality sleep.

6. If you're a Nana-napper, limit to 20-40 minutes.

7. Exercise. Doing so in the mid-afternoon / early evening has been shown to promote improved sleep. If Dr Dork wasn't nodding off, he'd source a reference....*Yawn*.


Sweet Dreams.


24 comments:

Fallen Angels said...

I knew that sleeping too much or sleeping too little are symptoms of depression...did not know early morning waking was! This has become a problem for me in the last few months. I had always been someone whom could sleep like a teenager at normal times and could sleep the week away when depressed. A night for me would be going to bed at 10 pm and needing a sonic boom to wake me at noon the next day. When depressed...I might wake at the sonic boom but would roll over and go right back to sleep for many more hours. Now I wake up between 3 and 5 am, every single day, no matter what time I went to bed. Going back to sleep doesn't work even if I am completely exhausted. I don't like it...and it makes school "interesting" to say the least...especially anatomy lab!

Surgeon in my dreams said...

Good tips, thanks!

My ex used to tell me that I quit breathing when I slept, but I figured it was just him holding a pillow over my face. When my "present" husband told me the same thing, I went to the doctor and had the sleep test.

They told me how many times per hour I quit breathing and for how long each time...I was shocked! No wonder I felt like crapola all the time. Nodded off at red lights.

Now I sleep with a CPAP. I have one of the more sexy masks (snort-snort)!

My (fairly new) husband figures I may look like Darth Vader, but at least I don't keep him awake any longer.

Happy Snoozin'.

Health Psych said...

I used to suffer early morning waking (around 3-4am). Funny thing is that since I started steroid therapy, it never happens.

Great tips. Some other things we advise our patients is to use the early morning light to set your biological clock (turn your face to the sun for a few minutes); morning or early afternoon exercise; have a LIGHT snack before bed - non-spicy with sedating potential ie. tryptophan containing (dairy or peanut butter); develop a sleep ritual eg. a warm bath, relaxation exercises, relaxing music; if unable to sleep within 20-30 minutes, get up and go to another room, do a quiet activity (nothing too stimulating, no bright lights) until sleepy; avoid oversleeping or lying in bed for prolonged periods.

Do these help? The most surprising thing was the peanut butter...helped one of my chronic insomniac patients a lot...but like with everything else, it's a question of what fits for the individual.

Happy sleeping.

Raine said...

but how do we stay awake after getting up at the morning rising time..........?

Dr Dork said...

Hi FA,
I recommend discussing this with your doc and/or psych.

SIMD,
I think OSA must be utterly exhausting for untreated sufferers - some wake up hundreds of times a night in a pre-asphyxiation state...yikes!

HP,
Thanks for the additions, all very good advice. I didn't know about the peanut butter...yum!

Hi Raine - well, I basically get up and about and busy as soon as I wake...that and sometimes liberal use of caffeine is a vice I subscribe to in the A.M. when struggling, I confess.

Kind regards
Dork

Nutty said...

I'm the opposite. When depressed, I can easily sleep 10 or more hours a night then go back to bed for 2-4 hours in the day. It's only when manic that I can wake early.

Fallen Angels said...

Not to worry Doc...both my GP and pdoc are aware of it...my therapist too. :P

Anthony the Loser said...

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Godwhacker said...

Thanks for another great post and the great song/video to go with it. Your efforts are appreciated.

Midwife with a Knife said...

Good sleep hygeine reminders, Dr. Dork.

I have to say that I think that poor or limited or inadequate sleep can also be very depressogenic (when it's not due to depression).

I take Zolpidem for post-call insomnia or circadian rhythm disturbance related insomnia on occaision, and have found it helpful, but it certainly can foster bad habits.

Midwife with a Knife said...

Good sleep hygeine reminders, Dr. Dork.

I have to say that I think that poor or limited or inadequate sleep can also be very depressogenic (when it's not due to depression).

