What are the consequences of not getting enough sleep? What is “normal” sleep and what constitutes disordered sleep? Is there a link between sleep adverse health outcomes such as cancer, cardiovascular disease or Alzheimer’s Disease?
In the first episode of this two part series, Andrew and Dr Mark Donohoe explore these questions and more. Mark helps us separate the fact from the fiction, expertly guiding us through the intricacies of sleep and sleep disorders, discussing what sleep is, why we need it, what happens to us if we don’t get enough of it, how anxiety affects sleep, and how we can optimise our sleep environment.
Covered in this episode
[00:59] Welcoming back Dr Mark Donohoe
[02:05] Introducing todays topic: sleep and sleep disorders
[04:14] What is sleep and why do we need it?
[08:30] The evolution of sleep
[12:47] Is there evidence on poor sleep and adverse outcomes?
[17:16] Sleep cycles
[20:56] Adrenal fatigue occurs in the brain
[23:52] Can bacteria in the gut affect sleep?
[26:26] Sunlight and melatonin connection
[28:26] Seasonal affective disorder and sleep
[32:05] The effects of blue light on sleep and anxiety
[39:54] Pain and disordered sleep
[44:24] Seeing colours in dreams
[46:58] The role of the practitioner in supporting a sleep disorder
[50:07] Optimising the sleep environment
[55:25] The dangers of prolonged sleep
[1:00:33] Closing remarks
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us in the studio again today is Dr Mark Donohoe who earned his medical degree from Sydney Uni in 1980. He worked in the hospital system for 3 years before opening his own general practice on the New South Wales Central Coast, and this is when patient groups such as farmers who could not afford to be sick presented with complex illnesses which had been left undiagnosed and untreated by his peers.
Mark attests that this is when his real medicine education began. So he then delved into environmental medicine, nutritional medicine and now lifestyle medicine with fellowships in each modality. Dr Donohoe is renowned for unravelling complex illness caused by toxic exposures, creating the first low exposure integrative hospital in Australia and remains a staunch vanguard for patient advocacy and health.
Welcome back to FX Medicine, Mark. How are you going?
Mark: I'm well. Lovely to be back.
Andrew: After a lovely night's sleep.
Mark: Yes. If only.
Mark: Last night's sleep was good. I have to own up that today we're talking about sleep, the whole gamut from what is it, what does it do, why do we lose it, how do we find it again, all the way on to next episode hopefully, what specifics we can manage in treatment and how we can help that recovery of the sleep cycle.
And first an admission: a lot of this is coming from the three months of the lived experience of a partner of a person who has an acquired sleep disorder. And it has been a fascinating time, a real eye opener. I am a male who, for 60 something years, I won't go into exactly how long, when my head hits the pillow, sleep happens. And there is not a thought about sleep.
Sleep is such a nonissue that I never realised I failed to ask the question in my own practice. The moment I have the lived experience of a partner of a person who can't find their sleep and I start asking questions, every patient has a sleep story. And I only just didn't notice it because I assumed everyone sleeps like me.
My sleep is now changed. My partner's sleep is now changed and that exploration, that three months of going into the “whys and wherefores” of it has been a fascinating journey.
Andrew: So before we get into this, there is so much to get into with sleep, and so much we don't know. So we have to cover this in two parts, at least.
So the first part is going to be just really based around what sleep is and some of the disorders. And then we're going to talk about interventions and treatment choices next podcast.
Mark: For the second break... I think that's best.
Andrew: All right.
Mark: Divide it up. What is it, why is it and what are we even talking about? And then, if the failures of just simple lifestyle and other interventions, if they don't work, what can we as practitioners bring to that story to help people recover their sleep? You know, orthodox, unorthodox, wild stuff that happens in the area of sleep, a kind of evidence free zone of human medicine.
Mark: No, it is a fascinating thing that a third of our lives roughly is taken up with an experience that we don't know why we do it. And we're in the field of evidence-based healthcare, evidence-based medicine, you would think something that occupies every single human all the way of their life for about a quarter to a third of their life, you would think that this is what we would know most about.
The best evidence that I've seen from a lot of neuroscientists was published about four or five years ago in "Scientific American." It was a great summary. The concept is that in a brain like ours, complicated, trillions of neurons and neuroglial cells and all of these, that there is sensory input which is vast, from all areas, from the five senses, from instinct. There are a whole lot of things go on in a day, and if you don't have a kind of “clearing out” episode at the end of every day or at the end of every second day, that there can be a kind of failure, which is not a computer failure. It's a failure of judgment of subtlety that goes wrong over a period of time that leads to more and more catastrophic outcomes.
And so do we have terrible data that says “if you miss sleep, you're going to get cancer?” No, we don't have that. We have information which says sleep is essential to a healthy life and when it goes AWOL, life's health breaks down in ways that are not dissimilar from something you and I have discussed which is the word "stress." Sleep deprivation or losing your sleep doesn't cause a thing. It means that whatever can go wrong will go wrong more reliably. And stress plays an enormous part in that concept of sleep and the sleep cycle.
So the upside of sleep may well be that all the experiences in the world...there's a flood of input during daylight hours - the eyes, the hearing, the senses around the body, the sense of fear and danger - that all of that needs to be aggregated, all the unnecessary stuff disposed of, and a summary put in at the end of a day.
And the summary goes down, whether it's to the hippocampus, whether this goes into a kind of a vaguely retrievable memory or just endocrine responses, respond to that. A whole lot of housekeeping work is done at the end of a day or at the end of a second day, or whatever. And that biology is really good. There are early birds and there are night owls and there is a kind of variation of the types of sleep that means as an individual, you get time to clear out the rubbish. But as a community, there are people that are awake almost all hours of the day. So a smallish number, a tribe of people of 50 or so. There's always going to be night owls that are alert into the early hours of the morning, and there are always going to be the early birds that are awake at sparrow fart.
So that variation says there's something about organisation of communities, of individuals, of the mind, the ability to retain important memories, to recall the things that are essential for our survival, but they're all tidied up at the end of the day. And that the 99% of sensory input that didn't have any impact on us needs to be washed out in some way. And that the neuronal reorganising and the regenerating, and the ability to generate new brainwaves in the morning that are supposedly there for us to wake refreshed and ready to go, is just a natural part of that lifecycle.
