The relationship between Stress and Insomnia – 1

We are all subject to stress, yet we know little about it, or more importantly, how it affects us every day (and night.) Stress is normal. There’s “good” stress, like a challenge if you will, normal  exercise or even excitement, which is called Eustress. Then there’s the “not good” stress, again this can be physical (e.g., broken arm, chronic illness, disorder or disease) or emotional ( e.g., worry, fear) , or organic mental disorder (e.g., depression, addiction, obsessions, compulsions or bi-polar). Continue reading “The relationship between Stress and Insomnia – 1”

Insomnia, Obstructive Sleep Apnea (OSA) and Post Traumatic Stress Disorder (PTSD)

We’ve discussed the role obstructive sleep apnea plays. The we went on to discuss stress. There’s a common ground between OSA and insomnia. One of the issues with OSA is that in order to stay alive flowing airway compromise is the necessity for a shock to the system, a last minute ‘wake up call.’

The issue here is that as much as its necessary to shock the sufferer into wakefulness (although its rarely remembered) in so doing it activates the sympathetic nervous system and that’s the part (opposite the parasympathetic) that readiness the body for trouble. This sympathetic activation or excitation is part of the problem in insomnia, where you’re mind just won’t shut off.

I have no scientific evidence but over time I’ve come to believe that although all the studies and scientific papers are about the sufferer of either snoring or OSA, the bedpartner often suffers from sleep deprivation for other reasons too.

For the bedpartner, yes, it’s terribly annoying

For the bedpartner, yes, it’s terribly annoying, it would be enough to ‘wake the dead’ let alone allow for a peaceful sleep. So why do so many bed-partners sleep lightly when they really need to sleep deeply!? Why, when many bed-partners are so tired, don’t they appear to sleep as deeply as the snorer/ OSA sufferer?

Big Chalk Question Mark on Blackboard
I think that for many, it can be viewed almost as a mild form of Post-Traumatic Stress Disorder (PTSD)

I think that for many, it can be viewed almost as a mild form of Post-Traumatic Stress Disorder (PTSD). I think that even if they don’t know the science behind the disease, they know that breath holding can’t be a good thing, and many have told me that they wait, often counting the seconds. If this is not a way to activate fear, worry and heightened anxiety I don’t know what is!

So, look at the big picture when it comes to sleep disorders and while we’re on the subject – a quick note about RLS or restless legs syndrome.

Insomnia IV

Severe emotional distress, such as bereavement, job loss or serious illness in those near and dear may require appropriate counselling prior to any specific sleep promoting therapy. Equally PTSD, may be managed appropriately prior to CBT-I.

Severe emotional distress, such as bereavement, job loss or serious illness in those near and dear may require appropriate counselling prior to any specific sleep promoting therapy. Equally PTSD, may be managed appropriately prior to CBT-I.

In some respects, it is unfortunate that emotional aspects such as these should be addressed first because good quality sleep generally helps these issues too, but common sense dictates that safety should come first.

Heavy or regular consumption of alcohol may also raise issues. Many people consider having a drink (night-cap) a good start to sleep. Alcohol is a soporific (sleep promoting), it has muscle relaxing properties. This is the main reason that snoring worsens after a drink or two. It is also a CNS (Central Nervous System) depressant, hence not drinking and driving. Unfortunately, alcohol, despite its appearance, does not promote good quality sleep. It disrupts sleep staging and normal sleep cycles, consequently it’s far from the ideal sleep medication!

Unfortunately, alcohol, despite its appearance, does not promote good quality sleep

Furthermore, excessive alcohol use (abuse) brings its own set of problems, as does the use of recreational or street drugs. Not only do they add chemical issues but they reduce compliance with plans that you put in place for yourself. Assistance is available and access is prudent for health maintenance. Smoking equally so, although smoking in itself has not been shown to adversely affect sleep improvement through CBT-I, smoking is clearly not in anyone’s best interest (except for the cigarette manufacturers and the government).

So, what about smoking – it can relax me, right?

