Sleep and money

Don’t you wish you could make money by sleeping? I suppose we all do. Unfortunately, right now, many people are losing sleep over money issues. For anybody with a stock portfolio, or any body with a job that could be down-sized, you are probably worrying about money.

Of course sometimes we worry about money in the day. But we get so busy doing things that we kind of forget about it for awhile. By the end of the day we are so tired we go to bed, only to wake up thinking about how to pay for the kids college, or how to pay for the rent, or how to pay for the car insurance, or whether or not we’ll even have a job in another couple of months. Thoughts like these can cause real anxiety and even panic attacks, and can really ruin sleep.

Someone once said that everything seems more gloomy in the night because being afraid at night made our ancestors stay huddled in their caves—safe from harm. In other words, it is normal for things to seem worse in the night, and it might even be a good thing.

When you are stressed, it is extra important the you follow good sleep habits, such as we post on the Goal of the Can’t Sleep Café. Sometimes people do the opposite—when they are stressed out, they quit all the good habits, and maybe start drinking a little more alcohol before bed, or lying in bed calculating accounts rather than sitting up and reading. Or worse—they go to be extra early because they are stressed, and allow themselves to sleep in late in the morning, since maybe they are a little depressed also. These kind of behaviors are called mal-adaptive, because they actually make sleep worse, both in the short term and in the long term.

Tough times are the times to be sure that you don’t spend excessive amounts of time in bed; that you take care of your body and eat right and drink right; that you set aside extra time for exercise and other relaxing activities; that you double up your Church time, prayer time, or meditation time; that you don’t try to sleep when your mind won’t—get up and do something else—or get up and worry in the kitchen, not the bed. Don’t overuse sleeping pills. Review my main tips on how to sleep better.

Lastly, remember, the stock market goes up and down, but if you get into bad sleep habits now, you might never recover. Enjoy your sleep.

Sleep disorders

Sleep disorders is a field that can cover just about any human condition—imagine if there was a field a “wake disorders.”

Usually though, the bladder and sleep are used in the same sentence only in regards to older men with larg prostates.  That is, waking up to urinate 1 to 3 times per night is quite common in this age group because the prostate makes it difficult to fully empty the bladder, so it fills up again more quickly.  

A worse problem is NOT waking up to urinate.  I saw JC again today, a 14 year old boy who has wet the bed almost every night of his life since being out of diapers.  He has seen his pediatrician and worked with a urologist.  He has had tests on his bladder—it is normal in all ways—and taken several medications.  These medications are of various types to decrease bladder tension, increase tension in the bladder outlet, and to decrease the amount of urine made.  Nothing has helped.  The “bell and pad” method, wherein a mattress pad beeps as soon as it gets wet has not helped.  Have any of you parents had experience with treatments for bedwetting?  Have medications like imipramine, amiytriptyline, or DDAVP been successful?  

Although most kids outgrow enuresis—and JC probably will in the next year or so—it is unusual to persist into teen age years, and JC looks even older than 14.  It can be considered a sleep disorder because the urination occurs during the deepest stages of sleep—stages 3 and 4, also called slow wave sleep, or delta sleep.  It’s kind of like sleep walking—there is a disconnect between the physical activity and the state of mind.  The body just does it’s thing, even though the brain remains awake.  JC snores, and sometimes snoring produces brain (EEG) arousals that trigger activities like sleep walking.  We’ll see if treating snoring stops the bedwetting in this nice young man.  It would be very interesting to know if others have had success with enuresis by treating snoring in children. 

Sleeping pills in the night

A new study published in SLEEP reports the results of a new formulation of Zolpidem (Ambien) which is placed under the tongue for people who have middle of the night insomnia. This is a patented lozenge which is said to dissolve quickly and have acid-base buffers that enhance its rapid absorption into the blood stream.

People were recruited who complained of trouble getting back to sleep in the middle of the night, but those with sleep disorders or depression were not allowed into the study. They were allowed to sleep for 4 hours, awakened by the researchers, took the lozenge, sat up for 30 minutes, and then tried to sleep again for 4 more hours. Each subject did this on two separate nights, once with the drug and once with placebo. Those taking the zolpidem lozenge fell asleep more quickly and had more sleep in the coming four hours. They are said to have had no morning side effects such as sleepiness or trouble doing a math task.

