RECENTLY A POLITICIAN was discussing his heartbreaking loss in a close election. When a reporter asked him how he felt, he replied: “It really didn’t bother me that much. In fact, the night I lost the election, I slept like a baby—I slept two hours, then I woke up crying. I slept two more hours, and I woke up crying.”
That’s what sleep means for many of us, much of the time—a dizzying combination of actual sleeping amid cycles of waking, dreaming, thinking, worrying, and so on. Yet a good night’s sleep is one of the most important means at our disposal to calm our immune system.
Remember that the immune system resembles a second brain. It tracks your emotions just as the mind does. It knows when you’re worried, threatened, or upset just as your mind senses these emotions. It hears the same signals.
One of the most important cues the immune system listens to is sleep. Yet just as we take breathing for granted, we often take sleep for granted. We do this because we begin life as excellent sleepers. Children tend to sleep very well, as do teens. Most people have to reach adulthood before they start to appreciate sleep—or the lack thereof.
When I was younger, I worked in an emergency room, where staying up all night was routine. After a shift, I’d go home, kiss my kids as they went off to school, and take a three-hour nap. That was it. Today, I’d need to sleep for eight hours to recover from just one night of that routine, no less several years of it.
These days, adult Americans experience an increasing number of sleep disorders. The causes are numerous.
Perhaps the most obvious is that people are growing increasingly stressed. With every passing year, the modern world seems more and more complicated, as does our ability to compete in our ever-changing, ever-more-difficult culture. Even the world itself seems more threatening. Many patients tell me that they can’t sleep because they’ve been spending so much time reading the bad news from all over the globe, from famine to war, from crime to climatological disaster. There’s no shortage of worrisome events, and these weigh heavily on sleep quality.
Another reason people aren’t sleeping well is substance abuse. By that I don’t mean hard drugs; I mean caffeine. Today it seems as if there’s a coffee bar on every corner of every city; there are currently more than 150 Starbucks locations in Manhattan alone.
The problem with caffeine is that its half-life is more than six hours, which means that six hours after you’ve drunk your last cup of coffee, half the caffeine remains in your system; six hours after that, a quarter is still left. Certain conditions, such as pregnancy, prolong that half-life even further, extending it to as much as eighteen hours; taking birth control pills extends the half-life of caffeine to more than twelve hours. Many medications prolong caffeine’s half-life as well, including the antibiotics Cipro and Levaquin, the antacid Tagamet, the antidepressant Luvox, the asthma medicine Zyflo, and the HIV drug Reyataz, to name just a few. Even grapefruit juice and green tea significantly prolong the effects of caffeine in the body.
So it’s easy to see that when people need to wind down, they’re often too caffeinated to manage it. What do they do? Many end up drinking alcohol to numb themselves into a sleepy stupor. All they’re really doing is temporarily numbing their brain cells. Drinking alcohol may enable you to fall asleep, but your liver will immediately start processing the alcohol, and three or four hours later, your blood alcohol levels will return to nearly zero. Now you’ll begin to experience a mini withdrawal syndrome that’s very stimulating. In fact, it causes arousal—and you’ll wake up.
Yawn! You’ve created a vicious circle that, over time, leads to sleep deprivation.
Caffeine and alcohol aren’t the only things that hinder sleep. There’s also the widespread use of sleep medications. Sleeping pills now rank among the most highly prescribed medications. The problem with such medications is that, while they can indeed help you fall asleep, they won’t keep you asleep. When the pills wear off a few hours after you take them, you may well wake up again and find yourself unable to get back to sleep. You may then be tempted to take another pill.
Sleeping pills can be habit-forming and even addictive. When you take such pills for more than a few days in a row, you build up a tolerance and may find that you need a higher and higher dose to fall asleep. As the dose escalates, you may fall into addiction.
Perhaps these reasons for lack of sleep aren’t a surprise—but did you know that excess weight can also affect sleep? The recent obesity epidemic has taken its toll on sleep as well as on health, because overweight people have more difficulty sleeping than others. For one thing, they can’t find a comfortable position in bed: if they lie on their back, they can’t breathe well; if they lie on their stomach, their breathing can become even more restricted. They end up constantly tired, and no matter how much time they spend in bed, they never seem to catch up on their rest. That fatigue only causes them to need even more time in bed.