Nicotine disrupts sleep and despite the general belief (like alcohol) use before bedtime disrupts sleep. Smoking can also increase the risk of developing sleep conditions like sleep apnea alone. However, since nicotine is a stimulant, smoking can mask tiredness. This is why for smokers; a cigarette can get you “up and going” for the day. Therefore, smoking disguises, the harm, it does.

Yes, coffee is a stimulant and excessive use may be used to counteract the problem of poor quality or deficient amounts of sleep. With a little insight we start to see just how bad the problem of poor sleep actually is! So, you want to be part of the solution, not part of the problem – good for you!

So, what about smoking – it can relax me, right?

Both smoking and vaping expose your body to the addictive stimulant nicotine. Research shows that nicotine disrupts sleep several ways:

It suppresses REM (rapid eye movement) sleep, that is restorative sleep. Research indicates that most smokers feel less rested than non-smokers because they spend more time in the earlier stages of sleep (Stages 1-3).

Nicotine also causes withdrawal symptoms during the night that can disturb the Circadian Rhythm too. Smokers are also more prone to OSA in the night and experience more apneic events than non-smokers. Nicotine may impair the signaling system between the brain and breathing.

Inhaling nicotine-infused smoke or vapor can lead to inflammation in the nose and throat and can narrow the bronchial tubes of the lungs, all of which can aggravate nighttime breathing. Smoking and vaping may trigger obstructive sleep apnea or make existing OSA worse.

Daily inflammation of your lungs can lead to long-term breathing problems like asthma and COPD, or acute or chronic respiratory illnesses like bronchitis or a nagging cough. These coughing fits, combined with not getting enough oxygen when you breath, can disrupt your sleep further and contribute to many other health problems.

So, as you guessed smoking’s not great. Don’t try and give up smoking at the same time as CBT-I. It’s a lot to deal with all at once!

There are other issues that can disrupt sleep and your attempts to overcome them, on the way to a better sleep. You have to remember that sleep is natural. I would imagine that given a perfectly smooth path in life, most of us would not have any difficulty in sleeping. Let’s face it, life (for most of us) isn’t that way. I’d go so far as to say that given the frequency it occurs, there must be something going on!

As Insomnia is defined as a complaint of difficulty falling or staying asleep, associated with significant distress or impairment in daytime function and occurring despite an adequate opportunity for sleep – it has an approximate general population point prevalence of 10%. This relates to significant ongoing insomnia and the number is likely greater if other factors are considered.

book and glasses - indicates an academic link
CLICK HERE for – Insomnia: Definition, Prevalence, Aetiology, and Consequences

Life isn’t easy generally and can occasionally be really quite difficult. For instance, if you feel that you’re under a lot of pressure right now (and with COVID-19 many are) your first step may be to seek support from some counselling sessions. Before you wonder why you would do this, remember; qualified counsellors are made to retain counsellors for themselves!

In the case of work or domestic disputes, tension or troubles, your body is potentially giving more than it can. It’s like having a bank account, but always withdrawing!

Let’s have a quick look at stress, what it is and how it can affect us.

Insomnia III

There are other sleep disorders like Restless Legs Syndrome (RLS) which cause fragmentation of  sleep. That just means that it ‘messes up’ your normal sleep cycles which you need to be your daytime best . The other reason I mention this, is that OSA can actually cause Insomnia.

Insomnia

Evidence (and common-sense) shows that choking and the inability to breathe at night often unconsciously (or otherwise), predisposes the sufferer to not want to go to sleep when this potentially fatal disease takes place. After all, if you were strangled every time you went to sleep, you might not be in a hurry to go to sleep either!

Anxiety and depression are frequently seen in association with OSA. Of course, if you’re suffering from insomnia and the resultant signs of sleep deprivation, it’s not likely that you’ll be on top of your game during the day either. Being ‘cranky’ with mood swings is a sign of poor sleep. The good news is that BSM and CBT-I is usually useful even if you have mild to moderate signs of anxiety or depression which makes sense when you think about it. Perhaps not surprisingly, those people may see greater overall benefits too!

But we have to be realistic, there will always be some for whom this won’t work – who are they?

So, those with Insomnia may also have SDB. Obviously if this is a component, failure to treat the SDB will likely compromise your Sleep Quality and likely resolution of Insomnia too.

