Sleep Hygiene September || Take 2 Tips: Read to Relax.

AUG 25 || HUFFINGTON POST
Great Motivational Quotes To Read Before Going To Sleep
"Countless studies have shown that people with higher levels of gratitude and positive thoughts before bed slept longer and reported better rest quality than those with more negative thoughts."

SEPT 14 || ROMPER
9 Books To Help You Cope With Anxiety
“Edmund Bourne's The Anxiety and Phobia Workbook is highly recommended for people suffering from anxiety. The book touches on cognitive therapy, relaxation techniques, and even lifestyle changes like diet and exercise."

Subscribe now to follow our daily September series:

||  TAKE 2 TIPS & FEEL BETTER IN THE MORNING  ||

To subscribe or follow, see all the available options in the right-hand column

WHAT'S HAPPENING: SLEEP AND THE 4 Ms: Mind, Mental Health, Mood, and Memory

Check out this latest curation of news stories appearing since July 15 which focus on Sleep and the 4 Ms: Mind, Mental Health, Mood, and Memory. Topics discussed in this latest curation include:

• Poor decision making, judgment, and vigilance as they relate to sleep deprivation
• Sleep deprivation and politics
• PTSD and sleep disorders
• Nightmares in people with other sleep disorders
• How childhood or long-past trauma can continue to impact sleep
• The link between TBI and poor sleep
• Bipolar disorders and circadian rhythms
• Cancer, poor sleep, and mood disorders
• Sleep's impact on the mental health of children, adolescents, and seniors
• How to sleep when the sky is falling
• Seasonal affective disorder... in the summer?
• Using sleep apps to help conquer depression and anxiety
• The research gap between sleep and emotions
• Sleep's impact on memory formation in the mentally ill
• Memory consolidation during sleep
• Using electronic nerve stimulation during sleep to assist in memory

[Go there now!]

IN CASE YOU MISSED IT: Some of our best posts on sleep and its link to mental and emotional wellness

SleepyHeadCENTRAL has already posted a lot of good information showing connections between sleep health and depression, anxiety, PTSD and other struggles with emotional or mental well being.

INSOMNIA

• Are Insomnia and Winter Depression linked?
• Insomnia: Why is it linked to depression?
• The problem with insomnia forums
• Sleep Disorders 101 || What is Insomnia?

PTSD

• Ken Scholes on Sleeping and PTSD
• Safe sleeping with PTSD
• The very real fear factor of PTSD-troubled sleep following heart attacks

THERAPIES FOR ANXIETY AND DEPRESSION

• How meditation can help
• Mother's Little Helper: Things You Should Know
• Sleep hygiene tips to help Junior overcome fear of the dark

SleepyHeadCENTRAL encourages you to see the connections during Mental Health Awareness Week, Oct 4-10

Some sleep disorders have nothing to do with mental health issues. And some mental health issues have little in common with sleep disorders. But there are plenty of reasons why people with sleep problems should be wary of the potential for succumbing to mental illness like depression or anxiety, and for those with either problem to be especially mindful of their sleep habits, as one can argue that the intersectionality between the two is not only common but based in scientific fact.

SleepyHeadCENTRAL strongly support Mental Health Awareness Week, observed October 4 through 10. Please read the following links curated below to improve your understanding of how sleep health and mental health are inextricably linked. More information about the week's sponsor, the National Alliance on Mental Illness, can be found here.

BUSTLE || 11 things people with anxiety want you to understand
"Be gentle with us if you see that we're tired and cranky, because we probably didn't sleep at all last night."

DAILY MAIL|| Lack of sleep drove me to the brink of madness... and it could happen to you too
"Four years on she wonders how many sleep-starved mothers are dismissed as post-natally depressed and prescribed anti-depressants when what they really need is eight hours’ sleep."

DAILY TIMES || 5 deadly things happen if you don’t get enough sleep
"Insomniacs are also twice as likely to develop depression, and preliminary research suggests that treating sleep problems may successfully treat depressive symptoms."

THE EXAMINER || SAD to say it is that time again
"An individual with this type of depression can experience a wide range of symptoms including increased moodiness, decreased energy, disturbed sleep, changes in appetite, increased anxiety, irritability and/or lack of motivation."

HARVARD BUSINESS ONLINE || Sleep Deficit: The Performance Killer
"In reality, the research suggests that even small amounts of sleep deprivation take a significant toll on our health, our mood, our cognitive capacity and our productivity."

HARVARD BUSINESS ONLINE || Sleep is More Important than Food
"In reality, the research suggests that even small amounts of sleep deprivation take a significant toll on our health, our mood, our cognitive capacity and our productivity."

HUFFINGTON POST HEALTHY LIVING || Is Sleep Deprivation Making You Suicidal?
"'[By being sleep deprived, you're] setting up the same situation as people with clinical depression,' explains Dr. Oexman, who oversees the Sleep to Live Institute's research studies, particularly the studies on the impact of the sleep environment on quality of sleep."

IOL || Children who have trouble sleeping are more likely to develop mental health problems, researchers warned recently
"They said disturbed sleep patterns could be a warning sign of future problems including anxiety, depression and schizophrenia, and disorders such as autism."

JOURNAL OF CLINICAL SLEEP MEDICINE || Depressive Symptoms before and after Treatment of Obstructive Sleep Apnea in Men and Women [abstract]
"Depressive symptoms are extremely common in people who have obstructive sleep apnea, and these symptoms improve significantly when sleep apnea is treated with continuous positive airway pressure therapy, a new study shows."

JOURNAL OF EMERGENCY MEDICAL SERVICES || Survey Reveals Alarming Rates of EMS Provider Stress and Thoughts of Suicide
"Sleep deprivation, feeling underappreciated, poor nutrition and exercise are just a few of many issues that may contribute to poor mental health in this field."

MEDICAL DAILY || Sleep Deprivation Messes With The Brain's Emotional Response, Makes Everything Seem Important
"Lack of sleep throws the brain regions associated with emotion off balance, finds a new study."

MEDLINE PLUS || Sleep Apnea May Raise Risk of Depression: Study suggests popular apnea treatment could help ease symptoms of mood disorder
"The findings highlight the potential for sleep apnea, a notoriously underdiagnosed condition, to be misdiagnosed as depression," he added."