THE IMPORTANCE OF HIGH-QUALITY SLEEP
Few issues concern patients as much as sleep. “How can I get more?” is probably the most common question I hear.
The real issue, however, is not the quantity of sleep; it’s the quality. Five hours of good sleep can be as refreshing as seven hours of bad sleep.
Scientists have recognized five stages of sleep, which are divided into two basic types—REM (rapid eye movement) and non-REM sleep.
REM sleep usually represents about 25 percent of the time spent sleeping. Dreaming takes place during this stage.
Non-REM sleep has four stages, each of which is progressively deeper. Stages III and IV are generally considered deep sleep, while stage IV in particular is the recuperative sleep that restores and recharges your body.
During each night, our sleep cycles through all the different stages. It’s normal to experience periods of light sleep (stages I and II) interspersed with deep sleep (stages III and IV) and dreaming (REM sleep). As the night progresses, we tend to have more frequent REM sleep, and in the early morning most of our sleep is REM—which explains, in part, why we often remember our dreams as we awaken.
Scientists don’t understand exactly what takes place inside our brains, or our bodies, during the different stages of non-REM and REM sleep, but a few concepts seem clear. For the most part, during REM sleep you are lying very still, and even though your eyes are moving rapidly, your arms and legs are completely motionless. This stillness explains why you may sometimes awake with lines on your face, or with tingling arms, from the uncomfortable positions you fall into—and remain in—during REM sleep.
Brain-wave measurements can help us to understand some of the brain activity that occurs during different phases of sleep.
Deep sleep (stages III and IV) ushers in the appearance of so-called delta waves on the brain-wave, or EEG, measurement. These slow waves represent the most restorative sleep. In contrast, during REM sleep, brain waves show a fairly active pattern that includes beta waves, which are also present during active thinking.
A lack of deep, restorative sleep, or of delta waves, has been repeatedly shown to cause immune activation. Consider sleep apnea; sufferers endure frequent and repeated episodes of halted breathing during sleep. This cessation often occurs because the person’s airway closes off, due to, for example, sleeping position; it’s most prevalent when people lie on their back. However, sleep apnea most frequently results from being overweight, because of the added thickness of the neck, cheeks, and tongue.
Whatever its cause, the restricted airway triggers a blockage of airflow, just as if you had held your breath purposefully.
When you consciously hold your breath, your carbon dioxide level starts to climb. Then you feel uncomfortable. Your heart rate increases. Now you desperately want to take a breath, you become very agitated, and eventually you just have to breathe—and you do.
That same process occurs in people with sleep apnea—their brain, recognizing they’re not breathing, sends a signal to arouse them. They then become restless, move around, and, usually with a loud snort, begin to breathe again. This arousal wakes them just enough to yank them out of deep sleep but not enough to wake them fully.
The problem here is that if apnea occurs too often, sufferers don’t spend sufficient time in restorative sleep. Their brain will keep rousing them to restore their breathing, and they have to start the sleep cycle all over again at stage I. (Unfortunately, you can’t arrive at stage IV without going through the first three stages.)
The result: people with sleep apnea never receive enough restorative deep sleep. So they never get their metaphorical batteries recharged, even if they stay in bed for nine hours. They always feel tired. They’re always dragging. They need to take naps and go to bed early.
Recent research has shown that sleep apnea sufferers also have higher levels of immune activation and higher CRP levels than normal sleepers. Studies from the Mayo Clinic, published in Circulation in May 2002, showed that patients with sleep apnea have CRP levels almost four times higher than those without. Research from Penn State University published in the Journal of Clinical Endocrinology & Metabolism in February 1997 also showed elevated levels of the cytokines interleukin-6 and TNF-alpha in patients with sleep apnea. Successful treatment of sleep apnea and the resumption of quality, deep sleep resulted in lowering of the subjects’ CRP and cytokine levels.
