Dr. Boggess (Medical Director)
Dr. Tony Boggess is a Physical Medicine and Rehabilitation (PM&R) physician, speaker, and writer who specializes in Nutritional and... read more
Chronic Sleep Problems
Sleep is Essential!
While we don’t understand sleep fully, we do know all mammals (humans and animals) require it. Requirements of course vary based on our activities, age, and state of health. But if we are suddenly deprived of sleep it can severely impact our physical and psychological well being to the point of psychosis if it goes on long enough. More chronically, any mild to moderate, sleep loss or even lack of restorative sleep is not alway obvious. However overtime it too can severely erode one’s health. In fact, research has consistently demonstrated that chronic sleep interruption, or lack of restorative sleep dramatically increases stress hormones, destabilizes blood sugar, interrupts cell and tissue repair mechanisms, decreases growth hormone as well as other hormones. In such case the body then does it’s best to make up for lost sleep by “up regulating” itself, which then leads to a vicious cycle of overstimulation, metabolic overdrive, catabolic breakdown, and the collapse of feel good neurochemicals in the brain that make a person, happy, well adjusted, and basically comfortable in their own skin…
Stages of Sleep
There are several well defined stages of sleep, but an easy line can be drawn between the early and later stages of sleep. We can further divide sleep into REM (Rapid Eye Movement) sleep characterized by “eye movements” and dreaming, and non-REM the absence of these movements. Non-REM sleep is categorized as starting out as shallow, progressing into deeper sleep; and then into what is called slow wave sleep. REM sleep then begins in sequence to maximally assist with restoration, learning, and physical recovery. Essentially, the deeper the sleep, the more repair mechanisms are activated, the more healing occurs, and the more healthy hormones are released.
Unhealthy sleep patterns or sleep disruption of any kind, such as deprivation, sleep apnea, restless legs, etc.. can interfere with the specific mechanisms that signal one to be sleepy or awake. For example certain byproducts of cellular metabolism regulate the amount of sleep one needs. One chemical, adenosine, accumulates throughout the day in tissues such as the brain and heart to make you sleepy. With healthy sleep, adenosine is supposed to be cleared away by the end of the night so you wake up feeling refreshed and ready to start your day. If adenosine is not cleared with REM sleep, or REM sleep is inhibited you don’t feel refreshed in the morning. It takes about three nights of good sleep to catch up, but if one is chronically sleep deprived the are many other mechanisms that kick in such as chronic stress hormones that lead to biological mayhem.
Categorizing Sleep Problems
There are a number of different kinds of chronic sleep problems to include breathing disorders, brain disorders, movement disorders, and day-night or circadian rhythm disorders all of which can have a dramatic impact on health and if left unaddressed will all but certainly prevent recovery from just about any other health issues.
Sleep apnea is defined as the cessation or decrease of nighttime breathing long enough to reduce the amount of oxygen the body needs. The consequence being a person will either arouse to lighter, less restorative sleep or awaken altogether. The condition is diagnosed with a sleep diagnostic test that measures air flow in from the nose and out from the mouth along with a pulse oximeter (a device that connects to your fingertip) to measure the oxygen percentage in your blood. Normal breathing when sleeping oxygenates blood ideally between 92-99%. A blood oxygen level below 90% for 10 or more seconds indicates a clinically relevant apnea. This can happen up to a hundred or more times per night. Such obstructions can occur due to a number of important mechanism (read full article). Essentially you are drowning in your sleep, coming up for air subconsciously, only to drown again. While snoring and waking up short of breath are obvious clues and are hard to miss, the more concerning versions of sleep apnea in my opinion are those who don’t snore, but rather grind their teeth, thrash around, and arouse unknowingly out of restorative deep sleep unknowingly. If there is audible snoring, you are actually wining some against the obstruction and getting at least a little air. The total lack of snoring yet waking up unrested in the morning is ALWAYS more concerning!
Obesity hypoventilation: This is the most severe form of obstructive sleep apnea and is also known as Pickwickian Syndrome. For the morbidly obese person this is the natural consequence of neck girth and excessive tissue intruding the airway in a gravity dependent manner. These patients suffer from such severe hypoxia at night that it leads to increased carbon dioxide during the day. A tell tale sign is red-flushed skin, especially the cheeks. With this condition there is such severe fluctuations in oxygen getting to the tissues that it causes extensive oxidative and toxic stress and ultimately leads to further injury and morbidity.
Upper airway resistance syndrome (UARS) is a very common but often overlooked cause for non-restorative sleep. It is not fully endorsed yet by conventional standards but more and more doctors worldwide are beginning to recognize it as a reasonable cause for concern and intervention. Rather than true obstruction and hypoxia, UARS causes sleep fragmentation with or without snoring. Patients with UARS wake up tired because their sleep is split anywhere from 20-120 times per hour. These disruptions are known as alpha wave intrusions and they prevent the onset of deeper, more restorative sleep states, including REM. This disturbance is characterized by a change in breathing pattern in response to the environment. Essentially, the airway resistance baseline is so nearly clinical that any slight aberration in sleep temperature, position, subtle noises, or even sleeping with your head under the covers can reduce the air reaching the lungs which arouses the brain prior to causing hypoxia. It is also suspected that UARS happens as a result of chronic sleep interruptions as a sensitization compensation, so to speak. While not technically sleep apnea, this less well understood sleep disorder can cause worsening metabolic stress, especially for those with mitochondrial stress, HPA axis disorders, or malnutrition.
