Balance Wellness Workshop: Amanda Swain, MD & Jacqueline Kloss, Ph.D.
Behavioral Sleep medicine Associates, LLC
Balance hosted another stellar Wellness Workshop last week on the topic of sleep. Dr. Amanda Swain and Dr. Jacqueline Kloss presented compelling data about the processes of sleep, the different stages of sleep throughout our lifespan, and the importance of sleep to our overall well-being. They also provided clear steps to improve sleep patterns based upon the behavioral cognitive strategies they have developed in treating people with a range of sleep disorders.
Dr. Swain and Dr. Kloss defined sleep as a dynamic biobehavioral state, involving specific brain activity and complex processes. It is a dynamic state paradoxically categorized by relative immobility (i.e. we aren’t moving much), perceptual disengagement (i.e. we have our eyes closed and don’t hear normal noises), and subdued consciousness (i.e. we are in la la land). While in this state, the complex processes our brains and bodies experience have proven essential to our optimal health and well-being. Healthy sleep is associated with improved immune function, better mood, cognitive function and physical performance as well as reduced risk for diseases, including diabetes and cardiovascular disease.
There are 4 important stages of sleep. NREM stage 1 is the transition stage between wakefulness and sleep and only lasts 5-10 minutes (I think mine might last 30 seconds). In NREM Stage 2, our body temperature falls, our heart rate slows and our brain shows activity indicative of sleep. This stage lasts about 20 minutes. NREM Stage 3 is when our deepest sleep occurs. This is often referred to as Delta sleep. It is during the NREM stages of sleep that the restorative aspects of sleep occur – the body restores tissues, builds muscle and even strengthens the immune system. (Cleveland Clinic ref) People under 30 year of age get about 2 hours of NREM sleep while people over 65 only get 30 minutes of NREM on average.
We cycle through NREM stages 2 and 3 until we enter the REM stage of sleep. REM sleep is more similar to the light sleep in NREM stages 1 and 2 but with heightened brain activity which leads to vivid dreams. Interestingly, the heightened brain activity is also combined with increased immobility so this stage of sleep is often called paradoxical sleep.2We spend about 25% of our sleep in REM. REM sleep is also particularly important for restoring energy and impacting functioning during the day.
Our sleep patterns involve an intricate dance between two competing biological rhythms – the homeostatic sleep/wake drive and our circadian biological clock.1Our sleep/wake drive basically alerts us as our need for sleep is building through the day. Drs. Swain and Kloss described this as a homeostatic pressure building throughout the day. This increased pressure, need for sleep, provides the signal to go to sleep and allows us to stay asleep for long enough to restore our homeostatic wake/drive. In theory, we SHOULD then wake up feeling restored and we SHOULD be most alert when we wake up. Of course, often we don’t and we are not. The reason is because of our Circadian biological clocks which don’t adhere to such a simple linear path as our sleep/wake drive. Our circadian clocks fluctuate throughout the course of the day. If we listened to our circadian clocks, adults would experience the strongest sleep drive between 2-4am (that makes sense) AND between 1-3pm (less optimal).
Our circadian biological clock is controlled by cells in a part of our brain (hypothalamus) that respond to light and dark. When light signals those cells that it is time to be awake, those cells send signals to raise our body temperature, make us start producing cortisol, and delay the release of melatonin. Melatonin is a hormone associated with sleep onset and is signaled by darkness, which causes elevated levels of melatonin throughout the course of the night which helps us to remain asleep long enough to restore our sleep/wake.1It is changes in our circadian rhythms that lead to different sleep patterns, and potential problems, at different stages of life.
Teenagers and Sleep
Drs. Swain and Kloss assured us that indeed our teenagers are not lazy. Teenagers experience a delayed circadian rhythm – meaning that melatonin in their blood does not reach peak secretion until later in the night. Consequently, they enter their REM state of sleep at the time they need to be getting to school. This means they physiologically can’t fall asleep early and have a hard time waking up early. With early school schedules, teenagers’ internal sleep patterns are not in sync with external schedules. Studies have found that only 5% of teenagers are getting the sleep they should.4Drs. Swain and Kloss have been active advocates for a later school start to help diminish the negative impact of this sleep cycle misalignment.
Although changes in teens clocks are biological, there are steps to take to help teenagers be more receptive to sleep earlier:
Turn screens off up to an hour before bed time. We know the blue light from screens can be stimulating. It also prevents photoreceptors in your eye from signaling your brain to release melatonin which prepares your body for the onset of sleep. (npr.org, December 2017).
Use strategic scheduling and try to avoid overscheduling
Help with stress management and time management · Use bright light in the mornings (melatonin at night, only if indicated)
Avoid drowsy driving o The risk of drowsy driving is particularly dangerous for new, inexperienced drivers. Studies have shown that getting 6 hours or less of sleep results in “drowsy driving” which can be equivalent to driving while drunk.
