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BTN Interview with Sleep MD, Dr. Daniel Barone, Part II

How much does the good doctor himself need to sleep and how much do you?  Is there a "magic bullet" fix for insomnia?  Our National Sleep Awareness Week feature with Dr. Daniel Barone continues...

LM: I think that sleep is a very suggestive thing, in general. 


DB: Suggestive? How so?


LM:  Well, it conjures up a lot of things for people.  You see people in the clinic that are coming to you because they already know they have some kind of problem.  I can tell you this though; the deeper I have gotten into the area of sleep and bedtime, the harder it has been for me to sleep from time to time.   But, I have learned that sleep is something you just can’t force.  My first episode with any insomnia happened during my first marriage, and then I ultimately learned that it wasn’t something I could force.  I had to give into it.  Many of my usual type-A plus personality “fixes” don’t apply to sleep.  It was a great big learning lesson in my twenties.


DB:  You are lucky to have learned that lesson because a lot of people don’t.  One of the things we see that perpetuates insomnia is an erratic sleep schedule.  We want to keep people on a regimen.   Obviously, one day here or there is fine, but with chronic insomnia, the way to tackle it is to get patients onto a strict schedule.


LM: You started to mention that some people could fall asleep anywhere, the “sleep easys,” as I refer to them, even in a loud bar for instance.  They might brag, “I can sleep easily, I don’t have a problem.” 


DB: It’s good to a point, but it can become pathologic.  For instance, in people with severe sleep apnea, we as doctors sometimes go out to the waiting room, and they are the ones sleeping out there.  They don’t get quality sleep at nighttime, or ever, and they start sleeping anywhere.  It’s true for apnea.  We see it with other diagnoses as well.  For instance, narcolepsy. 


LM:  Narcolepsy!  Such a scary thing to witness.  Have you ever seen that video of the poor dog that drops down suddenly and falls asleep anywhere?


DB:  Yes.  The Dobermans.  It’s a genetic thing and it was when narcolepsy was first studied.  Cataplexy. They get excited.   They are totally awake, but it looks like a drop attack or a seizure.  In humans with narcolepsy, it can be something as simple as their knees buckling, and it seems like they pass out, but it is REM sleep.  The body becomes paralyzed to prevent us from acting out our dreams.  In narcolepsy, it’s periods of REM sleep.  One of the things that results is atonia, or paralysis, and then it passes.

Narcolepsy is not necessarily what you see on TV, where people are just passing out in front of you, although that can happen. We call these “sleep attacks.”  More commonly we see people with an unrelenting need to sleep.  Sometimes, there’s a gap of about ten years from the time of having a symptom to the time of an actual diagnosis.  The typical teenager falling asleep in class, the teacher might think is just some lazy kid, and he might not be seen as needing a diagnosis.  But, they later get a job, and perhaps they’re falling asleep at their desk unintentionally.  Finally they come to see someone like me and they get diagnosed.


LM:  It’s pretty scary.  The issue of, “the anytime, anywhere, I can sleep person,” suddenly doesn’t sound so glamorous


But speaking of wanting to be able to sleep soundly all the time, these days we’re surrounded by so many different solutions meant to help us get the perfect night’s sleep. A normal person can become confused wondering, “Should I try this pillow, this potion?  Soak my feet?  Listen to this music?   Aromatherapy, lavender, linden flower, it seems there are a million and one possibilities out there.  So my question to you is this: in your mind, is there any one, single thing that leads to a best night’s sleep?  As you can imagine, at Bedtime Network we get asked this one a lot!


DB:  I’m sorry to say, “no.”  There’s no single, best thing; no “magic bullet.”   However, the best approach to any sleep problem is a combination of things:


1 - Keeping a regular sleeping and waking time. 

2 -  If, however, you’re doing that but you’re also watching TV in bed or doing work in bed or, if I give you a medication and you’re throwing everything else to the wind and suddenly not keeping a regular sleep and wake time, then you will not get better. 

It’s the  combined approach that makes a difference.


LM: Let’s talk about medication for a second.  In my mind, this breaks into two categories: natural remedies and unnatural ones.   There’s a lot in the news about the unnatural things --- and for the purposes of this interview, no particular drug in general needs to be mentioned, but there was a New York Times article very recently that referred to “Mother’s Little Helper” aka sleeping pills, as something that can kill you. Specifically, there was reference to a study that said that more than 18 pills a month can kill you.