THE IMMUNE SYSTEM AND SLEEP
I said earlier that it’s the quality, not the quantity, of sleep that counts. Some people need to be in bed for seven hours, some for five, others for nine. The differences in quantity of sleep required probably are due to the quality of that sleep.
Unfortunately, it’s very difficult to measure this quality. Unless somebody attaches electrodes to your head and prints out a brain-wave map, you can’t know for sure how much high-quality sleep you’re getting.
Your behavioral patterns during the day can provide useful clues, however. For example, do you often fall asleep while you’re reading a book or watching TV? Do you ever start to nod off when you’re driving your car for more than an hour or two? Do you doze in church? Do you find that you have to catch up on your sleep during the weekends? Do you wake up most mornings feeling tired rather than rested?
If so, you’re not getting enough quality sleep. You might be getting quantity sleep because you go to bed at, say, 10:30 p.m. and rise at 7 a.m. But if you’re still waking up tired, or feeling any of the above symptoms, you’re probably not sleeping well.
Research shows that the immune system exerts a powerful effect on sleep. For reasons that aren’t yet completely understood, there are times when our immune system plays a key role in regulating our sleep.
Immune system cytokines, including interleukins and TNF-alpha, affect the quality and stages of our sleep. All of us have had the flu or a bad cold or some other type of infection. When we’re sick, we want to sleep all day, and even after we’ve woken up, we’re still drowsy. It’s these cytokines, produced by the immune system, that make us feel this way.
The cytokines increase delta-wave (slow-wave) sleep and reduce REM sleep. When we are trying to recover from an infection, we need more rest, and in this way, our immune system and brain work together to produce more deep sleep.
Immune activation is probably the reason some people often feel lethargic even when they don’t have an infection. The lower the levels of immune activation, the more energetic, and less sleepy, you are likely to feel, and vice versa.
(Of course, there is an obvious feedback loop here: if you’re not getting enough sleep for whatever reason, you are activating your immune system; the immune system then produces the cytokines that make you sleepy, and so on.)
You may have heard of the disease known as sleeping sickness, which is caused by a parasitic protozoan (single-celled organism) called a trypanosome and is most commonly found in Africa. Symptoms of the disease, as you’ve probably guessed, are fatigue and sleepiness. The production of cytokines by the immune systems of infected individuals may be contributing to the sleepiness associated with trypanosome infection.
The immune system senses whether or not you have slept well. The better you sleep, the better it functions—ready, willing, and able to respond to any threat, but not overly active. When you’re getting enough deep, restful sleep, your immune system is calm and relaxed, and its cytokine production is turned off.
Though I’ve said quality matters more than quantity when it comes to sleep, getting the right amount of sleep is critical for your immune system; it requires sleep just as much as your brain does.
Brain researchers have found that while you sleep, your brain is repairing itself—something it can’t do at any other time. During a normal day, small connections in the brain can break, nutrients become depleted, and infrastructure needs repair; moreover, memory storage needs to be shifted, or “defragmented.” All of these small problems need to be remedied, and the brain knows how to do that—when it’s turned off.
It’s not unlike your computer. When major repairs are required, you don’t do them while the computer is up and running; repairs take place while the computer is down. Likewise, your brain can’t repair itself while it’s thinking, looking about, finding something to eat, and so on. Your brain’s too busy making sure you survive.
Like the brain, the immune system is constantly busy during the day: storing memories; examining every bit of food that you’ve digested; trying to figure out if there’s a friend or foe coming along; and communicating, as each and every cell talks to all the other cells throughout the body and tells them what it bumped into that day, shares memories, produces antibodies, and plays its part in taking care of your health. The immune system relies on sleep for a chance to repair, recharge, and perform its maintenance functions on your body.
Also, the immune system requires that our stress levels be turned off at regular intervals. Simply being awake and functioning during the day is a stressful process. Your immune system must remain constantly on alert, because anything can happen: a bicyclist could crash into you, your boss could yell at you, a bacterium or a grizzly bear could attack you.
