Let’s take a look at
some sleep disorders.
Now, we can have two broad categories;
we have dyssomnias and parasomnias.
So dyssomnias are abnormalities in the
amount, quality, or timing of sleep.
So insomnia is a
difficulty staying asleep.
So generally speaking, these are
like basic attributes of sleep.
On the flipside are abnormal
behaviors during sleep.
So, the two that I want
to highlight here are
the night terrors and
REM behavior disorder.
So night terrors are when you’re
having like really dramatic dreams.
And they’re not slightly scary.
These are terrors where you’re out
of control, you’re screaming,
and you’re acting out, behaviorally
acting out and screaming at your dreams,
and that’s tied into something
called REM behavior disorder.
So remember I mentioned that
REM is where you sleep --
is where you dream, sorry, and
part of the self-preservation
of REM is that it deactivates
all muscle movements.
So, you’re basically paralyzed so
that you don’t act out your dream.
Well, individuals with REM behavior
disorder, they actually have an issue
where this paralysis is lacking and
they actually do act out their dreams.
So when they enter the REM state and
if they’re dreaming of something,
they’ll actually illustrate that
movement and that behavior.
So one of the stories that I love
to share when it comes to REM
behavior disorder is with a patient
that we had at our clinic,
and I won’t actually say names
because I’m not allowed.
But this patient was in for
a sleep study but he was
actually referred to us
or mandated to come
to us by the police.
So this happens time to time.
And the patient was completely
unaware of why they were there.
So in our details in talking with
them, we said, you know, “What’s
going on and why are you here?”
and he says, “I don’t know.”
And he said that, “I’ve been told
by my doctor and the police that I
need to come for this test. I don’t
know what this test is about.”
And we said, “Okay.”
So the backstory
is with his wife.
His wife was going to the doctor and
reporting a lot of bruising and pain and
the doctor ran a whole bunch
of tests and blood work and
tried everything and nothing
was solving the problem.
So then the doctor asked,
“How are you sleeping?”
And she said, “I sleep great.”
And he asked her, “Do you dream? And
do you remember all your dreams?”
She goes, “Oh, I dream fantastic
and, you know, like I’m
getting my eight hours of sleep.
No problems there.”
And then the doctor said, “Well,
how is your husband sleeping?”
And she says, “My husband sleeps with me.
We sleep fine. We don’t see any issues.”
So after sort of exhausting all of his
options with the patient, he moved onto
-- onto him and said, “Well,
bring in your husband
and I’m just going to
take a look at him.”
And inspecting the husband, again, didn’t
see anything obvious, so he sent them both
to the sleep lab to
come take a look.
So she slept.
She slept fine.
She went through all the stages of
sleep and we didn’t see any issues.
He came in and he started
going to sleep and
he was all hooked up and we could see him
cycling through the stages of sleep.
And when he entered REM,
we realized that
he was actually --
had REM behavior disorder because
he was acting out his dreams.
Now, a little bit more backstories
if you read his file,
he happens to be 6’3” and
a black belt in karate,
and he mentioned this to
me before he went to bed.
He said, “Listen, for any reason, if you
need to come in, you might want to give me a
heads up because I have a tendency to karate
chop people because I’m a black belt.”
So, kind of scary.
So when he went to sleep,
we can monitor him on the
screens and we could see
that he was entering REM.
We can see that based on his
brain activity, his EEG.
And what did we notice?
We noticed kicking and wailing
and he happened to karate chop
the night lamp that was there and
partially destroyed the room
and he woke up in the
morning and he said,
“So, doc, how did everything go?
How did I do?”
And we said, “Oh,
you did just fine.”
And he said, “Well, there’s
a lot of mess in here.”
And we said, “Yeah, a
little bit of mess.”
And that was basically because
he was karate chopping the room.
So what was happening
was, back to our story,
is our patient was experiencing
REM behavior disorder
and he was inadvertently,
unconsciously hitting his wife,
which explained the
So the question you might
ask is, well, how did
she not know that she was
getting karate chopped?
And what happens a lot of times with
couples if they’re going to bed
together is they have synchronization
of their sleep schedules.
So she was actually in REM when he
was in REM, and she was unaware
that she was taking a beating, which
explained some of the bruising.
So I hope you kind of remember that story
to highlight that REM behavior disorder.