Of course, it also leaves the SDB sufferer (or their bedpartner) vulnerable to the consequences of that disorder.

OSA is heavily associated with High Blood Pressure (Hypertension), Heart Attack,

Stroke and Diabetes. As mentioned earlier Anxiety, Depression and Mood-Disorders are often associated.

Decision making and cognitive function are (not surprisingly) affected and the chance of a car crash is increased in those that have just moderate Obstructive Sleep Apnea, by op to 7 times the rate of healthy sleepers.

While there are different management tools for SDB, you will need to find someone who is not selling you their particular management tool, be it CPAP (mask, hose and pump), Oral or dental device (OAT), laser, surgery or one of a million unproven devices out there that border on snake oil sold by charlatans without any regulation, or on their part, often ethics either. However, having said that, management is crucial and for some it will be like having a new life, just be sure to ask questions. Unfortunately, even physicians can be heavily biased.

I also mentioned it was generally OK to use CBT-I to treat insomnia in those with mild to moderate anxiety and/or depression . If someone has serious (major) depression so that they are unable to work, find no pleasure in life and may even have suicidal thoughts, jumping over such issues to address insomnia management  first may be dangerous. Cases of severe anxiety, depression or other mood problems should be reviewed by your physician. Bi-polar disorder is another example that affects sleep.  Studies show poor medical recognition of Bi-polar Disorder, just as there is poor medical awareness of SDB.

Your family physician should always be your first port of call for these disorders in order that you can get care by referral, which may include counselling, psychotherapy, CBT or even medicines (usually not sleeping tablets). It is important not to overlook the presence of these issues, especially in someone suffering from insomnia.

What are some of the other issues that we should be aware of?

Insomnia II

I mentioned that Sleep Disordered Breathing (SDB) , which Includes Obstructive Sleep Apnea (OSA) is a common sleep complaint too. Insomnia and OSA have a strong association and it is wise to arrange a “sleep test” if you’re undergoing care for insomnia to rule out SDM. Anything that fragments sleep will make you feel dragged out and often lacking energy, sometimes with Excessive Daytime Sleepiness (EDS) too.

Insomnia

SDB is a disorder where there is limitation of airflow at night while you’re asleep and unable to protect your airway yourself. Snoring is a type of SDB and can cause the sufferer fragmented sleep. Often times it is their bedpartner who suffers insomnia! However, many studies have shown that heavy snoring can be the cause of cardio-vascular disease, especially heart attack and stroke. Alas, as medical awareness is poor, many snorers are not treated and their disorder goes on to cause a catastrophic even which is then blamed on to something else.

SDB comprises snoring, OSA and a disorder called Upper Airway Resistance Syndrome (UARS). OSA is a disorder where there can be complete blockage of the airway (called an apnea) as well as a partial blockage which as it allows some passage of air, cases snoring. Snoring and OSA often appear together but can exist separately, hence the value of a sleep test. A sleep test can often be performed at home (home test) although admittedly they tend not to promote sleep themselves – still diagnostically, they can be worth their weight in gold!

UARS is an interesting disorder because it occurs (not infrequently) in people you wouldn’t expect to have OSA. Therein lies the problem. One tends to assume that someone suffering from OSA will be male, middle aged and overweight. Because of this most of the screening tools used are for that stereotype, so UARS may get missed on the radar!

Only a decade or so ago, Upper Airway Resistance Syndrome was not on the radar and only a few years ago, I’ve heard physicians arguing against its existence! Still, I’ve also heard a physician claim that she “didn’t believe in OSA” although exactly what she meant by that I’m still not sure. There is still much misunderstanding out there and so it pays for you to find out what issues may be affecting you, if you want a better sleep.

UARS can be seen in the young, the slim, the fit and the healthy. Young women may also be affected yet everyone assumes that they can’t have OSA because they’re not middle-aged men, yet they do have it. Their breathing problem is more due to airway collapsibility than the blockage (usually the tongue and pharyngeal tissues) found in OSA.

UARS is also not so easily diagnosed as standard garden variety OSA which can also pose a problem. Sometimes a little common-sense may be required.

So, are there other problems we should know about before we look at insomnia?