Central sleep apnea is as less common brain mediated failure to initiate the effort to breathe. It can be due to the brain itself or any number of autonomic nervous system centers throughout the body such as the carotid bodies located in our largest arteries designed to sense oxygen/carbon dioxide levels in the blood. Patients with centrally based apnea either breathe too much or not at all at night, and often during the day too. Interestingly, it is actually the level of carbon dioxide in our bloodstream that triggers us to breathe. This mechanism can also be traced to the the sulfur chemistry pathways that lead to the production of hydrogen sulfide. Which is why sulfur restricted diets are often associated with shortness of breath when advised improperly to those who are genetically susceptible for transulfuration pathway problems. Central sleep apnea is a bit more difficult to diagnose and requires and in-lab, or in-hospital sleep study rather than a in-home sleep test.
Complex sleep apnea appears to start off as an obstructive apnea, but then converts to centrally mediated mechanism likely due to sensitization of the sleep cycle and the overnight stress of many arousals for an extended period of time. That is to say, chronic low grade obstruction overnight can lead to the brain shutting down the drive to breath overtime.
Please visit our Sleep Apnea page where we discuss in detail the complexities of Sleep Apnea.
Restless leg syndrome (RLS), is the most well-known of this class of sleep disruption and it continues to perplex the mainstream medical establishment. Patients with restless legs and other involuntary and uncomfortable movements during sleep are for the most part consciously awakened from sleep as apposed to apneas which often result in are subconscious (outside awareness) arousal’s. That is to say, most patients are very aware and in fact anticipating these involuntary movements to disrupt their sleep. Setting up a vicious cycle of sleeplessness and anxieny about sleeplessness. In our clinic, we have tracked RLS to sympathetic over activation, mineral derangements, medication side-effects, stressed mitochondria, and a host of nutritional deficiencies such Vitamin B12, iron, and magnesium. Likewise, syndromes, like periodic leg movement syndrome and rhythmic movement disorders in the pediatric population (such as head banging and limb movement) can also cause interrupted sleep and worsening presentations. Before proceeding with any conventional medication or sedatives, it is essential that all nutritional factors be ruled out. Also it needs to be said, that most (if not all) sleep medications will have a tendency to increase risk for the breathing disorders outlined above–creating a double edged sword. Finally, we need to consider other associations such as peripheral neuropathies, gastrointestinal malabsorption, or any other conditions that can impact or be related to nutritional deficiencies.
Circadian Rhythm Disorders
Our biological selves have natural rhythms that need to be paid attention to. Perhaps the most obvious examples of this are “Jet Lag” and “Third shift syndromes.” Such disruptions in our day-night cycles require adjustments, and for some, these adjustments can take longer than others. Up to months for sensitive individuals. Of course this is not normal and points towards other issues, but the bottom line is we were meant to follow the sun and hide from the moon so to speak. The result being that most people are signaled to go to bed between 9-10 p.m. and are generally at their deepest levels of sleep between 2-4 a.m. Sometimes if you stay up past these natural times, one can experience a catastrophic “second wind” that can keep you up all night long (also a red flag for HPA axis problems) Certainly things like jet lag, changing time zones, shift work, and exposure to bright lights (or any light for that mater) in the night can affect our circadian balance and should be accounted for if this category of sleep disorder is suspected. There are a number of areas that need to be examined if this is the case including the possibility that patients are hurting themselves by misusing supplements like melatonin or serotonin precursors. Also, if there is significant stress in our lives, our sleep cycles will be fragile at best, and we should pay attention to things like excessive blue light from our computers and cell phones, the lights in our home, the level of stimulation we are dealing with prior to bedtime, and even overexposure to EMF (electromagnetic frequencies) in our sleeping area. When you are strong and healthy these things mater much less, but when stressed and overburdened, the fight or flight aspect of your nervous system are dominate and this tends to make individuals much more sensitive to everything. (Read article related to chronic stress and sympathetic activation for more details).
Hypersomnia (excessive sleep)
Various syndromes such as the apneas, overuse of sedative, and misuse of supplements like melatonin can lead to an excessive need for sleep. However, the most extreme version of hypersomnia is a condition known as narcolepsy, which is actually very rare. This odd presentation causes one to lose consciousness and muscle tone immediately! It is quite dangerous and needs to be treated medically and ruled out as an autoimmune disorder if it is present. There is also some research that indicates a relationship between brain injury to the hypothalamus and or pituitary gland, and by extension the HPA axis causing severe episodes of instant hypersomnia, but this requires a daytime sleep diagnostic and is very difficult to identify.
This rare group of disorders is not well understood, but has been linked empirically to chemical abnormalities in the brain, elevated whole blood histamine, and numerous nutritional deficiencies such as niacin and magnesium. From our perspective, we treat whatever is obviously identified in our medical work up and often find that abnormal sleep behaviors like night terrors or sleep walking improve incidentally.
REM Behavioral Disorders
In other words “violent nightmares.” These are mostly identified in the very young or the elderly and are characterized by frightful dreams that arouse a person to lighter stages of sleep followed by aggressive and violent behaviors. Hitting, biting, head banging, cursing, and throwing things can be dangerous for bystanders and so in our practice this is considered something worth treating sooner rather than later. We have found that the use of HIRREM, a form of neurofeedback we offer can be helpful. Incidentally, this condition has also been associated with post-traumatic stress disorder and HIRREM is also known to be helpful for this as demostrated by the use of the tool by the US military for this purpose.
A sleep diagnostic test is always required to make any diagnosis or to provide treatment recommendations.
If you are not a patient of the clinic, one of the services we offer that consistently helps people with all types of sleeping disorders is a form of neurofeedback called Brain Wave Optimization or HIRREM.