This study is important because people who only have insomnia in the last half of the night have few options for medication treatment. All of the older benzodiazepine medications take too long to take effect and also take too long to be eliminated by morning. The only real option is Sonata (zaleplon), which can take effect in as little as 30 minutes and be pretty much eliminated in 2 or 3 hours. It is approved by the FDA to take with four or more hours of planned sleep, but it suffers from eratic absorption (food and fat delay it), and it has not been tested extensively in the middle of the night. Similarly, taking regular zolpidem (Ambien) in the night is a problem due to the time of absorption and the longer elimination period. About 7 hours of planned sleep is suggested for oral Ambien.

I know of patients and colleagues who use a sublingual (under the tongue) method for regular zolpidem and zaleplon. For zaleplon, you have to open the capsule, and dump the powder out and for zolpidem you have to crush the pill or wait for it to dissolve. The current study used a low dose of zolpidem (about 3 to 4 mg), and the best dose to be recommended remains to be determined. These problems will be much less when further studies of the lozenge are released.

In general, I favor the shortest acting sleeping pills so that there is less chance of residual effect and less total time of the drug in the body. The sublingual form allows for very rapid absorption, so the drug can get straight to work, and the liver and kidney can immediately metabolize it. Someone should have thought of this before !

Can’t sleep? What to do

One of the activities that we recommend in the Can’t Sleep Café is to get up from bed if you cannot sleep. This is to avoid the frustration of lying in bed, tossing and turning, worrying about tomorrow, and just being upset by the fact that you are awake at night--again.

But what to do? Well, even if you are going to be frustrated by being awake, and even if you will be worrying about performing tomorrow, and even if you are angry about being awake again, it is better to have these feelings while sitting up than while lying in your comfortable bed. This is to prevent the negative associations that can develop between “trying to fall asleep” and “the bed.” It is vitally important, and a long term issue, that your bed be a place of pleasantness, if not happiness and calmness. Being tortured in bed by insomnia just sets up your brain to be in that habit--not good for falling asleep.

The usual advice is to get up, go sit in a comfortable place in another room, and doing something relaxing. For example, I advise against vacuuming or paying the bills. Reading and having a hot tea is good, or just sitting and having a hot tea. This is a good time to meditate or to pray so that your mind is focused on something besides your sleep problem. Also, such an internal activity makes you independent—you don’t need that book, CD, or TV to distract you—you can do it yourself. Remember, however, that meditation, prayer, or a relaxation technique are not methods to actually put you to sleep; rather, they are general stress reducers that allow you to occupy your brain when you are forced to be awake.

They help sleep indirectly in several ways. Other good activities would probably include listening to relaxing music, but not dancing to it. Maybe TV, although the brighness and commercials are generally stimulating, so I don’t recommend it. A computer is fine, especially if you are reading boring political analysis for example, not surfing websites that are stimulating. A lot of people ask me if sex helps sleep. I’m not sure, but this is usually a short-lived activity that gets your mind off your problems, after which sleep might come easier; so give it a try too.

If you are going to worry, it is still better to do this in another room than your bed, if possible. If not possible, at least sit up, turn on a DIM light, and then worry. Make a list of things you are troubled by or need to get done this week. Many times, life seems worse in the night, and better in the morning. Although it is not technically true, in some ways, “the darkest hour is just before the dawn.”

I found a web site with some good suggestions for things to do in the night, and I have added it to my blog roll, isleepless.com.

This site is for people with insomnia, and it appears to be run by a person with insomnia. There are several good reads on this site, including a long list of things to do in the night, although I have not been to all of the site. Take a look some night when you can’t sleep; it will be one way to help yourself and your sleep.

Insomnia blog

Hello from insomnia land. A google alert flashed across my computer screen today, and I went to sleepstarved.org. This is a site started by a woman with insomnia by and for people with insomnia. It reminded me a lot of our own Can’t Sleep Café. Clearly, there are people with insomnia who want to talk about the problem, support other people with the problem, and be supported by others. This is really important for a condition that is often long-term, poorly understood, has limited treatment, and affects our sense of well-being so much.

But a lot of people with insomnia ignore it. They think that it is just part of life, part of the result of stress. Most people with insomnia never go to the doctor, although the direct-to-consumer advertising from the sleeping pill manufactures might have changed that. In fact, I almost think that people with insomnia don’t want to talk about it. So I am pleased to call your attention today to the Can’t Sleep Café and the insomnia site.

