The Importance of Sleep

Sleep has been a fascinating topic throughout the whole of human history. Early cultures believed it was a place to commune with the divine or that the experiences in sleep could foretell the future. There was a connection with death, with some pantheons like the Greek’s having their representation of death (Thanatos) be surrounded by sleep (his brother Hypnos) and night (his son Nix). Why did some people lay down to sleep after sickness and never wake? Why do our bodies wake with the rise of the great Sun God and lose our life force when the Sun God falls away from sight. It is no wonder that throughout human history, we have mythologized sleep and dreaming, and why we have so many cultural feelings about it. Sleeping late in the morning is laziness and nothing good will come of going out at night.

If only our subconscious fascination with sleep translated into an actual focus on sleep quality measures, I wouldn’t need to spend so much talking about it with patients. If our culture focused as much on sleep as our myths suggest it should, I probably wouldn’t have any patients. Out of all of the various treatments in psychiatry and neurology, from diet and exercise to supplements and medications, improving sleep is probably the most universal and consistent treatment available to patients, and one of the hardest. I’ve had patients focus on diet and spend two years either finding the right overall dietary approach or even their first migraine food trigger. When I use all of my medical training to pick the right medicine for a patient’s symptom clusters, there is a 70% chance at best that the first choice will be sufficiently effective AND well tolerated. I can never predict which physical therapist, chiropractor, or acupuncturist will help a patient’s symptoms until they try. However, every patient I’ve ever convinced to work on sleep as a priority has had improvement in various symptoms typically within weeks, and nearly every further sleep improvement measure continued to improve symptoms further.

So what conditions can poor sleep affect? The list is endless. Even one run of no sleep for as little as 4 nights has been shown to have permanent effects on cognition, lowering IQ and other measures for years after. I’ve never met a patient I truly believe had a manic episode without a run of insomnia. I’ve had patients with very difficult to control breakthrough seizures after being well controlled for decades just because of one night of no sleep. Sleep apnea can cause or speed the development of most dementias, cardiovascular disease, and stroke. Cause and effect are difficult, but poor sleep is connected to worsening depression, weight gain, diabetes, and many autoimmune conditions. I hope that your first reaction to this sort of information is “That can’t be. Nothing in life is a magic cure all.” That is most certainly true, but we aren’t talking about cures, we are talking about disease prevention and reduction, and of all of our treatments, sleep is one of the most universal and effective symptom reducers and illness preventers there is. But why?

I cannot speak to diabetes (at least I should not if I am to stay in my academic lane) but the connection between sleep and cognitive difficulties and mood disorders is very well understood. The two main processes of sleep that have been repeatedly shown to affect these are network restructuring and waste management.

While the biological correlates have only been clarified within the past few decades, neuroscientists and psychologists/neuropsychologists have opined about the nature of brain network changes in sleep for over a century. Various metaphor were proposed early on, but the general concept is that many partial brain connections form with our daily experiences, but these need to be trimmed in some cases and “consolidated” in others during sleep. In some ways, more things are happening in our brain than during wakefulness.

Wakefulness is mostly about getting food and worrying about things that don’t exist, but at night our brain is taking all of the sensory experiences we had during the day and making important connections stronger while it prunes back and eliminates the less important ones. Without sleep, and I mean proper sleep, the brain never gets the chance so all of the connections strengthen and weaken in a more chaotic fashion. The best literature on this comes from mouse models where memories and activities are reinforced during sleep by strengthening the memory networks for productive activities. WIth sleep, they remember how to get through the maze to the cheese quicker because those map memories strengthen during sleep and the failed pathways lose their valence.

