The Human Experiment, Part 2

Earlier this month, I posted about my own efforts to deal with insomnia, and how I inadvertently threw myself into caffeine withdrawal. I'm following up here.

So to summarize my experiment on myself, I manipulated the following variables, all at once, with no control group, and no way of knowing which variable was responsible for any changes I saw.

1) I stopped all caffeine. Well, mostly. After the caffeine withdrawal headache and fatigue, I decided there was no real rationale for this, and I've been drinking half a cup of coffee most mornings. In anticipation of the crowds and a purported 1:5000 person: porta-potty ratio at Obama's Inauguration, I did not have any coffee on that morning. I've had no Diet Coke (yes, this is possible) and my efforts to completely stop chocolate have been unsuccessful. So my caffeine intake has been limited to half a cup of coffee in the morning and episodic chocolate in reasonable (mostly) quantites. No artificial sweeteners.

2) I stopped drinking alcoholic beverages.

3) Since I have trouble falling asleep, but don't have trouble with daytime sleepiness, I wondered if I've simply come to need less sleep and I tried setting my alarm significantly earlier in the mornings. I am not a morning person, and this was awful (it lasted 2 days) but perhaps because it co-incided with my caffeine withdrawal. After that, I started going to bed at least an hour later than I was used to.

4) I increased the amount of exercise I was getting...oh, at least for a while. I also tried to add on some evening exercise to manipulate my body temperature several hours before bedtime-- a few minutes until I got flushed, but not sweaty enough to need a second shower. It was going well until a few days ago when I turned into a human slug. I resume a normal exercise schedule today.

5) Stress-- I started this plan during a time when stress was low and there was a long weekend in there. I've had some stuff going on since, and I spent a night away from home and my usual routine. Sometimes, life is just what it is.

My findings:

• It is easier to give up Diet Coke than it is to abstain from Chocolate.
• It is easier to give up alcohol than it is to abstain from chocolate.
• Decaffeinated tea is as happy an event as regular coffee.
  
• My daytime energy level has not changed with less morning coffee.
  
• One can actually have mild cravings for Diet Coke.
• It's easier to go to bed later than it is to get up earlier
• It's a pain in the neck to exercise every single day
• It is notably cheaper to eat in restaurants when there is no alcohol, soda, or after dinner beverage involved (I don't like decaf coffee).

Oh, and the results: most nights, I'm falling asleep within minutes and sleeping through the night.

Sweet Dreams!

The Human Experiment

There are things to do about symptomatic distress in addition to medications and therapy. I often encourage people to make themselves their own human experiments. There are a few things we can change easily: we alter our diets, sleep, exercise, and the assorted "substances" we ingest. I sometimes suggest to people that they do 2 week trials and see if something helps. Is your life better if you stop drinking for a couple of weeks, exercise mor or less, give up food additives, decrease the carbs in your diet, cut out or add caffeine? Pick a variable, change it for a time, and see if you feel better.

That being said, I've been having some trouble sleeping. I decided I'd take my own advice and change some things. Oh, but you know, I'm an impatient sort of soul, and I decided to change a few things all at once. They didn't seem like big things: I decided to cut out all alcohol and caffeine from my diet, to set the alarm for earlier in the morning and get up and exercise in the hopes of exhausting myself. I started on a Monday, not a day of the week I typically drink alcohol anyway, and also not a day I usually have time to exercise. And caffeine, well...a cup of java in the morning, maybe two, and a Diet Coke with dinner, maybe another during the day or maybe not. And I've gone months at a time without Diet Coke. I like it, but it's not the hardest thing to give up. Have I noticed that I feel better or sleep differently without soda? No. But this time, I'm giving up coffee, too.

5:45 AM, the alarm goes off, and 4 miles later, I begin my day, without coffee. No caffeine. No chocolate. No diet coke.
6:15 AM Tuesday, and this is a day I normally exercise. Only I'm dragging, and it was an uninspired work out. By afternoon, I'm feeling really lousy. My head aches. I'm tired and fatigued, and I really can't sleep that night. It's the sleep deprivation, I think, getting up earlier than I usually do, after a night when I've had trouble falling asleep. Ugh.

By Wednesday morning, my head has ached for 2 days, and while I'm caffeine & nutrisweet free, I'm now downing Tylenol and Motrin but my head still hurts. It finally occurs to me that I'm in caffeine withdrawal. But I was never addicted! How can I be withdrawing? I look this up and realize this can last for up to 9 days. Suddenly it seems sort of ridiculous that I've changed multiple variables at once, and even worse that I've given up caffeine cold turkey.


