Richard G. Petty, MD

Breathing Problems During Sleep and the Heart

We have talked about the importance of heart rate variability (HRV), which reflects the activity of many critical bodily functions. HRV is the result of a subtle interplay between the heart and the nervous system, and abnormalities in HRV may be an early warning of severe illness and even of death.

There are many reasons why peoples’ breathing can become disturbed during the night, and it is essential to be sure that we are treating the right thing.

In obstructive sleep apnea (OSA) the body stops breathing during sleep. The most common reason for OSA is swelling of the tissues at the back of the throat that then block the airway.

In central sleep apnea (CSA) is a breathing decreases or stops during sleep. It may occur as a result of a problem in the sleep centers in the brain, and/or the nerves supplying the heart. It usually follows a cycle, with people breathing normally for a while and then slowing or stopping altogether.

Continuous positive airway pressure (CPAP) that provides a steady stream of pressurized air is often the best treatment for sleep apnea.

There is a close relationship between breathing and the heart, and new research from the Alfred Hospital and Monash University in Melbourne, Australia has looked at a sleep-related breathing disorder that is common in heart failure, and increases HRV.

The researchers looked at the breathing patterns of 21 patients with heart failure who had sleep-related breathing disorder.

They found that as people transitioned from stable breathing to a sleep-related breathing disorder, there was an associated increase in HRV.

On the other hand, people with central sleep apnea (CSA) and obstructive sleep apnea (OSA) produce different patterns of HRV, suggesting that they each involve different mechanisms in the heart and the brain.

This may sound esoteric, but it is not.

Breathing problems during sleep are common and so is heart failure. Unfortunately heart failure carries a high mortality rate, and it is very valuable to have simple tests to guide us to give the correct treatment.

Simply measuring HRV during sleep will give us an idea about whether or not a person with heart failure is stable, or if we need to change treatments before he or she starts getting symptoms.

“All the energy that is used in the creation of every cell in the universe is on that breath that you are breathing in.”
--George King (English Spiritual Teacher, Writer and Founder of the Aetherius Society, 1919-1997)

“For breath is life, and if you breathe well you will live long on earth.”
--Sanskrit Proverb

“There is one human activity which is continuous, rhythmic, natural, easy, and pleasant. It is breathing. We may take advantage of its existence by combining it with a simple exercise to bring about a kind of meditation which will possess all these four mentioned attributes. The exercise is merely to repeat one word silently on the inhalation and another word on the exhalation. The two words must be such that they join together to make a suitable spiritual phrase or name. Here is one useful example: "God Is.”
--Paul Brunton (a.k.a. Raphael Hurst, English Philosopher, Traveler, Spiritual Teacher and Author, 1898-1981)

“You know that our breathing is the inhaling and exhaling of air.  The organ that serves for this is the lungs that lie round the heart, so that the air passing through them thereby envelops the heart.  Thus breathing is a natural way to the heart.  And so, having collected your mind within you, lead it into the channel of breathing through which air reaches the heart and, together with this inhaled air, force your mind to descend into the heart and to remain there.”
-- Nicephorus the Solitary (Calabrian Christian Mystic and Monk on Mount Athos, c.1250-1300)

Sleep Deprivation and Emotional Instability

Most of the time we are in control of our moods, rather than our moods being in control of us. One of the main things that we learn as we get older is not simply to damp down our emotional reactions, but to make them “contextually relevant:” we produce the right emotional response for the right situation. Yet we also know that there are exceptions: times when our emotions over-run any attempts at our control.

Second, we all know that sleep deprivation can be a Bad Thing. It is known to impair a range of mental and physical activities, including immune function, metabolic control and many cognitive processes, including learning and memory.

It has long been suspected that sleep deprivation can have significant effect on mood. Many of us feel irritable and distractible if we haven’t slept enough, and you may have had the experience of being up all night and feeling a little bit “high” in the morning. It has also been known for centuries that mood disorders are very commonly associated with sleep disturbances, and sleep disturbance is often the first sign that someone with mood problems is running into trouble. So mood and sleep must be linked in some way.

Despite these common observations, there has never been that much empirical evidence for the impact of sleep deprivation on mood, and in particular the effects of sleep deprivation on the brain.

An important new study by researchers from Harvard Medical School and the University of California at Berkeley has just been published in the journal Current Biology, and it is beginning to fill in some of the gaps in our knowledge.

The amygdala is known to be involved in processing of emotionally salient information, particularly unpleasant or aversive stimuli. In mature individuals, the emotional centers of the brain are usually controlled and modulated by an array of connected systems, mainly in the frontal regions of the brain. One particularly important part of the frontal lobes that is involved in controlling the amygdala is the medial-prefrontal cortex (MPFC). Under normal conditions the MPFC is supposed to exert an inhibitory, top-down control of the amygdala, so that we only generate appropriate emotional responses.

The scientists worked with 35 volunteers who were deprived of sleep for 35 hours. Blood flow can be used to deduce which specific regions of the brain are active. The researchers used functional magnetic resonance imaging (fMRI) to examine the blood flow – and therefore activity - in the brains of the volunteers in real time, both during and after sleep deprivation.

After going without sleep, the participants were asked to look at images that were designed to trigger angry or sad emotional responses. The investigators discovered that the amygdala showed 60% higher reactions to the images compared with people who are not sleep-deprived.

This is an extraordinarily large effect and implies that sleep deprivation knocks out the normal control mechanisms in the frontal lobes so that the sleep-deprived brain reverts to a more primitive pattern of activity. As a result we become unable to put emotional experiences into context and produce controlled, appropriate responses.

If we needed any more reasons to get a good night’s sleep, this one is very powerful. It also re-iterates something very important: if you or a loved one have had problems with mood, anger or anxiety, it is essential to watch your sleep pattern. Any change may be a harbinger or trouble, and is an excellent early warning that you or they need a hand to make sure that things stay on an even keel.

"Your brain shall be your servant instead of your master, you will rule it instead of allowing it to rule you.”
--Charles E. Popplestone (American Author of Every Man a Winner, 1936)

“Control your emotions or they will control you”
--Chinese Proverb

“For the uncontrolled there is no wisdom, nor for the uncontrolled is there the power of concentration; and for him without concentration there is no peace. And for the unpeaceful, how can there be happiness?”
--Bhagavad Gita (Ancient and Sacred Sanskrit Poem Incorporated into the Mahabharata)

“He who controls others may be powerful, but he who has mastered himself is mightier still.”
--Lao Tzu (Obscure Chinese Philosopher, Founder of Taoism and Alleged Author of the Tao-Te Ching, c. 604-c. 531 B.C.E.)

“ . . . let every man be swift to hear, slow to speak, slow to wrath.”
--The Bible, James 1:19

“When angry, count ten before you speak; if very angry, a hundred.”
--Thomas Jefferson (American Writer, Philosopher, Politician and, from 1801-1809, 3rd President of the United States, 1743-1826)

Mother’s Dreams

Having a baby is one of the Really Big events in life, and it is no surprise that both pregnancy and birth have a major influence on the structure and content of a mother’s dreams.

It is also not surprising that many of the dreams have a strong negative component to do with maternal responsibility, or depicting the new infant in dreamed situations of danger. These dreams can cause anxiety that can spill over into wakefulness. A new study from Montreal published in the journal Sleep has added something new: these kinds of dreams may be accompanied by complex sleep behaviors such as motor activity, speaking and expressing emotions.

The study from the Sleep Research Centre at the Hôpital du Sacré-Coeur de Montréal in Montréal, Québec, Canada, focused on 273 women, who were divided into three groups: postpartum, pregnant, and women who had not given birth. The subjects completed questionnaires about pregnancy and birth factors, personality and sleep. They were also interviewed and asked about the prevalence of recent infant dreams and nightmares, associated behaviors, anxiety, depression and other psychopathologic factors.

• The percentage of women in all groups who recalled dreams ranged from 88-91%
• Postpartum and pregnant women recalled infant dreams and nightmares with equal prevalence, but more postpartum women reported they contained anxiety (75%) and the infant in danger (73%) than did pregnant women (59%)
• Motor activity was present in twice as many postpartum (57%) as pregnant (24%) or non-pregnant (25%) women
• Expressing emotion was more prevalent among women without children (56%) than postpartum women (27%), but was not different from pregnant women (37%)
• Speaking while asleep was equal among the three groups (12-19%)
• Behaviors were associated with nightmares, dream anxiety and, among postpartum women, post-awakening anxiety (41%), confusion (51%), and a need to check on the infant (60%)

Most pregnant women experience daytime fatigue primarily because the quality of their sleep tends to be worse. Physical discomfort and awakenings are common, particularly during the third trimester.

Snoring often increases during pregnancy and obstructive sleep apnea may develop as the pregnancy progresses.

Two other sleep disorders that are more common during pregnancy are restless legs syndrome (RLS) and sleep related leg cramps. RLS affects nearly 25% of pregnant women and may be related to low iron stores. Leg cramps occur in about 40% of pregnant women, although they usually clear up after delivery. They tend to go away after delivery.

It is easy to understand these dreams from an evolutionary perspective. Though there is also a small literature on mothers who get intuitive flashes about their distressed infants. I have followed this work for many years. When I was an infant I chocked on a banana, and my mother who was some way off “saw” it happening in her mind’s eye and rushed in to find a very small RP who had already turned blue. She swore to her dying day that the tale was true.