Now the moment I started asking in my practice, "How's your sleep?" And I ask the details of it, "How long before you..." You know, latency. “How long from head down to sleep? How many times do you wake? Do you wake refreshed?” Ninety-five percent of my patients say, "I never wake refreshed. That's something I don't even remember since I was a child."
The rest of it is sleep variations that we can categorise and say, "Could it be anxiety? Could it be depression? Could it be something else?" And so as a doctor, I'm paying much more attention to something that I just casually said, "Are you sleeping okay?" And people go, "Yeah." Okay.” It was never okay.
Andrew: There's so many questions regarding even sleep hygiene, the preparation for sleep. So having the room at the right temperature, not having too many bed clothes but being comfortable, the right pillow, the right mattress, on and on. There's so many. It's not just light. It's not just one simple thing. There's a whole hygiene. There's a whole process that we have to go through.
Mark: There is, but Andrew, we did come from a time where cave floors…it was “Is there a boulder under my butt?”
Andrew: This is where I'm going.
Mark: Right, and so that we are focused on sleep hygiene the same way as we're focused on, you know, supermarket pesticides and everything else. Sleep happened in caves, happened with fearful humans where they could die before the morning if they slept at the wrong time. And so sleep is generally considered very robust. And the worst circumstances...no one had an iPad or an iPhone back in those days.
So there are different things. There was sleep-wake cycles, there was monthly cycles whether the moon was out or not out. Moon had a very big impact on the depth of sleep. So we do understand that sleep has got...you know, through evolution, sleep was an essential part that happened under the worst of circumstances. And I do think sometimes now we get into this, "Oh, we need sleep hygiene." What I think we need to do is say, "What is it from our evolutionary past which has changed right now?"
So there are stimuli now that are not part of what our biology could ever have considered, blue light in the middle of the night from a screen where people are looking up how to go to sleep.
Andrew: There's so many factors affecting sleep which are caused by modern day civilisation, which weren't there from an evolutionary perspective. But I'm really interested in that evolution. And you're really good at going back to this.
Here's my question. We know that teenagers have a vast variance or difference of sleep requirements from adults and elderly. And the teenagers tend to be more night owlish, but then they require longer amounts of sleep. Whereas the adults require slightly less amounts of sleep but in the night phase. And then you've got the elderly which require much less. I'm thinking about survival in a cave when there's predators around. Do you think there might've been a function for that? I’m wondering…
Mark: Are you meaning oldies like us got left behind?
Andrew: No. It's like the teenagers might've been the guardsmen. I'm trying to tie that back into other animals and it doesn't...I haven't got anything that I can tie it into.
Mark: I think you can go mad with evolutionary biology. What we do believe is that there was a value to a smallish community having variations of this type of sleep. If everyone's asleep at the same time, you are literally a smorgasbord. That's what you would call a group of sleeping humans. So there is value and you're right. The adolescent...even the children from around puberty on, their sleep cycle is more the midnight to 1:00 a.m. to maybe 10:00 a.m.
There are a whole normal distribution of night owls to early birds. They're the 5%, 10% on either side. But I have friends, myself. Their going-to-bed time is 8:30 each night. They're up at 4:00 in the morning walking dogs. I have other friends for whom going to bed before 2:00 a.m. is just anathema. You know, why would you do that? You're wasting the best time of the day when it's quiet, when you can get work done. And they wake up at 10:00 or 11:00 in the morning and adjust their life cycles.
One important thing is, as you say, something about sleep shrinks as our decades go by. Our needs shrink. We can regret people like Margaret Thatcher who slept for apparently three hours and had a chance to ruin the world for many more hours of every day but they are oddities that just need the three to four hours sleep and it does the job that for most of us, we expect eight hours sleep.
Andrew: Margaret Thatcher is one example of this advanced phase sleep disorder. Is that what it's called?
Mark: She just had things to do that required that she use an extra five hours up that most of us put to sleep. And you can make all kinds of arguments about it, but sleep has a wide variability which is absolutely natural.
And when you get to our century and say, "Everyone needs eight hours sleep or you get cancer or you get diabetes, or you get..." So the research which is relatively weak about terrible outcomes from sleep, is association.
Andrew: And yet it's coming out all the time. All the time.
Mark: Not only is it coming out, it's like the genome project and the SNP project. Epidemiologists will give you any answer that you want. And so is poor sleep quality associated with adverse outcomes? Yes, it is. There's no doubt at all about it. Is it cause, effect or association or an epiphenomenon? There's a whole separate question there.
So people with cancer, there is a clear possibility that the body is aware of cancer and immunology is aware of cancer long before we are aware of cancer and that the sleep cycles are broken because of the body dealing with cancer. We have a look at sleep and say, "Well, that's five years before we picked up the cancer. Maybe it's cause and effect." I think that sleep is a very important area to not create paranoia. This is one of my findings in my three months, is that yes, it's important to get the right sleep for you, but if you have abstract goals of, "I need eight hours of sleep and if I do not get them, terrible things are going to happen to me," you induce an anxiety and a secondary depression that does no good for your sleep whatsoever. And so I think that we need to separate that and say, "Let's go back to real studies of what do we need in sleep. What's the wide variation?"
There is a huge variation without apparent impacts on your health. The one thing we can say with high confidence is something like severe sleep apnoea will cause daytime sleepiness. And that's a symptom that is curable by getting the sleep apnoea looked after. Sleep apnoea was another good one. We had, "Oh, it causes heart attacks." Okay. It causes everything. And then when the meta-analyses were done and when the studies were properly done, except for severe sleep apnoea causing daytime sleepiness, we haven't got any other of those associations. So I think we've got to be careful about overstating it.
Andrew: That’s news.
Andrew: That's news to me. So these associations have been dampened basically by...
Mark: So in the early days of any medical technology, philosophically, parenthetically… early days, you found a test that diagnoses everything. And then it diagnoses not so much. Then when you finally have done the trials and the meta-analyses come out, it actually isn't important at all. But no one gives up on the technology.
