Sleep Dynamic Therapy

Archive for January, 2008

There’s an interesting topic by Megan McArdle about obesity and poverty at Atlantic.com. No surprise, there is no discussion about the sleep angle, so I added my comment there, which you can read below:

Sleep is an important link between obesity and poverty. Obesity radically drives up the risk of suffering from sleep-disordered breathing (SDB), a condition that destroys your sleep by two distinct processes: sleep fragmentation and oxygen fluctuations and desaturations. Both processes are very damaging to the brain, producing both temporary and irreversible changes in cognitive function most notable in the areas of attention, concentration and memory. As you would expect, these changes result in a lower IQ either permanently if the condition continues too long untreated or temporarily if the condition is reversed with proper treatment.

Some years ago we published information about two small studies on sleep disorders among individuals in welfare-to-work programs. The most striking finding was that more than 50% of these individuals, who were predominantly women, reported symptoms consistent with serious and complex sleep disorders likely to be compromising their intellectual function. These disorders included SDB, chronic insomnia, chronic nightmares, and sleep-related leg movement conditions. Many of the participants in our study were obese as well.

I have long advocated the use of sleep evaluations (and essential treatment) by various service programs that help individuals in lower socio-economic situations. The likely impact in terms of health benefits, quality of life,work performance, productivity, and cost-savings would no doubt be huge and certainly something for policymakers to “sleep on.”

You can find more discussion about sleep disorders and their impact on health, wealth, and quality of life at my blog: http://www.sleepdynamictherapy.com.

Gee, I wonder whether any of these guards have sleep disorders.

Several MSM articles like this one covered the just released research showing that there is an association between increased caffeine consumption (measured in coffee, sodas or tea) and miscarriage. Like so many studies before it and the coverage on this topic, the MSM is stuck in neutral as it fails to explore other possible explanations for the findings. The findings, after all, are associations, which means that no one is making any claims that caffeine causes miscarriages. Yet, in all the reports I read, most suggest pregnant women should consider reducing caffeine consumption, but few of them actually asked an expert, let alone a sleep expert, to given an alternate view on the findings.

So, here’s mine. It’s well known that caffeine is used to increase energy and ward off fatigue and sleepiness. Thus, it’s not rocket science to make the assumption that a fair number of heavy caffeine users are suffering from fatigue and sleepiness caused by sleep disorders. A potentially common sleep disorder in pregnant women is sleep-disordered breathing, a condition that causes oxidative stress and pro-inflammatory states, and previous research by the inventor of CPAP (the treatment for sleep apnea), Dr. Colin Sullivan, showed a strong link between sleep breathing problems and pre-eclampsia, a condition in pregnancy that may threaten the fetus.

Thus, a parsimonious theory is that pregnant women with sleep apnea are sufficiently tired and sleepy to reach for an extra cup of coffee, etc. So, what the research then really might be showing is that the excess caffeine drinkers actually suffer from undiagnosed sleep disorders, namely sleep-disordered breathing, which through it’s adverse effects on multiple organ systems in the body increases risk for miscarriages.

How the impact of sleep-disordered breathing (SDB) could produce this particular effect is unknown, but SDB causes a great deal of sympathetic nervous system activation by the constant awakenings triggered by disrupted breathing; and the disrupted breathing itself causes marked fluctuations or desaturations in oxygenation throughout the night. Neither of these two processes are considered healthy for the human body, so the most relevant theory would be that these processes are adversely influencing the physiology of pregnancy and the fetus.

At the CPAPTALK.com forum, a question was raised about my frequent comments in my book, Sound Sleep, Sound Mind, about higher intelligence levels among insomnia patients. The following is the post I wrote on that issue:

Human Intelligence

Human intelligence, as everyone knows, is a complex dimension to measure, and I am no expert in measuring it. However, as a sleep doc, I’ve formed some fairly clear perceptions about patients with insomnia, who I believe often ‘suffer’ from a higher than average level of ‘intellectual’ intelligence, for lack of a better term.

TFI System

This insight emerged in my own thinking once I realized that most human behavior is coupled to a fairly prominent system of consciousness called the TFI System. (T = Thoughts; F = Feelings; and I = Images.) I write extensively about this system in my book, Sound Sleep, Sound Mind, because the balance within any individual’s TFI system predicts who is most likely to suffer insomnia, who is most likely to have difficulty adjusting to PAP therapy, and who has the capacity to engage in sufficient, self-generated cognitive restructuring (‘changing your mind’) to overcome or adapt to either of these difficulties (insomnia or PAP issues).

To simplify, before you eat, you THINK about the need or desire for food, FEEL hungry for food, or PICTURE (IMAGE) in your mind’s eye the sumptuous Caesar salad you crave. Each of these three activities represents the unique and overlapping components of the TFI System. If you spend time ‘observing yourself’ throughout the day, you will notice you spend at least some time with each component preceding, during or after various behaviors.

In unusually well-adjusted individuals, great awareness of all 3 components is the norm, leading to a balanced system in which the individual freely moves through all components at any given time as needed to adapt to and interact with their environment and the people in it. Having said that, you can no doubt imagine a hundred interpretations of what a ‘balanced system’ entails or feels like. Without wishing to be cryptic, however, let me just say that tasting the experience of a balanced TFI System is a much easier way to know it than someone trying to explain it to you.

Lacking Balance in the TFI System

It’s much easier to explain the opposite’a lack of balance, in which one component of the system tends to predominate or one component tends to be relatively absent. Most of us learn to keep our TFI systems out of balance, and we usually adopt this jaded system some time in childhood or adolescence. As the most classic and relevant example to our discussion, many insomniacs show a high intellect that arguably developed out of a desire (usually unplanned) to adopt an imbalanced system dominated by thoughts and lacking in emotion, which turns out to be a perfect setup for insomnia.