Now, insomnia is difficulty falling
or staying asleep and this is
probably the most common sleep
disorder that most people have.
It explains the multimillion
dollar, billion dollar industry
of sleep agents because they
know that this is an issue.
So it’s different than occasional
sleep issues related to, say,
“I have a big test tomorrow like
the MCAT and I can’t go to sleep.”
You might have some
short-lived acute insomnia.
We’re talking about something
that’s a little bit longer,
and this isn’t just happening, you
know, a few days prior to your exam.
This is happening
on a regular basis
and it is a chronic issue
and a lot of times this is linked to chronic
stress or underlying chronic issues.
So if you’re in a really
stressful position, like
a lawyer or a doctor or a politician,
you have a lot on your plate.
You don’t even have to be a professional,
just as a -- as a, you know, as a parent.
You’re so concerned all the
time about your children and
how are we going to pay for bills
and the mortgage and this and that.
That chronic stress actually
can impact your ability
to sleep and that’s
expressed as an insomnia.
How do you deal with that?
The obvious thing is
good old medication.
And that’s a short fix because if the
underlying issue is chronic stress,
medication to help you fall asleep is not
going to get you to where you need to be.
The other problem with medication
is that it actually can
influence the stages of sleep
that you’re getting into.
So you’re getting the hours, but you’re
not getting the appropriate stages.
So we say you’re getting quantity,
but you’re not getting quality.
Because in order for you to feel rested and
for sleeping to do what it needs to do,
you need to hit stages one
through three, plus REM.
And a lot of the medication
prevents you from achieving REM,
and so you’re getting
stages one, two, three,
one, two, three, and
you’re not getting REM.
Another really important -- another
very sort of useful tool is relaxation.
And this is when simple
things like breathing
and doing things like
that really, really help.
We have a term called
And what that is, is we prompt
individuals who have trouble sleeping
to employ relaxation and to
cleanse their sleeping area.
So that includes things
like, you know, removing
a whole bunch of stimulus,
like all the lights.
Remove the lights.
You shouldn’t have
your iPad with you.
You shouldn’t have an alarm clock
blaring in your face with the time.
You should not be doing anything
in your bed other than sleeping.
Obviously, a lot of us like
this, some extracurricular
activities, but that’s not
what I’m talking about.
I mean you shouldn’t lie in your bed
eating a, you know, a sandwich,
watching TV, and reading a book
an hour before you’re
about to go to sleep.
So you should do that in
the appropriate place,
the kitchen or on a
sofa or a lounge chair.
But when it’s time to go to
bed, you go to bed in your bed.
You go to sleep in your bed.
So the idea is to create a relaxing
atmosphere to be relaxed when you
go to bed and not be thinking about
the MCAT that’s happening tomorrow.
You also want to avoid stimulants
before you go to sleep,
so drinking a cup of coffee, having
chocolate, having pop, going for a nice run.
These things are actually going to
increase arousal and stimulation
and that’s the opposite of
what we’re trying to achieve.
Another disorder is something
and this a periodic
overwhelming sleepiness during
waking periods and is usually
in response to a stimulus.
So what we’re referring to here is
the sudden loss of muscle control.
So we call that cataplexy or
sudden transient muscle weakness
and it’s linked to a dysfunction
of a region within the
hypothalamus which produces
a compound called orexin.
We don’t need to go
into all the specifics.
Just kind of be aware
that narcolepsy is
linked to cataplexy which
is driven by orexin.
And it’s a fairly alarming and odd
scenario that you’re speaking to somebody.
You might tell them a joke or they might
get startled by somebody walking in.
And that sudden activation actually
knocks them right into REM sleep
and that they’re
completely in cataplexy.
So they’re completely out.
Now, this is a potentially
dangerous situation if you
can imagine somebody with
narcolepsy driving a car.
And they’re driving a
car and unexpectedly
somebody honks a horn, they’re startled,
and they fall asleep at the wheel.
Kind of an obviously a dangerous
situation and this happens quite often.
Now, the interesting point is they
don’t just kind of slightly doze off.
They dramatically fall into sleep
and enter REM very, very quickly.
Okay. So that’s not typical.
Typically, you want to cycle through
the stages of sleep and get to REM.
In this scenario, they’re getting
to REM quite, quite quickly.
Now, another extremely prevalent
disorder that’s surfacing
lately over the last, I would
say, 15 years is sleep apnea.