However, yawning and daytime sleepiness and those kinds of problems is still important. Why? Because you're less functional during the day. You’re at work not being competitive with whoever you're working with, and you're driving cars. And so it's not trivial but we're trying to get it back into its place to say, "Here's the associations but here's the causation." And the causation is very, very limited.
The same goes for sleep. We've got very limited evidence that sleep deprivation causes a problem but what we should be doing is saying, "How do we get normal sleep hygiene? How do we adapt to those levels of sleep that are appropriate? And if it is causing a negative impact, if it's causing tiredness through the day, if it's causing anxiety or depression, if there are other factors coming from that, how do we reconsider sleep and establish normal cycles for that person?"
And normal cycles for that person can go out very, very quickly. As I've found on asking patients, a high stress, a loss of a job, something like that can lead to an angst of “How do I pay my bills?” The How do I pay my bills eats into the night-time and often the story is, "And I'm online finding out how to manage my anxiety, or I'm online doing this stuff." Screens are getting into bedrooms. Worries are escalating at the same time, and it's more an anxiety, a generalised anxiety that leads to a disruption of the sleep cycle.
And the more we do and focus on it, the worse it tends to get. It's like erectile dysfunction. Erectile dysfunction disappears if you're not focused on it for some people, but the more you pay attention to it, the more erectile dysfunction becomes a problem. So automatic processes in the body can be buggered up by us thinking about it too much. And I have a suspicion that cavemen and cavewomen and cave children didn't think about much apart from how they were going to get through the night.
Mark: That was enough of a stress for them and the body well adapted to that, found its way to sleep for basically the entire group.
Andrew: What about the different phases of sleep and the requirements? You and I were discussing earlier about within the non-REM pattern, you've got the slow wave phase and then you come out of it at certain intervals and then you go back down, come out of it, go back down.
Mark: It's like waves and tides.
Andrew: Yeah, so what governs that? And why is it that when you're at the peak, i.e. the lesser deep wave if you like that purportedly you can wake at those times and feel less sleep deprived or more refreshed?
Mark: More refreshed.
Mark: Yeah, and so in my clinical practice...now I have three months of asking every single person about sleep and what it does to them. The almost universal answer is, "I never wake refreshed." So what people are missing is the concept of, "I spring out of bed in the morning, say hello to the sunshine, open the windows wide. The melatonin gets sucked down by the sunlight and my adrenals kick in." That relatively...in fact, I haven't got a single patient who's told me that in three months. Not one. They will say, "Oh, my sleep's not bad." But what they mean is, "I only wake up a couple of times in the night and it's half an hour before I'm falling asleep."
So I don't think we have good sleep health. I think that what we put up with when we move to cities, when all the senses never get a chance to just fall under the kind of starlit sky or the moonlit sky, that what we end up having is low grade background noise. Sirens in the distance that are never a problem when you are really healthy and deeply asleep, but which perpetually wake the person for whom sleep is becoming an anxiety provoking event.
You have a lot of sensory input. Light is never black in the city. I mean, we've got streetlights and it is so hard. I tell people about making the room really dark. The way homes are designed, there are skylights, there are things everywhere and there's enough light pollution in the city to mean that there is never a dark period. Where in nature you have a cycle of a moon where the moon is up for some nights and roughly, you know, half the night skies are going to be partly moonlit, but there is a two-week period of almost jet blackness that we never get to experience anymore.
Those cycles are more than just diurnal cycles. So I describe this over and over to people. Melatonin and cortisol do a dance together, and I can pick the people whose melatonin is going to be okay because they've got good a.m. cortisol and a good drop in the p.m. And if they've got that, then you know that the melatonin and the cortisol are doing their dance cycle.
Andrew: And it's the high-low. It's not the level.
Mark: Yeah, that’s right.
Andrew: Like you can have a high-flat.
Mark: That's right. And so if I see a person whose morning cortisol… So just measuring cortisol, we think of 350 to 450 as a good, normal range for a person living in the 20th century. That's probably a bit higher than it was at other times, but in that 350 to 450 range. If the afternoon is say 150 to 200, then that means that the drop is there and it's appropriate. When you see people under acute stress, it's 500 or 600 in the morning and 300 or 450 in the afternoon.
Andrew: So it's high and flat?
Mark: That's right. The adrenals are pumping and they're not paying attention to the daily cycle.
Andrew: And then you've got exhaustion.
Mark: That's correct. When they both start to descend, you've got what used to be I think called adrenal exhaustion. I think we're recognising that it's more, “Oh well, we can't win that battle so go back to the basics of looking after you." And so you'll see a morning of say 250 or 220 and the afternoon, 280 or 210.
Andrew: So low-flat?
Mark: Fatigue. I'm not a fan.
Andrew: It's not adrenal fatigue.
Mark: Yeah. I'm not a fan of the term.
Andrew: It's brain fatigue.
Andrew: The brain changes volume.
Andrew: It's one of those vernaculars we've got to drop. It's like antioxidants, it's like leaky gut syndrome. They're incorrect.
Mark: Yeah. And we've heard this...I mean, there are some that promote the idea of adrenal fatigue and those that oppose it. But one question you can ask the brain with ACTH, adrenocorticotropic hormone is “Are you demanding more?”
Mark: When the brain is demanding more, the pituitary hormone called ACTH goes up. And I do have patients whose ACTH is double or triple saying, "Where is my adrenal response?" And so you pay a lot of attention to the adrenals. When the brain is saying, "Give me more," and the adrenals are not responding, then you're looking at Addisonian-type conditions and you're looking at why are the adrenals not responding.
And sometimes you find tumours or atrophy or autoimmune adrenal disease. But that's rare. For every person who says, "I've got adrenal fatigue," for every 100 people who say, "I've got adrenal fatigue," maybe one of those people will turn out to have a pituitary or a hypothalamic problem that is not saying, "Give me more," and the adrenals are not doing it.
