Sleep Soundly Every Night, Feel Fantastic Every Day (18 page)

Jerry's manager suggested he see me. “Hi Jerry, I understand your manager referred you because your travels are keeping you down?”

“That's a nice way to put it. I feel like I can't sleep and I can't wake up completely. So how do I deal with this jet lag thing, Doc? I've been reading up on the topic, and everybody's got a different opinion.”

“Jerry, there is a protocol to follow that I'll suggest, and it has to be followed pretty closely. Let me talk you through
it first, and I'll give you the instructions to take with you. The point is to prepare your body rhythm to change to the rhythm of your destination several days before your trip.

1.
 
Prior to leaving on your trip, go to bed one hour earlier each day for three days.

2.
 
Next, if you can get a flight that will bring you to your destination in the evening hours, that's a good thing. If you can't, if people are sleeping in France when you're on the airplane, then you try to sleep.

3.
 
When you arrive, if you do arrive early in the day, don't take any long naps. That will kill you. If you're absolutely exhausted, and you have to take a nap, then try to keep it to 30 minutes or so. That won't cut into your sleep that night.

4.
 
Don't drink any caffeine or alcohol on the plane. They dehydrate you as well as affect your body clock.

5.
 
When you land, obviously avoid caffeine and alcohol if you're trying to get to sleep.

6.
 
Try taking melatonin, as little as one milligram, an hour before bedtime at your destination for the first three days.

7.
 
Finally, get up the next morning and expose yourself to bright sunlight in the morning to try to get in sync.”

Jerry seemed very willing to jump into this routine, and remembered one question, “Doc, what about eating? I feel bloated, and have digestive issues.”

“Try to eat your meals on the day of travel and on the plane within similar time frames of when people are eating in England or France, or wherever you are going. Jerry, there are obvious benefits to adjusting as best you can, which requires that you know the zeitgebers that adjust the body clock to its normal state.”

“Hold on, Doc. What's a zietgeber?”

“Glad you asked that! Zeitgeber refers to the environmental cues that synchronize your body clock to the 24-hour cycle of light and dark.”

Jerry nodded and said, “Okay I get it. Sunrise … sunset. If I arrive 9 hours later in Paris when my body clock is ready for breakfast at 8:00 a.m. in California, then I have a light dinner and want to sleep, in keeping with the time zone I'm in. But I can't. The zeitgeber of sunlight is gone in Paris.”

“Yes, and that is a good thing because you don't want to be exposing yourself to bright sunlight since you'll be going to sleep. If you were to arrive in the afternoon, which means the sunlight hits your eyes, you're going to have more trouble falling asleep at an earlier hour, which is already your problem when you travel east. In that case, wear the blue blocker sunglasses, to avoid bright sunlight in the late afternoon, if possible.

“Then when you wake up the following morning, you should expose yourself to bright sunlight to help you get in phase with your new destination more easily.”

“So, if I follow all of these instructions, Doc, how long is it going to take me to get in sync?”

“My goal is that if you have a five-day trip, you should be able to enjoy it without the extreme fatigue. To do that, let me suggest one more point. I want you to start taking a small dose of melatonin at home for two days before your trip. One or two milligrams at about the time you would be going to bed in London or Paris affects your circadian clock without making you groggy. Just a small dose to duplicate what nighttime will be in England. You will re-sync your clock to your destination clock. If you do these things, I would say that instead of six or seven miserable days, your body will adjust within a day or two of landing.”

Jerry did follow these guidelines and returned the next month for his appointment. His smile said it all. “You know, Doc, in Paris, I wasn't myself for the first day or so.
After that, I was much better than I've ever been, and by day three, I was feeling great. Thank you, Dr. Rosenberg. I appreciate your help!”

Most of us know people who are “night owls.” They stay up very late and are often most productive in the middle of the night. Despite the benign nickname, these people are suffering from a highly disruptive circadian rhythm disorder known as delayed sleep phase syndrome (DSPS).