Let’s assume you are a smart person, and your intelligence is obvious to those around you as early as childhood. More importantly, let’s suppose you begin to notice in school or elsewhere that your mind is sharper or quicker than many others at certain intellectual tasks: solving math problems, remembering grammar rules, knowing more words, how to spell them and what they mean and so on. In a short time, you would receive a great deal of reinforcement (grades, praise, requests for advice/answers, etc.) buttressing the belief that your ‘thinking capacity’ is more advanced than others. Very soon, you will turn repeatedly to your powers of intellect to solve the problems you face. So far so good; this example describes a fair number of people who end up with graduate degrees in engineering, physics, medicine, other sciences and so on. In these individuals, ‘Thoughts’ are the predominant component of the TFI system and up to a point have served them well in society.

The question or problem arises at some point as to what happens to the other two components of the system: Feelings and Images. The answer for a lot of individuals is the person grows far too comfortable solving life’s problems with thoughts and conversely grows more uncomfortable attempting to manage emotions or mental imagery. Why so? Because the latter two components of the TFI system seem or feel chaotic; whereas, thoughts seem more controllable.

Over time, some individuals who go down the intellectual path will see a decay in their innate capacity to work effectively with feelings and mental imagery. In the single most classic example of this phenomenon, individuals no longer readily access their own emotions in direct fashion. Instead of ‘feeling their feelings,’ they ‘think about their feelings.’ If you describe this distinction to someone with a healthy and balanced TFI system, they immediately and fully understand the difference. If you make this point to an insomniac, they often need much more explanation (still more intellectual discussion) just to come close to understanding the distinction between ‘thinking about vs. feeling an emotion.’

Insomnia and the TFI System

And, therein lies the basis of my observations and theories. In my clinical and personal experience, people with balanced TFI systems rarely have trouble closing out the day at bedtime. Because they’ve spent much of the day processing a wide array of thoughts, feelings, and images, they fall asleep faster than you can say ‘lights out.’ But, for the individual with too much reliance on intellect, the lack of balance throughout the day means that emotional or imaginative residue probably lingers at bedtime and prevents the necessary closure that leads to the Land of Nod. In fact, among the majority of insomniacs, the single most common complaint is ‘I cannot turn off my mind,’ which means racing thoughts or other ruminations actively fuel the mind with too much alertness to permit sleep.

Returning now to the balance concept, the intellectually inclined individual has spent far too much time in life developing their ‘thinking smarts’ but now they pay for it with insomnia. Why would too much thinking lead to insomnia? Because thinking represents a very active component of consciousness within the TFI System, whereas feelings and imagery represent more receptive components.

When you fall asleep, can you guess which components are closer to the final point of wakefulness where sleep onset begins? The answer appears to be feelings as in feelings of comfort and sleepiness, followed by mental imagery as in little dreamlets that flash across your mental landscape just as you fall asleep.

In other words, active thinking is antithetical to sleep; but if you spend more of your day in the world of thought, there is no easy way to turn off the spigot of thoughts at bedtime. In my book, I describe at length how excess thinking in most insomniacs has actually become a ‘defense’ mechanism, which individuals use to avoid feelings and imagery. But, as I’ve just pointed out above, sleep does not follow from an active and ruminating mind; it follows from a receptive mind based on comfortable feelings and dreamy images.

Summing Up

Most insomniacs I’ve treated have a marked imbalance of the TFI System. The thinking system is so powerful it blocks most feelings and some images throughout the day. Eventually, it prevents the individual from fully processing the day’s experiences, because the system directs the person to think and self-talk about the day without processing deeper emotions or clearer images about the actual experiences during the day.

Finally, SDB patients with similar or other imbalances of the TFI System tend to have greater difficulty adjusting to PAP therapy, because the imbalance makes their personality somewhat more rigid. Their ability to ‘change their minds’ and adapt to the foreign nature of PAP therapy is less than it could be if their minds were more balanced.

In sum, in a large proportion of insomnia patients and some proportion of poorly adapting PAP therapy patients, I routinely see this highly intellectualized intellect, which in fact frequently correlates with a higher IQ. In my opinion, these patients ‘suffer’ a great deal from this lack of balance as they try to solve their sleep problems.

As promised some weeks back, here is a comparison of two expiratory flow curves, one normal, smooth and rounded (1st Graph) and the other abnormal, choppy, and irregular. These sleep epochs are taken from the same patient who is in stage 2 NREM sleep in the 1st graph and stage 3 NREM sleep in the 2nd graph. These are real sleep epochs taken from a 30-second period from the polysomnogram.

In the 1st graph notice how low the EPAP setting is at 3; whereas in the 2nd graph, the EPAP is now at 4.5, and the curve is no longer smooth but bumpy during this “end-expiration” period.

Now, we can all probably imagine a number of possible explanations for these changes, such as general airflow turbulence or some subtle form of leak, but in our clinical experience the pattern in the 2nd Graph is what we term “Expiratory Intolerance” or “Expiratory Instability.” We believe this description is accurate, because this pattern often emerges during a time when the patient may go on to develop a full-blown iatrogenic central apnea, that is, in response to EPAP, the patient cannot tolerate pressurized airflow coming in as they attempt to breathe out. When this “tension” reaches a tipping point, the patient simply stops breathing.

The pattern shown in the 2nd Graph is most frequently seen in patients on fixed CPAP pressure. And, we find that this expiratory pattern can be relieved by switching the patient to bilevel, through which we attempt to find the lowest possible EPAP that yields a normalized expiratory airflow curve (1st Graph) but which does not cause the jagged curves in the 2nd Graph.