NATIONAL SLEEP FOUNDATION || The Complex Relationship Between Sleep, Depression & Anxiety
"...[A]ltered sleep patterns are a hallmark of many mental health issues."

NIH || Sleep disturbances and suicide risk: A review of the literature [pdf]
"As a warning sign, disturbances in sleep may thus be especially useful to research and may serve as an important clinical target for future suicide intervention efforts."

PSYCH CENTRAL || Depression-Mortality Link in Heart Failure
"We know that depression is common in heart failure and affects 20 to 40 percent of patients. Depression is often related to loss of motivation, loss of interest in everyday activities, lower quality of life, loss of confidence, sleep disturbances, and change in appetite with corresponding weight change. This could explain the association we found between depression and mortality."--Professor John Cleland of Imperial College London, UK

RAW STORY || Here are 8 ways you don't realize stress is ruining your health
"As we get older, sleeping patterns often change and we may experience a decrease in the amount of deep sleep we get. ...This in turn leads to sleep deprivation, shown to cause memory lapses and lack of emotional control, leading to a further cycle of stress and sleep deprivation."

SCIENCE DAILY || Losing hope of a good night's sleep is risk factor for suicide
"'It turns out insomnia can lead to a very specific type of hopelessness and hopelessness by itself is a powerful predictor of suicide. ...It's fascinating because what it tells you is we have discovered a new predictor for suicidal thinking.'"-- Dr. W. Vaughn McCall, Chair of the Medical College of Georgia Department of Psychiatry and Health Behavior at Georgia Regents University

SCIENTIFIC AMERICAN || Can a Lack of Sleep Cause Psychiatric Disorders?Study shows that sleep deprivation leads to a rewiring of the brain's emotional circuitry
"Study shows that sleep deprivation leads to a rewiring of the brain's emotional circuitry."

VAN WINKLE'S || The Disturbing Relationship Between Sleep, Depression and Suicide
"At least 3/4 of clinically depressed people struggle with sleep, and insomnia is a well-proven risk factor for suicide."

WASHINGTON POST || Schools and parents need to help kids sleep more, says the CDC. Here’s how.
"Research shows that most teens get seven hours or less of shuteye a night, leaving them chronically sleep-deprived. And too little sleep leads to serious health risks, including depression, stress, obesity and car crashes induced by drowsiness."

WEBMD || Sleep and Depression
"If you've been diagnosed with clinical depression, you may be having trouble getting to sleep or staying asleep. There's a reason for that. There is a definite link between lack of sleep and depression. In fact, one of the common signs of depression is insomnia or an inability to fall and stay asleep."

Today's #Sleeptember FACT --- Teens sleep (or don't sleep) like that for a reason

By now you've probably heard that late bedtime and sleep-in periods for teenagers are part of the normal final development of their brain.

This delayed sleep phase in adolescents is usually just that--a phase--though adults may never "grow out of it" and end up being night owls. This can be a good or bad thing depending upon the goals of a person with late-night "eveningness," but that is the subject of another piece.

#SLEEPTEMBER

Teenagers are experiencing delayed sleep phase for a variety of reasons but what we all need to remember is that they still very much need their sleep, but aren't getting it. National Sleep Foundation Sleep in America polls annually bear out the truth: our teens are sleep deprived, due to burdensome schedules filled with homework, activities, sports and jobs.

On top of that, they are consuming large quantities of caffeine to medicate away their daytime sleepiness, getting into more automobile accidents than ever before, and suffering sleep-related health issues like anxiety, attention deficit, depression, even obesity, as a result.

To learn more about American teen sleep habits, check out the 2006 Sleep in America poll teen results here.

Today's #Sleeptember FACT --- Sleep apnea and the brains of women

If you're hip on your sleep knowledge, then you probably already know that obstructive sleep apnea (OSA) is not just a man's disease, but rather common in women, too.

If this is new to you, listen up: For decades it's been thought that women did not normally get OSA, but recent findings and regular clinical observation in sleep labs shows that women not only suffer from OSA, but they often do not even know that they have it.

#SLEEPTEMBER

It's not just common in obese women, either (though carrying extra weight is a major risk factor). Age, physiological structure of the cranium and jaw, pharmaceutical interactions, estrogen levels, pregnancy status, and other medical conditions can all contribute to sleep apnea.

The consequences of untreated sleep apnea for women mirror those for men, as well:

• High blood pressure
• Increased risk for stroke
• Development of heart disease
• Onset of diabetes
• Depression 

However, women with untreated OSA have been shown to actually suffer higher degrees of brain damage as an outcome when compared to their male counterparts.

In a multi-year study conducted at UCLA, "Sex Differences in White Matter Alterations Accompanying Obstructive Sleep Apnea," researchers confirmed that women, in fact, not only suffer brain damage from OSA (which is true for men, as well), but that they suffer it differently than men.

The areas in the front of the brain, which are responsible for decision-making and management of mood, were shown to have more OSA-related damage than in the same brain areas in men. This damage can lead to higher levels of depression and anxiety symptoms in women who have untreated OSA.

The differences were so pronounced in the study that its chief investigator, Paul Macey, concludes that "doctors should consider that [OSA] may be more problematic [for women] and therefore need earlier treatment in women than men."

Never assume that just because you are a slim young woman, that you are less likely to have OSA. If somebody tells you that you snore loudly and gasp or stop breathing in your sleep, take their observation seriously and consult a medical professional. Earlier treatment of hidden sleep breathing disorders like apnea is not only ideal, but critical for managing your overall health. 

Source: "Sex Differences in White Matter Alterations Accompanying Obstructive Sleep Apnea." Macey PM, Kumar R, Yan-Go FL, Woo MA, Harper RM. Sleep. 2012 December 1; 35(12): 1603–1613. Published online 2012 December 1. doi: 10.5665/sleep.2228

Today's #Sleeptember FACT --- Cancer and its treatments can cause enduring sleep problems

#SLEEPTEMBER

If you or a loved one has cancer, you probably already know this first hand: Cancer can lead to all sorts of problems with sleep.

The cancer itself can wreak havoc on the body in such a way that it either leads to extreme daytime somnolence and fatigue, nightmare syndrome or the curse of insomnia. Anxiety about cancer can lead to poor sleep. The pain that cancer causes can also make sleeping nearly impossible due to comfort issues. Add to the mix a variety of cancer treatments (and their delivery systems) as additional challenges to achieving quality sleep while fighting to overcome cancer. Good sleep helps the body heal, but it's just so hard to get good sleep as a cancer patient.

