Clinical Focus: A Case for Sleep
Mary returned to my office for the third time with her persistent troubles. We started our detective work four months ago.
She presented me with this list:
- Years of fatigue – slowly getting worse over the last 5 years. Her symptoms racked up enough hardship that she could qualify for disability.
- Constant Fearfulness: As a doctor, the label that comes to my mind is anxiety – maybe even PTSD [post-traumatic stress disorder.] Her growing fear started after she witnessed the traumatic death of a dear friend. Mary suffered a broken limb and a whiplash neck injury. The prescription opiate pain meds washed away most of her pain for months. She struggled to get off of these heavy medications. “When I take the pills, everything feels better. It’s like my body needs them to cope with all this.” As the doctor tapered her opiate prescriptions, she filled in the gaps with alcohol. When she asked her doctor for help, he, unfortunately, prescribed her “booze-in-a-pill.” Benzodiazepines. More about that below.
- Repeating Headaches – As a teenager, Mary suffered monthly migraines with her period. Over time headaches happened more often. Now she expects her head to hurt most days. She can’t remember the last time she went for a week without a headache.
- Pains in Her Abdomen: “I think I have irritable bowel,” she concluded after researching the internet. Pain random dances throughout her abdomen. “It’s worse when I eat. It’s even worse than that when I don’t eat.”
- “Foggy” Brain: She resists the depression-label. I don’t blame her. It’s a rotten one. Once you have got it placed upon you, it’s like tar. Sticky and impossible to remove. She shared the version of herself that she used to be: cheerful, smart and even playful. Now, her spirit-animal would be closer to a sloth than a hummingbird.
The labs showed normal thyroid, no anemia, and proper electrolyte report. She flashed a sign of anger when we ruled out the “easy” solutions.
At her previous visit, Mary reluctantly agreed to start taking medication for depression, but she was convinced these meds weren’t the answer. “My heart tells me this is not depression,” she insisted, “I think it’s something more.”
To begin this visit, I asked Mary to update me about her life.
“Doc, I took your depression medications,” she answered, “but I think they force me to sleep even more. I don’t have time for that much sleep. You remember that I take care of my mother-in-law and my six-month-old granddaughter.”
Mary is living an all-American lifestyle. She is in a constant rush from 6:00 in the morning until 11:30 at night. She falls asleep easily. Too easily. Holding grandbaby Sophia lulls her to sleep within minutes. To sit still is to sleep. Her middle-of-the-night awakenings stopped shortly after starting the depression medication, but now she complains, “Life is worse. Now I crave sleep. I want it all the time.”
She falls asleep and instantly sinks into a dream phase. Danger. Dreaming within minutes of falling asleep warns me of her chronic sleep deprivation. Set aside the history that she only sleeps 5-6 hours per night.
The roots of Mary’s energy problems flourish in many Americans. Research on the need for healthy sleep infiltrates every branch of medicine. The volume of sleep literature overwhelms even the most committed clinician.
Let’s use Mary’s case to summarize current research on the importance of healthy sleep:
The purpose of sleep is to repair our minds and bodies from the stresses of the previous day. This repair process begins when we dream but rises to a very efficient state during the deepest sleep. This deep sleep is called slow-wave sleep. This slow-wave sleep pushes us deep into a trance. When in the slow-wave sleep, the body won’t awaken until the cycle is complete. Healthy brains sink into this phase of sleep 3-5 times a night for a sum total of 12-15 minutes each night. [See my videos to learn more about the importance of sleep here, here and here.]
Mary’s “foggy” brain symptoms are likely due to the lack of sufficient time needed to reset her brain each night when she sleeps. Mary’s days are filled with intense, emotional interactions, and this “costs” her brain each night. When she sleeps her brain should repair. Mary’s brain needs time to file both short-term and long-term memories into storage during deep sleep. Her short sleep commitment fails to allow enough time for the memories to properly be tucked into place so that she can find them in the future. As a result, Mary struggles to remember appointments and certain words.
Just a few nights of shortened sleep can blunt memory retrieval. Chronic, sleep deprivation significantly impacts the brain and affects mood. Research has shown that the brain proteins needed to fight off mood problems are best manufactured in the deepest phases of sleep. These include BDNF, serotonin, dopamine, norepinephrine, oxytocin, and GABA. Mary’s depression medication helps to replenish some of these brain-molecules. The amount we need to feel good fluctuates according to our stress levels. The higher the stress, the greater the demand for these brain-based chemicals. Said another way, the higher the stress, the greater the demand for deep, restorative, slow-wave sleep.
