Chapter 9
Sleep: The Guardian of the Brain
In This Chapter
• Sleep’s role in maintaining good emotional functioning
• How caffeine can ruin sleep
• Common causes for sleep disturbances
Each night during sleep, in very complex ways, the brain performs maintenance on itself. A multitude of chemical reactions occur during sleep that keeps the brain operational and able to manage emotions more successfully. In this chapter, we will learn about sleep and how to maximize quality sleep.
Sleep: Necessary but Fragile
In studies of sleep deprivation, even modest amounts of deprivation, for example, two nights without sleep, result in the following:
• Fatigue (of course).
• Significant problems with the ability to think clearly and maintain attention.
• Impaired memory.
• Faltering of emotional controls. People are more emotionally sensitive and reactive, and they tend to take things more personally and have poorer frustration tolerance.
These problems are most pronounced when people do not get enough deep sleep (also referred to as restorative sleep). A night of sleep is no simple change in brain activity. In fact, the brain goes through a number of dramatically different stages of sleep each night. These are generally referred to as …
• Light sleep: twilight sleep, halfway between asleep and awake.
• Deep sleep: considered to be restorative sleep. Deep sleep is especially important for reducing daytime fatigue and maintaining good emotional control.
• REM sleep: REM is short for “rapid eye movement” sleep. Here the brain is very active; it is during REM sleep that most dreaming occurs.
Unfortunately even minor stress can disrupt sleep. When people are going through hard times, several forms of sleep disturbance can occur:
• Trouble falling asleep.
• Restless sleep: tossing and turning all night, with frequent awakenings.
• Early-morning awakening: waking up two to three hours before you want to wake up, (e.g. waking up at 4:30) and being unable to return to sleep even though feeling exhausted.
• Hypersomnia: Sleeping too much (10, 12, or 14 hours a day). Despite sleeping so much, most people with hypersomnia still feel very tired during the day.
Difficulty falling asleep is very common in people who are encountering stress in general or in those with anxiety disorders. Often when they try to go to sleep, despite feeling tired, the mind is still up and running. Generally here, people tend to worry, and the worries keep them awake and anxious. So they feel tired and wired. Stress and anxiety can also, at times, cause restless sleep.
Restless sleep also occurs during episodes of depression. Early-morning awakening is a classic and very common symptom of depression. Hypersomnia also occurs with depression.
def•i•ni•tion
Hypersomnia is sleeping too much. Although hypersomnia can occur in typical, garden-variety depressions, it is frequently associated with bipolar depression (a depressive episode seen in the context of bipolar illness). Hypersomnia is a red flag signaling the need to be evaluated for possible bipolar illness. This is especially important because many depressed people are treated with antidepressants. Antidepressant medications can be highly effective in treating most forms of depression. However, there are risks in using these drugs in individuals with bipolar disorder. Here antidepressants can make things worse by either triggering mania or making the overall disorder more severe.
Sleep Disturbances: The Usual Suspects
As mentioned, anxiety and stress in general, and depression, disrupt sleep. In fact, if you can successfully improve the quality of sleep, many stress symptoms subside. A number of stress symptoms are directly related to the sleep disturbance. In the last chapter, we saw how making sure that you don’t have medical conditions or use drugs that cause stress symptoms is the first order of business in managing negative moods. The second crucial step is to aggressively deal with sleep problems. To do so is a very high-yield coping strategy.
In addition, many other factors commonly have a very negative impact on sleep. Most of these take their greatest toll on deep sleep, with the consequences we listed previously.
Drugs That Ruin Sleep
The following drugs can dramatically interfere with sleep:
• Alcohol
• Tranquilizers (e.g. Xanax, Valium, Klonopin, Ativan)
• Most prescription sleeping pills (believe it or not!)
• Caffeine
• Decongestants (pseudoephedrine, nasal sprays, and many over-the-counter cold medications)
• Steroids
• Broncodilators (used to treat asthma and other respiratory disorders)
Alcohol, tranquilizers, and prescription sleeping pills are all very potent in knocking a person out; they really put people to sleep. They are all central-nervous-system depressants. However, the problem with these drugs is that they are notorious for causing a particular sleep disturbance: reduced time spent in deep sleep. No kidding!