According to the National Institutes of Health National Cancer Institute,

Sleep disorders are more common in people with cancer... as many as half of patients with cancer have problems sleeping.

Their website offers a wealth information about the relationship between sleep and cancer at their website. They discuss the impact of hospital stays, tumors, stress, drugs and other conditions on both cancer and sleep quality. They also discuss sleep health assessments and solutions for sleep problems that could offer many cancer patients relief and even aid in their healing.

• Learn more about identifying and treating sleep disorders in cancer patients at the National Cancer Institute
• Read about poor sleep and its potential to increase your cancer risk from the National Sleep Foundation
• Discover how poor sleep can impact a cancer patient's recovery rate from the American Academy of Sleep Medicine

ABCs of SLEEP || F is for Fragmentation

Fragmentation is what occurs during sleep when you struggle to maintain one long stretch of uninterrupted sleep. Instead, you awaken frequently, and can't get good blocks of deep sleep, as a result. It is a marker of sleep-maintenance insomnia, the kind of insomnia in which you have no trouble falling asleep, but you arouse easily and often and, therefore, cannot maintain sleep.

What makes fragmentation particularly difficult is that if you have multiple periods of awakening, you become conscious that you aren't sleeping, but that you should be sleeping. Rumination and hypervigilance about sleep loss tend to perpetuate anxiety, which then only adds to your inability to fall asleep again. If you have ever watched the clock all night long, after falling asleep easily but waking up frequently after you've fallen asleep, then you are experiencing fragmented sleep.

The worry that comes with not getting good sleep isn't without good reason. Fragmented sleep can be a nighttime devil for many.

When your sleep is fragmented, you are less likely to cycle through the slow-wave sleep that helps your body heal and you are more likely to wake up unrefreshed in the morning (because you've been awake, on and off, all night).

Sleep fragmentation also threatens certain brain processing functions like memory consolidation and can even interfere with the brains ability to keep consciousness and memory separate.

As we age, our sleep is more likely to fragment, though it's not well understood as to why. It could be a normal byproduct of aging or the result of medication use or the presence of other illnesses.

People with depression and anxiety, who also have fragmented sleep, may see their mental illness worsen. Also, people with Parkinson's Disease, dementia and other neurological troubles may report broken sleep patterns as a symptom of their condition.

Other sleep disorders, like narcolepsy, periodic leg movement disorder, restless legs, UARS and sleep apnea, may also lead to sleep fragmentation.

Treating sleep fragmentation requires identifying its root cause first and treating it. Easier said than done...  If there are no physical or mental illnesses or medications that could explain the sleep fragmentation, then doctors have little else to go on except for the presence of sleep-maintenance insomnia. Patients with this sleep disorder may benefit greatly from cognitive behavior therapy.

SLEEP STUFF: Smartphone apps for sleep

Probably more popular than any other category of "sleep stuff," smartphone apps are cheap, easy to access and make a lot of appealing promises to help improve sleep quality. If people think a $1.99 phone application will fix their sleep concerns, they will easily choose that over a visit to the doctor's office. Unfortunately, whether these apps actually work is still a matter of opinion and subject to scientific scrutiny. But some apps may help insomniacs fall asleep faster, and others might help with sleep hygiene or at least give the user a general idea about the nature of their sleep patterns.

What kinds of sleep apps are out there? What are the risks in trying these products? What's already been discussed about consumers using sleep apps?

KINDS OF APPS
Here are the main general categories of sleep apps, many of them belonging primarily to one category but often bundled with some features offered in other categories. Note: If your app requires a visual aid for you to use it, be warned that the blue spectrum light your device emits will turn off your body's natural melatonin production and delay sleep onset. Instead, use a blue-light filter on the device you are using to display the app, or wear blue-blocking eyewear, or best of all, use an app that doesn't require a visual display to work.

• Audio relaxation apps
  These include music, white or other "colored" background noise, verbal guided meditations, vocalized hypnosis, binaural beats, isochronic tones, and other sound effects that promise to help you relax so you can fall asleep. Examples: iSleep Easy, Pure Sleep | AmbiScience™, Relax Melodies, Sleep Bug, Sleep Sounds, Sleepy Time
• Breathing apps
  While technically not sleep apps, these programs can help induce sleep by borrowing from the breathing techniques often taught in yoga or relaxation classes. Ideally, you will learn the techniques and eventually not need to follow the prompts from the apps, but practice them as a good habit at bedtime. Examples: Breathe2Relax, Breathing Zone, Universal Breathing: Pranayama
• Sleep stage tracking apps
  Using various kinds of monitors, these apps claim to track vital or other biological signs in order to identify sleep staging and different elements of sleep quality. You might need to add additional wearable devices to get these to work. Examples: Beddit, FitBit Sleep Debt, Jawbone UP, MotionX 24/7 (Sleep Tracker feature), Sleep Better, SleepBot, Sleep Cycle. Also: While Sleepyti.me doesn't track your sleep, it does set your bedtime schedule based on your wake up time that morning.
• Kids sleep monitoring apps
  As suggested, these help parents to keep an eye on babies and even older children while they sleep. They include some claims about sleep stage tracking technology as well. Examples: Baby Connect, Kids Sleep Dr., Sleep Pillow Baby Lullaby
• Alarm clock apps
  More than just an alarm, this kind of app uses other effects with the promise that they will help you wake up more gracefully in the morning. Examples: EasyWakeUp, Morning Sun, Proactive Sleep, WakeApp
• Sleep disorder diagnostic and therapeutic apps
  Perhaps the most high-tech of the bunch, and potentially the most useful, these devices can help track and record key information that could help a physician diagnose a sleep breathing disorder, a movement disorder, parasomnia or insomnia. Examples: ApneaApp, CBT-i Coach, S+, SleepRate

RISKS

The most obvious risk is that the consumer spends money on a product that doesn't work. It could be 99 cents, or it could be $99, depending upon the device, the services it might require the user to link to and any additional hardware you need to buy.

Another risk is that the devices just aren't accurate. It may seem like devices these days can do darn well anything. A laptop seems to be the device that flies the airplane anymore, and we can send text messages to someone clear around the world. Why can't sleep apps do the heavy lifting?