And I still cannot eat bananas.

Sleep and Your Heart

The amount of sleep a person gets affects his or her physical health, emotional well-being, mental abilities, productivity and performance. Recent studies associate lack of sleep with serious health problems such as an increased risk of depression, obesity, cardiovascular disease and diabetes.

There was some interesting research presented at SLEEP 2007, the 21st Annual Meeting of the Associated Professional Sleep Societies in Minneapolis in the middle of June.

One study that caught my eye was conducted by Siobhan Banks of the University of Pennsylvania School of Medicine. The research was based on preliminary analysis of 39 subjects, each of whom participated in a laboratory-controlled chronic sleep restriction protocol. The subjects underwent two nights of baseline sleep followed by five hours of sleep restriction. The results showed a statistically significant decrease in the heart rate variability after just five nights of sleep restriction.

We already know that a reduction in heart rate variability may occur in several cardiological and non-cardiological diseases, and it is usually a harbinger of a poor outcome.

This work may provide the mechanism for why short sleep duration is associated with a heightened risk of heart and other circulatory problems.

The amount of sleep a person gets affects his or her physical health, emotional well-being, mental abilities, productivity and performance. Recent studies associate lack of sleep with serious health problems such as an increased risk of depression, obesity, cardiovascular disease and diabetes.

So if confirmed, the take home message is that sleep deprivation has a negative effect on a person's cardiac activity and that may in turn increase the risk of cardiovascular disease and mortality.

Fibromyalgia is Real! A Battle That Should Not Have To Be Fought Again

Fibromyalgia is a chronic, widespread pain in muscles and soft tissues accompanied by fatigue, it is a fairly common condition, affecting 3% to 6% of the general population, and is most commonly diagnosed in people between the ages of 20 and 50, though onset can occur in childhood. The disease is not life-threatening, though the degree of symptoms may vary greatly from day to day with periods of flares (severe worsening of symptoms) or remission. The syndrome is generally perceived as non-progressive, yet that issue is still a matter of debate.

The cardinal symptoms of fibromyalgia are chronic, widespread pain and tenderness to light touch together with moderate to severe fatigue. Those affected may also experience heightened sensitivity of the skin ("allodynia"), tingling of the skin that is often needle-like, a deep ache in the muscle and , less often, the tendons, prolonged muscle spasms, weakness in the limbs, and nerve pain. Chronic sleep disturbances are also characteristic of fibromyalgia, and some studies suggest that these sleep disturbances are the result of a sleep disorder called alpha-delta sleep , a condition in which deep sleep (associated with delta EEG waves) is frequently interrupted by bursts of brain activity similar to wakefulness (i.e. alpha waves). Deeper stages of sleep (stages 3 & 4) are often dramatically reduced, and that is the likely cause of the cognitive problems that so often accompany fibromyalgia.

There is not any structural damage in an organ, though it may sometimes start after trauma, such as a motor vehicle accident.

It is that last fact, that there is s often no obvious physical pathology, that has lead so many people to claim that fibromyalgia is “nothing more than” pain associated with depression. I have has some interesting “discussions” with health care professionals convinced that people wit fibromyalgia do not have a “real” illness, and that they need psychotherapy or antidepressants. Yet pain is pain, and the false dichotomy: “Is the pain my mind or in my body?” helps nobody.

Twenty-five years ago, Muhammad B. Yunus and his collaborators published the first controlled study of the clinical characteristics of fibromyalgia syndrome. That seminal article, published in Seminars in Arthritis and Rheumatism, led directly to formal recognition of this disease by the medical community. Last month, again in Seminars in Arthritis and Rheumatism, Muhammed makes another enormous contribution to the field of chronic pain and fatigue by meticulously synthesizing and interpreting the extensive body of scientific literature on fibromyalgia and his own insights into the concept of central sensitivity syndromes (CSS) that include irritable bowel syndrome, migraine and restless legs syndrome.

In fact there are at least 13 separate conditions that are related to central sensitization (CS), where the central nervous system becomes extremely sensitized with respect to certain parts of the body, so that even mild pressure or touch would cause much pain. This hypersensitivity may also be associated with other symptoms such as poor sleep and fatigue.

Muhammed took a rather more biological approach to fibromyalgia in the past, now emphasizes a biopsychosocial perspective:

“In my view, this is tremendously important because it is the only way to synthesize the disparate contributions of such variables as genes and adverse childhood experiences, life stress and distress, posttraumatic stress disorder, mood disorders, self-efficacy for pain control, catastrophizing, coping style, and social support into the evolving picture of central nervous system dysfunction vis-à-vis chronic pain and fatigue. Science and medicine now have rational scaffolding for understanding and treating chronic pain syndromes previously considered to be 'functional' or 'unexplained.' Neuroscience research will continue to reveal the mechanisms of CS, but only if informed through a biopsychosocial perspective and with the interdisciplinary collaboration of basic scientists, psychologists, sociologists, epidemiologists, and clinicians."

One of the reasons that I so like this new version of his model is because it fits so well with the concept of  “Salience Disruption Syndrome.” A fancy name for a common problem that I talk about in Healing, Meaning and Purpose.

So very many people are super-sensitive to the environment and also have trouble in filtering out and deciding what is important. As a result pain, attentional problems, impulse control disorders, addictions and several other things tend to cluster together.

Happily we now have an array of novel techniques for dealing with these problems, and I plan to put out more books and papers on ways in which we can help.

Aggressive Bullies, Sleep and Breathing

Here is yet another possible problem associated with poor quality sleep and breathing problems during sleep.

Research from the University of Michigan that was presented at SLEEP 2007, the 21st Annual Meeting of the Associated Professional Sleep Societies in Minneapolis this week, suggests a link with aggression.

Aggressive behavior and bullying are common amongst schoolchildren and are likely to have multiple causes. But a new one, and one which may be an undiagnosed, is sleep-related breathing disorder (SRBD).

The study focused on children in the second through fifth grades who attended school in an urban public school district. Parents completed two well-validated rating instruments: the Conners' Parent Rating ScalePediatric Sleep Questionnaire SDB Scale. Teachers completed the Conners' Teacher Rating Scale (CPRS) the  (CTRS). The numbers of discipline referrals in the previous 12 months were obtained from the six elementary schools.

A total of 345 CPRS's and 245 corresponding CTRS's were completed. The main finding was that schoolchildren who bully may be more likely to have an SRBD than their peers.

An SRBD may be a problem in more than 10 percent of children. It occurs when the airway is partially blocked during sleep. The most common example is snoring. The most severe form of an SRBD is obstructive sleep apnea. It occurs in about one percent to two percent of children.

If you suspect that your child or grandchild might be suffering from an SRBD or, for that matter, any type of sleep disorder, it is a really good idea to consult with your child's pediatrician, who can see of he or she needs to be referred to a sleep specialist.

We already know that treatment of an SRBD may improve other mood, attention and behaviors in children. We do not know if treatment might reduce aggression and bullying, and that will be the next research project.

Sleep Deprivation

When I was a young doctor we used to work absurdly long hours: for more than three years I worked every other night and every other weekend. It was not uncommon to be on your feet for three at a time. It is a wonder that we didn’t die or make more mistakes.

We know that sleep deprivation is not healthy, but we are only now beginning to find out just how damaging it can be. One of the biggest problems is that sleep deprivation interferes with the normal functioning of the immune system.

I saw an interesting paper (NR619) at the 2007 Annual Meeting of the American Psychiatric Association in San Diego last month.

A team from Korea took sixteen healthy volunteers and made them stay awake for 48 hours. They found that even this relatively short period of sleep deprivation produced some impressive effects on the body and the mind:

• Thyroid hormone levels rose
• The speed and accuracy of reaction times fell
• Blood glucose and protein levels rose, and there were disturbances in several liver function tests
• White blood counts increased
• There was a slight fall in immunoglobulin levels

We already know that insufficient sleep is associated with insulin resistance and weight gain, and it is likely that these are mediated by a rise in inflammatory mediators in the blood.

It is remarkable how quickly the effects occur.

And how pleased I am that young doctors no longer have to tolerate those incredibly long shifts.

Some things have changed for the better!

Larks, Owls and Depression

It is well known that mood disorders are associated with the disruption of many of the circadian rhythms of the body including sleep, temperature and thyroid function. These links are so well known that many experts believe that depression may be a consequence of disturbances in circadian rhythms.

Although circadian rhythms tend to be fairly consistent across individuals, but there are significant differences in these rhythms in different people: we call this the "morningness-eveningness” dimension (MED).

As part of a larger project, researchers from Providence, Rhode Island last month presented a most interesting study (NR293) at the 2007 Annual Meeting of the American Psychiatric Association in San Diego.

People with psychiatric problems tend to be owls: evening types who don't like mornings, and this was particularly striking in people with depression.

This suggests that “eveningness” may be reflecting a risk factor or vulnerability to psychopathology, in particular depression. It may actually be that if you are a “morning person,” you may have some protection against developing depression.

I remember seeing a study from Stanford in April that suggested that people labeled a “night owls” report more pathological symptoms related to insomnia, despite many having the opportunity to compensate for their nocturnal sleeplessness by extending their time in bed and being able to gain more total sleep time. So this may be the link with depression.

Non-pharmacological and Lifestyle Approaches to Attention-Deficit/Hyperactivity Disorder: 5. Exercise, Environment and Sleep

One of the most valuable things to do to help children or adults with ADHD is to help them to structure their time.

