Don’t Sleep on This, part trois
We’ve all heard the saying about waking up “on the wrong side of the bed,” but as it turns out, there’s quite a bit of truth behind this colloquialism. Americans in general are notoriously sleep deprived; lots of folks experience problems sleeping, not getting enough sleep, not feeling rested, and not sleeping well. This can lead to difficulties functioning during the daytime, and have very unpleasant effects on your work, relationships, and social and family life. Most people know firsthand that sleep affects their mental state, but do you know how closely connected sleep is to mental and emotional health? Sleep deprivation has major effects on your psychological state. The two- sleep and mental health- contribute greatly to one another, generally coexisting in a bidirectional relationship. People with mental health diagnoses are more likely to have insomnia and/ or other sleep disorders, and vice versa. Ultimately, mental health disorders tend to make it harder to sleep well, while at the same time, poor sleep and insomnia can be a contributing factor to the initiation and worsening of mental health issues.
Insomnia and other sleep issues have clearly demonstrated links to depression, anxiety, bipolar disorder, and other conditions like ADHD. In fact, chronic sleep problems affect 50% to 80% of psych patients, as compared to 10% to 18% of typical American adults. Both sleep and mental health are complex issues affected by a multitude of factors, but given their close association, there’s good reason to believe that improving sleep can have a hugely beneficial impact on mental health. In my opinion, helping to ensure a patient gets good sleep is an important component of treating most psych disorders.
Why is sleep so important? If you recall from last week, brain activity fluctuates during sleep, increasing and decreasing during different stages of the sleep cycle. In NREM- non-rapid eye movement- sleep, overall brain activity slows, but there are quick bursts of activity. In REM sleep, brain activity picks up very rapidly, which is why this stage is associated with more intense dreaming. Each stage plays a role in brain health, allowing activity in different parts of the brain to ramp up or down, and this enables better thinking, learning, and memory. Research has clearly demonstrated that all this brain activity while you’re sleeping has profound effects on emotional and mental health.
Sufficient sleep, especially REM sleep, facilitates the brain’s processing of emotional information. During sleep, the brain works to evaluate and remember thoughts and memories, and a lack of sleep is especially harmful to the consolidation of positive emotional content. This can influence mood and lead to emotional reactivity, and has been tied to various mental health issues and the severity thereof. It can even lead to suicidal ideation and behaviors. The old timers thought that sleep problems were strictly a symptom of mental health disorders, but after elucidating what goes on in the brain during sleep, science has made it clear that problems sleeping are not just a consequence of mental health issues, they can also be a cause of the same.
One of the major sleep disorders that people face is insomnia, which is basically an inability to get the amount of sleep needed to function efficiently during the daytime. It may be caused by difficulty falling asleep, difficulty staying asleep, or waking up too early in the morning. About 1 in 3 Americans report difficulty sleeping at least one night per week. Short-term insomnia is very common, and has a multitude of causes: stress, lifestyle, work schedule, travel, or other life events. It can generally be relieved by simple sleep hygiene interventions, things like exercise, a hot bath, warm milk, or changing your bedroom environment. On the other hand, long-term insomnia lasts for more than three weeks, and this should really be investigated by a physician, potentially with referral to a sleep disorder specialist.
Why? Because chronic insomnia is rarely an isolated issue, it’s usually a symptom of another illness, be it medical or psych, that requires investigation. Sometimes insomnia can be caused by obstructive sleep apnea, or OSA, which has also clearly been linked to mental health issues. OSA is a disorder that affects your breathing while sleeping. With OSA, your throat muscles intermittently relax and block your airway, causing you to repeatedly stop and start breathing while you sleep. This leads to a drop in the body’s oxygen levels, creating fragmented and disturbed sleep. In fact, OSA can cause as many as 30 sleep disruptions per hour. Yikes. There are serious repercussions for that. The human body likes oxygen, and it can get a little pissy when it doesn’t get enough of it. People with OSA experience these abrupt awakenings, accompanied by gasping or choking, along with morning headache, daytime drowsiness, difficulty concentrating during the day, forgetfulness, mood changes, high blood pressure, and decreased libido. It’s not good. Unfortunately, OSA occurs more frequently in people with psych disorders, and it’s a serious issue, as it detracts from physical health while simultaneously heightening mental distress. A 2017 study found that people with sleep apnea, when compared to those without, were 3.68 times more likely to have anxiety, 2.88 times more likely to experience severe psychological distress, and 3.11 times more likely to have depression. In addition, it found that their odds of suicidal ideation were 2.75 times higher. Sadly, the same study also found these patients with OSA reported a greater lack of mental health care and support.