Ideally, it will become as simple as this. Even home sleep testing has minimized some of the more complex preparation that an overnight sleep study requires; there are fewer sensors and the patient can conduct the test at home. But even these tests are for ruling out candidates and are largely not sensitive enough to make a confident diagnosis of any sleep disorder without the aid of the higher technology used in the actual sleep lab.

It also makes sense, from the point of view of a person who works in sleep technology, that the data collection on these devices has to be somewhat limited. Most of these devices do not accurately measure brain waves, which are necessary to identify sleep stages. Heart rate monitors cannot be relied upon to validate sleep stages, though some app developers will tell you otherwise.

Most of these apps rely on a form of actigraphy, a kind of wearable or local motion sensor you use with the app while you sleep to show your activity during the night. But while these sensors notice activity, they can't discern whether the data showing waking patterns is related to apnea, the dog jumping on the bed, or the activity of a sleepwalker.

In addition, sleep apps do not really have sophisticated enough sensors to measure sleep breathing patterns and blood oxygen levels unless they are paired up with a pulse oximeter and other expensive sensors. Even then, dips in O2 saturation aren't always due to apneas, so it's hard to guess at the root cause of changes in these important sleep-related vital signs without actual observation. 

The overnight polysomnogram remains the gold standard for diagnosing sleep disorders because it includes sensors that measure body limb movement, respiratory effort, heart rate and rhythm, respiratory rate, blood oxygen saturation, eye movement, brain waves, airflow, audible recording of resistance issues and video recording of behaviors like sleepwalking or restless legs that often need to be witnessed by the human eye to be confirmed.

Finally, there's a psychological component to using sleep trackers that may have a negative impact on users' sleeping habits. Dr. Siobhan Banks, a researcher for the Sleep Health Foundation, recently suggested that sleep apps may prevent some users from getting enough sleep due to worried obsession about what the tracker is recording, not unlike the same behavior that happens with insomniacs who watch the clock all night long.

UNDER SCRUTINY
Very recently, the Journal of Clinical Sleep Medicine shared the results of a small study of smartphone users using a specific app to determine its accuracy when compared to overnight polysomnographic (PSG) data collection (aka a sleep study) ("Is There a Clinical Role For Smartphone Sleep Apps? Comparison of Sleep Cycle Detection by a Smartphone Application to Polysomnography").

Their conclusion? "Our study shows that the absolute parameters and sleep staging reported by the Sleep Time app (Azumio, Inc.) for iPhones correlate poorly with PSG. Further studies comparing app sleep-wake detection to actigraphy may help elucidate its potential clinical utility."

Equally, parents who wish to monitor their kids' sleep should be cautious before investing in the accuracy of these devices. According to a report published by Monash University headed by Dr. Sarah Biggs (Melbourne Children’s Sleep Centre), “The results of our study showed that the smartphone application did not accurately assess sleep, substantially overestimating the amount of time the child was asleep and underestimating the number of awakenings during the night."

Accuracy is no small matter. The case of inaccuracy with blood pressure measuring apps shows the kind of ethical dilemma that may also be in store for the programmers of other kinds of medical apps. BP monitoring apps are offered "for entertainment purposes only" and are not cleared as medical devices by the FDA, and yet they are still among the most downloaded and used medical apps, despite their inaccuracy. The danger in the discrepancy between a reading on a phone BP measuring app and an actual blood pressure cuff reading may be enough to endanger someone's life.

Psychology Today offers this excellent discussion ("Sleep Cycle App: Precise or Placebo?

What's the verdict on sleep-tracking apps?"--Oct 2013) reviewing sleep apps (especially those interested in tracking staging and sleep quality) to help you decide whether these are right for you. Sleep Junkies puts specific apps to the test against the gold standard of the polysomnogram in this great consumer investigation of popular sleep tracking applications; they also explain in simple terms just what needs to be measured scientifically for a sleep disorder diagnosis to be conclusive. And the American Academy of Sleep Medicine has also taken on the subject ("Smartphones for sleep: Can sleep-tracking apps improve your sleep?"), providing guidelines for those who may be turning to phone apps because they are concerned and need to identify sleep problems. 

THE FUTURE

Whether the technology is accurate or worthwhile right now is probably not as important to note as where it might be headed. More sophisticated sensors and accurate tools for helping out people with serious sleep problems is an important goal, given the problems the population has with sleep health. 

For instance, more people suffer from insomnia than from any other sleep disorder. A new app, Zziesta, holds out hope as a means for helping insomniacs reclaim their shut-eye. While it's not on the market yet, and it's safe to assume it will have "bugs" to fix once released, the promise of sleep that this app offers, like all the other apps, is encouraging. 

Like many efforts in technology, this latest trend, if appropriated by diligent sleep health promoters and held to the highest standards of evidence-based testing, could mean helping a lot more people improve their sleeping habits and feel better, which ultimately means they will live longer and have a better quality of life. 

____________________________________________________

SleepyHeadCENTRAL strongly encourages people with ongoing sleep health problems to approach a medical professional to determine appropriate differential diagnoses and treatment. This post, like all other posts on SHC, is not intended to substitute for medical advice.

See SLEEP STUFF series main disclosure notifications here regarding any products discussed on this blog. 

WOMEN & SLEEP: Hormones, how could you?

When it comes to sleep problems, women get the added bonus of hormone-related issues which can disrupt nighttime sleep. Even healthy women with no other health conditions and no measurable sleep disorders can still struggle to get good sleep, thanks to visits with their monthly "friend." It can start as early as puberty and the start of menses (called menarche); can continue through young adulthood, pregnancy, and middle-age; and finally, it can lead right into the shifts we know as menopause. Any hormone therapies used at any time during the lifespan can also contribute to some sleep issues as well.

What is happening with female hormones that mess with the sleep process?

Let's review a typical menstrual cycle first.

Generally speaking, the menstrual cycle describes the full range of hormonal shifts generated by the body over a typical four-week period (of course, this varies widely from one individual to the next, but for our purposes, we're calling the cycle a 28-day one).

Menstruation involves several key organs: the ovaries, the uterus and endometrium, the vagina and the cervix.

The ovaries house a female's eggs; she is born with all of these, but they are not mature and will not be released until puberty, after new hormones flood the bloodstream and prompt their maturity. They are then distributed monthly over the reproductive lifespan of the female for the purpose of reproduction.

