Insomnia in the Time of COVID-19

I have talked about it before, but it bears revisiting this week. In the last three weeks that I have worked at home, I have heard several complaints repeated over and over again. One that is on everyone’s lips is this: “I can’t sleep.”

Now, I see a lot of folks who have depression, anxiety, trauma, grief and many other issues in my work, but there are certain kinds of symptoms that seem to be common across the spectrum of mental health illness or stress. When people get upset, their mood changes. They eat too little and lose weight, or they eat too much and gain weight. They notice changes in interest, motivation and energy levels. They isolate and have trouble connecting with those they love. They have a hard time focusing or paying attention to things that matter. Many of these symptoms might be present in anxiety disorders, mood disorders or even psychotic disorders. Still, the one thing besides a vague sense of anxiety that almost everyone is feeling, and complaining about in the midst of this pandemic, is the inability to get good, restful, restorative sleep. 

First, some normative data. What is normal sleep latency, the time that it takes most of us to drift off to sleep? Eight minutes is a good yardstick. How much sleep do we really need? One can read about numbers that vary wildly, but it still seems that most people do better with an average of seven to nine hours of sleep per night. How much of this needs to be REM (rapid eye movement) sleep, that stage of sleep where we actively dream? Well, if one gets nine hours of sleep and REM cycles repeat every ninety minutes or so, one could expect to have at least two good REM cycles per night. Twenty-five per cent of your total sleep time given to REM is about right for most people. 

Next, why is this important? Why do we need this much sleep anyway?  We think that sleep is important to maintain both good mental and physical health. While we sleep, our bodies repair and maintain organ systems and muscles and immune systems, and manufacture hormones. Memories and newly acquired information may also be cemented during sleep, so that this information can better be used later during waking hours. Getting the right amount of sleep may also be protective in guarding you against development of diabetes, weight gain, and heart disease. 

Why has sleep, or the lack of it, been such a constant complaint in the last few months as we navigate this COVID-19 pandemic? Many people are experiencing anxiety, which tends to make settling down, getting relaxed and falling asleep at night very difficult. This anxiety is low grade and chronic for many people, hard to describe but always there, and it tends to affect our ability to fall asleep, leading to what we call initial insomnia. This kind of anxiety and inability to fall asleep can build on itself night after night, becoming a chronic problem. 

Others may be battling depression, with superimposed grief over all the things that we have collectively lost because of the virus outbreak and its impact on our physical, emotional, vocational and financial lives. Depression sometimes leads to what we call early morning awakening. You are able to fall asleep just fine, as you are sometimes absolutely exhausted, but you find yourself waking up almost every night at four AM, not able to go back to sleep. 

Everyone wants to sleep. The quick fix, taking some kind of over the counter or prescription sleeping pill, seems to be the best answer. Not always so, I’m afraid. Sometimes one has to deal with the underlying anxiety, depression and grief that is depriving us of sleep in the first place. Sleep hygiene is also very important. You know, the steps that your doctor has told you to try, including not exercising in the evening, limiting late night eating and alcohol consumption, avoiding screen time for several hours before you go to bed. Regular bedtimes and awakening times are also crucial, as these rhythms tend to lead to more consistent and restorative sleep. 

During this pandemic, we are all a little out of sorts, our usual routines have been disrupted, our moods are different and our ability to relax is strained. Knowing what is normal, what is not and how to maximize our chances to sleep well each night will go a long way to help us not only weather this biological storm, but thrive as we get to the other side of it.  

Future Shock

There is a lot going on in our world right now.

From senate testimony in various hearings to war in foreign lands to giant bombs being dropped (no, not F-bombs, but then again…) to Brexit to special elections to Juneteenth celebrations to the near-explosions of talking heads because of the sheer volume and ambiguity of it all.

We really don’t know from day-to-day what will greet us in the newspapers that we read, podcasts that we listen to, or social media outlets that we frequent. If you’re like me, and many of you must be, or you wouldn’t read this blog, you can’t get enough of the excitement and frenzy of it all, but at the same time it scares the living daylights out of you.

What does the future hold?

No, I mean really. What does the future hold?

How can we know? How can we know, given the impulsivity of our leaders, the shallowness of thought, the depth of misery around us and the unpredictability of the world around us today?

The short, slightly comforting answer is that we can’t know.

