Chat transcript: Dr. Clete Kushida on sleep disorders
(CNN) -- The following is an edited transcript of a chat with Dr. Clete Kushida, of the Stanford University Sleep Clinic in Palo Alto, California. The chat was held on Friday, September 24.
Chat Moderator: Thank you for joining us today Dr. Kushida!
Dr. Clete Kushida: Sure, no problem.
Chat Moderator: Tell us a little bit about your background.
Dr. Clete Kushida: I've been involved with sleep and its disorders for a little more than 20 years. My background is that I'm board certified in sleep medicine and I've done basic and clinical research on sleep.
Chat Moderator: Tell us a little about the Stanford Sleep Clinic.
Dr. Clete Kushida: The Stanford Sleep Clinic was started in approximately 1972. And we have a main clinic and sleep laboratory at Stanford and a satellite clinic and laboratory in San Francisco. We typically see approximately 30 patients per day and we study up to seven patients in our laboratory per night. Our Stanford Sleep Laboratory is open five days a week and we do studies six nights per week.
Question from Mikko: What do you recommend when one can't sleep at night.
Dr. Clete Kushida: That's a difficult question. If this question is regarding insomnia, the most important element is to find out how many nights per week the person is having this problem. If it is once or twice per week, it is not that significant. If it is greater than three or more times per week, then the person should see a sleep specialist. For once or twice per week there are some sleep habit modifications that the person can do.
Probably the three most important sleep habit modifications are:
1.) Strict bedtime and wakeup time every night and morning.
2.) Use of light therapy, i.e., within 5 minutes of waking, expose yourself to 30 minutes of bright light. Go outside for 30 minutes or stay in a room that has lots of outside light. Additionally dim the lights in the bedroom 2 to 3 hours before bedtime. The person should not be exposed to bright light 2 to 3 hours before bedtime.
3.) A 20 minute rule -- this means that the person should avoid staying in bed for longer than 20 minutes. If the person cannot fall asleep, or cannot fall back asleep within 20 minutes, the person should get up, go to another room, and do something to make them feel drowsy. When he feels drowsy, he should go back to the bedroom. Condition the bedroom environment to be a place to sleep.
Other tips include, avoiding naps, avoiding reading and watching TV in bed (unless it helps them to fall asleep), avoiding caffeine, nicotine and alcohol for two to three hours before bedtime, avoiding heavy liquids, meals or exercise two to three hours prior to bedtime, avoiding work two to three hours before bedtime. In addition, it might help to do a "worry list" which means writing down all the things that are on your mind two hours before bedtime and dealing with those problems then instead of at bedtime.
Question from Luka: Dr. Kushida, I wake up at three a.m. not knowing if I can get back to sleep or if I should just stay awake.
Dr. Clete Kushida: If it happens on a fairly consistent basis, you should see a sleep specialist. The reason is that there may be reasons why you are waking up at three a.m., such as a sleep disorder -- a sleep-related breathing disorder, or arrhythmic leg movements which disrupt sleep. These conditions can be easily treated by seeing a sleep specialist.
Question from CMan: I find that caffeine helps me fall asleep, what does that result from?
Question from Pace: Nicotine and alcohol can sometimes help a person to fall asleep...why should someone avoid these things?
Dr. Clete Kushida: The problem with both caffeine and nicotine is that they are classified as stimulants, so they do have wake-promoting effects. In some people, there may be an unusual atypical effect, but in most people these compounds will cause a person to be alert. In the case of alcohol, it can cause tranquilizing effects. However, what alcohol does is to suppress deeper stages of sleep, shortens sleep and fragments sleep. In addition, alcohol tends to relax the upper airway muscles, so that if a person has a sleep-related breathing disorder, such as obstructive sleep apnea syndrome, alcohol can worsen this condition and cause more disruption in the person's sleep.
Question from cranky: Have you seen an increase in sleep disorders or complaints over the past 20 years?
Dr. Clete Kushida: Absolutely. Physicians and the general public are gradually becoming more aware of the impact of sleep on health and the prevalence of sleep disorders. In addition, there has been more media coverage of sleep and its disorders which has heightened public attention. Currently there are 88 different sleep disorders classified by our sleep organization.
Question from HiF|yer: What is known about the effects of melatonin on both the mental and physical relaxation of the body?
Dr. Clete Kushida: Melatonin is somewhat controversial among sleep specialists. The timing of melatonin administration can affect its sleep-promoting effects. In some people melatonin may produce insomnia if given at the wrong time for that particular person.