During sleep, however, your stress levels are sufficiently diminished so the immune system can recharge. But if, as you sleep, you’re feeling stress, the immune system can’t relax. For example, night terrors can cause your immune system to become overactive; these terrors are recognized as a sleep disorder that occurs during non-REM sleep, and they are one of the symptoms of sleep apnea. Researchers conjecture that they could, in part, result from the failure to breathe well, which in turn causes high levels of immune activation.
In the sleep disorder narcolepsy, people can be in the middle of a conversation when they abruptly fall asleep. Researchers at the Stanford Center for Narcolepsy Research found significantly elevated levels of the cytokines interleukin-1 and TNF-alpha in the blood of narcoleptic patients, indicating immune activation and elevated cytokines (Brain, Behavior, and Immunity, July 2004).
INSOMNIA
Just as sleep apnea and narcolepsy activate the immune system, so does insomnia.
Insomnia has a number of different causes. One is self-imposed, by people who don’t allot themselves enough time to sleep, or have unusual sleep arrangements.
Another type of insomnia is caused by mood disorders such as anxiety and depression. Sufferers don’t sleep well because they’re too worried—perhaps they’re going through a divorce, or have sick loved ones, or they’re caretakers who are always listening for a partner to fall out of bed, or an alarm, or the sound of a baby’s cry.
Research in 2003 conducted at Harvard Medical School and the Brigham and Women’s Hospital studied the effects of insomnia on immune activation and CRP levels. In the study, researchers kept ten healthy adults awake for eighty-eight straight hours. The subjects’ CRP levels were tested every ninety minutes for five days; over this period, the volunteers’ levels rose to about five times the normal amount.
In a second experiment, ten volunteers were allowed to sleep only 4.2 hours each night for ten consecutive nights. Hourly CRP levels were measured, and again CRP levels rose about fivefold.
In a study of more than twenty-eight thousand children and fifteen thousand adults, researchers at England’s Warwick Medical School found that shorter sleep duration was linked with almost double the normal risk of obesity, and that this risk held even for children as young as five years old.
And findings from the Nurses Health Study, involving 71,617 female nurses, revealed that women who slept five hours or less per night were 45 percent more likely to suffer heart problems. Even sleeping six hours a night was linked with a nearly 20 percent increase in heart problems.
Sleep deprivation and insomnia are important causes of immune activation. Thus it’s little surprise that sleep deprivation has been shown to not only double the risk of obesity but to increase the risk of heart disease as well.
Good quality sleep is important for health, for the immune system, and to decelerate aging. Impairment from sleep deprivation is equivalent to that from alcohol intoxication. When asked to perform various tasks, from simple calculations to walking a line, people who are sleep-deprived perform just as badly as those who are legally intoxicated.
The familiar concepts of getting one’s beauty sleep or sleeping like a baby are age-old and widespread—with good reason. If you’re not sleeping well, you’re not aging well.
TAKE ACTION: SLEEP
Sleep is very much a habit. It is also a learned behavior. This means you can retrain your mind and body to get back into the habit of sleeping well. But it takes practice.
Sleep conditioning is most successful if you follow these steps consistently. If you’re training dogs, for example, you don’t let them jump on the couch “sometimes.” They shouldn’t be taught to come “now and then.” You need to be consistent to produce the desired behavior.
An erratic sleeping pattern may suffice for those who have no trouble falling asleep. However, such people are rare. The rest of us must do everything possible to get a good night’s rest. Besides steady habits, that means creating the right environment and mastering the ability to relax the mind and body.
By following the guidelines outlined here, you’re most likely to succeed.
THE DOS
1. Set a bedtime:Sleep should have a uniform pattern. In other words, you should try to go to sleep at the same time every night and wake up at the same time every morning. Humans weren’t meant to go to bed at 9 p.m. one night, stay up until 2 a.m. the next, then go to sleep at 8 p.m. the following night. The body can’t learn to settle into the right habits with an erratic sleep pattern.
Set a bedtime. It doesn’t matter whether you choose 10 p.m. or 1 a.m. as long as you stick to it. Some people are morning people—they want to get up at 5 a.m. and watch the sunrise. Others want to sleep until 10 a.m. or later. That’s fine too. But it’s a mistake to alter the pattern, even on weekends, when you might want to sleep in. (If you’re finding that you always need to sleep in on the weekends, you’re probably not giving yourself enough quality sleep during the week.)