Mary’s Immune System:
Mary deprives her body of at least 90 minutes of sleep each night. This deficit adds up over time. As she accumulates more lost hours of sleep, Mary’s white blood cells become less efficient at fighting off infection. In the course of her normal, daily life, Mary’s body is exposed to hundreds of infections each week. Experts estimate that she will suffer symptoms four times as often because of her missing sleep.
The strength of our infection-fighting cells boosts when we achieve quality, restful sleep. Those same white blood cells weaken during chronic sleep deprivation. Eleven days without sleep kills the human body. How? After that long without sleep, the infection team of white blood cells simply fails to fight off any infections. Zip. Zero. You are a goner.
Mary’s chronic loss of much-needed sleep raises her blood pressure. If Mary ever needs heart surgery, research predicts that her heart’s ability to repair itself will be blunted because it has been lacking routine, restful sleep for the previous six months. The rate of deadly, heart attacks increases for folks that cheat their needed hours of sleep.
Thanks to Mary’s poor sleep history, her body has an easy time packing on the pounds. Simply put, poor sleep makes us fat. When we’re lacking sleep, levels of the hormones insulin, ghrelin, and leptin all slide in the wrong direction. Scary fact: This change in fat-making-hormones happens after only two nights of shortened sleep.
Mary does not see her prescription medications as an addiction. “I don’t take more than my doctor prescribes.” Since the traumatic accident, her bones healed but her brain remains damaged. Without giving her mind and brain the chance to heal, she could stay in this holding pattern until death.
The opiates-pain-killers provided the needed relief following her accident. However, her brain was not healthy before the accident. The weakened state of her brain’s wires made it easy to slip into dependency upon these meds. The doctor took her off of the opiates.
Mary did what many folks do: use alcohol to help settle the mind down. Now Mary can’t seem to sleep if she does not use booze or “booze-in-a-pill.” Benzodiazepines impact the brain just like booze. Like opiates, they don’t allow the brain to sink into the deep stages of sleep needed to repair things. Years of poor sleep create the perfect storm for brain-fog, slow thinking, irritability, cravings, impulsive thoughts and behaviors, alcohol, and other mindless forms of escape.
Mary’s benzodiazepine of choice is alprazolam, also known as Xanax. Other examples of booze-in-a-pill include Librium (chlordiazepoxide), Valium (Diazepam), and Klonopin (clonazepam) — just to name a few. These drugs are addictive and are not good for her brain. It’s been over 3 years since Mary’s accident. She now has a solid need for these meds. When she stops them, she will not sleep well during the withdrawal. This phase can last weeks in some patients.
So what is Mary to do?
Take a timeout, Mary.
Shut off all electronics in your house at 6:00 PM. Mary has a broken circuit in her brain. That pathway carrying the messages through her brain is glitching. The repair for this is to have ZERO stimuli before trying to sleep. Those electrical lights flash through her retina and ping her pineal gland. This stimulus keeps the short-circuits firing.
I mean 100% of the electronics need to be off. No TV. No Screens. No video games. No Facebook. Just stop. Your brain needs the proper environment to repair.
Spend time with a journal. Don’t know what to write? Use your non-dominant hand and write cursive l’s. Loops across the page – line after line – will settle the mind. It works quickly. If you’re right-handed, use your left hand to do the exercise. If you are left-handed, use your right hand. Set a timer for 3 minutes. Start there. When the timer dings, write a sentence or two about what you notice during the left-handed-loop exercise. I use this with my anxious patients in the clinic. We both shut up and write for 3 minutes. No talking. No laughing. No burping. No farting. Only writing loops with the non-dominant hand for 3 minutes. I notice that I am calmer afterward. The patient witnesses my example and copies me. AND … the results amaze me every time.
Mary suffers from a form of PTSD. This little brain-hack held the key to turn the corner for Mary. She did loops for 3 minutes at first. But before the week was up, she could do that for over 10 minutes. She was training her brain to shut down. The science behind this is cool. The left hand is not used to writing. The loops are awkward at first but after a short bit of practice, you find a rhythm. This rhythm is pinging your reptilian-brain that is deep inside your noggin. When we ignite this part of the brain to talk to the outer brain in a rhythmical pattern, we settle down. Calm fills us from the inside. When I do workshops inside the community jails, I do this exercise at the beginning of the workshop, again in the middle and at the end. I encourage the inmates to use this to settle their minds while living in confinement. After each workshop, I get unsolicited letters (handwritten!!) from inmates sharing how much better they slept.
Keep the room dark and cool.
The first several nights, when you find yourself sleepy, go to bed. Do not set an alarm. Sleep until you awaken without help. Warn all your loved ones, including pets, about your plan to reclaim a healthy sleep pattern.
By the fourth night of re-establishing your natural sleep pattern, your brain will find the amount of sleep it needs to cope with your current stress level.