DB: These are epidemiologic studies.  What they did in that study was to recognize that perhaps, you got prescribed “x” number of pills.  What happened to you years later?  Did you die of cancer?  Maybe the answer was, “yes.”  But there are further questions.  For instance, did these people actually fill that prescription? 


One sign and symptom of someone with cancer is that the body knows something is wrong and quite suddenly, someone may find that they cannot sleep as it is the body’s way of saying that there is a problem.  They go to the doctor and they say, I’m not sleeping.”  The doctor doesn’t think, “ Oh. Cancer.”  Instead, he may think, “let me give you something to help you sleep.”  Later, they are diagnosed with cancer and someone draws the conclusion that the sleeping pills were the culprit.

But what were the circumstances leading to the use of drugs?  If you’re taking 18 sleeping pills a month, what else are you taking?  What else are you taking with those drugs or in combination with that medication?  Did you take sleeping pills with a glass of wine?


LM: In terms of non-prescription drugs, is there anything you like?


DB: Ah yes!  I like melatonin.  It’s actually made by the pineal gland in our bodies, located in the middle of the brain.  In our most natural state (eg. when man is in the woods with no external stimuli) melatonin is made by the pineal gland as the light of day starts to fade.) That begins a complicated process in the body which ultimately enables us to fall asleep.


These days, the electronics in our society emit a lot of blue frequency light (the sun has a big spectrum of light) – and blue is what our eyes respond to mostly.  When we have computer screens, iPhones, and all sorts of devices bombarding our retinas with blue light, our bodies don’t make melatonin, and that’s one of the reasons sleep can become disrupted.


LM: Bedtime Network really speaks to the 40 plus year old woman.  Women are in charge of the sleep for the family, their own sleep, their kids and, they are probably somewhat in charge of their partner’s sleep patterns.  Quite possibly, there’s an elder’s concern somewhere in there too.  How is technology hurting the 40-plus year old woman at bedtime?


DB:  That’s a great question.  In America there is a tradition of watching TV before bedtime and now with the TV going (even if you’re not watching it), chances are you’ve also got your iPhone.  Maybe you have your computer with you too because you’re working in bed – and you say – why am I not sleeping?   Part of the solution is getting rid of all that stuff, at least a half hour to an hour before bedtime.


LM: Is insomnia more common in women than men?  What are some of the root causes?


DB:  Root causes?  It’s hard to say.  There can be many influences.  Mood disorders. Anxiety.  Depression.  Hormones.  All these things can play into it.  Depression is more common in women, however.


LM:  The one question that we get asked the most from women around the country is: “My night ends at 3:39 in the morning?  What can I do about this?”  Dr. Barone, this is the nugget issue for many Bedtime Network women, and you probably hear it all the time.  What can we tell them?


DB: That’s called sleep maintenance insomnia.  It means there is difficulty in maintaining sleep.  It’s usually around the same time every night. 


LM: They refer to it as, “my special time.”   You’d be surprised to know what women do during those wee hours.  We’ve heard everything from,  “I’m going into the basement to play my bagpipes to, “I’m painting my own Picassos,” at that hour.  Where does this come from?


DB:  There are multiple reasons.  A person may get up to use the bathroom.  Phases of life may be having an effect, especially as women begin to reach menopause.  Gearing this toward women, pregnancy can sometimes be a factor. 

But, one of the other reasons can be depression.  A symptom of a major depressive disorder can be early morning awakening.  Sleep apnea also does it and presents in women differently than in men. They may also have sleep maintenance insomnia from apnea.  They’re wired and they can’t fall back to sleep.  Poor sleep habits, watching TV, coffee late in the day.  These things don’t impact falling asleep, but their brain is going and then a few hours later they wake up.


LM: No good ritual to get themselves to bed.


DB:  Clinical depression does not necessarily present itself as, “I’m sad all the time,” which is one of the reasons it can be subtle or under-diagnosed.


LM: How is this treated?  What should somebody do?


DB: If there’s any hint of depression: see a psychiatrist.


LM:  I’ve known a few women that have taken Effexor.


DB: Effexor works on serotonin and norepinephrine and if taken in the morning, can make them feel better and may give them energy as well. 


LM: I hear this amongst random women chatting in the NYC dog park every morning! The problem with women is that if they can’t get sleep – and then they take a drug, sleep, and also get thin – they are thrilled!  It's almost too good to be true.