The Eastern health discipline known as Ayurveda recognizes and values the timing of cycles during the day. According to the practice, cycles progress in six four-hour units, beginning with awakening at 6 a.m. and with bedtime ideally set at 10 p.m. This pattern allows for eight hours of sleep and is said to be harmonious with the activity of the human mind and body.
If you’re following this pattern properly, you won’t need an alarm clock, because you’ll find you always awaken naturally at the same time.
2. Create a peaceful sleep environment: Allow as few distractions as possible. No noise, light, television, computers, or pagers should be present.
Most important: darkness. Your clock shouldn’t be glowing, light shouldn’t be shining under your door, the moon—or streetlights—shouldn’t be glowing through your windows.
Some people create a calming sleep environment by lighting candles in their bedroom, so that when they’re ready for sleep, they walk into a soothing setting. (Remember to blow them out before sleeping, however; flickering lights aren’t helpful or safe.)
You’ll want an inviting bed environment as well: a restful mattress, soft sheets, cozy blankets, and comfortable pillows, so that when you slip into bed, you say, “Ahhhh!” If your sheets are scratchy, your bedclothes messy, and the mattress lumpy, you simply won’t sleep well.
3. Develop a sleep ritual: A sleep ritual creates a conditioned response in which your body, your brain, and your immune system experience a familiar pattern that automatically leads to sleep.
For example, some people like to read in bed for half an hour. Others use a relaxation process, such as meditation, breathing exercises, or a few simple yoga poses. Still others like to write down all the things they have to worry about the next day, so they won’t obsess about them before, and while, they sleep.
Another sleep-conditioning technique is a muscle-relaxation exercise in which you relax one muscle at a time throughout your body, moving from your toes up to your feet, ankles, calves, knees, thighs, hips, back, belly, shoulders, arms, fingers, neck, and finally your face. By the time your face is completely relaxed—along with the rest of your body—you should be able to fall asleep.
And, of course, some people count sheep, or count backwards from one hundred.
Here’s a simple meditation exercise that can help bring on sleep. First, sit next to your bed (a chair or a pillow on the floor is equally fine, but leave the bed itself for sleeping only). Try to keep your back straight. Close your eyes. Take in three deep breaths, each time exhaling completely. Concentrate on your slow breathing, and with each breath out, feel the stress and tension leave your body. Now focus your mind on one thing that you love dearly, whether it’s a mate, child, friend, pet, or even an activity or object. Center on its essence. Feel all other thoughts, concerns, and tensions leave your mind. Sense your mind calming and your body feeling lighter. Continue your slow breathing, exhaling fully with each breath. If your mind wanders, don’t be upset; just calmly regain your focus.
Continue this meditation until you feel completely relaxed and calm and all the tension has drained from your body. At this point, move to your bed and fall into a gentle, deep slumber.
4. Find appropriate sleep accessories: Don’t worry about what you look like while you sleep. If you need help keeping light out, buy a cloth eyeshade. They come in various types and sizes, and work especially well for people whose bedrooms let in light no matter how many curtains and window shades have been hung.
Similarly, some people’s bedrooms are noisy. If this is the case for you, get earplugs. They come in many different varieties and materials. Inexpensive foam earplugs work quite well, and they’re usually comfortable even for people who sleep on their side. These plugs may take some getting used to, but I’ve never run into anyone who couldn’t find a pair that felt comfortable enough to ensure a good night’s sleep.
Also, if you enjoy sleeping in pajamas, splurge a little and find a few pairs that are unrestricting, soft, and comforting. Flannels in the winter and cotton or silk in warmer weather work well.
5. Talk to your sleep partner: If you sleep with someone, ask him or her to help you. If something is bothering you, get it off your chest. Allow your partner to soothe you. Snuggle. Make love. Massage each other’s neck, shoulders, or feet. A scalp massage is especially relaxing and easy to do. A foot massage, using a bit of massage oil, is also tremendously relaxing.
