Sleep Problems Often Solved By Common Sense — Not Drugs

Whenever I go into a new situation with a medical staff, the other psychiatrists seem to enjoy having me assess and treat people who have stumped them.  It doesn’t matter if it is a community mental health center, a VA facility, private HMO clinic, University hospital – whatever.  The favorite game is “Stump The Renegade Doctor.”

One challenge was a woman was 28 years old who was a little on the hypomanic side (meaning only a mild mood-swing toward the manic) and a little on the depressed side and a little paranoid — and a lot uncomfortable. She was informally and a tad sloppily dressed in clothes which nobody would have called “new” or “chic,” and her hair was a little messy.

She explained to me: “I can’t sleep.  I never get more than two or three hours in a night, with a lot of ups and downs and stuff.  I don’t know what is going on, but they already gave me all the medicines for sleep, and on me nothing works.”

Yeah, sure.  I suspected already that her problem had nothing to do with picking the “right” medicine, but people really do think that pills can fix anything psychiatric.  She had obviously had drilled into her head the idea that the right medicine would fix her. “They said you were good with pills, and you could figure me out,” she said.

I was flattered.  My colleagues generally won’t say such things to my face – they just dump their problem patients on me and go back to whatever they were doing.

I told her that first, we were going to talk about something called “sleep hygiene.”  She had never heard the words before and acted like I was talking a foreign language.  There are lots of things that can stop someone from sleeping, and lots of things that can help someone sleep.

The word “hygiene” comes from Hygieia the daughter of Aesculapius, the Greek god of doctors and healing. Her domain is more cleanliness and sanitation, preventing sickness and continuing good health.  It amuses me no end that Hygeia’s fields are governed by her, and not the same person who takes care of medicine.

As for sleep, “Hypnos,” the god of sleep lived in a cave where no light could reach, with poppies and other herbs that help people sleep growing at the entrance.

The folks at Stanford University have come up with a nice set of sleeping directions.

There is even an online test-yourself about this: Actually, I found this test fairly sophisticated.  I usually have fixed someone’s sleep problems with a lot of easier questions before I get to this stuff.

But “Hypnos” brings me to my first question.  I always ask people if their room is “light-tight.”  Except for children who are dealing with fear of the dark, everything from lights inside the room to streetlights outside can cause problems.  I also ask about temperature, circulating air, and general comfort. I ask about the mattress.  A mattress that is uncomfortable has stopped many a person from sleeping.  Sometimes we get to allergic symptoms, dust mites, mattress covers, and the like.

With this patient I did not even get that far.  She said that she had a bad spring in her bed, and every time she turned over on it, she woke up. I told her to find a friend who had an extra room with a better mattress.  Her insomnia improved instantly.  The last I heard, she was scraping up money for a mattress.“Why didn’t my other doctors think of that?” she wailed.

Sometimes “thinking like a doctor” doesn’t get you as far as common sense. More recently, I had another patient whom I was told could not sleep. He was using the television to get to sleep and left it on.  Sure, television puts some people to sleep.  I am one — however, it is a little content-dependent. Sometimes the content creeps into my dreams. Who wants creepy dreams?

Television has both light and sound.  If it is commercial late-night television, with news followed by talk shows, there are a lot of people who want to hook viewers, and proceed to do it in every way imaginable. I cured this one patient just by telling him to shut the television.  I didn’t even have to write it out on a prescription pad.  And people wonder why I get the big bucks!

I am sick of people telling me they have to be informed. Unfortunately, most of us cannot do a blessed thing about the things we want to be informed about.  If we need that kind of information, we can get it over the internet in a variety of forms.

I’m all in favor of seeking what you need and want, rather than passively waiting for it to be fed to you by some commercial news service who may have ulterior motives. Getting people to change what they do regularly is really tough.  That’s why TV is so successful.  They cultivate regular viewing habits, use popular shows to lead-into new and untested programs, spin-off successes and sequels.

Sleep habits are as hard to change as TV viewing habits.  I have found that patients need to be really serious about changing their insomnia.  I suggest such radical methods as to try wedging something between their bedroom door and the floor to block external light and sound, or to stop drinking coffee after a certain hour.  Caffeine is a potent stimulant but a poor soporific.

I try to be positive, encouraging patients to construct comforting rituals.  Reading is good if the book is soothing — or even dull.  I tell the Bible readers this is not a time to dwell on the Book of Revelations, but a really good time for the Beatitudes.

Repetitive or ritualistic things help.  You can, in fact, condition yourself to sleep, the same way that an experimental animal can learn to press a lever and expect food to be delivered.

It is hard to say exactly how many people in the United States are struggling with insomnia, but there seem to be quite a few.  Some sources estimate one out of every eight people in the country. I remember reading a report quite a while ago that sleep deprivation – insomnia — was likely responsible for more traffic accidents than drunk driving.

Frankly, since statistics are hard to get, lots of people lie – especially about their drinking. Alcohol can screw up someone’s sleep wake cycle for a year or so even after someone stops imbibing. It is hard to tell how much alcohol is to blame.

Sleep is a problem for a lot of people. I think sleep hygiene is important, even if it seems to be unfashionable to think about it.  I had someone tell me once it was “common sense.”  The patient who told me about that had not, of course, thought about it until after I asked. Besides – as Horace Greeley said — common sense is decidedly uncommon.

At any rate, I absolutely refuse to believe that sleep problems are due to any kind of chronic lack of easily addictive prescription drugs. Sleep is multifactorial, complex, and necessary. People who do not sleep may not die, but they can get pretty wacky after enough of a lack of sleep.  Sleep is necessary for human function.

Sleep deprivation, whether insomnia or being kept from sleeping for some reason, has been linked with multiple conditions. The treatment of insomnia is only one of many places in medicine where expensive procedures, such as sleep studies in a specialized laboratory, can sometimes be rendered unnecessary by the intelligent use of a doctor-patient interview.