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β€œIt is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Sunday, November 19, 2006

    I wish I had a dollar for every time I've heard this complaint: "Doctor, I can't sleep." The patient stares at me pathetically. "I'm so tired."

    Every doctor suffers from a common complaint that dogs their steps, that arouses all their sympathy when they hear a patient mention it. Fellow sufferer! I feel your pain! For some it's back pain, for some it's migraine, for some it's allergies... you get the picture.

    I am a proud card-carrying member of the International Insomniac Association. I've had trouble sleeping all my life; even as a child it was common for me to wake in the middle of the night and stare incessantly at the ceiling, wondering what time it was. (This was back before alarm clocks with digital displays were common, if they even existed.) In high school I was given an alarm clock with a digital display – I still have it - and it changed my life because I no longer had to wonder what time it was when I woke up in the middle of the night; all I had to do was look across the room. I understand that current advice for those who have trouble sleeping is to avoid looking at the clock, lest you obsess about what time it is and how long you've been awake. While there may be some point to this, I have to say that it is even easier to obsess if you DON'T know what time it is. (Speaking from experience.)

    Several years ago one of the rectors at my church preached a sermon that reassured me about my crazy sleep cycle, at least to a certain extent. She told us that in monasteries the service of Vigils, commonly sung between one and three a.m., was not a punishment; it came about because monastery routine called for the monks to get up shortly before sunrise and go to bed soon after sunset. Thus they would normally awaken in the middle of the night, because the time allotted for sleep could be nearly twelve hours (depending on the season). In other words, everybody was awake and staring at the ceiling anyway, so they might as well get up and worship.

    Somehow I felt better when I heard that. It was nice to know people were able to do something productive with their time lying awake even before electricity or the Industrial Revolution. These days we have the Internet (cue the chorus: what did we do before the Internet?), so on nights without sleep it's very easy to while away the hours surfing around, perhaps blogging, researching some esoteric topic or chatting online with our fellow insomniacs or some bored fellow in an office on the other side of the world. Back in my young days all we had to entertain ourselves on "white nights" was late-night television or perhaps the odd VCR movie we'd rented. Random thought: now that we have the Internet, does anybody even watch infomercials any more? They may soon be a dead art form.

    The good news is that in the last few years more modalities for treating sleep problems have become available than ever before. Safer sleep medications are now on the market. The specialty of sleep studies has gained respect and popularity. "Restless leg syndrome" can now be treated with an effective new medication. Somehow, though, it doesn't seem to be enough; patients want their insomnia problem fixed without resorting to pills. I have recently seen a new subgroup of postmenopausal patients who have declined estrogen replacement and as a consequence suffer from insomnia with a vengeance; apparently low estrogen levels will do that to you. Try to tell one of these women that she can either take estrogen or a sleeping pill to solve her problem and she will likely come at you with a deadly weapon, or at least a deadly rant. Tell her to try melatonin or valerian (both natural sleep remedies) and she will give you the "I've already tried that" look.

    Physicians still reiterate the basics of sleep hygiene, such as: Don't take naps during the day. Exercise. Avoid caffeine after noon. Cut back on the alcohol. Don't read/watch television/do crosswords in bed. Don't get into bed until you're ready to go to sleep. Etc. But, as always, the lifestyle modifications may not solve the problem entirely, or the patient may be reluctant to change his or her habits. My personal motto is This Is What Pills Are For, and I am happy to practice what I preach. I am not ashamed to say that Lunesta has changed my life. (In case you're wondering, no one asked me or paid me to endorse this medication.) I have tried the samples and I think they work great – although I have had two or three patients complain of a nasty taste in their mouths the next morning. I take it maybe once or twice a week, when I'm desperate. I feel fine the next day and haven't noticed any problems.

    Meditation or relaxation exercises will also work for insomnia (I think it's because they get your mind out of the vicious cycle of repeating your pet worries over and over again). Counting sheep never did it for me, but on those nights when the clock dial reads 2:47 and it's way too late to consider even Lunesta, I have a favorite exercise that usually helps. I am working on memorizing the California state highway system. Don't laugh; it's like counting sheep but better. It requires a little bit of cerebral exertion, but not much.

    Here is the website that has helped my insomnia the most (it gives information on the location of various highways and freeways throughout the state). To fight insomnia, the rules are you start at Highway 1 and keep going as long as you can. Feel free to adopt this for your own home state or country.

    Example: 1. Highway 1. Runs up and down the coast of California, I have driven parts of it. I visualize it, imagine myself in a convertible zipping up the coast on a sunny day past Malibu, relax. Move on.

    2. Highway 2. Goes to Glendale and Eagle Rock. In memory I see the intersection of the 2 and the 101 near my high school, back in the good old days of the carpool. Relax some more.

    3. The 3 is in the Bay Area somewhere, I think it goes to Berkeley, not really sure.

    4. No idea. Skip.

    5. Ah, Interstate 5. I remember the old strip of the 5 that used to run to Disneyland when I was a little thing growing up in Orange County. I remember the more recent pleasures of driving the 5 to and from San Francisco when I was a resident there.

    And so on, continuing as long as you can. California has a LOT of highways and freeways, so you can go well past 200 if you're really wide awake. Eventually, however, I usually fall asleep or slip into some sort of doze that works almost as well. Zzzz.