DB: If someone comes in and says that I’m waking up early in the morning, in a lot of cases, it requires a deeper look.  If this is your issue take a look.


LM: I am guilty of sometimes looking at my iPhone.


DB:   If you have no trouble getting back to sleep – it’s OK.  This is for people who have trouble getting back to sleep.   They get up and they know exactly what time it is.  One of the worst things you can do is look at the clock.  If you’re prone to anxiety or getting stressed out, it’s going to be a case of, “Oh no.  It’s 3:40 in the morning.”  And before you know it, it’s the worst thing and you’re not getting back to sleep.


LM: I have taken on a sleep mask!  My husband and I are not always synchronized.  As a composer/conductor he has musical sounds and notes running through his head all day and night and needs to drum it out with the sound of sports.  If you wake up in the middle of the night and you have a sleep mask on your face then by design, you’re not looking at the clock.  I think it’s an underestimated piece of equipment.


DM: Light’s an enemy at nighttime, going back to melatonin and the pineal gland.


LM: Any kind of word that you might have for pregnant women.  Do you see a lot of them here? 


DB: No. It’s a kind of given that it’s the, “way it is.”  What I would say is that there are certain conditions during pregnancy like insomnia, restless leg syndrome and others that can come on during pregnancy.  If they continue postpartum, tell your doctor.  Restless leg is diagnosed clinically.  If you answer yes to a certain number of these questions; then restless leg might be your diagnosis.  Periodic limb movement would be diagnosed by observation overnight.


LM: Are they keeping a camera on you?  You watch people all night long?  Throwing their covers off and on?


DB: Sometimes doing more interesting things.  Sleep talking.  Sleep walking.


LM: Sleep walking?  It’s not just a movie theme?


DB: It’s real.  Not as profound as a movie like “Stepbrothers.”  Even just getting up – screaming up and shouting out – these things are issues.


LM:  Is this related to "night terrors" in kids?


DB: Night terrors are more common in children and as you get older tend to go away.  In adults – sleep talking and sleep walking – the question there is whether something is disrupting their sleep causing these arousals to happen.  In and of itself, it’s usually not a problem, but there is a cause for these, “parasomnias.”


LM: It’s a good movie title.


DB: Actually – there has been one!


LM: What do you feel is the biggest challenge for people trying to get a good night’s sleep?


DB: In this day and age, the biggest challenge is the amount of potential stimuli around us.  It’s a killer.  The average person sleeps six hours a night, and we’re all doing our work in bed, and thinking in bed…Email, texting and, working -- all in bed.  After 10 pm, I tell my patients that at least a half an hour to an hour before bedtime, turn it off.


LM: Have you seen anything of the low blue light glasses?


DB: They were studied in people with bipolar disorder.  To my knowledge, I don’t know if they’ve been studied in people with real insomnia.  I think there’s some utility and the idea is good, but I’m not crazy about the way they are advertised. 


LM: Have you seen them advertised on late night TV?


DB: No.  I have not. They are a bit expensive.


LM: There’s a cheaper version I’ve seen on Amazon too.  It’s interesting.


DB: Definitely makes sense from a scientific point of view. 


LM: March around your house three hours before bedtime wearing these bizarre orange "sunglasses," or more properly stated, a pair of "low blue lights". ..


DB: It’s a good idea, but the science behind them is not complete so I would not necessarily be pushing these glasses and saying, “peace be with you.”  In theory it works, but there are things I would do aside from that.


LM:  (laughing).  Peace be with you!  That alone seems like good advice for a good night's sleep!


Stay tuned for Part III tomorrow.  

Dr. Daniel Barone is currently an Assistant Professor of Neurology at Weill Cornell Medical College and an Assistant Attending Neurologist at New York-Presbyterian/Weill Cornell Medical Center.  He sees patients primarily at the Weill Cornell Medical College Center of Sleep Medicine and specializes in the evaluation and management of patients with all forms of sleep disorders including sleep apnea, restless leg syndrome, insomnia, and narcolepsy.  He is certified by the American Board of Psychiatry and Neurology as well as the American Academy of Slep Medicine and is a member of the American Academy of Neurology and the American Academy of Sleep Medicine.  He was recently honored as a Consumer's Research Council of America's "Top Physician" in Sleep Medicine for 2012.