Excerpts of Dr. Richard Bonato’s radio interview on Sleep Disorders BFM Radio station – “The Bigger Picture – Health & Living” http://www.bfm.my/sleeping-disorders-dr-richard-bonato.html
On sleep in general
What is the science behind sleep that explains why it is so important?
From what we know today, there are about 30-40 theories on why we sleep. Primarily, we break sleep into two stages – REM (Rapid Eye Movement) sleep and non-REM sleep. During the first half of the night, we have predominantly non-REM sleep, where we have our deepest sleep. In this stage there is an increase in growth hormone secretion and protein synthesis. This is the part of the night where we have body restoration going on. The second half of the night is predominantly the REM sleep, and this is required for memory consolidation and learning. So think of the first half of the night as your body being restored and the second half as your brain being restored.
Does that mean that if we are not getting enough sleep we are missing out on the restoration?
Absolutely, and it depends on the stages the sleep is cut. When I used to teach at the university (which Uni?) I would always tell the students not to get up at four in the morning and cram for the exams, as they would be depriving themselves of REM sleep that is actually required to learn properly.
In both animal and human research we have found that if you deprive an animal of REM sleep, you interfere with their ability to learn tasks. In humans it interferes with the creative thinking abilities. It is really important for people doing shift work to know that depriving oneself of sleep will interfere with the ability for rational and good thinking. In research using soldiers, we found that they actually require a minimum sleep of 3 hours at night to actually function as a soldier.
Can you explain what a typical sleep cycle consists of?
When you fall asleep, you first go through a sleep onset period where neurons are fighting for dominance in the brain stem. As you fall asleep, you move into Stage 1, where you have periods of light and heavy drowsiness. Then you go into Stage Two sleep, which is really ‘bonafide’ sleep. And then, you have Stage Three, which is the deep sleep. About 90-110 minutes after you fall asleep, you actually enter REM sleep.
The first REM period of the night is about 10 minutes longer than the rest. Then you go back to Stage Two, a little less into Stage Three, back to Stage Two and into REM sleep again. This is called the non REM-REM sleep period and its ultradian rhythm lasts about 90 minutes.
In the sixties, Nathaniel Kleitman, coined the term ‘basic rest activity cycle’ and postulated that the 90-minute ultradian cycle of ‘active-inactive’ or ‘more active-less active’ periods in our body continues into the daytime and goes on 24 hours a day.
How long should we sleep? How do we know our sleep cycles and when we should wake up?
If you are using an alarm clock to wake up, you are depriving yourself of sleep. It is as simple as that. You should be listening to your body and getting up when you are rested. Unfortunately most of us do not have the luxury of doing so.
Studies have found that 100-120 years ago people were sleeping longer in the winter and the amount of sleep they had varied according to seasons and was attuned to natural light. Natural exposure to light is really important for a healthy lifestyle and does lock in our body clock.
How much sleep we actually need varies by individuals. Eight hours is an average. Some people need nine, while others can get by with five or six hours. What we have found is that people who sleep less than five hours and more than ten hours (a day) tend to live shorter lives, or have certain health issues.
One of the rules for sleep hygiene is to go to sleep only when tired. Do not go to sleep the time says eleven or so. If you cannot fall asleep within 15 minutes, leave the room and do something relaxing. Read a book, do not watch television or read news that may get you excited. It is important to limit the use of light – for example, I-pads or smartphones. People with insomnia need to limit what they do in the bedroom so that they associate the bedroom with sleep and not with anxiety.
How much does perception weigh into whether or not we slept well?
A lot! We all have nights where we wake up quite a bit and feel we had a horrible night’s sleep. If we measure our sleep on these nights with polysomnic equipment in a sleep lab, it would look like we had a lot of sleep. Researchers show that people with such little awakenings at regular intervals will not feel they have slept well.
We need consistent and consolidated sleep to have a perception of good quality sleep
On sleep disorders
Lack of sleep can lead to ‘sleep debt’. How do you suggest we go about trying to repay some of the sleep debt?
Some people sleep in on weekends. Some try to spend longer time in bed to try and get 8 hours of sleep. These are not necessarily the best ways to go about it.
We tell people to shorten their time in bed to better consolidate their sleep and be more consistent. If you are going to nap, do it everyday or not at all. Even on weekends try to go to bed and wake up around the same time as other days.
When you get up in the morning have exposure to bright light. Have breakfast facing the light. Exercise in the mornings or afternoons and not in the evenings. All these help to lock in your natural body rhythm and clock and are more conducive to sleeping better at night.