All the approaches that we have already discussed, from medications to diets, herbs and homeopathy are all tools designed to help people get to the point where they can create, accept and maintain more structure in their lives. Exercise, the environment and regular sleep are all essential contributors.

Exercise
Aerobic exercise may be particularly helpful for people who also have a mood disorder or anxiety probably by reducing inflammatory mediators in the blood.

There is a movement therapy called eurythmy that was developed by Rudolf Steiner. It is quite popular in central Europe, and there has been a report that it could help children with ADHD. 


Environment
There is evidence that children with ADHD do better if they are outside, and even being a green room seems to help them. 


There are plenty of anecdotes about children and some adults with ADHD improving if they have classical or New Age music in the background. Paradoxically some like and claim benefit from “heavy metal.” There is recent evidence from New Zealand indicating that music therapy may contribute to the reduction of a range of ADHD symptoms in adolescents, as it does in younger children. With the advent of the iPod, it is easy to make a playlist of music that helps attention and concentration.

The data on the effect of watching television, computer time or playing video games is a mixed bag. There are people who say that children under the age of three should not watch television at all, and the American Academy of Pediatrics recommends that children under the age of 2 years should watch no television, and that television time should be limited to less than 2 hours daily in older children. The research data has not produced a clear answer one way or the other. Some of the most recent research does suggest a link between the amount of time that children spend watching television and attention-deficit/hyperactivity disorder, but it remains unclear as to whether elevated levels of television viewing are the cause or result of ADHD symptoms. Other researchers have failed to find a connection. The best thing is to play safe and to keep television viewing to a minimum: there are so many other things for a child to be doing.
   
There have been questions about whether other environmental factors, particularly lead, mold and Candida could cause ADHD.

Lead toxicity is well-known to cause neurological problems, but studies of a link between lead levels and ADHD have usually failed to find a link, and in a study in which children with minimally elevated lead levels were given a drug – penicillamine - to remove lead, there was no change in ADHD rating scores. So it is unlikely that lead is a factor in most children.

Because of the high rates of allergies in people with ADHD, there have been attempts to see if mold or other environmental pollutants could be causing ADHD. So far the data has drawn a blank.

Another environmental factor that has been look at is the yeast Candida albicans. It can produce nasty infections in people with compromised immune systems. But in addition, some people have claimed that Candida infections can cause an array of medical problems, including ADHD-like symptoms. People who are thought to have Candida have been treated with diets as well as the antifungal agent nystatin, with mixed results. It would be good to do a formal study of Candida in ADHD and see if there is a link and if treatment helps. So far we just do not have one.

Sleep
Sleep disturbances are extremely common in ADHD. They often get better once an individual is treated, but it is still a good idea to practice good sleep hygiene.

1. Stress management
2. Exercise a couple of hours before retiring
3. Keeping mentally stimulated until it is time for bed
4. Though we want to have a regular bedtime and bedtime ritual, to begin with don't go to bed until you are tired
5. No caffeine, alcohol or nicotine after 6pm. (Preferably, of course, no nicotine ever!!) {Remember that many over the counter painkillers contain caffeine, as does chocolate}
6. Try to keep the bedroom atmosphere relaxing, and establish a sleep ritual
7. Keep the room quiet and dark
8. If you like aromatherapy, lavender and chamomile are usually best
9. If you cannot sleep, get up and do something relaxing: struggling to go to sleep is virtually impossible.
10. Do not have a television in the bedroom. Bedrooms should be reserved only for sleep in children and for one other activity in adults
11. Always get up at the same time in the morning, to try and re-set your brain, and as soon as you get up, be exposed to as much bright light as possible

Stonehenge

One of the most amazing monuments in England is Stonehenge. These days most people cannot enter it, but  when I first saw it as a teenager in the early 1970s you could still go inside, and it was one of the places that I was taught to dowse. The power of the place has undoubtedly risen with its fame and mystery, but the fact remains that most sensitive people are quite strongly affected by it.

Some of the stones were probably brought from South Wales and the entire Stonehenge complex was built in several construction phases spanning about 2,000 years, although there is evidence for activity both before and afterwards on the site. There was a wooden henge of the site long before the stones arrived.

The BBC is reporting that archaeologists have discovered a huge ancient settlement used by some of the people who built Stonehenge.

Excavations at Durrington Walls have uncovered remains of ancient houses. People seem to have occupied the sites seasonally, using them for ritual feasting and funeral ceremonies.

It is thought that in ancient times, this settlement would have housed hundreds of people, making it the largest Neolithic village ever found in Britain. The dwellings date back to 2,600-2,500 BC - according to the researchers, the same period that Stonehenge was being built or re-built.

Mike Parker Pearson from the University of Sheffield, said, "In what were houses, we have excavated the outlines on the floors of box beds and wooden dressers or cupboards."

The researchers have excavated eight houses in total at Durrington. But they have identified many other probable dwellings using geophysical surveying equipment. They think there could have been at least one hundred houses, each measuring about 5m (16ft). They are square, made of timber, with a clay floor and central hearth. The archaeologists found 4,600-year-old rubbish covering the floors of the houses.

And archaeologists love rubbish!

The evidence suggest that Stonehenge drew Neolithic people from all over the region, who came for massive feasts in the midwinter where they consumed prodigious quantities of food. The bones were then tossed on the floors of the houses.

Durrington has its own henge made of wood, which is strikingly similar in layout to Stonehenge. It was discovered in 1967.

Both henges line up with events in the astronomical calendar - but not the same ones. Stonehenge is aligned with the midwinter solstice sunset, while Durrington's timber circle is aligned with the midwinter solstice sunrise. So it would seem that they were complementary.

Stonehenge lies on an extraordinary system of ley lines that crisscross the British Isles, parts of Northern France and parts of China. The lines are usually dismissed as pseudoscience, and it is certainly sometimes difficult to follow what some writers have to say on the subject. There is also a small body of evidence that some people can sense these ley lines. For people who can, the sensation is much the same as feeling the acupuncture meridians of the body. This apparent similarity has lead some experts in Feng Shui to approach personal wellness in the same way that they recommend the placement of plants, mirrors and other objects. Both the body and the land are looked at like gardens that need to be cultivated.

With some people, where they live, how they lie in bed and where they are treated can all be affected by these lines. Others don't seem to notice a thing. I was once treating a lawyer with insomnia, and things were not going well. Until she went on vacation to England and she was fine for a couple of weeks. On her return to the USA we just moved her bed and the problem was solved. I just wish that it were always that easy!

It took me a long time to be persuaded that what I and others felt at Stonehenge and along these lines was real and not just make believe. But now I am convinced. The Ancients knew something about the relationship of the land to their lives, and we are finally recovering some of that knowledge for ourselves.

Blue Light at Night Morning Delight

                                 

Do you ever see that episode of the original Star Trek in which Spock is accidentally – and temporarily – blinded when he is exposed to ultra-bright light to drive out a parasite? For people who like to know such things, it was episode 29, entitled Operation: Annihilate!

In the end it turns out that he only needed to have been exposed to one invisible wavelength of light. Naturally enough, being Star Trek it all comes out all right in the end.

I was reminded of this as I examined some extraordinarily important recent research from Thomas Jefferson University in Philadelphia. We have known for a long time that light is an effective treatment for seasonal affective disorder (SAD). However, until now, nobody has been able to determine the best wavelength to use. This new research found that the most effective wavelength was blue. It is thought that blue light therapy may help a great many more things than SAD.

SAD is one of a group of disorders involving our circadian rhythms. Many experts are currently trying to establish the relationship between SAD and another major disturbance of circadian rhythms: bipolar disorder. They are certainly not the same thing, but they are closely related to each other. Some other circadian rhythm disturbances that may respond to blue light are sleep disturbances, jet lag, sleepiness during shift work and spaceflight.

It has always been assumed that the brain’s major pacemaker – the suprachiasmatic nucleus (SCN) – only responded to bright light at a certain time of day. The SCN regulates the production of melatonin by the pineal gland. The fact that lower-intensity blue light is more effective than the most visible kinds of light is part of a body of evidence that there is a separate photoreceptor system within the human eye. The system that resets the body clock to the 24-hour day is different from the rods and cones used in regular vision.

In linked research by the same investigators, as well as a team from and Brigham and Women’s Hospital and Harvard Medical School in Boston, blue light was shown to directly reduce sleepiness. People exposed to blue light were able to sustain a high level of alertness during the night when people usually feel most sleepy. The results suggest that light may be a powerful countermeasure for the negative effects of fatigue for people who work at night.

There is more to this research: breast cancer is linked to fluctuations in human circadian rhythms, with higher rates in industrialized countries where there is a great deal of exposure to artificial light at night. It has been suggested that melatonin may be a link between artificial light and breast cancer. Blue light may perhaps mitigate some of the effects of light on suppressing melatonin.

There is another point to be made here. Many people teach techniques of being able to see the human aura. Many of the techniques of the “See the aura in 30 seconds” type, are no more than visual illusions. But there is another group of techniques that involves the use of peripheral vision to gradually become aware of the fields around people, animals and plants. By a strange "conincidence" the ancients identified the pineal gland with the "third eye." Have the researchers inadvertently found a biological mechanism for seeing auras?