Unlike jet lag and shift work sleep disorders, DSPS is an organic disruption in the person's internal clock that causes it to run counter to the light–dark cycle of the outside world. People suffering from this disorder cannot fall asleep at a normal time. Instead, they typically turn in between 1:00 and 4:00 a.m.—hence the name “delayed.” Their sleep is otherwise uneventful. They typically go to bed around the same time each night, fall asleep easily, and stay asleep for a sufficient number of hours to feel rested.

The difficulty occurs when they try to adhere to a regular daytime schedule. They have trouble getting up for work or school. They report being irritable, tired, and foggy in the morning, with sleepiness decreasing throughout the day. Their mood also lifts as the evening approaches, but then the cycle begins all over again and repeats itself day in and day out.

When people with normal circadian rhythms have been deprived of sleep, they usually go to bed earlier the next night in order to catch up. In those with DSPS, however, this powerful sleep drive is overridden by their “delayed” circadian rhythm. This means they are not able to sleep earlier. After trying to adhere to their school or work schedule all week, they will play catch up with sleep on the weekends, which only perpetuates the disorder. While research is limited, scientists believe people with DSPS may have
a longer-than-normal circadian period. Their melatonin and core body temperature fluctuations also appear to be delayed. Some contend that they also are less sensitive to light than others, and the absence of this natural zeitgeber contributes to the disorder.

1.
 
Cannot go to sleep at the time you desire (may appear like an insomnia symptom)

2.
 
Cannot wake up when you want

3.
 
Feel excessively sleepy during the day

4.
 
Inability to wake up at the desired time and excessive daytime sleepiness

5.
 
Depression and behavior problems, due to daytime drowsiness that can lead to academic problems, fatigue, or dependency on caffeine, sleep aids, or alcohol

When Vita came to see me at the Sleep Disorders Center, she explained that she was having trouble in her college coursework because she was not making it to her morning classes on time. Several days a week, she'd turn off her alarm in a sleepy state instead of getting up and going to class.

“I am worried, Doctor Rosenberg, that I've already missed more than I should. The professor has the right to fail me just because I missed so much. The student counselor suggested that I really see a sleep specialist to find out if I could work out a better schedule.”

“Vita, what kind of symptoms did the counselor want you to discuss with me?”

“Oh, I wrote them down. I go to bed later than normal people. Now I've heard that all of my life. I go to bed usually between 2:00 a.m. and 3:00 a.m.”

“How do you function in your morning classes?”

“I feel groggy all morning, even after a good night's sleep. I attend class, but don't remember much. I have to borrow my friend's recording or read the text to keep up. I am afraid of falling behind, and all my classes over the next three months are morning classes.”

“How does the rest of your day go when you wake early and manage to get to class?”

“I feel more alert in the afternoon actually, and after an early dinner, I either study or put in several hours as a typist for a professor's research. Every bit helps you know. Then I hang with friends, study what I missed in the morning.… I don't really get tired until the morning hours, and I go to sleep.”

“Vita, your computer, television, those new LED bulbs that you say they put in your dormitory room, well they all give off tremendous amounts of blue light. Those lights make it even more difficult for you to go to sleep. Vita, if you can't turn off the computers or your roommates insist on keeping the lights on, you can get yourself blue blocker sunglasses and wear them for about three hours before bedtime. They block out the blue light and help reset your circadian clock. This will help you go to bed earlier. By the way, Vita, don't forget to take them off when you get into bed.”

Like jet lag and shift work sleep disorders, delayed sleep-phase disorder can be treated with morning light therapy to wake Vita up, as well as doses of melatonin at night to increase sleepiness.

Vita's designated sleep program was to gradually adjust her schedule to go to bed about 15 minutes earlier per day. Then, when she awakened, she was to get a bright dose of sunlight 15 minutes earlier each day, thus gradually nudging her circadian system until she reached a reasonable sleep–wake schedule.