These drugs are seductive since they clearly help people to fall asleep (giving the impression that they actually help sleep disorders). However, most people simply do not realize that the price paid is decreased total time in deep, restorative sleep. So they may sleep, but it is poor quality sleep and the next day they have fatigue, poor concentration, irritability, and such. Alas, for some people, if these drugs are used daily for more than a month, two additional problems can occur: the drugs are habit forming (you can become dependent on them), and these drugs directly can cause depression.
Bet You Didn’t Know
Two recently released prescription medications, Lunesta and Rozerem, appear to not adversely affect deep sleep and may not be habit forming. Check with your doctor.
Caffeine: The Real Sleeper
Caffeine use is widespread in our country. People like it because it has a rapid onset of positively experienced effects:
• Increases alertness.
• Combats fatigue.
• Caffeine also has mild, albeit transient antidepressant effects (depressed people feel a little less depressed for 20 minutes or so after ingesting caffeine).
No wonder it’s such a popular drug. But then there are the downsides:
• It can cause anxiety.
• Has a negative impact on your sleep.
• Discontinuation can cause caffeine withdrawal symptoms.
The Problems Associated with Caffeine
The first problem with caffeine is that it can cause anxiety. Caffeine use significantly increases blood levels of stress hormones such as adrenaline. People undergoing substantial stress are already anxious, so it seems counterintuitive that they would ingest something that ultimately makes anxiety worse. But the fact is that during times of high stress, people certainly feel tense and anxious, but they are often also exhausted.
Worry, tension, and anxiety wear people out. And many people going through difficult times also experience at least some degree of depression. The immediate impact of reducing fatigue and depression is just positive enough that people ingest caffeine. The more immediate effect feels positive, but during the day as caffeine levels build up in the blood stream, and so do stress hormone levels, and stress symptoms are amplified. During stressful times, many people often have a gradual increase in caffeine use.
Another problem with caffeine is the impact it has on sleep. Everyone knows that a cup of coffee in the evening may make it harder to fall asleep. And this certainly is a fact. However, what is not widely known is the effect of caffeine on the quality of sleep. This is the major problem with caffeine. Moderate amounts of caffeine taken during the day can dramatically reduce the amount of time spent in deep sleep and contribute to frequent awakenings.
Then guess what? There is more fatigue the next day, and subsequently, people tend to gravitate toward more caffeine use to combat the fatigue. Now we have a very common vicious cycle.
And the third problem with caffeine is that if you consume even modest amounts of caffeine per day, “cold-turkey” discontinuation can cause caffeine withdrawal that includes headaches, jitteriness, and, oddly enough, difficulty falling asleep. Thus a very gradual withdrawal approach is important, for example, reducing your caffeine by 20 percent each week.
But watch out. As you begin to reduce caffeine use, guess what? A wave of fatigue will probably hit you (since your brain has been accustomed to using caffeine to stay energized.) However, after several weeks, the fatigue should diminish as you begin to have improvement in the quality of sleep. By then your brain is doing a better job at regulating itself rather than relying on drugs.
How Much Is Too Much?
Generally, caffeine amounts that exceed 500 mg per day are problematic. In some people (especially in those over the age of 60) amounts more than 250 mg per day can be problematic. The questionnaire below will help you determine your caffeine intake.
Caffeine Consumption Questionnaire
When people are going through a very difficult time in their lives, it may seem silly or trivial to think that reducing caffeine can make any meaningful kind of difference. Please do not take this suggestion lightly. Sleep is tremendously important for maintaining good emotional functioning. I have had numerous psychotherapy clients who have found out the truth. Reducing caffeine, especially if it is done gradually, can be a very effective way to help your brain to more effectively regulate itself and reduce negative mood symptoms.
