Wednesday, April 28, 2010

Sleep Thieves

I went through a really nice period over the last couple of months where I was sleeping pretty well (without pharmacological assistance) and my brain was happy.

The last couple of weeks I've been feeling that buzz in the background of my thoughts getting louder as more and more chatter rolls around in my brain:

"What if I bomb the USMLE?"

"Why the hell are my knees giving me so much grief again despite all the TLC I've been giving THEM?"

"I should write a letter to my sister in law whose dad just died"

"I should recert my ACLS soon"

"How am I going to fit in studying for finals with all the workload on top?"

"I should email Nancy's family and thank them for the lovely letter they sent me"

"How am I going to get in better shape when I feel I have no spare time?"

"Where am I going to do electives?"

"What specialty am I going to do my electives in?"

"Should I shoot for a province I *want* to do a residency in or one that I'll have a *chance* at getting a residency in?"

And so on. And so on. And so on.

Haven't slept much in the past couple weeks. In particular not at all the past three days. I am in a daze and we've started the neurophysiology unit this week. And the more days I go like this the harder it is to get it right because now I am stressed that I can't sleep!

Ugh. I can't memorize, concentrate, think, learn when I feel totally exhausted.

And believe me I do ALL the right things to facilitate sleep. I exercise every day (but not too late). I hardly drink coffee/caffeine at all but if I do it is only one cup in the morning. I do yoga on a regular basis. I don't study in the room I sleep in (most of the time). I get up 1/2 an hour earlier than I need to. I don't eat too late. I stop working at 2130h-2200h and do something else for an hour. I have a cool room, with white noise in it.


Any other suggestions most welcome.

And yes I have 4 sleeping pills but I am saving them for finals when the sleep thieves inevitably come and snatch everything they can from me.


Medical Mojave said...

I go through this too sometimes. I have had good luck with meditation--5-10 minutes a day toward the end of the day but not necessarily right before bedtime. It helps switch from sympathetic to parasympathetic, but you have to actually do it. Yoga might have the same effect.

I have avoided prescriptions thus far, but do sometimes use Tylenol PM or Benadryl if necessary. And I reframe instead of "OMG, I'll never sleep" I picture myself sleeping and think "I'm going to sleep SO well tonight." This helps too.

Hope you get some sleep! I know it sucks! Prednisone really through me for a loop this past month and I'm having to work for my sleep now.


Medical Mojave said...

I meant threw not through.



Albinoblackbear said...

POP-- :) I didn't even notice the typo.

I appreciate your thoughts and yeah, I've been thinking about switching into more of a meditative practice instead of yoga at night.

I had to take prednisone a few years ago and *yeah* it's like the sugar/caffeine rush that never ends. Sending good sleep vibes your way as well!

OMDG said...

I think this is a 1st year med school thing. I remember getting a cold and then "getting hooked" on Nyquil to get to sleep. I was so petrified to go off of it and then *gasp* not sleep for a night. I ended up doing a really long (and probably pointless) taper.

A lot of your worries seem to be about things that won't happen for a while, eh?

"What if I bomb the USMLE?"
You won't. And it's in a YEAR!! You have plenty of time. No stressing allowed until 6 weeks to go.

"Why the hell are my knees giving me so much grief again despite all the TLC I've been giving THEM?"
You are old. Get used to it. ;-)

"I should write a letter to my sister in law whose dad just died"
Write the damn letter now.

"I should recert my ACLS soon"
Why? You're not seeing patients for another year. They made us do ACLS before our sub-i -- we didn't even need it for clerkships. Does it expire before the summer or something and do you need it to be a nurse? Then schedule after the semester is over and take it then.

"How am I going to fit in studying for finals with all the workload on top?"
You will. Everybody does. And then it will be over and you will be happy.

"I should email Nancy's family and thank them for the lovely letter they sent me"
Do it now.

"How am I going to get in better shape when I feel I have no spare time?"
You won't. Not in med school anyway. Try to focus on exercise as a relaxation/happiness tool rather than a get thinner/fitter tool.

"Where am I going to do electives?"
Isn't this problem 2 year away?

"What specialty am I going to do my electives in?"
See above. (and also -- Emergency Medicine, duh.)

"Should I shoot for a province I *want* to do a residency in or one that I'll have a *chance* at getting a residency in?"
Go where you want. Why are you selling yourself so short?

I know, my advice isn't helpful at all. I promise though, everything will be ok. You'll see.

Keet said...