Multiple studies recognize the correlation between OSA and poor mood, post traumatic stress disorder, and higher prevalence of psychosis and schizophrenia. The presence of OSA in the schizophrenic population has been found to be as high as 48 percent! Smoking and alcohol consumption further complicate this link between schizophrenia and OSA, as both are very common habits in people with schizophrenia, and both confer an increased risk of sleep apnea. And OSA isn’t just linked to schizophrenia. Existing studies note the prevalence of OSA in bipolar patients to be similar to that of schizophrenia.
There’s also a causal relationship between OSA and depression. Decreased oxygen levels overnight, called nocturnal hypoxia, cause chronic stress, which then increases the production of corticosteroids in response. Higher levels of corticosteroids, in turn, cause mood changes and impaired cognitive function, as well as increased inflammation in the body, all of which contribute to the development of depression. Conversely, patients with depression exhibit lower levels of serotonin, a neurotransmitter that’s also linked to muscle tone of the upper airways. Decreased serotonin levels in the body increase the likelihood that the upper throat will collapse, causing even more episodes of apnea. It can create the perfect sleep storm.
Because OSA and depression share several symptoms, it can be difficult to discern the impact of one disease over the other. Both result in disturbed sleep, fatigue and lethargy, restlessness, and loss of concentration. Given those facts, it should come as no surprise that both OSA and depression are associated with increased vehicle and workplace accidents due to increased fatigue and poor concentration.
Insomnia: Cause and Effect
How well you sleep tells a physician like me a lot. About half of insomnia cases are related to depression, anxiety, or general psychological stress. Very often, the qualities of a person’s insomnia, along with their other symptoms, can be helpful in determining the role of mental illness in their inability to sleep. This is why I always ask patients to tell me about how they’re not sleeping… just knowing you can’t isn’t enough. For instance, early morning wakefulness can be a sign of depression, especially if it comes along with low energy, an inability to concentrate, sadness, and a change in appetite or weight. On the other hand, a sudden dramatic decrease in sleep which is accompanied by an increase in energy- or the lack of need for sleep- can be a sign of mania. Many anxiety disorders are associated with difficulties sleeping, and obsessive compulsive disorder is frequently associated with poor sleep as well. Panic attacks during sleep may suggest a panic disorder, while poor sleep resulting from nightmares may be associated with post traumatic stress disorder.
Sleep and Specific Mental Health Diagnoses
The way that sleep and mental health are intertwined becomes even more apparent when you look at how sleep is tied to a number of specific mental health conditions.
It is estimated that over 300 million people worldwide have depression, a mood disorder marked by feelings of sadness or hopelessness. Around 75 percent of depressed people show symptoms of insomnia, and many people with depression also suffer from excessive daytime sleepiness and hypersomnia, which is sleeping too much. Historically, sleeping problems were seen as a consequence of depression, but in reality, poor sleep may also induce or exacerbate depression, and sleep problems and depressive symptoms are mutually reinforcing. It’s essentially a negative feedback loop, where poor sleep worsens depression that then further interrupts sleep. But on the bright side of that, a focus on improving sleep may also have a corollary benefit of reducing the symptoms of depression.
Seasonal Affective Disorder
You may remember from a few months ago that SAD is a subtype of depression that most often affects people during times of the year with reduced daylight hours, typically fall and winter. It’s closely tied to the disruption of a person’s internal biological clock, or circadian rhythm, that helps control multiple bodily processes, including sleep. It shouldn’t surprise you then that people with SAD experience changes to their sleep cycles, and tend to sleep either too much or too little.
Every year, anxiety disorders affect an estimated 20 percent of American adults and 25 percent of teenagers, creating excess fear or worry that can affect everyday life and create risks for other health issues, including heart disease and diabetes. Anxiety disorders- including social anxiety disorder, panic disorder, specific phobias, OCD, and PTSD- have a strong association with sleeping problems. In these disorders, worry and fear contribute to a state of hyperarousal, when the mind is constantly racing, which is a central contributor to insomnia. Sleep problems may then become an added source of worry, creating anticipatory anxiety at bedtime, which makes it that much harder to fall asleep. It can become a vicious cycle. Research has found an especially strong connection between PTSD and sleep. People with PTSD frequently replay negative events in their mind, suffer from nightmares, and experience a constant state of being on alert, all of which can interfere with sleep. PTSD affects many veterans; at least 90 percent of U.S. veterans with combat-related PTSD have symptoms of insomnia. But sleep problems aren’t just a result of anxiety. Research indicates that poor sleep can actually activate anxiety in people who are at high risk for it, and chronic insomnia appears to be a predisposing trait among people who later go on to develop anxiety disorders.
