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In addition to depression, sleep disturbances are associated with a range of other psychiatric conditions, among them:
* anxiety disorders, in which apprehension and uncertainty become magnified to the point at which they interfere with daily living.
* panic disorder, a form of anxiety characterized by sudden attacks of irrational terror and accompanying feelings of choking, pounding heart, dizziness, and sweating. Unlike patients with depression, those with panic disorders who have been deprived of a night’s sleep are more likely to experience a panic attack on the following day.
* phobia, a reaction that is far out of proportion to the actual danger present and that interferes with normal functioning. Many of us have fears that are rational and reasonable; it is appropriate to fear fire for example, because it can certainly hurt or destroy you. A phobia about fire, however, might lead a person to become frightened by the sight of a gas stove or refuse to enter a building made of wood. A range of phobias, from fear of heights to fear of open spaces, has been identified.
* obsessive-compulsive disorders, seen in people who repeatedly perform certain acts or rituals. One common example is the person whose obsession is cleanliness; the compulsive behavior that results might take the form of washing the hands hundreds of times a day.
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I sometimes combine the SRI clomipramine (Anafranil) with one of the selective SRIs (fluvoxamine [Luvox], fluoxetine [Prozac], paroxetine [Paxil], citalopram (Celexa), escitalopram (Lexapro), or sertraline[Zoloft]) if response to an adequate trial of one of them isn’t sufficient. Some patients do better on the combination than on either medication alone. In my clinical practice, 44% of patients responded when I added clomipramine to a selective SRI or vice versa. This response rate was somewhat higher than for other augmentation strategies, although the magnitude of the response wasn’t quite as large as for some of them. Nonetheless, because clomipramine is an excellent antidepressant, it may be a particularly appealing augmentation choice for people who are severely depressed. Although I generally recommend trying an augmenting agent for 8 weeks, I’d recommend trying clomipramine for 12 weeks before deciding whether it’s working well enough. I generally wouldn’t recommend combining clomipramine with a selective SRI without first attempting to optimize a trial with just one of them.
Because the selective SRIs have the potential to greatly increase clomipramine blood levels, which can be highly toxic at very high levels, a lower dose of clomipramine should generally be used than when clomipramine is used without another SRI. If a patient is already on an SSRI, I generally begin by adding only 25 mg a day of clomipramine and then gradually raise the dose, depending on the person’s clomipramine blood level. You should always check a clomipramine level when this medication is combined with a selective SRI to ascertain that it isn’t too high.
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Students and those whose occupation requires steady brainwork often find that their anxiety shows itself primarily in lack of concentration. They complain of an inability to study or to give full attention to the problem at hand. This of course is a common symptom at examination time. The student sits gazing at his text without reading, or alternatively he reads the same paragraph time after time without fully comprehending what it is all about. In addition to taking the general measures for the relief of anxiety which I will describe, the student can lead himself to greater self-discipline by setting himself a limited daily programme of study which he must always complete. If he starts with a daily schedule within his capacity, he will find that he can steadily increase the amount of work he can handle as his ability to relax increases. With these aids and the reduction of anxiety by the relaxing mental exercises, the ability to concentrate usually soon returns.

In other cases the same inability to concentrate is noticed in reading a novel, or the daily papers, or even in following the conversation of our friends.

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It is interesting to observe that some people fall asleep very easily, but some find it very difficult and need sleeping pills. Even the same person may fall asleep very easily at some times in his life but find it very difficult at other times. Why is this?

There are two sets of forces acting against each other which affect sleep onset. One group of forces includes good sleep hygiene, falling asleep at the right time of the biological clock, and, of course, being sleepy. The other group of forces includes poor sleep hygiene, trying to fall asleep at the wrong time of the biological clock, being unable to handle stress effectively, and, of course, having a genetic makeup that is of poor quality for sleeping. It is important to increase those forces that facilitate sleep onset and to decrease those that oppose it. Let us now analyse these factors in more detail.

Genetic make-up

Studies of identical twins show that much of our ability to sleep is coded in our genes. Identical twins, who have the same genes, have similar sleep patterns even if they live apart in different environments for years. Some people are born good sleepers and they can sleep at any time of the day and, in fact, anywhere. My wife is a good sleeper, and she could sleep easily at any time no matter what shift duty she was on when she was working as a nurse in the general hospital. My two daughters have different abilities to fall asleep. Melissa is more like me, whereas Melinda sleeps easily, very much like her mother. But for those of us who are not so lucky and have poor quality genes for sleep, we have to improve those factors that facilitate sleep onset so as to tip the balance in favour of the forces that bring about sleep.

