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Author: Matthew W. Kramer, D.O.
April 14, 2020

One of the most misunderstood aspects of our daily life is the purpose and function of sleep. Although we inherently know it’s important, we at times find falling and staying asleep to be very difficult.  In this blog I want identify common mistakes that affect the quality of your sleep and help you set reasonable expectations for making improvements.

Sleep is a time when our body can focus on necessary maintenance functions that had to be put on a lower priority when we were awake. Our body has only so much energy to work with at any one time and being alert, awake and active requires a vast majority of our resources.  One of the primary functions of sleep when you were much younger was growth. The human body grows only when it’s asleep. This is why good sleep habits are important at a young age to promote healthy development. Sleep is also when your immune system can finally go on the offense. Throughout the day your body’s military has only had enough funding to manage a defensive strategy against viruses, bacteria and other infectious agents. Now during sleep the military bases of your body (lymph nodes) are humming with activity recruiting soldiers to actively hunt down and destroy your body’s enemies and begin the mass production of “heat seeking missiles” known as antibodies, that will deactivate all the known enemies of your body. The activities you engaged in during the day have also caused an amount of damage to build up within your tissues. Now, finally, while asleep you have the energy and resources available for their repair. The final primary maintenance activity occurring during sleep is waste management. In fact, it is the production of waste that is the primary limiting factor of your brain’s ability to remain alert for extended periods of time. While awake your brain generates wastes at a rate that cannot be disposed of properly. Eventually the wastes build up and your ability to concentrate and remain focused drops accordingly. The build-up of wastes in your brain literally causes misfiring to occur within the neurons. Your brain is an electro-chemical powered machine and that built up waste within each neuron alters the electrical gradient across the cell membrane and saps the efficiency of the neurons ability to generate new signals. “Powering down” and allowing for the disposal of wastes to catch up with production is the only way to get back your full cognitive function. Caffeine, energy drinks and other stimulants will heighten cognitive function for a time, however they do nothing to address this waste management crisis.

To establish a rhythm for managing this maintenance function your brain has a “master clock” known as the suprachiasmatic nucleus (SCN) that sets the schedule for the course of the day. Your brain has a beautiful design where a certain combination of external clues balanced with the internal oscillation of the neurons in the SCN determine your Circadian Rhythm and Sleep Wake Cycle. However, these can be overridden at times deemed necessary by the conscious brain. Of the external clues for sleep, light is the most potent. We are hard-wired to begin producing melatonin when our environment becomes darkened. Melatonin is not a hormone that induces you into sleep, like many sleeping pills do. Instead, it works more as a trigger or release that allows the brain to begin the next step in the sleep cycle, but it does not force you into sleep. In fact, if being taken as a supplement the key factor with melatonin is to take the supplement at the exact same time every night. This is used to help reestablish a circadian rhythm but does not override your conscious brain which always has the final say as to when it’s time to sleep. If you are taking melatonin as a supplement you need to pick a time when, given on an average night, is the time you would like to get sleepy.  For instance, if you have weakened your circadian rhythm and you would like to be able to get sleepy at 10 PM – take melatonin at 9:30 PM EVERY night for several weeks (allowing 30 minutes for digestion and the onset of melatonin’s action). If you are going to stay up later than this for something like a movie and you plan on staying up until 11:30 PM the melatonin at 9:30 PM would make it so that you COULD fall asleep at 10 PM, but that night you could still choose to stay up later. This is fine and you will be able to fall asleep quickly when your movie is over (Safety Note – you should NOT be driving if you have taken a dose of melatonin). Remember that the beauty of this system is that the conscious mind can override the internal programming when deemed necessary. It is designed that way, so we can “push through” in difficult times and find rest on the other side. The downside is that this ability given to the conscious mind is also the greatest cause for our disrupted sleep patterns. Stress causes the mind to become fixated on looking at a problem from all the possible angles. It then begins thinking out contingency plans, and all the various factors that can be influenced. It then thinks out what might happen when each of these influences are acted upon. This process is mentally exhausting and strains the brain both consciously and subconsciously. It is communicating to the body that this is not a good time for rest. Does this scenario sound familiar? Your both mentally and physically exhausted. You lay down for bed, trying to quiet everything around you, however your mind continues to focus on the stresses currently going on in your life. You lie there restless, getting more and more frustrated. Eventually falling asleep out of sheer exhaustion, only to wake up a short time later without any relief to your exhaustion.  