The uterus is the womb, the large organ meant to house and grow a fetus from a fertilized egg or embryo to a full-grown baby. Its lining is known as the endometrium.

The vagina is the passageway that connects the interior of the women's reproductive system to the body's exterior.

The cervix is the opening between the vagina and the uterus; think of it as a gatekeeper that opens more easily during the most fertile time, but is less accessible during the infertile stages of one's menstrual cycle.

Let's talk about hormones now.

The ovaries also release varying amounts of two key hormones to help regulate this process: estrogen and progesterone. Their levels in the bloodstream influence the quality of the lining of the uterus as well as the quality of the cervix. Both organs are extremely sensitive to this changing chemistry. These two hormones work in synch to prepare all the female reproductive organs for the potential implantation of a fertilized egg. When no eggs are fertilized, the lining of the uterus sheds via the blood and other fluids and tissues that have collected there over the cycle (this is what we think of as our "period,") and then a new cycle begins.

Estrogen is responsible for helping the body to develop all the accessory organs of the reproductive system (the uterus, the breasts, pubic hair, fatty deposits along the hips and breasts) as well as encourage the widening of the pelvis in preparation of a potential pregnancy. Estrogen also plays a role in metabolism. But you can think of estrogen as the harbinger of puberty.

Progesterone is the key hormone for the growth of the embryo, so it plays a much larger role during pregnancy than at other times, by inhibiting contractions in the uterus during pregnancy and helping the breasts to develop milk. However, progesterone during pregnancy is no longer produced by the ovaries, but by the placenta, the sac inside which the embryo grows.

Two other critical hormones include follicle stimulating hormone (FSH) and luteinizing hormone (LH); the roles these hormones play are described below.

Though women think of their "time of the month" as just being a few days, the actual menstrual cycle is not just a one-week process.

The first five days of the cycle are called the menstrual phase. This is the actual "period" part of menstruation, where blood and cells are sloughed away from the lining of the uterus and voided through the vagina as "flow." There is a major drop in progesterone at this time due to the absence of an implanted embryo. This is a time of infertility with no ovarian activity.

From days 6 through 14, the proliferative phase, estrogen production amps up, stimulating the process of relining the uterus. This is the fertility period, in which eggs in the ovary are developed and released for potential fertilization (usually around day 14). Another hormone is responsible for this process: follicle-stimulating hormone (FSH). It helps to mature eggs in the ovary. Because of FSH, there is more mucus in the cervix, which will also dilate somewhat and soften to receive released eggs for potential fertilization and implantation.

The secretory phase, from days 15 through 28, leads to higher production of progesterone by a separate organ within the ovary (the corpus luteum), prompted by the estrogen-primed status of the uterus. Luteinizing hormone (LH) helps aid in the actual release of the mature egg. Progesterone is the hormone that helps to nourish the organs of both mother and baby in the event an embryo (fertilized egg) has been implanted in the lining of the uterus.

At the tail end of this phase, women who are not pregnant will experience cramping, bloating, mood swings and other premenstrual discomforts as the hormones respond by shifting to the infertility phase. The ovaries continue their careful chemistry balance and egg maturation, the lining of the uterus breaks down to be released in the flow described in the menstrual phase (above) and the cervix dries and firms up.

However, if there is an embryo, the progesterone levels continue to rise and the placenta takes over its production, allowing the ovaries to take a break during pregnancy.

This description of the menstrual cycle more or less describes what happens throughout a female's lifespan between the age of puberty onset and menopause, unless they are pregnant. During pregnancy, the major rise in progesterone during that period of time can lead to all kinds of side effects: See our introduction to sleep during pregnancy here for more details.

At menopause, estrogen levels drop as there are fewer eggs to mature and release until, eventually, your cycles stop entirely. These changes in hormone levels lead to erratic changes in flow, mood swings, hot flashes, night sweats, sleep disturbances and vaginal pain during intercourse. Perimenopause marks the period of this transition in hormones, whereas menopause marks the point in which 12 months have passed without a menstrual cycle, which confirms the egg supply is empty.

But how does any of this relate to sleep?????

Hormone levels have a tremendous impact on sleep. When women are younger, they experience fewer problems with hormone-related sleep disturbances, but as they age (or during pregnancy), their sleep can become more disturbed, lighter and less refreshing. Estrogen and progesterone both have a chemical influence on sleep and can be partly to blame for problems with daytime sleepiness and sleep disturbances when their levels are out of balance (usually during the premenstrual period, pregnancy, postpartum periods and perimenopause). Also, it's been shown that lower estrogen levels during menopause may lead to problems with increased upper airway resistance during sleep, snoring, and obstructive sleep apnea.

For those women, from menarche all the way to perimenopause, who are not pregnant, rapidly changing hormones on a monthly basis can still lead to pain, such as headache or cramping, that can disrupt sleep.

Pregnant women (see our 4-part series on Adventures in Sleep for the Pregnant Woman to learn more) can encounter a multitude of sleep problems that are related not only to the circumstances of pregnancy, but to raging hormones.

For women who are in perimenopause, side effects caused by changing hormone levels, like night sweats and mood swings, can also interrupt sleep. Dr. Sharon Wong of Adventist Medical Center in Portland quotes sleep studies that show that "women are more prone to having their sleep disturbed in the first half of the night by having a hot flash.” However, “[d]uring REM sleep, in the latter half of the night, women seemed to be more able to suppress their sleep disturbances.”

Fortunately, once menopause sets in, these side effects do subside.

What can a woman do about sleep problems that she suspects are related to hormonal changes? It's always a good idea to speak with your doctor first about your concerns. Sleep problems have multiple causes and root causes need to be ruled in or out. If your doctor determines your sleep issues are related to hormones, you will have to decide what therapy is right for you. There are drug therapies, herbal therapies, lifestyle changes and/or simply riding out the phase. Your therapy will reflect what is most important for you.

Ultimately, if hormones are messing with your sleep, one of the best things you can do for yourself is to practice excellent sleep hygiene and address any issues you may have with depression, mood swings or anxiety, which may be aggravating your sleep as well as the hormone shifts themselves.

Spectrum Health offers this informative Q&A Session with Dr. Diana Bitner, an OB-Gyn who has some good advice for dealing with sleep problems that could be the result of menstrual cycle issues.