Talk with your partner about other ways you can help each other to sleep better. It’s important for him or her to learn how best to work with you, particularly if he or she is doing something that’s keeping you awake. These discussions can be helpful in making adjustments to sleep positions, and deciding what to do if your partner wakes up often, frequently gets out of bed, or snores.
For some people, sleeping with a pet can be soothing. But as much as you may love your animal companions, if they are depriving you of sleep, consider keeping them off the bed—or out of the bedroom altogether if they wake you up every morning begging for love, or breakfast.
6. Use your nose: Certain aromas may help you sleep—-aromatherapeutic oils can have a soothing effect on the body. Although tastes vary from person to person, some oils that seem effective include jasmine, geranium, rose, and marjoram. You can place five to eight drops in a presleep bath, or buy an aromatic diffuser and let the odor waft through the room. You can also put a drop on a handkerchief and place it inside your pillowcase before you sleep.
7. Take a bath: A soothing, hot bath, infused with essential oils and taken before going to sleep, can help rest both body and mind, easing and relaxing sore muscles. It will also help calm your thoughts and your breathing. Inhaling the humidified air evaporating from a hot bath helps to hydrate and soothe the lungs and airways.
If you feel a little achy, add one-half cup Epsom salts (magnesium sulfate) to the water, plus an equal measure of baking soda (sodium bicarbonate).
8. Develop a dream mantra: A mantra is a mental pattern on which to focus. Try conjuring one up before going to bed. A mantra doesn’t have to be verbal. You can use an image, a thought, or a feeling. But your mind quiets down when you can lead it to focus on just one thing.
I know some people who like the phrase “I am so happy to be in bed,” and others who create a lovely image of a place where no one can bother them, or who conjure up a happy memory from the past. A mantra can be the mental image of swinging in a hammock in a grass-roofed hut, or lying with a lover, or floating in the ocean.
If you can create a successful dream mantra, eventually other intrusive thoughts will dissipate and you can drift into sleep. With practice, some people get so good that they can fall asleep almost immediately after conjuring up their dream mantra.
THE DON’TS
1. Don’t overcaffeinate: Pay attention to the quantity of stimulants, including caffeinated sodas and chocolate, that you ingest during the day. As mentioned, caffeine taken in the afternoon has effects at bedtime. Restrict your caffeine to mornings only.
Alcohol is also a stimulant, so if you find you are waking up a few hours after going to sleep, steer clear of alcohol—even that glass of wine with dinner.
2. Don’t overstimulate: Avoid watching the news on TV, surfing Internet news sites, or answering work-related e-mails before bed. Disturbing images and current events, or troublesome e-mails from work, will keep your mind churning and make it much more difficult to fall asleep.
3. Don’t overdo nighttime liquid intake: The urge to urinate is a common reason to awaken during the night. If you’re going too often, try reducing fluid intake two hours before bedtime—and don’t forget to empty your bladder just before bed.
4. Don’t eat before sleep: It takes a couple of hours to digest food, and it’s a process that works best when you are upright, not lying down in bed. Furthermore, this is not the best time to be adding calories to your system. Instead of snacking, if you feel restless, try a soothing bath, or lighting some candles, or meditating. A cup of chamomile tea is fine, as long as your bladder is not already waking you up at night.
5. Don’t use your bed for anything but sleeping (and love-making): If you use your bed as a place to answer e-mails, watch TV, or talk on the phone, you’re sending the wrong message to your brain. Your goal is to retrain your body to sleep easily and deeply. That training requires a consistent message—that bed is for sleeping, and when you enter it, you’re ready for rest, not work.
6. Don’t go to bed angry: If you’re mad at your mate, talk it out. Don’t take the issue to bed with you. Lying in bed stewing in your own juices will activate your immune system and prevent you from falling asleep. Make a pact: Don’t go to bed mad. Resolve the issue beforehand if it’s at all possible.
7. Don’t obsess about sleep: No one has ever died of insomnia (except in very rare cases involving serious genetic sleep disorders). The more worried you are about it, the tougher it gets. Sleep will come. Be patient. You can learn to do it better. Practice. Practice. Practice. Shhh. Soon you’ll be fast asleep.