“Sleeplessness is a desert without vegetation or inhabitants.”
--Jessamyn West (American Writer, 1902-1984)

Exercise and Mood

Most people who exercise on a regular basis soon begin to notice that if they miss a day or two, it will quickly have an effect on their mood and motivation. There’s recently even been some research to confirm it. Many years ago it was shown that one of the mechanisms for the “Runner’s high,” was the production of endorphins and we now have a great deal of research that is revealing the fundamental mechanisms linking exercise and mood.

Though the link between exercise and mood has been recognized for decades, in the last few years we have seen an increasing body of evidence that exercise can have a useful effect on people with mood disorders. The evidence is extensive (For example: 1. 2. 3.) and is now so strong that many clinicians – and certainly all practitioners of Integrated Medicine – routinely recommend physical exercise as part of a package of health care. There is particularly good evidence that exercise will help with some of the less common types of depression. An exercise program may particularly benefit  women with progesterone-related premenstrual mood disturbances.

We now have some good evidence  about the mechanisms by which exercise can improve mood. Researchers in China did some experimental work in rats with what they called “Chronic unpredictable stress.” It is just what it sounds like. If the little critters keep getting stressed, they develop many of the signs of depression: they show loss of appetite, social withdrawal and a reduction in exploratory behavior. We could say that the repeated stress reduces their resilience. Chronic stress causes dysfunction in the hormonal system that links the hypothalamus and pituitary glands at the base of the brain, with the adrenal glands that are perched atop the kidneys.

The researchers then gave some of the rats the opportunity to exercise on a wheel. The exercising rats had an increase in the amount of a growth factor called brain-derived neurotrophic factor (BDNF) in a key region of the brain called the hippocampus. In the non-exercisers, the levels of the growth factor went down as they experienced more and more stress. Exercise also smoothed out stress-induced rises in the hormone cortisol.

This is particularly interesting because previous research had shown us that exercise can increase BDNF levels in the brains of stressed and unstressed animals. We also know that if an antidepressant is going to work, it has to be able to stimulate the production of BDNF in the hippocampus of the brain.

One thing that has not been much studied is the impact of exercise on sleep architecture. Most exercisers know that a good workout, run or hike can make you sleep like a log. And there is increasing evidence that correcting sleep disturbances can be a most effective way of improving mood. So much so that many of us now believe the sleep disturbances underlie many mood disorders, rather than sleep disturbances being symptoms of sleep disorder.

My conclusion from reading the literature and working with countless individuals is that unless there is a medical contraindication, a combination or weight training and aerobic exercise should be part of the treatment program for anyone with depression. The biggest problem is motivating someone with depression t do something like exercise. Sometimes it is necessary to wait until the primary treatment has taken hold. Though we have often had a great deal of success by using some of the motivational systems that I’ve described in Healing, Meaning and Purpose.

Breathing

“Without mastering breathing, nothing can be mastered.”
--George Gurdjieff (Armenian-born Adept, Teacher and Writer, c.1873-1949)

I strongly recommend breathing. It’s actually one of my favorite pastimes….

Of course breathing is all-important, but it is just as important to ensure that you are breathing in good quality air. Scattered throughout the world are weather fronts accompanied by hot dry winds of ill repute:

• The Santa Ana Winds of Southern California,
• The Mistral of France
• The Khamsin of North Africa
• The Foehn of Switzerland
• The Sharav in Israel
• The Chinook of Canada
• The Sirocco in parts of the Mediterranean
• The Xlokk of Malta
• The Zonda in Argentina
• The Halny of the Carpathian Mountains

These are just some of these winds, that have been known for centuries to precipitate a variety of symptoms in the exposed population, including depression, irritability, insomnia and headaches. The explanation of these effects is an increase in the number of positive ions in the atmosphere, which alter the amount of serotonin in some parts of the brain. I was consulted about an epidemic of headaches amongst people working in an electrically insulated room. It soon became clear that the setup had allowed an enormous concentration of positive ions, and once they installed a negative ionizer virtually all the headaches stopped. We believe that many of the beneficial effects of high altitudes or of being near waterfalls of fountains spring from the way in which they generate large numbers of negative ions.

Poor oxygenation of the lungs has been known for many years to be associated with disease. Pulmonary tuberculosis classically affects the upper lobes of the lung, where there is the poorest oxygenation, and it has been known for a century that people suffering from a blockage of the mitral valve of the heart, which leads to high blood pressure in the lungs, do not get tuberculosis in that part of the lungs.

Conscious control of the breath enables us to modulate the activity of the autonomic nervous system. Specific types of breathing can induce specific psychological and physical effects.

We usually breathe through one nostril at a time. Either the right or left nostril is dominant for anywhere from 45 minutes to two hours. You then switch sides. This is known as the nasal cycle, and is one of the faster circadian rhythms. The popular yogic practice of single nostril breathing is thought to feedback directly into the hypothalamus of the brain. You can learn to use this to your advantage. If you are right handed, if you direct your focus onto opening the right nostril, you may well find an increase in salivation, which is an aid to good digestion. A useful trick that we have used for many years is at bedtime to start by lying on your left side, which has the effect of opening the right nostril, and after ten minutes roll onto your right side for sleep. Again you reverse this if you are left hand dominant. It seems that this simple trick lowers your core temperature, which is one of the main determinants of sleep. There is some research that opening the right nostril increases body temperature, while opening the left has a calming effect. These techniques are often very helpful. Apart from these physical effects, using the breath is one of the quickest ways to learn to sense the subtle forces of the body.

You may already have some breathing practice that you like, and by all means continue using it. If you need a new one, the simplest that I have ever been taught, and that I have used with countless students and patients is this:
Count your breaths. Breathe deeply using your abdominal muscles, so that you are drawing more air into your lungs. Stop immediately if you feel faint or dizzy. As thoughts come up, keep concentrating on the incoming and outgoing breath. Gradually slow the breath, by extending the pause between the inhalation and exhalation.

I always make myself unpopular when I insist that people check with a healthcare provider before stating any exercise plan, including breathing. But I'm going to say it anyway. It just makes good sense!

“Controlled deep breathing helps the body to transform the air we breathe into energy. The stream of energized air produced by properly executed and controlled deep breathing produces a current of inner energy which radiates throughout the entire body and can be channeled to the body areas that need it the most, on demand. It can be used to fuel a specific physical effort, such as tennis or jogging. Or you can use this current of inner energy to relieve muscular tension throughout the body, revitalize a tired mind, or soothe localized aches and pains.”
--Nancy Zi (American-born Chinese Opera Singer, Voice Teacher and Qigong Expert)

Hypnagogia: The Waking Dream

Most of us have experienced the brief transition between wakefulness and sleep as we fall asleep. This is the hypnagogic state, though it has been known by many names: “the borderland state," the “half-dream state,” the “pre-dream condition.” The name for these strange hallucinations is “hypnagogia.”

Although there are innumerable books about dreams, there is to my knowledge only one book in English that is dedicated to hypnagogia, by the psychologist Andreas Mavromatis. There are also not that many good websites dealing with the phenomenon, though I’ve found one or two really good ones. This is a little surprising, for the hypnagogic state is one of the most fascinating altered states of consciousness that we can experience without the use of drugs, and there are dozens of spiritual schools that encourage their students to work with these hypnagogic hallucinations. They are different form the hallucinations that may occur in neurological problems: those tend to occupy only one sense at a time, while the hypnagogic hallucinations, though sometimes no more that flashes of light or odd shapes, can be highly complex and involve multiple sensory modalities: what we call multi-modal hallucinations. Some people may feel as if they are floating, and it is not uncommon for people to kick out or grasp as they feel as if they are falling from a great height.

The term “hypnagogic” was coined by the 19th-century French psychologist Louis Ferdinand Alfred Maury, and is derived from two Greek words, Hypnos (Sleep) and agogeus (A guide, or leader). Some years later, the English poet, essayist and psychical researcher Frederic William Henry Myers coined the term, “hypnapompic,” to describe similar phenomena that may occur as we wake from sleep.

Long before Maury, many writers commented on these odd experiences. Here are just a few that I’ve heard about:

1. Aristotle spoke of the “affections we experience when sinking into slumber, and the images which present themselves to us in sleep.”
2. Iamblichus of Chalcis, the third century Neo-Platonic philosopher, wrote of the “voices” and “bright and tranquil lights” that came to him in the condition between sleeping and waking, that he believed were a form experience sent by God.
3. There is some evidence that the alchemists of the Middle Ages made use of a form of hypnagogia during their meditations, preparations and distillations. I’ve seen it suggested that the weird characters and eerie landscapes that seem to fill alchemical illustrations might have been the fruits of focusing on hypnagogic hallucinations, though they could just as easily have come from dreams or drugs.
4. In 1600, the Elizabethan astrologer and occultist Simon Forman wrote of his apocalyptic visions. He saw mountains and hills that came rolling against him on the point of sleep and beyond which he could see vast boiling waters.
5. Thomas Hobbes spoke of images of lines and angles seen on the edge of sleep accompanied by an “odd kind of fancy” to which he could give no particular name.
6. Emmanuel Swedenborg the 18th century philosopher, scientist and visionary developed a method of inducing and exploring hypnagogic states, during which he claimed to have traveled to Heaven, Hell and other planets. He recorded several other techniques that he used to gain his insights, including a particular type of hyperventilation.
7. The theosophical writer Oliver Fox used the hypnagogic hallucinations as a “doorway” through which he was able to go astral traveling.
8. Rudolf Steiner, advised that the best time for communicating with the dead was in the period between waking and sleep. He claimed that if you asked the dead a question as you fell asleep, they would answer you the next morning His records look very much like hypnagogic hallucinations.
9. The Russian writer and philosopher P.D. Ouspensky is someone else who made a detailed study of hypnagogia. Like many of the others that I’ve mentioned, he made a number of interesting discoveries about the Universe while in this state. It is these insights, and their similarities across cultures that suggest that there’s more to hypnagogia than random neuronal firing.