Sources

Hertz G, Cataletto ME, Benbadis SR. "Sleep Dysfunction in Women." Medscape. (2013, May 14). Retrieved on May 22, 2015 from http://emedicine.medscape.com/article/1189087-overview

Marieb EN. (2012). Essentials of Human Anatomy and Physiology. San Francisco: Pearson Education.

Popovic RM, White DP. "Upper airway muscle activity in normal women: influence of hormonal status." Journal of  Applied Physiology. March 1998;84(3):1055-62

Ross, M.  "Women: Depressed, agitated, can't sleep? It could be hormones." Contra Costa Times. (2014, April 30). Retrieved on May 22, 2015 from http://www.mercurynews.com/bay-area-living/ci_25661843/women-depressed-agitated-cant-sleep-hormones

Shaw, G. "Women, Hormones and Sleep Problems." WebMD, nd. Retrieved on May 22, 2015 from http://www.webmd.com/sleep-disorders/features/women-hormones-sleep-problems

WOMEN & SLEEP || Introducing Adventures in Sleep for the Pregnant Woman

It may or may not surprise the new mother-to-be to learn that their sleeping habits may suffer even before they have their baby, even as soon as a few short weeks into pregnancy. In fact, the sleep deprivation that comes of starting a new family can begin well before the baby is even born!

The first part of a woman's pregnancy is a busy time for the body; major changes are taking place that may not be outwardly obvious. The bloodstream is racing with new levels of progesterone, which can lead to swelling, changes in the actual structure of certain tissues, extreme changes in energy levels, unusual cravings, nausea and, for many, a deep desire to sleep all day every day. 

Over the next few days, SHC will discuss the "adventures in sleep" by breaking down what to expect by way of trimesters before birth and into the days postpartum. Generally speaking, however, a woman who is newly pregnant can expect to experience changes with some or all of the following body functions over the course of their pregnancy. 

Anxiety: The uncertainties of pregnancy, when added to the day's list of other worries, can take its toll on sleep. 

Appetite: Some women have immense cravings and feel like they cannot eat enough. These feelings don't just happen during mealtimes, either; sometimes hunger pangs can wake up the soundest sleepers when they are pregnant. 

Congestion: Your body overall will swell as it holds more fluids, and that can lead to stuffy noses that can make it difficult to breathe comfortably at night.

Fitness impacts: Levels of fatigue may swing high or low depending upon the pregnancy. Also, one's ability to exercise can be interrupted by many of these other symptoms. Exercise can help tremendously with a good night's sleep, but if it's done too close to bedtime, it can leave stress hormones at too high a level to promote an easy transition to sleep. 

Frequent urination: The uterus and the bladder will have many battles over real estate across the entirety of pregnancy as pressure from the uterus will place more voiding demands on the bladder. This can mean lots of nocturnal awakenings to use the bathroom.

General discomfort: The processes that define pregnancy are complex; so many different organs and tissues are undergoing transformation more or less at the same time. Your body, no doubt, will feel different and, sometimes, downright uncomfortable. Sleeping may be an uncomfortable experience as the body shape changes, weight distribution falls out of normal balance and joints and connective tissues try to keep everything in place. 

Heartburn and indigestion: This is a common side effect of pregnancy and can lead to reflux disease at night, which can keep many pregnant women up late (especially if they are having nighttime food cravings). 

Insomnia: There are multiple reasons why pregnant women, who are tired all the day, end up suffering with insomnia as well. Blame it on body chemistry and changes in mood, but don't rule out other possibilities, like sleep apnea or restless legs.

Leg cramps: Again, this is a chemistry imbalance; the body needs its electrolytes and when it doesn't get them in full balance, the legs are often the first place to reveal this problem. Nighttime charleyhorses can result; they are no fun during the day, and at night, they can be tenfold worse because they disrupt your sleep. 

Medications: If you are taking any medications while pregnant, make sure it is safe to do so. And keep in mind that medications are essentially chemistry. You add chemistry to your body chemistry every time you take a drug; at nighttime, this can lead to problems with insomnia when chemistry collides. 

Nausea: Some women experiences runs of nausea that blunt their appetite; unfortunately, morning sickness doesn't always wait until morning.

Restless legs: This could have been a "thing" before pregnancy, or it could happen while being pregnant. There are multiple causes for these and they should be identified and treated whenever possible. One cause among pregnant women is anemia; the twitching and discomfort can make it very difficult to fall asleep.

Sleep apnea: More general edema in the body means plumper tissues and more opportunities to interfere with the upper airway. Swollen areas around the feet during the day can become swollen areas around the neck at the end of the day when the pregnant woman lies down to sleep, as fluids are redistributed. This can lead to sleep breathing disorders like Upper Airway Resistance Syndrome (UARS) and Obstructive Sleep Apnea (OSA). 

Snoring: Just as with sleep apnea, the added fluids that build up in the body can create resistance in the upper airway; add to that any congestion issues in the nasal passages and the odds of becoming a first-time-ever snorer are pretty good.

Vivid dreams: Dreams are a product of REM activity. With all the other changes in the body, it's not surprising to learn that the brain is also adjusting, redirecting focus, learning, processing anxiety, consolidating new information as memories. Pregnancy is a heightened state; it makes sense that crazy dreams would follow.

________
Stay tuned: next week SHC will discuss sleep challenges based specifically on what's going on during the trimesters.

INSOMNIA: Twenty of our best previous posts on the topic

SHC has been publishing some great content on the subject of insomnia going back as far as last June. Please scroll down to this custom archive of 20 previous posts to find links related to insomnia of special interest to you and your loved ones.


June 6, 2014
INSOMNIA CENTRAL|| Can Insomnia Lead to High Blood Pressure?

July 11, 2014
INSOMNIA CENTRAL || Is There a Connection Between Insomnia and Suicide?

July 14, 2014
SLEEP HYGIENE TIP OF THE WEEK || Forget About Those Nightcaps

July 21, 2014
SLEEP HYGIENE TIP OF THE WEEK || What Alarm Clock?