To manage this, you cannot simply “make your stress go away” and then fall asleep normally but you can maximize all the external inputs that can promote restful sleep in what is called your “sleep hygiene” and develop life-long habits that create greater resiliency for the future. As we all know, a poor night of sleep makes the stress of the following day much worse. This becomes magnified with several bad nights in a row having severe consequences in our ability to manage our daily tasks, maintain healthy relationships and it begins eroding the health of our body. Lifelong habits that we all need to work on for improving our sleep hygiene include the following:

Light:  Our world changed with the advent of the incandescent light. The ability to work after the sun has gone down and now even having whole work cycles where night-time is the active time of your day, has had a huge impact on our circadian rhythm. Assuming you are not a night shift worker, you need to allow as much sunlight into the house during the day and allow the natural darkening with the sunset to occur. Interior lights in the house after sunset need to be dim. Be in the habit of using lower wattage indirect lighting from lamps until it is time for lights out. The biggest negative impact on our production of melatonin is “screen time." Screens not only transmit light that directly impact the body’s master clock but they also engage the conscious mind whether passively through entertainment or actively through thought processes such as writing on a laptop or playing a video game. The key to minimizing the “double whammy” effect that screens have is to protect your bed. Your brain has to associate the bed with sleep. If you use a screen while in bed it confuses your mind. Is this sleep time or catch up on Facebook time? The comfort of the bed, the feel and smell of the pillow against your face, have to be directly associated with sleep in order to maximize your chances of letting your mind shut down. Suggestions: A television should not be in your bedroom. There should be a separation between the entertainment provided by your TV and the space that has been set aside in the evening for sleep. At the very least, set up chairs in your bedroom and do not watch the screen from bed.

Temperature:  The bedroom and the bed should ideally be a bit cooler (of course this is a highly relative measurement depending on the individual) but the brain will shut down better if the temperature is a bit cooler. This is also another reason for not lying in bed for a time before actually going to sleep, your body temperature warms the mattress and pillow before you’ve had a chance to shut down.

Sound:  It goes without saying that the room needs to be quiet. White noise is acceptable and at times very helpful, as it can block out small but disruptive sounds such as the house creaking or squirrels on the roof, etc. However, white noise can over time develop a slight dependency and make it difficult to fall asleep in a setting in which you don’t have your white noise. Also, television/radio or anything with speech is NOT white noise. It may be a background noise that you unfortunately have associated with comfort (possibly grew up with a TV on in the next room or having the sound of people reassures you). This however is bad sleep hygiene. The human voice specifically engages your mind and will prevent deep restful delta wave sleep. A bad habit that needs to be slowly replaced with white noise.

Food:  Eating right before bed is a bad habit for multiple reasons. We tend to be drawn toward the “comfort food” spectrum which is not a healthy spectrum from either nutrition or caloric intake perspectives. It also sets the stage for developing Acid Reflux. Although digestion is a restful activity, it still is an activity and your body will have to divert energy from your immune system, waste disposal and repair to handle the digestion of food as it cannot be put off until morning. It is overall a bad habit and if you have this habit, try using a glass of water about an hour before bed then urinating just before going to bed. You’ll find that the “aching” that you were relieving with food can also be relieved with water.