Throughout the body, but especially in the brain, sleep is also vital for removing cellular waste products. Each activity that the body performs includes proteins and chemicals that have a shelf life. When those chemicals have been used enough, they break down and need to be removed from the body. Most people learn about how oxygen is processed and turns into carbon dioxide that we breathe out, but there are a million other proteins being processed from what we eat and what our body produces, and each eventually becomes an unhelpful protein or chemical that we need to get rid of. Since many of them don’t pass back into the blood stream as easily (requiring a different system of drains called the lymph system), and most cannot be breathed out, our liver and our kidneys do a lot of work to to break things down enough to be sent out of the body in various ways (breath, sweat, urine, and poop mostly). The brain, however, has a much harder time of this. The “blood brain barrier” that protects the brain from all of the waste (and toxins) in the blood stream also keeps the heavier waste products from easily escaping. It also doesn’t have the same lymph system to help remove things. Honestly, it is a miracle that our brains don’t clog up with garbage by the time we are 2 years old and start dying.

Luckily the brain does have a few other processes to help drain out the waste products. The “other brain cells” we don’t talk about as much, called Glia, have a thousand functions but one of them is to help flow this waste out via a different system called the “glymphatics”. This system helps pull waste into the cerebrospinal fluid and back into the blood stream, but it is so small and weak that we didn’t discover it until about 2010. During sleep, however, it ramps up. In 2019, scientists first clarified a pulsing throughout the night where the brain slowly fills up with extra fluid and then slowly drains it out of the glymphatic system. With poor sleep quality, this pulsing is less robust. While there are a thousand mechanisms the brain uses to break down proteins and “package” that waste for removal, without good plumbing with glymphatic flow, waste products will build up. Fundamentally, many believe that is what happens in most of the degenerative conditions, from Alzheimer’s to Parkinson’s to ALS. The main difference between those conditions is what protein the brain can’t flush out properly.

Thoroughly convinced that sleep is important? Welcome to the club. Insomnia is one of the most common complaints (or admissions) in any medical interview. Patients mostly know they don’t sleep well, and those who don’t “check that box” will often admit that they need a lot of coffee to feel human when they wake despite 7 hours, or that it is ok because they are a “non-sleeper” and only need 2 hours per night. Convincing either of those two groups that their sleep status is related to their exhaustion, brain fog, and other symptoms is a bit more difficult. I can’t do that here, so I will just focus on those people reading this article who are frustrated believers. What can they do to get better sleep?

A simple online search for sleep hygiene will direct people to some pretty good resources to start from. The Sleep Foundation Website has a pretty good overview of some of the different categories of habit changes that can help sleep. The major categories most people focus on are setting a firm sleep schedule, developing a night time routine, improving daytime habits, and making the bedroom sacred. However, each of those major elements has a thousand sub-components and developing a sleep hygiene program can involve changes to nearly every daytime activity.

Therapists have a lot of tools to help with this, most being familiar with basic guides, workbooks and strategies for “CBT-I” or Cognitive Behavioral Therapy for Insomnia. There are even specialists who go above and beyond standard training and utilize more intense tracking and often counterintuitive strategies like using exhaustion to set the sleep cycle. Simple things like what you eat, when you eat it, and how much of it you eat are also major components of your brain clock. Obviously any stimulants like caffeine or nicotine play a major role, and sedatives rarely help. The biggest problem with sedatives is that they will knock you out, but they don’t allow the brain to do its job in setting a normal cycle of deep and shallow sleep throughout the night, consequently ruining both of the important brain processes I described above. Sleeping on Ambien may be better than simply staying awake all night, but it doesn’t protect from the worst consequences of depression, cognitive decline, and cardiac disease.

You can definitely start implementing behavioral strategies for sleep before getting off of sleep medicines, but you aren’t done until you can sleep without a sedative and wake without caffeine. There are some obvious medical caveats to this like sleep apnea, narcolepsy, and the narcolepsy lite syndrome we call “Idiopathic Hypersomnolence Syndrome”. Sleep hygiene measures obviously won’t cure narcolepsy, but with poor sleep habits, neither can our medicines. In some cases, medications like Amitriptyline and Mirtazapine can be used for other conditions like migraine and poor appetite with a “sedative bonus” that is pretty safe. Other medications like trazodone are much safer than benzodiazepines. Some of the newest medications we use for more extreme cases like suvorexant may hold hope for the future regarding sleep cycle regulation, but for now the main available treatments for sleep pale in comparison to behavioral change when it comes to improving cognition, preventing dementia, and protecting overall health.