It is interesting that although hypnagogia can produce millions of different experiences. When people start using them for exploration, they seem to generate many similar insights. This is rather different from the mystical experience. In which peoples’ experiences have similar form, but different content.

The most widely used criteria of the mystical experience were assembled by the English philosopher W.T. Stace, who taught at Princeton for many years:

1. Deeply positive mood
2. Experience of Union
3. Ineffable sense
4. Enhanced sense of meaning, authenticity and reality
5. Altered space and time perception/transcendence
6. Acceptance of normally contradictory propositions

I shall have more to say about mystical experiences in another posting.

For now, if you are interested in doing some self-exploration, and you are not using either medications or alcohol, the hypnagogic state is a great place to start. Occasionally people find the exploration scary, so only do this if you are up to it, and don’t if you are given to nervous or psychological problems. When I’m working with people I always ensure that they are in tip top condition before trying ANY kind of psychological exploration.

Try becoming aware of the transition between wakefulness and sleep. At first you will fall asleep, but with a small amount of practice, most people can quickly begin to keep themselves in the state, and then start exploring. Many people find that they get some profound intuitions while in the hypnagogic state, and unlike the kinds of “insights” that people get while under the influence of drugs or alcohol, they make sense in the morning. Relax, keep a diary, take it in easy stages, and see what you can discover for yourself. If you come across anything unpleasant, stop, and we can try some different exercises.

Pramipexole

Pramipexole is a remarkably interesting medicine about which you are likely to hear a lot in the near future. It is an agonist, which means that it has a positive effect, on D2 dopamine receptors and also on a little-known group of dopamine receptors, known as the D3 group. If you want to get really clever the dopamine receptor D3 group is abbreviated to DRD3. Pramipexole has been in use for almost a decade in the treatment of Parkinson's disease, and approximately 9.1 million prescriptions for pramipexole have been written in the U.S. since its launch in 1997. It is not without its problems. In Parkinson’s disease it may cause dizziness, involuntary movement, hallucinations, headache, difficulty falling asleep, sleepiness, and nausea. Some people have also had behavioral dyscontrol while taking it.

At a meeting in Athens in February of 2006, we saw confirmation of something that had been shown in previous research: pramipexole seems to be a very effective treatment for restless legs syndrome (RLS). A study published in the journal Neurology has given us a more detailed understanding of the risks and benefits of pramipexole.

The investigators report a 12-week, multicenter, double-blind, randomized, placebo-controlled study of fixed daily doses of pramipexole (0.25 mg, 0.50 mg, and 0.75 mg) involving 344 patients with moderate to severe RLS. Data from 339 patients were analyzed to evaluate the effect of pramipexole treatment on efficacy and safety. The mean age of patients was 51.4 years and the mean duration of RLS symptoms was 5.1 years. The results were very promising, even though half of the patients on placebo also showed an improvement. The most commonly reported side effect included nausea (19.0%), headache (17.8%), insomnia (10.5%) and somnolence (10.1%).

In Europe pramipexole it has been approved for use in this indication. It is marketed as Sifrol® / Mirapexin® In the United States we currently only have one approved medical treatment for RLS, and that is the GlaxoSmithKline medicine ropinirole (Requip), that works at the same D3 receptors in the brain and spinal cord. Ropinirole is effective in a proportion of people with RLS, but it has also been linked to sleepiness, drops in blood pressure and fainting, so those are included in its label.

RLS may be associated with some other illnesses so I was very interested to see two reports of the use of pramipexole in bipolar depression as well as a report of its possible use in REM Behavior Sleep Disorder.

One of the most exciting potential uses for pramipexole may be in some people with fibromyalgia. I’ve mentioned that fibromyalgia, bipolar disorder and some other psychiatric illnesses may be connected. The idea that we might be able to use just one medicine to support our Integrated Medicine approach is very attractive, and also helps point us toward a deeper understanding of what exactly goes wrong at the physical level in RLS, depression and fibromyalgia.

I’ll keep you posted.

Restless Legs Syndrome and Integrated Medicine

In the last entry we looked at RLS: what it is, and some of the conventional approaches to treating it. I now want to spend a moment talking about some of the other approaches that we have tried. For most of these there is very little evidence, so we use them in conjunction with conventional medicine.

If you want to try any of them, discuss them with your health care provider, so that he or she can guide you toward the best ways of putting treatments together.

1. Diet: A low sugar diet helps some people, and it is always worth keeping a food diary for a week to see if there’s any association between something that you’ve eaten and a worsening of your symptoms.
2. If you like juicing, there have been a number of anecdotal reports of the use of carrot, celery and spinach juices helping some people. (I am writing this while we are still in the middle of the spinach/E. coli scare, so leave this one out until the FDA has given us the all clear.
3. There have been publications about the use of vitamins E and B and folic acid in RLS. Vitamin E can cause a GI upset in some people and if used in too high a dose (above 800IU/day) may elevate blood pressure; folic acid has to be used with caution in people on anticonvulsants. If you try these options, bear in mind that no supplement is likely to work unless it is taken for at least a month.
4. Acupuncture sometimes helps: there are three acupuncture points in the legs that come up in the prescription: Urinary bladder 57, Spleen 6 and Stomach 36.
5. Homeopathic remedies have been reported to help, and I’ve had some success. The precise remedy always depends on the precise characteristics of the individual, but the most common ones have been Rhus Toxicodendron, Causticum, Tarentula Hispanica and Zincum Metallicum. If you live in a place in which there are good homeopaths available for consultation, it’s another option.
6. Several herbal remedies have been reported to help: Passion Flower, Cimicifuga, Valerian, Black Cohosh and Piper Methysticum. Just remember that some of the herbs sold in health food stores don’t contain what they should, and Valerian and Black Cohosh have recently been associated with liver toxicity in some people.
7. Here is an old trick from China: take a one inch piece of fresh ginger root and grate it into a bowl of warm water. Then soak your feet in the water for about ten minutes. I’ve never seen that one work myself, by some people whom I respect have.

I also think it important not to neglect the psychological aspects of this problem, and sometimes some psychotherapy can be a helpful adjunct.

Finally, ask yourself what the RLS is trying to teach you.

These are all options that have been tried and have helped some people. If you are not having success from conventional medicine alone, or if you don’t care for conventional medicine, then discuss these options with a professional, use your intuition, and let us know if you have success.

Restless Legs Syndrome

Restless legs syndrome (RLS) is a common (3-15% of the population) and sometimes very unpleasant problem in which people have uncontrollable urges to move their legs. If they do not move, they will begin to feel uncomfortable, painful or odd sensations in their legs, and sometimes also in other parts of the body. The restlessness may last for minutes or even hours. Movement affords people very temporary relief. The sensations are usually between the ankle and the knees, but they can also involve the thighs. If other parts of the body are involved it always makes us question the diagnosis.

The severity of the problem is highly variable, running from a mild annoyance to an incapacitating problem. In most people the symptoms are worse when sitting or at night, and often lead to loss of sleep. Not surprisingly many people feel of exhausted and irritable during the day.

With such enormous variations in the severity of the problem, and even the parts of the legs affected, it is highly likely that RLS is a symptom of a group of illnesses.

The International Restless Legs Syndrome Study Group (IRLSSG) identified four criteria that must be present for an RLS diagnosis:

1. An urge to move, usually due to uncomfortable sensations that occur primarily in the legs.
2. Motor restlessness, expressed as activity, that relieves the urge to move.
3. Worsening of symptoms by relaxation.
4. Variability over the course of the day-night cycle, with symptoms worse in the evening and early in the night.

About 80% of the people with restless legs syndrome also suffer from a separate condition called periodic limb movements in sleep (PLMS). Periodic limb movements in sleep are involuntary jerking movements in extremities, usually the legs. You can have PLMS without having RLS, and vice versa.

RLS may start at any age, including early childhood, and is a progressive disease for a certain percentage of sufferers, although it has been known for the symptoms to disappear permanently in some sufferers. The condition runs in families; children of RLS sufferers are more likely than other people to develop RLS.

It has some similarities to a syndrome known as akathisia that occurs in people taking some medications that work in the dopamine pathways of the brain. There are some subtle ways of telling the two apart, but RLS also seems to be caused by disturbances in one of the dopamine pathways of the brain.

It has been known for many years that there is an association between RLS and iron deficiency, but this link is probably not causal: just giving iron only helps a proportion of sufferers. But because of this link, everyone with RLS should have their ferritin levels tested; ferritin levels should be at least 75 mcg for those with RLS. If it’s below this level, iron supplements may help, but they are best administered by a physician, because ferritin needs to be monitored and there are down sides to taking too much iron. In a moment I'll tell you about some very new research on iron and RLS

Caffeine and other stimulants usually make RLS worse. Restless legs syndrome frequently occurs during pregnancy. About 15% of pregnant women develop RLS symptoms during the last few months of their pregnancy. The sensations usually stop after the woman delivers the baby.