Sleep hygiene

This is the most important force in facilitating sleep onset. As discussed, caffeine is the number one enemy; absolutely no coffee or tea. The bedroom is reserved for sleep and sex and no other activities. Leave the clock under the bed, but set the alarm to the same time every morning, even on Sundays and public holidays. A regular waking up time in the morning is an important Zeitgeber for entraining our circadian rhythm to the 24 hour clock. Daytime exercises are good, as they increase the amounts of NREM sleep.

Biological clock

If our circadian rhythm is entrained to the 24 hour clock, we should feel sleepy at about the same time every night. Also, our ultradian rhythm causes us to feel sleepy about every 90 minutes. Hence when we feel sleepy at night, we should go to bed and sleep, for this is the easiest time to fall asleep. It is a bad idea to finish a book or a television program before going to bed. Remember, for the insomniac, if you stay up a little later in the night and miss the 90 minute window, you may not feel sleepy again for a further 90 minutes or so. If your 90 minute window is at 10 p.m., it does not mean that you will be more sleepy at 10.30 p.m.

Stress management

Ordinary stress is everyday stress and, if you cannot cope with it and carry it over to your bedtime, it may become the biggest force in opposing your sleep. If you are unable to cope with ordinary stress, it may be a good idea to seek professional help.

How sleepy are you?

Sleep deprived people or people who have not been sleeping well for a few days fall asleep easily and deeply. It has been shown that, for the sleep deprived subject, the ultradian rhythm disappears. This means we can fall asleep at any time irrespective of where we are in the circadian or ultradian rhythm. This is the biggest facilitating force to sleep. If you are really sleepy and your body needs the sleep, you will sleep. We all possess a natural in-built mechanism in the brain that allows us to fall asleep regularly every night. Our body has a self-regulatory mechanism that allows us to fall asleep if we have not had sufficient sleep. If you are very sleepy, no matter how hard you want to stay awake you may find it impossible.

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A magician, complete with top hat and tails, was swinging a pocket watch in front of a well-dressed lady. Her eyes were following intensely the to and fro movement of the pocket watch. She could hear nothing but the voice of the magician murmuring repeatedly, ‘Go to sleep. Go to sleep’. A moment later, the lady closed her eyes as though she had fallen asleep.

I saw this performed many years ago and it was how I first came into contact with hypnosis, and I suppose this is probably what most of you know about hypnosis. Many people would ask if the lady really did fall asleep, and whether she remembered anything afterwards. Some would suggest that there is no such thing as hypnosis and that the lady was just a partner of the magician and it was all an act.

I have practised medical hypnosis for years and find it very useful in the treatment of many medical problems, including insomnia, anxiety, phobia, and smoking. Now, what is hypnosis? The story of hypnosis started a few hundred years ago. The first record of the use of hypnosis on patients has to be that of Dr Franz Mesmer. He graduated from medical school with honours in 1765. He practiced first in Vienna and later in Paris. Pierre Janet, in his book Psychological Healing, gave the following description of Mesmer’s method of practice. Mesmer used an elaborate apparatus. In the centre of a hall, which was filled with the sound of ceremonial music, he placed a large oak tub, Mesmers famous ‘baquet’. This was filled with water, iron filings, and powdered glass. It had a lid pierced with holes and coming up through the holes were iron rods. The patients, who were completely silent and expected something to happen, would join hands and apply the iron rods to those parts of their bodies afflicted with the ailment. Mesmer, the great magnetizer, in a silken robe of lilac colour, would then appear with a long iron wand in his hand. He would pass slowly in front of his patients, fixing his eyes on them and passing his hands on their bodies or touching them with his magnetic wand. These patients, because of his great name, were expecting something to happen. Some did not feel anything, but some felt uneasy, some went into a trance, and some, especially young women, fell down on the ground and went into convulsion. This was supposed to be therapeutic, and after a few of these ceremonies, and payment of enormous fees, many patients declared that they had been cured of many of their ailments.

One of the commonest causes of insomnia is stress. My version of stress is given here and I have suggested how you may cope with it better and consequently achieve a better sleep.