So what should you start with? Apart from reading a few articles and maybe a book or two on different routine changes that are helpful with sleep, I tend to recommend people try the below steps as a self-guided process. If it doesn’t work after about 6 months, I recommend they get a dedicated sleep therapist.

Step 1: Every night write down when you go to bed, when you wake up, and a rough estimation of how long you think you stared at the ceiling and how many times you woke up. This may sound easy, but getting into this habit can be very difficult.

Step 2: Decide on a specific “down-time” and “up-time” that you can make as consistent as possible. No “catching up on the weekends” because an erratic sleep cycle is a bad sleep cycle.

Step 3: Implement an insomnia protocol. Generally, laying and staring at the ceiling is counterproductive if it lasts more than about 20 minutes. Instead, go to a separate room with soft lighting and do something simple like read a silly book and sip on warm water or caffeine-free tea for 15 minutes. Then try to go to bed again.

Step 4: Create an evening ritual (not in the bedroom), done every night, that may last between 30 minutes and an hour, or even longer. This wind-down time should be very consistent and not include anything stimulating. Reading is much better than watching TV because your brain can slowly reduce the speed of your reading while TV or music usually drives the pace. Some people add a meditation or a prayer, where others do a stretching or breathing routine or drink a nighttime tea (ginger, lemon balm, chamomile, or valerian root are common). This should be tailored to your personality.

Step 5: Search for inappropriate habits throughout the day and slowly reduce them. Caffeine should have a hard endpoint in the day. Some people can have caffeine till around 2pm, but many people benefit from stopping at noon or before. No sugary drinks, especially after 2-3pm. Alcohol may seem to help people fall asleep, but it (and many sedatives) actually ruins the sleep quality. A good rule of thumb is to not feel any of the effects of alcohol at least an hour before bedtime. Mid-day exercise is important for sleep quality, but evening exercise is stimulating if done after around 5pm.

Step 6: Make all other habits as consistent as possible. If you drink coffee, drink alcohol, or smoke marijuana, doing a lot one day and very little the next will wreck your sleep quality. Exercising heavily for 5 days and then taking days off will confuse your cycle. Eating big meals every other day will confuse your whole metabolic system. Apart from work, each day should roughly resemble the next.

Step 7: Do a deep search for patterns. Some foods (especially nighttime foods) can make it far more difficult to fall asleep. Some people may wind you up and make it difficult to settle into a nighttime routine.

Step 8: Make the bedroom sacred. Ideally, the bedroom should be for sleep and sex only. Some people say sleep only, but that is ridiculous because sex is a very important part of nighttime mental and physical health. Getting rid of anything that could trigger you to start planning for the next day or distract you should be removed. No cell phones or laptops, no bright lights. Dark curtains and soothing images only.

Step 9: Take a slow deep breath and realize there is always more to do, but no one is perfect. If you have been able to achieve a fraction of the above, you have already done more than the majority of people out there. What you have done will be good for your mental health, your heart, and your brain, and you should be applauded even if you had failures along the way.

Step 10: Go back to step 1 and start the process all over again, because you can always do more, and it will always help your symptoms and your health.

With the above basics, most people can really improve their sleep habits. Remember as always, with any habit change, the first three days are the hardest, the first three weeks are the weirdest, and after 3 months it is usually a habit. Of course, if you’ve spent 50 years with a bad habit, it may take longer to fix than if you just started a bad routine last year.

What else? There are always more things to consider. If you find you cannot sleep because your mind is always racing, some basic therapies and medications usually used for anxiety can be a necessary component of treatment. If you just feel “wired” in the evening, there are some wonderful devices that stimulate the vagus nerve that can help the body settle down so that the brain can as well. However, there is no anxiety medication or fancy gadget that will replace good old fashion habit changes.

So, now that you know, give it a go. If you feel like you’ve tried the basics but medications are getting in the way, or if you aren’t sure if you’re doing the therapy right, I would be happy to see you in a consultation to discuss and help guide you to developing a plan that works.

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