I'm with OMDG.
And if that doesn't work, there is also the option of, *gasp* - talking to your GP and getting a short/small script for some ambien or something to get you through this. Keep in mind the stuff you're going through. Grief is not simple or straightforward, and it can affect your sleep. I know you'll work it out. Maybe you can talk the gentleman suitor in your life for a little massage before bed. or try some lavender under your pillow.
Or come visit me! Maybe I can read you my epidemiology textbook and bore you to sleep.
I'll sort you out! LOL

Bostonian in NY said...

Been there too and survived it. Med school is definitely one of the more anxiety producing ordeals that one can put themselves through. Being the type-a people we are, we worry about being in control of everything. I'd go through these cycles of not being able to sleep for a few weeks and then crashing (usually in sync with the test schedule which was awesome with bi-weekly exams first year).

Best advice I can give is for you to control what you know you can control and let everything else go...

OMDG said...

Oh, also I wanted to add that neuroanatomy was one of the two most stressful blocks for me all year. One night I woke up freaked out because I couldn't remember the circuitry of the basal ganglia. I got up at 4AM and made myself learn it right then and there. PSYCHO!!

The only block worse for me was renal. Clinics are stressful in a different way, but somehow it was easier for me. Probably because walking around was involved.

Anonymous said...

"And believe me I do ALL the right things to facilitate sleep. I exercise every day (but not too late). I hardly..."

From the AASM Classification of Sleep Disorder's interpretation of psychophysiologic insomnia,
"Learned internal associations consist mainly of a marked over concern with the inability to sleep. A vicious cycle then develops: the more one strives to sleep, the more agitated one becomes, and the less able one is to fall asleep. Patients in whom this internal factor (trying too hard to sleep) is a driving force for insomnia often find that they fall asleep easily when not trying to do so (e.g., while watch- ing television, reading, or driving)" (AASM, 1997, p.28).

*ducks to avoid thrown coffee mug.

Cartoon Characters said...

Mersyndol works for can ask for it OTC in Canada....its got the tylenol, a little bit of codeine and the same thing that is in diclectin. Nice thing is, the antihistamine (diclectin minus the vit B) helps with the allergy thing if that is a problem, and the other 2 drugs help with any aches and's a wonder drug. See if you can get it there in Ireland, but here u don't need a script for it.
If u can't sleep try reading something really boring for a while, don't worry about not sleeping.
But the Mersyndol really works well. It is also used for migraines btw....

RH said...

OMDG is right.

You are creating lists in you head at night because you are stressed. Everything you listed are things that are in your control, but mostly things that are a ways off. Realize that you are doing everything you need to do and you will be prepared for them when they arrive.

I am not going to suggest any medications for sleep since they never leave me feeling rested (Benadryl is great for knocking you out for six hours and waking up tired).

I suggest talking with some friends, professors, or the school counselor (every medical school has one right; not just mine?)about the most stressful issues. Drink some nice soothing tea and enjoy the ride!

Anonymous said...

Poor ABB insomnia sucks. I have struggled and continue to struggle with it too. I worry about all the things I have to do and I stay up way too late studying. I think you are doing everything right, taking some very helpful and healthy steps to deal, but you are in an inordinately stressful situation right now so its not surprising that you are still having some troubles. Some additional things I would suggest are:

1) 1 to 1/2 tab of Unisom (doxylamine succinate). Its the most effective sleep aid I've found that doesn't give me a sleep hangover, after years of switching day and night shifts.

2) When I finally do get to bed I use visualization. I put everything I'm worrying about out of my mind and think about things that make me happy. Like I pretend I've won the lottery and I think about how I would pay off all my debts and all the things I would do to help my friends and family with the money. Or I pretend that I'm done with/not in medical school and I think about where I would go and what I would do, like laying on a beach or taking pictures and sketching all day in Italy.

3) I also make lists of everything I have to do. Then I know I'm not forgetting anything and I can work on the most important things the next day when I'm rested.

4) And I would listen to OMDG :). Just go with your gut, prioritize, do what you can, and I *promise* you will be just fine.

Good luck dear! I hope you get some sleep!

Albinoblackbear said...

First of all--thanks everyone (even Beavermedic--hahaha) for the thoughts and advice. It is much appreciated.

OMDG--Hahah, no it's true about a lot of things being far off. It was funny actually, as I was writing the top things that came into my head I realised how far away most of my worries were projected. I am definitely a 'worrier', have been since I was a kid. I remember being about 7 and thinking--'ok great, today seems like there are no big things I need to dwell on today'. 7!!! What worries can you have when you are 7??

