Monthly Archives: November 2013

Like many of the patients I see, I sometimes struggle to get a good night’s sleep.  One valuable lesson from my experience with insomnia is that worrying about sleep makes it even more difficult to do.  When we become anxious, our body’s fight or flight system becomes activated.  Our adrenal glands secrete norepinephrine, epinephrine, and cortisol in preparation for taking on a threat to our survival.  All of this is not a recipe for sound slumber. 

So if I happen to wake up in the middle of the night, I try to tell myself in a Stuart Smiley kind of voice, “It’s gonna be OK. It’s not the end of the world if I don’t get all of the sleep I want tonight.”  I also tell myself that it’s perfectly normal to wake up during the night—because it is.

In fact, as David Randall reports in his book Dreamland, scholars from two different fields of study have discovered that sleep hasn’t always been the long block we consider it today.  The first of these scholars is Virginia Tech history professor Roger Ekirch.  Reading documents and literature from prior days, Ekirch

kept noticing strange references to sleep.  In the Canterbury Tales, for instance, one of the characters in “The Squire’s Tale” wakes up in the early morning following her ‘first sleep’ and then goes back to bed.  A fifteenth-century medical book, meanwhile, advised readers advised readers to spend the ‘first sleep’ on the right side and after that to lie on their left.  And a scholar in England wrote that the time between the ‘first sleep’ and the ‘second sleep’ was the best time for serious study.

 

Ekirch rediscovered a fact of life that was once as common as eating breakfast.  Every night, people fell asleep not long after the sun went down and stayed that way until some time after midnight.  This was the first sleep that kept popping up in the old tales.  Once a person woke up, he or she would stay that way for an hour or so before going back to sleep until morning–the so-called second sleep.  The time between the two bouts of sleep was a natural and expected part of the night and, depending on your needs, was spent praying, reading, contemplating your dream, urinating, or having sex.  

 

While it was clear to Ekirch that modern people sleep quite differently than our ancestors, “saying that the whole of the industrialized world sleeps unnaturally was a big leap.” It was thus fortuitous that at the same time was Ekirch was making his discovery, a neuroscientist stumbled upon the same phenomenon.  At the National Institute of Mental Health, the psychiatrist Thomas Wehr wondered if “the ubiquitous artificial light we see every day could have some unknown effect on our sleep habits.  On a whim, he deprived subjects of artificial light for up to fourteen hours a day in hopes of re-creating the lighting conditions common to early humans.”  Wehr noticed that the people he studied “began to stir a little after midnight, lie awake in bed for an hour of so, and then fall back to sleep again. It was the same sort of segmented sleep that Ekirch  found in the historical records. . . The experiment revealed the innate wiring in the brain, unearthed only after the body was sheltered from modern life.”

Wehr soon decided to investigate further.  Once again, he blocked subjects from exposure to artificial light.  This time, however, he drew some of their blood during the night.  The results showed that the hour humans once spent awake in the middle of the night was probably the most relaxing block of time in their lives.  Chemically, the body was in a state equivalent to what you might feel after spending a day at a spa.  During the time between the two sleeps, the subjects’ brains pumped out higher levels of prolactin, a hormone that helps reduce stress. . . The subjects in Wehr’s study described the time between the two halves of sleep as close to a period of meditation.

 

Learning these fascinating facts about the history and biology of sleep makes me wonder if insomnia is largely an environmentally-produced health condition.  Just as asbestos produces mesothelioma and tobacco smoke accounts for most cases of lung cancer and emphysema, much of our modern plague of difficulty sleeping can be laid at the feet of Thomas Edison’s world-changing invention.

23andMe is a personal genomics and biotechnology company which for $99 conducts a comprehensive analysis of your DNA.  In recent days, the Food and Drug Administration (FDA) instructed 23andMe to halt sales of its main product.  The FDA’s problem with 23andMe does not seem to be the accuracy of their testing methods.  Reading NIH director Francis Collins’ book The Language of Life, in which he describes his experience using 23andMe, it seems evident that this uber-informed genetic scientist trusts the validity of their results.   The FDA’s concern is apparently that the company has not met all of the complex regulatory requirements demanded by the type of entity the FDA considers them to be. 

In his Slate article, Gary Marchant argues that the FDA’s burdensome regulations essentially make it impossible for companies to provide affordable personalized genetic testing.  