Adjust your bedtime to allow for 30 minutes to wind-down. ” Sleep until you feel refreshed. Keep those electronics and screens away from your eyeballs. At the onset of this training, your brain will easily slip back into old habits.
This should be between 7.5 hours to 8.5 hours of actual sleep time.
Mary does not identify herself as an addict. I don’t force that label on her either. I approached her treatment plan knowing that her brain is wired incorrectly. Because of this, Mary will struggle to reset her sleep pattern without some help. When I reviewed the rules for sleep hygiene above, Mary rolled her eyes in exhausted frustration. “Doc, don’t you think I’ve tried all that? I can’t sleep without these meds. I just hang out in my bed with my brain going a million different directions.“
She’s right. Mary’s brain was not healthy before the event. Her poor sleep habits are a long time in the making. The use of those mediations wired Mary’s brain much like an alcoholics. Now, she uses her prescription medications to sleep. The quality of sleep fails to sink into the deep, reparative sleep needed for healing her injuries. At best she gets a “light” sleep each night.
Now she is in a pickle. The traumatic injury followed by benzodiazepines and opiates changed her brain.
Now we need to change it back.
In my clinic, I use a special class of medications to rewire brains of addiction. This protocol was taught to me by a sleep specialist when I was in training and has served my patients well. I have used this protocol in thousands of patients that want to get off of addictive medications like benzodiazepines, opiates, or alcohol.
These chemicals are all depressants. Alcohol, benzodiazepines, and opiates slow the brain. When removing an addictive substance, withdrawal symptoms occur. Withdrawal symptoms from a depressant cause the opposite effect of the drug. The opposite of depress is to stimulate or to wake up. If the habit-forming substance slows down the brain, your brain will race when withdrawing. If your brain races into medium gear, symptoms of anxiety, worry, and racing thoughts keep them from shutting down. If your brain races into high gear during withdrawal, you can have a seizure. YES. Death from alcohol withdrawal happens because the patient seizes.
Cocaine or crystal meth stimulate the body and brain. The opposite effect of these “speedy” drugs is fatigue. Watch a person withdrawal from stimulants like cocaine or crystal meth. They can sleep for days as their body tries to reset.
Mary needs my help to rewire her brain.
Taking medication to reverse the effects of other medication sounds ridiculous. However, the human brain will take weeks –even years– to undo this mess. Many times patients return to the addictive substance out of frustration and exhaustion. Our goal is to rewire the brain for the proper deep sleep and taper off the replacement medication. The process works surprisingly well.
The first night without alcohol or a benzodiazepine, I will order Mary to take a medication called olanzapine. This drug was first in its class to be FDA approved. Originally the FDA granted this drug into the black bags of doctors to treat brains going way too fast: schizophrenics. Schizophrenic patients have a “brain loop” that repeats over and over. This loop causes them to see and hear things that are not really there. The movie A BEAUTIFUL MIND does a brilliant job of showing normal people what the mind of a schizophrenic is really like. They think SO FAST. Too fast. At the end of that movie, the patient was on a medication like olanzapine. These class of drugs is called atypical antipsychotics.
When asking patients to take this medication, I warn them, “If you google this medication, you are going to think that I think you are crazy. You are NOT crazy!”
I further explain that in order for their brains to find the nerves connecting their bm to deeper sleep, we need to shut down the brain. Hold on! I don’t really mean a total shutdown of the brain. Rather this sort of reset reminds me of what happens when I turn off my computer, then turn it back on. A reboot. Olanzapine strengthens the messages pulling the patient into the deepest of sleep. We use this medication to help your brain sink into the deepest phase of sleep on that on the very first night. That deep sleep is called SLOW WAVE SLEEP (SWS.)
Olanzapine kicks butt. It is the oldest of this class of medications and has been studied extensively in the power of reprogramming sleep patterns. The significant increase in total sleep time, sleep efficiency, slow wave sleep (SWS) and rapid eye movement (REM) sleep with decreases in wake time were observed after olanzapine. That’s doctor-speak for: Olanzapine improved every part of the sleep cycle that I want to fix in a brain that has been sleeping poorly for weeks.
Olanzapine stands in first place as the medication that resets the minds of patients with PTSD, severe depression, chronic pain, recurring nightmares, and insomnia.
The benefit of this strong medication: I can program your brain to sleep well in three nights.
The disadvantage of this medication: I need you to stop your life while we reboot things.
Reboot Rules for Mary:
- Prepare for deep sleep. I need the noise in your life to pause for 3 days. This may sound silly, but the greatest form of sabotage for this protocol is the patient or their family. They want to continue their fast-paced life. That can’t happen if you want their brains to reset. Don’t get me wrong- you can reset the brain without this medication. Research using sleep studies to reset sleep teaches us that it takes 4-6 weeks of perfect behavior to see disorganized sleep patterns reset to the healthy, organized shutdown of the body. Follow the rules of sleep hygiene. A list is provided at the end of this article.