We normally divide RLS into primary and secondary. Primary RLS usually starts before age 40 and the onset is often slow. The RLS may disappear for months, or even years. But it can be progressive and get worse as the person ages.

Secondary RLS often had a sudden onset and may be daily from the very beginning. Apart from pregnancy, secondary RLS is a result of a number of medical conditions, so it is always important to rule them out. They include:

1. Iron deficiency anemia
2. Macrocytic anemia due to folate or vitamin B12 deficiency
3. Diabetes mellitus
4. Peripheral neuropathy
5. Alcohol abuse
6. Some types of cancer, particularly of the lung
7. Celiac disease
8. Renal failure
9. Inflammatory arthritis

There have been reports of associations of RLS with other illnesses, but most seem rare. Interestingly people who undergo surgery often find that RLS symptoms become worse, which may be another clue as to the cause of the problem.

An international conference entitled SLEEP 2006, the 20th Anniversary Meeting of the Associated Professional Sleep Societies took place from June 17-22, 2006 in Salt Lake City, Utah. There were a great many interesting papers this year, including several on RLS

An international group of collaborators presented the results of the first population-based pediatric RLS survey. They used the National Institutes of Health pediatric RLS diagnostic criteria and collected data from over 10,000 families. The criteria for definite RLS were met in 1.9% of 8- to 11-year-olds and in 2% of 12- to 17-year-olds. Two different papers explored the value of using a single screening question to identify possible RLS patients. Those who answered, “Yes,” then answered more detailed questions to determine whether they met the International RLS Study Group diagnostic criteria.

A single screening question can eliminate people without RLS rapidly and direct appropriate subjects to further evaluation. Two groups of researchers found a high level of sensitivity with the question, "When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings that can be relieved by walking or movement?"

As I mentioned, it has been known for decades that RLS may be associated with low iron, and especially with low ferritin levels. These may be present in symptomatic RLS patients during pregnancy and in people with iron-deficiency anemia and end-stage renal disease. Previous studies had suggested that supplemental iron was beneficial for RLS patients with low ferritin levels. One paper presented further evidence of the possible efficacy of supplemental iron in the treatment of selected RLS patients with a prospective, randomized, placebo-controlled, double-blind study of RLS patients with low to normal ferritin levels (15-75 mcg/L). The RLS subjects were given either placebo or iron 325 mg twice daily and were monitored with a validated RLS symptom scale. The preliminary findings showed that the iron supplementation group had significant increases in their ferritin levels and had improved quality of life compared with those on placebo; however, the interim data presented did not show a significant change in the RLS symptom score. The study is ongoing.

Treatment for RLS is based on how disruptive the symptoms are. Apart from iron, people should review their lifestyle and see what changes could be made to reduce or eliminate their RLS symptoms. These include: Finding the right level of exercise (too much worsens it, too little may trigger it)
Eliminating caffeine
Stopping smoking
Reducing alcohol intake

Several drugs have been tried for RLS: Some of the same medications used in Parkinson's disease, benzodiazepines, anticonvulsants like carbamazepine and gabapentin.

Last month saw the publication of an important paper indicating that the medicine pramipexole, another anti-Parkinsonan drug, helps many people with RLS

In the next article I shall review some of the other approaches used by Integrated Medicine.

Prostate Cancer, Shift Work and Vitamin D

One out of six American men will develop prostate cancer and more than a third of them will experience a recurrence after undergoing treatment, putting them at high risk to die of the disease.

A study from Japan in this month’s issue of the American Journal of Epidemiology, reports prospective research that examined the association between shift work and the risk of prostate cancer incidence among 14,052 working men. Compared with day workers, people who worked rotating shifts were significantly at risk for prostate cancer whereas fixed-night work was associated with a small and non-significant increase in risk. This report is the first to reveal a significant relation between rotating-shift work and prostate cancer. Previous research has found that shift work may be linked to an increased risk of breast and colon cancer.

It’s important not to jump off the deep end: we are long way from saying that sleep disturbance is linked to prostate cancer. But it is another piece of evidence suggesting a link between environmental factors and genes, since there are a number of genes that may increase a man’s risk for prostate cancer.

However, there have now been several reports that disturbances in normal body rhythms might be linked to some cancers and this report adds to that evidence. It has never been shown that the actual sleep disturbance itself is responsible for the slight increase in risk seen in these studies. It could also be that people with abnormal sleep patterns are more likely to be doing something else, for instance smoking or eating junk food that would interfere with sleep and increase people’s cancer risk.

But here’s something to think about: shift workers have been found to have reduced secretion of the sleep-inducing hormone melatonin. Melatonin has also been shown in some studies to have some potential anti-cancer effects. The studies are controversial and certainly not conclusive, despite what one or two melatonin manufacturers may say. But something that is true is that reduced secretion of melatonin has been linked to increased production of sex hormones, which play a role in regulating prostate tissues. Under normal circumstances, secretion of the hormone is low during daytime, increases soon after the onset of darkness, peaks in the middle of the night, and gradually falls until morning. In shift workers the melatonin cycle becomes disrupted.

There has been some recent evidence that maintaining adequate levels of vitamin D may reduce a man’s risk of prostate cancer.

Another study, this time on pancreatic cancer and led by Northwestern University in Illinois has indicated that taking the US Recommended Daily Allowance (RDA) of vitamin D (400 IU/day) reduces the risk of pancreatic cancer by 43%. It is published in this month’s issue of Cancer Epidemiology Biomarkers & Prevention. This does not mean that we should start taking vitamin D supplements to reduce our cancer risk. But it ties in with research indicating that some exposure to sunlight might actually reduce the risk of some cancers. But all things in moderation: malignant melanoma and basal cell carcinoma of the skin have been increasing with increased exposure to sunlight.

Artificial Light and the Biological Clock

Many of the things that we do to babies and young children have been called into question in recent years.

The debate about doing an excessive number of fetal ultrasounds and high tone deafness seems to have gone away for now. Though not disappeared: there is a paper in the week's Proceedings of the National Academy of Sciences that revisits this important issue. Then there was the realization that doctors were not good at recognizing and dealing with pain in very young children.

And now there is another one that has worried me for years: what happens to babies who are exposed to constant high levels of light? Doesn't it damage the development of normal circadian rhythms?

I have just seen a study that seems to confirm some of those fears.

Investigators from Vanderbilt University in Nashville examined the impact of exposing babt mice to constant light. The main biological clock is in the brain, and is located in a region called  the suprachiasmatic nuclei (SCN). It is responsible for orchestrating an orderly internal physiological and behavioral cycle. It influences the activity of virtually all our organs, including the brain, heart, liver and lungs. It egulates the daily activity cycles that we call circadian rhythms.

When the mice are exposed to normal variations in light the cells of the SCN quickly become synchronized, and a normal circadian rhythm is established. Constant exposure to light disrupted the development of the SCN and prevented the animals from developing normal circadian rhythms.

This is far from being an academic exercise: each year around 14 million premature babies are born worldwide, and many are exposed to artificial lighting in hospitals. If their biological clocks are not allowed to develop normally, we would anticipate that they would, in later life, have less psychological resilience, and to be prediposed to sleep and mood disorders.

I could conceive of a way to test that experimentally by looking at records of people wth those problems. Secondly, we need to see if reducing unnecessary light exposure would have a real benefit for babies, and for the children and audlts that they will become. I would be astonished if exposing babies to a natural spectrum of light and a natural light cycle did  not have enormous benefits for them as they grow up.

Insulin Resistance, Polycystic Ovarian Syndrome and Sleep Apnea

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder that affects between 5-10% of women in the Western World. It is a leading cause of infertility, and although the underlying cause is still speculative, it is very heavily associated with insulin resistance.

There was an International Consensus Workshop sponsored by the European Society of Human Reproduction and Embryology and the American Society of Reproductive Medicine came up with this set of criteria. PCOS is present if a woman has at least two out of three of:

1. Oligoovulation and/or anovulation (ovulating only occasionally or not  at all)
   
2. Excess androgen (male sex hormone) activity
3. Polycystic ovaries (which needs a gynecological ultrasonography) and other causes of PCOS are excluded

There is still a great deal of debate about the precise way to define the syndrome. We are currently preparing a scholarly article on the subject and our literature review has included over three thousand papers.

The combination of an excess of the male (androgenic) hormones and insulin resistance can cause an array of symptoms apart form the menstrual disturbances and infertility, including:
Central obesity
Acne
Hirsutism, while at the same time experiencing alopecia
Skin flaps and dark patches of skin, usually on the neck or in the armpit
Sleep apnea

It is the last of these that I would like to highlight today.

A new study by Dr. Esra Tasali and her colleagues from the University of Chicago has found that in women with PCOS, sleep apnea is, as expected, associated with high fasting insulin levels. Sleep apnea might worsen the metabolic consequences of insulin resistance.

Regular readers may recall that I highlighted the association between insomnia, insulin resistance, weight and diabetes a couple of months ago. Here we have yet more confirmation of this link.

Not getting enough sleep – for any reason - can play havoc with your metabolism. It seems that in women with PCOS, it’s really easy for a vicious circle to become established:
Insulin resistance -> weight gain -> sleep apnea -> insomnia -> more insulin resistance -> more weight gain and so on.