The problem is that (the FDA’s) regulatory approval pathways generally require clinical testing that takes several years to complete and costs millions of dollars. 23andMe or any other entrant into this field would have to pursue such approval for each test it offers—and 23andMe offers tests for more than 250 diseases and conditions. Moreover, because of rapid advances in the field of genetics, any such test would likely be outdated, replaced by a more precise and advanced test, before the clinical testing and regulatory approval could be completed for the initial test. In other words, the PMA regulatory pathway is infeasible and impracticable for these types of tests, and the FDA’s insistence on such a step is a death sentence for direct-to-consumer genetic testing.

 

Beyond debating the technical legalities of the FDA’s action, it is worth considering whether what it did will result in more overall harm or good.  Let’s first consider the benefits of direct-to-consumer genetic testing.  The first is privacy.  As Marchant writes, “To many people, their genetic information is very private, and they prefer to get the results privately at home rather than through their physician, who will likely put the information in the patient’s medical record.”  A second benefit is the low price of 23andMe’s product.  To quote Marchant again, “It is much cheaper to get tested through 23andMe, which is currently offering its entire battery of genetic tests for only $99. It would cost many hundreds if not thousands of dollars to get the same tests through one’s physician, and health insurance does not cover the cost of most genetic tests presently.”

What are the concerns held by the FDA and other critics of direct-to-consumer genetic testing?  One worry is that people might undergo unnecessary tests and procedures based on the information 23andMe provides.  For example, critics worry that a woman who is found to have a false-positive BRCA mutation might have a prophylactic mastectomy inappropriately.  This seems to me to be an impractical concern.  It is difficult imagine a surgeon operating in such a situation without first verifying the genetic testing through another lab and extensively discussing the benefits and risks of such an approach with the patient.  

Another concern about direct-to-consumer genetic testing is the psychological impact that the information can have.  How might a person react if he or she finds they have an increased risk of developing Alzheimer’s disease, something which they are powerless to prevent?  When I received my 23andMe results, it was apparent that the company takes this issue seriously.  The results for my risk of developing Parkinson’s Disease and Alzheimer’s were locked.  I was required to read through a long explanation of the meaning and  implications of the test results before I could access them.  It turns out, however, that people seem to be less psychologically devastated by adverse genetic test results than many of the experts anticipated.  For instance, a study published in the New England Journal of Medicine found that “in sample of subjects who completed follow-up after undergoing consumer genomewide testing, such testing did not result in any measurable short-term changes in psychological health, diet or exercise behavior, or use of screening tests.”  

After considering the benefits and risks of direct-to-consumer genetic tests such as 23andMe, it seems that they likely result in more good than harm.  I reckon our federal government’s resources would be better spent taking on public health risks much greater than those posed by 23andMe.

After a busy, intense day of work at the clinic, I sometimes try to make an early evening yoga class at a nearby studio. It is a relief to empty my mind and focus on performing the poses the instructor sets forth.  

Over time, multiple studies have corroborated my experience of the benefits of yoga and meditation.  As Dr. Andrew Newberg of Thomas Jefferson University Hospital and Medical College writes, 

If you stay in a contemplative state for twenty minutes to an hour, your experiences will tend to feel more real, affecting your nervous system in ways that enhance physical and emotional health.  Antistress hormones and neurochemicals are released throughout the body, as well as pleasure-enhancing and depression-decreasing neurotransmitters like dopamine and serotonin.  Even ten to fifteen minutes of meditation appears to have significantly positive effects on cognition, relaxation, and psychological health, and it has been shown to reduce smoking and binge-drinking behavior.  

One of the pioneers in the study of the health benefits of meditation is Dr. Herbert Benson, Professor at Harvard Medical School.  His book, The Relaxation Response, is a classic and a great introduction to this field.

The pediatrician Margaret Morhman tells the story of caring for a young girl in the ICU who developed a devastating case of meningitis.  One day when she came to check on her patient, the girl’s mother asked Morhman why her daughter had become sick.  As Morhman began to explain what meningitis is and how it is transmitted, it quickly became clear to her she was missing the meaning of the mother’s question.  Like Job, the mother was struggling to make sense of why her daughter was being made to suffer.

Whether we realize it or not, each of us operates with beliefs about causality and meaning.  Who or what controls the course of events in our lives and the world?   Do blind physical forces alone determine our destiny?  Is God or some other force like karma in control?  These basic beliefs often come into play when we get sick and seek to make sense of our suffering.

For instance, some people may interpret their disease as a kind of punishment for bad health decisions like smoking or alcohol abuse.  Others may find a spiritual purpose in being ill.  Still others may believe they became sick due to sheer bad luck.