July 28, 2014
SLEEP HYGIENE TIP OF THE WEEK || Step Away From the [Blue Spectrum] Light

Aug 11, 2014
SLEEP HYGIENE TIP OF THE WEEK || Stay Cool

Aug 18, 2014
SLEEP HYGIENE TIP OF THE WEEK || Just Say No to Phones in Beds

Aug 19, 2014
AASM NEWS HEADLINES || FDA approves new sleeping pill Belsomra (suvorexant) for insomnia

Aug 25, 2014
SLEEP HYGIENE TIP OF THE WEEK || Think carefully before napping

Aug 30, 2014
NEW TECHNOLOGIES || Blue light blocking shields for electronics

Sept 1, 2014
SLEEP HYGIENE TIP OF THE WEEK || Capture your worries first

Sept 14, 2014
SLEEP Rx || Mother's Little Helper: Things You Should Know

Sept 17, 2014
INSOMNIA CENTRAL || Do you have Insomnia...or do you have Sleep Apnea?

Oct 13, 2014
MONSTERS OF SLEEP || When naps set you up for a visit with the Insomnia Vampire

Oct 29, 2014
MONSTERS OF SLEEP || Insomnia? Find your vampire friends online

Nov 4, 2014
SHED SOME LIGHT || Are insomnia and winter depression linked?

Dec 10, 2014
VISIONS OF SUGARPLUMS || Why insomnia and sleep deprivation cause cravings

Jan 26, 2015
SLEEP HYGIENE TIP OF THE WEEK || How Meditation Can Help

Feb 17, 2015
ALTERNATIVES || Valerian, aka "Nature's Valium" -- safe to use, effective? You be the judge

Feb 19, 2015
ALTERNATIVES || Guest Post: Acupuncture can relieve insomnia and, possibly, more [Dr. Dave Shirazi]

MONSTERS OF SLEEP || Don't read these books before bedtime... unless you WANT to be scared!

Here are some lists of super scary books that might be better off read during the light of day. Or, since it's Halloween, you can sit in a dark room with friends and read out loud to get your spook on. ...Your choice.

HAPPY HALLOWEEN!

LIST 25's 25 Scary Books That Will Keep You Up at Night

Amazon UK's Horror Books That Will Keep You Awake All Night

Mandatory's 20 Terrifying Two-Sentence Horror Stories

Thought Catalog's 13 Short, Creepy Stories That Will Scare the Crap Out of You

MONSTERS OF SLEEP || Research shows that women have the scariest nightmares... Why?

A British study found that women suffered through more nightmares, on the order of 30% versus 19% of men, and that their nightmares are far more terrifying.

Researcher Dr Jennie Parker explains one theory: that "nightmares help the brain 'rehearse' distressing and disturbing events that one is likely to encounter in the future."

In addition, the study acknowledges that there could be a correlation between changes in body temperature and dreams. Women experience body temperature changes as a result of their menstrual cycles which may be a factor in the quality and frequency of their dreams.

Also, Dr Chris Idikowski, director of the Edinburgh Sleep Centre, contends that women tend to verbalize more of their interior life than men do, which may explain the fact that they remember their dreams more often, and which might better explain why they have more nightmares which are more scary.

What do you think? Is it the way women and men are wired, or do you think it's something else?

Check out the original article at the Daily Mail: Why women have the scariest nightmares

MONSTERS OF SLEEP || SLEEP Rx || Having nightmares? Maybe it's your prescriptions

Public domain image: "Pferdefleisch ist gesund und bekömmlich" by Honore Daumier, 1856.

If you are experiencing repeated nightmares and are taking any of these classes of pharmaceuticals, you might want to pass this observation on to your doctor to make sure you aren't experiencing nightmares as either a side effect or as a result of drug interactions.

Whatever you do, DON'T stop taking a prescription without first discussing your concerns with your prescribing doctor. It can be dangerous to stop taking something without at first understanding the risks, and some drugs cannot be stopped suddenly, as they require a slow withdrawal in order to fend off other undesirable, even dangerous consequences.

Editor's note: Please don't automatically assume these drugs will give you nightmares. I take (or have taken) a handful of these myself and I do not have nightmares. Remember that every person will respond differently to any given medication based on their own personal chemistry, their preexisting health conditions and what other medications they might also be taking. 

• ADHD drugs: Ritalin, Vyvanse, Adderall
• AIDS drugs: Sustiva
• Anxiolytics: Cymbalta, Effexor
• Antibiotics: Cipro
• Antidepressants: Tricyclics (Elavil, Tofranil, Remeron); SSRIs (Prozac, Paxil, Lexapro, Celexa); Non-tricyclics (Wellbutrin); MAOI inhibitors (Nardil)
• Antihistamines
• Antiseizure drugs: Phenobarbital, Klonopin, Valpax
• Dementia drugs: Aricept, Risperdal, Exelon
• Heart medications: Beta blockers (Tenormin, Nadolol); also Digoxin, Coumadin
• Hypertension drugs: ACE-inhibitors (Vasotec); calciumchannel blockers (Plendil, Sular, Covera); also: Kapvay, Nexiclon, Cozaar
• Pain relievers: Naproxen, Ketamine, morphine
• Parkinsonism drugs: Symadine, Symmetrel, Requip
• Schizophrenia drugs: Clozapine, Risperdal, Zyprexa
• Sleep Aids: Restoril, Halcion, Ambien, Lunesta
• Smoking-cessation drugs: Chantix, nicotine patches, Zyban
• Statins: Lipitor, Zocor, Crestor

Hat tip to WKYC for the lede and The Consultant Pharmacist/June 2011 for providing source materials.

MONSTERS OF SLEEP: The very real fear factor of PTSD-troubled sleep following heart attacks

Post Traumatic Stress Disorder (PTSD) can occur if you go through a traumatic event that seems to keep haunting you later. Soldiers in combat can experience PTSD, so do victims of abuse and terrorism and those who have suffered through serious accidents or disasters. What’s more, you can develop PTSD after having a serious medical event like a heart attack.

PTSD can leave you feeling afraid for your life or fearing for others’ lives. You may feel like you have lost control of your life. One of the ways that PTSD shows up is through the process of sleep. Sudden problems with getting to sleep or staying asleep can take root, and often, people with PTSD often have terrible nightmares that replay the episodes of their trauma repeatedly. Without quality sleep, both physical health and mental health problems like PTSD can only get worse. 

Doctors have long wondered about the relationship between sleep health, heart health and PTSD. The National Sleep Foundation recently reported on studies from Columbia University Medical Center. They examined how common it was for heart attack victims to suffer from symptoms of PTSD afterward. They found that 1 in 8 survivors of heart attacks do indeed suffer from PTSD; their risk for having another cardiac event, or even dying within 3 years after the vent, doubled when compared to survivors of heart attacks who did not develop PTSD.