There is no way to make up for lost sleep. You can make up in terms of restoration by trying to be consistent all days of the week.
What are the effects of sleep deprivation on the mind and the body?
When I was involved in research at the university we found that even after one night of no sleep the ability for divergent and creative thinking plummets dramatically and is on par with people with closed brain injury. It is scary to think that the people who are awake all night working and making crucial decisions can be suffering such effects.
It is interesting to note that a major decision like the launching of the space shuttle ‘Challenger’ was made in the middle of the morning. And that major accidents like the Exxon Valdez grounding off the coast of Alaska (1986) and the Three Mile Island nuclear plant meltdown (1979) happened in the graveyard shift.
Lack of sleep is also said to affect our eating habits. Could you explain more about that?
Sleep plays an important role in controlling our highly regulated metabolic system. When you are tired you can have hunger urges or cravings for carbohydrates. Research has shown that when a person or animal is deprived of sleep they can increase their caloric intake (that is, eat more food) and continue to lose weight. In other words, if you deprive yourself of sleep you would eventually die.
What is insomnia? This does not seem to give us a choice in going against our body’s natural need for sleep.
Insomnia is a ‘catch-all’ phrase for our inability to catch or maintain sleep
Primary insomnia occurs when it is the problem itself and when the person develops anxiety or conditions himself not to sleep. Practice of sleep hygiene habits as I explained before can help. Insomnia can also be secondary to other symptoms caused by chronic pain or depression.
Insomnia thus depends on the cause and the solution follows the cause.
What are the most common sleep disorders?
Snoring for one. It is an alarm telling us something is wrong with our breathing during sleep. There are apps you can download to record and let you know if you snore.
Snoring is often associated with a more serious condition called sleep apnea, where people stop breathing and their blood oxygen plummets to levels that were at one time thought to be incompatible with life. People literally wake up gasping, choking and sometimes dying in their sleep.Another predictor for sleep apnea is the presence of scalloping on the border of your tongue.
Sleep apnea is a primary sleep disorder but people who have this disorder react differently. Some react with their bodies feeling exhausted leading to excessive daytime sleep. Others may have hypertension, atrial fibrillation or run a high risk of stroke and heart disease. Some others may react by becoming depressed due to lack of energy.
What about issues of body temperature? What happens if they keep waking up because they cannot regulate the right temperature for sleep?
If this is associated with menopause I would suggest consulting the family physician.
One of the reasons we recommend exercising in the morning or afternoon is because intense exercise gets you sweating and your cardiovascular system going. This slightly changes your core body temperature and can positively impact your ability to fall sleep. For some, a warm bath at night could help.
Is chipping of teeth due to grinding a sleep disorder?
Sleep bruxism may be a sleep disorder on its own. However, newer research suggests it may be related to sleep apnea. It could be the body’s attempt to open the airway. Oral appliances from a dentist can be very helpful.
On getting enough sleep
How do you start getting more sleep?
Start with a sleep-wake log to record the hours of sleep.
If you were in bed for eight hours but slept only for four, your sleep efficiency is 50%. The goal is to get to a sleep efficiency of over 85%. We do that by reducing the number of hours in bed, and recording the sleep-wake hours. As the sleep efficiency increases, we extend the hours in bed progressively by 15 min.
Generally sleep specialists try to take patients off sleeping pills. Good sleep hygiene rules help – exercise, diet, exposure to sunlight, reducing caffeine, nicotine and alcohol.
You need a wind down period and this depends on the individual. It could be reading, a bath. I know of someone who needs to do precise measurement to wind down. Find out your wind down routine.
Sleep supplements like melatonin may be used to offset jetlag or combat effects of shift work.
If you still keep awake, find out what you are doing while awake. For example, frequent visits to the bathroom at night are often associated with sleep apnea.
Can I make up for lack of sleep with naps?
If you have to work a night shift, you could have a ‘prophylactic’ nap in anticipation of sleep deprivation. Do however be aware that it will reduce your deep sleep time.
If you have a lifestyle that includes naps, do so consistently. A siesta culture is OK. Try and not use an alarm clock for naps. Your body will wake you up when ready.
Using an alarm clock deprives us of sleep. Continuously adding minutes on and on while snoozing adds to the deprivation without adding any restoration. Your body does not have a chance to return to a restored deep sleep. If you really had a good sleep, you should be waking up five minutes before your alarm rings.
How do I get deep sleep?
Recollect a child who falls asleep in the car. When you pick them up and take them to bed, you know they are in a different zone.