But most sleep specialists do not object to the person trying melatonin to see if it works in that particular person.
Question from Pace: How do you feel about the use of medical sleep aids? Are they necessarily addictive?
Dr. Clete Kushida: If you are referring to medications to help a person sleep, yes, there is evidence that the majority of hypnotic medications can produce tolerance or dependence in patients. This means that over time, if the patient uses medication every night, or almost every night, what happens is that the medication gradually loses its effectiveness in that patient and the patient has to take more and more of this medication to achieve the same effect. Eventually when the patient stops the medication, the patient has what is called, rebound insomnia, meaning that the insomnia worsens immediately after stopping the medication. Examples of these types of medications which produce tolerance are benzodiazepines, Ativan, Valium.
Chat Moderator: Do about over-the-counter drugs?
Dr. Clete Kushida: Yes, over the counter medications can also produce tolerance. Some people have used antihistamines such as Benadryl to help them sleep. Unfortunately, these first-generation antihistamines can result in daytime drowsiness and performance decreases the next day.
Question from Luka: How about Valerian?
Dr. Clete Kushida: Valerian tea is something that we have recommended people try if they are interested in holistic type substances. This compound does appear to have natural sleep inducing properties when given in the tea form.
Question from Do: Do you know if using marijuana can be linked to getting to sleep easier? What are the pros and cons?
Dr. Clete Kushida: Obviously use of marijuana is illegal. The problem with marijuana as a sleep aid, studies have shown, is that it produces poor sleep and amnesia and also may be associated with unusual behaviors during sleep.
Question from Eriki: Dr. Kushida, sometimes I wake up from sleeping, but can't move...like I'm paralyzed. I've heard of a disorder called the night terror, but I'm not sure if that's what it is.
Dr. Clete Kushida: "Night terrors" is a term for a condition where the person will suddenly sit up in bed and start screaming. The heart rate and breathing are usually increased and the person appears fearful. However, the person does not usually remember this episode. Night terrors frequently occur in children between the ages of 4 and 8 years. And it is unusual for this condition to persist after the age of 15 years. What you are referring to regarding the inability to move upon awakening is called sleep paralysis. In most cases, this condition is not serious because it can occur in normal individuals. However, it should be evaluated by a sleep specialist if it occurs frequently throughout the night or occurs several times during the week. It should also be evaluated by a specialist if it is accompanied by excessive daytime sleepiness, hallucinations, or cataplexy (sudden drops in muscle tone, often precipitated by sudden emotion).
Question from sleeping: My problem is clear: I just feel tired and want to sleep at any given time during the day. I sleep perfectly well, but I have noticed a marked increase in the numbers of hours that I sleep in a day.
Dr. Clete Kushida: That by itself may not be unusual. However if it is accompanied by symptoms of depression or daytime drowsiness, or decrease in daytime performance, then you should be evaluated by a sleep specialist.
Question from molly: My father had narcolepsy and took Ritalin; my sister has multiple sclerosis and also takes Ritalin... Is there some sort of connection?
Dr. Clete Kushida: At the present time, there does not appear to be a connection MS and narcolepsy. But we do not know enough about the genetics at this time. There is a new medication called modafinil (provigil-R), which is a new medication for the treatment of the daytime sleepiness of narcolepsy.
Question from Is: Is it possible for people to have a non-24-hour internal schedule? Mine seems more like 30.
Dr. Clete Kushida: Absolutely. Most people have a normal circadian internal clock, which is longer than a 24-hour period. This means that they have a natural tendency to want to sleep later each successive night and get up later each successive morning. The only way to keep this internal clock in line is to keep a strict bedtime and wakeup schedule, and using bright light in the morning help synchronize this internal clock.
Question from cranky: Are most sleep disorders related to lifestyle or to physical reasons?
Dr. Clete Kushida: Good question cranky. They're both. I don't believe that it is either one or the other. There are some disorders such as sleep apnea or narcolepsy, which are physical problems. But there are some types of insomnia which may be more psychophysiological.
Question from HiF|yer: Is there a preferential type of outside light for a room...i.e., northern exposure, southern...?
Dr. Clete Kushida: No, there isn't. The best way to use external light is in the morning and not near sundown.
Chat Moderator: Do you do any dream research?
Dr. Clete Kushida: I personally don't do dream research. There is a dream institute near Stanford that does some dream research called the Lucidity Institute. It can be accessed through the web.