Smell:  This is considered one of the lesser factors for humans (much more significant in other mammals) however it’s worth mentioning as we can have an impact on it. I will admit that this is not an area of expertise for me and the variance of how each person responds to smell is quite significant. The take home points are that a soft pleasant relaxing smell improves chances of falling asleep. This said, as we all know what is soft for one person can be gut wrenchingly powerful to another. Also, what one individual believes to be a relaxing odor can be irritating to another. Everyone generally has a sense (pun intended) for this, but here are a couple of points to take note of:  Smells tend to have a desensitizing effect over time (you may notice that you have to keep upping the intensity to get the same effect). To help with this, avoid having the smell be “around the clock.”  Use it as a way to help your mind wind down. If your spouse is very sensitive to smells and you’re not, then the aroma from a hot tea or something else that’s mild and transient may need to be your approach. Also, although the human sense of smell is not overly acute, it is sensitive to the smells of stress. These are smells we tend to lump together in the phrase “body odor.”  When you are stressed, much of the hormones and toxins from being stressed are discharged through your skin. This is another reason for not lying in bed before going to sleep, your stress odors get onto your linens and help reinforce the fact that right now you are stressed and maybe this isn’t the best time for rest. Another option that may help with not only the smells of stress but with relaxation in general is to take a bath or shower not long before bed when you feel stressed.

Association:  It is very important that your brain associates the bed and pillow with sleep.  We’ve mentioned this several times already, but this is one of the biggest “take home” points. Other than lying in bed doing mentally engaging activities before bed, the other big mistake made when having difficulty falling or staying asleep is lying in bed TRYING to fall asleep for too long. Anyone who has experienced a restless night knows that lying there and being unable to fall asleep is STRESSFUL. When you first begin to feel frustrated lying in bed, it’s time to get up and do something else for a bit. I recommend getting up slowly and carefully laying the covers open (cooling the sheets and letting smells evaporate away) then go do a small task that does not engage the brain much – examples would be loading or unloading the dishwasher, paying a bill or two, sweeping up the floor knowing that the room will look better when you come into it later in the morning. The key is something small, completable and lets your mind “check off” a completed task. Reading is a relaxing activity that is very tricky and not usually recommended. Although reading can be very relaxing it can also be very engaging (the chapter ended with a cliff hanger, etc) and generally requires good lighting. However, as we all know, sometimes it’s exactly what we need. In those certain times when you start getting very drowsy while reading, close the book and return to the bed so you can drift off to sleep quickly.

Sleep is incredibly important to your over-all health. It really begins to show its importance when we begin feeling stressed. A lack of sleep can easily cause things to spiral out of control. In this blog I did purposely shy away from talking about medications used for sleep. I did this for several reasons. First and foremost because I feel that Sleep Hygiene is far more important. Often times we jump to a “quick fix” as medications often seem to do, but as time goes on, if you do not have good sleep hygiene habits then the medications stop working.  Another reason is that the topic of sleep aids includes a huge variety of supplements, vitamins, herbs, essential oils, over the counter and prescription medications. There’s too much information to combine with sleep hygiene in one blog. However, my approach to sleep supplements and medications is the same as it is with almost ALL medications. Avoid anything that causes dependency or addiction. Generally speaking, when it comes to sleep, almost all prescription medications are dependency forming. You should think of any medication or supplement as a tool to be used for a time in completing a job. Then it gets put away. Be mindful of side effects and especially when taking something that helps with sleep, DO NOT operate machinery such as driving, for at least the next 8 hours. If this is an area that you are struggling with you need to speak with your doctor. Sleep medication dependency is very common and is not a sustainable long-term strategy.  

Final thoughts.  For those of you who struggle with sleep, I know this list is quite daunting… “No TV in the Bedroom!  ARE YOU KIDDING ME?” The truth is that you CAN do it. You truly can have restful nights and not dread the thought of lying there quietly hoping your brain shuts off tonight. The good news is, you can do this in little bits.  Start with just one change at a time.  Build on your successes.  Avoid the temptation of settling with being just able to fall asleep most nights. This is a long process, but we tend to lose momentum when we can fall asleep OK. At that point, you will still be very vulnerable for when life becomes more stressful and we all know full well that there will be times of more stress. I find that having a strong imagination that allows you to go somewhere peaceful in your mind is very helpful and will in time replace that reward feeling given to you by watching something entertaining before bed. This is about your overall health. Developing good sleep habits builds much greater health resiliency. This in turn gives us more fulfilling lives and allows us to teach our children good sleep habits that they can use for the rest of their lives.