The meaning we attribute to a symptom such as pain can influence how we experience it.  This is because our perception of pain is mediated through our central nervous system, through our brain, through our mind.  For example, if I had a headache right now, I would experience it in a radically different way depending on if I attributed it to stress or if I feared it was due to a life-threatening brain tumor.

Our emotional and spiritual state of being can also influence how physical ailments feel.  In my work in hospice, I have cared for patients with severe pain that did not respond to higher and higher doses of potent analgesics.  Only after somebody identified and addressed a spiritual crisis, such as a fear of dying or an agonizing regret, did the suffering person find relief.  

I turned 36 almost a week ago and for some reason, this birthday prompted me to reflect on the scarcity of time.  When we are young, it seems like the days will go on forever.  The reality of an ending, of death, hardly enters our mind.  I adore this care-free innocence I witness in the life of my 5 year old son.

But as we enter adulthood, there is value in clearly seeing that our days are numbered.  It can motivate us to contemplate what really matters and how we want to spend the rest of their lives.

The psychology professor Mihaly Csikszentmihalyi has carefully studied how people spend their time.  He points out that what we do during an average day can be divided into three major kinds of activities.

The first way we spend our time is producing, or generating the resources such as money that ensure our survival and comfort.  The amount of time we spend working in this way differs across time and places.  Csikszentmihalyi writes that “according to some anthropologists, among certain societies, such as the tribesman of Brazilian jungles or the African deserts, grown men rarely spend more than four hours a day providing for their livelihood–the rest of the time they spend resting, chatting, singing, and dancing.  On the other hand, during the hundred years or so of industrialization in the West, before unions were to regulate working time, it was not unusual for workers to spend twelve or more hours a day in the factory.  So the eight-hour workday, which is currently the norm, is about halfway between the two extremes.”

The second way we spend our time is preserving the body and its possessions.  Csikszentmihalyi calls eating, resting, grooming, cooking, shopping, housework, and driving maintenance activities.  Traditionally women have taken on a greater portion of the maintenance work, while men spent more time on productive roles.  But, of course, this division of labor has changed over time and will continue to evolve.  

The time left over from production and maintenance is free time or leisure.  Csikszentmihalyi notes that our free time is divided into three major sorts of activities.  The first is media consumption, consisting mostly of watching television and surfing the internet.  The second is conversation.  The third is hobbies such as making music or art, engaging in sports and exercise, and reading.  Interestingly, Csikszentmihalyi does not specify how he would categorize service and volunteer work or being involved in a spiritual community.  Is this work or leisure? 

I think Csikszentmihalyi’s poetic summary of how we spend our days is worth sharing.

These three main functions–production, maintenance, and leisure–absorb our psychic energy.  They provide the information that goes through the mind day after day, from birth to the end of life.  Thus, in essence, what our life is consists in experiences related to work, to keeping things we already have from falling apart, and to whatever else we do in our free time.  It is within these parameters that life unfolds, and it is how we choose what we do, and how we approach it, that will determine whether the sum of our days adds up to a formless blur, or to something resembling a work of art.

 

I love that last thought: Will the sum of our days add up to a formless blur, or to something resembling a work of art?

One of the common symptoms of depression is difficulty sleeping.  Now a new study suggests that curing insomnia in people with depression could double their chance of full recovery.  The New York Times reports that the trial conducted at Ryerson University “found that 87% of patients who resolved their insomnia in four biweekly talk therapy sessions saw their depression symptoms dissolve after eight weeks of treatment, either with an antidepressant drug or a placebo pill–almost twice the rate those who could not shake insomnia.”

The therapy used to treat insomnia was cognitive behavioral therapy (CBT).  The therapist works with clients to help them establish optimal sleep habits.  Below are some specific behavioral changes that CBT promotes:

Keep a consistent bedtime and wake-time.  Our bodies get used to going to bed and getting up at certain times.  Disrupting this internal rhythm, by excessive napping, staying up late, or sleeping in is a recipe for insomnia.

Avoid caffeine after noon.  The stimulatory effects of caffeine stay in your system several hours after intake.

Get regular exercise. Studies show that exercise improves sleep quality.

Keep your bedroom cool.  Our bodies’ temperature decreases when we sleep.  A cool sleep environment mimics this activity.

Take time to calm your mind before bed.  Dedicate 30-60 minutes before bedtime to something that relaxes you.  A warm bath, a pleasurable novel, meditation, etc. Doing this will not only help you get to sleep, but improve your sleep quality.  Avoid bright lights from your computer, phone, or television since this simulates the activating effect of the sun.