The Oxford Dictionary defines ‘stress’ as a force, an effort, a demand upon physical or mental energy. We use the word ‘stress’ very often, but what is stress, what is it doing to us, and how do we react to stress and cope with it? Stress can be compared to a mechanical force or pressure exerted on an object. To understand the relationship between stress and the object under stress, let us look at a simple example, such as what happens when pressure is exerted on a piece of fruit.

If you put a lot of apples in a bag, the apples exert pressure on each other, and each apple is subject to pressure from surrounding apples. This is a normal level of pressure and stress. However, if you take an apple out of the bag and drop it to the floor, the apple is bruised. If you accidentally step on this apple, you leave a big scar on it. Dropping the apple and stepping on it are both extraordinary stresses not normally exerted on apples.

Hence, to put it in plain language, there are two kinds of stresses in our lives: ordinary stress, which most of us experience everyday, as in the example of the apples in the bag, and extraordinary stress, comparable to dropping the apple or stepping on it, which we only experience once or twice in our lives, and which some of us may never have to face at all.

However, we are not all apples. Some of us may be stronger, like a coconut, which when dropped on the floor will not be harmed as it takes a few strokes of a hammer to crack it. Or some of us may be weak, like a ripe tomato, that even ordinary pressure can bruise. People come in all shapes and sizes and possess different inner strengths and energies. Some of us may be like coconuts, some like apples, and some like ripe tomatoes. We have no choice as to what we are, as part of this is our inheritance from our parents and part is based on our life experience, just as an apple cannot change into a coconut, and a tomato cannot change into an apple. However, with some help we can strengthen ourselves a lot more and can deal with stress a lot better. Einstein reminded us that we use only 10 per cent of our potential, and there is a lot of strength inside us that we have not recognized.

Hence there are two factors in stress. The first factor is the kind of stress, whether it is ordinary stress or extraordinary stress. The other factor is how tough the person is. Some of us may not be able to face up to ordinary stress, just as the ripe tomato. But some of us may be extremely tough and need a hammer to crack us, like the coconut.

The psychological reaction to each kind of stress is similar, but the magnitude is different. Of course, a lot of stress falls in between, and the reaction is moderate. If we can understand the ordinary stress and the extraordinary stress, the magnitude of the moderate reaction will be easily deduced.

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It is now believed that benzodiazepine exerts an inhibitory effect on the transmission of signals between nerves, so that there is a slowing down in the relay of signals between nerve cells and hence the person becomes less excitable and more relaxed.

Benzodiazepine competes with a naturally occurring chemical in the nerve endings known as GABA (gamma amino butyric acid). It appears to displace GABA off these nerve endings, which increases the amount of freely available GABA. GABA is known to inhibit transmission of impulses between nerve cells.

There are two main kinds of benzodiazepine, the long acting and the short acting. By long action, we mean that once the drug is absorbed into the body it stays active for a long time and can be detected in the body after many days. The drug is eliminated from the body by two mechanisms, either destroyed by metabolism in the liver or excreted by the kidneys in the urine. The faster the metabolism, the shorter the half-life of the drug, which is the time taken for half of the drug in the body to be eliminated. This elimination phase can be much longer in older people than in younger people because their kidneys are not normally so efficient. The long acting hypnotic drugs have a long half-life and can sustain sleep longer, but they may give a hangover feeling the next morning; people who take these drugs often complain that they feel like a zombie the following morning. If this drug is taken nightly and regularly, it tends to accumulate in the body. One of the longer acting drugs is Flurazepam, commonly known as Dalmane, and its half-life is nearly 80 hours. This is rarely prescribed in Australia now.

The short acting benzodiazepine has a short half-life and is eliminated from the body much more quickly, usually within a few hours. It can initiate sleep more easily, but may not be as effective in sustaining sleep. There is very little hangover feeling in the morning and accumulation of the drug in the body is less likely even if taken regularly. A common short acting drug is Temazepam, which is marketed in Australia as Euhypnos or Normison; its half-life is 5.8 hours.

Health authorities all over the world have now recognized the abuse of benzodiazepines. They have found that they are addictive. As the number of deaths from barbiturates fell, it became apparent that quite a large number of people suffer from the distressing effects of dependence on benzodiazepines. In Australia alone there are about 6.5 million prescriptions for benzodiazepines written each year, and there are only 15 million people here.