How then can we focus on, contemplate in a serious manner, think about intentionally, plan for, reasonably anticipate, embrace, and not fear the future?

I’m trying to take this bull by the horns in a few ways.

One is to break down my response to that lump in my throat that rises periodically, fueled by uncertainly and fear, into three easily considered and actionable steps that I can take every day.

  1. I intentionally contemplate three things that I’m looking forward to tomorrow.
  2. I think about three things that I plan to do in the next year.
  3. I think about three really important things that I want to do before I die.

This may not work for you, but along with other intentional reviews of my activities, my short, intermediate and long-term goals and my actionable plans, it works for me. It keeps me grounded, helps me make achievable plans and keeps me looking at the future as a time that will be healthy, happy and exciting for me and my family.

I also conceptualize the way that I look at the future in this way, utilizing a series of feedback loops:

One of my goals is to decrease fear.

One of the ways that I know really helps me to tame my fear is to learn more about the thing that is making me afraid.

Once I learn more and thus decrease my fear, I am more likely to take action.

When I take action, I experience growth.

Growth further decreases my fear, which helps me to take more action, and so forth.

Growth also leads to happiness, and with continued, ongoing happiness, contentment.

 

Does the future make you feel afraid?

Try the simple contemplation exercises I listed above.

When you are afraid of something, learn more about it, take action based on what you learn, experience the growth that comes with actionable knowledge, and from that growth begin to experience happiness on the way to true contentment.

We can’t fully predict the future, but we can productively shape our responses to it.

Have a great Thursday.

 

 

 

Why Do We All Want to Die?

I use an ongoing spreadsheet to keep track of and to report my demographics and stats for each telepsychiatry consult shift I do.  I’ve done thousands of consults in over two dozen South Carolina emergency departments over the last half-dozen years. We have now gone over thirty thousand consults as a group.

It never ceases to amaze me, as I fire up my computer, log on to my systems and bring up that spreadsheet for the shift ahead, that one column is remarkably uniform and consistent, sometimes for days at a time. It is the column that asks for an abbreviated reason for the consultation request. It usually looks like this:

SI

SI

SI

SI

SI

SI

SI stands for suicidal ideation, and that is one of the most common chief psychiatric complaints that we see in the emergency department.

Sometime I am simply so busy trying to see all of these people (there was a multi-day stretch recently that we had up to thirty different consults queued up waiting for one of us to see them) that I cannot afford the luxury of slowing down, looking for trends, trying to analyze why we might be so busy during that particular weekend, and the like. There is just not time. However, it is hard not to see the obvious pattern created by the number of people who come into the EDs and state to a staff member that they want to kill themselves.

Why do we all want to die?

Sure, the world has its ups and downs and stresses, but there seem to be so many people who are bent on their own destruction lately that it is mind-boggling.

Allow me to posit some reasons for this disturbing trend.

We do not feel that we belong.

I heard something on the way to something else the  other day that stated that folks who are forced to check that box called “Other” on standard forms do not feel special when doing so. They actually can be made to feel apart, cast out, cut off from the mainstream, in that they do not fit any of the standard groups listed on such forms. To be “other” is to be different, odd, not a part of the group. It is socially and emotionally ostracizing. It means that we do not belong. That hurts.

We do not feel loved.

Okay, okay, I know that is shrink talk and too touchy feely for some of you, but hear me out. I hears over and over from folks in the ED that they do not feel loved by their parents, their spouse, their children, or anyone else. Once again, whether it is feeling like the “other” or not loved by anyone at all, it is a massive cause of self loathing, isolation and hopelessness that will drive someone towards not wanting to exist at all.

Everything seems too hard these days. Nothing is guaranteed.

It used to be if you went to school, graduated, kept your nose clean and played by the rules, you would almost certainly succeed in life. You would be able to find a job, you would have a place to live, you might find love and even raise a family. Today, it seems that none of this is guaranteed, and that for some it all seems just out of reach. Sometimes, people who appear at first blush to be lazy are just depressed, unmotivated, not well-trained, not educated, and simply down on their luck. They see little hope for success no matter how hard they try, so they don’t try. It is sometimes easier to just give up, find someone or something to blame, and give up, rather than really working to make things better.

We feel hopeless.