The rest of it is modified by the brain. And the brain is an incredibly capable organ of turning things up and down to the point that they're not going to damage you. So it causes the adrenals to over-respond under acute stress and then there's the trade-off. If you have acute stress becoming chronic stress and you keep the cortisol up that high, you get into real metabolic problems with that. And so the brain will turn it down and say, "Okay. The acute stress response did not work out. How do we just get through this?" And it will turn down the body temperature, the thyroid will go down, the whole metabolic rate goes down and it's the closest thing that we humans have to hibernation.
We interpret it as adrenal fatigue and say, "If we just hype up the adrenals..." But you can't hype them up. The brain doesn't ask for more. The only thing you can really do is give them cortisone and no one wants to do that.
Andrew: But I think the interesting thing is we then fall into the trap of thinking that these nutritional, herbal interventions are therefore no longer useful because we named them for the adrenals. They were never for the adrenals.
Andrew: It's just we got caught up in the wrong vernacular, you know. Like American ginseng is a mind ginseng. There's this...
Mark: We have our predispositions to name things and then think that we know what the mechanism is. So I absolutely agree with you. In fact, it's one of the things that...one of the lectures I loved many years ago was, we were talking to Chinese medicine people saying, "If only you'd use proper diagnostic techniques." To which they said back, "If only you would, then we would be able to find out whether your drugs worked as well as our herbs."
Mark: When have we ever been off topic in all of our years together?
Andrew: Bifidobacterium Infantis, one would then think it's only in infants...it's for infants. No, it's not. It's just we named it that, you know?
Mark: Be careful what you call something. It can define its future. I did just want to touch on that as well. There is pretty strong evidence from work I began in '94 of the gastrointestinal tract of what used to be called...
Mark: FS. Yeah.
Mark: Richard Brown.
Mark: And I worked with he and Henry Butt who has now moved down to Melbourne and is a microbiologist. And there was very strong evidence that what goes on during the day is a build-up of this thing called “FS” or it was French for sleep factor, factor sleep or whatever the French call it.
But it was a product of the bacteria in the gut long before it became very, very trendy to do this. And that what was going on during the night was as this factor built up, a clearance occurred. Enzyme function went up in the evening with the eyes closed, that got rid of the FS. Got rid of this what was, really, a bacterial end product of bacterial toxin. It built up in the body.
Their answer for why do we sleep was, "Well, it was to clear out all the bacterial crap that came through from the bowel." You've got to have a period of no sensory input or as minimal sensory input as you have. And so that concept of drop the sensation down to a level which is no longer overwhelming and let the literal biochemical rubbish be cleared out, it was very mechanistic but it was in fact very interesting because probiotics make a big difference. And I know we're not getting onto treatment yet, but dysbiosis...
Andrew: That even affect...
Mark: Yeah. Yeah. Dysbiosis affects sleep and at a very direct level. Now all the theories of “Is it via the vagus nerve? Is it via this? Is it via immunology? Is it via everything?” I don't want to get into that but there is something about having a healthy gut. And you may know that there's this program that often used with stewed apple and probiotics.
Andrew: I've heard of this.
Mark: Yes. I know. It's obscure. I’ve probably never mentioned it before.
Andrew: Forgive us.
Mark: But one of the fascinating outcomes has been that when I ask people...even when their fatigue syndrome is not better, what has happened as a result, they will volunteer, "Look, my gut's all better. The diarrhoea or the constipation has changed. That's all fine and I'm sleeping better but I'm still tired." And the bottom...and I'm sleeping better, I kind of always put that down as, “Oh, okay, it's good you're sleeping better.”
But there is something about the gut and its regulation of the sleep cycle. There is something about sunlight and its regulation of the sleep cycle. Not just in the eyes, either. This is a fascinating one. The experiments done of little photoreceptors put on the elbow, on the inside of the elbow to regulate the cycle. Every cell in the body carries a chronograph, a little thing that says "Is there light around?”
Andrew: Really interesting.
Mark: We think of it as eyes and say, "Get out and, you know, look in bright lights in the morning." But every cell in the body carries this thing of, "Am I coordinated with the rest of the body on my daily cycle?"
Andrew: But this is really interesting to me, just on the point of physiology. I mean, I was, you know, one of these blockheads that thought, “No, the melatonin is made by the pineal gland on reception of light...
Andrew: ...of the light stimuli.” But I've since learned that people who told me - and I rebuked them for thinking this - were correct in that melatonin is actually made, by a tiny amount, within the eyes and other tissues around the body.
Andrew: But it's just not the major point of production.
Mark: No, that's true. And, you know, it sits above the optic chiasm and there are reasons to think that the primary driver is sunlight exposure of the early dawn and that we peak at...you know, we start to drop our melatonin at the first light and it varies months over the year and the further away you get from the equator, the more that effect is apparent.
My daughter lives in Canada up at Whitehorse where they have barely sunlight at all, you know, for maybe a couple of hours a day through winter and all sunlight at a low level all the way through the summer. And so they only get a couple of months where there's any reasonable mental function going on and sleep is not related to light whatsoever. And my daughter's reporting of it coming from Sydney is, "Well, they're not just polite Canadians. They're mad polite Canadians."
Andrew: But, you know, there was the thought that there was a far higher incidence of seasonal affective disorder in the higher latitudes. Does this continue to be true or is this something that we might have again associated with our western culture? Whereas if you look at other cultures, they don't have this?
Mark: Yeah. The answer is I don't know. I know that we as Caucasians spread out across the world into latitudes that would've been fairly difficult for us. But there's good evidence that Caucasians who are at latitudes that had this kind of seasonal variability where it was almost pure sunlight for three months of the year and almost pure dark for three months of the year.
So we are adaptable. We do find our way through that. But my point was simply she goes from a Sydney-sider to a high latitude one, and for her, the sleep cycle is clearly lost.
Mark: And she struggles even years later to find that seven, six, eight-hour period. What is the right period for that? How does it change when you go from almost all dark to all light?
I have a feeling that the melatonin story is an important one and we'll come to that when we move onto treatment on the next occasion. But the melatonin and the cortisol and the stress response and the sensory input, there is an entirely different world that we are lodged in. Just as I say, you know, supermarkets are not food stores, they're food-like substances stores. We are not in a natural environment.