So Caffeine Withdrawal is an official DSM psychiatric diagnosis. From the Johns Hopkins Medicine:

The researchers identified five clusters of common withdrawal symptoms: headache; fatigue or drowsiness; dysphoric mood including depression and irritability; difficulty concentrating; and flu-like symptoms of nausea, vomiting and muscle pain or stiffness. In experimental studies, 50 percent of people experienced headache and 13 percent had clinically significant distress or functional impairment -- for example, severe headache and other symptoms incompatible with working. Typically, onset of symptoms occurred 12 to 24 hours after stopping caffeine, with peak intensity between one and two days, and for a duration of two to nine days. In general, the incidence or severity of symptoms increased with increases in daily dose, but abstinence from doses as low as 100 milligrams per day, or about one small cup of coffee, also produced symptoms.

Wednesday morning, I have a half a cup of coffee. Within a half hour, my headache is gone and my energy level is normal, I feel like myself again. I go for a swim and sit in the hot whirlpool for a while, ahhhhh.....

I've learned a thing or two about being my own human experiment.

Final Results of the Sidebar Poll on What's Your Favorite Sleep Medication

I posted the results of our sidebar poll and I meant to take it down and put up a new one: What's Your Favorite Anti-Psychotic? of course. But I never got around to it and people have just kept voting.

And it's Sunday: coffee and The New York Times. The Magazine's lead article is about is by Jon Mooallem and is called "The Sleep-Industrial Complex." It's a long piece that talks about mattresses (What's YOUR sleep number?), pills, the history of sleep, our expectations and perceptions of what goes on in those wee hours.

So the final results of our Sleep Med survey--please SCROLL DOWN (there's a technical glitch here and I can't seem to get rid of "error loading data" but it's loaded!):

	Answer Text	Votes	%
	ambien	36	19%
	trazodone	33	17%
	dalmane/restoril/klonopin/ativan/valium/serax (benzodiazepines)	26	14%
	benedryl/tylenol PM/ visteril (antihistamines)	21	11%
	Other...	20	11%
	seroquel or zyprexa (off label)	18	10%
	lunesta	6	3%
	sonata	6	3%
	rozerem	3	2%
		189

	Other
		hot Chocolate
		Prefer not to take them
		remeron
		resterol
		Klonopin
		medical marujana
		clonidine
		A good workout at the gym
		melatonin
		Remeron
		amitriptyline
		zopiclone
		Melatonin
		Prefer not to take them
		zopiclone
		bourbon
		I watch mindless TV until I fall asleep. Sometimes it works, sometimes it doesn
		no caffeine after 6 p.m.
		zopiclone
		ethanol

How This Shrink Picks A Sleep Medication

I have more to say about sleep medications. But I have a lot less to say about choosing a sleep medication than I do about choosing an anti-depressant, and my thinking on this is a lot less structured.

Everyone who wants medication to help them sleep gets a talk about the obvious sleep hygiene issues. Here are the basics:
-- Choose a 7 hour period during which you'd like to sleep. Keep it the same everyday, for example, midnight to 7 am, but the exact hours aren't important. The regularity is. Set an alarm.
--Don't nap.
--Don't watch TV or do anything else interesting in bed (sleep and sex, that's it)
--No caffeine after 2 pm. And not much before that. That includes caffeinated soda and iced tea and sadly, chocolate.
--Exercise regularly, preferably 3 hours before you go to bed, but absolutely no closer to bedtime.
--Limit alcohol, and don't drink it near bedtime, it screws up your sleep architecture.
--If you have sleep apnea, use your CPAP machine. Really.

No one follows these recommendations, at least not when I make them.
Linda, the self-proclaimed sleep Nazi, would add: No Screens of any kind after 11 pm for adults and 10 pm for kids-- no computers, TV, video games. Even I'm glad I don't live at her house.

I prescribe sleep medications frequently, insomnia's a common complaint. Sometimes I feel strongly that someone should take a sleep medication-- disturbed sleep goes hand-in-hand with affective (mood) disorders and in patients subject to manic episodes, sleep is really important and I worry that poor sleep habits might either announce or precipitate an episode. Often, though, I feel like it's not the end of the world if every night's sleep is not perfect (great blogging gets done in those wee hours), and that some people are too quick to look to pills to fix problems. I'm probably going to get blasted for that one.

