Why can’t I sleep?

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You’ve just finished watching the Toronto Raptors win their FIRST NBA championship in history. You smile at yourself for being so smart as to get this awesome 60″ plasma screen TV installed in your bedroom. You belt out one last rendition of “O Canada,” before you check the time and realize, “oh fuck it’s almost midnight!”

You hurry off to bed, and give half an honest effort to brushing your teeth in a slight haze as you digest the half dozen beer you drank over the last three and a half hours.

Finally. Bed. You lay down and close your eyes, just to be flooded with images of – Kentucky Fried Chicken?! You think that’s odd, before you remember the commercial for KFC playing repeatedly throughout the game.

You wonder, “why can’t I sleep?”

Your brain is essentially a large glob of fat, composed of microscopic cells, that act like wires. Likes wires, the cells connect to each other. Brain functioning in every domain – think attention, cognition, mood, vision, movement, everything you can imagine – is not about the individual brain cells, but rather, how the cells connect to each other.

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Why is this important? We have a saying in medicine that goes like, “neurons that fire together wire together.” That means that in a baby, the cells in the brain are essentially randomly connected, with very weak connections, and the end result is very little complex behaviour. Over time, as a baby matures into a child into a teen into an adult, they use their brain more, and the brain recognizes what connections are being used. The brain reinforces and strengthens those connections, and gets rid of, “or prunes,” extra connections that are needlessly using up energy. (As a side note, this neurological phenomenon is also behind the old adage, “if you don’t use it, you lose it!”)

The end result is that the brain becomes very good at recognizing patterns. I promise that’s all of the complicated brain science!

This ability to recognize patterns is why when you smell baking blueberry pie, you may think of your grandmother. It’s why a caveman, when he smells bison scat in the air, might think there’s a herd nearby. This is an over simplification of the human brain, but on a surface level, the evolutionary benefit of pattern recognition is obvious.

As things go, in our modern day society, this ability for patter recognition can sometimes cause us harm. In particular, in bed.

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The number one environmental factor I see in my clinic that contributes to insomnia is screen time in the bedroom. When people spend time in bed on their cellphone, answering emails, using a laptop, or watching TV, the brain learns to associate the bedroom with a place where work is done. Train your brain to read emails in bed too often, and that’s where your brain will immediately go when you lay your head down to rest, even if you’re on vacation and haven’t received an email in two weeks. I recommend to patients that cellphones be charged at night outside of the bedroom, and that there should not be a TV in the bedroom. I myself can attest to this – when I was in medical school, I had roommates, and all of my belongings in the world (including the TV) were in my bedroom. Since beginning residency, I don’t have roommates, and I get to sleep incredibly easier, now that my TV is in the living room!

You should also not spend time in bed awake. What do I mean? If it’s late at night, and you just can’t seem to fall asleep, get up! Go in another room, and sit down for a few minutes. Some people might read a chapter of a calm book under low light for a few minutes. Once you feel tired again, which is usually within fifteen minutes, go back to bed. This way, your brain begins to associate the bed with sleep. The more often you practice this, the better reinforced those brain connections get, and it gets easier and easier. As we say in the field, the only things you should do in bed, are sleep and sex!

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Finally, we can also use our brain’s super powered pattern-recognition to our advantage, with having regularity to our sleep schedules. This means going to bed and waking up at the same time, each and every day, even if you don’t feel too tired at one, point, or really want to sleep in the next day (I give you a free pass on Saturday’s). This can be difficult at first and you may find you become slightly under slept. Don’t worry, hang in there! I promise that it will get easier, with practice!

Hopefully you find this helps you and your sleeping patterns (ba-dum-pshhhhh)!

 

Editor’s Note: Stay tuned for more on sleep hygiene and the effect of day/night cycles on sleep!

 

Dr. Travis Barron is a resident physician in Toronto, Canada.

The first patient I cured

“So ya, that’s everything that’s going on…”

There was a long silence before I responded, “that fucking sucks, it really does.”

“You’re telling me…”

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I had just started as a resident doctor at a hospital in Ontario, Canada, and was working with one of the first patients I would ever follow in my outpatient psychiatry clinic. I met a woman, Ms. G, who worked as an engineer. Ms. G had been referred to the clinic by her family physician (known as a general practitioner outside of Canada) for an assessment of low mood and sleep disturbance.