A lot of the information about poor sleep comes from sources who have a particular interest in the condition. Obviously, for example, those who make and sell sleeping pills want you to be concerned about insomnia and to ask your doctor about it. Others might be biased toward doing sleep tests on everyone with insomnia, or perhaps being opposed to the use of sleeping pills believing that they are harmful. Others might be particularly enamored with certain remedies like herbal supplements.

I can tell you that everyone with insomnia is different, and that some people benefit from each and every treatment out there, including sleeping pills. The most important aspects of understanding insomnia are to try and understand the cause, not to become anxious about the insomnia itself, and to use behavioral and relaxation techniques in combination with medications. I think that another aspect of treating insomnia is to talk to other people who have dealt with it, coped with it, and found their own way to improve it or to accept it.

You can start your own discussion of insomnia here, and then you might even better enjoy your sleep.

Sleep, marriage, and arguments

Mira Kirshenbaum has a great blog about getting along with your life partner, called Healthy Relationships. Recently she talked about the problem of getting sleep when you are having a rough spot in your relationship, or after a big fight. All of her advice is excellent. I want to talk a little bit about her first of five rules for getting good sleep while under this kind of stress: "You CAN go to bed angry." Well, yes and no.

Mira's point is that you can't keep arguing all night—you need some sleep in order to function the next day. This is true and important. However, NEVER actually go to bed angry. You might not be able to finish or resolve the problem, but don't be angry while you are lying in bed trying to sleep. Those of you who are familiar with my blog and the concept behind learned insomnia know that being angry, frustrated, anxious, or stressed out while lying in bed is one of the main reasons that people develop long-term insomnia.

At some point you need to quit arguing or otherwise let your anger pass. If you have stopped fighting and are still keyed up, I would recommend sitting in the dark or making a hot tea. Don't try to sleep when you know that you cannot. After a while, you might feel sleepy and then you can get into bed and try to sleep. Until then, lying in bed angry or stressed sets the stage for future sleep problems. You'll just have to get by the next day on less sleep—you have to anyway—so sit up if you cannot sleep.

"Don't' go to bed angry" does not mean that you have to keep fighting all night. During periods of stress you will sleep less. This is normal. Keep healthy sleep habits even during these times. Don't booze it up, sleep with the TV on, or be angry in bed. Also, sleeping pills are perfect for this situation—short-term stresses.

Sometimes it is the only way to get some sleep. Use them and follow the advice on sleep habits as well, and use them only for a week or two. And remember, no matter what, enjoy your sleep.

Patterns of insomnia

One of our Can't Sleep Cafe group members says that she is sleeping a lot better after starting CPAP therapy for sleep apnea.

We don't usually think about insomnia and sleep apnea in the same person, so I wanted to tell all what the pattern of your insomnia might suggest is the cause of your insomnia. These are general rules, not absolutely true all the time.

The first pattern is called sleep-onset insomnia. This is difficulty falling asleep in the beginning of the night, but sleeping pretty well through the night. This pattern of insomnia can be typical of anxiety, restless legs syndrome, or delayed sleep phase syndrome (typical in teenagers). In addition, so called "primary insomnia," which is sometimes called conditioned insomnia, learned insomnia, or psychophysiologic insomnia, usually causes difficulty falling asleep at the beginning of the night.

A second pattern of insomnia is sleep-offset insomnia, also called "end of night awakening," or terminal insomnia. This is the problem of falling asleep easily at the start of the night, but waking up too early and being unable to fall back to sleep, say at 3 am. This pattern of insomnia is famous as a symptom of depression, but can be caused by any type of stress as well, and our sleep is lighter in the last half of the night so thoughts can more easily intrude. It is also typical of advanced sleep phase syndrome, in which the body clock is running early, so the person gets sleepy in the evening but then is awake too early. This pattern of insomnia is more common in older people. A similar pattern is to wake up for a few hours in the night and then fall back to sleep just in time for the alarm—stress or alcohol intake are typical causes.

Lastly, sleep-maintenance insomnia is when you keep waking up in the night but falling back to sleep. Needing to get up to urinate 4 times in an older man is an example. However, for others, frequent awakenings are a sign that something physical is happening in the night that awakens you. Breathing disturbances, pain, or leg jerks are perhaps the most common. It is this pattern of insomnia that is more likely to cause daytime sleepiness, and it is this pattern of insomnia that should definitely make you see a doctor and get a sleep study.