Sleep Solutions: Michael Breus, PhD
A good night's sleep is essential for good physical and mental health. But most of us don't get enough sleep. Do you? We discussed eye-opening sleep issues from apnea to insomnia when WebMD's own sleep disorders expert, Michael Breus, PhD, was our guest.
By Michael Breus
The opinions expressed in this transcript are those of the health professional and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician
Moderator: Welcome once again, Dr. Breus. Thanks for being our guest for this Live Event. Let's get right to some questions.
Member: I often wake up with headaches after sleeping. Does this mean I have not slept enough?
Breus: That's an excellent question. There are many reasons why someone may wake up with headaches -- anything from issues surrounding migraine to obstructive sleep apnea. Oftentimes, I have neurologists refer headache patients to me to screen for these sleep disorders. Generally speaking, people don't wake with headaches due to lack of sleep. I would suggest speaking with your primary care physician about seeing a sleep specialist to help get to the root of this issue.
Member: What characterizes a sleep disorder? How do I know if I have a sleep disorder?
Breus: It is sometimes difficult to tell if, in fact, one has a sleep disorder. What we often tell our patients is if you remain sleepy even after getting seven to eight hours of sleep a night, or you are unable to get seven or eight hours of sleep a night, then it is worth further investigation before a formal diagnosis can be made.
Member: What can I do to stay asleep? I have arthritis and when I roll over the pain wakes me, than it can take one or two hours before I can go back to sleep. I don't like taking strong pain medicine because it can also keep me awake and jittery.
Breus: You are in somewhat of a unique situation. But one that is surely not something that is incurable. I would first consider speaking to your rheumatologist to explain this dilemma. For some of our patients with these issues the medication Klonopin has been found to be useful in keeping people still at night. If your current medication regimen is not [controlling] this arthritic pain, it may also be important to make your rheumatologist aware. This may be more of a pain issue than a sleep issue.
Member: My husband snores and I am light sleeper. We have been sleeping in separate rooms. What do you recommend? I have an air filter to try to drown it out but I still hear it.
Breus: This is an extremely common problem and one that has various solutions. Of primary concern would be whether or not your husband simply snores or has an underlying sleep disorder, such as sleep apnea. If his snoring starts and stops or you hear him quit breathing at night, this may require further investigation. If indeed he does have sleep apnea, the treatment for this will cure his snoring as well. But let's say he does not have sleep apnea for a second. Other options may include ear plugs (for you!), a Breathe-Right strip for him, and a review of the use of decongestants and nasal steroids to help reduce swelling, which may cause snoring.
I have had many people ask me about some of the throat sprays on the market for snoring, and to date I am unaware of any scientific evidence showing their efficacy. A final option would include surgical intervention by an ear, nose, and throat physician.
Member: I have sleep apnea and wear a CPAP mask, but after two hours, my nose gets plugged and I have to take it off. What should I do?
Breus: This is a common problem and there are several probable solutions. First, consider heated humidification as an adjunct to your CPAP machine. More times than not this should get rid of congestion almost immediately. I have also had patients who, in addition to humidification, would require decongestants or nasal steroids, which can be prescribed by your physician. But it's most important to allow your physician who is treating your sleep disorder to know congestion is a problem. Otherwise, he or she will not be able to help.
Member: I only sleep about three hours at a stretch, then either wake up and roll over or get up to use the restroom. Often, I feel very sleepy during the day, sometimes nodding off while reading or watching TV. I am 55, female, and in relatively good health. Is this a sleeping problem or something else?
Breus: This is relatively normal sleep behavior as long as you can fall back to sleep. You may find, however, that as you get older you may require more total sleep than you once did. I often suggest to people that they increase their total sleep time to eight-and-a-half hours for approximately two weeks. If, after that time, they remain sleepy, it may be best to see a sleep specialist.
Moderator: Is there a "fall back to sleep" time limit? If it takes half an hour or an hour to fall back to sleep, do you consider that a problem?
Breus: Generally speaking, most people should be able to fall back asleep within 20 to 30 minutes. If not, then there are several possibilities as to what may be keeping you awake. For example, many of our patients, once awake, begin to think too much and cannot turn off their brains. What I often suggest to them is to do something distracting but boring enough at the same time to help them sleep. Although this may sound funny, I ask them to count backwards from 300 by threes. This requires significant mental calculation and you aren't allowed to think of much else. Believe me, it would put anyone to sleep. Give it a try, and let me know what happens.
Member: I usually spend about seven to eight hours total in bed, but it is very difficult for me to get up. I lie in bed and doze off and on for some time before I finally get up.