Question from Is: Does Seasonal Affective Disorder have an effect on sleep patterns or sleep quality?
Dr. Clete Kushida: Definitely. Patients with seasonal affective disorder often have sleep problems such as insomnia or excessive sleepiness. The best approach for patients with sleep complaints and seasonal affective disorder is to be evaluated by a sleep specialist and a psychiatrist or therapist.
Question from Pace: Is it good or bad for you to sleep in as late as you want to every day, or does that promote sleep disorders?
Dr. Clete Kushida: The best thing to do is to maintain a regular sleep-wake schedule. If you tend to sleep in on weekends, this may make you drowsy and have poor performance in the first half of the workweek during the morning hours.
Question from Hi: Is the therapeutic action of new medications such as modafinil known? And what other side effects are there, both known and unknown?
Dr .Clete Kushida: The precise mechanism through which modafinil promotes wakefulness is unknown. However, in terms of side effects, this medication has been evaluated. Like any other medication, there are adverse side effects. The most common side effects are headache, nausea, rhinitis and nervousness.
Question from jenna: One of my daughters never closes her eyes all the way when she sleeps. Is that a problem?
Dr. Clete Kushida: Not really. It's only a problem if she awakens with dry, irritated eyes. Then she might need supplemental saline drops for her eyes. This is because during some stages of REM, the eye movements are very fast. These movements can irritate the eyes if not fully shut.
Chat Moderator: Will you be speaking at or attending a society meeting in Europe?
Dr. Clete Kushida: There is a World Federation of Sleep Research Society's meeting in Dresden, Germany from Oct 5th to 9th which will cover basic clinical topics on sleep. I will be attending that meeting. I'll be giving a talk here at Stanford this afternoon for my research fellows and clinical fellows.
Question from HiF|yer: Is there any relationship between high blood pressure and sleep disorder?
Dr. Clete Kushida: Yes, especially for the obstructive sleep apnea syndrome, there is an apparent association between high blood pressure and sleep apnea.
Question from sol_seeker: Does the lack of sleep cause psychosis?
Dr. Clete Kushida: No, this theory was based on early sleep deprivation studies in humans in the late 50s and early 60s. However, it turned out that the people who appeared to develop psychosis with sleep deprivation already had signs of psychosis prior to sleep deprivation. It is known that sleep deprivation can worsen preexisting mental disorders such as psychosis or depression.
Question from Is: I have this theory that nearsighted people may have a harder time waking fully because they can't focus their surroundings. Do you think there might be anything to that?
Dr. Clete Kushida: I don't know of any research concentrated on this topic at the present time.
Question from Rick_r: How is insomnia diagnosed and what kind of treatments are available?
Dr. Clete Kushida: Insomnia is primarily a clinical diagnosis based on the history and symptoms of the patient by a sleep specialist. There are different types of insomnia. The standard treatment for insomnia is primarily behavioral with medications. The behavioral treatment consists of such techniques as cognitive behavioral therapy, sleep restriction, and conditioning therapy. But treatment for insomnia should be conducted by a sleep specialist in order to maximize effectiveness and recovery time.
Question from michial: Is there a name for a sleep disorder in which a persons legs and arms jerk violently when they try to go to sleep, and if so how is it treated?
Dr. Clete Kushida: If you are referring to one episode per night at the onset of sleep accompanied by the sensation of falling this is referred to as a "sleep start" or "hypnic jerk." This is a normal sensation found in the majority of people. However, if you are referring to repeated jerking of the arms or legs or both throughout the night, this condition can either be restless legs syndrome or periodic limb movement disorder, both of which should be evaluated by a sleep specialist.
Chat Moderator: Do you have any final thoughts for us?
Dr. Clete Kushida: As one caller mentioned, sleep and its disorders have become more recognized by physicians and the general public over the past 20 years. However there is much research and work that still needs to be done in this area and there are many people that have sleep disorders that are currently not being diagnosed or treated. If you have problems sleeping or have unusual behaviors during sleep, or have excessive daytime sleepiness, you should definitely be evaluated at a sleep clinic or laboratory.
Chat Moderator: Thank you for chatting with us Dr. Kushida.
Dr. Clete Kushida: Sure! Bye bye! Our web page is http://www.med.stanford.edu/school/psychiatry/humansleep/
Too little sleep as bad as too much booze, study says
September 27, 1999
Fatigue: How to know when to see a doctor
September 21, 1999
Sleepless in America
June 1, 1999
Stanford University Center for Sleep Research
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