Hope keeps us getting up in the morning. Hope keeps us going to school, working our way up the ladder, doing the jobs that no one else wants to do, taking on challenges that we are afraid of. If we lose hope, we have lost our will to challenge ourselves. We have lost our dreams for the future. We have lost our ability to see ourselves in the distance, happy and healthy and successful.

What exacerbates these core states and feelings? What makes it hard to fight back and move past them? What do I see most often in the emergency department when someone has come in after cutting, swallowing a bottle of Tylenol, or drinking themselves into oblivion?

Relationship problems are always in the mix. A teenager breaks up with the love of her life and now thinks that life is over. (She cuts herself on the arms and legs where no one can easily see her attempts to deal with her pain). A middle-aged man is a raging alcoholic but has no insight into how this is devastating his family. His wife leaves him, taking their three small children with her. He comes in with a blood alcohol level five times the legal limit. An elderly man has just lost his wife of sixty years to cancer. He is quite literally lost without her, and he does not want to go on. He is a retired police officer, owns several handguns, and knows how to use them.

Financial problems and reversals can produce high levels of anxiety that seem insurmountable. Some folks are almost paralyzed by just not being able to buy gas for the car or groceries for the kids this week. Others may be more well to do, but the shock of losing value in their retirement portfolios or not being able to make the mortgage payment on a huge house that they really cannot afford leads to guilt and shame and feelings of failure. Both can feel like the easiest way out is to simply not be here any more.

Some patients are dealing with chronic mental or physical conditions that they are simply tired of. The ups and downs of bipolar disorder, the pain of congenital spinal malformations, the physical and emotional trauma of cancer and its treatment can all lead to feelings that it would just be better to end things on your own terms rather than waiting on the  diseases to decide when it is time for you to die.

Perceived failures and disappointments (both disappointing yourself or others) often leads to the mistaken notion that if you kill yourself, the problem goes away for not just you, but everyone involved with you. The thing that most of these folks have not thought about to any degree is the pure devastation that is left in the wake of a suicide. The family members, spouses and friends who must live on after you are gone must ask all the hard questions, the “what ifs”, the whys. The guilt and emotional suffering they feel is tremendous and it never really, truly goes away.

Fear and anxiety drive many suicide attempts. Odd, in that most people think that only those who are severely depressed kill themselves. Anxiety, severe and unrelenting, actually leads more folks to actually successfully complete an attempt than depression. The underlying shame, guilt, or other emotions that drive the anxiety are often not discovered in time, or are so well hidden by the patient that it is only after the successful suicide that these are uncovered and better understood, often from the note or other communication left by the deceased.

What is the common feeling that weaves its way through it all? Hopelessness. If you think that there is no way out, that there are no viable solutions left, that you have exhausted all reasonable possibilities for making your situation better, then that gun or bottle of pills or telephone pole look like rational and logical answers for your unanswerable questions. You give up. You quit looking for answers. You feel lighter, happier, more confident because you have made that decision to just let it all go. If there is no intervention, swift and appropriate, you will die.

What are all these stresses and problems complicated by, as if it could get any worse?

One of the most common accelerants for suicidal ideation and attempts is intoxication with alcohol and other drugs. Decreased inhibitions, poor judgment, impulsivity and poor decision-making all lead to potential problems when one is already contemplating self harm. If you are already stressed, at the end of your rope, and contemplating ending it to escape the anxiety and pain you feel, reach out and get help. Drinking, smoking and popping pills rarely makes things look better.

Poor social support is another major deficit that exacerbates suicidality. I see countless patients who truly do not have family, friends, church or anyone else they can call on in time of need. They are really, truly alone. Isolation and disconnection from other people kills.

Lack of access to care also makes things worse just when the help is needed the most. The shrinking of available mental health resources in this county has lead to a dearth of programs that address acute illness and this does not bode well for someone who needs help now, not three weeks from now or at the next available appointment time.

Concomitant mental and physical illnesses can spell disaster. Those dealing with longstanding cardiac disease, severe diabetes, metastatic cancer, and other devastating illnesses may be overwhelmed with the emotional counterpart of the illness and if not noticed or addressed, it may steadily worsen and become malignant itself.

What to do if you find that you are one of those people who is thinking that death looks like your only option?

Call 1-800-273-TALK.

Talk to your family, your girlfriend, your husband, your minister or priest.