Addiction means an increased tolerance of the body to the drug; hence a higher and higher dose is required to achieve the same drug effect. The body also becomes physically dependent on the drug to function effectively. If the drag is withdrawn suddenly, the body craves it, and the person experiences a whole range of psychological and physical symptoms. With benzodiazepine about 20 withdrawal symptoms have been described. These include tension, sweating, agitation, muscle ache, and irritability, but the most important is ‘rebound insomnia’.

In the sleep laboratory it is shown that REM sleep occupies about 25 per cent of the time spent in sleep. When a person takes sleeping pills, REM sleep is reduced to 5 or 10 per cent of sleep time, but if the pills are continued for many days the REM component gradually returns to 25 per cent. However, it has been shown that if sleeping pills are suddenly stopped there is an increase in REM sleep to about 40 per cent of sleep time, and, in the following nights, more dreams and nightmares are experienced. This is because the sleep induced by drugs is not a natural sleep—it has less of a REM component. When the drugs are stopped, there is a catch up in REM sleep, and this is called ‘rebound of REM sleep’ or ‘rebound insomnia’.

Initially benzodiazepine is prescribed for the treatment of insomnia arising from stress or some other reason. When the original stress is over, and the reason for taking these pills is gone, the drugs are stopped abruptly. This is when rebound insomnia sets in. People who suffer from rebound insomnia believe that they have lost the innate ability to sleep. This rebound insomnia is only transient and lasts just a few days. If these people persevere, the rebound insomnia passes and their sleep becomes normal again. However, there may be some who become psychologically dependent on these pills, meaning their confidence to sleep has disappeared..

It has also been shown that sleeping pills stop working after two weeks. The reason is that the body develops an increasing tolerance to the pills. The same dose of sleeping pill is no longer resulting in sleep as it used to. But then why do people persist in taking them? The answer is to prevent the withdrawal symptom—rebound insomnia.

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Every morning when we wake up and open our eyes we see the sun shining through the window. The light/dark cycle appears to be very important in the resetting of our circadian rhythm. When we open our eyes in the morning, the light stimulates the light-sensitive part of our eyes, the retina. The retinae from both eyes convey the light message along the optic nerves to a central point called the optic chiasma, which is in the middle of the brain stem adjacent to the hypothalamus. Half of this light message crosses the optic chiasma and is relayed to the rear part of the cerebral cortex. Scientists now believe that part of the light message is also relayed to a group of nerve cells in the hypothalamus adjacent to the optic chiasma. This area is called the suprachiasmatic nucleus (SCN) in the hypothalamus and is the site of master control of the circadian rhythm. In animals destruction of the SCN abolishes the circadian rhythm.

It is thought that the SCN possesses an endogenous oscillating mechanism which in free running conditions in man is 25 hours. The SCN is the master oscillator, and it is believed that there are other suboscillators which control hormone rhythm, body temperature rhythm, etc. Hence in cases of jet lag or shift work, the phase maps of the different suboscillators are thrown out of phase with each other. By resetting the master oscillator, the SCN, the circadian rhythm, and the suboscillators are put back into place.

Chronobiologists have recently studied the SCN in detail, both in animals and in man. They have found that if a strong light message is received in the SCN at an hour different to normal sunrise, the SCN is reset into a new circadian rhythm after a few days. Chronobiologists call the light signal the Zeitgeber, synchronizer, or time giver, and the resetting process the entrainment.

The Zeitgeber for crabs that are flown from one coast to the other in the USA is the light/dark cycle of the new location. The Zeitgeber for Dr Charles Czeisler to entrain his jet lag patient to a new circadian rhythm is artificial bright light. Dr Thomas Wehr of the National Institute of Mental Health in the USA has been using light treatment and sleep deprivation to treat certain kinds of depressive illness. It is believed that, by adjusting the master oscillator, its suboscillator that modulates mood and depression will also be adjusted and lead to recovery from the depressive illness.

At present, in Australia and New Zealand, a great deal of research is being conducted on the chemistry of the biological clock. Melatonin, a chemical secreted from the pineal gland situated at the base of the brain, has been shown to be closely related to the circadian rhythm. During the night, the SCN relays impulses to the pineal gland and melatonin is secreted into the blood. In the day, sunlight has an inhibitory effect on the SCN, and this stops the pineal gland from releasing melatonin. The concentration of melatonin in the blood hence becomes a good marker of the circadian rhythm.