Bipolar disorder involves episodes of extreme moods that can be both high, with mania, and low, with depression. A person’s feelings and symptoms are quite different depending on the type of episode, but both manic and depressive periods can cause major impairment in everyday life. In people with bipolar disorder, sleep patterns change considerably depending on their emotional state. During manic periods, they usually feel less need to sleep, but during depressed periods, they often sleep excessively. Very often, sleep disruptions continue when a person is between episodes. Research has found that many people with bipolar disorder experience changes in their sleep patterns just before the onset of an episode. There is clear evidence that sleeping problems induce or worsen manic and depressive periods, but that because of the bidirectional relationship between bipolar disorder and sleep, treatment for insomnia can reduce the impact of a person’s bipolar disorder.
Schizophrenia is a mental health disorder characterized by a difficulty in differentiating between what is and is not real. People with schizophrenia are more likely to experience insomnia and circadian rhythm disorders, and these issues can actually be exacerbated by medications that are used to treat schizophrenia. But once again, poor sleep and symptoms of schizophrenia may be mutually reinforcing, so there are potential benefits to stabilizing and normalizing sleep patterns.
ADHD is a neurodevelopmental disorder that involves reduced attention span and increased impulsiveness. While usually diagnosed in children, it may last into adulthood, and is sometimes only formally diagnosed when someone is already an adult. Sleeping problems are common in people with ADHD. They may have difficulty falling asleep, frequent awakenings, and excessive daytime sleepiness. Rates of other sleep disturbances, such as obstructive sleep apnea and restless leg syndrome (RLS) also appear to be higher in people with ADHD. Once again, there is clear evidence of a bidirectional relationship between sleep and ADHD; in addition to being a consequence of ADHD, sleep problems may aggravate symptoms, especially in reduced attention span or behavior problems.
Substance use disorders can also cause problems with sleep. While alcohol is sedating in limited quantities, alcohol intoxication disturbs your sleep patterns and can make you wake up numerous times in the night. Some sedative medications may cause sleepiness during intoxication, but it’s far too easy to develop a dependency on them, and ultimately they’ll disturb sleep and cause serious problems sleeping in people who are misusing or withdrawing from them. Illicit drugs like LSD and ecstasy are also associated with interruptions in sleep.
Keep in mind that many mental health conditions don’t arise in isolation, and that coexisting conditions can influence one another, as well as a person’s sleep. For example, it’s not uncommon for people to experience both depression and anxiety, and people with both conditions have been found to have worse sleep than people with “just” depression or anxiety.
As you can see, poor sleep has clearly been shown to significantly worsen the symptoms of many mental health issues. This is down to the bottom line, that lack of sleep will change your brain, at the very least making it harder to get through the day. At the same time, severe sleep problems can decrease the effectiveness of certain psych treatments. Treatment of sleep disorders has been studied in relationship to schizophrenia, ADHD and other psych issues, and all of the scientific data shows the connection between them. Good sleep is necessary for recovery- or prevention- in both conditions. It’s a multifaceted, bidirectional relationship. Sleep has a very important restorative function in ‘recharging’ the brain at the end of each day, just like we need to charge a mobile phone. You know what happens if you don’t plug that in, right? It dies. Enough said. Poor quality of sleep may seem like a minor symptom, but if it’s chronic, it can be a sign of something much bigger. Good sleep can enhance quality of life and positively contribute to managing any concurrent mental illness. In fact, the relationship between mental health and sleep is so strong that steps to improve sleep may even form part of a preventive mental health strategy.
Next week, we’ll talk about what you can do to help ensure good, restorative sleep. I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!
Anorexia nervosa (AN), also known as simply Anorexia, is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. It is often coupled with a distorted self image which may be maintained by various cognitive biases that alter how the affected individual evaluates and thinks about her or his body, food and eating. Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600–800 calories per day, but extreme cases of complete self-starvation are known. It is a serious mental illness with a high incidence ofcomorbidity and the highest mortality rate of any psychiatric disorder.
Anorexia most often has its onset in adolescence and is most prevalent among adolescent girls. However, more recent studies show that the onset age of anorexia decreased from an average of 13 to 17 years of age to 9 to 12. While it can affect men and women of any age,race, and socioeconomic and cultural background, Anorexia nervosa occurs in females 10 times more than in males.Learn More