As these things go, you get some information in advance of the consultation from the referral form. Ms. G had never been involved with the mental health system. She was in her 50’s, married, and had three adult children. She was also not presently taking any medications.

I’m excited. A blank slate, a canvas ready to be worked with. So much potential. I quickly opened my copy of Prescriber’s Guide, and reviewed the starting doses for all of the basic antidepressants. Would today be my first fluoxetine start? Sertraline? Maybe even escitalopram?

The consultation time quickly arrived and I stepped out into the waiting area to ask for my client. Ms. G was average height, was wearing business attire, and had been using her cellphone immediately prior to my arrival, which she peered at through a pair of thin, golden reading glasses. Ms. G shook my hand and we walked together to the office.

Ms. G and I spoke for almost an hour. She detailed her struggles with low mood, decreased enjoyment in life, poor sleep, poor appetite, and difficulties concentrating. There were profound feelings of guilt and worthlessness. Her mental status exam was actually relatively benign. You were certainly given the impression that this person was tired and frustrated, but you certainly weren’t put in mind of someone in the throes of a severe depressive episode. With this information, I was able to determine that Ms. G met criteria for a Major Depressive Episode, mild/moderate severity.

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Ms. G also owned her house. Her and her husband had just renovated the home, and it was beautiful. That was before the flood. A month prior, Ms. G’s home was the most recent victim in a spat of Toronto city floodings. Everything in the basement was destroyed. A lot of the renovations, which included the downstairs bar and family room, had not even been properly enjoyed yet, only to be destroyed by the flood. Even worse, Ms. G’s home was the only one on her block to sustain significant damage.

“that fucking sucks, it does.”

“You’re telling me…”

Our consultation wrapped up and it was time to discuss the impression, plan, and treatment with Ms. G.

“Based on everything we have discussed, your presentation is not suggestive of any mental illness.” This peaked her interest.

“Then how do you explain what’s going on? I can’t sleep, I feel awful all the time…”

“Well, you have a lot on the go. You just renovated your home, spent tens of thousands of dollars, and now you’re faced with the flood. In a way, you’re re-traumatized every single day when you get home from work and have to be reminded of the damage, since the repairs are yet to be done. It makes sense to feel this way.”

Ms. G liked my opinion and asked me what she could do to feel better. I told her to hang in there, and to continue working on the repairs. I told her my suspicion was that she would feel a lot better once the repairs were taken care of. She would be able to move on.

I also told her I did not expect medications to have any effect on her mood. This wasn’t depression. This was an exaggerated form of a really, really bad day. I did offer a short supply of some sleeping pills which she gladly accepted.

I also told her I wanted to see her again, and I followed up with her twice over the coming months. At the second follow up, she was smiling, and I noticed the bags under her eyes were quite less pronounced.

“Good morning doctor.”

“Good morning Ms. G. How are you today?”

“I’m great – you were right!”

“I tend to be,” I said as I laughed. “But just so we’re on the same page, what are you referring to?”

“It’s finally over.”

“The renovations?”

“Yes!”

“I’m so happy for you.”

“Thanks for everything, doc! You cured me.”

Editor’s note: I didn’t cure this woman – as these things often go, time in many ways heals most wounds. This was the natural history of getting through psychological distress following something like a home flooding. This is not what I would expect to happen with true and blue depression, which often needs a combination of therapy and medications.


Ms. G met criteria for depression; that does not mean she has depression. You can meet criteria for any number of mental illnesses, and it is up to you and your doctor to synthesize all of the available information, and to interpret it in the way that makes the most sense.

 

Dr. Travis Barron is a resident physician in Toronto, Canada.

 

Mental illnesses are made up (sort of)

You’ve experienced some swelling in your neck for the last three months and decide to see your doctor.

They do a physical exam and run some tests. At the follow up appointment, they give you the absolute last thing you wanted to hear.

“You have lymphoma.”

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When I started medical school, a memorable preceptor told me that I was about to learn an entirely new language. An understanding of that language, she said, would empower me to become a wonderful physician.