Sleep issues take on a life of their own. People get anxious about not sleeping and it builds on itself. They have all sorts of expectations about how much sleep they need or should have-- one patient was beside herself because she was only sleeping 6 hours a night and felt she needed 8 to 9 hours. Maybe she was right, but when I suggested that maybe she only needed 6 hours and that's why she was waking up, she felt I was dismissive and she found another doc. Another patient said he was greatly relieved when I told him his body was getting rest by just lying there quietly, he stopped worrying so much, and his sleep improved (plus, he turned on his CPAP machine).

All medications have the potential for side effects and adverse effects. Sleep medications are no exception. And many sleep medications are addictive and many patients insist they won't become addicted. And even folks who don't become addicted in an up-the-dose, abuse-the-med kind of way, they get habit-forming, whatever that means, and there are people who will end up taking a pill to sleep every night of their lives and won't hear of even trying to stop the medicine.

So my non-scientific, mostly random method of picking a sleep medication:

If the patient presents with depression, I hope that as the depression resolves, the sleep disturbance will resolve. Some anti-depressants are so sedating (TCAs, Remeron, Serzone, Trazodone) that they are effectively sleeping pills. Other times the anti-depressant, especially SSRIs, cause the sleep disturbance.

Trazodone. It works well in combination with SSRI's. It's cheap. It's not addictive. It's easy to stop. The down side: the fear of priapism and there have been case reports of patients who need surgical intervention. Ouch. The other downside: it doesn't always work, even in escalating doses. Or, it works but patients complain of feeling drugged for hours after waking up. When it's good, it's good.


If trazodone doesn't work or isn't tolerated, and there is no history of substance abuse (particularly of issues with alcohol/benzos), then I try Ambien. This usually works, and it doesn't have a hangover. At least it works for a while, some people get tolerant to it's effects. And some people never want to stop taking it. It's theoretically not very addictive, but it does hit those same benzodiazepine receptors.

If there's a history of substance abuse, I may try visteril. This works only rarely. Once someone has had extended exposure to alcohol or benzodiazepines, it's hard to knock them out.

If visteril doesn't work, I try Rozerem, even though I hate the Abe Lincoln/Beaver advertising campaign, and even though it costs a small fortune, and even though it did terribly on our survey. It does seem to work.

Sometimes I use seroquel or zyprexa. These work, though they have that same effect of leaving some people feeling groggy in the A.M. With all the concern about how these medications are linked with diabetes and lipid disorders, I use low-doses, as needed only for the short-term, and I don't prescribe it as quickly as I used to. Unlike many sleep medications, these are fairly easy to stop.

If there's no history of substance abuse, if the patient is a light social drinker with no history of abuse, then I may try ativan or valium for a short term issue. Restoril works well, though with it's long half-life, it's always a bit surprising that people don't feel groggy on this the next day.

I've never prescribed Sonata, and the first and only patient I gave Lunesta to complained of a horrible taste in her mouth.

With those thoughts, Good Night, Sleep Tight, Don't let the Bed Bugs bite.

My Three Shrinks Podcast 29: Suicidal Breast Implants

[28] . . . [29] . . . [30] . . . [All]

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This time we recorded inside Clink's place, away from the buses and the birds and the helicoptors. I also did not use the GarageBand filter ("Female Radio") which I usually use to filter out low-volume background noises during silent periods. Let me know your thoughts about how it sounds. We are *thinking* about maybe getting lapel mikes and an inexpensive little mixer to balance out our voices better (any suggestions on products welcomed).

Also, we recorded this last weekend. Since it is a shrink rule that we must take off in August (I swear, they'll kick you out of the APA if you don't), we prerecorded two more podcasts (actually, more like one-and-a-half) which I will dribble out over the next few weeks, but we will return with fresh bloviating blather towards the end of August. (Can't wait? Listen to some old My Three Shrinks.)
July 22, 2007: #29 Suicidal Breast Implants


Topics include:

• Brief discussion about iTunes. We hit #6 in the Medicine section in iTunes last week, thanks in part to KevinMD blogging about our last podcast. We are now getting about 8-9000 podcast downloads per month, which we all find rather amazing. Of course, after the U.S., the country we get the most hits from is China, so we figure there must be Chinese people somewhere trying to learn English from us (big mistake). For the handful of psychiatrists out there (Chinese or otherwise), perhaps we'll release one of those Dummies books about how to make podcasts.
  
