Rage, hunger, lust, and sleep.

Just thinking the beeper will beep

Will keep you from getting good sleep,

            Then hunger you must           

            There’s anger and lust

And you tend to sigh and to weep.


The amygdala, an almond-shaped piece of your brain, is charged with a lot of things, among them hunger, anger, sexuality and sleep.  If you mess with one, you mess with them all.  And every knows it.

If you are hungry, you can’t sleep, you’ve got a short temper, and you have no perspective on sex.

If you’re sexually deprived, you’ve got a short temper, you can’t control your appetite, and you can’t sleep.

If you’re angry, you can’t sleep, you either can’t eat or you can’t stop eating, and you have no perspective on sex (nothing kills a sexual relationship faster than anger).

If you’re sleep deprived, you can’t control your appetite, you have a short temper, and you have no sexual perspective.

I remember speaking with a medical school classmate in that stressful third year.  She’d been on call the night before and hadn’t slept well most of the rotation.  I asked her how she was, and she said, “How do you think I am?  I’m down to the limbic system level.”  Which she then detailed, graphically. 

I see a lot of illness which has been exaggerated by sleeplessness.  Diabetes, we now know, improves dramatically if sleep pattern can be normalized; CPAP treatment for diabetics with sleep apnea is the equivalent of 1000 mg twice daily of metformin.  Much, not all, of fibromyalgia comes down to a sleep disorder.  Sleep apnea makes high blood pressure much worse.

In patients with rheumatoid arthritis, sleeping poorly the night before predicts pain level better than pain level during the day predicts sleeping poorly at night.

In another state (remember, I’ve had licenses in seven states so it is not possible for the readership to identify the patients) I cared for a pair of brothers who became psychotic after doing too much speed and not sleeping for a week.  After a couple of good night’s sleep in the psych ward they were saying things like, “I can’t believe I…, I remember it and I remember how it all seemed so real.”

Then there are the correlates of depression, and you can’t have depression without sleep disturbance nor sleep disturbance without depression.  You can treat the depression till you retire but you won’t make real progress if there is a sleep disorder that needs to be treated.

If you sleep well the night after your flu shot, you get antibody levels five times higher than if you go on call and don’t sleep at all, and the antibody levels never completely catch up.

Many patients are resistant to normalization of sleep patterns because they have disordered family dynamics, and sleeping lousy keeps them from functional interaction with their families.  For those patients I recommend marital counseling, which they usually won’t accept.

Good sleep hygiene takes care of most (not all) sleep problems:

             Nicotine:  Tobacco is evil.  It also cuts down on the time you spend in Stage IV and REM sleep, the restful stages.  The effect lasts for months after you quit.

            Caffeine:  This one is not rocket science.  Caffeine is supposed to keep you up. Most people don’t realize that the effect of the caffeine persists months after the last dose, though most of the recovery is done in two weeks.

            Alcohol:  Booze puts you to sleep for four hours without the restful stages of sleep (Stage IV and REM), then you wake up and you can’t get back to sleep.  If you’ve been drinking hard your sleep EEG will not normalize for six months after your last drink.

            Television:  On a regular basis people will stay up late to watch the evening news, and go to sleep half an hour later than they would have normally.  Or they’ll stay up to watch a favorite show.  My advice is to get the TV out of the bedroom all together.  Nothing on TV is worth the time it takes to watch it.

            Meal timing:  Wait for three hours after eating before laying down.  If you’re going to have a bedtime snack, make it light with a low glycemic index.

            Exercise:  Don’t do it right before you go to bed, you’ll be too hot.

            A quiet, comfortable, safe place to sleep:  I have a friend who doesn’t sleep well if  no dog is there as a guard.  Don’t expect to sleep well in an uncomfortable bed with an abusive partner.

            Adequate sexual frequency: It’s different for each person.

            Anger management:  This is a much thornier issue.  I’ve started to advise writing for twenty minutes before bedtime, starting with the worst thing that ever happened.  Longer term anger management is best addressed with professional  counseling.

A lot of people will tell me they sleep fine because they fall asleep quickly and they stay asleep through the night but they wake up feeling rested less than half the time.  They need effective sleep.

Like many other things, sleep deprivation/loss of appetite control/anger/loss of intimacy tend to a vicious cycle; people gain weight, get sleep apnea, can’t control their hunger, gain more weight, their knees hurt, they can’t exercise, they gain more weight, they sleep worse, they’re so angry that their loved ones shrink from their short tempers, they eat more, they sleep worse, etc, etc.

Sleep problems of doctors come from frequent night-time awakenings while on call, and from vigilance.  Aside from a few years while I was with the Indian Health Service, I’ve done OB.  If you have patients after 36 weeks gestation you don’t sleep well, you’re always waiting from the call from Labor and Delivery.

Vigilance murders sleep.  Ask any mother of a newborn.  Ask any doctor on call.

Sleeping during the day after call helps but it doesn’t make up for the deficit.

As time goes on, my resilience to sleep deprivation has weakened.  Twenty three years ago if I stayed up all night with a hard delivery or a series of admissions I could sleep the next afternoon and I’d be OK the day after.  Now if I’m up all night on Monday I feel terrible till about Thursday. 

I’m on call this weekend.

Even if I don’t get called, the fact that I’m liable to be called will rob my sleep.

I’m hoping when I slow down I’ll have more down time before and after call, so that I’ll rest better more of the time.


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4 Responses to “Rage, hunger, lust, and sleep.”

  1. 2010 in review « Walkaboutdoc's Blog Says:

    […] Rage, hunger, lust, and sleep. March 2010 4 […]

  2. no sleep Says:

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  3. Darnell Lavin Says:

    Rage, hunger, lust, and sleep. | Walkaboutdoc

    […]Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can happen in folks who’ve skilled or witnessed a traumatic event equivalent to a natural catastrophe, a critical accident, a terrorist act, war/fight, rape or different violent…

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