And this is when you intermittently,
periodically stop breathing during sleep.
Now, you might say, “Well,
what’s the big deal if I
kind of stop breathing a
little bit here and there?”
Well, we’re not talking about the
occasional, you know, you stop breathing.
This is very, very dramatic and this
is happening throughout the night.
So episodes can last from
seconds to just over a minute.
So we had this kind of, I don’t want to
say a contest, but a running tally of
the longest apnea event that we’ve ever
had at our -- at our sleep institute
and it was a minute and
thirty two seconds.
Again, you might say, “What’s the big deal?
A minute and a half almost.”
Well, right now at your desk,
I want you to hold your breath and
hold it just for five seconds.
Okay? So let’s do that.
Okay. That was five seconds.
How do you feel right now?
I’m not saying you’re completely
winded, but you can feel
the effects of just holding
your breath for five seconds.
Now try that for 20 seconds.
And after the 20 seconds,
what do you do?
You’re like --
okay, I’m good, I’m good.
Now, a minute and a half
is a long period of time, and
this isn’t just happening once.
This happens repeatedly over
and over throughout the night.
Sometimes 80, 100, 140 times.
So what this actually
does is two things.
One, it’s physically draining,
you’re quite tired,
and you’re not getting the
oxygen that your body needs.
So normally when you’re
breathing, you’re bringing
in oxygen, you’re
expelling carbon dioxide.
So you’re bringing in oxygen,
which your body needs very badly,
and you’re expelling the waste
product of carbon dioxide.
So you’re not allowed to do that.
So that’s not a good thing.
The second thing that it does is
it actually causes an awakening.
So you might be in a
deeper stage of sleep,
stage three for example,
which is that restful,
restorative stage of sleep,
and all of a sudden,
you have this apnea event
where you stop breathing.
And then, the way you get
out of apnea is there’s a
deep part of your brain that
handles autonomic functions,
so the basic things like
breathing and blood pressure.
It detects that you’ve stopped
breathing and it kicks you back in.
And so what you typically do is you’re
-- and then you start breathing again.
Now that action is enough
to kick you out of the
deeper stage of sleep into
a lighter stage of sleep.
The majority of people who have apnea
are unaware that they have apnea,
and so, they come and say, “I don’t know
what’s wrong with me, but I’m bushed.
I’m just exhausted. I’m getting
eight, nine hours of sleep,
but I wake up and I’m done.
I have zero energy.”
And it’s because, again, they’re
getting quantity, eight hours,
but they’re not getting quality
because they keep getting bumped out
of that lighter stage of sleep,
not enough to wake them up, but enough to
get them out of that deep stage of sleep.
The events are repeated
throughout the night,
and this is accompanied a lot of
times by heavy, heavy snoring.
Now, apnea is linked to snoring, and
snoring and apnea is linked to obesity.
And generally speaking, in North
America, that is a huge epidemic
right now, is increasing and
increasing amounts of obesity.
As obesity goes up, health outcomes go down,
snoring and apnea events are going up.
So it’s extremely, extremely prevalent now these days.
You know, 15 years ago, we would see, you
know, a certain amount of apnea patients.
We’ve seen probably in the last
10 years a doubling of that.
So what is the treatment?
The obvious treatment is just straight
up weight loss, so lifestyle changes.
Lose a little bit of weight and
become a little bit more active,
eat a little bit a better,
you’ll lose weight.
And the weight that we’re talking
about, there are two places,
is right around your neck and the
weight around your chest and abdomen.
So, all that weight, when
you lie down, falls on you.
And actually, what it does is,
it prevents your airway from
working well and it collapses it.
So another option is
something called CPAP.
It’s where you wear a mask
and it’s attached to a
machine, and the machine
delivers positive air.
So that’s where you get
the abbreviation of CPAP,
it’s continuous positive
And CPAP is delivering
this air and is preventing
your airway from collapsing
and it’s keeping it open.
So the analogy I always
use when I try to explain
this to people is imagine
sticking your head out of a
moving car going down the
road, going down a highway,
so you’re going fast enough
and when you try to breathe.
The air is being forced
up your nose and mouth.
So it’s like trying
to breathe in,
which is easy when it’s blowing at
you, and trying to breathe out against
the air that’s coming at you when
you’re driving down a highway.
Okay? So again, what it does is it
prevents the airway from collapsing.