Other Common Causes of Sleep Disturbance
The following medical conditions can greatly disrupt the quality of sleep:
• Chronic pain conditions
• Congestive heart failure
• Respiratory diseases
• Acid reflux
• Hot flashes associated with perimenopause
• Restless legs syndrome
• Sleep apnea
• Exercise, if it occurs within three hours before retiring to bed
Sleep apnea deserves special attention, because it is often not recognized by the sufferer. Apnea affects 13 million people in the United States, it can continue for years undetected, and yet be responsible for fatigue and considerable emotional suffering. Let’s see what this is all about.
Bet You Didn’t Know
The impact of marijuana and nicotine on sleep are not well understood. Major illicit drugs, especially cocaine and methamphetamine, absolutely destroy sleep. Among prescription drugs, antidepressants and the anti-convulsant drug, Gabatril, may increase the amount of time spent in deep sleep.
Gasping for Breath: Sleep Apnea
Apnea is where a person stops breathing for a brief period of time during the night. Most people do this three or four times a night and it’s no big deal. But with clinical sleep apnea, the episodes occur 200 to 400 times per night. Spells of apnea may last 10 seconds, and up to 2 minutes. This greatly interferes with getting quality sleep.
The most common cause is what is referred to as obstructive sleep apnea. Here the muscles in the throat and upper airway relax too much, collapsing and blocking the airway. The person cannot breathe. As oxygen levels in the blood get lower and lower, the person will then begin to gasp. The gasping may sound like snoring or may include odd noises as inhalation tries to open up the blocked airway.
Many people who have sleep apnea never know it, and may suffer for years or even decades. However, it is hard to miss if you happen to be sleeping with someone who has apnea. The bed partner will surely recognize the loud snoring and other manifestations of apnea. If emotional stress symptoms are accompanied by noticeable daytime fatigue, it is always very important to determine if you snore. It may be a red flag for apnea.
Lots of people who snore may keep the whole neighborhood awake at night, and yet they do not know they snore or may strongly deny it. So asking your bed partner about the presence of snoring is important. Not everyone who snores has apnea, but all people who have apnea snore.
Fatigue + snoring = possible apnea.
If you suspect sleep apnea, talk to your doctor about seeing a sleep disorder specialist. Millions of people have apnea (about 4 percent of the population), don’t know it, and suffer needlessly. There are medical treatments for apnea. I have had a number of my psychotherapy clients who suffered for years with fatigue and depression get diagnosed as having apnea. They didn’t need psychotherapy. They didn’t need antidepressants. They needed and responded to medical treatments for sleep apnea. After treatment, the change can often be remarkable!
Think About It
The simplest approach to treating apnea is to sew a tennis ball into the middle of the back of your pajamas. When people turn over on to their backs during sleep, the ball will cause a bit of discomfort and result in their rolling over on to their sides. Apnea is more pronounced if you sleep on your back. Medical treatments include the use of a devise called CPAP (continuous positive air pressure). It is a mask worn over the nose that pushes air into the airway under pressure. This is often quite effective. Should CPAP not be effective, there are some surgical procedures that may treat severe sleep apnea.
Exercise: For Better and For Worse
In Chapter 11, we will see the many benefits of exercise, including how it can significantly improve the quality of sleep. However, it is important to know that moderate-to-strenuous exercise occurring during a period of three hours before going to bed can interfere with the ability to go to sleep. Exercise has many positive effects; however, it does result in temporary increases in stress hormones, which stay in the body for two or three hours and may cause difficulties in falling asleep. So plan exercise for earlier in the day.
In the next chapter, we will explore a number of additional strategies that can very effectively enhance sleep and thus aid in coping with difficult moods.
The Least You Need to Know
• Good quality sleep is absolutely essential for effective emotional coping.
• Sleep can be easily disrupted by even moderate amounts of stress.
• Tranquilizers, prescription sleeping pills, and alcohol actually ruin quality sleep.
• Caffeine can cause a marked decrease in the amount of time spent in deep, restorative sleep.
• Sleep apnea is often not diagnosed and results in years or even decades of fatigue and emotional suffering.
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