Hodgkin’s lymphoma is an example of a disease. What makes a disease? The presence of a clear, well-defined pathological phenomenon. Cancer is not a disease. And neither is lymphoma. Hodgkin’s lymphoma, however, is closer to the mark. Why does this matter? Because a disease is a very specific entity, and one that is by-and-large understood. It’s specificity allows us to target very specific elements of the disease, to develop treatment. There are (almost) no diseases in psychiatry.

Syndromes, or disorders, are clusters of symptoms that tend to appear together and suggest to the observer (usually a physician) the type of problem which may be going on. For example, someone presenting to an emergency department with swollen legs, shortness of breath, and chest pain, likely has heart failure (a syndrome; heart failure with preserved ejection fraction may be the disease). We have many syndromes in psychiatry. Someone presenting with an inability to get out of bed, tearfulness, and suicidal thoughts, may have depression. Someone who hears voices and believes they are being monitored by the CIA may have psychosis.

So why the disconnect? Because the brain is cool.

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The pathophysiology behind heart failure and lymphoma is relatively clear. This is not the case with mental illness. The human brain is extraordinarily complex, and is not easily studied under the microscope, or in labs with rats. It’s an exciting time in psychiatric research, as the human brain is in many ways considered the final frontier of medicine. For patients and individuals, it’s a frustrating time..

This ambiguity has caused us to rely on describing syndromes, as opposed to clear, well-defined diseases, in our practices. Syndromes, or disorders, can be seen all over psychiatry. Major Depressive Disorder. Generalized Anxiety Disorder. And I could go on.

Why is this important? A syndrome can be the result of a variety of things. Someone with chest pain, swollen legs, and shortness of breath, may also be having a heart attack. Someone presenting as depressed might have depression, bipolar disorder, hypothyroidism, or could be having a regular ol’ bad day. This helps explain why some people respond to medications, and why some do not. Why some people get great help from cognitive behavioural therapy, and others find it a waste of time. Since we’re dealing with a mixing pot of a variety of potential explanations, some trial and error is required as you and your doctor arrive at a suitable treatment. I get almost as frustrated as a patient when we are going through treatment and a medication doesn’t work, or a therapy isn’t suitable. It can be demoralizing to everybody involved. What can help is keeping in mind that that mystery and ambiguity are not unexpected, and are completely normal part of moving through the mental health system.

 

Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.

One hundred diagnoses

“You have depression.”

“I think it may be bipolar disorder.”

“Borderline Personality is most likely.”

“Have you ever heard of Posttraumatic Stress Disorder?”

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You’ve been feeling down lately and you decide to see your doctor. They might refer you to a psychiatrist, or choose to diagnose you themselves. You might do this several times over your lifetime, and each time, you get a different answer. You go, “what the fuck?”

It’s a common conundrum.

In psychiatry, we do not have the luxury of many of the tests and tools used by other fields of medicine. In other words, we don’t have the luxury of x-rays and blood tests to aid in the diagnosis of the vast majority of illnesses we work with. What does that mean? As psychiatrists, we rely primarily on our clinical expertise, the histories provided by individuals and their families, mental status exams, and whatever collateral information is available to come to our conclusions.

After we have gathered all of the available information we arrive at a hypothesis, or best guess – don’t worry. We’re usually right! Psychiatric diagnosis is a finicky thing, because I’d be lying to you if I said I, or any other physician, had the ability to understand perfectly the inner workings of your mind and your own personal experience in an hour-long conversation. The point is, people are complicated, and what may appear as depression one day may come to reveal itself as posttraumatic stress disorder on another.

So what’s the point of seeing somebody, if their diagnosis may be fluid? We can help. Working with a mental health professional at times of difficulty can be an important resource, especially when in a publicly funded healthcare system such as Canada’s. Even if your diagnosis may evolve over time, our treatments are often (and usually) pointed in the right direction. The treatment for depression and anxiety are often the same, and the same is true for bipolar disorder and schizophrenia. Most importantly, regularly seeing a physician can be a rock during times of turbulence, and I would recommend that to anyone, regardless of diagnosis.

 

Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.