Breus: In your situation, if you continue to have a difficult time waking in the morning and you're still getting enough sleep, it may be time to seek the help of a sleep specialist.
Member: I have trouble getting to sleep before usually 5 a.m., and I sleep until late afternoon. I have read about a sleep disorder called delayed sleep phase syndrome -- do you think this is what I have?
Breus: Although it's difficult to say, your sleep pattern is somewhat consistent with what research shows as delayed sleep phase syndrome. For a formal diagnosis, consider monitoring yourself over two weeks and present the data to a sleep specialist for formal diagnosis and possible treatment.
Member: I've seen two different doctors for this, and both have tried to refer me to a psychiatrist. This has been going on for over five years. No one seems to take me seriously when I say I think I have a sleep disorder.
Breus: Oftentimes, primary care physicians have not been formally trained in sleep disorders except to think that any issues with falling asleep are psychiatric in nature. As I mentioned, a sleep specialist can help you out with these issues.
Moderator: You've mentioned finding a sleep specialist a few times. What's the best way to find someone who can help?
Breus: There is a web site available that lists board certified individuals in sleep medicine in all 50 states. Go to www.aasmnet.org, and press the button that says public, which will give you a list of options that will give you a list of centers and a map of the U.S. Click on your state for a listing of centers and doctors in your area.
Member: What about finding a sleep specialist in Canada? Any ideas?
Breus: It's actually quite difficult finding sleep centers in Canada. There is, however, a Canadian Sleep Society. I would suggest contacting the American Academy of Sleep Medicine and asking them about possible listings for Canadian sleep doctors and centers.
Member: Do you recommend taking herbal supplements to assist sleep, such as valerian?
Breus: The research shows that valerian is one of the few herbal supplements that do help to enhance sleep. However, due to the nature of it not being regulated by the FDA, anyone can produce valerian and sell it at the local health food store. There is, however, a new product on the market made by GlaxoSmithKline called Alluna, which is a mixture of valerian and hops, which has been shown to be quite effective.
Member: I am a light sleeper and have a problem sleeping in even the slightest noise. I have been trying to acclimate to a white noise generator, but even that has been waking me after three to four hours. And earplugs seem to be uncomfortable. Is there anything you could recommend?
Breus: In these situations, oftentimes some type of sedative medication will help, including tricyclic antidepressants and hypnotics. Usually, someone's acute sense of hearing can have an underlying anxiety component attached to it, making people listen for noises that keep them awake. What we have found is if we can decrease anxiety surrounding noise and sleep, people will often fall asleep quickly. Another possibility is to deprive oneself of sleep such that you become so sleepy that you will fall asleep no matter what. Remember this can be quite dangerous in that if you are driving while sleepy you can be a hazard to yourself and those around you.
Member: Are sleeping pills a good idea?
Breus: It really depends upon the situation. We find that many people need sleeping pills to combat insomnia the same way that many people require hypertension medication to reduce their blood pressure. It is unfortunate that sleep meds have often gotten a bad rap by society. But if used properly, they are quite effective and harmless.
Member: Why do you think some people are light sleepers and some are heavier sleepers?
Breus: Actually, there has been little research in this area, but some people's brains have a tendency toward more deep sleep than others and it makes them more likely to be a deep sleeper as opposed to a light sleeper. There are many things that will create light sleep such as sleep disorders, certain medications, stress, and certain [emotional] problems, including depression and anxiety.
Member: I am on the maximum dosage of Provigil. How come it is not doing anything for me? I am as tired as ever. I have had all the blood tests done and everything is OK. Why am I so tired? Why isn't the medicine working?
Breus: In patients who've used Provigil within our practice, we start with 200 mg and move to 400 mg, and at times have used as much as 600 mg. However, that was under very close supervision. In our experience, we find Provigil to be most effective for individuals recently diagnosed as opposed to people with longstanding cases of sleepiness. There have also been instances where we have used Ritalin in small dosages in conjunction with Provigil with great success. If at this time you are not being effectively treated, it's important to let your physician know so he or she can try new combinations. I had one patient who required three different medications to keep them awake.
Member: I take Serzone and Effexor. One of them does make me sleepy. I can fall asleep but never can stay asleep. I can take Ambien, but it does not last long. Any suggestions?
Breus: In our experience with these medications, Serzone although initially helpful in consolidating sleep, can often cause later liver problems and we have decided in our practice to no longer use it. Effexor, being an SSRI [selective serotonin reuptake inhibitor] can also fragment sleep, causing someone to have an inability to sleep soundly throughout the night. Our practice has often found it necessary to escalate dosages to help people sleep longer. If, in fact, Ambien at any dose is not useful, then maybe a stronger hypnotic may be necessary. Consider speaking to your doctor prescribing these medications about your sleep problems so he or she can help.