I take Zolpidem for post-call insomnia or circadian rhythm disturbance related insomnia on occaision, and have found it helpful, but it certainly can foster bad habits.

Bo... said...

I've struggled with sleep problems since I was a child. These days I am sort of resigned to it. (I was re-reading "The Prince of Tides" this week--and noted that one of Conroy's characters sees black dogs...)

Dr. Deb said...

Would you be open to trying blue light therapy? You can purchase a very good one on Amazon. I swear by it! And many of my patients have reported similar improvement with their sleeping.

Dr Michelle Tempest said...

Thanks for the sensible blog about sleep. Sleep is so important and it is said that our generation gets less sleep than any other previous generation...we should not forget how important it is. Thanks again. Michelle

Calavera said...

This is a really useful post, and I'm going to note down some of the points to use when I next have a bout of insomnia. You're right, it's so exhausting and almost painful to be a crap sleeper, like I am, from time to time. :(

dragonflyfilly said...

Hey there Doc!

very good Post and very sound advice, oh and i love the photo of my favourite kind of bear, but technically not a bear, well never mind, the post is about sleep, not bears.

but just sign me off as
"cracker crumbs between the sheets"

p.s. oh do you remember that game: "under the blanket" ...no, not THAT one..the one we used to play as kids, you would say something silly, and add..."under the blanket" ???

later,
pj

dragonflyfilly said...

Hey there Doc!

very good Post and very sound advice, oh and i love the photo of my favourite kind of bear, but technically not a bear, well never mind, the post is about sleep, not bears.

but just sign me off as
"cracker crumbs between the sheets"

p.s. oh do you remember that game: "under the blanket" ...no, not THAT one..the one we used to play as kids, you would say something silly, and add..."under the blanket" ???

later,
pj

Stefan D. Tarlow MD said...

I am an orthopedic surgeon specializing in the knee in Scottsdale, Arizona. I followed doctor blogs for the past year and recently started my own. I recently came across your blog and wanted to touch base with other Drs with more experience. I wanted to invite you to visit my blog at http://tarlowmd.blogspot.com and would enjoy hearing any comments that you have. Keep up the good work.
-Dr. Tarlow

NeoNurseChic said...

Hiya Dr. Dork,

I went for my first and only sleep study back in 2005 - just before graduating from nursing school. It was rough - I did not like it one bit. First off, even though they attempted to keep the room dark and quiet, I could hear repetitive sounds - know how sometimes you can hear the electricity in the walls? Well - when I latch onto stuff like that, then I can't turn it off and thus can't sleep. The first night, I stayed up the entire night. The next day, I was miserable. I had to lie down for timed "naps" and then had to rate whether or not I fell asleep. I couldn't tell. I was irritable and beyond exhausted, but once I haven't been able to sleep for hours, it just gets worse. So that night - preparing for the 2nd night of the sleep study, I took my sleep aid and said, "to hell with it!" I don't think I moved the entire night. I was diagnosed with excessive daytime sleepiness marked with insomnia, RLS, and PLMS. Sure, sure...that doesn't bode well.

I go through phases where I can't sleep and then times where I can do nothing BUT sleep. Now is one of those times where I could literally sleep 24/7 without problem. I could take a 2 hour nap from 4-6pm and then go to bed at 9pm again. I think part of the reason I'm so tired all the time is because of my cluster headaches. They wake me up at all odd hours - and even if I get one aborted quickly with oxygen, I still have woken up. When I first got them, I used to have attacks at 5pm, 7pm, 9pm, 11pm, 2am and 4am every single night. In the beginning, I was too afraid to fall asleep and then wake up with the most unbearable pain I'd ever felt - and I had a good clusterbuddy Dan who would stay up all night chatting with me on IM until the 4am attack ended, and then I would finally sleep for about an hour or two before having to get up for classes. Once I went on verapamil, I stopped having clockwork clusters, but I have always continued to have an attack at 4am...EST, that is! My clusters were terribly thrown off when I was in England! I tried frovatriptan preventatively when in England, but I got breakthroughs whenever they felt like it! The beast is a dreadful thing for sleep... But sometimes when I awake with an attack, it is more of a shadow than an attack - I have all the autonomic symptoms of eye drooping and watering, nasal stuffiness, etc...but without the excruciating nerve-on-fire pain in my face/head/eye. Those don't happen often but isn't it funny that one's hypothalamus would continue to wake you up at the exact same time, with the autonomic features of an attack, but without the severe pain? Clusters are a strange beast, indeed - but rob many of us of a good night's sleep!

