Insomnia #3: What Happens When you Sleep

white bed linen
Photo by Kristin Vogt on Pexels.com

The Awake Brain

Your brain is designed to work in cycles. In the morning, your brain is in its it’s full functional state. Your sensory organs are fully engaged, allowing for sight, hearing, touch, taste and scent. Your eyes will operate normally, and your blink reflex (the response to a fast moving object coming towards your face) is active. You are also in complete control of your motor cortex, so you have full control of your muscles, allowing for normal movements.

Your heart beat is on an automatic system but gets outside input from the vagus nerve. Your heart rate will rise when physical demand requires more blood flow. Your breathing is automatic as well. You can override the automatic breathing cycle yourself by doing something like meditation or breath holding. Your respiratory system will go back to your default automatic program as soon as your conscious brain moves on to something else.

During the awake state, your digestive system is ready to work, and particularly during the day hours the stomach, small intestines, and colon work in coordination to digest for and extract nutrients as well as eliminate waste.

The Drowsy Brain

You begin to register the sensation of feeling sleepy when your blood pressure begins to drop. Your heart rate will also begin to slow down. Your ability to form new memories decreases, and any new information that reaches your brain will not be stored. The electrical activity in your brain begins to change as well which can be seen on an EEG. This corresponds to an alteration in your eyes, which will start an automatic slow back and forth movement.

Light Sleep

N2 or light sleep will follow the first stage of sleep. The electrical activity of the brain will continue to change, reflecting a lower amplitude of activity on EEG’s. The eyes will stop moving at this point, tending to stay in one place. Breathing is now automatic. When your awake, if you hold your breath, you will get a strong urge to breathe within a few seconds due to your body’s mechanism to respond to elevated carbon monoxide levels in the blood stream. In N2 sleep, your body may not do this. You will spend about half of the night in this stage of sleep.

N3 sleep

In this deeper stage of sleep, brain activity continues to slow even more. Your brain will cycle between N2 and N3 several times throughout the night. The body is even less responsive to rises in carbon dioxide in the blood stream than in the lighter stages of sleep.

REM sleep

REM, or Rapid Eye Movement, is the necessary sleep stage that allows for true rest. It is during this phase that the all motor control is frequently lost; This is the stage of sleep when dreams occur.

Waking up

After going through several cycles of sleep throughout a night, your body will prepare to wakes itself. In the early morning hours, your blood sugar will rise. This effect can become exaggerated in diabetics, leading to the Dawn Phenomenon, or early morning high blood sugars despite being in a fasting state. The cycle starts again

Sleeping is a complex process, and as you can see, there are many steps in the process to ensure a good night’s sleep. I frequently discuss an abbreviated form of the the sleep process with patients because many people don’t realize that the highly coordinated process is deeply disrupted with alcohol, several medications, as well as bad habits such as ruminating at bed time.

Once again, I am so appreciative for readers that stop by to read my blog. Being a practicing physician, many of these important topics I often rush through, so it’s nice to spend a little more time on issues.

In my next insomnia post, I will start delving deeper into how to analyze your sleep issue and approaches to deal with them.

Resources:

Goldman, L., & Schafer, A. I. (2016). Goldman-Cecil medicine. Retrieved June 2, 2018.

Insomnia #2-How to talk to your doctor about insomnia

Handy list of questions for insomnia

Lunar Eclipse 2015 blogphoto

Discussing insomnia with your physician  is an important decision. Doing some analysis of the situation will not only help you resolve the situation, but will help your physician work with you more effectively.  

Here are a few questions to consider before going in to see your physician:  

How long have you had sleep issues?

If this started just a few nights ago, likely there is a cause the patient can pin down themselves.  If it has been over a month, we’ll need to dig a little deeper. If it’s been over 6 months, likely you will be diagnosed with insomnia but we still need more details.  

Do you have trouble falling asleep? Or do you wake up after a few hours?

There are different types of insomnia. Having some awareness of if rather your issue is trouble with initiating sleep, waking up frequently, or waking up very early.  You may want to consider keeping track of your sleep with a sleep journal. It can be a cell phone app, information from your activity tracker, or just a list of bedtimes and waking times.

Are you a shift worker?

Naturally, if your work requires you to work overnight, or change scheduled frequently, we’ll need to discuss how this affects you.  

What’s your medical history?

Are you diabetic?  Do you have a condition that’s causing pain?  Are you prone to depression?

Almost any medical condition can disrupt sleep. The muscle aches (myalgia) of the flu can wake you up. If your becoming short of breath when you lay flat that can be a sign of heart disease. Anemia sometimes presents as insomnia. Although one of the main symptoms of anemia is fatigue, many people often notice restless leg symptoms at bedtime. This is because as they lose iron,  the nerves of the legs to become increasingly sensitive to pain.

It may be your diabetic nerve pain (also called diabetic neuropathy) that’s causing pain at night.  Diabetic neuropathy can be one of the first symptoms on diabetes.

Are you reading this blog now when it should be bedtime?