The second step in Vita's sleep program was for her to take a small dose of melatonin an hour before each
night's bedtime. She was to maintain this practice on weekends or she would fall back into old patterns.

Vita did well in her adjustment over time. However, there will be instances when patients like Vita will have difficulty. The solution can be to prescribe a sleep aid or to counsel such patients to adapt their work schedules, if they can, to their circadian disorder. An example would be someone with DSPS getting an evening shift job.

This disorder is like DSPS in reverse. Those with advanced sleep phase syndrome (ASPS) are known as larks as opposed to night owls. Larks greet the sunrise, are focused and active at dawn and during the ensuing hours, until the lark tires as the day goes on. Typically, they are in bed between 6:00 and 9:00 p.m. and awake far too early—usually around 4:00 or 5:00 a.m. They may feel refreshed, or simply be unable to sleep any longer. Then they experience increasing sleepiness throughout the day. Whereas delayed sleep has negative effects on morning activities such as work and school, those persons with ASPS have difficulty staying awake at night for parties, work, or any social activities. Treatment includes light therapy, typically in the evening, to help advanced sleep phase patients stay up later.

The name of this disorder, free-running, suggests that a person's circadian rhythm is not in sync, or is no longer entrained, with the 24-hour cycle of light and dark. Characteristic of this disorder is a decreased sensitivity to light that keeps one's body clock from resetting its rhythm and regulating sleep. Instead of the normal 24-hour sleep–wake cycle,
people suffering from this disorder do not adjust to the light signals or time cues. Their bedtime cycle tends to drift progressively to one hour later to bed and one hour later to wake in the morning. Eventually, their sleep–wake schedule can progress all the way around the clock.

Free-running disorder is most common in the blind, and the primary issues are insomnia and daytime fatigue that impact, to varying degrees, their social and professional lives. About 50% of totally blind people suffer from free-running disorder. Others are able to structure their sleep patterns around cues other than light, such as a routine for their daytime activities.

Of the sighted population, most at risk are adolescent males with onset in the teens through the twenties. It is not as likely to occur after age 30. Free-running disorder is more likely to be secondary to a mental health disorder or evolve from delayed sleep phase disorder.

Such circumstances are so rare that research is qualitative, as in case studies of the patients' situations. For example, I recently read an interesting journal article describing the case study of a 67-year-old man with sight. He carefully recorded every night for 22 years when he went to bed at progressively delayed times, and he did cycle around the 24-hour period about every 30 days. His agoraphobia, a form of anxiety disorder in which the person fears being in public and/or leaving his home, may have aggravated the free-running disorder. Depression accompanied his anxiety.

Treatments for sighted people with this disorder are similar to those for DSPS, including light therapy and melatonin. Melatonin in rather high doses has been effective with blind patients. There is no known cure for this condition, only management, and as of yet, there is no FDA-approved pharmacological treatment.

This circadian rhythm disorder is characterized by an undefined sleep–wake cycle that results in chronic insomnia and excessive sleepiness, or a combination of the two. These sleep patterns have no rhyme or reason and usually consist of sleep for several hours at various times, regardless of whether it is day or night, around the clock; but when you add up these hours, they usually come out to a normal seven to nine hours total per 24-hour cycle. Most of the people with this disorder are elderly and not that physically active, as well as those with neurobiological disorders such as Alzheimer's and people in nursing homes. It is also found in children with intellectual disability.

The goal of treatment is to lengthen the sleep period to a normal length. One of the methods is to teach patients about sleep hygiene, such as keeping the sleep environment cool, dark, and quiet. There are also several supplements and other medications that can be taken to either stay awake or induce sleepiness. Light exposure during the daytime hours is very important; it is also helpful to adhere to a schedule of activities each day. This circadian rhythm disorder is very rare and not well understood, so a combination of treatments unique to the person is required.