Member: My father is on lithium for manic depression, yet now finds he has tinnitus. Could this be from the lithium? It is affecting his sleep habits as well. This is serious in nature, in that his third wife is ready to leave him. What is a guy to do, when sleep clinics are not available in Canada?
Breus: The tinnitus may be attacked by an ENT (ear, nose, and throat) doctor with certain devices that can mask the ringing in his ears. Lithium should not hinder sleep, but likely help it; thus the root of your issue may in fact be the poorly treated tinnitus. In this situation I would consider treatment of the tinnitus first to help with the sleep second.
Member: How much sleep does a person need?
Breus: Every individual's sleep need is just that, individual. The way to know how much sleep you need is to sleep until you feel refreshed on a regular basis. Sometimes this may not be easy due to social constraints but you must try anyway.
Member: I have a toddler, almost 3 years old. I can't get her to sleep at night. She fights me all the time. How can I get her to go to sleep? She also wakes up and doesn't want to go back to sleep.
Breus: There is a wonderful book called Solve Your Child's Sleep Problems, by Dr. Richard Ferber. He has written a chapter detailing a program for this. I would consider purchasing this book and using his program.
Moderator Also, please check out the archives for the transcript of our chat all about children's sleep issues with Tracy Hogg, author of The Baby Whisperer.
Member: Is it true that if you have an infant and try to keep some noise around while they are sleeping that they will not be light sleepers when they get older because they are accustomed to the noise?
Breus: Yes. That is true. Children will often times adapt to the noises around them if exposed to noise early on.
Member: Is there a way to contact you after this program?
Breus: Go to the WebMD Sleep Disorders message board. I am happy to answer all questions on the message board whenever possible. I try to answer questions each day, but sometimes it may take a day or so. Please be patient with me. I am looking forward to hearing from you.
Member: I am unable to fall asleep at night, most times at least until 3 a.m. and then wake up two to three times before getting up. I arise usually by 7 or 7:30 a.m. Is there any hope for my sleep disorder? This is making me extremely lethargic and agitated.
Breus: Probably the best thing to do in this situation would be to consider seeing a sleep specialist who should be able to determine why you may not be sleeping. However, I would also consider our sleep hygiene recommendations which you can find on the message board under Dr. Mike's FAQ's.
Member: What about people who work the night shift and then change to a day job; could this mess up sleep habits?
Breus: This is actually quite common and extremely poor for your internal biological sleep clock. Many people can do this for a time but eventually it catches up with them. I would consider taking only one job or at least one work schedule.
Member: What are your opinions on melatonin?
Breus: Pharmaceutical grade melatonin has been shown to be extremely effective in helping people sleep as well as resetting their internal biological clock. However, most melatonin these days is non-FDA regulated and oftentimes extracted from cow vomit. Thus I would be skeptical about using it.
Member: Do you recommend LAUP surgery? Are there any major negative side effects? I have heard a 33% chance of not much success.
Breus: Depending upon the circumstance, LAUP can be extremely effective. However, it is best to be identified by an ENT physician as to whether or not one is a candidate. In general, LAUP is 50-60% effective for curing obstructive sleep apnea. LAUP is laser assisted uvula pharyngioplasty, and it's a technique that's been used for the past five years for sleep apnea surgery.
Member: Is it OK to eat dinner an hour and a half before bed? Or will that keep someone awake?
Breus: It depends on what you eat. If you eat anything with caffeine or high volumes of sugar, it may, in fact, keep you awake. And alcohol, although helping put you to sleep will keep you in the lighter stages of sleep and will allow you to wake easily.
Member: Is it common for Sonata to not help?
Breus: Sonata is an extremely fast-acting sedative and if it does not work in the first 15-30 minutes, it may not be effective. It was originally designed for individuals who wake in the middle of the night to go back to sleep. Don't be discouraged. Just speak to your physician. You may need to try something else.
Moderator: We are almost out of time. Before we wrap up for today, do you have any final comments for us, Dr. Mike?
Breus: Thank you for attending this chat. I look forward to answering your questions on the message board here at WebMD, since we provide the highest quality health information in the world. Thanks again from Dr. Mike.
Moderator: Unfortunately, we are out of time. Thanks for joining us, members, and thanks to Michael Breus, PhD, ABSM, for being our guest. For more information, visit his sleep disorders message board here at WebMD.
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