See a psychiatrist or other qualified mental health professional right away. If you are turned away when you call, call somewhere else. Don’t accept anything less than an option for immediate assessment. This is your life in the balance, and it is important.

Suicide kills over forty-four thousand people in the United States every year. For each completed suicide there are twenty-five attempts. On average, there are over one hundred twenty suicides per day in the US.

There are many reasons that many of us really want to die.

The job for the rest of us is to convince those folks on the edge that there is help.

There is treatment.

There is hope.

 

 

Born to Worry

“So you’re doing better then, all together?”

He paused, sitting there, round-bellied, balding, a half-grin on his ruddy face. 

“Yeah, Doc, I guess so. But,  you know, I don’t sleep, I’m not eating as much as I used to. I have this pain in my little finger here, and my shoulder is always hurting me. I feel dizzy a lot. I get tired. My stomach stays upset.”

“So, you have a lot of little physical things that worry you every day.”

“Doc, to be honest with you, I think I was born to worry.”

Anxiety. 

A mostly normal, adaptive response to variation in our daily routine. It is a a feeling that is always at minimum a little bit uncomfortable, at maximum debilitating and relentless. 

Think about one of those times that you were facing something new. A date with a person you didn’t know. A difficult academic exam. A visit with the doctor when you were sick. You most likely felt a a little mild fear and trepidation, a heightened sense of awareness of your surroundings, and a weird “I think I may have to get up and run away” kind of vibe. You knew it was strange and not all together pleasant, but it was not going to keep you from going on the date (which you enjoyed), taking the test (which you passed because you had studied) , or having the checkup with the doctor (which was entirely normal). 

Mild anxiety, adaptive and normal, helps us to focus on the task at hand. It helps us prepare for a challenge. it sharpens our senses, increases our cognitive processing power, makes us more alert, and gets us ready to make decisions. You’ve no doubt heard of the fight or flight response. Anxiety helps get us ready for making the decision necessary to take a stand, or it gets us ready to run like hell in the other direction. 

Now, in medicine in general, and in psychiatry in particular, I see a lot of people who are anxious. I would argue that on many days, anxiety complaints outnumber depression symptoms by a wide margin. I know that medical problems can mimic anxiety disorders, and that I need to be vigilant for them. Thyroid problems (over or underactivity) may have a prominent anxiety component. Someone in the hospital who is extremely anxious and short of breath with chest pain may be having a pulmonary embolism or heart attack. Chronic obstructive pulmonary disease may lead to decreased oxygenation and physical difficulty with breathing, leading to anxiety. Substance abuse, especially abuse of things like cocaine, PCP, meth, and stimulants, will lead to extremes anxiety in some people. The hallmark of mental illnesses such as generalized anxiety, panic disorder, and general or specific phobias is subjective anxiety. 

Debilitating, extreme, paralyzingly anxiety that might come from those problems listed above or many others is not normal. It is very uncomfortable, it makes you afraid, it keeps you from getting out of bed or leaving your house or talking to people. It causes you to abandon a full shopping cart of groceries in Wal Mart and to run, not walk, back to the safety of your car in the parking lot. Of the handful of folks I’ve seen in the past who were successful at killing themselves, two thirds of them did it primarily because they were so extremely anxious that they could not stand it any more. They saw suicide as their only viable option for peace and as a way out of insurmountable suffering. 

Mild anxiety is normal, and even helpful. 

Unfortunately, we have been conditioned in our modern world to think that any little ache or pain, any twinge, any mild, fleeting anxious moment, any night or two of disturbed sleep means that we are sick, that we are ill, that we have a mental illness or cancer or worse. 

Not true. 

I spend a lot of time nowadays trying to convince people that what they need is not another prescription for Xanax, but the courage to stand up for themselves, vote their convictions as it were, and make good decisions without fear or guilt. I try to convince them that a night or two of tossing and turning and not sleeping well is not a sickness or sign of impending doom. An episode or two of decreased concentration or outright forgetfulness does not mean you automatically have Alzheimer’s disease and dementia. 

It would be very nice if we all started to view mild anxiety as a tool in our toolkit of life. It is a marker, a signpost that lets us know how we’re doing, how far along a road we have come and what obstacles might be in our way up ahead. It primes us to act, to accomplish and to succeed. 

We were not born to worry.

We were born to live.

Anxiety is one of those normal things that we must sometimes deal with along the way.