I no longer take sleep aids unless I'm having a particularly bad insomniac night. Anymore, my main problem is staying asleep - not so much falling asleep. And I find that most of the sleep aids prevent me from getting a rest-ful night's sleep...I end up exhausted the next day. But at least I no longer rotate between day and night shift - that was dreadful! My sleep doc is actually quite well-known in the field....Dr. Karl Doghramji - he actually has cluster headaches as well - albeit he is fortunately not a chronic clusterhead. ;)

Hope you're doing well! Take care!
Carrie :)

Sid Schwab said...

It would have been a good post in any case; including Roy Orbison places it into a level of excellence and beyond.

Dr Dork said...

Hi all,

Nutty,
I think hypersomnolence is quite common as well, the spectrum of sleep disturbances in depression is nothing if not broad.

GW,
No thanks needed, glad you liked the vid. If I only I can find an excuse to put up Blue Bayou...

MWWAK,
I have the luxury of freedom from shiftwork nowadays and after many years of sleep disturbance - including vocational - I for myself can generally always get through a day fine no matter how little I sleep. Once I get started, that is. Mind you, I don't operate on people, and no-ones going to cark it if I'm a tad un-coordinated from sleep deprivation !

Boheme,
Will have to have alook at that, ta.

Dr's deb and michelle,
Hope I didn't make any major blunders, this is you guy's professional sphere, not mine!
Deb, I'm not familiar with it, I have found sticking to an exercise routine works wonders for me within days if things get out of whack. We certainly have no shortage of light down here in Oz at present. I wonder which UV spectrum these lights use ?

Cal,
Glad you found it helpful. I recall the worst mistake I made as a student was probably overdoing it on caffeine too late in the day. Spent 90 out of 96 hours awake once during an exam bloc. Not fun...but my borderline delerium was probably funny to watch!

Hi pj,
I've heard of "The Blanket Show", which may be similar. Koalas (aka Drop Bears) look cute but they kill several people every year.

Hi Dr Tarlow,
Had a squiz at your blog, good to see an ortho posting, I'm not aware of any others. Very useful topics you seem to be covering as well...I think probably everyone I know over 30 has dodgy knees in some regard.

Hi carrie,
Glad things are on the up - it's always hard to sleep for anyone rotating days and nights - I used to loathe it when I did Ed and ICU stints.

Hi Sid,
More Big O to come hopefully. Any excuse will do...

Kind regards
Dork

marvin said...

Good Night Sleep

Lack of sleep can result in stress, lack of concentration, moodiness, memory loss, lower motivation and fatigue. It is important to get a good night sleep otherwise it may lead to different sleep disorders. More than eighty percent of people suffering from depression are suffering with sleep problems.

At present, one of the most common problems is Sleep deprivation. In fact the Better Sleep Council surveyed a thousand adult respondents and discovered that more than 30% of them confessed to not getting enough sleep each night.

Here are 101 ways to get good night sleep for those who experience difficulty in getting sleep.

http://www.sleepdisordersguide.com/blog/good-night-sleep-101-ways/

Dr Dork said...

Hi Marvin,

Are you a son of Alvin ?

(sorry - obscure joke relating to Aussie cinema a few decades past..)

Seriously, many good suggestions on that link, thanks.

Dork

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