Don’t clock-watch.  If you get up during the night, avoid looking at what time it is.  This will likely cause anxiety about how much time you have left to get the sleep you need.  Revving up your system with such thoughts will make it even harder to get back to sleep.  So hide your alarm clock in a drawer or cover it with a book.

Limit alcohol before bedtime. Although alcohol may help you get to sleep, it impairs sleep quality and makes you more likely to wake up during the night.

Keep your bedroom dark and quiet.  

Use your bed only for sleep and sex.  You want to condition your mind to associate your bed with sleep, not reading, thinking, talking, and other activities.

If you wake up during the night and can’t go back to sleep, get up and do something relaxing.  Don’t try to fight your way back into unconsciousness.

Keep a Sleep Journal. Write down what time you go to bed every night, what time you tried to fall asleep, how long it took, how many awakenings you had, and what time you woke up.  Keeping track of this information will allow you to monitor your progress and understand what factors help you get the sleep you need.

Many robust studies show that cholesterol-lowering medicines called statins decrease the risk of having a heart attack or stroke.  Indeed, the widespread use of statins in people with or at risk for heart disease is at least partially responsible for the decreasing mortality from heart disease over the past few decades.

But almost nothing good in life or medicine comes without a cost.   With statins, the most common problem is muscle aches.  Some studies have estimated that as many as 20% of people on statins experience this symptom, which usually goes away when the medicine is stopped.  This issue can also be effectively addressed by lowering the dose or changing to a different statin.

A more recent concern about statins is the announcement last year by the FDA that a small number of people on statins report experiencing memory loss, forgetfulness and confusion.  The FDA reported that “in general, the symptoms were not serious and were reversible within a few weeks after the patient stopped using the statin.”  Today the Annals of Internal Medicine published a systematic review of available evidence on the relationship between statins and cognitive impairment.   

Researchers searched PubMed, Embase, and the Cochrane Library through October 2012 for randomized, controlled trials (RCTs) and cohort, case-control and cross-sectional studies that assessed cognition in patients taking statins. They also searched FDA databases from January 1986 through March 2012 to identify reports of adverse events related to statins.

Based on this extensive analysis, the study authors concluded that the currently available evidence does not support the theory that statins have negative cognitive effects.  They did note, however, that no randomized controlled trials have yet been conducted to investigate this issue.  Thus, they concluded that “larger and better-designed studies are needed to draw unequivocal conclusions about the effect of statins on cognition.”  

Here is a link to the review which received no industry funding.  And here is a Medscape article on the study.

About two weeks ago, my wife looked over at me in disgust as I spit a large volume of saliva into a plastic test tube just before we went to bed.  I had recently received a testing kit from a company called 23andMe, which for $99, conducts a comprehensive analysis of your DNA. 

I first learned about this kind of thing a few years ago reading Francis Collins’ book The Language of Life:  DNA and the Revolution of Personalized Medicine.  In the introduction, Collins describes how he submitted his DNA to 23andMe and two other companies offering complex DNA analysis.  Learning he had a higher than average risk of developing type 2 diabetes, he resolved to “go ahead with a long-postponed plan to contact a personal trainer and work harder at a diet and exercise program.”  He was also relieved to learn that he had a low risk of developing Alzheimer’s disease. 

Today when I received an email telling me my results were back I felt apprehensive about that component of what I would find.  As Collins writes in his book, the test for Alzheimer’s disease is “one of the strongest genetic risk factors yet identified, capable of increasing one’s risk by as much as eightfold.  And at the present state of medical research, there is nothing you can do about it, other than use the information to plan for the future.”  Ultimately, the desire to know quickly overcame any qualms I had about what I’d do with the information.  So when I pulled up to Jack  Brown Cleaners to pick up my clothes, I logged in to my 23andMe account through my iPhone.  Before receiving the results of my risk for developing Alzheimer’s and Parkinson’s disease, I was required to read a lengthy, informative warning about the implications of learning this information.  While appreciating the company’s attempt to act responsibly, I quickly scrolled down the page looking for the results, holding my breath as I did so.  Then I saw it:  My risk for getting Alzheimer’s between the ages of 50-79 was 4.3% compared the 7.2% average. I felt like I’d just received a good grade on my report card, except that I had done nothing to deserve it.

I did find that I have a higher than average risk of developing certain health problems.  Thankfully, most of these are conditions that can be screened for and treated.

I also learned that my ancestry is pretty homogeneous:  96.6 percent European, with 2.7 percent East Asian and Native American thrown in just to spice things up a little bit.