So a lot of the job that medicine and naturopathy and lifestyle medicine does is can we match ourselves back to...somewhere closer to a lifestyle that we evolved in, and see if we can establish normal patterns that way? Can we eat real food? Can we put vegetables in? There's a whole lot of questions that we have to ask about diet, lifestyle, light exposure, sound exposure, sensory input, stress response and then there's the final factor, the difference between my partner and I, Fiona, is very definitely a high alert, aware of everything.
I had a plant in my room that I consult in for nearly a year and had never noticed that I had a plant there. A patient walked in and said, "Oh, you've got a new plant." And I said, "It must've just gone in." I have been in that room every day over the year that it has been in there. For many people, the world is all about sensory input and the difficulty, if you like, is filtering it. For some of us like me, the difficulty is noticing any difference whatsoever and just plunging through life as if, "Yeah, there's a world out there but I wouldn't know it was there."
And I do think that we've got good evidence now that what we have now in medicine called depression is not really depression. It's anxiety leading to a kind of heightened brain response and a neurological, a GABA/glutamate imbalance which does put pressure on the people with heightened sensitivity. Much more than 90% of my patients are highly sensitive emotionally. They can pick up on other people's emotions. They're artistic and creative. That's not the average person in the world but they're the kind of people who keep on having this sensory overload where anxieties, stresses and the like seem to play out in a different way and who routinely have a sleep cycle which is on edge. They're hyper alert all the way through the night. They wake exhausted in the mornings because they've never been fully deeply asleep. And as doctors we often make the mistake of medicating them into submission. That's not the right way to do it which again, we're not dealing with today.
There are lifestyle factors though. And one that I've become a little bit obsessed about is the blue light of screens, that it is a massive difference. In my lifetime, you know...I started practice in the 1980s and a screen was an odd thing. We read newspapers, we had paper. Everything was written on...
Andrew: I remember the TV was the scourge of the younger generation back then.
Mark: I know. And then the video games was the next... So everything has the scourge of the new. And I have a suspicion that that's because there are people who are affected by it quite markedly and we pay a lot of attention to it, and then don't recognise the resilience of humans in adapting to whatever.
But a lot of people, their sleep cycle is changed by their having screens all the way through the day. Attention is eternally being taken to something. There is the kind of FOMO, you know, “I'm missing out on something because everyone else's life is great.” But that's, yeah, that's always been the case. The grass is always greener on your neighbour's side. It didn't matter whether it was a fence for a farm, or anything else. But the screens do have an effect and especially in young people. Kids that are not getting sleep, that are failing in their exams, their addiction to screens is not trivial.
Andrew: But it's also what they're watching on the screens. Like I was just thinking just before that perhaps, you know, you should...instead of watching something exciting like, you know, Formula...sorry, touring car motor racing at late nights, you should watch something more boring like cricket. There's cricket.
Mark: Cricket will put you to sleep although that green of the fields is too close to the blue for my liking. So what we need is probably more brownish coloured grass around the cricket fields. We would have some...
Andrew: There's going to be somebody out there that's going to take umbrage to that comment.
Mark: Yes, I know. I mean, I'm one of those tragics that we all here, but I do think that we do have a question to answer and that is: if you're sleepless, the typical thing that happens is some event happens at the beginning which disturbs the sleep cycle, which if left alone would return in its own time to a normal sleep cycle. Until you add anxiety about missing out on sleep.
So there is a meta-side to anxiety, and that is there's the anxiety that disturbs sleep which has a cycle of its own. Then there is the anxiety about missing sleep, which is almost a positive feedback loop that is so, so difficult to break. And so one of the first things to understand is, is there real harm coming from my lack of sleep or is this simply something that is going to have no consequence to me? It's somewhere in between those two.
When you lose sleep and don't sleep through an entire night as you build up that sleep debt, you will sleep eventually. No matter what happens, the body goes back to sleep even if it reminds you more of semiconsciousness or unconsciousness. But our tendency is to want to do something about it. And the doing something about it...when I ask people to stop using their screens, to stop watching the TV in the bedroom, there's a remarkable resistance to that because the habit has been, "Well, I used to be able to do that, so why can't I keep on doing that?" And when you're at your best, you can do almost anything wrong and you will still sleep.
But when you get into that cycle of anxiety and with a kind of consequent depression, because the hyper-responsiveness of the mind has a downside and a flatness, we doctors have tended to call it depression. The delightful paper came out just within the last two weeks of a group that used an antidepressant and said, "Well, it doesn't actually do anything about depression. It's an anti-anxiety drug that works within the first week. Not the antidepressant that works three weeks later." And I sat there and I thought, "Well, how did we miss that?" The answer is those drugs were tested on people with what we used to call endogenous depression. There was no upside to their lives. There was no anxiety. These are the type of person that are the black hole...
Andrew: The melancholic.
Mark: How are you ever going to exit from that world? Whereas the type of depression we tend to see more today is anxiety, crash, up and down. We focus on depression. We have drugs. Again, the name of them was antidepressants, but they weren't. The tricyclics were originally antihistamines. Did you know that?
The drugs that now that we think of SSRIs… We have all of our major theories of depression. Our antianxiety drugs that used at different dosages allow the anxiety to be reduced and that's why people who go on those drugs often get benefit within three to five days, not the three weeks that we say they're going to have to wait for the depression to lift.
So we're learning stuff about the rapid cycling which is what we used to call cyclothymic you know, the rapid ups and downs and the crash and how that can impact the person who's lost their sleep cycle. Their fears, worries and anxieties go on. “I'm missing my sleep cycle. How do I fix that?” And as you do that, as you focus more on that, sleep gets further and further away from you.
One job every practitioner can do is to reassure people that there are not the consequences that we used to have or we used to say were there in the past. They're not doing irreparable damage to their bodies. Their bodies will eventually come back to that sleep cycle, and the question is how did they find their way back. It's more a journey on the way back.
Getting rid of screens is one of those things, getting rid of TVs in the bedroom. I think more and more there's evidence that getting rid of electromagnetic items in the bedroom is a really, really good idea as well. We don't have a particular receptor for EMR, except with your eyes. I mean, obviously certain types of EMR, we've got very good receptors for.