  
• "Curbing Nocturnal Binges in Sleep-Related Eating Disorder." Clink talks about this article from Current Psychiatry, about eating in your sleep, particularly after taking Ambien, or zolpidem. Clink read us a related poem:
  
  

  My Grandma had a habit Of chewing in her sleep. She chewed on Grandpa's whiskers, And called it Shredded Wheat.
  

  The article lists weird things people eat in their sleep, including coffee grounds, cat food, and buttered cigarettes (yum!). [I don't think it mentioned eating your own placenta.]
  
  
  
  
• You're Supposed to Get Better. Dinah's post about how to know when you are making progress in therapy, and when to move on. (On the blog, this led to a series of emotional posts and comments about therapy, the power inequity between therapist and patient, and the differences between docs blogging about pts and vice versa. Go here, here, and there to read more.)
  
  
• Archetypewriting.com. Dinah provides an unsolicited (and unpaid) advertisement for this website ("The Fiction Writer's Guide to Psychology") about injecting believable shrinkiness into your fiction, while Clink shows off her new nerdy book (2000 Most Challenging and Obscure Words, by Norman W. Schur) by declaring the word of the day to be hircine.
  
  
• Cosmetic Breast Augmentation and Suicide. Dinah reviews this article from the July issue of AJP, from David B. Sarwer, et al., which finds "Across the six studies, the suicide rate of women who received cosmetic breast implants is approximately twice the expected rate based on estimates of the general population." I guess we need a black box warning on silicone breast implants now. (We had a post a year ago about the Good Breast; this one is obviously the Bad Breast.)
  
  
• Q&A: "Is chronic antidepressant use harmful in the long term?" We don't really do this topic justice, but Dinah refers to a prior post here.
  
  
• Coming up on the next podcast: 3 AJP articles on suicide and depression treatment; federal parity laws; managing agitated patients in your office.
  

I haven't been able to get this song out of my head for the last 2 weeks (prompting me to get the song from iTunes and then buy the CD), so I thought I'd share the infection with everyone: Mr. Blue Sky by Electric Light Orchestra (ELO). For a really cute video of this song, check out CurlyLisa's gang on YouTube.

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Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Viagra, East of Java

I read today of a study in hamsters showing that a low-dose of Viagra (sildenafil) helps to reduce the effects of jet lag -- but only when traveling eastward! That is called a phase advance, when the new time is earlier than your body's clock.

No, they didn't put the hamsters on Hooters Airlines... they just woke them up early:

The team observed how easily the hamsters adjusted by noting how soon the nocturnal animals began running on their exercise wheels when the lights went out.

They found that sildenafil boosted the ability of hamsters to recover 25 to 50 per cent quicker than untreated animals. Sunlight is thought to be a key influence on the body clock by its involvement in a neurochemical pathway in which cGMP is involved, and in this way the drug is thought to make the brain more sensitive to the effects of light, Dr Golombek said.

However, the drug only worked when applied before an advance in the light/dark cycle, equivalent to an eastbound flight.

Encouragingly, Viagra worked at doses low enough not to trigger erections, though Dr Golombek stressed that human tests would be needed to confirm that this was also true for people.

How did they measure hamster hard-ons, I wonder.

The scientists believe that frequent fliers and shift workers may well benefit from moderate doses of sildenafil, with passengers probably taking it during flights.

"Shift work and chronic jet lag reduce mental acuity and increase the risk of a number of medical problems," Dr Golombek said.

"A potential jet-lag treatment for advancing cycles could also be important for the safety of counter-clockwise rotating shift work and the potential long-term health consequences for airline crews regularly crossing time zones."

So now there may be a whole 'nother mile-high club... just for jet-lagged shift-workers traveling eastward. (Maybe one would use depo-provera for westward jet lag, huh?)

Makes me think of the B-52's song, Lava:

My body's burnin' like a lava from a Mauna Loa
My heart's crackin' like a Krakatoa
Krakatoa, east of Java, molten bodies, fiery lava

Fire, fire, burnin' bright
Turn on your love lava
Turn on your lava light
Fire, oh volcano, over you
Don't let your lava love turn to stone
Keep it burnin'
Keep it burnin' here at home