Perhaps because the tests did not reveal any very concerning abnormalities, I have a feeling that this report on my DNA is something that I will soon largely forget.  Nonetheless, it was an enlightening preview of the kind of personalized, gene-based analysis that will likely become a common component of health care in coming years.

Allie Brosh is a writer whose skillful storytelling and wonderful comic art have earned her blog, Hyperbole and a Half, an enormous following.  In a moving interview on NPR’s Fresh Air, she provides a revealing portrait of depression by sharing her own experience with this condition.  When asked to describe her depression, she says:

The first part was all sorts of feelings and a lot of self-loathing. … And then slowly it transitioned to feeling nothing and feeling very detached and bored with everything because I couldn’t connect in a meaningful way to the things I enjoyed or the things around me. …

 

I’ve always sort of secretly thought of feelings as a weakness. I think growing up I always wanted to be someone tougher than I am, and so when I first started not having feelings anymore I thought, “I’m finally this person who doesn’t react. I’m not sensitive anymore.” I enjoyed that for a short time, especially when I hadn’t lost my feelings completely, where I just felt like I was emotionally very strong. And then once all of my emotions disappeared, I very quickly realized that emotions are the only thing that provide variation in your life.

 

I think there’s a common misconception that depression is about something or depression is sadness or some form of negativity. It can represent a sadness or a self-loathing, as the first half of my depression did. It sort of circled back on itself and made me dislike myself more because I was so sad, and I didn’t know why, and I felt like I needed a reason. … It took me a long time to figure out that something was broken on a fundamental level. There was no reason behind it; it was just the way things were.

 

One of Brosh’s most beloved blog posts is one she wrote about her experience with depression and Here is a link to it.

I have an instinct to be a kind of good-read evangelist, compelled to share whatever I’ve read that’s been interesting, inspiring, and/or enriching.  Here’s some of the best stuff I’ve come across lately.  

In the journal Nature, a young neuroscientist writes about being diagnosed with Parkinson’s Disease.  He recalls when he first knew that something was wrong.  He was only 36 years old when 

I was filling out a mountain of order forms for new lab equipment. After a few pages, my hand became a quaking lump of flesh and bone, locked uselessly in a tense rigor. A few days later, I noticed my walk was changing: rather than swinging my arm at my side, I held it in front of me rigidly, even grabbing the bottom edge of my shirt.

 

He writes that ever since his diagnosis, 

I have had a different relationship with the brain — my scientific focus for the past 20 years. I now know what it is like to have a brain disorder and can explore its manifestations first hand. Take the very peculiar symptom known as ‘freezing’. Occasionally, when I attempt to lift my hand it well … won’t. Notice that I didn’t say can’t. There is nothing wrong with my arm. It is still strong and capable of moving, but I have to put effort, even focus, into getting it to move — frequently to such a degree that I have to pause whatever else my brain is doing (including talking or thinking). Sometimes, when no one else is around, I use my other hand to move it.

 

As a neuroscientist, it is simultaneously fascinating and terrifying to be directly confronted with the intersection of the neurophysiological and philosophical constructs of ‘will’. The way my mind and body do battle forces me to reconsider the homunculus, a typically pejorative (among neuroscientists) caricature of a little man pulling levers inside our heads, reading the input and dispatching the output. Virtually all that we know about how the brain is organized belies this image, and yet there is a dualism to my daily experience.

 

I keep coming across the subject of music and the brain lately.  For my younger son with autism, a music class has brought to life hitherto hidden parts of his precious mind.  And a study from George Mason University “found that nursing home patients with dementia who sang along with show tunes did better on cognitive tests than counterparts who just listened to the music.”  

Over a four-month study, the mental performance of patients who took part in regular group singing sessions improved compared with others who just listened.

In the sessions, patients were led through familiar songs from The Sound of Music, Oklahoma, The Wizard of Oz and Pinocchio.

The sessions appeared to have the most striking effect on people with moderate to severe dementia, with patients scoring higher on cognitive and drawing tests, and also on a satisfaction-with-life questionnaire at the end of the study.

All of this makes me want to read Oliver Sacks’ Musicophilia, his book exploring the relationship between music and the brain.  

These days many people seem to love to hate Malcolm Gladwell.  But I’m reading his new book David and Goliath and finding it so very fun and thought-provoking.  Its theme is that sometimes what seem like weaknesses and disadvantages can become great strengths.  He wrote a great essay in the New Yorker in 2009 exploring this idea.