But the type of 50 hertz, the low buzz, hum that's below the level of consciousness, there are many of my patients for whom the critical factor in getting their sleep back is turning off and unplugging every single thing within five meters of themselves in their bedroom. The other thing is getting a black bedroom, getting a room that is really, truly dark. And you can tell that.
If you're lying in bed and your eyes are open and everything can be seen quite clearly in your bedroom, that's not a dark room. If you can see colours, that's definitely not a dark room. So if the macular can pick up colour and things, you are not in a room which is suitable for you to be sleeping in. So I think that we can do something more to say, "You can close blinds, you can pull curtains, you can put extra on there. Get the electromagnetics out, get the room really, truly dark."
And then sleep hygiene says, "Look. Try and have your meal at the same time. Try and get to bed at around about the same time." I think personally again that diet may play a very big part in this. Not by nutrient availability or cardiovascular risk reduction or any of that, but just simply happy microbes in the gut tend to keep on giving the signal of a diurnal cycle themselves. And people with good guts, people who have done the patented stewed apple kind of protocol who find...
Andrew: Which we will put up on the FX Medicine website.
Mark: Yes, which we always do.
Mark: But the secondary gain of sleep is not an unexpected thing. There's good research behind that it should occur, but it's not sufficient. You cannot just say all the gut and everything else can stay the same. But it's the art of not panicking a person but saying, "There are steps that you can take before we think of herbs, drugs, pills, potions, melatonins or anything else. There are steps that you can take." And if you can break the anxiety cycle of "I'm not sleeping enough," and just reassure that the cycles of sleep vary according to season, according to age, according to a lot of other factors, and when you step from one cycle to another it can be quite disturbing for a person who's already anxious about it.
Andrew: Two parts I want to just clear up and they've sort of resurfaced. So the first one is sleep related disorders and you said that the effects were watered down. But there's recent research that talks about for instance chronic sleep deprivation and increased risk of Alzheimer's.
Similar effects on immunity, on metabolism, insulin resistance, things like this. Metabolic disorders is what I always meant to say. Even pain perception, heightened pain perception with chronic sleep deprivation. Now there's a cause and effect issue.
Mark: Yeah, so that's actually a really good example. People in pain have different sleep to people who do not have pain. People who have different sleep perceive pain differently to the people who have normal sleep. Which one causes which or which one is the result of which? That I think has not been...that's the question unanswered.
Andrew: To look at this in a more proper way, instead of people that have already got pain which might be affecting sleep, you look at people who are poor sleepers and who are not as a control group. And then you look at, dare I say the word introducing pain having undergone surgery.
Andrew: Let's say, you know, a major abdominal surgery. And then you track those two groups and see who's got on average the greater need for pain relief medication.
Mark: It's a great study. I mean, I think that that's the kind of stuff that we should do. But right now I think the consensus is there are associations between sleep depth, duration, you know, you give a sleep score each night. There's apps that will even do this if you're wearing these watches around the place.
Andrew: Which of course then you've got EMF.
Mark: Yep. That's right. You've got a little battery right on your wrist. But there are associations that are absolutely clear. What's not clear is the causation about a person who's got pain will always have distorted sleep. A person with distorted sleep patterns will perceive pain more acutely than a person who's got normal sleep patterns. Where the two of them go together is people who have got this...what is now called central sensory sensitivity. They perceive normal input, photophobia, phonophobia, heightened touch sensation, those people are always on a lighter level of sleep and more prone to waking. And they perceive it as pain. People describe this as pain. What kind of pain is it? It's a kind of vague sensory overload pain. It's not the kind of pain that you would say is burning, hot, sharp, tooth...you know, a dull toothache like. It's a whole different system there.
So in all of those cases, there are people who have got...developing Alzheimer's. There is definitely something going on in the circuitry of the brain long before we ever see anything there. Even if you believe in the kind of plaque theory and the like, we don't know apart from one hint people who lose their sense of smell without having any sinusitis or rhinitis or anything like that, where the sense of smell is diminishing as time goes by, that is one of our better predictors about who's likely to develop Alzheimer's or degenerative brain disorders.
And part of the reason is the only real card-carrying members of the brain that hang outside the brain cavity are the olfactory nerves. They are real living brain cells that just droop down into that cavity and they regenerate themselves roughly every 30 days. They maintain smell memory. And if anything is going to reflect what's going on in the brain, it's almost certainly going to be olfactory nerve, the first cranial nerve.
So that's a good example, if you like, of there being primary brain pathology that we should be thinking about what is going on with the brain that's running itself down that way. But I don't think that you can un-sleep yourself into Alzheimer's. If you haven't got any of the predispositions, you're on a good diet, I don't think for a second that sleep deprivation...
Andrew: Single bullet theory.
Mark: Yes, is the cause of anything there. I would also say sleep deprivation...when you use experimental models, you've got to be careful. I mean, what the American troops in Iraq proved is you could destroy a person's health and life and even kill them if you waterboard them, keep them awake and do not let them sleep and keep the lights on all of the time. It's a potentially fatal outcome but that's not, you know, losing your sleep cycle. That is abuse, attack, stress. That is a whole lot of factors and you can't take and extrapolate anything from that about what would happen to a normal person.
Mark: Yeah, dreams are fascinating. They're... Chris Reading, a grand old friend of mine many, many years, back in the '60s and '70s and '80s did ask the critical question. When you sleep, whether you sleep well or not, do you dream? Can you recall your dreams? A surprising number of his patients and of mine, when you ask that question, say, "No, I don't dream."
Now what we knew from electrical studies was they do go into REM sleep. They should have dreams. The dreams are there but they don't retrieve them. And so Chris was very big on that, "Look. Let's return the brain to a level of function using vitamin B6 and zinc," which we'd now think of as a kind of cryptopyrrol kind of group of things. We give it different names every kind of decade or two.
But what it would do is just up the B6 and the zinc dosage sometimes to massive levels and what people would go through is, "I don't recall dreams. Oh, I have dreams but I don't recall them well. I recall dreams but there's no colour in them." And for Chris the stopping point was when you dream in colour and you can recall the colours, then you are adequate in that part of the neurological cycle.
Andrew: Toxicity is an olid dream, isn't it?
