To sleep-to sleep, perchance to dream.

Updated: Nov 16, 2021


At social gatherings if asked by a new acquaintance what I do for a living and I reply psychiatrist, I first note a slight social retreat, as if they are wondering whether I'll judge them more harshly than I judge myself. Once that hurtle has been crossed and the conversation warms up, I'm frequently asked about sleep, and whether I have any advice on how sleep quality can be improved.


I'm not at all surprised by the question because about a third of Americans at any given time are having trouble with sleep, and one in ten have chronic difficulty to such a degree that the problem impairs ones quality of life.


So here is what I say. First off, sleep is like a horse, if it is not trained it will run amuck. The problem stems from the fact that the brain has a clock, and sleep is tied to our circadian rhythms. Unfortunately, the brain's clock is off a bit, perhaps 15 minutes per day, and it is reset by exposure to light. So at night time while sleeping we surround ourselves in darkness. Come daylight, some of the pathways from the eye instead of going to the visual centers go to deep brain areas and reset the clock to the proper daily rhythm. All of this is to say that exposure to light in the middle of the night, or significantly irregular wake up times in the morning, throw the brain's clock into chaos. Regular circadian rhythms are disturbed, and consequently, sleep quality potentially suffers.


To wit, keep your wake up times fairly regular and if awake in the middle of the night, keep your surround quiet and dim.


Secondly, the brain has momentum. We have all heard a young mother tell her family or friends, 'don't get the kids wound up, it's close to bedtime.' Yes, the brain is like a top, you spin it hard and it takes a while to settle down. So, to encourage a quick transition to sleep once in bed, govern your behavior for a time before going to bed .


To wit, good sleepers generally have pre-bedtime routines involving quiet activities.


Additionally, people need to be aware that the quantity of sleep required amongst individuals varies. 7 or 8 hours is an average. People get into difficulty if they expect to need more sleep more than their body actually requires. This leads to the advice to not spend much more time in bed than one actually needs. Problems arise when the six hour sleeper expects to need 8 hours. She ends up tossing and turning in bed and develops negative association to the bed and its possibilities for sleep.


A final important issue. Sleep is disturbed by stress. If we are contending with significant problems that threaten our security sleep goes by the wayside. This is adaptive and makes sense. Our brains developed in primitive times in which significant problems were much more likely to kill us than they might these days. Better to lose a nights sleep problem solving then ignore the challenge and suffer the consequences.


To wit, tend to your daily life's challenges as best you can, it will pay off at night time.


We all have heard most of the advice above, and many still don't sleep well so it's time to talk about drugs and the physiology of sleep.


We all know about caffeine, and its role in wakefulness. Mentioning caffeine is a good transition to talk about drugs. The first we might mention is alcohol. Moderate drinking is no evil, but consumption close to bedtime can be problematic. At issue is the fact that while alcohol has sedating qualities, it is metabolized so quickly by the body that its rapid disappearance can shock the body into wakefulness a few hours after consumption. So avoid drinking close to bedtime.


Sleep aids are amongst the most widely prescribed pharmaceuticals. The majority are sedatives in the so called benzodiazepine class- Valium being the most famous of this class. For a large number of people, these traditional meds work fine for short term use, however, longer term their action tends to wane, and they have the liability of causing physical dependence.


Other classes of medications include sedating antidepressants and antihistamines. These drugs are sometimes helpful but overall they can be inelegant, having a lot of biological activity that is not simply limited to helping a person sleep. An exception is when a person's insomnia is a consequence of a related condition such as a mood disorder.


There have been exciting advances in our understanding of the mechanism of sleep. These advances have led to the development of much more specific sleep aids. In particular, drugs that effect Melatonin have a lot of promise. The physiology of sleep is interesting and is increasingly being elucidated. It goes something like this.


As they day progress, our brains become tired. This is not surprising as the brain uses a lot of energy, along the lines of 25 percent of the body's total energy consumption. What's interesting is that as the brain is becoming more fatigues throughout the day, we don't feel it. It turns out that there are activating circuits that energize us- caffeine in fact is one drug that stimulates these circuits. So while the brain is getting more and more tired during the day we don't feel it because of the counterbalancing activity of our activating circuits. Yet toward bedtime once lights dim and activity quiets down Levels of Melatonin, a natural endogenous compound, rise. This rise in Melatonin shuts down the activating circuits allowing the feeling of fatigue to ensue and the hence the desire to sleep.


Exciting new drugs are coming on line targeted to interacting with melatonin circuits. At least one of which, Ramelteon is generic and can be obtained out of pocket at a reasonable price. These drugs are currently approved for insomnia, but also have great potential to manipulate the biological clock, training circadian rhythms when it is helpful to do so.


We can conclude by going back to basics. Sleep problems are often difficult to treat but all treatments begin with a behavioral assessment to make sure that a patient engaging in the right behaviors to encourage good sleep: keep the circadian rhythms optimized with consistent wake up times and avoid bright light during sleeping hours. Avoid excess stimulation within a few hours of bedtime. Stimulation can be either excess activity or can come from drugs such as caffeine. Tend to daytime stress. If you think your insomnia is associated with a psychiatric problem, get it assessed and addressed. Avoid alcohol close to bedtime.


If these straight forward solutions are not helpful seek out the help of a sleep specialist. The latter have tools and in depth understanding. One such tool, polysomnography can help better define the specific architecture of a person's sleep and diagnose possible underlying conditions such as sleep apnea that may be at the root of the problem.


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