The following recommendations were outlined in a study published in the Journal of American Medical Association (JAMA): Teenagers should get 8-10 hours of sleep, one hour of moderate intensity physical activity and limit screen time to less than 2 hours within a 24 hour time period.3
In terms of letting teenagers sleep late on the weekends, Drs. Swain and Kloss advised that it was fine as long as it wasn’t creating problems with falling asleep Sunday evening. They did point out, however, that we don’t “make up” sleep that easily.
Aging and Sleep
In contrast to teenagers, as we age our circadian clocks work on an advanced (earlier) cycle. Natural variations in melatonin mean older folks want to go to bed earlier and wake up earlier. Similar to teenagers, however, is that this clock is often out of sync with external restrictions and schedules. In addition, older individuals are also often taking medications for other health reasons which can make it harder for them to get the sleep they need. They might take more naps during the day and they might be less physically active. The myth that you need less sleep as you age is not correct but the reality is you often obtain less sleep than you need.
Things to do:
Adapt to changes and sleep within your cycle
Keep a regular sleep schedule
Increase physical activity
Use sleep aids judicially
Another critical life stage that is often accompanied by sleep disorders is menopause. Drs. Swain and Kroll discussed the different processes occurring in a woman’s body during this life stage. They explained that menopause does not cause insomnia directly. However, it is a time of life where a lot is going on, physically and emotionally, all of which can influence the sleep cycle and exacerbate sleep problems. 40-60% of women experience sleep problems. How women respond to the night waking and insomnia is what makes a big difference in the impact of those sleep problems. Cognitive behavioral therapy can provide concrete steps for managing insomnia.
What to do:
Identify the factors that trigger insomnia and help maintain it and try to minimize those factors
Behavior strategies including stimulus control, sleep restriction and increased physical activity can all be beneficial
Cognitive strategies including scheduled worry time and creating a pre bed sleep routine, or sleep buffer, can help
Sleep and weight loss
Sleep is linked with both hormonal and metabolic processes. Sleep deprivation is linked with increased obesity and diseases such as type 2 diabetes. When you are sleep deprived, your body has a harder time regulating glucose, maintaining hormonal balance, and distinguishing between flight and fight responses. Staying in extending periods of flight response uses more energy and may be related to increased appetite. Finally, being sleep deprived can lead to subclinical inflammation - low levels of chronic inflammation. Drs. Swain and Kloss explained that while we don’t know the exact long-term impacts of inflammation, we know it is not good. One of the patterns they described is an “eveningness” pattern in which we are less active, in front of screens, and snacking. Obviously, trying to change or limit this pattern is more conducive to healthier sleep patterns.
“It’s a bad thing to be awake when reason sleeps.” Dr. Perlis
Although we have talked about changes in sleep through life, we haven’t really talked about insomnia directly. There are different kinds of sleep problems – falling asleep, staying asleep, and night waking. With all these, however, a common component is the presence of unhelpful thoughts. Problematic patterns include:
Staying in bed worrying.
Prioritizing sleep over everything else
Spending too much time in bed not sleeping
Trying to make up for lost sleep by napping
What to do:
Drs. Swain and Kloss recommend “taking the worry out of bed”
Bed should be solely for sleep and getting into bed should be a cue to your body to prepare for sleep
Don’t spend excessive time in bed doing other things – on computer, reading, etc.
Engage in Cognitive Behavioral strategies to help minimize unhelpful thoughts in bed – define worry time, try to separate out nighttime worrying from problem solving, and try not to get too protective of bedtimes (although keeping a regular schedule is healthy).
Drs. Swain and Kloss ended by encouraging us all to create and protect our sleep zones. Use whatever helps you sleep, helps you stay asleep and improves the quality of your sleep, including:
Cool, dark and quite atmosphere
Working with your circadian rhythms –natural sleep is the goal
Using sleep aids judicially. While there are benefits to taking some types of medicine for sleep, in general, there is no substitute for natural sleep and sleep aids often come with side effects and rebound effects that may not help long term.
Each person’s sleep cycle is different and the internal and external factors impacting quality of sleep are just as unique. The evidence linking sleep with overall health and well-being is clear and increasing. Just as we know that regular physical activity and hydration are essential to cognitive and physical functioning, sleep plays an equally significant role. When unhealthy sleep patterns exist, cognitive behavioral strategies help identify and modify triggers of sleep disorders.
Perhaps reading this article has helped prepare you to drift off to sleep, if so, my work is done. Sleep well.
National Sleep Foundation (www.sleepfoundation.org)
American Academy of Sleep Medicine (aasm.org)https://www.jetlagrooster.com/
3. https://jamanetwork.com/journals/jamapediatrics/article-abstract/27235184. Knell G, Durand CP, Kohl HW, Wu IHC, Pettee Gabriel K. Prevalence and Likelihood of Meeting Sleep, Physical Activity, and Screen-Time Guidelines Among US Youth. JAMA Pediatr. 2019;173(4):387–389. doi:10.1001/jamapediatrics.2018.4847