Mark: Yeah. That's right. You hype it right up to one of those screens in Harvey Norman where you walk in and it hurts the eyes. But it was fascinating that people were going through sleep cycles but they were going through sleep cycles that seemed like they did an inadequate job of whatever that clean out effect was going to be doing. And they did remarkably well on Chris's...I mean, he also did take them off wheat and milk. So there were other parts to Chris's program that were routine.
But I was quite impressed by the reliability of that as an indicator. Do you dream? Can you recall it? What are the colours in it? And people...a surprising proportion of people with sleep disorders just say, "I can't recall any colour ever." And then they start recalling colours and it's a blue dress or it's a, you know, bright field or those type of things.
So I...well, I mean, I disagree a bit with Chris where it came to using doses of the 100 or more milligrams of zinc, you know. There is issues of zinc toxicity and B6 toxicity that we know about now.
Andrew: But short-term...
Mark: No, you're right. Short-term that you can…
Andrew: As long as that's not prolonged like more than, say three months.
Mark: I mean, look at lithium and what we use in medicine. You know, short-term lithium at those very high doses has a very obvious effect. And the problem is the long-term.
Andrew: Yes, there was that classic example of strontium.
Mark: Yes. Yes, there has been as well. So look, what I'd summarise it is if we as practitioners, when a person presents to us with a sleep disorder think “What initiated it? What were the events that led up to that? Were there stresses? Anxieties? Were there things which led to mood disorders or an event, sometimes a very...either a catastrophic event, a death or something like that that led to the initial problem?” What stops a person from recovering is more frequently their anxiety about the sleep loss than the anxiety that caused the sleep loss.
Andrew: But yet at some point you have to intervene and it's very hard.
Mark: You do and that's why we're having part two. We're keeping away from that right now.
Andrew: We're trying to. We're trying to. But sometimes you need to have this blend. So let's just...let's call it a segue.
Andrew: When we're talking about intervening to help somebody who is acutely anxious or their anxiety is perpetuating and it's about the condition.
Andrew: So in this instance, it's about sleeplessness, insomnia.
Andrew: What factors do you have to take into account when you choose the strength of agent that you're going to initiate with?
Mark: First of all, I'd say as a practitioner, we are in a remarkably strong place to provide reassurance to a person that what they're going through is not them alone and unique to them and that that focus on sleep is going to harm or damage them in some ways.
So before we even get into thinking about intervention, one thing that has proven very useful is to say, "I know about sleep and I know that you're anxious about the loss of sleep but I can reassure you that that loss of sleep is not going to do harm to you." We try and separate short-term or acute insomnia from chronic. If you've been getting sleep disorders going on for three months, then you start to think are you effective in life and there's far, far more need for intervention there. Most people who are losing their sleep want it back tomorrow or the next day and that's part of what we've done in medicine is the magic of drugs is “I can give you enough of a pill, like temazepam, that you will sleep no matter what.”
The problem there is that we can destroy the sleep architecture. We can say, "If you are not conscious, that'll do.” Whereas sleep is not being unconscious. Sleep is being...going through the phases, as you said, the cycles over those 90-minute periods where we come in and out of various phases. So many of the drugs destroy the sleep architecture just to prove to a person that you can sleep and not be tired the next day. Is it good sleep? No. I don't think anyone is saying that.
So the first thing that every practitioner can do is say, "I know about sleep. I know you are experiencing distress about sleep but I can reassure you that in the short-term you will be doing no harm to yourself if you just let that cycle play out." And then do the basics of the lifestyle interventions. The “get the screens out of the room, make the room dark, get the temperature.”
Andrew: Well, I can tell you in a hotel room it's vastly disparate between me and my wife. When we stay in a hotel room, we have to always get a blanket for Lee because I require cold. I like 20, 21. Give me an open window, please. In summer, give me five fans. This is my actuality.
Mark: This is a problem with heterosexuality.
Andrew: I know. But with Lee, she'd like a blanket, please. She likes to be snuggled up. Having said that, what I have found as I age is that where I used to kick bed clothes off and things like that, I now do like my cotton blanket and it's like a wowie. It's like a security blanket. I don't know. Regression.
Mark: So much to unpack here, Andrew. And I think we'll leave that for another podcast when you're not around.
Andrew: I think it's really interesting about the temperature requirements of supposed snuggled warmth versus restful sleep and I prefer a cooler environment overall.
Mark: All right. So what...in fact, that was perfect because what I was about to say is there is no right temperature. There is temperatures for summer, winter. There's variations from outside temperatures. On the whole, males like to sleep cooler than females. On the whole, females have a higher need for pressure and weight upon them. So it's not just about warmth. Now there are, and among the sleepless community, there are these blankets that are weighed down with glass beads inside them that are heavy but not hot.
Mark: And they're used for that sense of snuggle and pressure and a sense of security. Your security blanket may be defeminising of you and I don't want to go down that path because that again is another podcast. But there is something about all the factors, the amount of pressure, the amount of closeness. Heterosexuality has its upside and its downside but one of them is being in the same bed of two people with utterly different temperature needs can make it extremely difficult for one or the other.
As one pulls the blankets on or turns the air-conditioning down, the other one wants it to go in the other direction. And that can also make a mess of sleep. And so that...I don't think that's an unusual thing of a male and females having entirely separate temperature needs. Entirely separate sensory needs, I think, in my practice anyway, females are by far the more sensitive, tending to wake during the night, and we always go back to it and say, "That's so that they hear the babies and if the babies are crying."
But for all the evidence, when we have babies, we're always up with the parents until we decided to separate them anyway. But there is something about the female mind where small stimulus from the outside has bigger impact even during their sleep cycle. Males, not everyone but lots of males tend to be able to sleep through, you know, hurricanes and... A bomb went off in our suburb a year ago. I would not have paid any attention to it. It caused panic amongst Fiona and some of her friends.
So we have complexity in the bedroom which is difficult to manage. We think we like heat or we think we like cold but in fact we're fussing around all the way through the night.