- The bedroom needs to be quiet, dark and distraction free. I have had people check into a hotel for 3 nights because it was the only way to fully remove the chaos.
- You will need a chaperone. The most important role of the chaperone is to protect the environment against intruders or other obstacles. I implemented this rule into my clinical practice after my patient’s spouse called the ambulance. A woman in desperate need of sleep had come to see me. After finding no organic reason for her insomnia, we planned to initiate the protocol on a Thursday night. On Friday, she slept so deeply that her husband thought she was in a coma and called the ambulance. He had no idea she had taken this strong medication. Unfortunately, the patient was so sleepy that the doctors all thought she had overdosed on something and racked up a whopper of a bill trying to figure out what had happened. Lesson learned: include the chaperone in the plan.
- The patient must take 10 mg of this medication at 5 PM. It takes 2 hours to get the medication from tongue to brain.
- If the patient feels sleepy before 7 PM, by all means, go to bed. Sometimes it takes the medicine 3 hours or 4 hours to begin working. Once they feel tired, get them to bed.
- DO NOT WAKE THEM UP. They need to sleep until they awaken. The longer and deeper they sleep on the first night, the better this protocol works. I had one patient pee the bed. For real. She had not slept for more than a couple hours in several weeks. She had been enduring the suffering of a tragic story and could not shut down. She could not shut her mind off. She approached a total shutdown if we could not get her to sleep. The medication worked so well, that she actually peed the bed. This has only happened one time in thousands of patients.
- When the patient awakens in the morning, let them take it easy. Adding a list of tasks to their day is not helpful. No painting the house or cleaning the cupboards. No driving or busying them with distractions. Just take it easy. If they feel tired, let them go back to bed.
- Often they will nap on and off well into the afternoon. Let them do this. Their brain is hungry for deep sleep and that is what we are trying to deliver. Many times the patient will not remember this day. If I could study their brain, it would be in a hypnotic type situation. This is the reason for the chaperone.
- The second night, repeat the medication at 5 PM. On this night I usually discuss with the chaperone if the patient should take 1 or 2 of the 5mg pills. As stated above, the first dose is 2 pills for a total of 10 mg. If they sleep well, I can usually get by with only 1 pill of the 5mg tablets the second night. If they are irritable or did not sleep well the first night, I will repeat the dose at 10mg.
- Once again, wait for the medication to start working and get them to bed. The second night is very important to “awaken” the nerves linking to the deep sleep. It is usually the morning after the second night sleep that the patient begins to feel better.
- No driving or extra activities on the second day.
- The third evening 5 mg (or one pill) is usually enough. The medication lasts for 12 hours. Taking it at 5 PM allows most patients to awaken at 6:00 or 7:00 AM without a hangover from the medicine.
- Most patients can return to a rather normal schedule after that third night of deep sleep.
- Over the next several days we decrease the interval of medication from nightly to every other night. After 6-7 days of successful sleep with that pattern, patients take no medication for 2 nights using the medicine only on the third night. After 2-3 weeks of that interval, I recommend the medication on an as-needed basis. If they feel they have not been shutting down fully, take the medication at 5 PM. Most brains successfully lengthen the interval between medications to 5 days, then 10 days, then only as needed. I ask patients to use the medication only after 2-3 nights of poor sleep.
One bottle of 30 pills will often last the patient a whole year. The longer they use the medication, the stronger their neural pathway gets at shutting down. This is the goal. Like any habit, at first, the strength of the signal is weak. With continued practice, their brain settles into the healthy pattern of sleep every night. The medication is rarely needed once that pattern is reset.
RULES OF SLEEP HYGIENE
- Consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations. You can “force” a brain to wake up. You can’t force it to shut off. Focus on the awakening time. The shutoff time will follow.
- Set a bedtime that is early enough for you to get at least 7 hours of sleep.
- Don’t go to bed unless you are sleepy. Keep the awakening time stable.
- If you don’t fall asleep after 20 minutes, get out of bed.
- Establish a relaxing bedtime routine.
- Use your bed only for sleep and sex.
- Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
- Limit exposure to bright light in the evenings.
- No electronic devices 60 minutes before bedtime.
- No food 2 hours before bed.
- Exercise regularly.
- Avoid caffeine 6 hours before bed.
- Avoid alcohol 4 hours before bed. Avoid benzodiazepines.
- Reduce your fluid intake before bedtime.
How much sleep do you get a night?
Tell me in the comments, I really want to know!