Your body will take care of deep sleep, which is the first part of the night sleep. The only time you will not get the deep restoration sleep is when you have sleep disorders.
Interestingly, it is during deep sleep that we have sleepwalking and sleep talking. Disorders that happen during deep sleep are disorders of partial arousal. The conscious self is still asleep, while the part of the brain that controls motor activity is still active.
Can low volume and low frequency noises cause problems for my sleep?
Anything in the environment can cause a problem. Research has shown that light exposure can suppress the production of melatonin and thus reduce the quality of sleep.
What is interesting is that part of our brain is always monitoring the environment. For example a mother may sleep through a thunderstorm but will wake up to a crying baby.
Is there a difference between a teenager and an adult? What is the ideal sleep time for teenagers?
During teenage years there is a lot of growth. When teenagers hit puberty that is the time they are really growing and will sleep longer. Deep sleep is when you have an increased secretion of growth hormones.
In teenage and young adult years, the body clock is a little longer than 24 hours. If you allow them to go to sleep and wake up when they want they may do so at odd hours. They need the deep sleep to grow, it is part of their maturation process.
How about babies?
Children do not have a body clock until they are about six months old.. You have to cope with it, as frustrating as it may seem and be. Around six months they will start developing their body clock. Their sleep periods will increase and they will start sleeping through the night.
Why do we dream?
Dreaming is really a mental activity. People think you only dream during REM sleep. It is just that we are more likely to recall or remember our dreams during REM sleep.
Think of REM sleep as an inactive body and an active brain. There is a gate at the top of your spinal cord, there is a bunch of neurons and these brain cells get hyper polarized. They go to an extreme point where it is like a door being closed. Signals are sent from the brain stem to the higher part of your brain to activate it. This is based on Dr. Hobson’s Activation synthesis hypothesis. When you have an active brain in a paralyzed body your brain is closer (if you measure it electronically) to the way your brain waves are during wakefulness than it is during deep sleep.
So when you wake someone up during REM sleep, the brain is more active and is able to access those memories. Dream recall is about 80%. When we wake them up from Stage Two or non-REM sleep, the dream recall is only about 50%. When you wake someone up from deep sleep they are usually groggy and may recall only 20% of the time.
So when someone says I never dream, is it a matter of dream recall?
If you want to remember your dreams all you need to do is to place a note pad, pen or pencil next to you and before you go to sleep rehearse to yourself, “I will remember my dreams.” Make a conscious effort when you wake up in the morning to write down your dreams. You will find yourself increasingly remembering your dreams.
And when someone says I had many weird dreams, does it mean that he was not in deep sleep and his body is not well rested?
Most dreams are mundane, boring and down to earth. They originate in the mental activity that happened in the past 24-48 hours. Freud called it the ‘day residue’. These form the cornerstone of our dreams.
However, some people do have bizarre dreams. People with post-traumatic disorders are more likely to have nightmares. Nightmares can be symptoms sometimes. The way to know that you have had a nightmare is to ask yourself if it was a bad dream. If it was and it made you feel bad, it was a nightmare.
Dreams have a mood regulatory function and can be draining even if you had physical rest. If they consistently create a foul mood have a conversation with a health professional.
For the most part, I would say, enjoy your dreams.
On seeking professional help
When would someone need to seek professional help?
If you are not able to have a solid sleep, if you are not comfortable with your sleep habits and feel exhausted all the time, have a conversation with your family physician. Most family physicians know a little about sleep but you may need them to refer you to an expert, a sleep specialist.
How are sleep disorders treated? No one size fits all. Would it be talk therapy or pharmaceutical therapy?
It would depend on the sleep disorder. If it is insomnia most doctors will try to use behavioral therapy. A pharmaceutical approach to insomnia is rather limited. For short- term insomnia caused by say loss of a loved one, short-term use of pills may be helpful. However for something like narcolepsy, where there is a strong genetic component, a pharmacological approach is used. These drugs tend to be stimulants to help keep the patients awake during the day, to counter excessive daytime sleepiness associated with narcolepsy.
For sleep apnea and snoring, the most common treatments are the use of oral appliances and CPAPs. CPAPs are medical devices.
Whether it is behavioral therapy, drug treatment or use of medical equipment, treatment really depends on the specific type of disorder.
Overall sleep is vital. It is a fundamental thing we do every night for one-third of our life. People who have solid sleep are happier, healthier and more productive. About 25-50% of hyperactive children do not have ADHD but undiagnosed sleep disorder breathing. Getting good sleep therefore makes sense for everyone – for the self and for the community at large.