It is important for everyone to know about this association, because chances are that you know someone with PCOS and/or sleep apnea.

Bipolar Disorder, Insomnia and Suicide

For many years now, I have advised on the treatment of many well-known people with all sorts of problems and illnesses. I always admire people who reveal that they have suffered from a problem in the hope of helping other sufferers.

The actor Stephen Fry has recently described his struggles with bipolar disorder and why he suddenly abandoned a play in London after developing stage fright. You may have seen him playing Jeeves to Hugh Laurie’s Wooster, or in the Blackadder shows.

Stephen was once described as a man with a “Brain the size of Kent.” He said that he became so knowledgeable because of terrible insomnia, which kept him up nights: he used the time to read enormous numbers of books. He also described a suicide attempt and a very serious plan to kill himself.

Though I've not examined Stephen, I can now explain several things to you:
1.    Bipolar disorder is not uncommon, and is rather more common in highly creative people. That being said, we must not romanticize an illness that carries a substantial mortality. The illness is frequently misdiagnosed, and when it is, there is an ever-present risk of suicide, as well as a host of other medical problems.
2.    Anxiety disorders occur in 80-90% of people struggling with bipolar disorder, and stage fright is one of these anxiety states
3.    Stephen may not have had insomnia as much as a reduced need for sleep, which is a classic symptom of one type of bipolar disorder. People with insomnia cannot sleep and usually go through the day feeling un-rested. People with a reduced need for sleep not only stay awake, but don’t get tired until they have been up for days at a time. Doing something like reading lots of books at night is another classic symptom.

Stephen Fry has just made a documentary for the BBC in which he talks about bipolar disorder with Carrie Fisher, Richard Dreyfuss and Robbie Williams.

They all deserve our gratitude for speaking out, telling their stories, and hopefully helping alleviate some of the stigma of mental illness, and helping more people get the diagnosis and treatment that they need.

Thank you Stephen!

P.S. There has recently been a rumor going round that your humble reporter was the model for Hugh Laurie's Golden Globe award-winning portrayal of Dr. Gregory House. I don't know where it started, but there's absolutely no truth in this vile calumny. I'm never irritable or curmudgeonly...

Technorati tags: Stephen Fry Bipolar disorder Stigma Hugh Laurie Blackadder Gregory House

Sleep, Weight, Insulin Resistance and Diabetes

I am often asked why there seem to be such close links between food and mood. Not just comfort eating, or the sudden shock of lots of carbs when we need an energy jolt, but why drugs that alter mood so often alter appetite?

You will probably not know this, gentle reader, but I only learned of it from reading scholarly papers. Apparently many people report that using marijuana makes them very hungry. On the other hand, cocaine and amphetamine affect not just the metabolism, but also appetite. The link has to do with the evolutionary development of feeding behaviors with the motivation to find food and to be satisfied by it.

Another link that has interested me for many years is the connection between metabolism and sleep. We have always presumed that this link has to do with hibernation: even humans have maintained some hibernation responses.

There is extremely good evidence that there is an inverse relationship between the number of hours that you sleep and an increase in your weight. There have been a great many studies on this, but one of the best was published by a group of researchers from the Mood and Anxiety Disorders Program, at the National Institute of Mental Health, the Psychiatric University Hospital, Zurich, Switzerland; University of Pittsburgh School of Medicine and the Department of Psychosocial Medicine, Zürich University Hospital, Switzerland in the Journal Sleep in 2004.

A report from the BBC concerning a study presented to the American Thoracic Society International Conference in San Diego provides yet more evidence of this link between sleep and weight. Researchers from Case Western Reserve University in Ohio, followed nearly 70,000 women for 16 years. They found that women who slept five or fewer hours a night were a third more likely to put on at least 33lbs (15kg) than sound sleepers during that time. It also found that compared with women who slept for seven hours a night. lighter sleepers were 15% more likely to become obese (have a Body Mass Index (BMI) of 30 or more. {BMI is calculated by dividing your weight in kilograms by the square of your height in meters}).

Previous studies, some of which I have reported before, have shown that after just a few days of sleep restriction, the hormones that control appetite cause people to become hungrier. However the women in the study appeared to eat less. I say “appeared to,” since the use of personal evaluations of food intake are notoriously inaccurate.

In dozens of countries arond the world, I am regarded as an authority in the fields of endocrinology, metabolism and nutrition. But when a group of us tried to estimate our daily intake and compare it with meticulous diaries, we discovered that we – a group of internationally renowned experts – were off by around 500 calories per day.

All kinds of explanations have been advanced, from people who didn’t sleep getting up and binge eating; to the effects of sleep-deprived people craving high carbohydrate, high fat food; to insomnia being a result of anxiety or depression that releases hormones that cause us to lay down fat in our tummies.

For all kinds of complex biochemical reasons, I have always felt that a lack of sleep would lead to an increase in insulin resistance, that may cause an increase in the deposition of fat in key regions of the body.

Some new research suggests that I may have been right on this one. A group based at Yale University School of Medicine, in New Haven, Connecticut has just published a report that should be of interest to all of us, and in particular you multi-tasking insomniacs out there.

The investigators studied a cohort of men from the Massachusetts Male Aging Study who did not have diabetes at baseline (1987–1989) and who were followed until 2004 to look for the development of diabetes mellitus. They came to the conclusion that BOTH very short and extra long sleep durations increase the risk of developing diabetes, independent of confounding factors.

The take home message?

If you do not get 7-8 hours sleep each night, you are vulnerable to a great many problems, and perhaps the biggest of all is the risk of weight gain, insulin resistance and diabetes mellitus.

I do not recommend using sleeping tablets unless absolutely necessary, and then for just a few days at a time. Instead follow all the sleep strategies that I have talked about in earlier blog entries.

During a recent visit to Danville, Virginia, I was delighted to learn that one of the non-pharmacological approaches that I have found helpful – putting a cold compress on the abdomen – was used by General Stonewall Jackson who used this very technique that I had to learn by going all the way to China.

The bottom line? Before your sleep gets disrupted by being  overweight and you develop sleep apnea, try some simple sleep hygiene, and a few of these novel techniques.

Technorati tags: Insulin Insulin resistance Insulin resistance syndrome insomnia alternative medicine resilience 

Modafinil and ADD

The Washington Post has just reported that the FDA has turned an application from the Pharmaceutical Company Cephalon to have modafinil approved for use in children with ADD, because of worries about a potentially serious skin reaction called Stevens-Johnson syndrome .

This is a real shame: we need more options for treating children and adults with ADD, and although I am a huge proponent of non-pharmacological methods of treatment, the fact is that a lot of people simply do not respond to the methods that we currently have available, and some do not even respond to the medications that are available.

Modafinil had looked very promising: in December 1998 the FDA approved modafinil under the brand name Provigil for treating adults with sleepiness associated with narcolepsy. Its main mechanism of action is to inhibit the reuptake of dopamine in key regions of the brain, effectively increasing the amount of dopamine available. It has been used off-label for excessive daytime sleepiness and last year a study form the University of Pennsylvania indicated that it might help some cocaine addicts fight their cravings. It is an open secret that a great many students and academics have been using it for years to enable them to study and work longer. I remember an article from someone who was due to lecture in India, immediately after his arrival from the United States. He admitted to taking modafinil to help him get through the ordeal.

The application to use modafinil in ADD is not dead. The FDA has said that they want a 3000 patients study to assess the risk of Stevens-Johnson syndrome, and the company will discuss that with them. But it will inevitably mean delays.

Technorati tags: ADD, ADHD Modafinil

Some Suggestions for Dealing with Insomnia

I have received an interesting question from a 50-year-old professional woman, who has had sleep problems that are especially severe during times of stress. As she says:

“I seem not to have the shut down switch in my brain.” She is worried about taking medications, and wonders if there is anything else that she can do to help herself.

____________________________

It is always unwise to make specific recommendations about someone without seeing them face-to-face, and the evaluation of a problem like this will normally take several hours. But the points that she raises have a great deal of relevance for so many people that I thought that a few comments would be helpful and equip everyone reading this with some information to discuss with their healthcare providers.

As usual, I think that it is a good idea to look at the question from the multiple dimensions of physical, psychological, social, subtle and spiritual. They are all inter-related, so dividing them up is simply a convenient way to help us think through the problem.

Before we do anything, we have to try and find out why someone has problems with sleep, and that may need investigations up to and including a sleep study.

The first thing is that my correspondent is female and likely either menopausal or perimenopausal. That is important, because as most women know, hormones have potent effects on sleep. It is not just that uncomfortable hot flashes can wake a person; it is also a direct effect of estrogen and probably of some of the releasing hormones in the hypothalamus. Hormone replacement therapy alone, does help some women but by no means all. Even at the physical level we see the general principle that there is rarely one cause for one problem. Typical menopausal sleep disturbances include a difficulty in falling asleep, and around 20% of menopausal women report that they sleep less than six hours a night. There is also some degradation in what we call sleep efficacy and an increase in deep slow wave sleep. Estrogen has effects on nasal mucosa, and when estrogen levels fall obstructive sleep apnea is more likely to occur. A major physical and psychological issue is that insomnia may become a learned habit that can persist even in the face of the best treatments.