I think you channeled my older sister in your comment--hahah. She lives by the 'suck it up and get on with things this is the life you chose' mantra. :) Sometimes I like to whine though! Have you noticed?? Is it getting old? Heh.

And yes you are a psycho for memorizing the basal ganglia circuitry at four in the morning! ;)

Keet-Yah right. I am never going to the doctor to get sleeping pills. I will go back to India and buy them OTC again before I do that! :P
The last time I asked a doc for sleep aids was on my last trip to India--when everyone told me that I wouldn't be able to sleep at altitude. He totally gave me the gears about it even though he was a colleague that knew me and knew I wasn't some crazed drug seeker.

Tobes is very good and gives me almost q nightly back rubs, feet rubs, head scratches, etc. So I really *cannot* complain about that at all! You can read me some epi when I get to London (in 2 weeks!!!!)

BINY--Yep, I think it's sound advice. I am also going to try and adopt the 'one day at a time' approach. :)

Beav--Thanks for the citation! hahahah. I am definitely putting the 'psycho' in 'psychophysiological insomnia'.

Nurse--Hmmm...I'll have to see if we have that here in Ireland, I've never heard of it before. Ireland seems a bit stricter with the OTC's but I haven't actually tried to get anything so that might be just a misconception I've picked up along the way. Thanks for the suggestion! I could always get some when I head home for the summer.

RH--I am the same as you with the benadryl. And some of those drugs actually make me *wired* (not fun to discover on a long-haul flight to Australia a few years ago!!)

We do have a counselor here--apparently a few months ago they brought it to the attention of the medical school that most of the students that were coming to the office for sleep aids/anti-d/counseling services were medical students! Go figure.

And you are right. I am doing the things I ought to be to achieve what I want (what is it I want again?? hahah) I just need to tone down the type-A'ness and become more chill. It's hard though to make that switch.

Ninja--Yes! I do the happy thing too! I have been doing that since I was a kid. It is my #1 strategy for falling asleep.

It seems like the past few days though evil *medical* words want to come into my head and then I go "corpus striatum? What the hell does that do? Where is it? Ahhhhh! Why can't I remember?"

(Toss, turn, repeat).

I like the list making, I really think that would work for me. It's the reason why I've been actively doing a lot of the things that I know I ought to be doing--because those nagging reminders when I am trying to fall asleep are motivation enough.

Thanks for all of your suggestions, I am already visualizing a better nights sleep tonight. :)

Gelfling said...

When I am stressed/having trouble sleeping, I won't let myself lie in bed all night. I'll get up and cook something. Usually by the time the loaf of bread is coming out of the oven, I am nearly dead to the world and pass out as soon as my head hits the pillow.

Fordo said...

Sounds like you are doing the right things, but sometimes the brain just won't shut off.

I recommend dimming your lights 1-2 hours before you want to go to sleep. It gets your brain accustomed to the idea.

What's been working for me lately is doing something mindless at bedtime. Lets your mind focus on something that doesn't really require much thought, but focuses your mind on something other than the issues of the day. Lately, easy Sudoku have worked for me. I would imagine word searches, jigsaw puzzles, sewing, coloring, and the like might work as well.

A bath before bedtime might help too.

Hope you find sleep soon.

Albinoblackbear said...

Gelfing--I like the cooking idea! Though it is a bit awkward in a house of 4 people, I am sure my roommies would not appreciate me banging around in the kitchen at 1am. Hahha

Actually, that reminds me--I came home one morning from a 12h night shift and thought I'd surprise my boyfriend by making this super gourmet pear and brie tartlet for breakfast. Anyway, I made the thing, popped it in the oven and promptly fell asleep on the couch. I was woken up by the staffing office calling to see if I could come in to work an afternoon shift. The oven buzzer had been going off for about 1/2 an hour and I'd slept riiiiiiigghht through it.

The tartlet was saved and it was the only time I was ever happy to have been woken up by the staffing office after a night shift! :)

Fordo--Yes I think I'll give that a try. See the problem with me is my 'downtime' activities generally get me all excited and think-y as well so I think that is a grand idea.

I would have a bath but alas here in res we are not blessed with such extravagances! :) Next year.

Thanks for your thoughts.

GENOVEZ said...

It seems there´s no any advice left for me to give you...I just can wish the best for you... I hope your dreams stay big and your worries stay small, and never need to carry more than you can hold... :D:D

Anonymous said...