Waking frequently through the night is not a great thing. So prostates are often a problem for males where they get up four or five or six times a night to do a little pee and that can ruin their sleep cycle because the bladders say, "Hey, still got more here. Didn't empty fully the first time." So there are particular conditions that we as doctors and practitioners should make sure are not there.
The other problems are metabolic disturbances. People with diabetes, people with neurological disorders after strokes and the like, there are always variations on the sleep patterns for those people who need to take that into account as well. So there's no excuse for bad medicine. You still need to ask all the questions about those impetuses, or impeti I suppose, about the reasons why sleep is affected.
But in general, what we want is can we re-establish a normal sleep cycle by doing the basics, getting the room right, getting the temperatures approximately right? If necessary...I mean, we now have McMansions. Separate the male and female during those hours of the night if each needs separate environments. Cool one and warm the other. And those...and get the screens out. And I keep on coming back to get the screens out.
Many people of my practice choose to move to country areas, choose to move out of the city because the impingement on the sensory input of the sirens, the cars, the light, the things that go along with the city that in many ways make it safer rather than less safe, they actually...you know, they have their “head to Queensland" moment, head out into the bush. And they find their sleep back in a normal sleep cycle where the moon rises and you can see the moon and you can see the Milky Way. That's the other thing for me, is if you can see the Milky Way clearly, you're probably in a place where light pollution is not terrible.
Andrew: Yeah, that's right. Like I love going into the country where we can see so much more of the Milky Way. Of course, there's still light pollution but for instance, I was blessed to go to Uluru and wow, what an awakening that was.
Mark: Yes? I believe that that's marvellous.
Andrew: But to see the stars out there, that's incredible.
Just a little quick question before we go. I remember watching...I think it was a TV program on being shellshocked, so post-traumatic stress disorder. And the various treatments throughout the ages, World War I, World War II, Vietnam, etc. But one of the earlier treatments...of course, doctors could basically could do what they wanted, was to chronically almost anaesthetise patients. They were kept asleep for weeks and weeks and they would wake up only to feed and then go back to sleep. Is there any benefit to that? Has there been any benefits to prolonged sleep? Or does that muck up the sleep patterns, the sleep structure?
Mark: Yes, the benefit is called population reduction. This was the Chelmsford group of doctors who did the deep sleep therapy where there was a fatality rate of 30%. Right?
Andrew: Right. Okay.
Mark: It proved to be…and then there was the suicide of the doctors involved. It was flawed. The idea is that it's like pressing the reset button on a computer. And this was instead of just pressing the reset button, pull the cord out and see if you can anaesthetise the person to that level of unconsciousness where you hope that they would emerge on the other side okay.
I think the same concept was done with electric convulsive therapy. We thought of the computer...I'm sorry, we thought of the brain as if it was an electrified organ and if you just charge something in, it would reorganise everything in the right direction. Which it didn't. It scrambled the brain and sometimes people emerged from that not remembering the reasons that they were anxious or depressed. And generally speaking, it wiped out memories.
So I think that there is this idea of medicine that if what you're doing isn't good enough, go deeper, go more dangerous, go to the very edges. And there's nothing to suggest that we are like a computer where a reset button or pulling the cord out sees an automatic reboot back into the right state. We tend to have our genetics. We tend to have our predispositions. Our sensory inputs do not change over that time so that the amount of information coming in...and I think a lot of the focus has been if we can just stop people having any sense or sensation, they might restart their cycles all over again.
I don't see any problem with the theory, but once you've got evidence that putting them into that state has high fatality rates, you don't go doing that too often. And I think everyone kind of regrets that we went down that path. So I don't think it'll be done again.
I think, look, for what we can say for part one is sleep disorders related to anxiety and depression - that kind of anxious depression which is far more common than deep depression - sleep disorders after particular events are common and generally self-regulating. But sometimes you go from the anxiety to the anxiety about sleep. And that transfer over creates a real difficulty. The more you focus on sleep, the more excited and agitated you are about getting sleep, the further it disappears from you.
And that leads us to do all the lifestyle things that we can. Change the bedroom, make the sleep hours appropriate, get into some kind of order before we move on to CBTs and everything next time, that you do all of that and primarily reassure the person that the high likelihood is, that if they don't go down any other path that they'll re-establish their sleep cycle normal for them at that age if they let go of some expectations.
And that's a very powerful intervention without doing a thing. Just the ability for the person to know this isn't weird. I'm not going to die of something if I don't sleep enough, and that the body will always revert to that.
The exception for the doctor is we always have the thought about the incredibly rare condition that could be...you know, the sleep disorder could be the marker of and so I think generally these days a doctor will think, "We'll do an MRI and just see that there is no structural alteration there that we should know about."
And I have had just in this last week a patient who kept on running into these sleep problems and the neurologist found nothing wrong and everyone found nothing wrong and it wasn't that. It was really a gut problem. I'll tell you that ahead of time. But everyone said, "Oh, it's all psychological. Just don't worry about it." They did the MRI, normal pressure hydrocephalus and only 30% of the brain cortex sitting around the place there. What was extraordinary is, every doctor went from “It's all psychological,” to “We have to deal with this!” And $300,000 later she'd had the surgical procedures, she had had everything and they pronounced her cured and exactly the same problems were there as were there before.
So there is this mental concept of medicine is, “No, you're a little bit psychological. You’re just stressed. Gasp! You've got a real thing!” and we will separate money from Medicare for that real thing and then pronounce you cured and you should be grateful and go on your way without there ever having been a dealing with the problem. The sleep problems were still there, the gut problems were still there.
Andrew: Once more you've awakened us to the issue that just because it's all in your head, doesn't mean it's not real.
Andrew: It's in your head with regards to sleep.
Mark: Yeah, go to sleep. Shut up and go to sleep, Andrew.
Andrew: But there are so many factors and as you say, there are so many other sideways, triggers, if you like, of poor sleep that come in and muck things up so much. So thank you for taking us through those today. We look forward to seeing you again next time, part two, and we'll go through some therapies which we can help people to relax and get some restful sleep.
Mark: Get their cycle back.
Andrew: And remember that you can check out FX Omics of course, your own podcast. Thank you so much though for coming in today and sharing your expertise.
Mark: It's been great. Thank you.
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.