This leads me to the second dimension, and that is psychological. The writer of the letter mentioned that she couldn’t turn off her thoughts. You would be amazed at how frequently I have been asked to consult on someone with a sleep problem and the individual has never been asked the question, “What is it that stops you falling asleep?” I have seen countless people prescribed sleeping tablets, when the real problem was anxiety or some other nasty problem that needed to be tackled first. In a moment I am going to make some suggestions that will try and help with both sleep and the ruminations and anxieties that may be contributing to its disturbance. Similarly, I have known a great many people whose sleep problems were the result of relationship difficulties or of something as simple as one person being a night owl and the other an early morning riser.

I always start with some simple sleep hygiene:

1. Stress management
2. Exercise a couple of hours before retiring
3. Keeping mentally stimulated until it is time for bed
4. Don't go to bed until you are tired
5. No caffeine, alcohol or nicotine after 6pm. (Preferably, of course, no nicotine ever!!) {Remember that many over the counter painkillers contain caffeine, as does chocolate}
6. There are some specific dietary recommendations for helping with sleep, and I shall write about those on a future occasion
7. Try to keep the bedroom atmosphere relaxing, and establish a sleep ritual
8. If you cannot sleep, get up and do something relaxing: struggling to go to sleep is virtually impossible.
9. Always get up at the same time in the morning, to try and re-set your brain, and as soon as you get up, be exposed to as much bright light as possible.

Now let me give you a few tricks that work on the five dimensions.

1. Start by lying on your left side for 5-10 minutes and then roll onto your right side. This appears to work by exploiting the so-called nasal cycle, which I shall write more about on a future occasion.
2. Still on the subject of the nose, one of the reasons that aromatherapy can be helpful, is because smell is unique amongst our senses, in that it is the only one that is not filtered by the thalamus. The regions of the brain that respond to smells are also directly related to some of the memory centers. The result is that smells can evoke memories extremely rapidly. You will probably have had the experience of smelling a perfume or cologne and instantly remembering someone who wore it in the past. This close linkage of smell and memory has enormous survival advantages: the smell of a predator can cause us to respond extremely rapidly. We can also use this knowledge to our advantage. Lavender has been used as a sleep aid for centuries. You can try putting a few drops of lavender oil on a cloth on your night-stand. Or you can use an electric diffuser or aromatherapy lamp. When I was growing up, we grew lavender and would put sprigs of it in the bed linens. It certainly seemed to help.
3. Some people have found that melatonin can be very helpful, and it is readily available. Discuss it with your health care provider.
4. Here is an old trick from traditional Chinese medicine. If you cannot sleep, soak a washcloth in cold water, lie down and put it on your abdomen for about ten minutes. I was taught that this works by pulling excess energy out of your head and neck down into the abdomen. There’s not a shred of scientific evidence that the technique works, but it does surprisingly often.
5. If people who are good at visualization, some have reported great success by creating a picture of a warm, calm and relaxing place. And not just a picture, but also a five senses experience. It has to be personal, and perhaps even a place to go back to on a regular basis. When I first learned to do hypnotherapy I was put into a light trance by one of my teachers. To this day, more than 25 years later I can still vividly recall the experience of being told that I was drowsing on a grassy knoll on a warm summer’s day on the Downs of Southern England, and actually feeling that I was there. I can still evoke the memory at will and I’ve made it more detailed over time. If you are a visualizer, try that.
6. Another technique that I learned from an early teacher, is to review the day backwards. Remembering what you did immediately before going to bed, and before that and so on. A simpler and often effective technique is just to start slowly counting backwards from 100.
7. Herbs: There are three that are widely used, and for which there is some research base. There is good evidence that the herb Valerian can induce drowsiness, and it is widely used – even by doctors – in France and Germany. An important point about valerian is that it is poorly absorbed and chemically and thermally unstable. So it needs to be kept cool, and used fairly soon after it is prepared. As with all herbs, Valerian has side effects and can interact with prescription medications and alcohol, so it really is essential to discuss its use with your health care provider. The same goes for the other two widely used herbs: Hops and Passionflower.
8. There is some evidence, though it’s not that strong, that taking a combined calcium/magnesium supplement (500mg calcium and 250-500mg magnesium) an hour before bed helps some people.
9. I recommend massaging your facial muscles before lying down to sleep. Not only does this reduce muscle tension, but also the face is covered in acupuncture points, and so that may be another reason why it can help.
10. Do not read or watch television in bed, but listen to a little calming music before retiring.

I do hope that will help you in your discussions with your health care provider. And I am always interested in hearing other suggestions, particularly if there is some research to back them up.

Technorati tags: Insomnia, menopause, herbal medicine, sleep hygiene, insomnia remedies, women's health

Sleep and Mood

The interaction between sleep and mood is fascinating, complex and supremely practical.

I have received a couple of queries and comments. Let me start with one from a physician:

“I have a question about sleep disorders. My patients seem to suffer from this even after their depression is better.” 

This is an extremely interesting issue.

Every healthcare student has been taught about the sleep disturbances that may occur in association with mood disorders. The classic problems in depression are early morning wakening, difficulty in getting off to sleep and sometimes waking in the early hours. Some others will sleep for very long periods, and there has been speculation that this may be a form of hibernation behavior. People with abnormally elevated mood can often stay awake for days at a time. There is also the well-known problem of seasonal affective disorder, in which the long winter nights can cause depression. Fortunately the depression is often relieved by the use of a light box.

Many experts now consider that the disturbances of sleep are often the primary problem, which then cause depressed or elevated mood. This is actually not a new idea: one of the old fashioned treatments for depression was sleep deprivation and many of us who have worked all night have experienced the mildly manic symptoms of sleep deprivation. On early morning rounds at the hospital I commented that it was easy to tell if some of the residents had been working all night, even before they presented their reports. The giggling, high energy and disturbances in thought patterns were not at all what one sees when someone is tired.

It is not just the sleep deprivation, but also light. It is well known that people suffering with bipolar disorder are more likely to get manic episode in the spring and early summer, as the amount of ambient light increases. It is the converse of the seasonal affective disorder problem.

So what often happens is that antidepressant medications do indeed help with the depressed mood, but the underlying sleep problem takes much longer to correct itself. This is also one of the reasons why people who have seen their mood improve on treatment still have cognitive problems that can go on for months after the mood symptoms have been corrected. It is probably a combination of sleep deprivation and also the impact of corticosteroids that can rise in some sufferers causing transient damage to some key regions of the brain.

It would be nice if we could modulate people’s sleep/wake cycles and thereby treat the mood problems directly, but at the moment, despite the enormous advances in pharmacological treatments of sleep problems, we are still not able to do that reliably.

Technorati tags: Sleep, Mood, bipolar disorder, Depression,

Thinking and Sleep

There is an important article in a recent issue of the Journal of the American Medical Association (Effects of Sleep Inertia on Cognition Adam T. Wertz; Kenneth P. Wright Jr; Joseph M. Ronda; Charles A. Czeisler JAMA. 2006;295:163-164.)

The study by a team at the Brigham and Women’s Hospital in Boston and the University of Colorado examined the phenomenon of sleep inertia: how long it takes for someone to wake up and think effectively, and to compare that with thinking after a person has been awake for 24 hours. For most of the first three years after I graduated from medical school, I worked on what was then known as a “one in two” on-call roster: every other night and every other weekend. Fortunately that inhumane system was abandoned some years ago, but it was not uncommon to be up and working for three straight days at the weekends, and we all became absolute experts on sleep and how to handle sleep deprivation. The problem was that if we did manage to get a few minutes sleep, there was always the chance of being awoken and being asked immediately to perform important tasks that would require very high levels of thinking and analysis. The results of this new study will not be a surprise to anyone who has done night work, or anyone who has been out all night burning the candle at both ends.

The study participants had had six nights of monitored sleep lasting eight hours per night, they were given a performance test that involved adding randomly generated, two-digit numbers. Based on the results of this test, the researchers concluded the subjects exhibited the most severe impairments to their short-term memory, counting skills and cognitive abilities from sleep inertia within the first three minutes after awakening. The most severe effects of sleep inertia generally dissipated within the first 10 minutes, although its effects were often detectable for up to two hours.

The study follows other research that has looked at the effects of going without sleep for over 24 hours, and found that the cognitive impairments were roughly the same as being drunk. Yet in the Colorado experiments, the cognitive skills of test subjects were worse upon awakening than after extended sleep deprivation: In a nutshell, the effects of sleep inertia may be as bad as or worse than being legally drunk. The most likely explanation is that certain areas of the brain take longer to "wake up".

Previous research has shown that the prefrontal cortex, which is responsible for executive functions: planning, problem solving, complex thought and emotional control, is one of the brain regions that takes longer to come "on-line" following sleep.

What should be the conclusions from these studies?

1. Ideally, nobody should be doing anything really important for 15 to 30 minutes after they wake up.

2. If you are asleep, it's a much bigger transition to go from that to being awake, rather than staying awake, even for a long time, because then you will be aware that you are drowsy.

3. The study did not examine emotion and motivation, and that may come in to play. If you are asleep in a hotel and the fire alarms go off, you may well be able to wake up and think very well and very quickly for a few minutes, but then you brain plays “catch-up,” and you will once again we groggy and cognitively impaired.

As a young doctor, there was no option: I had to wake up fast and be able to think straight. So I just did it, and fortunately the quality of my decisions seemed to be fine when older and wiser physicians checked them the next morning. Though I am VERY pleased not to have to work like that any more!

Technorati tags: Sleep, thinking,