Fordo's comment on the lighting is good one. I had the opportunity to do a small (N=18) exp in 3rd year undergrad on the effects of sleeping with a nightlight. In the process of researching it I read quite a bit about so called 'light pollution'. I'll see if I can find a few of the better studies to check out.

There is a, at least theoretical, biological link between ambient light and the effects on sleep hygiene. Those quirky ipGRC cells of the retina do not travel directly through either the dorsal or ventral visual stream and instead synapse in strange places like the SCN (which plays a critical role in circadian rhythms).

I read another study, British opthalmology one - can't remember the authors off-hand, that found the eyelids act as red-pass filters. So if you are overly sensitive to sleep disturbances point away the bright red numbers on the alarm clock.

Sigmoid Freud said...

Along the lines of what medrninja suggested of a list, a therapist once suggested to me about my at times obsessive worrying to set aside "worry times" during the day. I had a 15 minute time in the morning and a 15 minute time in the evening where I would have to worry. If I got thoughts at any other time during the day, I'd write them down on my "worry list" and then remind myself I can worry about it during my scheduled "worry time" later. If the worry pops up again, I remind myself I have it on my worry list which will get addressed during worry time. It does sound kind of corny, but it did help me at that time. It may not work for you, but it can't hurt to try.

One other tip I've heard related to sleep hygiene that others didn't already mention: If you find that you haven't fallen asleep by a pre-determined amount of time (say 20-30 minutes), get up and go to another room and do something relaxing that will take your mind off your worries. Do this for 15 minutes or until you feel ready to go back to sleep.

You can try Googling sleep hygiene or cognitive behavior therapy for insomnia and you might get some more ideas.

Good luck.

Anonymous said...

Albinoblackbear said...

Beaver--I did read a few studies last year also about night shift workers who put on dark sunglasses before leaving the hospital in the morning and wore them until arriving in darkened room. Seemed to operate on the same premise as what you're talking about. Showed good results as well.

I started doing it at the end of the summer. Of course it was a N=1 study and probably worked due to placebo! :)

Oh and thanks for the link. Yeah, I love Fizzy's stuff. Pure comedy.

Sig--I have actually heard that trick works for a lot of people. I always feel like my worries are so intertwined with my thoughts that it'd be hard for me to both identify them and then actually stop the process. But it is definitely worth a try!

Yes I have also heard of the 20-30 min rule and I do read sometimes for a while if I can't sleep. I am just always paranoid that anything I do instead of tossing and turning is only going to wake me up even more. :) Thanks for your thoughts.

Liana said...


I had similar issues throughout medical school and residency and they got even worse when I started practicing on my own. If you think it's bad worrying about exams and ACLS recerts (incidentally, if I were you I would do it before finals and save the week off as a holiday instead...), I can honestly say it's 100 times worse if you're worrying about patients you saw that day and whether you missed something...

I'll write down a to do list before I go to sleep. That way everything's on paper. It helps :)

Rogue Medic said...

Worried about ACLS? You seem to understand the stuff. It should only take a quick review of the algorithms and just remembering the basics. CPR, epi q 3 - 5 minutes, antiarrhythmics when there is an arrhythmia, and look for potentially reversible causes. The ACLS for living patients should also be familiar to you.

Control is just an illusion. You need to accept that you do not control anything, except your own response to things. Then you only need to deal with your response to that. You'll be fine.

Another What OMDG said.

Here is an interesting video presentation on sleep.

Matt Walker: Secrets of the Sleeping Brain

I used to use Benadryl now and then, now I tend to listen to audio books with a low profile earpiece in the ear that is not on the pillow. Or I watch video of somebody talking about the sleep that I am not getting. If I don't sleep, I learn something, or enjoy a novel or movie or whatever. if I drift off to sleep, I get the sleep I need.

You might think that a good accounting discussion would help, but my mind wanders with something like that and I am less likely to sleep.

Or you could redesign your blog's appearance.

Rogue Medic said...

Some information on procrastination and studying.

Wohl, M., Pychyl, T., & Bennett, S. (2010). I forgive myself, now I can study: How self-forgiveness for procrastinating can reduce future procrastination. Personality and Individual Differences, 48 (7), 803-808 DOI: 10.1016/j.paid.2010.01.029

I do not have access to the full paper, but it is briefly covered at the British Psychological Society's research blog.

The cure for procrastination? Forgive yourself!

Albinoblackbear said...

Thanks for the links Rogue!

The talk was actually really interesting (and didn't make me feel too guilty for procrastinating as it was pertinent to neuroscience!)


peace said...

Relaxing yoga at bed time?

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