I know my natural tendency is to be a little sedating, and I’ve been batting around the idea of using my blog as a sleep aid.  But screen time has a very strongly association with insomnia. The light coming from your screen (and this counts for cell phones, tablets and televisions) activates your optic nerve.  This stimulus will have direct effects on the sleep center in your brain, the Pineal Gland, which will lead to a wakeful state. By the way, you can find an excellent pineal gland meditation here

Are you going to be angry?

Are you laying down in a peaceful state?  Or are you plopping down in the bed after an 18 hour day in which you missed lunch, never stopped moving and multitasking.  Your state of mind can be a major source of insomnia that we definitely do not want to treat with prescription sleep aids.

What did  you eat before bed?

Your diet choices make a difference when it comes to your sleep.  Caffeine intake naturally will disrupt your sleep. Caffeine has many benefits, but it is a drug with many effects on the body.  You may be especially sensitive to the effects of caffeine, and a stop at the local coffee shop at work may guarantee you a long restless night.

Are you using alcohol to sleep?

Alcoholic beverages have an immediate sedating effect. Paradoxically,  alcohol disrupt the normal sleep cycle, leading to disrupted poor quality sleep.

Are you being treated for chronic pain with narcotics?

Opioids can disrupt normal sleep architecture.  You may fall asleep very quickly, but then you wake up within hours feeling tired.

Do you fall asleep during the day?

It’s natural to have periods during the day of fatigue or sleepiness. But if you’re finding your sleeping at inopportune times, such as on meetings, during conversations, or while  driving, this will require an in depth conversation with your physician.

I recommend patients jot down some notes prior to going to their physician as this can help.  Any information patients bring to the physician will help with a diagnosis and treatment.

In future post, I’ll dive deeper into what happens when humans sleep, as well as using the Chakra system to classify the causes of insomnia.

 

Insomnia

Photograph by Charlyce Davis

 

It’s only 2am….

You’re already awake…

… And your reading this blog thinking …I need to sleep tonight

So you lay there, wishing for sleep.

Then it’s 3am

Then it’s 4am.

As you finally drift off to sleep….your alarm goes off, letting you know your day is about to start, sleep or not..

Insomnia. Oh lovely blessing of long, endless nights. If your finishing an amazing novel you may not mind taking 2-3 hours to get to sleep. If your next day is demanding or high stakes such as a job interview, you need the rest.

Insomnia is a BIG topic in my clinic. My personal estimation is that nearly ⅓ of patients that I see suffer from insomnia. The prevalence of insomnia disorder is approximately 10-20%, with approximately 50% having a chronic course.¹

Insomnia is defined as trouble falling asleep, staying asleep, or getting up too early.

Sleep is frequently disrupted at some point in our lives. Most humans will experience sleep disruption from either a self imposed cause (due to schedule changes, wanting to be productive, socializing) or from an external cause (a new baby). While it’s not ideal, most of us will be okay with one or two nights of short sleep as long as we can get to bed within a few nights.

I have personally dealt with sleep issues. During my residency, overnight call in the hospital meant a few hours of sleep, and possibly no sleep at all. Later, after a stressful breakup I frequently found myself waking up hours earlier than I needed. I know the terrible brain fog patients speak of when you need to be at your best but you can’t be.

When most patients tell me about the insomnia they are suffering, they typically have had either insomnia one month of severely interrupted sleep, a chronic course of poor quality sleep, or a several years long history of frequent bouts of poor sleep.

Thanks to development of prescription sleep aids with great marketing material, including beautiful butterflies drifting you off to sleep,

Photograph by Charlyce Davis

 

most patient anticipate that once they tell the physician they can’t sleep, they will be prescribed a medication that will eliminate the problem. Many patients are surprised that once they discuss their insomnia with me, I’m likely not to write a prescription.

Why would I avoid writing a prescription for a real medical issue? Medical research has shown that the best treatment for insomnia is behavioral treatment. The ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I), as the initial treatment for chronic insomnia disorder². Furthermore, “many medications used regularly and long term for insomnia disorders have an FDA indication only for short-term, as-needed use, in part because hypnotics are associated with dementia, fracture, major injuries, and possibly cancer.”³

One of my aims with this blog is to take an honest look at health. Insomnia is one of the topics that I feel somewhat hypocritical due to the pressures and time constraints of modern health practice. Patients present to me with insomnia, and for years, I treated their insomnia completely differently from how I treated my own insomnia. I’m so happy to have this venue to spend more time on this important topic.

Over the next several post, I’m going to cover the topic of insomnia in more detail. I’m hoping that my blog as well as other sources can start to shift the conversation from insomnia as a condition that requires a multicomponent solution. Thank you so much for visiting my blog, and please stop by soon on my next entry on insomnia.

1.   Buysse DJ.   Insomnia. JAMA. 2013 Feb 20;309(7):706-16. doi: 10.1001/jama.2013.193. Review.
2.  Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine,165(2), 125. doi:10.7326/m15-2175
3. Wilt, T. J. (n.d.). Pharmacologic Treatment of Insomnia Disorder. Annals of Internal Medicine.