A separate study at Columbia’s Center for Behavioral Cardiovascular Health supports this finding and even suggests that poor sleep may be to blame for those who suffer from PTSD after a heart attack. 

It’s fairly simple: the worse symptoms the PTSD sufferers had, the worse their own reports of sleep quality following the heart attack. Sleep quality, in this case, means shorter sleep time, more disturbances while asleep, the need for sleep aids to achieve sleep, and poor daytime work performance due to poor overall sleep quality the night before.

Interestingly, the study showed that the most likely people to suffer from poor sleep following a heart attack are women, obese patients and those with depression.

Doctors are now theorizing that it is not enough to say that PTSD causes poor sleep, or that poor sleep worsens PTSD. Both disrupted sleep and PTSD have nervous system problems in common which need to be addressed. They believe, instead, that these are two underlying conditions, following major cardiac events, must be treated simultaneously.

Further research is needed, but here’s the bottom line: If you or a loved one have had a heart attack and develop PTSD afterward, a mindful approach to reclaiming quality sleep could be a real lifesaver in the long term.

Sources

What is PTSD? (also available in Spanish: ¿Qué es el TEPT? | Ver todos)
National Center for PTSD || http://www.ptsd.va.gov/public/PTSD-overview/basics/what-is-ptsd.asp

Poor Sleep Linked to PTSD After Heart Attack
National Sleep Foundation || http://sleepfoundation.org/sleep-news/poor-sleep-linked-ptsd-after-heart-attack

Sleep Hygiene Tip of the Week || Capture your worries first

"Girl suffering from anxiety" by MikaelF.
CC BY-SA 3.0 

Who hasn't had racing thoughts at one time or another? It's a perfectly human experience to go to bed with a lot weighing on your mind. Life can be very challenging, and stress from change, from fear and from events beyond our control can leave us sorting out what we can or should do next, often without arriving at any obvious answers. Ideally, we learn to cope with our dilemmas and return to better nights of sleep as solutions are applied and problems are ameliorated.

However, if you have racing thoughts every single night when you go to bed, and they aren't spawned by singular events of change or stress, but belong to a category of more generalized worry, then you might actually need to figure out why you are experiencing this. Racing thoughts at bedtime can cut into the very important physiological process of sleep, leading to serious consequences down the line.

What are racing thoughts, exactly?

Racing thoughts are one way our body and brain present anxiety, which we all understand variously as worrying, nerves or unease about things in life that are uncertain.

Anxiety has an influence not only on how much we think about recurring concerns--"How will my daughter do on the flight by herself?" or "When will I get that raise?", in example--but how we frame our concerns. Anxiety doesn't typically pose thoughts positively; therefore, racing thoughts often acquire a negative tone which increases with obsessive returns to the thoughts themselves. Anxiety can lead our minds to repeat these negative thoughts with such negativity that they often become magnified. What might be smaller problems in the beginning can become psychologically insurmountable if racing thoughts aren't held in check. These thoughts can be extremely distracting or seemingly benign (like the same musical phrase repeating itself over and over in your head), but if you can't control them, you will find yourself growing even more anxious! It can become a vicious circle.

Daytime presentation of anxiety through the presence of racing thoughts can be troublesome enough and worth looking into if you just can't seem to ditch this kind of behavior and it distracts you from activities of daily life. However, when racing thoughts have a negative impact on your nighttime sleep over an extended period of time, it's imperative that you figure out why and try to correct the problem. If your thoughts prevent you from sleeping, make it hard to focus, bring up subjects that you find shameful, or otherwise cause you ongoing distress, you need to be concerned.

A disastrous side effect of untreated nighttime anxiety is sleep deprivation, otherwise known as insufficient sleep. Insufficient sleep, over time, will lead to many dangerous consequences, including the likelihood of being in a fatal car accident, chronic damage to the cardiovascular system, the development of type II diabetes and increased risks for stroke and the development of obesity.

Racing thoughts may also be symptomatic of an anxiety disorder, such as bipolar disorder, ADHD, panic attacks, generalized anxiety disorder, obsessive compulsive disorder and, yes, sleep insufficiency caused by other means. It's definitely worthwhile to check with your doctor if you have repeated nights of racing thoughts for more than a few days here or there, as well as for other symptoms that point to any of these potentially underlying conditions.

If you have racing thoughts from time to time, but do not think they are connected to any hidden emotional health concerns, you may wish to consider various relaxation techniques at bedtime.

One of the most empowering ways to conquer racing thoughts at bedtime is to write down your worries at night before going to bed. This nonpharmaceutical treatment for anxiety can be your first line of defense against chronic anxiety, in fact.

It's simple. Keep a pen and notebook at your bedside. When you climb into bed at the end of the day, write down your worrisome thoughts in this notebook. It's so simple it seems like it could be a useless task, but the fact is, your brain "frets" because it wants to avoid forgetting important things. Sometimes "important things" are a grocery list or the names of the people you work with at your new job. Then again, "important things" might also be tasks you need to complete on a deadline or a series of emotionally intense encounters you have recently experienced with a loved one. Whatever your "important things" are, it's up to you to define them as the sources of your racing thoughts.

By writing them down, you are literally capturing your anxiety on the page. (Think of the page as their cage.) In doing so, you also then more clearly identify the sources of your stress. If all your thoughts point to one source, or to multiple sources, their presence in this "cage" gives you something concrete to work with later. Now your brain can relax and let these thoughts go, at least temporarily, while you sleep  because it knows your concerns are now safely captured elsewhere. And then you can then feel better knowing your thoughts will be there to address the next day after you've had some quality time to sleep on your problems. You might even have a dream or two which offers a solution!

Not only that, but your "cage" of "important things" can be an excellent basis for forming an action plan during your waking hours, which can be very positive and empowering.

You can even write your worries down, then turn to a back page in your notebook, where you have written the following: "I don't need to think about this right now. I can look for solutions when I wake up tomorrow," and repeat that as a kind of mantra until you can relax and fall asleep. Often, this positive affirmation is all you need to let your racing thoughts go.

Ultimately, by practicing this nightly, you should find satisfaction in having created an avenue for solving your problems, enough so that you can find calm at bedtime and re-train your thoughts on the more pleasant subjects that you turn to in order to encourage peace and sleep.